News & Events

Moving violations: negative impacts of standing and walking in nurses’ health

From the Massachusetts Nurse Newsletter
October 2008 Edition

By Thomas P. Fuller, ScD, CIH, MSPH, MBA
Evelyn I. Bain, M Ed, RN, COHN-S, FAAOHN
Associate Director, MNA Health and Safety

You might just think your feet or legs hurt after working that 12-hour shift, but it is a fact. Several studies have shown that walking and standing are associated with a wide variety of lower extremity disorders. Long periods of walking and standing are associated with plantar fasciitis, tendonitis, cumulative muscle fatigue, and varicose veins. Chronic venous disease including primary/idiopathic abnormalities of the venous system and secondary sequelae after deep venous thrombosis have also been associated with women who work in standing positions. In general, long periods of walking and standing without adequate rest periods is bad for your health.

In a study of over a million female workers in a variety of industrial sectors it was shown that hospital workers had substantially more injuries to the lower extremities. Disorders include significant discomfort and pain in the legs, knees, ankles and feet. 

  Table 1.
Recommended shoe features
for health and comfort
    Cushioned soles  
          >1.5 cm at metatarsal zone  
              1.8 – 3.6 cm at heel  
        Arched footbeds to match the feet  
        Wide toe boxes  
        Leather uppers  
        Adjustable to fit snuggly but not too tight  

The primary reason for increased lower extremity musculoskeletal injuries is the extension of work-hours of healthcare workers over the past several years. Insufficient sleep or recovery time between extended exposures can increase risks of cardiovascular morbidity. The lack of sufficient physical and psychological recovery periods can exacerbate the health effects associated with prolonged work exposures and cognitive stress-related demands.

Changes in health care work organization and the physical layout of hospital facilities have both been shown to result in negative impacts on worker health. In the past two decades there has been a substantial shift in the hours that nurses work. Many nurses and hospital administrators see benefits in working longer days, more hours per week, and/or both. Whether it is more pay, fewer hours spent commuting, or reduced overhead costs, both workers and employers are accepting the work hour changes.

A 2006 study of 2,273 nurses showed that more than half of those sampled reported they typically worked 12 or more hours per day, some over 13 hours. A third reported working more than 40 hours per week, and/or six or more consecutive days, periodically. Many reported working extra shifts on scheduled days off and vacation days, working through scheduled breaks, working more than one job, and working rotating shifts that interfered with sleep schedules. Many nurses reported working 50 to 60 hours per week and up to 15 hours per day with insufficient time for rest and recuperation between shifts. The demanding workloads, pressing time schedules, psychological stresses, and poor work organization then lead to increases in lower extremity disorders.

The selection of shoes and stockings is the next most important factor associated with lower ex t remit y disorders. Comfortable and properly fitted footwear is essential in reducing fatigue and discomfort in lower extremities for workers who stand for extended periods. The foot bed should have a cushion to protect the foot from hard surfaces and be arched to properly support the foot.

The functions of the shoe midsole and outsole are mainly to provide shock absorption, friction, and to reduce the foot impact force when walking. The shoe-sole material and thickness influence the shock absorption effectiveness. Wearing viscoelastic (gel like) material in soles can relieve leg and foot pain for extended-standing workers.

The dimensions of shoe shape, such as instep height, toe box depth, and forefoot breadth, affect footwear comfort. For example, a narrow toe box tends to increase the strain on the medial side of the forefoot, and thus, it is recommended that standing workers should wear shoes with a wide toe box. Heel height also has an effect on the foot pressure distribution and vertical impact force. Reports indicated that high heel height generates greater vertical impact force, whereas flat shoes tend to produce lower impact force. Heel height also affects the ankle movement, muscle activity, center of gravity, and ground reaction force (GRF) patterns. Shoes should be designed with arch support to reduce muscle fatigue in the calf and disperse arch pressure across the foot.

Shoes should have outsoles with 1.5 cm (about â…” inches) thickness in the metatarsal zone in order to produce lower metatarsal pressure, vertical impact force, and reduce low back discomfort. Shoes should have soft leather uppers to encase and protect the feet while allowing the foot to breathe and midsoles made from ethylene vinyl acetate (EVA) or polyurethane (PU) materials that increase whole body and foot comfort. Shoe outsoles should be designed with heel height between 1.8 and 3.6 cm to generate lower heel pressure and vertical impact force in the forefoot and to reduce ankle discomfort. Some key features to consider when purchasing shoe are listed in Table 1.

Prolonged upright postures tend to disrupt the circulation of the lower leg and reduce the effectiveness of venous–muscle pump mechanisms. It has been shown that wearing compression hosiery can enhance venous return, and alleviate edema. Compression hosiery also demonstrated a positive effect on reducing the subjective feelings of discomfort in the lower back, knee, calf, and in the metatarsal and heel regions.

Walking and standing for long periods of time puts excessive strain on the lower extremities. Over the past several years there has been a trend for nurses to work longer hours and this is leading to an increase in adverse health effects. Occupational health practitioners need to take a proactive approach with both management and nurses to convince them to seek alternatives in work practices, footwear selection and facility design.