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. 2020 Aug 3;15(8):e0236782. doi: 10.1371/journal.pone.0236782

Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study

Yohannes Baye 1,*, Tesfaye Demeke 2, Nigusie Birhan 2, Agumasie Semahegn 1, Simon Birhanu 1
Editor: Sergio A Useche3
PMCID: PMC7398531  PMID: 32745142

Abstract

Introduction

Work-related stress causes poor quality of nursing care and increases the risk of medical errors. Research evidence is so limited to nurses’ work-related stress in eastern Ethiopia. Therefore, this study aimed to assess work-related stress and associated factors among nurses working in governmental hospitals in Harar, Eastern Ethiopia.

Methods

Institution-based quantitative cross-sectional study was conducted among 367 nurses from 15th to 30th March, 2015. Simple random sampling technique was applied to recruit study participants. Data were collected using structured self-administered questionnaire. Descriptive statistics, bivariate and multivariate logistic regressions were carried out. The statistical association was declared using adjusted odds ratio at 95% confidence interval (CI) and P-value of less than 0.05.

Results

A total of 398 study participants were involved in the study, and the response rate was 92.2% (367/398). More than half of 202(55%) of the participants were males. One third (33.8%, n = 124) of study participants’ age ranged between 26 to 34 years. The prevalence of work-related stress in the current study was 66.2%. Nurses, who reared child (AOR = 2.1, 95% CI: 1.2, 3.7), working in intensive care units (AOR = 4.5, 95% CI: 1.4, 17.7), work on rotation (AOR = 2.5, 95% CI: 1.4, 4.4), and nurses who had a chronic medical illness (AOR = 2.6, 95% CI: 1.2, 5.7) were significantly associated with nurses’ work-related stress.

Conclusion

Two-thirds of nurses who were working at government hospitals had work-related stress. Work-related stress was associated with child-rearing, working units, work on rotation, and chronic medical illness. We suggested the hospital's administration, and other concerned stakeholders should design a strategy to undertake necessary measures such as hiring more nurses to minimize workload and rescheduling work shift to alleviate work-related stress among nurses.

Introduction

World Health Organization has considered stress as a global epidemic, which has recently observed to be associated with 90% of visits to physicians [1]. Work-related stress is one of the most important workplace health risks for employees worldwide [2]. Work-related stress results in substantial costs to employees and organizations [3–5], related to employees absenteeism and turnover, decreased productivity, physical illness, poor quality of health care services, and increase risk of medical errors [6].

Globally, the costs of work-related stress are estimated to be $5.4 billion each year, which is one of the most frequently reported occupational health problems [7]. Stress is derived from the word “Stringi”, which means “to be drawn tight”. Stress can be defined as a physical or psychological stimulus that can produce mental tension or physiological reactions that may lead to illness [8].

Work-related stress has recognized as the main challenge for the nursing profession throughout the world and has negative emotional, physical, and psychological effects on the nurse [9, 10]. Research evidence demonstrated that nurses suffer from high levels of work-related stress are threatening their health, patients’ lives, compromise the quality of nursing care, and increasing the cost of health care [11]. Excessive occupational stress has been found to reduce the quality of nursing care [12]. If a nurse is stressed, it is difficult to give holistic nursing care to patients which may increase patient mortality rate [13, 14].

Nursing job (work-related) stress can be defined as the physical and emotional reactions that occur when the nurses' abilities and resources imbalance with the demands and requests of their work [15, 16]. Occupational stress, job stress, organizational stress, and work-related stress are interchangeably used terms [17].

The nature of the nursing profession and the health care system are some of the contributors to work-related stress [18, 19]. Research findings have indicated that the sources of occupational stress, its levels, and effects vary depending on local factors such as the nature of work, work setting, and cultural orientation. Thus, occupational stress among nurses may have significant differences in different countries due to different work settings and levels of social support [20]. Therefore, identification of the sources and contributing factors to work-related stress is necessary for improving the stress management program in the organization.

In Ethiopia, nurses have been playing a crucial role in the health care delivery system. However, there is limited research evidence regarding work-related stress among nurses, specifically in the study area. Therefore, this study aimed to assess work-related stress and associated factors among nurses working in governmental hospitals in Harar, Eastern Ethiopia.

Methods and materials

Study setting and design

An institution-based quantitative cross-sectional study was carried out among nurses working in governmental hospitals in Harar City, Harari Regional State, Eastern Ethiopia from March 15 to 30, 2015. Harar city is the political capital of the Harari Regional State. There are a total of four governmental hospitals (2 military and 2 public hospitals) in Harar. Namely, the 2 military hospitals are Police Hospital (PH) and Army Hospital (AH). Likewise, the 2 public hospitals are Haramaya University Specialized Teaching Hospital (HUSTH) and Jugel Hospital (JH). The military hospitals are for the police, army, and their families. On the other hand, public hospitals have been serving the general public. This study was conducted in the four governmental hospitals in Harar. There were a total of 446 nurses working in these four governmental hospitals during the study period. Out of these, HUSTH comprised 244 nurses and JH had 97 nurses. Similarly, there were 55 nurses in AH and 50 nurses in PH working in different departments.

Participants and sampling procedure

All nurses (446) who were working in government hospitals in the Harari region were the source population. The sample size was calculated using a single population proportion formula at 95% significance level, by considering the proportion of work-related stress (37.8%) in Addis Ababa [21] with a 5% margin of error, and adding 10% non-response rate. Then, the total sample size was 398 nurses. The calculated sample size was proportionally allocated to the size of the four government hospitals, HUSTH, JH, AH, and PH constituted 217, 87, 49, and 45 participants respectively. The sampling frame was constructed for each hospital separately by taking the nurses list from the human resource management department of each hospital. Then, study participants were selected from respective hospital units using a simple random sampling technique.

Study population

All nurses who were fulltime employees of Harari Regional State governmental hospitals were included in the study. Nevertheless, nurses who were seriously ill or unable to give responses due to this illness during the data collection period were excluded.

Data collection tools and procedures

Data were collected using a structured and pre-tested self-administered questionnaire. The tool consisted of the socio-demographics and questions related to the work environment, substance use, illness, and stress. Work-related stress was assessed based on the Expanded Nursing Stress Scale (ENSS). ENSS is an expanded and updated Nursing Stress Scale developed by French SE and her colleagues The Scale comprised of 57 items in nine subscales. These are; 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) [22].

Participants were asked to indicate the frequency of work-related stress using a 4-point response scale. Response options are ‘never stressful’ (1), ‘occasionally stressful’ (2), ‘frequently stressful’ (3), and ‘always stressful’ (4). The category “not applicable” was scored as zero (0). To compute the total stress score, we added together with the scores on all 57 items. To measure scores on specific subscales, the appropriate items should be added together and the higher the score, the greater the frequency of stress on any subscale. The higher the score, the more the respondent agrees that the situation was stressful. Work-related stress is determined by computing the mean of all 57 items for every study participant. In this study, the mean values 2 and above were assumed to indicate Work-related stress. The overall ENSS reliability with Cronbach’s alpha (α) was 0.96. The individual subscale reliability ranged from α = 0.88 (problems with supervisors) to α = 0.65 (discrimination) [22]. In the current study, the internal consistency (reliability) of the items with Cronbach’s alpha was found to be 0.86 for the overall scales (Table 1).

Table 1. Reliability test of the expanded nursing stress scale, 2015.

Stressors Number of items Scale Mean Scale Variance Cronbach's Alpha
Work load 9 106.64 703.14 0.85
Death and dying 7 107.84 749.96 0.84
Uncertainty concerning treatment 9 108.53 737.29 0.84
Patient and family 8 109.34 716.60 0.83
Problems with supervisors 7 111.58 735.06 0.83
Problems with peers 6 115.17 764.26 0.83
Conflict with physicians 5 116.42 824.13 0.84
Inadequate emotional preparation 3 120.79 872.15 0.85
Discrimination 3 122.73 864.23 0.86
Total 57 0.86
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Operational definitions

Work-related stress is defined as the physical and emotional reactions that occur when the nurses' abilities and resources imbalance with the demands and requests of their work [15, 16].

Nurses' work-related stress was rated from 1 (never stressful) to 4 (always stressful); the mean score of 2 or higher of 57 items was considered as work-related stress [22].

Substance use

Use or consumption of any substance such as alcohol, chat, cigarettes, shisha, and hashish, regardless of the amount and frequency of use for the past 3 months [21].

Job satisfaction

Job Satisfaction was defined as whether respondents like (satisfied) or dislike (dissatisfied) their jobs [21]. In this study, nurses who answered “yes” were assumed to be satisfied with their job.

Chronic medical illness

Chronic medical disease was categorized as ‘yes’ if hypertension, cardiovascular disease, AIDS, diabetes mellitus, or arthritis had been diagnosed [23].

Child-rearing

Child rearing was categorized as ‘yes’ if the person is parenting or taking care of a child/children.

Quality control measures

Training of the data collectors and supervisors was performed by the investigators. Pretesting was undertaken on 20 respondents before the actual data collection at other hospital and some questions were modified based on the participant’s response. Each filled questionnaires were checked thoroughly for its completeness and consistency, and necessary feedback was offered to a data collector in the next morning.

Data processing and statistical analysis

Collected data were entered into EpiInfo7 and then exported into SPSS (20) software for analysis. Data exploration was performed by executing frequency distribution with a normal curve and box plot to identify outliers and some data anomalies. Data cleaning was carried out as necessary. Descriptive statistics were carried out to compute proportion, frequency, mean and standard deviations. Binary logistic regression was computed to identify association between independent variables with nurses’ work-related stress. Variables that had a p-value of less than 0.20 in bivariate analysis were in cluded in the multivariate analysis to control for possible confounders. Finally, 95% confidence interval, adjusted odds ratio, and P-values less than 0.05 was used to determine the statistically significant association between independent variables and nurses’ work-related stress.

Ethical approval and consent to participant

Ethical clearance was obtained from the ethical review committee of the Department of Nursing, University of Gondar. A formal letter of cooperation was written to Harari People's National Regional State Health Bureau and respective hospitals. Informed written consent was obtained from each study participant. The purpose of the study was explained to each study participant. All information obtained from the study subject would be kept confidential anonymously.

Results

Socioeconomic and demographic characteristics of study participants

A total of 398 nurses have participated in the study, and the response rate was 92.2% (n = 367). More than half of 202(55%) of the participants were males. The median age was 28 (interquartile range (IQR) = 24–38) years. One third (33.8%, n = 124) of study participants’ age ranged between 26 to 34 years. More than half (58.6%, n = 215) of participants were belonging Ethiopian Orthodox Christianity. Most of the participants were the Amhara ethnicity (46.6%, n = 171). Nearly half (48.2%, n = 177) of participants were married. More than half (51.8%, n = 190) of nurses have not reared the child. More than half (58.3%, n = 214) of study participants had a Bachelor of Science Degree in Nursing (Table 2).

Table 2. Socio-demographic characteristics of nurses working in governmental hospitals in Harar, Eastern Ethiopia, 2015 (n = 367).

Variables Categories Frequency %
Age (Years) ≤ 25 123 33.5
26–34 124 33.8
35–44 93 25.3
≥45 27 7.3
Sex Male 202 55
Female 165 45
Religion Orthodox 215 58.6
Muslim 81 22.1
Protestant 65 17.7
Catholic 6 1.6
Ethnicity Amhara 171 46.6
Oromo 107 29.2
Tigre 33 9
Harari 26 7.1
Guraghe 20 5.4
''Others'' 10 2.7
Marital status Married 177 48.2
Single 168 45.8
Divorced 10 2.7
Separated 8 2.2
Widowed 4 1.1
Child rearing No 190 51.8
Yes 177 48.2
Level of Education BSc 214 58.3
Diploma 153 41.7
Monthly salary (in Birr) 1200–1560 32 8.7
1561–2100 67 18.3
2101–2620 83 22.6
>2620 185 50.4
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''Others'' include; Kembata, Somali and Wolayta.

Work environment and behavioral characteristics of study participants

The study participants were working in Haramaya University specialized Teaching Hospital 200 (54.4%), Jugol hospital 80(21.7%), Army hospital 45(12.3%), and Police hospital 42(11.4%). Nurses who were working in outpatient departments, surgical wards, medical wards, and intensive care units were 15.0%, 14.4%, 13.6%, and 12.8% respectively. Two-thirds (67.0%, n = 246) of the nurses worked rotating shift and reported having ≤7 years of work experience with the median year of nurses' work experience was 4 (IQR = 1 to 11) years. Approximately three-fourth (71.7%, n = 263) of nurses worked 35 to 50 hours per week. Almost half (51.5%, n = 189) of nurses reported being dissatisfied with their jobs (Table 3).

Table 3. Work environment and behavioral characteristics of Nurses in Harar, Eastern Ethiopia, 2015 (n = 367).

Variables Categories Frequency %
Work unit Medical ward 50 13.6
Surgical ward 53 14.4
Pediatrics ward 29 7.9
Maternity ward 41 11.2
Psychiatry ward 13 3.5
Emergency unit 40 10.9
Intensive care unit 47 12.8
Operation room 39 10.6
Outpatient department 55 15.0
Work shift Rotating 246 67.0
Fixed 121 33.0
Job rank Basic nurse 331 90.2
Head nurse 36 9.8
Working hours per week 35–50 263 71.7
51–65 76 20.7
66–80 24 6.5
≥81 4 1.1
Job satisfaction No 189 51.5
Yes 178 48.5
Work experience ≤ 7 years 250 68.1
8–14 years 46 12.5
15–21 years 44 12.0
22–28 years 21 5.7
29–38 years 6 1.6
Having a chronic medical illness No 302 82.3
Yes 65 17.7
Substance use No 304 82.8
Yes 63 17.2
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Prevalence of nurses’ work-related stress

The total ENSS score for nurses’ ranged from 52 to 194 and the mean ranged from 0.9 to 3.4. The prevalence of nurses’ work-related stress was 66.2%. Nurses’ workload was the most frequently reported stressful sub-scale (mean = 20.7) followed by death and dying (mean = 19.5) (Table 4).

Table 4. Means and standard deviations of the stressors among nurses in Harar, Eastern Ethiopia, 2015 (n = 367).

Stressors Number of items Mean SD
Work load 9 20.7 6.9
Death and dying 7 19.5 5.4
Uncertainty concerning treatment 9 18.8 6.1
Patient and family 8 18.0 5.7
Problems with supervisors 7 15.8 5.3
Problems with peers 6 12.2 4.4
Conflict with physicians 5 11.0 3.8
Inadequate emotional preparation 3 6.6 2.7
Discrimination 3 4.7 3.7
Total 57
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“SD” = Standard deviation.

Factors associated with nurses’ work-related stress

In bivariate analysis nurses’ child-rearing, working unit, work shift, chronic medical illness, and work experience were significantly associated with nurses’ work-related stress. However, in the multivariate analysis; child-rearing, working unit, work shift, and chronic medical illness showed a significant association with nurses’ work-related stress. Nurses who reared children were 2 times more likely to experience work-related stress than those who did not rear child (AOR = 2.1, 95% CI: 1.2, 3.7). Nurses who were working in the intensive care unit were 4.5 times more likely to experience work-related stress than nurses were working in the outpatient department (AOR = 4.5, 95% CI: 1.2, 17.7). The odds of nurses who were working in psychiatry wards were 90% less likely report work-related stress than nurses who were working in the outpatient department (AOR = 0.1, 95% CI: 0.0, 0.6). Nurses who were working on rotating shifts were 2.5 times more likely to experience occupational stress than those who were working on fixed shifts (AOR = 2.5, 95% CI: 1.4, 4.4). Nurses who had chronic medical illnesses were 2.6 times more likely to suffer from work-related stress than nurses who had no known chronic illness (AOR = 2.6, 95% CI: 1.2, 5.7) (Table 5).

Table 5. Work-related stress and associated factors among nurses in Harar, Eastern Ethiopia, 2015.

Variables Categories Work-related stress COR (95% CI) AOR(95% CI)
Non- stressed Stressed
Child rearing No 81 109 1.00 1.00
Yes 43 134 2.3(1.5,3.6)a 2.1(1.2,3.7)b
Work unit OPD 22 33 1.00 1.00
Surgical ward 21 32 1.0(0.5,2.2) 0.5(0.2,1.1)
Medical ward 19 31 1.1(0.5,2.4) 0.6(0.2,1.5)
ICU 3 44 9.8(2.7,35.4)a 4.5(1.2,17.7)b
Maternity ward 18 23 0.9(0.4,1.9) 0.6(0.3,1.5)
Emergency ward 7 33 3.1(1.2,8.4)a 2.0(0.7,5.8)
Operation room 16 23 1.0(0.4,2.2) 0.6(0.2,1.4)
Pediatrics ward 8 21 1.8(0.7,4.6) 0.9(0.3,2.7)
Psychiatry ward 10 3 0.20(0.0,0.8)a 0.1(0.0,0.6)b
Work shift Fixed 58 63 1.00 1.00
Rotating 66 180 2.5(1.6,4.0)a 2.5(1.4,4.4)b
Chronic medical illness No 114 188 1.00 1.00
Yes 10 55 3.3(1.6,6.8)a 2.6(1.2,5.7)b
Work experience (in a year) 29–38 4 2 1.00 1.00
≤7 95 155 3.3(0.6,18.2) 2.4(0.4,15.6)
8–14 6 40 13.3(2.0,89.3)a 7.0(0.9,53.6)
15–21 12 32 5.3(0.9,33.0) 2.5(0.3,17.6)
22–28 7 14 4.0(0.6,27.4) 2.6(0.3,21.1)
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N.B.

a Significant at p < 0.20

b Significant at p < 0.05

Discussion

This study determined the level of nurses’ work-related stress. The prevalence of work-related stress was 66.2%. This finding is much higher as compared to a study in Addis Ababa (37.8%) [21]. The difference might be due to the tool used in Addis Ababa which was NSS. This study was also much higher as compared to a study conducted in Malacca (28.3%) [24]. The possible reason for the difference might be due to the study setting in which the Malacca study was conducted only in maternal and child health clinics. Similarly, the number of nurses reporting work-related stress in this study was higher than the stress in Kuala Lumpur (24.6%) [25], Brazil (23.6%) [26] and Taiwan (17.2%) [27]. The difference between these studies and the current study might be due to the tools used and study settings. However, the prevalence of the current study was lower when compared to studies done in Malaysia (100%) [28], Egypt (92%) [29], China (86.9%) [23] and India (73.5%) [30]. The possible reason for this variation might be.due to the tools used and study setting. Similarly, the current study was lower when compared to a study conducted in Iran which reported that 73.4% of nurses experienced work-related stress [31]. This variation might be due to the study setting since the Iranian study was carried out only in a teaching hospital, whereas the current study included all types of hospitals. The descriptive analysis indicated that the workload was the most stressful subscale for nurses. This might be due to a shortage of staff, extra non-nursing tasks, and less time to accomplish the work and support each other emotionally. Ethiopia, like other developing countries, suffers from a shortage of nurses (2 nurses for 10,000 people) [8] which increases nurses’ workload. This finding was in line with researches reported in Addis Ababa which stated that a greater source of stress for nurses was “not enough staff to adequately cover unit” followed by “not enough time to finish all their nursing tasks [21], South Africa which indicated nurses’ stress was caused by “not enough staff to adequately cover unit” [32], and Thailand which was found that heavy workloads caused high work-related stress in nurses [33].

In this study, a significant association was found between working units and work-related stress. Nurses who worked in intensive care units were experienced more stress than other units/wards. This was consistent with studies conducted in Malaysia [28] and Ireland [34] which have revealed that nurses working in ICU were found to have a high level of work-related stress. This might be due to nurses working in intensive care units are busy, caring for critical patients, and have little time to support each other emotionally. This finding was different from a study in Addis Ababa which reported that nurses who worked in medical wards and emergency units were stressed more [21]. The reason might be due to the number of nurses assigned to intensive care units and patient flow in this study area would not be proportioned. Similarly, this finding was inconsistent with a study in Malaysia which showed that respondents working in the department of medicine experienced a higher level of stress compared to those working in the other departments [25].

In this study, a significant association was also found between work shift and work-related stress. Rotating shift nurses were more stressed than fixed shift nurses. This finding was consistent with researches reported in Addis Ababa [21], Egypt [35], and Jordan [36] which have indicated that nurses who worked rotating shifts were more stressed than nurses who worked fixed shifts. Researchers also found a significant association between child-rearing and work-related stress in this study; nurses who reared children were more likely to experience work-related stress than those who did not rear child. This finding was supported by a South Korean study [37] that stated nurses' working stress had significant correlation with parenting.

Even though this research could not differentiate temporal relationships, respondents who reported chronic medical illness were more likely to report work-related stress than those without illness. This finding was consistent with studies conducted in Ethiopia [21], China [23], and research reported by Seyle’s [38].

Strength and limitation of the study

This study had some limitations, where the cross-sectional study design used in this study cannot conclude a temporal relationship between exposure and disease. Since stress is mainly subjective and psychological, the qualitative approach would provide rich and meaningful information about the nurses' experiences with stress and related concepts.

Conclusion

This study determined the level of work-related stress among nurses working in government hospitals in Harar, Ethiopia. Two-third of nurses working in governmental hospitals had work-related stress. Child rearing, working unit, work shift, and chronic medical illness were statistically significantly associated with nurses’ work-related stress. Nurses have a tremendous role in the health care delivery system in Ethiopia. Because nurses worked in a poor resource setting and overflow of patients with communicable and non-communicable health problems, nurses have been facing many challenges in their work environment. In the meantime, nurses experienced work-related stress which may affect the quality of health care service, increase medical errors and resource wastage. We suggested the need for organizational interventions to reduce the effect of this work-related stress. Hiring more nurses might be a potential remedy to minimize workload with increasing clerical staff to reduce non-nursing tasks. Strategies that reduce stress due to shift work should be considered such as rescheduling. Further study using a mixed-method and analytical design in governmental and private health facilities is recommended to establish a real cause-effect relationship.

Acknowledgments

We would like to acknowledge study sites' administrative bodies for their kindly cooperation during the data collection period. We also would like to thank data collectors and study participants without whom this could not be realized.

Acronyms and abbreviations

AH

Army Hospital

AOR

Adjusted odds ratio

COR

Crude odds ratio

CI

Confidence interval

ENSS

Expanded nurses stress scale

HUSTH

Haramaya University specialized Teaching Hospital

ICU

Intensive care unit

IQR

Interquartile range

JU

Jugel Hospital

NSS

Nurses stress scale

OPD

Outpatient department

PH

Police Hospital

Data Availability

All relevant data are within the manuscript.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Sphiwe Madiba

10 Oct 2019

PONE-D-19-14479

Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study

PLOS ONE

Dear MR. Baye,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Nov 24 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

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Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Sphiwe Madiba, DrPH

Academic Editor

PLOS ONE

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  • A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

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3. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

https://www.researchgate.net/publication/264888293_Effect_Procrastination_on_Work-Related_Stress

http://www.imedpub.com/articles/occupational-stress-management-among-nurses-in-selected-hospital-in-benin-city-edo-state-nigeria.php?aid=12016

https://www.scirp.org/journal/PaperInformation.aspx?PaperID=91107

The text that needs to be addressed is in the Background section

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.  If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

5. Thank you for stating the following in the Acknowledgments Section of your manuscript:

'We would like to thank the University of Gondar for financial support.'

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

'The author(s) received no specific funding for this work.'

Additional Editor Comments

The introduction is too brief; there is need for a thorough review of literature to indicate the problem. For example, the authors need to indicate the prevalence and effects on work-related stress on the performance of the organization as well as the nurses in other countries and in Ethiopia. Furthermore, the authors did not justify the reason for conducting the study. The paragraph on the implication of the study can be worked into the justification or introduction.

I agree that the sampling is confusing and needs to be revisited and clarified.

In the discussion, the authors compare their findings to studies conducted elsewhere with little efforts to compare to studies in Ethiopia and other parts of Africa. There is adequate research conducted in this topic in many parts of sub Saharan Africa to support the study findings. It is also not clear why the authors compare their findings to those with different study populations.

The authors state that working in ICU was significantly associated with work related stress, they further stated that the association might be due to the fact that nurses working in intensive care units are busy, caring for critical patients, and have little time to support each other emotionally.  It is important that the authors report what other studies attributed the link between working in ICU and work related stress to.

The author need to summarize and synthesize the findings, for example they report that “Their finding was consistent with research done in Addis Ababa which reported that nurses who worked rotating shifts were more stressed than nurses who worked fixed shifts (17). Similarly, this finding was consistent with a study in Egypt that revealed nurses working at rotating shift were more stressed than those who were working in the morning shift (18) and in Jordan reported that work shift was the best predictor of nurses’ stress (19)” this should be summarized. 

The work related stressors assessed through Expanded Nursing Stress Scale (ENSS) are not well discussed; there is only mention of workload as the main stressor.

The authors need to review the conclusion once they revise the discussion and introduction.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Abstract

From conclusion part it is better describing the measures for those significantly associated factors separately rather than reporting like " ....undertake necessary measures on associated factors " ( line 20)

Methods and materials

study settings and design sections lack more information's on ;

Total number of governmental hospitals in the study area (in Harar region) and selection of hospitals is not clear ?

total number of health professionals and nurses as well working during the study time ?

what are the inclusion and exclusion criteria's of the study ? not clearly mentioned or I think it is missed from the manuscript ?

What is your assumption with the outcome variables from the study units or across hospitals ,is it similar or different ?

variable measurement or operational definition Missed.

First, a definition of work related stress would be helpful to the reader.

then, the measurements of your outcome variable work related stress ; "stressed or not stressed " ,should be clearly defined .when did you say "there was nurse's work related stressed ? and/or not stressed ?" .

Hint; how could you measure the tool Expanded Nursing Stress 19 Scale (ENSS) which contains 57 items that assess nine areas of stress having multiple response ?

Similar measurement clarifications may also necessary for other independent variables like ;job satisfaction ,work load ?

What is Cronbach’s alpha coefficient implications and its cut off point for conclusion? (table 1)

Discussion

was the tools used for the study were, the primary justifications for variations of different findings with yours,what are other possible expectations or perspectives behind for the difference can you suggest? (table 2 ,5)

Conclusion

making the general conclusion with the descriptive result is not recommended.so try to remove this sentence "The descriptive analysis showed that the work load was the most frequently stressful sub-scale ."

Reviewer #2: The manuscript has no page numbers. Editor relies on whole article pagination as downloaded from website. Assuming that the Abstract is on page 8.

Please include socio-demographics in abstract results

2. Sampling section not clearly written. Please revisit. Author starts with simple random sampling but ends up with stratified random sampling but provides numbers for each strata. The sampling frame is small (446). Why was a census not considered?

4. There are serious language and typographical errors in the whole manuscript. This needs serious attention.

Keep reporting of numbers to 1 decimal place.

Pg 8 ln 9: …statistics were carried out. For what?

Pg 9 ln 4 and 20. Fix English: change has incurred to incurs and employed to carried out .

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Getnet Gedif Engida

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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PLoS One. 2020 Aug 3;15(8):e0236782. doi: 10.1371/journal.pone.0236782.r002

Author response to Decision Letter 0

6 Jan 2020

Response to Reviewers’

First of all, we would like to appreciate the PLOSE ONE Journal Academic Editor and Reviewers for providing us timely and constructive comments to revise our manuscript that suits the PLOS ONE Journal standards and requirements. We are also pleased to submit the revision that responds to each point raised by the academic editor/ reviewers and presented as follows.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Upon our revision, we have seen that some of the manuscript parts do not meet the PLOS ONE's style requirements. After thoroughly reading the PLOS ONE's submission guidelines we made changes that meet the requirement.

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar.

As much as possible we tried to improve the manuscript for language usage, spelling, and grammar by consulting our colleagues and staff language professionals.

3. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

https://www.researchgate.net/publication/264888293_Effect_Procrastination_on_Work-Related_Stress

http://www.imedpub.com/articles/occupational-stress-management-among-nurses-in-selected-hospital-in-benin-city-edo-state-nigeria.php?aid=12016

https://www.scirp.org/journal/PaperInformation.aspx?PaperID=91107

Thanks for your link and we searched and have seen some minor occurrence of overlapping text especially with the last two papers. The overlapping was on the definition of “stress” and we quoted for that and rephrased the rest text.

4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses.

As mentioned in the methodology part of the manuscript, the tool (questionnaire) is a structured and pre-tested self-administered questionnaire. The tool consisted of the socio-demographics and ques¬tions related to the work environment, substance use, illness, and stress.

Work-related stress was assessed based on the Expanded Nursing Stress Scale (ENSS). ENSS is an expanded and updated Nursing Stress Scale developed by French SE, Lenton R, Walters V, and Eyles J. The ENSS was obtained directly from the author Susan French communicating through email (susan.french@mcgill.ca) and getting permission.

The Expanded Nursing Stress Scale contained 57 items in nine subscales: 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). Participants were asked to indicate the frequency of work-related stress using a 4-point Likert response scale. Response options were ‘never stressful’ (1), ‘occasionally stressful’ (2), ‘frequently stressful’ (3) and ‘always stressful’ (4). The category “not applicable” was scored as zero (0).

In order to compute the total stress score, we added together with the scores on all 57 items. In order to measure scores on specific subscales, the appropriate items should be added together and the higher the score, the greater the frequency of stress on any subscale. The higher the score, the more the respondent agrees that the situation was stressful.

Work-related stress is determined by computing the mean of all 57 items for every study participant.

In this study, the mean values 2 and above were assumed to indicate Work-related stress.

Based on a study done on a random sample of 2,280 nurses in Ontario, Canda, the authors demonstrated the ENSS reliability with Cronbach’s alpha (α = 0.96) and the individual subscale reliability ranged from α = 0.88 (problems with supervisors) to α = 0.65 (discrimination) [31].

In the current study, Cronbach’s alpha coefficient was found to be 0.86 for the overall scales [Table1].

5. We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

We removed funding information in our revised manuscript and only included in the Funding Statement section of the online submission form.

6. The introduction is too brief; there is a need for a thorough review of literature to indicate the problem.

In the revised manuscript we have included the prevalence and effects of work-related stress on the performance of the organization as well as the nurses in Ethiopia and other countries. We also incorporated the justification of conducting this study.

We revised the methodology part and made some clarification.

We also incorporated and compared similar studies conducted in Ethiopia and other parts of Africa.

7. The total number of governmental hospitals in the study area (in the Harar region) and the selection of hospitals is not clear?

There are a total of four governmental hospitals (2 military and 2 public hospitals) in the Harari region. Namely, the 2 military hospitals are Police Hospital (PH) and Army Hospital (AH). Likewise, the 2 public hospitals are Haramaya University Specialized Teaching Hospital (HUSTH) and Jugel Hospital (JH). The military hospitals usually serve the police and army population, on the other hand, the public hospitals serve the general population.

The study was conducted in the four Governmental hospitals found in the Harari region. There were a total of 446 nurses working in these four Governmental hospitals during the study period. Out of these, HUSTH comprised 244 nurses and JH had 97 nurses. Similarly, there were 55 nurses in AH and 50 nurses in PH working in different departments.

The sample size was calculated using a single population proportion formula at 95% significance level, by considering the proportion of work-related stress (37.8%) in Addis Ababa with 5% margin of error, and adding 10% non-response rate. Therefore, the total sample size was 398 nurses.

A stratified sampling technique was applied considering the difference in the level of work-related stress across hospitals. Therefore, the total sample size was proportionally allocated to the size of the four government hospitals so that HUSTH, JH, AH and PH constituted 217, 87, 49 and 45 participants respectively. The sampling frame was constructed for each hospital separately by taking the nurses list from the human resource management department of each hospital. Then, study participants were selected from respective hospital units using a simple random sampling technique.

8. What are the inclusion and exclusion criteria of the study? Not clearly mentioned or I think it is missed from the manuscript?

Of course, we have seen that we missed the inclusion and exclusion criteria of the study in our submitted manuscript so that we incorporated in the revised manuscript.

Inclusion and exclusion criteria of the study

Inclusion Criteria

� All nurses who were fulltime employees of Harari regional state governmental hospitals were included.

Exclusion Criteria

� Nurses who were seriously ill or unable to give responses due to this illness during the data collection period were excluded.

9. What is your assumption with the outcome variables from the study units or across hospitals is it similar or different?

We assumed that the level of work-related stress across each hospital is different due to the difference in the population they served so that a stratified random sampling technique was used to select study participants from each hospital to maintain proportionality among each hospital.

10. Variable measurement or operational definition Missed.

Operational Definitions:

� Work-related stress: is defined as the physical and emotional reactions that occur when the nurses' abilities and resources imbalance with the demands and requests of their work.

� Nurses' work-related stress: was rated from 1 (never stressful) to 4 (always stressful); the mean score of 2 or higher of 57 items was considered as work-related stress.

� Substance use: use or consumption of any substance such as alcohol, chat, cigarettes, shisha, and hashish, regardless of the amount and frequency of use for the past 3 months.

� Job satisfaction: Job Satisfaction was defined as whether respondents like (satisfied) or dislike (dissatisfied) their jobs. In this study, nurses who a¬swered “yes” were assumed to be satisfied with their job.

� Chronic medical illness: ‘Chronic medical disease’ was categorized as ‘yes’ if hypertension, cardiovascular disease, AIDS, diabetes mellitus or arthritis had been diagnosed.

11. What is Cronbach’s alpha coefficient implications and its cut off point for conclusion?

Cronbach’s alpha coefficient is a measure of internal consistency.

It is considered to be a measure of scale reliability.

A reliability coefficient of 0.70 or higher is considered acceptable for conclusion.

12. Was the tools used for the study were, the primary justifications for variations of different findings with yours, what are other possible expectations or perspectives behind for the difference can you suggest?

In fact, the cause of stress in an individual person is difficult to determine since the stressors may vary from culture to culture even nurses working in different hospital units exposed to different types of work-related stress. Therefore, the variations for the level of stress among study findings might be due to the difference in the working environment itself or other factors in addition to the tools used to measure the stress level. So, further qualitative research could be used to explore and describe the experiences of stress among nurses in the work environment.

13. Making the general conclusion with the descriptive result is not recommended.so try to remove this sentence "The descriptive analysis showed that the workload was the most frequently stressful sub-scale.”

We accepted it and removed it in the revised manuscript.

14. The manuscript has no page numbers. The editor relies on whole article pagination as downloaded from the website. Assuming that the Abstract is on page 8.

Sorry for the omission unintentionally and we have inserted page numbers and line numbers for each page of the manuscript.

15. Please include socio-demographics in abstract results.

We accepted and did it in the revised manuscript.

16. The sampling section was not clearly written. Please revisit. The author starts with simple random sampling but ends up with stratified random sampling but provides numbers for each stratum. The sampling frame is small (446). Why was a census not considered?

We have indicated how to select study samples in question number 7 of this letter.

It could be sounder enough if we had applied census for the study but we did not have adequate resources and time to apply census during the study period and we also considered that the sample size is acceptable for this study.

17. Keep reporting of numbers to 1 decimal place.

We accepted and did it in the revised manuscript.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (32KB, docx)

Decision Letter 1

Sphiwe Madiba

4 Feb 2020

PONE-D-19-14479R1

Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study

PLOS ONE

Dear MR. Baye,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Mar 20 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Sphiwe Madiba, DrPH

Academic Editor

PLOS ONE

Additional Editor Comments 

  1. Please correct the sampling technique uses, in the abstract you stated that simple random sampling was used and in the method section, you mention stratified random sampling. 

  2. The study population was 442 and the sample 398, I do not understand how simple random sampling was used when almost all the nurses were included in the study. How did you randomly select 217 from 244 nurses, 96 from 97 nurses and 50 from 55 nurses? The appropriate sampling technique for the study would be a census were all the nurses were eligible to participate. Provide details or change the sampling to a census and clarify how the participants were recruited to the study.

  3. Delete the sub heading “Inclusion and exclusion criteria” and integrate the description of the population under study population

  4. Figure, “distribution of study participants by the hospital, is not necessary, delete and present the data in the narrative

  5. Please explain child rearing

Discussion

Make this the second statement after the prevalence. The descriptive analysis indicated that the workload was the most 298 stressful subscale for nurses. Tell us why this is the case and the implications of the findings before telling us that- this was consistent with other studies in different countries [(2717, 299 36-4624-34]). This might be due to a shortage of staffs, extra non-nursing tasks and less time to support each other emotionally-support this statement with literature. Only then can you compare the prevalence with other studies. Please be brief in you comparison and group all the studies that are similar then those that are in contrast.

The implication should be part of the conclusion and not a subheading-see my comments above.

Conclusion

Child rearing is not discussed but appears in the conclusion

There are still major grammar, tenses, and punctuation errors-the manuscript should be copy edited by a professional English language editor. Please provide proof with your re-submission.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear academic Editor

I try to check for author’s response to my review comments and it is well done.

I agreed all the responses given that was constructive and educative responses and help to improve the quality of the paper. 

Reviewer #2: The comments and suggestions that I raised in the review have been adequately attended to by the authors.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Getnet Gedif

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Aug 3;15(8):e0236782. doi: 10.1371/journal.pone.0236782.r004

Author response to Decision Letter 1

20 Mar 2020

Response to Reviewers’

First of all, we would like to appreciate the PLOSE ONE Journal Academic Editor and Reviewers for providing us timely and constructive comments to revise our manuscript that suits the PLOS ONE Journal standards and requirements. We are also pleased to submit the revision that responds to each point raised by the academic editor/ reviewers and presented as follows.

1. Please correct the sampling technique uses, in the abstract, you stated that simple random sampling was used and in the method section, you mention stratified random sampling.

As you mentioned, we have seen that stratified random sampling was reported in the methods section and simple random sampling both in the abstract and in the methods section. A stratified sampling technique was used to proportionally allocate the number of participants to be involved in the study by considering the difference in the level of work-related stress across hospitals. Then we used a simple random sampling technique to select study participants from each hospital.

2. The study population was 442 and the sample 398, I do not understand how simple random sampling was used when almost all the nurses were included in the study. How did you randomly select 217 from 244 nurses, 96 from 97 nurses and 50 from 55 nurses? The appropriate sampling technique for the study would be a census were all the nurses were eligible to participate. Provide details or change the sampling to a census and clarify how the participants were recruited to the study.

The study population was 446 and the sample 398. Out of 446 study population, HUSTH comprised 244 nurses and JH had 97 nurses. Similarly, there were 55 nurses in AH and 50 nurses in PH. As we have indicated in the methods section, the total sample size was proportionally allocated to the size of the four government hospitals so that HUSTH, JH, AH and PH constituted 217, 87, 49 and 45 participants respectively. Then, the sampling frame was constructed for each hospital separately by taking the nurses list from the human resource management department of each hospital and study participants were selected from respective hospitals using a simple random sampling technique.

In fact, It could be sounder enough if we had applied census for the study but we did not have adequate resources and time to apply census during the study period and we also considered that the sample size was acceptable for this study.

3. Delete the subheading “Inclusion and exclusion criteria” and integrate the description of the population under study population

We accepted and corrected it in the revised manuscript.

4. Figure,“distribution of study participants by the hospital, is not necessary, delete and present the data in the narrative

We accepted and corrected it in the revised manuscript.

5. Please explain child rearing

Child-rearing: Child rearing was categorized as ‘yes’ if the person is parenting or taking care of a child/children

We also incorporated it under operational definition of variables in the revised manuscript.

6. Make this the second statement after the prevalence. The descriptive analysis indicated that the workload was the most 298 stressful subscale for nurses. Tell us why this is the case and the implications of the findings before telling us that- this was consistent with other studies in different countries [(2717, 299 36-4624-34]). This might be due to a shortage of staff, extra non-nursing tasks and less time to support each other emotionally-support this statement with literature. Only then can you compare the prevalence with other studies. Please be brief in your comparison and group all the studies that are similar then those that are in contrast.

We accepted and corrected it in the revised manuscript.

7. The implication should be part of the conclusion and not a subheading

We accepted and corrected it in the revised manuscript.

8. Child-rearing is not discussed but appears in the conclusion

We have seen and corrected it in the revised manuscript.

9. There are still major grammar, tenses, and punctuation errors-the manuscript should be copy edited by a professional English language editor. Please provide proof with your re-submission.

We tried to improve the manuscript for grammar, tenses, and punctuation errors by consulting our colleagues and staff language professionals.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (25.8KB, docx)

Decision Letter 2

Sergio A Useche

27 May 2020

PONE-D-19-14479R2

Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study

PLOS ONE

Dear Dr. Baye,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Your paper has been reviewed again by the academic referees performing the first assessment, having a positive appraisal. nevertheless, one of these reviewers requests for a set of minor changes before suggesting the acceptance of the manuscript in PLOS ONE. Specifically, there are crucial issues related to 1) the sampling procedure and its validity, that remains pending to be clarified, and 2) the English writing of the paper, that needs additional revisions, to be (ideally) carried out through a professional reading-proof.

Please submit your revised manuscript by Jul 11 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Sergio A. Useche, Ph.D.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Academic Editor

Confirmation to the authors’ response to the reviewer 1 Comments

Title: Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia:

A cross-sectional study"

Manuscript number: (PONE-D-19-14479R2 )

I tried to check out authors' response to my review comments and it is well done.

I agreed to all the responses' given which was constructive and educative in addition to improve

quality of the paper.

I have re-checked and confirmed all the authors’ response

to my review comments that was fully a dressed.

Reviewer #2: The issues of sampling is not adequately addressed. One of the reviewer comments was adequate. That the sampling likely followed a census rather than random sampling. It is difficult to understand how one can obtain a random sample of 398 from a population of 446 people using the technique given in manuscript.

Also there are still grammatical and typographical errors in the manuscript. These still to be addressed.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Getnet Gedif

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Aug 3;15(8):e0236782. doi: 10.1371/journal.pone.0236782.r006

Author response to Decision Letter 2

9 Jun 2020

Response to Reviewers’

First of all, we would like to appreciate the PLOSE ONE Journal Academic Editor and Reviewers for providing us timely and constructive comments to revise our manuscript that suits the PLOS ONE Journal standards and requirements. We are also pleased to submit the revision that responds to each point raised by the academic editor/ reviewers and presented as follows.

1. The sampling procedure and its validity, that remains pending to be clarified.

The calculated sample size (398) was proportionally allocated to four government hospitals (HUSTH, JH, AH, and PH) as indicated in the methods section of the revised manuscript.

Then, the sampling frame was constructed for each hospital separately by taking the nurses list from the human resource management department of each hospital and study participants were selected from respective hospitals using simple random sampling technique.

We have reported what we have done in the study.we considered that the sampling procedure followed acceptable scientific standards and the sample size was adequate for this study.

2. The English writing of the paper, that needs additional revisions.

We made extensive revisions to the revised manuscript to improve grammar, tenses, and punctuation errors by consulting our colleagues and staff English language professionals.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (24KB, docx)

Decision Letter 3

Sergio A Useche

15 Jul 2020

Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study

PONE-D-19-14479R3

Dear Dr. Baye,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sergio A. Useche, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I would have wanted the authors to motivate why they could not do a census rather than sampling given that the sample size and the sampling frame numbers are close.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Prof Paul Chelule

Acceptance letter

Sergio A Useche

23 Jul 2020

PONE-D-19-14479R3

Nurses’ work-related stress and associated factors in governmental hospitals in Harar, Eastern Ethiopia: A cross-sectional study

Dear Dr. Baye:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sergio A. Useche

Academic Editor

PLOS ONE

Associated Data

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    Data Availability Statement

    All relevant data are within the manuscript.

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