Int. J. Occup. Safety Health, Volume 13, No 3 (2023), 375-385 https://www.nepjol.info/index.php/IJOSH 375 Original Article Prevalence and Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center in Nepal Karki P1, Joshi YP1,2, Khanal SP3, Gautam S1, Paudel S4, Karki R1, Acharya R5 1Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal 2Faculty of Science Health and Technology, Nepal Open University, Lalitpur, Nepal 3Central Department of Statistics, Tribhuvan University, Kathmandu, Nepal 4Department of Public Health, CiST college, Naya Baneshwor, Kathmandu, Nepal 5 School of Medical Science, Kathmandu University, Kavrepalanchok, Nepal ABSTRACT Introduction: Musculoskeletal disorders (MSDs) are injuries or pain in the human musculoskeletal system which could lead to temporary or permanent impairments. The nature of nursing jobs makes nurses vulnerable to MSDs. This study aimed to assess the prevalence and potential risk factors associated with MSDs among nurses. Methods: In between March to June 2021, a cross-sectional study was conducted among 165 nurses using self-administered questionnaires. A standardized Nordic Questionnaire was used to measure MSDs. Pearson’s chi-square test and binary logistic regression at a 5% level of significance were performed to identify factors associated with upper extremities and spinal musculoskeletal disorders (UMSD) and lower extremities musculoskeletal disorders (LMSD). Variables associated with UMSD and LMSD in bivariate analysis were subjected to multiple logistic regression. Results: The prevalence of UMSD and LMSD experienced by nurses was 86.1% (95% CI: 79.4%-90.9%) and 66.1% (95% CI: 58.9%-74.3%), respectively. Among several factors, working in same position for long periods (AOR: 4.16, 95% CI: 1.2- 13.4), not receiving training in injury prevention programs (AOR: 3.15, 95% CI: 1.0- 9.2), not enough rest breaks during the day (AOR: 4.65, 95% CI: 1.3-15.9) and moderate to higher job stress (AOR: 3.62, 95% CI: 1.2-10.8) were found to be significantly associated with UMSD. Not having enough rest breaks during the day (AOR: 2.19, 95% CI: 1.0-4.7) was significantly associated with LMSD. Conclusion: Higher prevalence of MSDs among nurses is a serious concern that threatens individual health as well as the overall healthcare system. Sensitization and capacity enhancement programs on the issue could prevent MSDs among nurses. Keywords: Ergonomics, Musculoskeletal disorder, Nepal, Nurses Occupational health, Prevalence, Risk factors Introduction Musculoskeletal disorders (MSDs) are injuries or pain in the human musculoskeletal system such as muscles, nerves, tendons, joints, and structures supporting limbs, neck and back resulted due to sudden or sustained exposure to stressors such as external forces, repetitive motions, vibrations, and awkward positions.1 MSDs are the most serious public health hazard, which could result in individuals' temporary or permanent impairment.2 Globally, MSDs have become a leading cause of disability.3, 4 The healthcare sector is known to have a significant risk of MSDs.5-7 Healthcare personnel such as physicians, nurses, and paramedics are exposed to repeated stress Corresponding author: Pratima Karki, MPH Graduate, Department of Public Health, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal Tel.: 9844700662 E-mail: pratima.karki216@gmail.com ORCID ID: https://orcid.org/0000-0002- 9287-616X Date of submission: 26.01.2023 Date of acceptance: 06.04.2023 Date of publication: 01.07.2023 Conflicts of interest: None Supporting agencies: None DOI:https://doi.org/10.3126/ijosh.v13i3 .51792 Copyright: This work is licensed under a Creative Commons Attribution- NonCommercial 4.0 International License ISSN: 2091-0878 (Online) ISSN: 2738-9707 (Print) https://www.nepjol.info/index.php/IJOSH mailto:pratima.karki216@gmail.com https://orcid.org/0000-0002-9287-616X https://orcid.org/0000-0002-9287-616X https://doi.org/10.3126/ijosh.v13i3.51792 https://doi.org/10.3126/ijosh.v13i3.51792 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 376 and frequent strains while performing daily patient care activities which can lead to chronic sickness and musculoskeletal problems.8, 9 Even among healthcare professionals, nurses are suggested to have a higher risk of MSDs.10-12 The nature of the nursing job requires activities such as manual lifting heavy loads and patients, bending over patients, transporting patients from bed to the floor, pulling and pushing equipment, and sometimes working in confined spaces and awkward postures making them more prone to injury.9, 13, 14 The presence of MSDs not only affects the quality of life of the nurses but also could lead to increased work resistance, absenteeism, early retirement, transfer to another job, and even disability which ultimately results in financial hardship on an individual as well as to the family and society in general.15-17 Studies throughout the world suggest that the 12- month prevalence of MSDs in the nursing population varies between 21.0% and 91.9%.6,9,18-20 In South Asia, this prevalence lies between 21.0% and 89.2%.19,21,22 In Nepal, limited studies have assessed musculoskeletal pain or disorders in the general population while few have targeted healthcare professionals focusing only on lower back pain. From these limited studies, the prevalence of lower back pain among nurses was observed to be around 60.0%-78.0%.24-26 However, there is no evidence illustrating the overall rate of MSDs experienced by nurses in seven days and/or twelve months duration as well as its impact and determinants in these vulnerable populations. The occurrence of MSDs in the nursing population could impact the overall health system of the nation as nurses are one of the major health workforces. Identifying these risk factors is critical for understanding the causative linkages of these disorders and implementing the most effective preventative measures in the workplace. For this reason, this study aimed to measure the prevalence and potential risk factors associated with musculoskeletal disorders among nurses working in a tertiary care center in Nepal. Methods The cross-sectional study was conducted among the nurses working at Dhulikhel Hospital between March and June 2021. Dhulikhel Hospital situated in Dhulikhel Municipality of Kavre district is one of the biggest tertiary hospitals in Nepal. The hospital provides a wide range of preventive and curative services with a total of 336 nurses working actively in its 22 departments. The sample size was calculated using the Cochrane formula for estimation of proportion, n=z2pq/ d2, using a past prevalence of MSD among nurses at a 95% confidence interval (CI) and at a 5% margin of error. The MSD prevalence of 89.1% from a past study was taken for the estimation of sample size.23 The initial sample size was estimated at 149 nurses which was optimized to 165 after adjusting the 10% non-response rate. Nurses were selected randomly using a systematic random sampling technique. For this, every kth (336/149=2.74≈2.25) i.e. 3rd nurse from the provided sample frame was approached to be enrolled as a participant. The nurses who reported a prior history of medically diagnosed musculoskeletal problems before starting their job and nurses who were pregnant or had a child under two years of age were excluded from the study to control confounding and to assure the observed MSD is associated with the nature of their job. A self-administered questionnaire was used for data collection. The questionnaire used for data collection consisted of four sections including questions related to the socio-demographic profiles of the nurses, perceived stress scale,27 to measure job stress, questions related to ergonomic factors, and Standardized Nordic Questionnaire (SNQ)28 to measure musculoskeletal disorders.29 SNQ consists of diagrammatic marking of nine anatomical regions for precision. It also reports whether the discomfort has prevented the participants from doing their normal work and if they have consulted a physician during the last 12 months for their condition.28 The Nursing In- charge arranged a private place where the selected nurses were invited for orientation. The questionnaire was distributed and explained to the nurses, and their informed consent was acquired during the orientation. The nurses were allowed to fill out the questionnaire at their time of convenience. The anthropometric measurements (height and weight) of the selected nurses were also taken at the time of distribution of the questionnaire. It was ensured that the complete response for each of the questions was acquired from the participants before collecting all the questionnaires. Thus, a 100% response rate was achieved from 165 nurses. The collected data were entered and analyzed through Statistical Package for Social Sciences version 22. The data were summarized in terms of frequency and proportion. Pearson’s chi-square tests and binary logistic regression were performed to identify the factors associated with UMSD and LMSD at a 5% level of significance. The variables which were significant in bivariate analysis were subjected to multivariate analysis to assess the adjusted odds ratio. Crude odds ratio Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 377 (COR) has also been reported along with the adjusted odds ratio for those variables which were significant in bivariate analysis for each model. For the multivariate analysis, the Variance Inflation Factor (VIF) test was performed to check multi-collinearity among independent variables.30,31 The Hosmer-Lemeshow test (HL test) for goodness-of-fit was performed and Nagelkerke R square was reported. The study was ethically approved by the Institutional Review Committee of Manmohan Memorial Institute of Health Science (Registration no: MMIHS-IR 580) and the Institutional Review Committee of Kathmandu University School of Medical Sciences (Approval No: 33/2020). Written informed consent was obtained from all the participants before conducting the study and all the information was kept confidential. Results The prevalence of UMSD and LMSD experienced by the nurses in the past 12 months was found to be 86.1% and 66.1% respectively. Likewise, in the context of MSD experienced by nurses in the past week, 53.9% reported having UMSD, and 33.3% reported having LMSD. Lower back pain was the predominant MSD in the last 12 months at 75.8% followed by neck pain and upper back pain at 60.0% and 51.5% respectively (Table 1). Table 1: Prevalence of musculoskeletal disorders (n=165) Body region MSD in 12 months MSD in 7 days n (%) 95% CI n (%) 95% CI Neck Yes 99(60.0) 52.8-67.3 41(24.8) 20.0-31.4 No 66 (40.0) 32.7-47.2 124(75.2) 68.6-80.0 Shoulder Yes 75(45.5) 38.3-54.4 31(18.8) 12.2-26.1 No 90(54.5) 45.6-61.7 134(81.2) 73.9-87.8 Elbows Yes 12(7.3) 4.2-12.0 4(2.4) 0.6-4.8 No 153(92.7) 88.0-95.8 161(97.6) 95.2-99.4 Wrists/hands Yes 71(43.0) 36.4-50.3 27(16.4) 11.5-21.2 No 94(57.0) 49.7-63.6 138(83.6) 78.8-88.5 Upper back Yes 85(51.5) 44.9-59.8 37(22.4) 15.9-29.1 No 80(48.5) 40.2-55.1 128(77.6) 70.9-84.1 Lower back Yes 125(75.8) 68.6-81.8 69(41.8) 33.9-49.6 No 40(24.2) 18.2-31.4 96(58.2) 50.4-66.1 Hips/Thighs Yes 58(35.2) 27.5-42.9 26(15.8) 10.4-21.7 No 107(64.8) 57.1-72.5 139(84.2) 78.3-89.6 Knees Yes 64(38.8) 31.5-47.9 30(18.2) 13.3-24.8 No 101(61.2) 52.1-68.5 135 (81.8) 75.2-86.7 Ankles/Feet Yes 61(37.0) 29.2-44.2 32(19.4) 13.9-26.6 No 104(63.0) 55.8-70.8 133(80.6) 73.4-86.1 Overall UMSD Yes 142(86.1) 79.4-90.9 89(53.9) 45.6-61.7 No 23(13.9) 9.1-20.6 76(46.1) 38.3-54.4 Overall LMSD Yes 109(66.1) 58.9-74.3 55(33.3) 26.1-41.1 No 56(33.9) 25.7-41.1 110(66.7) 58.9-73.9 Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 378 Out of the total nurses who experienced low back pain in the past 12 months, a majority (62.4%) reported the pain has affected their daily activities, whereas, only less than a quarter (20.0%)consulted physicians for treatment. Likewise, only 16.1% of the nurses with chronic neck pain were consulting a physician for their condition while almost half (44.4%) reported that chronic neck pain has impacted their daily activities (Table 2). In bivariate analysis, general characteristics of the participants such as age, marital status, education, and BMI were not found to be significantly associated with UMSD. However, the participant’s age was found to be significantly associated with LMSD at a 5% level of significance (p<0.05) (Table 3). Table 2: Impact on daily activities due to MSDs in 12 months and physician consultation (n=165) Body regions Limit normal activities Consulted Physician Yes (%) No (%) Yes (%) No (%) Neck (n=99) 44 (44.4) 55 (55.6) 16 (16.1) 83 (83.9) Shoulder (n=75) 34 (45.3) 41 (54.7) 9 (12.0) 66 (88.0) Elbows (n=12) 6 (50.0) 6 (50.0) 0 (0.0%) 12 (100.0) Wrists/Hands (n=71) 32 (45.1) 39 (54.9) 5 (7.0) 66 (93.0) Upper back (n=85) 48 (56.5) 37 (43.5) 11 (13.0) 74 (87.0) Low back (n=125) 78 (62.4) 47 (37.6) 25 (20.0) 100 (80.0) Hips/thighs (n=58) 33 (56.9) 25(43.1) 6 (10.3) 52 (89.7) Knees (n=64) 31 (48.4) 33 (51.6) 11 (17.2) 53 (82.8) Ankles/Feet (n=61) 44 (44.4) 55 (55.6) 16 (16.1) 83 (83.9) Table 3: Association between general characteristics with UMSD and LMSD (n=165) Variable UMSD  (p- value) LMSD  (p- value) Yes (%) No (%) Yes (%) No (%) Age(years) <25 58(90.6) 6(9.4) 3.048 (0.218) 48(75.0) 16(25.0) 9.891 (0.007) 25 -30 65(85.5) 11(14.5) 51(67.1) 25(32.9) >30 19(76.0) 6(24.0) 10(40.0) 15(60.0) Marital status Married 62(86.1) 10(13.9) 0.000 (0.987) 42(58.3) 30(41.7) 3.402 (0.065) Single 80(86.0) 13(14.0) 67(72.0) 26(28.0) Education PCL nursing 124(86.1) 20(13.9) 0.002 (0.961) 96(66.7) 48(33.3) 0.185 (0.667) BSc nursing 18(85.7) 3(14.3) 13(61.9) 8(38.1) BMI Normal 93(86.1) 15(13.9) 0.413 (0.813) 76(70.4) 32(29.6) 4.575 (0.102) Underweight 13(81.2) 3(18.8) 7(43.8) 9(56.2) Overweight/Obese 36(87.8) 5(12.2) 26(63.4) 15(36.6) In the context of work-related factors, rest breaks during the day and work schedules were found to be associated with both UMSD and LMSD at p<0.05. Moreover, training in injury prevention, treating a large number of patients in a day, and job stress were found to have a statistically significant relationship with UMSD. Similarly, participants' work experience was found to be associated with LMSD (Table 4). In context of ergonomic factors, working in awkward or cramped positions, carrying/lifting/ moving heavy materials or equipment, performing same task repeatedly, and working in same position for long periods were found to be associated with UMSD at p<0.05. However, no association was found between LMSD and ergonomic factors (Table 5). Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 379 Table 4: Association between work-related factors with UMSD and LMSD (n=165) Variable UMSD  (p- value) LMSD  (p- value) Yes (%) No (%) Yes (%) No (%) Work experience < 5 years 91(85.0) 16(15.0) 7(12.1) 0.261 (0.610) 79(73.8) 28(26.2) 8.199 (0.004) ≥ 5 years 51(87.9) 30(51.7) 28(48.3) Work shift Rotation 121(85.8) 20(14.2) 0.049 (0.826) 97(68.8) 44(31.2) 3.231 (0.072) Fixed 21(87.5) 3(12.5) 12(50.0) 12(50.0) Training in injury prevention Yes 37(74.0) 13(26.0) 8.699 (0.003) 29(58.0) 21(42.0) 2.079 (0.149) No 105(91.3) 10(8.7) 80(69.6) 35(30.4) Treat large number of patients in a day No 26(74.3) 9(25.7) 5.134 (0.023) 20(57.1) 15(42.9) 1.576 (0.209) Yes 116(89.2) 14(10.8) 89(68.5) 41(31.5) Rest breaks during the daya Enough 31(72.1) 12(27.9) 9.458 (0.002) 21(48.8) 22(51.2) 7.695 (0.006) Not enough 111(91.0) 11(9.0) 88(72.1) 34(27.9) Assist patients at gait activities Rarely 47(82.5) 10(17.5) 0.943 (0.331) 37(64.9) 20(35.1) 0.051 (0.821) Frequently 95(88.0) 13(12.0) 72(66.7) 36(33.3) Work at or near your physical limits Rarely 57(85.1) 10(14.9) 0.091 (0.762) 43(64.2) 24(35.8) 0.178 (0.673) Frequently 85(86.7) 13(13.3) 66(67.3) 32(32.7) Work with confused/ agitated patients Rarely 34(79.1) 9(20.9) 2.369 (0.124) 24(55.8) 19(44.2) 2.723 (0.099) Frequently 108(88.5) 14(11.5) 85(69.7) 37(30.3) Work scheduleb Normal 18(72.0) 7(28.0) 4.856 (0.028) 12(48.0) 13(52.0) 4.287 (0.038) Overtime 124(88.6) 16(11.4) 97(69.3) 43(30.7) Job Satisfaction Satisfied 76(81.7) 17(18.3) 3.347 (0.067) 56(60.2) 37(39.8) 3.248 (0.072) Dissatisfied 66(91.7) 6(8.3) 53(73.6) 19(26.4) Job Stress Low stress 44(75.9) 14(24.1) 7.755 (0.005) 35(60.3) 23(39.7) 1.303 (0.254) Moderate/High Stress 98(91.6) 9(91.6) 74(69.2) 33(30.8) aRest breaks during the day: Enough ≥30 minutes, Not enough < 30 minutes bWork schedule: Normal ≤8 hours a day, Overtime >8 hours a day Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 380 Table 5: Association between Ergonomic Factors with UMSD and LMSD (n=165) Variable UMSD  (p- value) LMSD  (p- value) Yes (%) No (%) Yes (%) No (%) Work in awkward or cramped positions Rarely 53(79.1) 14(20.9) 4.550 (0.033) 41(61.2) 26(38.8) 1.192 (0.275) Frequently 89(90.8) 9(9.2) 68(69.4) 30(30.6) Lift or transfer dependent patients Rarely 53(81.5) 12(18.5) 1.828 (0.176) 41(63.1) 24(36.9) 0.426 (0.514 Frequently 89(89.0) 11(11.0) 68(68.0) 32(32.0) Carry, lift, or move heavy materials or equipment Rarely 32(74.4) 11(25.6) 6.571 (0.010) 26(60.5) 17(39.5) 0.812 (0.367) Frequently 110(90.2) 12(9.8) 83(68.0) 39(32.0) Repeated task Rarely 19(73.1) 7(26.9) 4.337 (0.037) 13(50.0) 13(50.0) 3.551 (0.060) Frequently 123(88.5) 16(11.5) 96(69.1) 43(30.9) Perform manual orthopedic techniques Rarely 38(79.2) 10(20.8) 2.682 (0.102) 29(60.4) 19(39.6) 0.962 (0.327) Frequently 104(88.9) 13(11.1) 80(68.4) 37(31.6) Work in the same position for long periods Rarely 45(77.6) 13(22.4) 5.354 (0.021) 39(67.2) 19(32.8) 0.056 (0.814) Frequently 97(90.7) 10(9.3) 70(65.4) 37(34.6 For multivariate analysis, the Variance Inflation Factor (VIF) test among the independent variables was performed where the highest reported VIF was 1.793so there was no issue of multi- collinearity. Nurses reporting moderate to higher job stress were found to have three times more odds (AOR: 3.621, 95% CI: 1.2-10.8) of experiencing UMSD as compared to nurses who reported lower job stress. Likewise, nurses reporting not having enough rest breaks had a four-fold increase in odds of UMSD (AOR: 4.657, 95% CI: 1.3-15.9) as compared to nurses who reported having enough rest breaks. The odds of UMSD were found 4.16 times higher (AOR: 4.163, 95% CI: 1.2-13.4) among nurses who reported working in the same position for a long duration of time. Similarly, nurses who did not receive training in injury prevention were thrice more likely to have UMSDs (AOR: 3.150, 95% CI: 1.0-9.2) in comparison to those who had received training. (Table 6). In the context of lower extremities musculoskeletal disorders, not having enough rest breaks during the day was found to increase the odds of LMSD among nurses by two folds (AOR:2.193, 95% CI:1.0-4.7) as compared to nurses reporting enough rest breaks while adjusting with all the associated factors (Table 7). Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 381 Table 6: Multivariate analysis for UMSD among the nurses (n=165) Variables COR 95%CI p-value AOR 95%CI p-value Work in awkward/ cramped positions Rarely Ref Ref Frequently 2.612 1.0-6.4 0.037 1.399 0.4-4.6 0.582 Carry/lift/ move heavy materials/ equipment Rarely Ref Ref Frequently 3.151 1.2-7.8 0.013 2.276 0.7-6.6 0.132 Repeated task Rarely Ref Ref Frequently 2.382 1.0-7.7 0.044 1.557 0.3-6.2 0.530 Work in the same position for long periods Rarely Ref Ref Frequently 2.802 1.1-6.8 0.024 4.163 1.2-13.4 0.017 Training in injury prevention Yes Ref Ref No 3.689 1.4-9.1 0.005 3.150 1.0-9.2 0.036 Treat large number of patients in a day Yes 2.868 1.1-7.3 0.028 1.155 0.3-3.8 0.815 No Ref Ref Work schedulea Normal Ref Ref Overtime 3.014 1.0-8.3 0.033 0.718 0.1-2.7 0.632 Rest breaks during the dayb Enough Ref Ref Not enough 3.906 1.5-9.7 0.003 4.657 1.3-15.9 0.014 Job Stress Low Ref Ref Moderate/High 3.465 1.3-8.6 0.007 3.621 1.2-10.8 0.022 Nagelkerker R Square 0.332; Hosmer Lemeshow Chi-square 5.449, p=0.709 CI: confidence interval, COR: Crude odds ratio, AOR: Adjusted odds ratio Table 7: Multivariate analysis for LMSD among the nurses (n=165) Variables COR 95%CI p-value AOR 95%CI p-value Age <25 4.500 1.6-11.9 0.003 2.100 0.6-7.1 0.234 25-30 3.060 1.2-7.7 0.019 1.943 0.6-5.4 0.210 >30 Ref Work experience <5 years 2.633 1.3-5.1 0.005 1.993 0.8-4.6 0.108 ≥5 years Ref Ref Work schedulea Normal Ref Ref Overtime 2.444 1.0-5.7 0.042 2.007 0.7-5.0 0.140 Rest breaks during the dayb Enough Ref Ref Not enough 2.711 1.3-5.5 0.006 2.193 1.0-4.7 0.048 Nagelkerker R Square 0.149; Hosmer Lemeshow Chi-square 6.411, p=0.379 CI: confidence interval, COR: Crude odds ratio, AOR: Adjusted odds ratio Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 382 Discussions A higher rate of UMSD and LMSD were observed among the nurses at 86.1% and 66.1% respectively. The finding is in line with the studies from India where the 12 months MSD among nurses was found to range between 81% to 89.2%.19,20 Similarly, a higher rate of MSDs was observed among nurses of both developing as well as developed nations such as Nigeria, Zimbabwe, Vietnam, and China where more than three- fourths of the nurses were found to have experienced any form of MSD in the past 12 months.9, 32-34 Furthermore, lower back pain, neck pain and upper back pain were the major forms of MSDs among nurses. The past studies from two of the major tertiary hospitals of Nepal; Sahid Gangalal National Heart Centre and Tribhuvan University Teaching Hospital revealed that 78% and 64.5% of the nurses experienced lower back pain.24,25 Despite a higher prevalence of these disorders among the nurses which has affected their daily activities, only a few of them sought treatment. A similar observation was seen in the study from Bangladesh where out of all nurses who experienced lower back pain only 36.2% reported seeking medical care for their condition.35 This indicates many of the nurses are troubled by musculoskeletal pain and discomfort which has heavily impacted their work efficiency but very few are seeking proper medical attention. The reason behind this poor health-seeking behavior among healthcare professionals needs to be further studied. These findings point to a significant and under-researched occupational health problem among Nepalese nurses. The ergonomic factors such as working in awkward/cramped positions, carrying heavy material and/or equipment, performing repeated actions, and working in the same positions for a long period were found to be associated with UMSDs in bivariate analysis. This is in line with the findings from past studies suggesting that working in the same position for a long time duration has been perceived to be a major contributor to work-related MSDs among the nursing population.9,36,37 Findings from past studies showed that working in awkward/cramped positions is significantly associated with MSDs among nurses.34,38 It was also noted that nurses not receiving enough rest during the day were four times more likely to experience UMSD and twice times more likely to experience LMSD as compared to nurses having enough rest. Similar to this finding, rest breaks were found to be a protective factor for MSDs in the studies from Saudi Arabia and China.34, 38 The positive association between rest breaks and MSDs has been observed in other occupations as well. For instance, a randomized control trial performed among agriculture workers noted the nature of rest breaks could significantly result in the alleviation of musculoskeletal pain in the neck, shoulder, back, and upper limbs.39 The continuous exertion of force and repeated movements could lead to inflammation and pain in body tissues resulting in reduced motor function, or muscle/bone discomfort and inducing risk of injuries. Thus, proper rest breaks during work should be ensured among nurses to prevent them from such discomforts and assure their efficiency. Training in injury prevention can be another crucial intervention to prevent MSD as the nurses who did not receive training in injury prevention were found to have three-fold higher odds of MSD. Similar observations were made by the study from Zimbabwe where ergonomic training was significantly associated with work-related musculoskeletal disorders among nurses (p<0.05).33 In line with current findings, studies suggest education and training on ergonomics and MSDs could be an effective intervention for MSD prevention among nurses.40-42 This finding emphasizes the importance of ergonomic training and MSD education. Hospitals should provide training for their employees to improve their injury prevention abilities and thereby lower the risk of MSDs. Thus, providing proper training and educational programs on MSDs targeting nurses and other health professionals might be a crucial strategy to reduce the risk of MSD in this vital health workforce. The nurses who reported experiencing moderate or high stress were thrice more at odds of experiencing UMSD as compared to nurses with a low level of stress. This is in line with past studies from China, Thailand, Uganda and Canada where a significant association between mental stress and musculoskeletal discomfort was observed among the nurses.14,21,34,43 Tension and stress cause muscle strain and hardness. Furthermore, anxious nurses are more likely to notice any form of discomfort that occurs in their body as a result of attending to negative thoughts when they self- report their MSDs.21 This finding suggests that hospitals should arrange recreational activities to reduce stress and anxiety among nurses to reduce the risk of experiencing MSDs. Despite being one of the few studies examining the prevalence and risk factors for MSDs among nursing population this study is not free from its Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 383 limitations. The information of MSDs is self- reported by the participants rather than medical diagnosis thus there are some chances of reporting bias though the study population was nurses. The study was conducted in one of the major tertiary hospitals of Nepal which might not provide a complete representation of all Nepalese nurses working in primary healthcare centers and/or small health units. However, the nurses selected in this study were working at different departments and wards of Dhulikhel Hospital so the diversity of the selected participants aids in the generalizability of the results. The findings of this study are expected to provide fruitful insights to the concerned stakeholders to focus on occupational health. Conclusion There is a high prevalence of MSDs among nurses which could impact the overall healthcare system. Working in the same position for a long duration, not receiving training in injury prevention, not having enough rest breaks, and job stress were the major factors found to be associated factors with musculoskeletal disorders among nurses. Thus, providing healthcare professionals with training related to injury prevention and educating them about ergonomics and posture could reduce their risk of MSDs. References 1. Bernard BP. A critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Musculoskeletal disorders and workplace factors. 1997. Available from: https://cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf. 2. Apeldoorn AT, Bosselaar H, Ostelo RW, Blom- Luberti T, van der Ploeg T, Fritz JM, et al. Identification of patients with chronic low back pain who might benefit from additional psychological assessment. The Clinical Journal of Pain. 2012;28(1):23-31. Available from: https://doi.org/10.1097/ajp.0b013e31822019d0 3. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990- 2013;2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396(10258):1204-22. Available from: https://doi.org/10.1016/S0140-6736(20)30925-9 4. World Health Organization. Musculoskeletal conditions Fact sheets 2021 [2021/10/17]. Available from: https://who.int/news-room/fact- sheets/detail/musculoskeletal-conditions. 5. Smith DR, Leggat PA. Musculoskeletal disorders among rural Australian nursing students. The Australian Journal of rural health. 2004;12(6):241-5. Available from: https://doi.org/10.1111/j.1440- 1854.2004.00620.x 6. Smith DR, Wei N, Ishitake T, Wang RS. Musculoskeletal disorders among Chinese medical students. The Kurume medical journal. 2005;52(4):139-46. Available from: https://doi.org/10.2739/kurumemedj.52.139 7. Warnakulasuriya SS, Peiris-John RJ, Coggon D, Ntani G, Sathiakumar N, Wickremasinghe AR. Musculoskeletal pain in four occupational populations in Sri Lanka. Occup Med (Lond). 2012;62(4):269-72. Available from: https://doi.org/10.1093/occmed/kqs057 8. Koyuncu N, Karcioglu Ö. Musculoskeletal complaints in healthcare personnel in hospital: An interdepartmental, cross-sectional comparison. Medicine (Baltimore). 2018;97(40):e12597-e. Available from: https://doi.org/10.1097/MD.0000000000012597 9. Tinubu BMS, Mbada CE, Oyeyemi AL, Fabunmi AA. Work-Related Musculoskeletal Disorders among Nurses in Ibadan, South-west Nigeria: a cross-sectional survey. BMC Musculoskeletal Disorders. 2010;11(1):12. Available from: https://doi.org/10.1186/1471-2474-11-12 10. Dawson AP, McLennan SN, Schiller SD, Jull GA, Hodges PW, Stewart S. Interventions to prevent back pain and back injury in nurses: a systematic review. Occup Environ Med. 2007;64(10):642-50. Available from: https://doi.org/10.1136/oem.2006.030643 11. Fronteira I, Ferrinho P. Do nurses have a different physical health profile? A systematic review of experimental and observational studies on nurses' physical health. Journal of clinical nursing. 2011;20(17-18):2404-24. Available from: https://doi.org/10.1111/j.1365-2702.2011.03721.x 12. Yassi A, Lockhart K. Work-relatedness of low back pain in nursing personnel: a systematic review. International Journal of Occupational and Environmental Health. 2013;19(3):223-44. Available from: https://doi.org/10.1179/2049396713y.0000000027 13. Silverstein BA, Fine LJ, Armstrong TJ. Occupational factors and carpal tunnel syndrome. American Journal of industrial medicine. 1987;11(3):343-58. Available from: https://doi.org/10.1002/ajim.4700110310 14. Munabi IG, Buwembo W, Kitara DL, Ochieng J, Mwaka ES. Musculoskeletal disorder risk factors among nursing professionals in low resource settings: a cross-sectional study in Uganda. BMC Nursing. 2014;13(1):7. Available from: https://doi.org/10.1186/1472-6955-13-7 15. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. Journal of electromyography and kinesiology : official journal https://cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf https://doi.org/10.1097/ajp.0b013e31822019d0 https://doi.org/10.1016/S0140-6736(20)30925-9 https://who.int/news-room/fact-sheets/detail/musculoskeletal-conditions https://who.int/news-room/fact-sheets/detail/musculoskeletal-conditions https://doi.org/10.1111/j.1440-1854.2004.00620.x https://doi.org/10.1111/j.1440-1854.2004.00620.x https://doi.org/10.2739/kurumemedj.52.139 https://doi.org/10.1093/occmed/kqs057 https://doi.org/10.1097/MD.0000000000012597 https://doi.org/10.1186/1471-2474-11-12 https://doi.org/10.1136/oem.2006.030643 https://doi.org/10.1111/j.1365-2702.2011.03721.x https://doi.org/10.1179/2049396713y.0000000027 https://doi.org/10.1002/ajim.4700110310 https://doi.org/10.1186/1472-6955-13-7 Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 384 of the International Society of Electrophysiological Kinesiology. 2004;14(1):13-23. Avaialble from: https://doi.org/10.1016/j.jelekin.2003.09.015 16. Buckle PW, Devereux JJ. The nature of work-related neck and upper limb musculoskeletal disorders. Applied ergonomics. 2002;33(3):207-17. Available from: https://doi.org/10.1016/s0003-6870(02)00014-5 17. March L, Smith EU, Hoy DG, Cross MJ, Sanchez- Riera L, Blyth F, et al. Burden of disability due to musculoskeletal (MSK) disorders. Best practice & research Clinical rheumatology. 2014;28(3):353-66. Avaialble from: https://doi.org/10.1016/j.berh.2014.08.002 18. Thinkhamrop W, Laohasiriwong W. Factors Associated with Musculoskeletal Disorders among Registered Nurses: Evidence from the Thai Nurse Cohort Study. Kathmandu University medical journal (KUMJ). 2015;13(51):238-43. Available from: https://doi.org/10.3126/kumj.v13i3.16815 19. Raithatha AS, Mishra DG. Musculoskeletal Disorders and Perceived Work Demands among Female Nurses at a Tertiary Care Hospital in India. International Journal of Chronic Diseases.;2016:5038381. Available from: https://doi.org/10.1155/2016/5038381 20. Smith DR, Kondo N, Tanaka E, Tanaka H, Hirasawa K, Yamagata Z. Musculoskeletal disorders among hospital nurses in rural Japan. Rural and remote health. 2003;3(3):241. Available from: https://pubmed.ncbi.nlm.nih.gov/15882100/ 21. Rathore FA, Attique R, Asmaa Y. Prevalence and Perceptions of Musculoskeletal Disorders Among Hospital Nurses in Pakistan: A Cross-sectional Survey. Cureus. 2017;9(1):e1001. Available from: https://doi.org/10.7759/cureus.1001 22. Warnakulasuriya S, Jone RP, Wickramasinghe AR, Sathiakumar N. Musculoskeletal disorders and associated factors among nurses in Sri Lanka. Journal of Epidemiology and Community Health. 2011;65(Suppl 1):A372-A. Available from: https://doi.org/10.1136/jech.2011.142976m.74 23. Anap D, Iyer C, Rao K. Work related musculoskeletal disorders among hospital nurses in rural Maharashtra, India: A multi-center survey. International Journal of Research in Medical Sciences. 2013;1:101-7. Available from: https://msjonline.org/index.php/ijrms/article/view/2 568 24. Adhikari S, Dhakal G. Prevalent Causes of Low Back Pain and its Impact among Nurses Working in Sahid Gangalal National Heart Centre. Journal of Nepal Health Research Council. 2014;12(28):167-71. Available from: https://pubmed.ncbi.nlm.nih.gov/26032053/ 25. Gautam CJ, Shrestha N, Shrestha P, Neupane S. Prevalence And Contributing Factors Of Low Back Pain Among Nurses In Tertiary Level Hospital. Journal of Gandaki Medical College-Nepal. 2019;12:46-52. Available from: https://doi.org/10.3126/jgmcn.v12i2.27172 26. Manandhar N, Subedi S. Prevalence and risk factors of low back pain among nurses of a medical college at Bharatpur, Nepal. Scirea J Health. 2016;1(1):1-10. Available from: http://article.scirea.org/pdf/33000.pdf 27. Cohen S. Perceived stress in a probability sample of the United States. The social psychology of health. The Claremont Symposium on Applied Social Psychology. Thousand Oaks, CA, US: Sage Publications, Inc.1988;31-67. Available from: https://cmu.edu/dietrich/psychology/stress- immunity-disease-lab/scales/pdf/cohen,-s.-- williamson,-g.-1988.pdf 28. Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen F, Andersson G, et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Applied ergonomics. 1987;18(3):233-7. Available from: https://doi.org/10.1016/0003-6870(87)90010-x 29. Shakya N, Shrestha S. Prevalence of work related musculoskeletal disorders among canteen staff of Kathmandu University. Journal of Kathmandu Medical College. 2018;7:162-7. Available from: https://doi.org/10.3126/jkmc.v7i4.23318 30. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate data analysis. 6th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2006. Available from: https://www.scirp.org/(S(351jmbntvnsjt1aadkposzj e))/reference/ReferencesPapers.aspx?ReferenceID=1 385913 31. Kutner MH, Nachtsheim CJ, Neter J, Li W. Applied linear statistical models. 5th ed. New York: McGraw-Hill; 2005. Available from: https://scirp.org/reference/ReferencesPapers.aspx?R eferenceID=1678785 32. Luan HD, Hai NT, Xanh PT, Giang HT, Van Thuc P, Hong NM, et al. Musculoskeletal Disorders: Prevalence and Associated Factors among District Hospital Nurses in Haiphong, Vietnam. 2018;2018:3162564. Available from: https://doi.org/10.1155/2018/3162564 33. Chiwaridzo M, Makotore V, Dambi JM, Munambah N, Mhlanga M. Work-related musculoskeletal disorders among registered general nurses: a case of a large central hospital in Harare, Zimbabwe. BMC Research Notes. 2018;11(1):315. Available from: https://doi.org/10.1186/s13104-018-3412-8 34. Dong H, Zhang Q, Liu G, Shao T, Xu Y. Prevalence and associated factors of musculoskeletal disorders among Chinese healthcare professionals working in tertiary hospitals: a cross-sectional study. BMC Musculoskeletal Disorders. 2019;20(1):175. Available from: https://doi.org/10.1186/s12891-019- 2557-5 35. Sanjoy SS, Ahsan GU, Nabi H, Joy ZF, Hossain A. https://doi.org/10.1016/j.jelekin.2003.09.015 https://doi.org/10.1016/s0003-6870(02)00014-5 https://doi.org/10.1016/j.berh.2014.08.002 https://doi.org/10.3126/kumj.v13i3.16815 https://doi.org/10.1155/2016/5038381 https://pubmed.ncbi.nlm.nih.gov/15882100/ https://doi.org/10.7759/cureus.1001 https://doi.org/10.1136/jech.2011.142976m.74 https://msjonline.org/index.php/ijrms/article/view/2568 https://msjonline.org/index.php/ijrms/article/view/2568 https://pubmed.ncbi.nlm.nih.gov/26032053/ https://doi.org/10.3126/jgmcn.v12i2.27172 http://article.scirea.org/pdf/33000.pdf https://cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/pdf/cohen,-s.--williamson,-g.-1988.pdf https://cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/pdf/cohen,-s.--williamson,-g.-1988.pdf https://cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/pdf/cohen,-s.--williamson,-g.-1988.pdf https://doi.org/10.1016/0003-6870(87)90010-x https://doi.org/10.3126/jkmc.v7i4.23318 https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?ReferenceID=1385913 https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?ReferenceID=1385913 https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?ReferenceID=1385913 https://scirp.org/reference/ReferencesPapers.aspx?ReferenceID=1678785 https://scirp.org/reference/ReferencesPapers.aspx?ReferenceID=1678785 https://doi.org/10.1155/2018/3162564 https://doi.org/10.1186/s13104-018-3412-8 https://doi.org/10.1186/s12891-019-2557-5 https://doi.org/10.1186/s12891-019-2557-5 Karki et al. Prevalence & Factors Associated with Occupational Musculoskeletal Disorders among the Nurses of a Tertiary Care Center of Nepal 385 Occupational factors and low back pain: a cross- sectional study of Bangladeshi female nurses. BMC Res Notes. 2017;10(1):173. Available from: https://doi.org/10.1186/s13104-017-2492-1 36. Pleho D, Mačak Hadžiomerović A, Pleho K, Pleho J, Remić D, Arslanagić D, et al. Work Caused Musculoskeletal Disorders in Health Professionals. Journal of Health Sciences. 2021;11(1):7-16. Available from: https://doi.org/10.17532/jhsci.2021.1209 37. Yasobant S, Rajkumar P. Work-related musculoskeletal disorders among health care professionals: A cross-sectional assessment of risk factors in a tertiary hospital, India. Indian J Occup Environ Med. 2014;18(2):75-81. Available from: https://doi.org/10.4103/0019-5278.146896 38. Alwabli Y, Almatroudi MA, Alharbi MA, Alharbi MY, Alreshood S, Althwiny FA. Work-Related Musculoskeletal Disorders Among Medical Practitioners in the Hospitals of Al'Qassim Region, Saudi Arabia. Cureus. 2020;12(5):e8382. Available from: https://doi.org/10.7759/cureus.8382 39. Stock SR, Nicolakakis N, Vézina N, Vézina M, Gilbert L, Turcot A, et al. Are work organization interventions effective in preventing or reducing work-related musculoskeletal disorders? A systematic review of the literature. Scandinavian journal of work, environment & health. 2018;44(2):113-33. Available from: https://doi.org/10.5271/sjweh.3696 40. Brisson C, Montreuil S, Punnett L. Effects of an ergonomic training program on workers with video display units. Scandinavian journal of work, environment & health. 1999;25(3):255-63. Available from: https://doi.org/10.5271/sjweh.432 41. Garg A, Kapellusch JM. Long-term efficacy of an ergonomics program that includes patient-handling devices on reducing musculoskeletal injuries to nursing personnel. Human factors. 2012;54(4):608- 25. Available from: https://doi.org/10.1177/0018720812438614 42. Clari M, Garzaro G, Di Maso M, Donato F. Upper Limb Work-Related Musculoskeletal Disorders in Operating Room Nurses: A Multicenter Cross- Sectional Study. 2019;16(16). Available from: https://doi.org/10.3390/ijerph16162844 43. Murray E, Franche RL, Ibrahim S, Smith P, Carnide N, Côté P, et al. Pain-related work interference is a key factor in a worker/workplace model of work absence duration due to musculoskeletal conditions in Canadian nurses. Journal of occupational rehabilitation. 2013;23(4):585-96. Available from: https://doi.org/10.1007/s10926-012-9408-7 https://doi.org/10.1186/s13104-017-2492-1 https://doi.org/10.17532/jhsci.2021.1209 https://doi.org/10.4103/0019-5278.146896 https://doi.org/10.7759/cureus.8382 https://doi.org/10.5271/sjweh.3696 https://doi.org/10.5271/sjweh.432 https://doi.org/10.1177/0018720812438614 https://doi.org/10.3390/ijerph16162844 https://doi.org/10.1007/s10926-012-9408-7