The effect of the online stress management program on individual workload perception and stress in nurses: a non-randomized quasi-experimental design study

Abstract

Background

One of the most important factors causing stress in nurses is a perception of high workload. However, the efficacy of any intervention is contingent upon the specificity of its content, delivery method, and structural alignment. Therefore, the aim of this study is to evaluate the effect of a structured Online Stress Management (OSM) program on nurses’ workload perception and stress.

Methods

This study used a quasi-experimental study design with a pre-test, post-test control group was carried out between April 2024 and June 2025 at a university-affiliated hospital in Türkiye. The participants consist of a total of 86 nurses (experimental group n = 42 and control group n = 44) selected through purposeful sampling. Due to workload, shift schedules, and voluntary participation, non-probability convenience sampling was employed. The experimental group was given a stress management programme on an online platform as 40–50 min sessions once a week for six weeks. Data were collected with the “Participant Information Form,” ‘Individual Workload Perception Scale’ (IWPS), and ‘Nurse Stress Scale’ (NSS). Time and group changes in individual workload perception and stress were computed using a repeated measures analysis of variance (ANOVA) model was used to test the between-group differences from baseline to six weeks.

Results

After the intervention, the total IWPS (27.21 ± 18.16) and NSS (-23.89 ± 6.30) scores of the experimental group changed significantly compared to the baseline (p < 0.05 and p < 0.001, respectively). Additionally, a significant difference was found regarding the changes seen in the inter-group peer support, workload and intent to stay sub-dimension and total IWPS scores (group*time interaction; p < 0.05) and changes observed in workload, conflict with peers and insufficient support sub-dimension and total NSS scores (group*time interaction; p < 0.001).

Conclusion

This study showed that the OSM program reduced nurses’ stress and workload perception.

Trial registration

ClinicalTrials.gov identifier: NCT06406361 (Initial Release: 05/06/2024).

Background

Nursing is a profession which is characterized by high stress levels and heavy workloads. Nurses are constantly under pressure from a large number of factors such as heavy and intense working conditions, shift working, staff shortages and long working hours [1]. These difficult conditions for nurses lead to a negative perception of workload, exhaustion, stress, dissatisfaction with work, and a reduction in professional performance. It also has a negative effect on nurses’ physical and mental health, lowers the quality of patient care, and causes manpower losses in health institutions [2–4]. Nursing is one of the most stressed healthcare professions due to the heavy workload and intense demands of patient care [3, 5]. According to statistics reported in the literature, 70% of nurses suffer from stress [6]. In a meta-analysis study by Hermansyah and Riyadi (2019), it was found that while the percentage of nurses with heavy workload experiencing stress was 62.4%, the percentage of nurses with a heavy workload who did not experience work stress was more than 37.6%, and there was a significant relationship between workload and stress in nurses [7]. In the study by Ali and Gir (2025), it was found that 50.0% of nurses were excessively stressed because of work intensity, and that 69.3% were exhausted when they finished work [5].

Increasing workload perception and stress in nurses leads to serious negative physical and psychosocial consequences. This in turn has such results as work dissatisfaction, a reduction in performance, workforce losses and a high rate of leaving the profession [4, 8, 9]. Researchers have shown that an increasing workload raises stress levels on nurses and lowers professional productivity, and this causes a reduction in patient care quality and an increase in safety problems [10, 11]. In order to solve these problems, measures must be taken at both an individual and an institutional level. It has been found that improving nurses’ perceptions such as prejudice, attitude and belief at the individual level and improving work environment conditions at the institutional level play a critical role in stress management [12, 13].

Stress management is a set of strategies that help employees re-evaluate work-related stress factors, reduce the negative effects of stress, and prevent physical or psychological health problems [14, 15]. Research indicates that stress management interventions can improve the work environment [16] and positive workload perception [17]. It is extremely important to implement psychological interventions to improve the workload perception and reduce the stress of nurses will have a positive effect on their professional productivity, general health, and quality of life. In the literature, evaluations have been made of the effectiveness of many intervention techniques and programs to reduce stress in nurses [18–21], and face-to-face training has also been shown to be effective in stress management [22, 23]. However, the effectiveness of such interventions varies depending on their content, delivery method, and targeted outcomes. Effective interventions to reduce occupational stress, improve coping skills, and enhance the well-being of nurses are needed [24]. Therefore, structured, low-cost, and effective online programs such as the OSM program need to be evaluated to provide evidence-based guidance for nursing practice. Moreover, there appears to be a gap in the literature regarding intervention studies evaluating the effects of interventions aimed at nurses on both their workload perception and stress. Accordingly, this study was undertaken to provide evidence-based and practical guidance. It is expected that the results will contribute to the development of stress management programs which are effective, accessible, and applicable for nurses.

Methods

Study design

This study was aimed at evaluating the effect of an OSM program on individual workload perception and stress among nurses working at a university-affiliated hospital in the Black Sea region of Türkiye. It was carried out between April 2024 and June 2025 at a university-affiliated hospital located in an urban center in the Black Sea Region of Türkiye, where tertiary healthcare services are provided. The hospital is the largest training and research facility in the city, providing a wide range of tertiary healthcare services such as internal medicine, surgery, intensive care, and emergency care. It also serves as a teaching hospital for nursing and medical students, where high patient volume and limited staffing contribute to increased workload and stress among nurses.

Research hypotheses

H1:

There is a difference in Nurse Stress Scale scores between the intervention group (participants of the OSM program) and the control group (non-participants).

H2:

There is a difference in Workload Perception Scale scores between the intervention group (participants of the OSM program) and the control group (non-participants).

Sample size and study participants

The population of the study was the 240 nurses working at a university-affiliated hospital located in a city in the Black Sea region in the north of Türkiye. G Power 3.1.9.7 software was utilized to conduct power analysis and calculate the sample size of the study. Based on the data from randomized controlled studies on stress conducted by Hersch et al. (2016), and by Mao et al. (2021), the effect size was calculated as 0.62 [25, 26]. With an effect size (d) of 0.62, a significance level (α) of 0.05, a power of 95% (1- β), and an 80% ability to represent that, the sample size was determined as 84 nurses (experimental group = 42 and control group = 42). 92 nurses fulfilled all inclusion criteria and signed the informed consent form; 46 were allocated to the experimental group and 46 to the control group. Because of practical constraints such as heavy workload, staff shortages, shift schedules, and voluntary participation, randomization was not possible. Therefore, a quasi-experimental study design with a pre-test, post-test control group was used. In this design, participants were selected using purposeful sampling and then assigned to the experimental and control groups without randomization. Nurses who voluntarily agreed to participate were assigned to the experimental group, and those who declined to the control group. To ensure group homogeneity, participants were matched based on key factors like age, experience, and clinic workload. Efforts were made to minimize interaction between groups by scheduling different shifts and advising participants not to share intervention details; however, some contact could not be fully avoided and is acknowledged as a limitation. The control group did not receive the intervention during the study period, but they continued to receive standard care, and no disadvantages beyond the absence of training were expected. After assignation to the groups, two nurses who did not participate in two or more sessions of the OSM program were removed from the study. During the administration of the post-test, two nurses in the experimental group could not be contacted, and two nurses in the control group did not voluntarily complete the final test. Therefore, the study was completed with a total of 86 nurses, 42 in the experimental group and 44 in the control group (Fig. 1).

Fig. 1.

Flow chart of recruitment and participant attrition

Participant inclusion and exclusion criteria

The inclusion criteria for participants were as follows: being aged 18 years or older; working as a nurse at the hospital during the study period; not being on illness or maternity leave; having no visual or hearing disorders; having no diagnosed chronic disease or mental health condition that could prevent participation; not using anxiolytic or psychiatric medications; having internet access; agreeing to participate voluntarily; and not having previously received structured training on workload.

The exclusion criteria were: being on leave for any reason during the study period, lacking internet access, and having previously participated in any stress management or similar programs.

Data collection methods

The primary outcome of this study was to determine the change in nurses’ individual workload perception, and the secondary outcome was to determine the change in their stress levels. These outcomes were directly aligned with the main aim of the study, which was to evaluate the effect of the OSM program on both workload perception and stress among nurses. The nurses were visited in the clinics where they worked. They were given information on the content and mode of application of the OSM program and on legal rights and responsibilities, and their written consent was obtained. A message group was set up with the experimental group via WhatsApp Messenger to enable the participants and the researchers to easily access each other in the event of any negative situation and to ensure timely participation in the program sessions. To minimize the risk of contamination bias between the experimental and control groups, several strategies were adopted. For example, participants were selected from separate units or shitfs, instructed to avoid sharing intervention content, and access to the OSM programme was restricted to the experimental group through a secure, password-protected online platform. Additionally, the control group did not receive any similar training during the study period. A participant information form, the Nurse Stress Scale (NSS) and the Individual Workload Perception Scale (IWPS) were used as data collection tools in the study. After the OSM program was applied to the experimental group with one session each week for a total of six weeks, the post-test data were collected a few weeks after the final session by re-administering the NSS and the IWPS to the experimental group and simultaneously to the control group, which did not receive any intervention during the study period. Data from the two groups were compared at two points in time: a few weeks before the intervention and a few weeks after the intervention.

The OSM program

After applying the data collection tools (pretest) to the nurses who fulfilled the eligibility criteria, these nurses were included in the study process in accordance with the group in which they were included. The content of the OSM program was developed in line with the literature [12, 19, 20, 25, 27] (Table 1). Feedback on the program content and implementation method was obtained from four experts in psychiatric nursing and one psychiatrist. Following minor revisions based on these expert opinions, a pilot study was conducted with three nurses. After confirming its comprehensibility and feasibility, the final version of the program was established. After confirming its comprehensibility and feasibility, the final version of the program was established, and the OSM Program was implemented in the experimental group. The OSM program is a psycho-education-based intervention in which different topics are presented at each session, and which includes the reduction of negative workload perception and stress and the creation of stress management and awareness [25, 28].

Table 1.

The content of the OSM programme

Week	Topics	Description	Time
First week	Introduction to the OSM program. Defining workload perception, creating awareness of workload types and the factors affecting workload perception	In the first week of the OSM program, the program content was introduced. Workload and related concepts were explained. Nurses were provided with information about the workload characteristics of the work environment, the support of their managers, peers and units, and continuing their current job, which affect their perception of workload. Physical and mental workloads which could arise from working life were explained and exemplified [2, 4, 9, 10, 13].	50 min
Second week	The relation between workload perception, the nursing profession and stress	In order to raise awareness about the difficulties experienced by nurses regarding the perception and types of workload in the work environment, they were asked to describe their experiences, and possible coping strategies were discussed. The relationship between workload perception and stress and the situations created by the relationship were explained and examples were given. The relationship between negative physical and mental workload and the profession and stress was explained and information was given about the effect of workload on the profession [4, 6–11, 13, 22].	50 min
Third week	Diagnosis of stress, awareness creation and evaluating sources of stress	Explanations were given of the concept of stress, stress levels, causes of stress, how stress affects emotions, thoughts and behaviors, and what symptoms are seen in stress situations. Examples were given of sources of stress which could come from working life [5,10,16–21,29,30].	40 min
Fourth week	Stress management strategies and mental techniques to cope with stress	The relationship between event-thought-emotion and behavior was explained. Examples of automatic thoughts and cognitive distortions were given. Determination and use of mental coping methods (evidence review, presenting contrary evidence, creating alternative thoughts, thought postponement, etc.) in a stressful event experienced in the work environment were taught [21, 25–30].	45 min
Fifth week	Stress management strategies and physical techniques for coping with stress	Participants were made aware of the tension that stress creates in the body. Breathing and deep relaxation techniques were taught to reduce or remove the symptoms of stress. Techniques of breathing, deep relaxation and imagination or visualization were performed. Homework was given on performing breathing and deep relaxation exercises after a stressful event in working life and on recording stress levels before and after the exercises [20, 22, 24–30].	45 min
Sixth week	Reviewing the stress, and providing suggestions about increasing pleasant behaviors and planning strategies to manage future stress.	The homework was checked. The stress management program was evaluated. Thoughts, feelings and recommendations on the program were shared [7, 23–30].	50 min

The OSM program was implemented every week via the Zoom program (Zoom Video Conferencing Software Inc., San Francisco, CA, USA) by a researcher with a PhD in the field of psychiatric nursing, on a day and time that suited the work schedule of the experimental group nurses. The program comprised six sessions, and Powerpoint presentations and videos, interactive teaching methods, discussion and question–answer sessions were used. Each session in the program lasted for approximately 40–50 min, and was structured with a detailed guide. Sessions were conducted with all participants at the same time, according to the nurses’ online availability. The participants could access the training sessions in the OSM program both at work and outside work, for example at home. In order that the participants should have no difficulty in accessing the program and in order to respond to their questions, the researchers could be accessed by telephone. The experimental group were reminded to comply with the session times and participate in the program by messages sent on the message group. After the collection of the post-test data, the participants in the control group were given one session of OSM at no cost.

Data collection tools

Participant Information Form: This form was created by the researchers in accordance with the literature. It had 12 questions on age, gender, education status, marital status, income, place of work (unit), position, weekly working hours and length of time working in that unit [29, 30].

Individual Workload Perception Scale (IWPS): The IWPS was developed in 2003 by Cox to measure health workers’ individual work load perceptions, and validity and reliability work was conducted by Cox in 2007 [31]. The scale was adapted to Turkish by Saygılı and Çelik in 2011 [29] and it was revised by Azizoglu et al. in 2021 [2]. In this study, the scale whose Turkish validity and reliability were revised in 2021 was used [2]. The scale evaluates workers’ working environment perceptions, and has 31 items in five sub-dimensions: Manager Support, Peer Support, Unit Support, Workload and Intent to Stay. Each item on the scale is evaluated on a five-way Likert-type scale from “I definitely disagree” (1 point) to “I completely agree” (5 points) [2]. Higher scores reflect a more positive perception of workload in the work environment, whereas lower scores indicate a more negative perception [2]. The Cronbach alpha coefficient of the IWPS revised by Azizoglu et al. is 0.894 [2]. In the present study, the Cronbach alpha value was found to be 0.89 before the intervention and 0.96 after the intervention.

Nurse Stress Scale (NSS): The Nurse Stress Scale was developed in 1981 by Gray-Toft and Anderson [32], and Turkish validity and reliability work was performed by Mert et al. in 2020 [30]. The scale has 34 items in seven factors: Uncertainty Concerning Treatment, Workload, The Death of a Patient, Conflict with a Physician, Conflict with Peers, Insufficient Support, and Suffering Patient [30]. The scale is scored using a four-way Likert-type scale: never (1), to occasionally (2), to frequently (3), to very frequently (4) [30]. The total score measures the frequency of stress experienced by a nurse and can be calculated by adding the participant’s responses to all items. A high overall score indicates that the nurse experiences more frequent stress periods about individual stress problems in the physical, psychological, and physical environment [30]. A lower score indicates that the nurse experiences less stress in the same situations [30]. In the Turkish validity and reliability, the Cronbach alpha reliability coefficient was 0.938 [30]. In the present study, the Cronbach alpha reliability coefficient was found to be 0.87 before the intervention and 0.99 after the intervention.

Data analysis and assessment

Data analyses were carried out using the SPSS software package (Statistical Package for Social Science, version 22.0, IBM, Armonk, NY, USA). The normality of data distribution was examined using the Shapiro–Wilk test. Descriptive statistics were presented as mean ± standard deviation, and nominal variables were presented as the number of cases and percentages (%). To compare the baseline (pre-intervention) and post-intervention differences between the intervention and control groups, the independent samples t-test was used for continuous variables, while the Chi-square test and Fisher-Freeman-Halton exact test were employed for nominal variables.

Within-group differences in the dependent groups were analyzed using a paired samples t‐test. To evaluate post-intervention differences between the groups over time (from baseline to week 6), a repeated measures analysis of variance (ANOVA) was used to assess the time * group interaction. For time * group interactions, effect size was calculated using partial eta squared (η²), where η² = 0.01 represents a small effect, η² = 0.06 indicates a medium effect, and η² = 0.14 suggests a large effect [33]. Cronbach’s alpha coefficient was used in determining internal consistency levels. The confidence interval of 95.0% and p < 0.05 were considered significant in all statistical tests.

Results

Characteristics of the participants

This study analyzed 86 nurses (experimental group = 42 and control group = 44) at the end of six weeks. Their mean age was 36.04 ± 6.34 years in the experimental group, and 36.27 ± 4.78 years in the control group. The majority of the nurses were women, they had a bachelor’s degree, they were married, they were working as service nurses, they were working in internal medicine service and were working shifts. The descriptive characteristics of the experimental group and control group did not show any statistically significant differences (p > 0.05) (Table 2).

Table 2.

Demographic characteristics of the nurses in the experimental and control groups

	Experimental Group (n = 42)	Control Group (n = 44)	Test and p values
	Mean ± sd	Mean ± sd
Age (years)	36.04 ± 6.34	36.27 ± 4.78	t=-0.157, p  = 0.876
Total working time (years)	11.29 ± 4.89	12.8 ± 4.41	t=-1.239, p = 0.220
Working time in the current workplace (years)	8.54 ± 3.37	7.1 ± 2.98	t = 1.722, p = 0.091
	n (%)	n (%)
Gender			χ2 = 0.043, p = 0.835
Woman	33 (78.6)	34(77.3)
Man	9 (21.4)	10(22.7)
Marital Status			χ2 = 0.646, p = 0.421
Married	32(76.2)	36(81.8)
Single/Divorced	10 (23.8)	8(18.2)
Educational status			χ2 = 0.569, p = 0.752
High school/associate degree	14 (33.3)	13(29.5)
Bachelor’s degree	20 (47.6)	22(50.0)
Master’s degree	8 (19.0)	9(20.4)
Position title			χ2 = 1.166, p = 0.280
Servise nurse	36(85.7)	40(90.9)
Nursing manager	6(14.3)	4(9.1)
Working schedule			χ2 = 0.232, p = 0.630
Shift	37(88.1)	39(88.6)
Non-shift	5(11.9)	5(11.4)
Weekly working time			χ2 = 0.689, p = 0.876
40 h	14(33.3)	15(34.1)
48 h	13(31.0)	12(27.3)
56 h	7(16.7)	8(18.2)
64 h and over	8(19.0)	9(20.4)
Type of unit			χ2 = 3.733, p = 0.652
Internal medicine service	14(33.3)	12(27.3)
Surgical unit	10(23.8)	11(25.0)
Emergency service	4(9.5)	5(11.4)
Intensive care unit	4(9.5)	4(9.1)
Operating room	6(14.3)	9(20.4)
Other units	4(9.5)	3(6.8)

t = Independent samples t test

χ² = Chi-square test (Fisher-Freeman-Halton exact test was used for type of unit)

There was no statistically significant difference between the groups’ baseline IWPS scores (p > 0.05) (Table 3). In the experimental group, increases in the sub-dimensions of peer support, workload and intent to stay and in IWPS total scores were found to be significant after the intervention compared to before the intervention (p < 0.05). In the control group, changes were found not to be significant (p > 0.05) (Table 3).

Table 3.

Changes in IWPS scale and subscales scores

	Experimental Group (n = 42)			Control Group (n = 44)			p (group* time)	Effect size (η2p)	p-value between groups
	Before	After	Change	Before	After	Change			Before	After	Change
IWPS
Manager support	21,11 ± 6,25	21,18 ± 6,13	0,07 ± 0,54	20 ± 7,73	20,03 ± 8,06	0,03 ± 0,67	0.813	0.001	0,553	0,547	0,813
Peer support	13,61 ± 5,49	33,54 ± 6,82	19,93 ± 10,14**	16,5 ± 6,53	16,57 ± 6,65	0,07 ± 0,74	< 0.001**	0.672	0,074	< 0,001*	< 0,001*
Unit support	17,71 ± 2,93	17,86 ± 2,92	0,14 ± 0,93	16,97 ± 5,96	17 ± 5,84	0,03 ± 0,56	0.586	0.005	0,544	0,479	0,586
Workload	19,18 ± 4,36	22,96 ± 6,95	3,79 ± 7,73*	16,7 ± 5,21	16,73 ± 5,19	0,03 ± 0,41	0.010*	0.112	0,055	< 0,001*	0,016*
Intent to stay	8,43 ± 3,08	11,71 ± 3,4	3,29 ± 4,69**	7,33 ± 2,78	7,2 ± 2,68	-0,13 ± 0,43	< 0.001**	0.220	0,161	< 0,001*	0,001*
IWPS Total	80,04 ± 13,8	107,25 ± 17,31	27,21 ± 18,16**	77,5 ± 23,42	77,53 ± 23,4	0,03 ± 0,32	< 0.001**	0.546	0,615	< 0,001*	< 0,001*

Data was presented as mean ± standard deviation, Within group changes were compared using paired samples t test, time*group interaction was tested using Repeated measures Anova

*p < 0.05, **p < 0.01

After the six-week OSM program, a significant difference was found in the comparison between the groups in terms of changes observed in the sub-dimension scores of peer support (experimental group: 19.93 ± 10.14, control group: 0.07 ± 0.74), workload (experimental group: 3.79 ± 7.73, control group: 0.03 ± 0.41) and intent to stay (experimental group: 3.29 ± 4.69, control group: -0.13 ± 0.43) and in total IWPS (experimental group: 27.21 ± 18.16, control group: 0.03 ± 0.32) (group×time interaction, p < 0.05). Changes were greater in the experimental group than in the control group (Table 3).

There was no statistically significant difference between the groups’ baseline total NSS scores except for the death of a patient and insufficient support sub-dimension (p > 0.05) (Table 4).

Table 4.

Changes in NSS scale and subscales scores

	Experimental Group (n = 42)			Control Group (n = 44)			p (group* time)	Effect size (η2p)	p-value between groups
	Before	After	Change	Before	After	Change			Before	After	Change
NSS
Uncertainty concerning treatment	22,82 ± 2,34	22,68 ± 2,28	-0,14 ± 0,59	24,77 ± 4,87	24,73 ± 4,02	-0,03 ± 1,9	0.772	0.002	0,057	0,020*	0,766
Workload	19,96 ± 1,97	9,82 ± 3,21	-10,14 ± 3,83**	19,03 ± 3,06	19,07 ± 2,97	0,03 ± 0,96	< 0.001**	0.780	0,177	< 0,001*	< 0,001*
The death of a patient	16,54 ± 2,03	16,43 ± 2,01	-0,11 ± 0,5	14,9 ± 2,43	14,87 ± 2,96	-0,03 ± 1,47	0.802	0.001	0,007*	0,023*	0,797
Conflict with a physician	15,29 ± 1,88	15,14 ± 1,92	-0,14 ± 0,8	15,33 ± 1,79	15,3 ± 2,2	-0,03 ± 1,47	0.729	0.002	0,922	0,774	0,725
Conflict with peers	16,14 ± 1,67	8,18 ± 2,2	-7,96 ± 2,33**	15,93 ± 2,21	15,87 ± 2,56	-0,07 ± 1,17	< 0.001**	0.829	0,687	< 0,001*	< 0,001*
Insufficient support	10,36 ± 1,39	5,07 ± 1,78	-5,29 ± 1,86**	9,43 ± 0,94	9,4 ± 0,97	-0,03 ± 0,72	< 0.001**	0.786	0,005*	< 0,001*	< 0,001*
Suffering patient	6,18 ± 1,19	6,07 ± 1,05	-0,11 ± 0,83	5,73 ± 1,66	5,77 ± 1,5	0,03 ± 0,81	0.517	0.008	0,248	0,378	0,517
NSS Total	107,29 ± 6,17	83,39 ± 7,4	-23,89 ± 6,3**	105,13 ± 14,37	105 ± 14,07	-0,13 ± 0,9	< 0.001**	0.882	0,458	< 0,001*	< 0,001*

Data was presented as mean ± standard deviation, Within group changes were compared using paired samples t test, time*group interaction was tested using

Repeated measures Anova

*p < 0.05, **p < 0.01

In the experimental group, reductions in the scores after the intervention of the sub-dimensions of workload, conflict with peers and insufficient support and of total NSS scores compared to before the intervention were found to be significant (p < 0.001). In the control group, the changes were not found to be significant (p > 0.05) (Table 4).

After the six-week OSM program, a significant difference was found in the comparison between the groups in terms of changes observed in the sub-dimension scores of workload (experimental group: -10.14 ± 3.83, control group: 0.03 ± 0.96), conflict with peers (experimental group: -7.96 ± 2.33, control group: -0.07 ± 1.17) and insufficient support (experimental group: -5.29 ± 1.86, control group: -0.03 ± 0.72), and in the total NSS scores (experimental group: -23.89 ± 6.3, control group: -0.13 ± 0.9) (group*time interaction, p < 0.001). Changes were greater in the experimental group than in the control group (Table 4).

Discussion

Although many studies have explored the relationship between workload perception and stress among nurses [34–36], few have evaluated the short- or long-term effects of structured interventions on these outcomes using high-level evidence. This quasi-experimental study contributes to this gap by assessing the effectiveness of an (OSM) program in improving individual workload perception and reducing stress among nurses. The results confirmed the study hypotheses, demonstrating that the OSM program significantly improved general satisfaction regarding workload perception and reduced stress levels.

Individual workload perception

After the six-week OSM intervention, the experimental group showed a significant increase in IWPS total scores compared to baseline (p < 0.05). Workload is associated with an increased intention to leave the occupation and is mediated by nurses’ satisfaction with work-life balance [37]. In this study, following the six-week stress management intervention, the experimental group showed a significant increase in workload perception scores, suggesting heightened awareness of workload perception-related challenges. The OSM program may contribute to this outcome by providing structured content and interactive methods aimed at improving coping strategies and reframing perceptions. Participants may have become more conscious of internal and external stressors affecting their workload. Stress management intervention-based studies effecting nurses’ workload perception are currently lack in the literature. Nevertheless, these findings align with a few studies indicating that Multi-media health education could reduce nurses’ workload [38] and that speech-based interventions can reduce anger levels and perceived workload among employees such as drivers [39].

In addition to total IWPS scores, statistically significant differences were found in key subdimensions-peer support, workload, and intent to stay (group*time; p < 0.05). These findings suggest that the OSM program had a multidimensional effect on how nurses perceived and responded to their working conditions. Prior studies have linked negative workload perception to job dissatisfaction, burnout, and intention to leave the profession [10, 40]. Moreover, evidence suggests that increased perceived workload may compromise patient outcomes such as medication errors, infections, and falls [35, 41].

The largest change was observed in the “peer support” subscale (Δ = 19.93 ± 10.14), highlighting the critical role of peer relationships in shaping perceived workload. Peer support is grounded in shared responsibility, mutual respect, and professional trust [12, 42]. The literature consistently demonstrates that strong peer support enhances nurses’ psychological resilience, job satisfaction, and work performance [9, 29, 43]. In our study, the post-intervention increase in perceived peer support indicates the program’s success in fostering a collaborative and supportive work culture. It is noteworthy that participants in the experimental group had not previously received structured training related to workload, and the hospital setting-being the only training and research facility in the region-likely contributed to high patient-to-nurse ratios. These contextual factors may have influenced baseline scores and made participants more receptive to the intervention. Therefore, interventions like the OSM program, which demonstrated improvements in workload perception and stress reduction, are highly relevant for supporting nurses in demanding clinical environments.

Stress

As expected, stress levels decreased significantly in the experimental group after the OSM program, with marked reductions in NSS total scores and the subscales of workload, conflict with peers, and insufficient support (group*time; p < 0.001). These results are consistent with the literature, which identifies stress as a pervasive issue among nurses globally [5, 35]. Contributing factors include excessive workload, inadequate managerial support, low staffing levels, and the emotional demands of patient care [44, 45].

The OSM program aimed to address these challenges by enhancing cognitive, emotional, and behavioral coping mechanisms. The observed reductions in stress confirm the program’s effectiveness and align with findings from RCTs evaluating similar interventions [25, 46]. For example, Alkhawaldeh et al. [47] reported significant stress reductions among public health nurses following a stress management intervention. Similarly, Hersch et al. [25] demonstrated significant stress reduction through the web-based BREATH program. Our results reinforce the utility of online programs in supporting nurse well-being.

Nevertheless, some authors have reported that offline, in-person interventions may produce more lasting improvements in resilience and stress management skills [48]. While the flexibility and accessibility of online interventions are advantageous, their long-term impact should be evaluated through longitudinal studies.

The absence of significant improvement in stressors such as uncertainty concerning treatment, the death of a patient, conflict with a physician, and suffering patients following the OSM program highlights both the limitations of the intervention and the structural nature of these stressors. Stress associated with patient death and suffering is often linked to grief processes and therefore requires deeper and institutionally based support rather than solely individual coping skills [25, 49]. Uncertainty concerning treatment typically stems from challenges in clinical decision-making, ambiguous protocols, and insufficient information flow, indicating that organizational-level modifications, rather than individual interventions, are necessary [25, 50]. Similarly, conflicts with physicians are rooted in organizational culture, hierarchical dynamics, and communication issues, which can only be effectively addressed when individual coping strategies are integrated with team-based communication training, leadership support, and interprofessional collaboration protocols [25, 51]. Therefore, the lack of significant changes in these subscales is likely related to the inherently structural and relational nature of these stressors.

Conclusion and recommendations

The study demonstrated that nurses initially exhibited moderate workload perception but high stress levels. After the OSM program, the experimental group showed significant improvements in workload perception and stress, indicating that the program effectively reduced both workload perception and stress levels. These findings support the use of the OSM program as a time-efficient, low-cost, and scalable intervention that may be particularly beneficial in resource-limited or high-demand settings. Given the promising short-term outcomes, we recommend integrating OSM programs into occupational health and continuing professional development initiatives. To evaluate long-term effectiveness, future studies should employ longitudinal designs and include follow-up assessments. Additionally, larger multi-center trials could assess the program’s generalizability and effectiveness across diverse clinical settings. Based on the positive results, it is also recommended that the OSM program be repeated at regular intervals or adapted as a continuous training module in order to maintain and reinforce its effects.

Strengths and limitations

This study is the first known experimental research in Türkiye to evaluate the effects of an OSM program on both individual workload perception and stress among nurses. However, it has several limitations.

Several measures were taken to minimize potential biases, though some limitations remain. Contamination bias could not be entirely eliminated, despite restricting intervention materials to the experimental group and instructing participants not to share content. Selection/self-selection bias was addressed by including nurses with diverse backgrounds in age, clinical experience, and specialty, recruiting from different units and shifts, and performing baseline comparisons, which revealed no statistically significant differences between experimental and control groups in key demographic and pre-intervention variables, suggesting that the groups were comparable at the outset and strengthening the internal validity of the findings despite the absence of random assignment. Self-reporting bias was mitigated through standardized and validated instruments, consistent data collection procedures, assurances of confidentiality and anonymity, standardized questionnaire administration, and avoidance of incentives that could influence participation. Potential confounding factors, including work history, educational level, marital or economic status, and personality traits, were not controlled and may have influenced the results. Sampling/generalizability bias arises from the single-hospital setting, a predominantly female sample, and exclusion of nurses without internet access. Finally, random assignment and blinding were not feasible due to ethical and practical constraints within the hospital setting. Participation in the intervention required nurses’ voluntary involvement in the OSM program, which involved additional time and effort beyond their routine duties. Assigning nurses to groups randomly could have violated ethical principles by forcing participation in a program they did not consent to, and practical constraints such as differing work schedules, shift patterns, and limited availability also made randomization difficult, making group allocation apparent to participants. While these steps cannot completely eliminate bias, they help mitigate its potential impact on the study findings. However, this lack of prior exposure also limits comparisons with individuals experienced in such programs and restricts generalizability to broader populations.

Importantly, the study was limited to short-term outcomes; thus, it remains unclear whether the observed improvements are sustainable over time. Future studies should explore whether repeated or booster sessions are needed to maintain the benefits of such programs. Given the paucity of research on interventions targeting positive workload perception, this study lays important groundwork for future experimental designs in occupational health.

Author contributions

G.Y.D.G: Conceptualization, Methodology, Investigation, Software, Formal analysis, Writing-original draft preparation, Writing- Reviewing and Editing. N.D: Methodology, Investigation, Software, Writing- Original draft preparation, Writing- Reviewing and Editing. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

The data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Non-Interventional Ethics Committee of Amasya University (date: 23.01.2024 and approval no: E-76988455-050.04-175127). Then, the administrative permission was obtained from the Provincial Health Directorate of the province and the administration board of the hospital where the study was carried out. The study was conducted in accordance with the guidelines set forth in the Declaration of Helsinki. All participants were informed about the purpose and benefits of the study, their roles in the research, the confidentiality of their information, and that their participation was entirely voluntary. Written informed consent was obtained from all participants. Permission was also obtained from the authors for the use of the NSS and the IWPS for data collection.

Competing interests

The authors declare no competing interests.