International Journal of

Environmental Research
and Public Health

Article
Prevalence of Work-Related Musculoskeletal Disorders:
Psychological and Physical Risk Factors
K. Saraswathi Krishnan 1 , Gunasunderi Raju 1, * and Omar Shawkataly 2

1 School of Distance Education, Universiti Sains Malaysia, Gelugor 11800, Malaysia; [email protected]
2 UniKL MICET Lot 1988, Kawasan Perindustrian Bandar Vendor, Taboh Naning, Alor Gajah 78000, Malaysia;
[email protected]
* Correspondence: [email protected]

Abstract: Purpose—This study aimed to estimate the prevalence and risk factors of MSD pain
in various anatomical regions among nurses. Method—A cross-sectional study involving a self-
administered questionnaire by registered nurses with clinical experience. Data was collected using
convenience sampling after obtaining informed consent. The results were drawn from a total of
300 nurses. Results—The nurses presented with occasional mental exhaustion (44.3%) and often
physical exhaustion (44.0%). Almost all (97.3%) the nurses complained of having work-related pain
during the last 12 months. Body parts with the most pain were the lower back (86.7%), ankles (86.7%),
neck (86.0%), shoulders (85.0%), lower legs (84.7%) and upper back (84.3%). The pain frequency was
rated as occasional pain for the neck and upper back, pain was often felt for the rest of the parts.
Nurses complained of severe pain in the lower back (19.7%), right shoulder (29.7%) and left shoulder
(30.3%). The frequency of having musculoskeletal symptoms in any body region was increased with



age, lower education level, female gender, high BMI, job tenure and lifestyle. Conclusions—Nurses’

 WRMSD complaints should be taken seriously to curb further risk and musculoskeletal hazards.
Citation: Krishnan, K.S.; Raju, G.;
Shawkataly, O. Prevalence of Keywords: prevalence works related musculoskeletal disorders; psychological risk factors; physical
Work-Related Musculoskeletal factors; nursing
Disorders: Psychological and Physical
Risk Factors. Int. J. Environ. Res. Public
Health 2021, 18, 9361. https://doi.org/
10.3390/ijerph18179361 1. Introduction
WRMSDs are the largest contributors to the occupational disease burden and are
Academic Editor: Paul B. Tchounwou
largely related to ergonomic factors found in the workplace [1]. The World Health Organi-
zation (WHO) reported that musculoskeletal conditions are the most common causes of
Received: 5 August 2021
Accepted: 1 September 2021
disability and limitation related to daily living and gainful employment [2].
Published: 4 September 2021
As evidenced in a variety of ergonomic studies, the workplace has not adapted to
the changing technological advances [3]. Developed countries, such as United States,
Publisher’s Note: MDPI stays neutral
Sweden, United Kingdom and Japan, are quite concerned about safety and health since
with regard to jurisdictional claims in
they significantly contribute to the productivity of human resources, which has an impact
published maps and institutional affil- on a country’s economy. The issue of safety and health has become the main agenda to
iations. ensure a safe working environment and does not pose a risk to employees. These risks lead
to employees working in environments that are not comfortable and therefore contribute
to the high burden of WRMSDs. In studies performed in the Indian and Portuguese
populations, results were obtained showing a higher prevalence of WRMSDs in the nursing
Copyright: © 2021 by the authors.
workers [4,5].
Licensee MDPI, Basel, Switzerland.
Nurses are in great demand in most countries, regardless of whether it be for a devel-
This article is an open access article
oped country, such as the United States, or a developing country, such as Malaysia. Based
distributed under the terms and on the reviewed healthcare research, the demand for nursing jobs increased simultaneously
conditions of the Creative Commons with the population in Malaysia [6]. The statistics indicate that more than 70% of the
Attribution (CC BY) license (https:// hospitals in Malaysia do not have enough nursing staff [7].
creativecommons.org/licenses/by/ Long working hours with inadequate staffing (shortage) increase nurses’ risk of
4.0/). developing conditions, such as musculoskeletal disorder, hypertension and depression.

Int. J. Environ. Res. Public Health 2021, 18, 9361. https://doi.org/10.3390/ijerph18179361 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 9361 2 of 11

Working under physical overload due to long work hours and patient handling
demands leads to a high risk of developing WRMSDs [8]. Job demand is directly related
to MSD development among nurses [9]. It was reported that manual patient handling is
the main contribution toward WRMSDs among nurses working in hospitals [10]. Female
nurses are more liable to endure WRMSDs, as they are also fulfilling responsibilities after
work, including taking care of children and house chores, with insufficient rest time and
a lack of exercise. Women were seen 2.1 times more often for the development of MSDs
than men [11]. In general, WRMSDs hamper the working efficiency of nurses, which has
an impact on patient safety in clinical practice. Due to the increasing cases of MSDs and
job burnout among employees, especially among nurses, a study of the ergonomic aspects
and WRMSDs toward job performance is crucial to estimate the prevalence and risk factors
of MSDs among nurses.

1.1. Work-Related Musculoskeletal Disorders

Musculoskeletal disorders (MSDs) were identified as work-related diseases from
the time of Ramazzini in the 18th century, who described classical cases of such injuries
in his book [12]. Musculoskeletal disorders (MSDs) are further classified as specific or
non-specific disorders. Specific musculoskeletal disorders have clear clinical features,
whereas non-specific musculoskeletal disorders present with pain without evidence of a
clear specific disorder. WRMSDs are known by many terms and are used interchangeably,
such as repetitive motion injuries (RMIs), cumulative trauma disorders (CTDs), repetitive
strain injuries (RSIs), overuse syndrome, regional musculoskeletal disorders and soft tissue
disorders (STDs) [13].

1.2. Prevalence, Nurses and Work-Related Musculoskeletal Disorders (MSDs)

Nursing is ranked as the top occupation among all the professions that have the
potential to develop MSDs, with the highest prevalence rate of MSDs in the world [14].
According to the World Health Organization (WHO), the issues of WRMSDs become worse
when nurses’ daily working activities become hectic [15]. This is because this occupation
has the most physically demanding jobs that involve excessive manual handling of patients
and sometimes awkward postures during tasks [16]. Nurses’ work-related musculoskeletal
symptoms vary depending on the wards, the hospital and even the countries they work
in [4,17], which appear to be related to many different nursing occupational exposures to
WRMSDs hazards.
The body regions with the greatest prevalences of WRMSDs are the low back, neck,
shoulders, knees, forearms, hands and ankles/feet, although recently, the lower extremities
have received more attention. MSDs may involve the upper or lower extremities and
the trunk.
Studies have documented a higher annual prevalence of musculoskeletal disorders
(MSDs) in at least one human body part and/or region that varied between 40 and 95% in a
population of Asian nurses, and in Western populations, the low back, neck and shoulders
are the most significantly affected body parts, with prevalences of 29–64%, 34–63% and
17–75%, respectively [13,18]. In contrast, a narrative literature review conducted on MSDs
over the last 12 months among female nurse personnel showed that the knee and ankle/foot
regions were most affected by MSDs. In the knees, the prevalence of MSDs ranged between
7.5 and 77%, and in the ankles, between 3.2 and 100%. The prevalence of MSDs in the lower
legs (the shins) varied between 8.5 and 10.5%, and in the thigh/hip area, the prevalence
range was 11–100% [19].

1.3. Psychosocial Factors

Psychosocial factors at work refer to interactions between the work environment,
job content, organizational conditions and the workers’ capacities, needs, culture and
personal extra-job considerations that may influence their health, work performance and
job satisfaction. Nurses may need to face different types of difficulties during their work
Int. J. Environ. Res. Public Health 2021, 18, 9361 3 of 11

that contribute toward WRMSDs, including stress, issues with patients, issues with man-
agement and doctors [5]. A study revealed that nurses’ experiences of musculoskeletal
pain are mostly related to psychosocial factors. It seems there was a positive relationship
between somatic stress symptoms, including stomachache, headache, palpitations and
musculoskeletal discomfort or pain. A study [20] related to psychosocial factors revealed
that participants with at least one WRMSD in any of their body segments reported that they
were not satisfied with their occupation and that there was a lack of cooperation between
staff, poor nurse–physician interaction and a lack of support from immediate supervisors.

1.4. Physical Factors

Physical risk factors for WRMSDs include forces, repetition, vibrations and awk-
ward postures. Patient handling tasks were documented as major contributing factors for
WRMSDs among nursing staff. Many physical factors affect the health of nurses when
performing their tasks in the hospital environment. The perceived physical demands that
are commonly experienced by nurses include moving objects pulling/pushing machines,
lifting patients, recurring motions and extreme flexion, bending, twisting and sudden
movements [21]. These physical demands increased the risk of complaints in different
body regions [18,22,23]. Other factors that are related to MSDs were being in standing
positions for a prolonged time and awkward postures (during transferring patients from
one location and to bed again) [24].

1.5. Conceptual Framework

The conceptual framework was developed based on a review of the literature, which
was intended to be used as a guide.

2. Methods
This study employed a cross-sectional study to measure the outcome (MSD pain/
discomfort) and any attribute, characteristic or exposure the nursing population experi-
ences that increase the likelihood of developing work-related musculoskeletal disorders
(WRMSDs). The presence or absence of both the exposure and the outcome (MSD pain)
were determined at the same time point. The selected participants for the study were
assessed for their exposures and outcomes by the investigator. The study was conducted
at Hospital Sultan Abdul Halim (HSAH), Sungai Petani Kedah, Malaysia. The sampling
frame for the study was drawn from all female registered nurses working in normal
in-patient wards.
The selection of subjects for the study population was based on inclusion and exclusion
criteria. Based on published material by [13], the prevalence of work-related musculoskele-
tal disorders (WRMSDs) among nurses was reported as being 73% (0.73). Using a statistical
significance α of 0.05 [25], a power of 0.80 [26], precision at 0.05 and estimated prevalence
of WRMSDs as 73% for an unknown population size, 303 nurses was the required sample
size. Assuming an additional 10% to account for the drop-out rate, the total number of
nurses required in the sample was 334. The sample size was estimated using a sample size
calculation for a prevalence study without a finite population correction.
The study employed convenience sampling, where the sample for the study was
obtained from six wards where the registered nurses (RNs) were working in in-patient
wards with non-office hours. A total of 55 questionnaires were delivered to each ward by a
researcher according to an arranged date and time frame that was agreed to by each ward
nursing manager with hospital authority consent. The unit managers were contacted via
a direct visit to the unit, WhatsApp and a direct telephone call at least twice weekly as a
gentle reminder of the questionnaires.
The survey was carried out within 2–4 weeks’ time with a minimum of 2–3 visits to
each unit (to the ward nursing manager’s office) upon official approval from the relevant
authority. Each participant needed 15–20 min to complete the questionnaire. In this study,
quantitative data were collected through questionnaire surveys. The survey questionnaire
Int. J. Environ. Res. Public Health 2021, 18, 9361 4 of 11

had 4 types of questionnaire instruments in English and a patient information sheet with
an informed consent form. A pre-test was conducted among 50 registered nurses (RNs)
who were working an office hours schedule (8 a.m.–5 p.m.) at the same hospital using
an adapted questionnaire. The pre-test allowed the researchers to evaluate the content
validity, feasibility and time requirements. Some small adaptations to the questionnaire
were applied to improve the questions’ clarity and understanding. Data were analyzed
using SPSS software version 13 (IBM, Armonk, NY, USA). Descriptive statistics, such as
the frequencies, percentages, mean and standard deviations, were used to describe the
Int. J. Environ. Res.demographic
Public Health 2021,
and18, work-related
x data. 5
Chi-square and logistic regression were used to determine the associations between
some of the study variables and reported MSDs. The MSDs were assumed to be the
the workplace dependent
factors were variables.
definedDemographic
as independentcharacteristics and some
variables, as shown of the
in Figure 1. workplace
A p-value <factors
0.05 was
were defined as independent variables, as shown in Figure 1. A p-value < 0.05 was
considered significant.
considered significant.

Figure 1. Conceptual framework.

3. Results
Figure 1. Conceptual framework.
In total, 303 questionnaires were distributed, and 300 nurses gave their consent to
participate in the study; therefore, the response rate was 99.0%. Table 1 below shows the
3. Results demographic information of the respondents.

Table 1. Socio-demographic characteristics.

In total, 303 questionnaires were distributed, and 300 nurses gave their consent to participate in the study; there
Variables
the response rate was 99.0%. Frequency information of Percentage
Table 1 below shows the demographic the respondents.
Female 300 100.0
Age group
23–29 years 40 13.3
30–39 years
Table 1. Socio-demographic
187
characteristics. 62.3
40–49 years 57 19.0
50–55 years Variables 16 Frequency Percentage
5.3
Academic qualification
Diploma
Female 281
300 100.0
93.7
Degree Age group19 6.3
23–29studies
Currently pursuing higher years 40 13.3
Yes 142 47.3
No 30–39 years 158 187 62.3
52.7
Married 40–49 years 252 57 19.0
84.0
No child 50–55 years 72 16 28.65.3
Single child 25 9.9
Academic qualification
Diploma 281 93.7
Degree 19 6.3
Currently pursuing higher studies
Yes 142 47.3
Int. J. Environ. Res. Public Health 2021, 18, 9361 5 of 11

Table 1. Cont.

Variables Frequency Percentage

2 children 59 23.4
3 children 51 20.2
4 children 34 13.5
5 children 10 4.0
6 children 1 0.4
Single 16 5.3
Widow 8 2.7
Separated/divorced 24 8.0
Job tenure
Less than 3 months 3 1.00
3 months to 1 year 7 2.33
1 year to 5 years 41 13.67
5 years to 10 years 117 39.00
More than 10 years 132 44.00
BMI (WHO classification) (kg/m2 )
Underweight (<18.5) 14 4.7
Normal (18.5–24.9) 136 45.3
Overweight (25–29.9) 102 34.0
Obese (30 and above) 48 16.0
BMI (Asia–Pacific classification) (kg/m2 )
Underweight (<18.5) 14 4.7
Normal (18.5–22.9) 83 27.7
Overweight (23–24.9) 53 17.7
Obese (25 and above) 150 50.0

3.1. Demographic Factors

The majority (187, 62.3%) of the respondents were 30–39 years old, indicating that
most of the nurses were young. As per the WHO cut-offs for BMI, 136 (45.3%) nurses had a
normal weight (BMI 18.5 to 24.9 kg/m2 ), meanwhile based on the Asia–Pacific cut-offs for
BMI, 150 (50.0%) were classified as obese (BMI ≥ 25 kg/m2 ), as shown in Table 1 above.
Surprisingly, 34% (102) of the nurses were classified as overweight (BMI 25–29.9 kg/m2 )
and 16% (48) were obese (BMI ≥ 30 kg/m2 ) based on the WHO guidelines, compared to
17.7% (53) of nurses who were overweight (BMI 23.0–24.9 kg/m2 ) and 50% (150) who were
obese (BMI ≥ 25 kg/m2 ) based on the Asia–Pacific guidelines.
The majority (281, 93.7%) of nurses possessed a diploma in nursing, while 6.3% had
a bachelor’s degree in nursing. In addition, 47.3% (142 nurses) were currently pursuing
higher study part-time and the rest (52.7%) of the nurses remained at their previous
academic qualifications. Regarding the years of experience, 39.0% (117 nurses) of the
respondents had 5–10 years and 44.0% (132 nurses) had more than 10 years of nursing
experience in public health services. The job tenure of a majority (83%) of the nurses was
more or equivalent to 5 years of service.

3.2. Prevalence Findings Regarding WRMSDs for Different Body Regions

The self-reported prevalence rates (%) of musculoskeletal complaints or discomfort for
13 different parts of the body over 12 months among hospital nurses are shown in Table 2.
More than three-quarters of the respondents had experienced symptoms in the lower back
(86.7%), ankle/feet (86.7%), neck (86.0%), shoulder (85.3%), lower legs (85.0%), upper back
(84.3%), knees (77.3%) and thighs (73.7%) in the previous 12 months. Moderate prevalence
(less than 70%) of trouble was found for hip (66.0%) and forearm pain (61.7%). The
parts of the body with lower prevalences of musculoskeletal complaints were wrist/hand
(63.0%) and elbow (55.0%) discomfort/pain. In view of the prevalence rates, WRMSDs were
estimated based on the pain occurrence frequency and intensity or degree of pain frequency
at 13 body regions of the 300 participant nurses in the survey. The authors decided to
focus on the top six body regions with a high prevalence (>80.0%) rate of WRMSDs for the
Int. J. Environ. Res. Public Health 2021, 18, 9361 6 of 11

analysis of the risk factor results. A high number of nurses (97.3%) complained of having
work-related musculoskeletal pain during the previous 12 months.

Table 2. Prevalence of WRMSDs.

Proportion Confidence Interval

No. Body Regions No. (Proportion)
(95% CI)
1. Lower back 260 (86.7%) 82.8–90.5%
2. Ankles/feet 260 (86.7%) 82.8–90.5%
3. Neck 258 (86.0%) 82.1–89.9%
4. Shoulders 256 (85.3%) 81.3–89.4%
6. Lower legs 255 (85.0%) 80.9–89.1%
7. Upper back 253 (84.3%) 80.2–88.5%
8. Knees 232 (77.33%) 72.6–82.1%
9. Thighs 221 (73.7%) 68.7–78.7%
10. Hips 198 (66.0%) 60.6–71.4%
11. Wrist/hand 189 (63.0%) 57.5–67.2%
12. Forearms 185 (61.7%) 56.1–67.2%
13. Elbows 165 (55.0%) 49.3–60.7%

Psychosocial Factor
The overall percentage of scoring value for the 14 scales of psychosocial factors (COP-
SOQ II), which consisted of the six main combined domains, were interpersonal relations
and leadership (64.9%), work organization and job content (63.0%), work–individual inter-
face (53.1%), values at the workplace (51.9%), health and well-being (48.7%) and demands
at work (44.9%); these are shown in Figure 2 for the 300 nurse participants in the study. The
work-related psychosocial factors with the highest scores (75.4, 71.7 and 64.5 on a 100-point
scale) were meaningful work, followed by role clarity and job satisfaction respectively. The
Int. J. Environ. Res. Public Health 2021, 18, x 8 of 15
lowest scores (40.7 and 41.5 on a 100-point scale) were recorded for emotional demands
and work–life conflicts among the participants, respectively.

Figure 2. COPSOQ II results with 14 scales of psychosocial scoring for the nursing population.

Figure 2. COPSOQ II results with 14 scales of psychosocial scoring for the nursing population.

The nurse participants from Hospital Sultan Abdul Halim (HSAH) had a better psychosocial working environment
in terms of the meaning of work, role clarity, job satisfaction and possibilities for development and only in terms of
Int. J. Environ. Res. Public Health 2021, 18, 9361 7 of 11

The nurse participants from Hospital Sultan Abdul Halim (HSAH) had a better
psychosocial working environment in terms of the meaning of work, role clarity, job
satisfaction and possibilities for development and only in terms of emotional demands and
work–life conflicts was the psychosocial working situation worse for them.
A high prevalence rate of lower back pain was obtained from research by Sheikzadeh
et al. [27], who reported 84.0%, and Mirmohammadi et al. [28] reported an 89.1% preva-
lence rate of lower back among nurses in Isfahan, Iran. This may have been because of
bending/twisting the back in awkward ways, standing for long hours when treating a
large number of patients, inadequate breaks and lifting/transferring dependent patients.
The lower back pain had a uniquely high prevalence rate among body parts; this high
prevalence is common in nurses because of risk factors that they are exposed to, work-
ing in various environments and the job demands (psychosocial risk factors), such as
stress [29–31].

3.3. Assessment of Occupational Job Tasks

Table 3 shows the percentages of the risk levels obtained based on the HIRARC 2008
in terms of the studied occupational job tasks among the nurses. More than 280 nurses
(93%) were found to be at a medium risk level. These scores were obtained from an analysis
of the job tasks listed in Table 4. These job tasks fell in the medium risk level as most of the
participants nurses experienced a maximum level of discomfort (>20%) and sprain/strain
symptoms (>23%) when a force was exerted on the body during job performance. The
symptoms assessment from the work task were listed as no pain, pain, excess fatigue,
sprain and strain, injury, discomfort and other symptoms by the participants to produce
the risk level. The scores were obtained from job tasks such as sponging, dressing, pushing
a bed, patient bed transfer and helping a patient walk. These job tasks required a maximum
level of force to carry out, such as patient bed transfer, where the nurses needed to manually
lift the patients, which included obese patients, who required more force to transfer them.
The relative risk values fell within the medium category, as shown in Table 3 for all listed
perceived job risk factors causing WRMSDs among nurses during their hospital duties.
This requires a planned approach to controlling the hazards, including applying temporary
measures if required.

Table 3. List of job tasks undertaken by nurses at the hospital with their WRMSD symptom frequencies.

No. Job Task Frequency Percentage

1. Repetitive motion
No risk 8 2.67
2. Body vibration
No risk 22 7.3
Medium risk 278 92.67

Table 4. Risk assessment based on the HIRARC guidelines [32].

No. Effects Based on Hazards during Job Task Frequency Percentage

1. Repetitive motion
No pain 8 2.67
Pain 60 20.00
Excess fatigue 48 16.00
Sprain and strain 64 21.33
Injury 26 8.67
Discomfort 65 21.67
Others 29 9.67
Int. J. Environ. Res. Public Health 2021, 18, 9361 8 of 11

Table 4. Cont.

No. Effects Based on Hazards during Job Task Frequency Percentage

2. Whole-body vibration
No pain 22 7.33
Pain 63 21.00
Excess fatigue 37 12.33
Sprain and strain 59 19.67
Injury 9 3.00
Discomfort 67 22.33
Others 43 14.33

4. Discussion
The high prevalence of MSDs among the nurses, particularly (97.3%) in this study, is
worrisome as it may mean that the healthcare facility control measures against the risks
of acquiring MSDs remain critical. This is also a grave concern because MSDs are the
main contributing factors for an early exit from work and represent the most common
cause of absenteeism among healthcare workers [33]. This finding is similar to a study
done by Singh et al. [24], where the most common site affected was the lower back (36%),
followed by the ankles/feet (26%), the neck (10%) and shoulders (8%). Another study done
by Attar [34], in line with the present analysis results, found lower back and ankle/feet
discomfort (88.7%), followed by neck (86.0%) and shoulder discomfort (85.3%), among the
studied nursing population. The current study attempted to explore this association, which
was significantly associated with the medical department, where nurses were more likely to
have higher odds of upper back WRMSDs than nurses working in other departments. This
study indicated that the physical workload varies between nurses depending on the nature
of their wards and the variety of their task demands, which can consequently be specified
as the frequency and duration of exposure to extreme postures. As shown in this research,
most of the study participants were exposed to frequent high-risk and complex tasks,
although the portion of time spent in extreme postures varied according to their wards.
This may not be considered surprising given the variety of physically demanding tasks that
are given to hospital nurses when undertaking their routine activities. Nurses from SCN
(pediatrics) and orthopedic wards were less likely (lower odds) (OR: 0.13, 95% CI: 0.33–0.55,
p = 0.006 and OR: 0.20, 95% CI: 0.05–0.87, p = 0.031, respectively) to have upper back pain
as compared to nurses in the medical ward. The results indicated that awkward posture
and increased physical workload among nurses working in the medical, orthopedic and
pediatrics wards was generally higher than for other participants. According to [35], nurses
working in the emergency department showed the highest prevalence of WRMSDs among
nurses since they were involved in frequent lifting and pushing in the clinical practice.
In another supportive study regarding the effect of the department/ward, operation
room nurses had the highest (74.3%) prevalence rate WRMSDs in terms of discomfort
incidence because of the peculiarity of the job tasks undertaken throughout the surgery
process [33]. Some epidemiologic studies indicated an association between occupational
factors and WRMSDs. Further, some reported that the prevalence and location of pain,
along with other symptoms, can be related to the standing posture, work habits and
other demographic characteristics [36]. Logistic regression analysis revealed a significant
relationship between job tenure and pain in the ankles/feet, neck, shoulders and lower
legs (p < 0.05). In other studies, the rate of WRMSDs significantly increased with increasing
work experience, which is similar to the results obtained in our study [5].
Nurses working for more than seven hours per day for continuous six days (>42 h)
were less likely (lower odds) to have lower back and shoulder pain as compared to those
who worked for six days at seven hours per day (42 h) in the current study, which is
consistent with the result of Koohpayehzadeh et al. [37] for shoulder pain in 512 nursing
personnel in the Iran Medical University of Medical Sciences in Tehran and the findings
Int. J. Environ. Res. Public Health 2021, 18, 9361 9 of 11

of [38] regarding low back pain. In contrast with our study results, other studies found
that there was no significant association between working hours and MSD pain [3,39,40].

5. Limitations
This study yielded important results on the prevalence and risk factors of WRMSDs
among nurses in Malaysia. However, it had a few limitations. First, the results were from
a single institution. Thus, future studies should be involved with several institutions to
increase the generalizability. This study had a possible response bias, as the questionnaires
were distributed and collected by the nurse managers of the various wards and units from
which the participants were selected. However, the researchers believe that any coercive
pressure arising from the nurse managers as go-betweens was negated by the instructions
given to the respondents to seal the completed questionnaires in the envelopes provided
before returning them to the nurse managers. This, included with the assignment of a
unique code to each respondent, ensured confidentiality and anonymity.

6. Conclusions
This study showed a high prevalence of WRMSDs in nurses (97.3%), with the highest
prevalence rates being for low back and ankle/feet pain, followed by neck and shoulder
pain, whereas the prevalence rate for elbow pain was lowest among the thirteen body
regions covered by the study. In this study, the major risk factors that were responsible
for MSDs were age, lower education level, female gender, high BMI and job tenure. These
association patterns also suggest prospects for intervention strategies to stimulate healthy
lifestyles and increase a positive psychosocial work environment. Postural education
should be provided to nurses by encouraging short breaks. Proper screening programs
should be conducted regarding the risk factors of musculoskeletal pain in nurses, and
prevention, early diagnosis, treatment, rehabilitation and counseling are necessary. In addi-
tion, nurses with MSD issues might be helped by increasing the number of employees and
having their working hours rescheduled by the healthcare manager or top management.

Author Contributions: Conceptualization, G.R. and K.S.K.; methodology, K.S.K.; formal analysis,
K.S.K.; investigation, K.S.K.; writing—original draft preparation, K.S.K.; writing—review and editing
K.S.K.; G.R. and O.S.; supervision, G.R. and O.S. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: All aspects of the study protocol were reviewed and au-
thorized by the National Medical Research Register (NMRR) and the ethics committee of the USM.
Ethics approval was obtained from MREC and other relevant approvals for study-related activities
with NMRR (nmrr-19-106-45694 (IIR)) and JEPEM USM (USM/JEPem/20060320) ethics committee
study approval verification IDs. The study protocol adhered to the principles of the Declaration of
Helsinki and the Malaysian Good Clinical Practice Guidelines. Participation in the study was on a
voluntary basis.
Informed Consent Statement: Written informed consent has been obtained from the nurse partici-
pations to publish this paper.
Data Availability Statement: The data presented in this study are available from the corresponding
author on request.
Conflicts of Interest: The authors declare no conflict of interest. The authors declare that they had no
known competing financial interests or personal relationships that could have influenced the work
reported in this paper.

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