Foot and Ankle Disorders in Nurses Exposed to Prolonged Standing Environments: A Scoping Review

Background: Prolonged standing environments constitute an occupational risk factor for nurses, particularly for developing foot and ankle disorders. The definitions and potential relationship to hours spent walking or standing are poorly understood. This scoping review aimed to synthesize the main disorders found on nurses’ ankles and feet, their prevalence, the influence of hours spent walking or standing, and gender differences. Methods: This review followed a previously published protocol. Primary and secondary studies were retrieved from relevant databases from December 2020 to March 2021. Potential articles were collated to Mendeley, and two independent reviewers assessed the title and abstracts. Studies meeting inclusion criteria were included. Two researchers retrieved and reviewed the full text of these studies independently. A predetermined extraction tool was used to retrieve relevant data, summarized in a tabular and narrative format. Findings: The most common disorder was pain, followed by numbness, burning feet, bunions, structural deformities, and calluses. Prevalence differed among studies, depending on settings and specific local policies. Discussion: Various foot and ankle disorders and related variables have been found, with clear gaps that may be addressed in the future. Conclusion/Applications to Practice:: Few studies have focused on nurses’ foot and ankle disorders. Mapping signs and symptoms may contribute to the future development of preventive interventions for nurses’ workplaces.


Background
According to a recent report by the European Agency for Safety and Health at Work (EU-OSHA, 2021) entitled, Prolonged constrained standing at work-Health effects and good practice advice, one in five workers in the European Union (EU; 20%) spend most of their working time standing, 60% identify musculoskeletal disorder (MSD) as the most severe issue, and 29% report muscular pain in the lower limbs in the past 12 months. Moreover, the International Labour Organization (ILO, 2013) considers MSD a significant public health concern in Europe, being the most frequent work-related health disorder.
In general, prolonged walking and standing contexts are associated with decreased blood circulation to the lower extremities, reducing nutrient supply to muscles, thus leading to fatigue and pain (EU-OSHA, 2019; Peddie et al., 2021). The manifestations of MSDs can be divided into specific (clear clinical features) or nonspecific disorders such as pain without evidence of clear specific disorders (Krishnan et al., 2021).
Many occupations require prolonged daily standing, such as food service, factory, retail environments (Anderson et al., 2018), and the healthcare professions, specifically nursing. While performing interventions in static positions or walking long distances throughout the day, nurses are exposed to consequences associated with prolonged walking and standing, predisposing their lower extremities to stress, especially in the ankle and foot region (Stolt et al., 2018). Getie et al. (2021) state that 24% of nurses were absent from work in the past 12 months due to foot and ankle pain, which was the second reason for absenteeism among healthcare professionals.
According to Getie et al. (2021), foot and ankle pain is a sensory and emotional experience caused by inflammatory and degenerative damage to any region distal to the tibia or fibula, including bones, joints, muscles, nerves, skin, and vascular structures. In addition, constant exposure to prolonged standing has a 1.7-fold increase in the risk of foot pain (Anderson et al., 2018).
The existing evidence on foot and ankle disorders among nurses is particularly challenging for research as it is dispersed and very heterogeneous, with a clear dependence on the type of occupational context. Regarding the prevalence of pain, values range from 21.2% in Portugal (Moura et al., 2019), 23% in Japan (Tojo et al., 2018), 42% in Poland (Rypicz et al., 2020), to as much as 55.3% in Australia (Reed et al., 2014).
Although it is an area identified as a priority to improve the quality of life among nurses (Ou et al., 2021), research focusing on nurses' feet is scarce (Stolt et al., 2017), and a preliminary search of the literature has revealed that no reviews have been conducted or are underway about this topic. Furthermore, few studies focus on the relationship between prolonged standing, signs and symptoms of foot and ankle disorders, hours spent walking or in static positions, and gender-based differences.
Therefore, our objective was to identify the main foot and ankle disorders among nurses, their prevalence, the influence of hours spent walking or standing, and gender differences.

Methods
This scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR; Tricco et al., 2018) and by the protocol with the respective methodology, which has been published previously (Bernardes et al., 2021).

Inclusion and Exclusion Criteria
The inclusion criteria were defined through participants, concept, and context. Regarding participants, this review considered studies that include only nursing professionals and midwives. The concept of the study refers to "foot and ankle disorders," whether of a musculoskeletal, neurological, or other nature. As for context, this review considered studies concerning standing environments in acute hospital settings. As such, studies with nurses who usually work in a stationary environment for most of the time (e.g., clinical appointments) were excluded.

Data Extraction
The scoping review was conducted on a total of 12 databases, search engines, and research repositories: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latindex, Scientific Electronic Library Online (SciELO), Web of Sciences, Cochrane Database of Systematic Reviews, Joanna Briggs Institute Clinical Online Network of Evidence for Care and Therapeutics (JBI Connect Plus), PROSPERO, and, for unpublished studies and gray literature, Google Scholar, Open Gray, Directory of Open Access Repositories (OpenDOAR), and ProQuest Dissertation and Theses Global.
An initial limited search of MEDLINE (through PubMed) was conducted with pilot keywords related to the participants, the concept, and the context, leading to the development of a full search strategy, using the index terms in titles and abstracts. The next step included an extensive search of the remaining databases. Finally, the reference lists of all included papers were searched manually for additional studies of interest.
The search strategy used for MEDLINE (through PubMed) was further adapted for the remaining databases, taking into consideration specific thesaurus, and can be found in Supplemental Table 1. Relevant filters applied to all databases were limited to Portuguese, English, French, and Spanish results and studies published from the earliest point until March 2021.
Databases were searched for original articles reporting primary research and secondary research, such as literature reviews and other relevant documents. Gray literature was also included for a more comprehensive review and to reduce bias in the findings (Paez, 2017). The first database to be searched was MEDLINE (through PubMed) in December 2020, and the last database to be searched was CINAHL Complete (through EBSCOhost) in March 2021. All documents were first screened by two independent reviewers, considering the title and abstract, and the second stage was based on the full-text reading. When the title or abstract had insufficient information to assess inclusion, the reviewers performed a full-text analysis. Final data were extracted from a tool previously developed (Bernardes et al., 2021). Any disagreements between reviewers were solved by discussion or with a third reviewer. Data have been organized using tables, as defined in the protocol.
Mendeley® reference manager (Elsevier®) was used to collate studies and perform the screening and selection.

Results
A total of 2,184 results were retrieved from the selected databases, search engines, and repositories ( Figure 1). After identifying relevant studies and excluding those that did not meet the criteria or were duplicated, 515 studies were screened for eligibility. Following this step, and after a manual identification from citation searching, a total of 39 studies were included in the review.

Foot and Ankle Disorders and Relevant Signs and Symptoms
The most common disorder reported in the literature was pain, reported explicitly in 19 studies (Table 2), followed by numbness, burning feet, bunions/hallux valgus/bone spurs, structural deformities-low or high foot arches and flat feet, fungal infections, and calluses/corns.

Reported Prevalence of Foot and Ankle Disorders
The prevalence was significantly heterogeneous between studies on hospital-based contexts (Table 3), with three studies evidencing foot and ankle MSDs as the most prevalent in relation to other body regions. Two studies found that they were the least prevalent.

Walking and Standing Hours
Regarding the hours that nurses spent exposed to standing environments, either walking or in static postures, only five studies (13.16%) reported specific values.
In 1987, Baty and Stubbs conducted an observational study with 52 geriatric nurses, reporting that standing positions accounted for 21.8% of shift time, while walking had 53.7% of shift time. The authors concluded that nurses usually walk more on the late shift-21% of the time, against 18.6% on the early shift-whereas standing is equally distributed throughout the shift-56.6% for the early shift and 53.8% for the late shift.
On the contrary, a study in Brazil (Gonçalves et al., 2001) reported that day shift nurses spend more than 70% of the time standing (roughly 8.4 hours) and that night shift nurses spend about half of the shift (51%) standing (an average of 6.12 hours).
Similar to the previous study, Kołcz et al. (2019) says that 41% of nurses spend more than 8 hours in standing positions and 59% between 5 and 8 hours in these positions.
In a mixed-methods study with 20 nurses from medical/ surgical and intensive care unit (ICU) wards, Li, Sommerich, and Chipps (2020) reported 53.7% of shift time was spent standing, 14.7% of shift time walking in ICU wards, and 56.3% of time spent standing and 14.03% of time walking for the latter. For ICU wards, the average time on foot, including time standing Note. PRISMA-ScR = Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. a Full texts were not available and original authors were contacted but gave no feedback. b Manual searching.

Contact dermatitis
• Dry and shiny inflamed skin; • Skin cracks; • Demarcation along the line of the shoe. Sabine (1999) and Stolt et al. (2017).
Ingrown toenail • Inappropriate nail cutting, tight-fitting shoes, pressure on the skin around the nails, and/or moist skin; • Swelling with concomitant infection and pain. Sabine (1999) and Stolt et al. (2017).
Reed (2007)  and walking, is 68.3%, whereas for medical/surgical wards, the value is slightly higher (70.4%). More generally, Almhdawi et al. (2020), in a study with 597 nurses, indicated that 44.2% spend long periods in the same position (either static or dynamic), one to three times a day.

Gender Specifications
In general, female nurses were significantly more affected than male nurses (p < .001), reporting MSDs more frequently and presenting a higher prevalence of foot and ankle pain (Nguyen et al., 2020;Omidi et al., 2018Antochevis-de-Oliveira et al., 2017Choobineh et al., 2010;Yang et al., 2018). Stolt et al. (2016) considered gender a significant risk factor for developing foot and ankle disorders. Regarding body regions, Stolt et al. (2016) concluded that female nurses have more knee pain (40.4%), whereas male nurses have ankle pain (68.8%) more often.

Discussion
The recommended practices for safety and health at work provided by the Occupational Safety and Health Administration (OSHA, 2016) suggested that the failure to identify hazards that are either present or could have been anticipated is a root cause for injuries. A root cause analysis recommends the investigation of underlying causes, similar clustering incidents, and common symptomatic trends. Despite this, our findings suggested that nurses' foot and ankle disorders were still an understudied topic, with no consensus regarding their classifications. Whereas some (Bazazan et al., 2019;Stolt et al., 2015) present a conceptual definition that considers change or damage to the anatomical structures of the ankles and feet (e.g., muscles, tendons, ligaments, and nerves), others offer a functional definition graded in terms of severity (Kee & Seo, 2007). Different conceptual frameworks may have contributed to the heterogeneity of reported symptoms, which undermines the potential for data pooling and comparison. We believe this gap is partly caused by the lack of guidance on what data should be collected to assess foot and ankle disorders, emphasizing the need for an expert-driven consensus that can work as a guideline in future studies.
Although the most reported disorder, none of the included studies comprehensively described pain's location, radiation, onset mode, character, or intensity. This gap undermines our efforts to highlight current strategies to prevent or mitigate foot and ankle disorders, which could be used to bolster nurses' health and well-being.
Interestingly, the temporal patterns for nurses' ankle and foot pain were addressed by some authors (Nur et al., 2016;Stolt et al., 2018), with important implications for occupational health research. After years of exposure to standing environments, especially in hospital-based settings, nurses tend to be more aware and report foot and ankle symptomatology more frequently. Throughout nurses' professional careers, alongside physiological changes associated with the aging process, standing environments seem to contribute to a gradual, cumulative effect, increasing the severity of the damage caused to local anatomical structures (Amin et al., 2020).
Prevalence rates over 12 months significantly varied between studies, suggesting that nurses' foot and ankle disorders seem multifactorial in nature, converging with the latest report by the EU-OSHA (2021). Our results showed that organizational factors (e.g., unit layout/design), sociodemographic factors (e.g., age, gender), body mass index (BMI), vascular comorbidities/ impairments, specific phenotypes, and self-care behaviors (e.g., type of footwear, lack of physical exercise) contribute to the incidence of foot and ankle disorders.
Despite the risk factors identified in our review, we believe that prevalence rates diverged significantly between authors due to the different conceptual frameworks and the data collection methods used by the authors. For example, in studies where authors used self-reported questionnaires (Amin et al., 2020), prevalence rates were higher than in more objective assessments, as in the case of baropodometric evaluations (Kołcz et al., 2019). This may be due to the subjective nature of the initial symptoms, such as pain and tenderness. Moreover, in earlier stages, common symptoms such as pain may be misinterpreted as an expected outcome after a long working day, disregarding the harmful effects of standing environments over time on nurses' health and quality of life. Several authors (Antochevis- de-Oliveira et al., 2017;Gurgueira et al., 2003;Santos et al., 2017) identified that nurses perceived foot and ankle disorders as a condition that undermines their well-being and efficiency in the workplace, which, in more severe cases, could lead to absenteeism or desire to change the clinical setting and/or job role. Our findings must be considered within this review's limitations. Although not required for scoping reviews, the methodological quality of the included studies was not assessed, which may result in confounding, selection, and information bias. Moreover, research and outcome heterogeneity made it difficult to compare the included studies in specific areas such as the average number of hours spent walking and standing during clinical practice, the type of footwear used and recommended by the healthcare organization (if such recommendations exist), nurses' previous health comorbidities that can increase the risk of foot and ankle disorders, and studies with samples having more female nurses.
Finally, given that most studies focused on analyzing MSDs of body regions using the Nordic Musculoskeletal Questionnaire, we believe that future studies must focus on developing evidence-informed, robust instruments that identify and classify foot and ankle disorders, standardizing data collection in this field.

Implications for Occupational Health Nursing Practice
According to the International Council of Nurses (ICN, 2017), the working conditions that nurses are subjected to are among the most dangerous for their health, resulting in occupational injuries, which increase psychological stress and job dissatisfaction. This review synthesized the major foot and ankle disorders, and related signs and symptoms in nurses exposed to standing environments. In addition, it provided insight into prevalence, walking and standing hours, and gender-specific influences on the onset of disorders.
The construction of robust and standardized frameworks for the early identification, prediction, prevention, and personalized treatment of foot and ankle disorders is a good practice for strengthening occupational health policies within organizations. In this sense, current guidelines, recommendations, and position statements on nurses' occupational health may benefit from the findings of this review. We suggest the following possible directions: (a) cooperation with local occupational health professionals to draw decision algorithms on how to prevent specific disorders as different signs and symptoms require different treatments and preventive measures, including clear recommendations on personalized footwear; (b) raise awareness among healthcare professionals and administrators, actively including them in the characterization of present difficulties and prospective solutions; (c) discuss and endorse occupational strategies that promote nurses' self-care; (d) promote locally endorsed studies that focus on the prevalence of this health condition among nurses, correlating it with work demands and environmental variables; and (e) international collaboration with professional associations to develop rigorous and evidence-based guidelines for prevention, diagnosis, and treatment of foot and ankle disorders.

In Summary
• • Nurses are highly exposed to foot and ankle MSDs as they need to walk or stand for long periods. This reality must be adequately identified and described by employers and administrators as professionals might find themselves in a physically stressful situation, leading to absence from work. • • The most common foot and ankle disorder is pain, also called metatarsalgia, generalized forefoot pain, or discomfort. It is an unspecific disorder and should not be confused with the common symptom of "pain" found in most disorders. This elicits the importance of early identification of signs and symptoms and nurses' awareness of the topic to prevent future incapacitating complications adequately. • • The prevalence of foot and ankle disorders is dependent on a variety of factors, either subjective (awareness level, work-related stress, and level of physical exercise) or objective (nature of work and ward typology, availability of new technology that might alleviate nurses' work, foot structure, BMI, prior injuries, and footwear). Personalizing occupational health policies to each ward typology and work type is a mandatory intervention. • • Future research is required to provide correlational evidence on the impact of the amount of walking and standing hours on the development of certain foot disorders, how architecture and organizational factors influence nurses' daily routines and their physical burden, and whether awareness of the topic provides a rapid modification of working habits.
We are now submitting the findings of the review.