Work Supporting Musculoskeletal Awareness, Research & Training In the Early Years (SMARTey)

Musculoskeletal Disorders and Pain in the Workforce

Musculoskeletal disorders (MSDs) and musculoskeletal pain (MSP) are among the leading causes of disability worldwide, with an estimated 1.7 billion people living with these conditions (Cieza et al., 2021). Low back pain alone accounts for nearly half a billion cases, representing the single largest contributor to years lived with disability in many nations (Vos et al., 2020).

In the workplace, MSDs remain the primary health challenge, accounting for approximately 60% of occupational health complaints across the EU (EU-OSHA, 2019). Work-related MSDs in the UK affect around 543,000 workers annually, leading to 7.8 million lost working days (HSE, 2024). When broader musculoskeletal conditions are included, this figure rises to nearly 30 million days lost (Public Health England, 2020; NHS England, 2024). Global data shows ergonomic risks in the workplace to be one of the largest single contributing factors in the development of MSDs (WHO & ILO, 2021). Concurrently, work-related MSP has predominantly been approached from a biomechanical perspective, identifying physical load and tissue strain as the primary drivers of pain and injury (Pomarensky et al., 2021). Consequently, workplace regulations and guidance tend to focus on acute, visible risks (such as heavy manual handling, falls from height, or machinery operation) and on task-specific standards designed to prevent ‘catastrophic’ harm (HSE, 2024) These are important measures which have been crucial in reducing serious traumatic injuries. However, the risks posed to workers by smaller (but more common and frequent) can also be the cause of considerable strain, physical demand and injury. Particularly in cases where individuals are routinely required to work in ergonomically challenging positions or environments. Yet these risks are not given the same oversight and guidance as the aforementioned examples.

These figures underscore the immense impact MSDs and MSP have on an individual’s ability to work and participate fully in daily life. Beyond the personal toll, they are a major driver of work limitation, reduced labour market participation, and substantial economic cost (Public Health England, 2020; House of Commons Library, 2024). It is accurate to say these data present a stark picture of the problems and challenges faced, but they also offer a clear and realisable opportunity to improve the working lives of millions.

The UK Early Years sector – Overview, Recruitment & Retention

The 2023 Survey of English Childcare and early years providers estimated there to be around 56,400 early years settings in the UK (a fall of more than 3000 on the previous year’s figures), with approximately 347,300 people working across the sector (259,300 staff in group-based provision; 55,800 staff in school-based provision; 32,200 childminders and childminding assistants) (UK GOV, 2023). More recent data from the 2024 survey indicates a continued decline in provision, with the number of settings falling to approximately 54,700 (a further drop of 3% from the previous year). However, the total workforce has seen a recovery, rising to approximately 368,100 staff, although this increase is largely concentrated in group-based settings while childminder numbers continue to fall (UK Government, 2024a).

Data indicate this population to be around 96% female, with around 40% of the workforce currently under 30 years. The Social Mobility Commission (2020) reports that childcare workers frequently put in longer hours than those in similar jobs, with 11% working over 42 hours a week, compared to 3% in retail and 6% among women overall. The need for practitioners to work longer hours was found to be more common in areas of higher deprivation (DFE, 2022). Despite this higher workload, pay for these roles is very low.

In 2020, 60% of early years practitioners reported wages ranging from £5 to £9 per hour, just 12% of early years workers made above £11 per hour, with women employed in comparable sectors of employment often undertaking less work and receive markedly higher rates of pay (The Social Mobility Commission, 2020). Statutory increases to the National Living Wage (rising to £11.44 in April 2024 and £12.21 in April 2025) have shifted the baseline upward. However, the sector remains low-paid relative to inflation, with the majority of practitioners still earning at or near this statutory minimum rather than a competitive salary (UK Government, 2024b, Low Pay Commission, 2024). As a consequence of this low remuneration, The Education Policy Institute reports that early years practitioners experience a high degree of financial insecurity, and in as many as 45% of cases, early years practitioners rely on state benefits and/or tax credits to supplement their income (Bonetti, 2019). It is therefore no surprise that the Sutton Trust notes lack of opportunities for development and progression are key factors that motivate people to leave the sector (Pascal et al., 2020). Indeed, opportunities for training after joining the field are scarce, with only 17% of early years workers receiving job-related training. Therefore, despite a strong passion for their work, a significant percentage (37%) of early years workers leave their employer/employment within two years, with a greater proportion of these being from the under 30 age bracket (The Social Mobility Commission, 2020). Thus, those working in the early years experience several significant push and pull factors that may cause them to leave the sector, namely comparatively higher workloads, lower remuneration, and fewer opportunities for progression than other roles that they would be able to transfer into. This is somewhat consistent with the Social Mobility Commission report (The Social Mobility Commission, 2020) that in settings where higher levels of pay and training for staff are provided, rates of staff retention are better.

Based on this picture of underpayment, overwork, and lack of opportunity, it is unsurprising to find the UK early years sector is currently struggling to attract new practitioners and retain those already there. A 2021 report from the Early Years Alliance (EYA, 2021), highlights these issues, with 84% of settings reporting difficulties recruiting staff members. This trend has persisted; the 2024 EYA survey reports that 78% of settings continue to struggle with recruitment, describing the crisis as ‘endemic,’ while 61% of respondents reported staff leaving the sector entirely in the previous six months (EYA, 2024). Furthermore, turnover rates remain significantly higher in private, voluntary, and independent (PVI) settings compared to maintained schools.

Research investigating factors contributing to staff recruitment and retention shows back pain and other musculoskeletal disorders (MSDs) associated with, or exacerbated by job demands, can act as significant push factors, with increased incidence of MSD associated with greater rates of staff departure (Lallukka et al., 2018). Despite this, a recent UK government report titled; “The Early Years Workforce: Recruitment, Retention, and Business Planning” (DFE, 2022), does not include considerations of MSK risk specifically, or practitioner health in general, as contributing factors. Similarly, the “Childcare and early years providers survey: 2023” report (UK GOV, 2023), also omits practitioner health as a factor.

Further evidence of this lack of consideration is demonstrated by legislative action taken shortly after the publication of this 2023 report, when the statutory minimum staff-to-child ratio for two-year-olds in England changed from 1:4 to 1:5 (Department for Education, 2025). This effectively increases the workload and physical demand on practitioners

While a potentially well-meaning attempt to mitigate recruitment challenges for early years settings, the willingness to reduce staffing ratios and increase individual workload regarding childcare supervision may reflect a lack of awareness regarding the issues faced. Actioning changes such as these (e.g. increasing staff-child ratio guidelines), could further exacerbate challenges in retention/recruitment by increasing demands placed on individual practitioners and reducing the quality of provision provided to children (Early Education and Childcare Coalition, 2023). Despite direct consideration from government, current efforts to address staff recruitment and retention rates in the early years still overlook important challenges and problems within the sector, particularly with respect to practitioner health. This has the potential to pose considerable ongoing problems for individuals who work in the sector, and settings looking to attract and retain members of staff.

Musculoskeletal Disorders and Pain in the UK Early Years workforce

Exposure to small physical demands such as those mentioned above is routine in Early Years education, where the role demands physical closeness, responsiveness, and interaction at the child’s level (Department for Education, 2025). Research into the daily reality of nursery and childcare workers highlights a pattern of frequent lifting, working at low tables or on the floor, repeated kneeling, stooping, and twisting, often within cramped spaces designed for children rather than adults (Grant et al., 1995; Tsuboi et al., 2002; Shi et al., 2022). The health risks associated with repeated exposure to these cumulative demands are well established (da Costa & Vieira, 2010). International research supports this, reporting widespread MSP, particularly among those working with the youngest children. A US study found that 61% of Early Childhood Education workers reported back pain linked to awkward or heavy lifting and static postures (Grant et al., 1995). Notably, staff caring for infants (six weeks to 18 months) performed more lifting and adopted more awkward postures than those working with older children (3–4 years). Although small in scale, this study highlighted clear physical strains and the urgent need for environmental and occupational change. Larger studies from Japan mirror these findings. Kindergarten and nursery staff reported higher rates of low back, neck, shoulder, and arm pain compared to staff working with older children, with the highest prevalence again found among infant caregivers (Tsuboi et al., 2002; Ono, 2002). Here, pain was associated with frequent lifting, high workload, and poor working conditions, further underlining the cumulative nature of the risk.

In the UK, anecdotal reports of work-related pain are commonplace among practitioners. However, at the inception of this project, it became apparent that no independent research had specifically investigated the scale and nature of this problem in the UK Early Years population. The closest available measure was the Labour Force Survey (LFS) for Education workers in England and Wales which reported an MSD incidence rate of just 0.9% (HSE, 2022). Compared to the global data reported above, this number appeared strikingly low. Closer inspection of the LFS methodology helped explain this discrepancy: the survey only records cases where an individual formally takes sick leave due to an MSD. It fails to capture the incidence of actual health events and the reality of “presenteeism” (staff continuing to work while managing significant pain). Without accurate data, the problem remains invisible, and the path to addressing it remains obscured.

Levels of work-related MSP in the UK early years workforce

Associations between role demands and environments, and experiences of work-related MSP

How work related MSP affects turnover intention, and tendency to take sick leave

Differences between those in predominantly practitioner, or leadership roles

Perceptions of provision of measures to protect physical health, and whether these need to be improved.

How do participants describe their experiences of work-related Musculoskeletal Pain (MSP)?

How do participants understand their condition, and do they consider their role/environment to be ‘painogenic’ (a cause/risk of MSP)?

How do participants respond to work-related MSP?

What responses are encountered when MSP is reported to an employer?

What factors might cause participants not to report their pain?

Has work-related pain led participants to consider leaving the early years profession?

This stage of the project is currently in development, with plans to undertake initial work in the second quarter of 2026.

work-related strain occurs when physical or psychological “demands” (e.g., lifting children, low-height working) outweigh available “resources” (e.g., ergonomic equipment, staff support), leading to injury and exhaustion.

An organizational-level framework measuring leadership’s commitment to worker health; a strong PSC acts as an “upstream” resource that reduces physical risks and encourages a culture where health is prioritized over production.

“Safety Voice” is the proactive communication of hazards to prevent harm; “Safety Silence” is the intentional withholding of concerns, often driven by a belief that reporting is futile (Acquiescent Silence) or a desire to avoid being a burden (Prosocial Silence).

Early education practitioners are exposed to a significant degree of risk to their musculoskeletal health, 98% of participants reported pain while carrying out their roles.

A greater duration of time spent working in the early years is associated with a higher number of reported pain locations (independently of age).

Frequency of exposure to high musculoskeletal risk actions at work predicts pain frequency, onset, and need to take sickness absence.

Practitioners perceive a greater need for improvement compared to leaders or managers, greater perceived need predicts increased likelihood of considering leaving early education roles.

Project Approach:

Work SMARTey designed and delivered the UK’s first empirical study into work-related MSP in the early years sector. Beyond simply establishing prevalence, this study gathered detailed measures on pain severity, frequency, duration, onset, and crucially ‘bothersomeness’.

The study design also allowed for key comparisons between those in leadership or management positions and those in primarily ‘practitioner’ roles. Furthermore, the application of regression analyses enabled the work to identify specific factors that predict an increased likelihood of MSDs.

A cohort of 196 early years practitioners and leaders was recruited from across the UK and invited to complete an online questionnaire. This survey explored their work-related pain experiences, their specific daily duties, and the link between their roles and their work-related MSP. We also investigated the wider professional impact of MSP, asking participants about sick leave, reporting procedures, and whether pain had led them to consider leaving the sector entirely.

Project findings:

Our analysis of the findings revealed a situation more severe and widespread than we had anticipated. A staggering 98% of participants reported experiencing work-related pain, with the lower back being the most common site (89%). This was not fleeting discomfort; for most, the pain had a long history (onset >12 months ago), recurring on average every 7–14 days, with episodes lasting on average 1–2 weeks.

Regression analysis provided further insight: frequent exposure to physically demanding tasks significantly predicted both higher pain frequency and earlier onset. Notably, we found that the longer an individual works in the early years sector, the greater the number of painful body locations they report. Crucially, this finding was independent of the practitioner’s age; while older participants did report longer durations of pain events, the data showed that the spread of pain across the body was associated with job demands, not by aging. Finally, while leaders and practitioners both reported performing high-risk musculoskeletal activities at similar frequencies, their perceptions of workplace safety differ. Practitioners expressed a strong need for greater protective measures. In contrast, leaders who possess more years of service (median 22 years vs. 18) were more likely to believe adequate safety resources are already available.

The occupational impact of this is profound. Unsurprisingly, intense pain and high-risk activities (such as lifting, stooping, or working at floor level) were identified as major drivers of sickness absence. Furthermore, and particularly worrying for the sector, the combination of frequent, bothersome pain and a perceived lack of protective action from employers emerged as a significant factor in staff considering leaving the profession entirely. In sum, the results provided a clear and strong indication of what many had already known. There exists a significant and unmet need for many working in the early years sector regarding the risks faced and harm associated with the demands of their roles and working environments. For the first time in the UK we had robust data to back up those suspicions.

The findings from the quantitative phase of the ‘Work-SMARTey’ project provide a clear mandate for change. For those supporting this sector, the data suggests that generic manual handling training is insufficient. Instead, interventions must be sector-specific, acknowledging the unique ergonomic reality of the Early Years environment where working at low heights and lifting moving children are unavoidable tasks.

To reduce the burden of MSDs, the sector requires a “prehabilitative” approach, shifting focus from reactive management of injury to proactive prevention. This relies on development in several key areas:

• Tailored Risk Assessment: Standard risk assessments are ill-suited for Early Years settings. Protocols that specifically addresses “low-height working” and tasks such as floor-based play.
• Ergonomic Investment: Providing ergonomically congruent supports and furniture for adults (such as low-height stools with lumbar support) can significantly reduce the cumulative strain of static postures.
• Leadership Education: Our data indicated a discrepancy between the support leaders believed they provided and the protection practitioners felt they received. Closing this gap requires training leaders to recognise the early warning signs of MSDs and to foster a culture where reporting pain is encouraged, not stigmatised.

Turvill, A. J., Sheffield, D., & Taylor, L. (2024). Musculoskeletal pain and working practices in the UK early childhood education workforce. Safety Science, 178, 106592. https://doi.org/10.1016/j.ssci.2024.106592

Painogenic Environment: The ECE sector is structurally set up to promote pain (High physical demands/low provision of adult ergonomics), yet this is often internalized by staff as “part of the job.”

Safety Silence: A pervasive culture of silence exists where reporting is viewed as futile (Acquiescent) or burdensome (Prosocial), masking the true extent of the problem.

Reactive vs. Proactive: Current organizational responses are inconsistent and reactive; the sector lacks a proactive Psychosocial Safety Climate (PSC) to prevent injury.

Sustainability Crisis: Unmanaged MSP is a critical “push factor” driving skilled staff out of the workforce due to fear of future physical incapacity.