Occupational stress among the nurses working in a Medical College Hospital in Nepal

Abstract

Background:

Nursing is a stressful profession that can damage one’s physical and mental health and affect professional outcomes. There is sufficient evidence to suggest that occupational (work-related) stress decreases the quality of nursing care and increases the chances of making errors while working.

Aim:

To assess the occupational stress among the nurses working in a Medical College Hospital in Nepal.

Materials and Methods:

This was a descriptive cross-sectional study conducted among the 311 nurses working in a Medical College Hospital in Nepal. Data were collected using a self-designed questionnaire which also incorporated the Expanded Nursing Stress Scale (ENSS). Chi-square test and independent sample t-test were used for statistical analysis.

Results:

The mean (SD) age was 26.2 (4.3) years, more than half (52.4%) were below 25 years and almost three-fifths (58.2%) were single. Occupational stress was found among two-fifths (41.2%) of the nurses. The mean (SD) ENSS score was highest in the area of problems related to supervisors [2.3 (0.5)], workload [2.3 (0.4)], and uncertainty concerning treatment [2.3 (0.5)], and least in the area of discrimination [1.4 (0.6)].

Conclusion:

Above two-fifths of Nepalese nurses experienced occupational stress. Nurses often felt stressed by unnecessary demands of patients and their families, and their stress was also related to their problems with the supervisors, uncertainty concerning treatment, and excess workload. There was a significant level of stress among the nurses working in highly demanding stations like intensive care units. Institutional interventions may be necessary to reduce occupational stress among nurses.

A process of temporary adaptation in any occupational setting usually presents with a variety of physiological, emotional, and cognitive symptoms that may be considered as occupational or work-related stress. It has been considered to be the most important factor for occupational health risks.[1]

The nursing profession is regarded as one of the stressful careers that may impair one’s physical and mental health, and affect professional outcomes.[2] Occupational stress also decreases the quality of care and increases the chances of occupational errors among nurses.[3] Nurses are the ones who are under the most pressure in comparison to all other medical or healthcare professionals.[4] Occupational stress also impacts employee productivity through regular or prolonged absenteeism.[5]

Globally, occupational stress is one of the most frequently reported occupational health problems, with the estimated economic burden to be $5.4 billion each year.[6]

Stress among nurses has important implications not only for the nurses but also for the patients and other healthcare workers. However, occupational stress has not received its due attention in the Nepalese healthcare system. There are very few studies on occupational stress among Nepalese healthcare workers, in general, and nurses, in particular. Keeping these facts under consideration, we attempted this study to assess the frequency and associated burden of occupational stress among the nurses working in a Medical College Teaching hospital in Nepal.

MATERIALS AND METHODS

Ethics statement

Ethical approval for this study was obtained from the Institutional Review Committee of Kathmandu University School of Medical Sciences (IRC-KUSMS) on November 30, 2023. Written informed consent was obtained from all the prospective participants before initiating the study. Participants were aware that their participation was completely voluntary, and they could withdraw from the study at any time without providing any reason.

Study setting

Kathmandu University School of Medical Sciences (KUSMS), Medical College Hospital, caters to almost 1450 staff, and among them, 430 nurses are working in different departments.

Sample size

The sample size was calculated by using the following formula:

n = Z²P (1 − P)/d²

We did not have comparable data on the Nepalese nurses. However, we had earlier conducted a study on stress among the medical students from the same Medical College Teaching hospital, which was found to be 27.0%.[7]

Hence, we considered P = 27% = 0.27.

Considering absolute allowable error (L) as 5%, and 95% confidence interval (CI), and assuming the non-response rate to be 10%, we calculated the required sample size to be 345 (315 + 30).

Study population

All nurses who were employees of Kathmandu University Teaching Hospital were included in the study.

Data collection

As soon as we received the approval from the IRC-KUSMS, we initiated the study. We approached all the nurses of Kathmandu University Medical College Hospital. No exclusion criteria were specified. Among them, 345 contacted us which would fulfill our sample size requirement. However, we obtained complete responses from 311 participants only: 11 did not consent, 13 did not contact further, and 10 provided incomplete responses. The response rate was thus 90.1% (311/345).

The process of interviewing and collecting the data was completed over the 3-month period: December 1, 2023 to February 29, 2024.

Data collection tools

Data were collected using a self-designed self-administered questionnaire pertaining to sociodemographic and work-station-related items, and a psychometric instrument for quantifying work-related stress.

The following items were included in the data collection proforma:

1. Sociodemographic variables:

   1. Age group: dichotomized as above and below 25 years

   2. Marital status: single or married

   3. Residence: urban or rural

   4. Educational level: Proficiency Certificate Level (PCL) and Bachelors and above

2. Occupation-related variables:

   1. Work experience: dichotomized as above and below 5 years

   2. Work station: dichotomized as intensive care unit (ICU) and non-ICU setting.

Expanded Nursing Stress Scale (ENSS)

The scale comprised 57 items in nine subscales. These are as follows:

Death and dying (7 items); conflict with physicians (5 items); inadequate emotional preparation (3 items); problems relating to peers (6 items); problems relating to supervisors (7 items); workload (9 items); patients and their families (8 items); discrimination (3 items), and treatment uncertainty (9 items).

These subscales are further categorized into three forms of working environments for descriptive and comparative purposes:

1. Subscale workload refers to the physical working environment.

2. Subscales of death and dying, inadequate preparation, and uncertainty concerning treatment refer to the psychological working environment.

3. The third factor of the social working environment is described by the remaining five subscales, i.e. conflicts with physicians, problems with peers, problems with supervisors, patients, and their families, and discrimination.[8]

To compute the total stress score, the scores of all 57 items are added. Since our nursing staff were able to understand, read, and write in English, the original English version of ENSS was applied in this study.

Validity and reliability

The Cronbach’s alpha score of the original ENSS scale is 0.9, indicating high reliability.[9] We also calculated the Cronbach’s alpha score in our sample, which also turned out to be 0.90. Hence, ENSS is reliable in our setting as well.

To ascertain comprehensibility, cultural appropriateness and face validity of this scale among the Nepalese population, a sort of pilot test was performed among a group of 20 final-year Bachelor in nursing students. All the items of the original English version of ENSS were discussed among them. It was found to be understandable and applicable to that population. Hence, we assume the scale to be valid among Nepalese nurses.

Statistical analysis

Data were analyzed with the SPSS 21 version. The sociodemographic variables were tabulated in the form of mean and percentages, whichever was appropriate. The frequency of occupational stress was calculated in percentages (with 95% CI). The scores on the scales and subscales have been expressed in terms of mean and standard deviations. To determine statistically significant differences between different sociodemographic characteristics, we used the Chi-square (χ²) test.

The mean stress scores on the three forms of working environment were compared using the independent t-test. P <0.05 was considered a parameter for assessing statistical significance.

RESULTS

The total ENSS score for nurses ranged from 71 to 212, and the mean (SD) was 129.2 (20.7). Hence, the values above 129 were considered to indicate occupational stress. The frequency of nurses’ occupational stress (those having total score >129) was 41.2% (35.5, 46.5). The mean scores of the nine subscales of ENSS were also calculated.

The mean ENSS score was highest in the area of problems related to supervisors [2.3 (0.5)], workload [2.3 (0.4)], and uncertainty concerning treatment [2.3 (0.4)], and least in the area of discrimination [1.4 (0.6)] [Table 1].

Table 1.

Scores [mean (SD)] of the nine individual subscales of the Expanded Nursing Stress Scale (ENSS)

Subscales	Mean	SD
Death and dying	2.2	0.6
Conflict with physician	2.1	0.4
Inadequate emotional preparation	2.2	0.5
Problems related to peers	1.9	0.5
Problems related to supervisors	2.3	0.5
Workload	2.3	0.4
Uncertainty concerning treatment	2.3	0.4
Patients and their families	2.4	0.5
Discrimination	1.4	0.6

Out of the total 311 nurses who participated in the study, more than half (52.4%) were below 25 years and almost three-fifths (58.2%) were single; the mean age was 26.2 (4.3) years. More than two-thirds (86.8%) of participants had a certificate-level degree in nursing. 198 out of 311 (63.7%) had experience of less than 5 years. Most of the participants (93.6%) were from urban areas. The majority of participants (62.1%) were from the outpatient department, and almost two-fifths (37.9%) were from ICUs [Table 2].

Table 2.

Association of sociodemographic and work-related variables of the study participants (n=311) with stress category

Variables	Categories	Frequency (%)	Stress category		P*
			No stress n (%)	Stress n (5 %)
Age group	Up to 25 years	163 (52.4)	98 (53.6)	65 (50.8)	0.6
	25 years and above	148 (47.6)	85 (46.4)	63 (49.2)
Marital status	Single	181 (58.2)	98 (53.6)	83 (64.8)	0.04
	Married	130 (41.8)	85 (46.4)	45 (35.2)
Residence	Urban	291 (93.6)	178 (94.5)	118 (92.2)	0.4
	Rural	20 (6.4)	10 (5.5)	10 (7.8)
Level of education	PCL	270 (86.8)	163 (89.1)	107 (83.6)	0.1
	Bachelors and above	41 (13.2)	20 (10.9)	21 (16.4)
Work experience	Up to 5 years	198 (63.7)	119 (65.0)	79 ((61.7)	0.5
	5 years and above	113 (36.3)	64 (35.0)	49 (38.3)
Workstation	ICU setting	118 (37.9)	37 (20.2)	81 (63.3)	0.000
	Non-ICU setting	193 (62.1)	146 (79.8)	47 (36.7)

*Chi-square test

Stress was found significantly high among the nurses who were single in comparison to those who were married (64.8% vs. 35.2; P < 0.05). Also, a higher level of stress was seen among the nurses working in the ICU settings in comparison to those working in the non-ICU setting (63.3% vs. 35.3%; P < 0.001) [Table 2].

The mean stress score was consistently higher among the nurses working in the ICU settings across all the subscales and in all three factors of working environments (physical, psychological, and social). The mean stress score was also higher among the less-experienced nurses (who have worked below 5 years) in the two subscales of the psychological working environment component (death and dying, and overall psychological environment). Nurses, who were single, also had high-stress scores in those two subscales of the psychological environment component, and also in the patients and their families’ subscales of the social environment component.

DISCUSSION

More than two-fifths of the Nepalese nurses had work-related stress of some kind. Some of the earlier local studies have reported higher levels of stress.[10,11] However, a study from the neighboring country India (48.9%) is in line with our findings.[12] Furthermore, Nepalese nurses are found to be more stressed than those from Malaysia (24.6%),[13] and Taiwan (mean score of work stress perception: 4.15).[14] Methodological, instrument-related, cultural, and geographical variations usually bring about such differences in the frequency or percentages. But it is true that nurses, as health professionals, suffer from occupational stress globally, and our study has also clearly revealed that fact.

Working conditions related to a social, psychological, and physical environment are considered to be the most common factors for occupational stress among nurses.[8] A study from Pakistan also pointed out various psychosocial and physical factors leading to stress among working nurses.[15] Our study also showed the nurses, particularly those who were less experienced, who were single, and those working in the ICU settings were mostly affected by these physical, psychological, and social factors, contributing toward occupational stress.

Unreasonable demands from patients and their families, conflicts with supervisors, uncertainty concerning treatment, workload, and lack of prior experience with death and dying were the main themes associated with occupational stress among the Nepalese nurses in this study. Similar reasons were given by the nurses from Saudi Arabia and India as the major contributors to their work-related stress; they were mainly concerned regarding the demanding patients and families, excessive workload, and unending discussions with the supervisors.[16,17,18] However, Nepalese nurses rarely experience any discrimination, which indicates a positive working environment among the nurses in our hospital. A study from Dubai also reported a nondiscriminating working unit.[19]

Problems related to peers have consistently emerged as the least stressful issues in many studies,[16,20,21] which was in agreement with the results of our study as well.

Work experience was significantly associated with the psychological component of the working environment leading to stress among our nurses; less experienced nurses (those who worked below 5 years) were less exposed to the event related to death and dying. Similar findings were reported by one recent study from South India.[12] Experienced nurses eventually learn coping skills for high-stress circumstances like a patient’s death, and will be less stressful.

There was a significant association of work-related stress with some variables like death and dying, overall psychological environment, and problems with patients and families, and also with the sociodemographic variable like marital status. This fact was consistent with a mixed-method study.[22]

The most significant finding of our study is the strong relationship between workstation and workplace stress. The overall physical, psychological, and social conditions caused more stress for ICU nurses than for nurses working on other units. This conclusion was in line with other studies.[23,24]

Limitations

Despite being one of the pioneering studies to look for the possible factors associated with occupational stress among Nepalese nurses, our study had many limitations. Conventional way of sampling and cross-sectional questionnaire use may not have been an appropriate study design. The specific highly demanding working areas (e.g., intensive cardiac care unit, operation theater, and emergency) were not explored separately. Nurses’ individual personal, psychological, and personality-related factors that could have contributed to stress were not considered. We included all the nurses who consented, and there were no exclusion criteria. Also, our sample size calculation was based on the study from medical students which may have compromised our findings.

CONCLUSION

Above two-fifths of Nepalese nurses in our hospital experienced occupational stress. Nurses often felt stressed by unnecessary demands of patients and their families, and their stress was also related to their problems with the supervisors, uncertainty concerning treatment, and excess workload. There was a significant level of stress among the nurses working in highly-demanding stations like ICUs. Institutional interventions may be necessary to reduce occupational stress among nurses.

Authors’ contributions

DK: Concept and design, data analysis, drafting the manuscript;

BS and SS: Data collection and analysis;

AR: Intellectual Input, data interpretation, revision, approval, and finalization.

Data availability statement

Data of this study is freely available without restriction. The person can request the corresponding author for the data file which shall be provided freely.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent forms from the study subjects (participating Nurses). In the form, the subjects have given their consent for their information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.