Psychological working conditions and predictors of occupational stress among nurses, Salaga Government Hospital, Ghana, 2016

Introduction Occupational stress is a recognized health problem among nurses. Globally, its prevalence varies between 9.2% and 68.0%. It detracts from nurses' quality of life and efficiency of job performance. In Ghana, we do not know the important contributory factors to this problem. Our study sought to identify the important predictors of occupational stress among nurses. Methods In January 2016, we conducted an institutional-based survey among nurses of Salaga Government Hospital. They completed a five-point Likert type questionnaire adopted from the British Psychological Working Conditions Survey, and the Nurse Stress Index. Across 30 predictor variables, a mean score of 4.00 to 5.00 represented high to extreme occupational stress. We performed bivariate and multivariate analyses to identify important predictors of occupational stress at 95% confidence level. Results Of 167 nurses, 58.1% (97) were females. Respondents who experienced high to extreme stress levels had a 2.3 times odds of reporting sickness absence (CI: 1.03-5.14). Sources of occupational stress included: manual lifting of patients and pieces of equipment (OR: 16.23; CI: 6.28 - 41.92), the risks of acquiring infections (OR: 14.67; CI 5.90 - 36.46), receiving feedback only upon unsatisfactory performance (OR: 28.00; CI: 9.72 - 80.64), and inadequate opportunities for continuous professional development (OR: 63.50; CI: 19.99 - 201.75). Conclusion The working conditions of nurses were stressful. The most significant predictors of occupational stress were poor supportive supervision by superiors, lack of adequate skills to perform routine tasks, uncertainty about their job role, and the lack of adequate opportunities for career advancements.


Introduction
Stress is the psychological and physiological response to undesirable experiences generally termed as stressors [1]. Though "stress" is more commonly thought of as harmful, responses to stress are a spectrum that stretch from the less discussed "eustress" -where positive responses such as innovation and improved productivity result, to "distress" -which is associated in varying degrees to the better known negative outcomes of stress [2]. An individual's stress threshold is influenced by the source of stress, their personal characteristics, experiences, and coping skills [3]. Stress, stressrelated diseases, and their ensuing disabilities are prevalent the world over [4].
Four main sources of stress have been described viz. the physical environment, social stressors, physiological, and psychological [5]. In varying degrees of importance, all these sources of stress prevail in various occupational settings [6]. Occupational stress results from a perceived imbalance between workplace stressors and coping abilities of the worker; leading to negative health outcomes [7]. According to the American Institute of Stress, about eight of ten occupational injuries, and four of every ten employee turnovers are largely stress related [8]. Occupational stress has also been implicated in the aetiologies of anxiety and depressive symptoms [7,9].
Occupational stress is a recognized health problem among nurses [10]. Globally, its prevalence among nurses varies widely between 9.2% and 68.0% [5]. An interplay of several factors at the workplace contributes to occupational stress among nurses. Key among these factors are: excessive workloads, the need for a constant attention to details of patient care, dealing with both physically and emotionally exhausting situations, the lack of adequate autonomy for decision making, and low levels of cooperation from patients and their relatives [4,11]. Furthermore, work settings and the sociocultural orientation of nurses have been reported to influence thresholds for developing stress across communities and countries [12].
Occupational stress detracts from nurses' quality of life and efficiency of job performance [10]. Nursing related stress also contributes to absenteeism and high turnover rates in the profession [13]. Stressed nurses tend to be apathetic towards patients, thereby increasing their error rates in administering treatments [14]. The results are poor patient care, poor disease outcomes, and increased cost of healthcare services [15].
Assessing this subjective phenomenon of stress is bound to be difficult, and particularly so in an occupation such as nursing that requires diverse skills, team work, concentration, and emotional control. Yet, in order to tackle this problem among nurses, a good understanding of their sources of stress is non-negotiable.

Study area
The study was conducted in Salaga Government Hospital. It is a primary healthcare facility located in Salaga; one of the rural districts in Northern Ghana. Based on a population of 135,000 from the 2010 census, Salaga Government Hospital serves a projected population of about 170,000 people within its catchment area [17]. Services offered by the hospital include: outpatient consultation, in-patient care, general surgeries, obstetric and gynaecological services, antenatal and postnatal care, biomedical and radiological diagnostic services. It also serves as a referral center for smaller health facilities; in and around the district.
The average nurse in the hospital is expected to work a maximum of seven hours for day duties, and twelve (12) hours for night shifts.
Depending on the working unit and the prevailing staff strength, night shifts run for four (4) to seven (7) days followed by three (3)

Operational definition of occupational stress
This is the harmful physical and emotional responses that occur when a worker's capabilities, resources, or needs do not match the job demands.

Study design
The study was an institutional-based survey.

Population
The source population was all nurses of Salaga Government Hospital.
The study population was all nurses of Salaga Government Hospital who were available in the facility during the data collection period.

Inclusion and exclusion criteria
All nurses in three categories (state registered nurses, midwives, and enrolled nurses) who were working in the hospital at the time of data collection and consented to participate in the study were included.
Nurses on pre-appointment orientation were excluded from the study.

Data collection instrument
In January 2016, we collected data over a period of four weeks using

Data quality control
Data were entered into Ms-Excel version 2010 and assessed for completeness, consistency, and missing values. Two questionnaires that were incomplete were excluded from the analysis.

Data analysis
The cleaned data from excel were imported to STATA 13.1 version for analysis. We performed summary descriptive statistics; including the computation of percentage mean scores for each of the six (6) stress subscales using the following formula: (Actual Computed Mean Score / Maximum Potential Mean Score) X 100%.
The percentage mean scores were used to compare the relative importance of the six subscales on occupational stress among the nurses. Absolute mean scores were computed for each respondent by summing scores of the 30 items on potential predictors of occupational stress and dividing by 30. For each respondent a mean score range of 1.00 to 3.00 across the 30 predictor variables represented low to moderate stress, and a mean score range of 4.00 to 5.00 represented high to extreme stress. All statistical analysis were performed at 95% confidence level. We used bivariate logistic regression to determine variables that were independently predictive of high to extreme occupational stress. We then used the stepwise backward elimination process to enter selected variables into a multiple logistic regression model based on positive association with outcome variable with a p < 0.10 at the preliminary bivariate analysis.
In the resulting model, statistical significance for predictors of high to extreme occupational stress was set at p < 0.05.

Ethical considerations
The study was conducted as part of a health needs assessment with institutional permission from the hospital health management team.
It was an in-service research aimed at improving the health of staff and quality of care for patients. The nurses understood that the study was optional, and they could withdraw summarily from it at any point without any sanctions. They also understood that, participation in the study did not come with any personal gains; financial or otherwise.
To maintain confidentiality, respondents understood and complied with the instructions that personal identifiers were not accepted on the questionnaire sheets, and that completed questionnaires were to be returned in sealed envelopes that were provided. These were deposited at the hospital administration and opened at the end of the data collection period.

Socio-demographic and work related characteristics of respondents
A total of 189 eligible nurses were invited to participate. Of these, 167 returned completed questionnaires giving a response rate of 88.4%.
The median age of respondents was 32 years (range 19 -62 years).

Psychological working conditions of respondents
Of the 167 nurses, 35 (21.0%) experienced high to extreme levels of occupational stress. All the nurses worked an average of 45 ± 3.7 hours each week. In the year preceding the assessment, a total of 82 working days were lost to sickness absence from 40 nurses.
Compared to nurses who had mild to moderate stress levels, nurses who experienced high to extreme stress levels had a 2.3 times odds of reporting sickness absence (CI: 1.03-5.14). Burnout was the leading condition (37.5%) implicated in sickness absences among the nurses ( Figure 1). Whereas 44.3% (74) of respondents perceived that their work adversely impacted their physical health, 82.0% (137) perceived the mental health was more adversely impacted by their work (Figure 2).

Predictors of occupational stress among respondents
Of the six (6) subscales, workload produced the highest percentage mean score of 79.66% (Table 2).
From a bivariate analysis, all the predictors had positive associations (OR crude > 1) with high to extreme levels of occupational stress among the nurses (Table 3, Table 4, Table 5 ). However, six (6)  outcomes are bound to be sub-optimal also [3,14]. In a descriptive correlational cross sectional study of nurses' perceived job related stress and job satisfaction in Amman private hospitals in Jordan, an insufficient number of nurses resulting in excessive workloads was among the leading causes of perceived occupational stress [22].
In our study, compared to those who do not undertake trivial tasks (dusting, mobbing floors, picking medicines from the pharmacy), those who did were over 8 times more likely to experience high to extreme levels of stress. It has been suggested that, to reduce workload of nurses, staffing levels of both nurses and administrative staff must be increased, and more of the paper work delegated to the administrative staff [23]. By extension, though these trivial tasks are traditionally part of nursing duties, delegating such tasks to another cadre of staff should take some workload off the nurses. In China also, a study by Wu and colleagues on the relationship between burnout and occupational stress among nurses, work overload was reported as an important source of stress [24].
Dealing with terminally ill patients and dying patients is a source of stress among our respondents. In particular, counselling bereaved patient relatives has about a threefold significant risk (CI: 1.18 -6.24) of stressing up our respondents. This finding is in keeping with findings from a cross sectional study on job related stress among nurses working in some public hospitals in Ethiopia, where an overall job related stress resulted from dealing with death and dying patients [5]. Also, in an assessment by Makie of stress and coping strategies amongst registered nurses in a tertiary hospital in South Africa, emotional issues surrounding death and the dying patient was perceived by respondents to be one of the most stressful aspects of their work [25].
Among our respondents, those who experience verbal and physical abuse from patient relatives have a five-fold significant risk  [27]. In a study that explored the sources of verbal abuses suffered by nurses, verbal abuse from patient relatives was found to be second (25%) only to verbal abuse of nurses by other nurses (27%) [28].
Inadequate opportunities for our respondents to advance their career and skills through continuous professional developments had a significant influence in their perception of high to extreme levels of stress. After controlling for confounders, the unfulfilled desire of respondents to advance their careers remained a significant predictor of high to extreme levels of stress. In their study of leadership, organizational stress, and emotional exhaustion among hospital nursing staff in Belgium, Sabine and colleagues found a negative correlation between intellectual stimulation and stress [29]. Inability to update their skills in the face of fast changing work demands is an agreeable reason for occupational stress perception. Our findings also show that, lack of specialized training for present tasks and uncertainty about job description (also termed role ambiguity) were strongly associated with high to extreme levels of occupational stress.  [27,32,33]. According to the influential Job Demands-Control (JD-C) model, job related stress is expected to result from high job demands and low job control as well as an interaction between both job characteristics. An inclusive organisational leadership that allows nurses to participate in work scheduling and the determination of acceptable methods of performing some tasks makes them less vulnerable to occupational stress [34].

Study limitations
First, the data obtained and analysed in this study are based on evaluations of subjective responses. Though most of the nurses participated, sample size was still small. As such some of the confidence intervals were very wide and hence the estimation of the strength associations of predictors to the outcome (high to extreme stress) could be exaggerated. Second, the generalizability of the findings of this study is limited to primary level hospitals like Salaga Government Hospital that are situated in rural areas. Therefore, the findings may not be generalized to include nurses who work in both public and private hospitals located in urban areas where workplace conditions and staffing strengths are mostly better.

Conclusion
The What is known about this topic  Even with the best of working conditions, nursing is stressful;  Stress adversely affects the health and performance of nurses and has also been associated with poor patient outcomes;  Factors known to contribute to occupational stress among