Occupational Stress Amongst Nurses in Tertiary care Hospital in Lahore, Punjab (Pakistan)

Fazeelat Tahira^*, Muhammad Afzal1 and Robina Shaheen
^*Correspondence: Fazeelat Tahira, The University of Lahore, Pakistan, Email:

Keywords

Nurses • Occupational • Tertiary • Stress level • Factors • Coping style

 

Introduction

Nursing is a health care profession exhibiting itself while nurses’ carrying on its values playing a vital role in health organizations [1]. Depression includes feelings of indisposition, shortage of energy, despair, uselessness, disinterestedness and pessimism leading to suicide which is 9 to 20 percent in the society whereas its exact criterion proved it to be 3% in men and 4 to 9 % in women [2]. Depression and physical stress being directly inter-related are contributed by physical, psychological and social stimulants whereas various stressors creating chronic weariness result in depression [3].

Job stress is defined as the harmful physical and emotional responses arising from mismatch of jobs requirements with workers’ capabilities, resources and needs. It causes poor health, hypertension, cardiac problems, substance abuse reducing life enjoyment, and immunity, mental and physical wellbeing leading to frustration and irritability whereas stressful work multiplies substance abuse used to cope with stress.

Private hospital nurses feel more burdened as contrary to those working in public hospitals. Shift duties, time pressure, lack of respect from patients, doctors, administrators, insufficient staff, interpersonal relationship, death and low pay scale increase stress among nurses. This is a highly risky profession regarding stress related diseases and judging magnitude of the problem faced by tertiary care government hospital and studying its responsible factors is very essential which will help in streamlining the stress management programes towards a specific direction ensuring professionals’ health, better delivery and enhancing qualitative health services for the entire population.

Although the occupational stress stands scrutinized and explored by researchers using various methodologies over the past 20 years, yet its literature requires to be reviewed using a postmodernist theoretical framework aiming at exploring the stress phenomenon and its application to stress management interventions within the health service [4].

The occupational stress is now accepted as a major factor for staff sickness and absenteeism within National Health Service NHS which adds to organizational insufficiency, high staff turnover, absenteeism owing to sickness, decrease quality and quantity of care, decrease job satisfaction and increased costs of health care.

People with different jobs encounter stress differently due to cost problem. Others declared nursing a stressful profession having close relationship between occupational stress and job performance [5]. High stress resulting from both working environment and personal factors affects nurses’ physical and mental health [6].

Whearas workplace stress affects workforce tremendously and nurses’ performance requires to be determined weather it enhances or reduces their intention to stay at work [7]. The occupational stress being common the world over is regarded as a major health problem for health care professionals especially nurses which reportedly effects their job satisfaction and job performances and the significant differences therein exist due to different work settings [8]. Research proves that 50-60 % of all lost working days are stress related (C0x et al 2000). Employees’ stress assessment and work fitness being extremely important provides valuable information about their workforce as well as basis for effective intervention to handle the well- established pressures affecting this occupational group [9].

Aim of the Study

Detecting the causes of occupational stress among nurses and revealing the best interventions and coping strategies are the main aims of this study. Thus, the research questions guiding these studies were formulated as:

To assess the stress level of nurses in Fatima Memorial Hospital, Lahore (Pak).

To identify the factors of stress in nurses of Fatima Memorial Hospital, Lahore. (Pak).

To assess the coping style of stress in nurses of Fatima Memorial Hospital, Lahore. (Pak).

Literate Review

• Literature Review helped to understand the scientific work done by different researchers, the methodology used for this purpose, help to clarify stress concepts, its coping strategies, life style modification and life quality. It also helped the researchers to frame questions for interview and convinced the researchers as well to study stress from Mumbai context because the only available literature was regarding stress as perceived by the suffering people and their coping strategies.

• A large majority of nurses (87.4 %) found their job stressful whereas 32.2% (28/87) severe or very stressful. Similarly, 87.4% found a little stress whereas 28.7% (25/87) severe. There was neither a significant difference between stress levels depending on hospital type (p=0.54) nor amongst married nurses (88.6 %) and unmarried ones (82.4%) (p=0.63) [10].

• The only 35.7% nurses opined to rejoin nursing profession whereas 57.1% (4/7) of them (35.7%) refused to do so. On the other hand, only 1 out of 11 nurses reporting “no job stress” wanted to change the profession. (p=0.04). All nurses reporting no job stress went for vacation once a year whereas none of 7 nurses reporting severe job stress went for vacation more than once a year. (p<0.01) [11].

• The only 1 nurse (1.1 %) reported feeling suicidal since start of her job whereas 79 (90.8%) never felt so and 7 once (8%) were not sure of ever feeling suicidal when asked about handling their daily routine problems, e-g, a family/ personal crises, no nurse reporting severe jobs stress, found their ability excellent whereas 35.70 % considered their ability and the rest ones found it good (64.3%).

Stressors like worry about children and their studies, home life disturbance due to nature of job, dependent relatives, mismanagement of household activities increase nurses’ professional stress for compromising their skill over the aforesaid issues. “Time Pressures” was found to be the most stressful whereas “Discrimination” the least one. High level skill requirement and learning new things proved to be the most important sources whereas supervisors/ senior sisters, being not helpful the least important one in the profession [3].

• 34.5 % nurses handled stress by talking to people, 57.5 % opted not to avoid people whereas most of them did not indulge in smoking or drinking even without changing their eating and sleeping habits to handle stress [3].

• 87.4 % nurses reported 87.4 % occupational stress finding “Time pressure” the most stressful stress whereas “Discrimination” the least one in daily life including the other ones like handling various life issues with occupation such as caring for their own children/ parents, own work situation, personal responsibilities, learning new things and attending numerous patients at the same time.

• The literature shows contradictory result regarding relationship between job stress and job performance. Several researchers found effects of social support on job stress as contrary to job performance with the only study showing its reducing effects on the said relationships among hospital nurses [5].

• In china, the traditional disease-centered nursing care model is being replaced by the patient-centered patient centered nursing care model resulting in growing need of patients as well as their dissatisfaction with nursing care. Moreover, nursing shortage being a global issue is more serious in China due to vast population base where coping with routine demands of work place lead nurses to stress [6]. High stress resulting from both working environment and personal factors affects physical and mental health of nurses.

• Research proves that 50-60 % of all lost working days are stress related. Employees’ stress assessment and work fitness being extremely important furnish valuable information about their workforce as well as basis for effective intervention to handle pressures affecting this occupational group [9].

• Health care workers’ growing interest in psychological work environment has grown for being at high risk of stress, burnout, role conflict and job dissatisfaction. The occupational stress can prove harmful to nursing quality and patient safety. Whereas a heavy workload not only increases turnover but also affects nurses’ health and professional satisfaction greatly.

• Pathological conditions like emotional exhaustion. Fatigue, and low back pain are linked with nurses stress. Low decision latitude and professional characteristic predict coronary heart disease whereas high effort and low rewards are risk factors for common mental disorder proving the importance of psychological work environment or the same. Nurses in developing countries experiencing high effort-reward imbalance intend to leave their job as contrary to those working in stable countries.

• Apart from heavy workload and role conflict, various factors like responsibility, involvement with death, uncertainty are also known as work related stressors with organizational structure being the potential one in attracting and retaining nurses.

Methodology

Research design

A cross sectional descriptive study was adopted.

Study design

A cross- sectional descriptive study to collect data on nurses’ occupational stress level, its responsible factors and coping style was conducted in October 2016 in Fatima Memorial Hospital, Lahore comprising 200 nurses. Questionnaires were distributed to the interested nurses through a group of helper and collected back after completing the questions.

Study participants

The study participants comprised 200 charge nurses (Team leaders/ Supervisors/Head nurses) working in Fatima Memorial Hospital, Lahore.

Inclusion criteria

The inclusion criterion of study was all married and unmarried charge nurses, team leaders/supervisors and head nurses of Fatima Memorial Hospital, Lahore.

Exclusion criteria

All unmarried and married staff nurses, nursing assistant, non-working in the hospital and non- participants were excluded from the study.

Sampling technique

Sampling technique is a way of selecting the participant from the target population and selecting the subject of research. The study sample was followed by the set inclusive criterion based on randomized convenient to sampling technique. The subject were free to participate in the study.

Sampling method

Slovan’s sampling method used to find sample size of study.

N=Population. n=Sample size. E=Margin error=0.05. n=N/1+N (E)2 n=200/1+200(0.05)2 =200/1+200(0.0025) =200/1+0.42 n=200/1.42 n=133

The total sample size is 133.

Sample size

The representative sample size of 133 nurses was identified and included in the study.

Research instrument

A well-constructed close ended and choice selection questionnaire developed by consulting literature and discussing with the supervisor was distributed to 10 persons to check understanding of the questions (Appendix B).

Material used in study

A questionnaire (Paper), pen, help of persons and a laptop were used in order to collect, analyze and write the data and research results.

Data collection

The Pilot testing of the questionnaire was done on 10 persons to assess understanding of the questions and then distributed among nurses of Fatima Memorial Hospital, Lahore meeting the inclusion criteria and collected back after their filled response (Appendix B).

Ethical considerations

Research proposal was approved by the ethical committee of Hazara University (Vertex College of Science and Technology, Informed written consent had been obtained from the participant before participating in the study, (Appendix A). All secrecy of the study except publicity at the required places was assured and participant willingness was obtained prior to responding to the questionnaire.

Method to analyze the data

The primary researcher entered the data on Statistical Package for Social Sciences (SPSS) (version 21). Computer program on personal laptop. Percentages and mean of different variables are calculated statistically. Tables and graphs had been developed to portray the data to explain and discuss the variables.

Study duration

The study was conducted from October 2016 to March 2017.

Procedure

This descriptive cross-sectional study was conducted among nurses aged 20-40 years, married and unmarried charge nurses, Team leaders, Supervisors and Head nurses of Fatima Memorial Hospital, Lahore. Participants were given questionnaire with ample time to read, understand and mark their response thereon, collected back and handed over to the primary researcher. The field questionnaires were allocated a code number from 01 to 133 in order to enter the data on Statistical Package for Social Sciences (SPSS, version 21). Therefore, the primary researcher interpreted and understood the variables with the help of colleagues and then wrote down the data on the paper.

Results

In reference to Table 1 in socio-demographic characteristics, majority of the participants was female 121 out of 133 (91%) being unmarried more than married ones 76 out of 133 (57.1%). The majority of participants 61(45.9%) was aged 26-30 years whereas second majority 48(36%) aged 20-25 years.

Table 1: Socio-demographic characteristics of the participants (n =133).

The majority of participants was professionally nursing diploma 78 out of 133 (59%), Generic BSN 12 out of 133 (9.0%) and the Post RN being 43 out of 133 (32.3%). According to designation, the data revealed 116 (87.2%) participants were charge nurses 11(8.3%) Head nurses and only 6(4.5%) Team leaders.

The Table 2 presents that 28 (21.7%) participants are in high stress and 11.5% no stress due to time pressure and 22 (16.5%) participants in high stress and 16 (12%) no stress due to time pressure. 26 (19.5%) participants no stress due to family safety, 38 (28.6%) participants very low stress due to caring for others. 41(31%) low stress due to financial situation, 33(25%) moderate stress due to physical problem and 9(6.8%) in extreme stress due to work situation.

Table 2: Stress level (n =133).

The Table 3 revealed the stress factors as 6 (4.5%) stress strongly disagree due to high death rates, seniors not helpful, numerous patients at the same time and conflicts with colleagues, 30 (23%) disagree due to seniors’ not being helpful, 47 (35.3%) neutral for all factors, 53 (40%) agree to learn new things, 45 (34%) strongly agree because job requires high skills level.

Table 3: Factors of stress (n =133).

The Table 4 datarevealed as 54 (40%) participants agree with coping style of the stress mentioned in the table, 33 (25%) out of 133 strongly agree with sleeping more than usual, 33 (25%) disagree coping stress by medication. 50 (38%) neutral by eating more than usual whereas 21 (16%) strongly disagree by medication.

Table 4: Coping style of stress (n =133).

Results are further explained in figures (Figures 1 to Figure 11).

Discussion

Discussion includes feelings of indisposition, shortage of energy, despair, uselessness, disinterestedness and pessimism leading to suicide which is 9 to 20 percent in the society whereas its exact criterion proved it to be 3% in men and 4 to 9 % in women.

Depression and physical stress being directly inter-related are contributed by environment, physical, psychological and social stimulants whereas various stressors creating weariness result in depression [3]. Job stress is defined as the harmful physical and emotional responses arising from mismatch of job requirements with workers’ capabilities, resources and needs. It causes poor health, hypertension, cardiac problem, substance abuse reducing life enjoyment, immunity, mental and physical wellbeing of workers leading to frustration and irritability. Stressful work multiplies the substance abuse used to cope with stress.

This study is meant to assess stress level, its responsible factors and coping styles. Results showed that 28 (24.7 %) respondents are in high stress due to time pressure, 22 (16.5 %) in high stress and 16 (12 %) no stress due to time pressure. 26 (19.5 %) participants no stress due to family safety, 38 (28.6 %) very low stress due to caring for others, 41 (31 %) low stress due to financial situation, 33 (25 %) moderate stress due to physical problem, whereas 9 (6.8 %) in extreme stress due to own work situation.

Table 3 revealed the stress factors as 6 (4.5 %) stress strongly disagree due to high death rates, seniors’ not helpful, numerous patients at the same time and conflicts with colleagues, 30 (23 %) disagree due to seniors’ not being helpful, 47 (35.5 %) neutral for all factors, 53 (40 %) agree to learn new things, 45 (34 %), strongly agree because job requires a high skills level.

The Table 4 data revealed as: 54 (40 %) participants agree with the coping style of stress mentioned in the table, 33 (25 %) out of 133 strongly agree with sleeping more than usual, 33 (25 %) disagree coping stress by medication, 50 (38 %) neutral by eating more than usual whereas 21 (16 %) strongly disagree by medication.

Nurses have their own perception about stress sources due to their changing roles and workplaces like in the United Kingdom health services suggesting handling measures such as taking initiatives to handle workforce stress identifying future direction.

A literature search from January 1985 to April 2003 using the key words, nursing, stress, distress, management, job satisfaction, staff turnover was conducted to identify stress sources in adult and child care nursing.

Workplace stress in nursing: Stress intervention measures should focus on stress prevention for individuals as well as handling organizational issues requiring to evaluate intensity of individual distress. Several studies focusing on the relation between stress, illness and people responses distinguish various stress aspects including focusing on stress at work to explore possible management strategie [9].

Others classify stress in the workplace as “Occupational stress” caused by work demands pressure or problems effecting not only services quality but also the staff psychology driving employees to depression, absenteeism or job resignations causing increased staff turnover with serious financial concerns for an organization.

The most common complaints of stress as shown in the Table 2 are as follows:

“Carson & Kuipers” model Investigated the work environment changing factors and classified them into three groups:

• Specific occupational stressors varying according to the problems or strains faced by each professional group. (e.g. changes in the health service may be a major source of stress).

• Stressors that are derived from major life events.

• Minor stressors that obtain power and can affect the individuals as they accumulate.

Murphy (1999) suggested that actions which aim to eliminate stressful job characteristics or conditions can be defined as organizational stress interventions and are classified as:

• Primary prevention: Which includes role clarification, increase of autonomy or increase of control which employees have to reduce work overload.

• Secondary prevention: Help workers develop coping skills as a means of handling management stress.

• Tertiary prevention: Special assistance programs i.e. the treatment of workers who suffer from stress related disorders.

Conclusion

Stress starting from headache, backache, mental fatigue, frustration and tension leading to chronic illness like cardiovascular diseases, hypertension, colitis, depression or anxiety not only affects individuals’ work performance and their physical and psychological health if prolonged or not timely controlled, but also influences quality of health care delivery and patient safety. The occupational stress such as workload and organizational leadership are the major factors whereas effective management and coping strategies produce nurses’ work achievement and reduce their stress level. This study was meant to reveal causes and coping strategies of stress to build awareness and knowledge among nurses and nursing students requiring managers and supervisors to develop strategies to promote quality of working conditions for the profession and reduce the working stress.

Limitations

This study has several limitations for having been conducted only on female charge nurses, team leaders and head nurses of semi-private hospital of Lahore without associating their male partners as well as government hospital and health care nurses. This is worth-mentioning here that the study finds no role of demo-graphic factors therein.

Recommendations

This study aimed at reducing stress through nursing management and the well- planned organizations not only support nurses but also help to develop the profession as evident from the fact that nurses working therein comparatively produce high quality care. The study found out stress causes and its management interventions regarding importance of social support and role of leadership. The author recommends to combine literature review with other research methods like qualitative and quantitative directly related with nurses through interviews which would provide study with an accurate data, specific details and more information. An empirical study in this regard would evaluate nurses’ feelings about stress as contrary to literature review.

Stress therapies such as message, acupuncture and acupressure stand proved to be the stress relief and reducing the burn out. Other coping strategies including motivations towards social activities, hobbies and interests help the nurses to get rid of stress syndrome without experiencing harmful consequences. Any activity or action like sports, meditation, cognitive therapy and relaxation techniques can serve as stress relief. There are other methods also like holistic ones demanding nursing to participate in self-care actions like exercises, eating healthy and involving in new hobbies for the reasons that the only person healthy in body, mind and spirit can provide health care to others.

Conflict of Interest

All authors declare no conflicts of interest regarding this manuscript.

Acknowledgement

Quite at the outset, I thank the Almighty Allah, the most gracious. The most merciful. For providing me with strength and courage to keep me going throughout the period of my studies, even when there seemed to be no way.

During my research and preparation of this report, I got support, advice, and encouragement from several respected persons whom I am profoundly indebted to and express utmost gratitude and most sincere thanks to all of them.

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