Determinants of occupational stress among health care professionals working at a setting of a specialized mental hospital, Addis Ababa, Ethiopia, 2017: a hospital-based cross-sectional study CURRENT STATUS: UNDER REVISION

BACKGROUND: Stress at workplace among health professionals predisposes to an inefficient organization, absenteeism from work, job dissatisfaction, and various physical, psychological as well as behavioral health problems. Despite this, little has been done into this health issue. So, this study assessed occupational stress and its determinants among health care professionals. METHODS: Hospital-based cross-sectional study was implemented among 398 participants from May 1 to June 1, 2017, at Amanuel hospital, Addis Ababa, Ethiopia. A pretested and self-administered questionnaire was used to collect data. Nursing stress scale was used to asses occupational stress. Data was entered to Epi-info-version-7 and analyzed with SPSS-20. Descriptive statistics were also utilized. Binary logistic regressions with odds ratios and 95% confidence interval were used. P-value < 0.05 in final model was significant. RESULTS: Among 398 participants included in the study, 393 provided complete information which gives a response rate of 98.7%. This study showed that 46.8% (95%CI: 41.7, 51.7) of health professional were having occupational stress. Multivariable binary logistic regression analysis showed that working in emergency department (AOR=3.48; 95% CI: 2.12, 12.08), forensic psychiatry unit (AOR=3.48; 95% CI: 1.25, 35.06) and job dissatisfaction (AOR=2.606; 95% CI: 1.563, 4.345) were risk factors for occupational stress. CONCLUSION: Occupational stress among health professionals was high. Work-related variables (working in the emergency department and dissatisfaction with the job) were its risk factors. Attention has to be given for such an important public health issue.

Occupational tress could be defined as the psychological or physiological response of workers when challenged with much workloads and duties which are not proportional to their capacities and knowledge which results in an inability to cope with their work demand (1).. Healthcare settings are particular risks for occupational stress, burnout and job dissatisfaction because of the increased patient load and the high patient to health professional ratios (2).. In general, an imbalance between work demands and the capacity to cope with such demands will cause stress (3)(4)(5). Impacts of stress in work were estimated to be approximately $5.4 billion every year worldwide (6).. Half a million employee in Britanie was facing stress at an ill-health causing level (7)..
A study from Jordan revealed stress among general physicians, dentists, pharmacists, and physician assistants was 33%, 32%, 25%) and 19% respectively (8).. A study in Ireland showed that occupational stress was 57.5% among pharmacist (9).. A Study in Pakistan found that 52% of the participants had job stress (10).. A study in Taiwan showed that 66% of nurses, 61.8% of physician assistants, 38.6% of physicians had job-related stress (11).. Another study in Taiwan revealed 17.2% of nurses were stressed (12).
A study in Jordan revealed that the risk factors for occupational stress among health professionals were dealing with difficult patients and Heavy workloads (16).. Similar earlier researches also showed that risk factors for occupational stress were age, sex, education, marital status, having children, hours worked per week, poor social support in USA (17),, poor interaction with superiors, not finding the suitable job, feeling anxious about the future and financial difficulties in turkey (18),,workplace violence in Italy (19),, type A behavior pattern (20),, job strain and over commitment (11),, widowed/divorced, low workplace support (12),, Job insecurity (21),,uncertainty regarding patient treatment, conflict with supervisor and workload in Ethiopia (22)..
Occupational stress leads to various transient and long-term complications which can be physical like hypertension and heart diseases, behavioral like substance abuse and emotional such anxiety as well as depressive symptoms (23).. Besides stress, at workplace decrease, the efficiency of organizational, contribute to increased staff turnover, frequent absence from work due to sickness, and decreased satisfaction in one's job (10,21)..
Behavioral irritability, concentration difficulty at the workplace, somatic complains like gastrointestinal problems, common cold, chronic back pain, and headaches are also frequent impacts of work-related stress (8,24,25

Study population
The survey population comprised of health workers at Amanuel Specialized Hospital in the study period and who were incorporated in the sample. Health staffs seriously ill during at the time of questionnaire distribution and those who had not worked for a minimum of six months were not included.

Sampling procedures
Single population formula had been utilized to predict the study's appropriate sample.
Considerations during the calculation of the magnitude of the sample were a 95 % CI, 5 % margin of error, the magnitude of occupational stress 38% from an earlier Ethiopia study (15) and 10% non-response rate. The predicted final sample was 398. Then proportional allocation for each profession was done and 208 nurses, 50 MSc psychiatry practitioners, 18 BSc prescribers, 9 psychiatrists, 30 general physicians, 56 pharmacy professionals, 22 laboratory technologists, and 5 clinical psychologists were included. A profession-specific simple random sampling was implemented to collect data.

Operational definitions
Occupational stress: A score greater than or equal to 43 which is the median score of nursing stress scale in the current study was considered as stressed (26).. Current substance use: Use of Khat, alcohol, and cigarette ninety days before the collection of data.  Type A personality behavior was assessed by 12 questions and a score greater or equal to 17 out of 32 is considered as having type A personality (15).. Job satisfaction was assessed using the Minnesota Satisfaction Questionnaire (28.

Data management and quality control issues
The questionnaire had been translated to the Amharic language to make it understandable by all participants. Short term training was provided for supervisors as well as data collectors. A pre-test was implemented on 5%(20) of sample size two days before the start of real data collection among St. Paul millennium medical college hospital staffs, a hospital located 6 kilometers far from the study area and the results were not included in the final study. Incomplete questionnaires were not included in the analysis.

Data processing and analysis
Epi-info version-7 had been utilized as a data entry tool and analysis was conducted with version-20 of SPSS. Bivariate regression was implemented by running each factor variables and occupational stress. Explanatory variables having p-value<0.2 in bivariate regression were together entered to a multivariate logistic regression model to identify the factors of occupational stress. Association of factor variables and the outcome was investigated by the odds ratio with 95% CI and a p-value <0.05 in the last model was used as a declaration point to identify the factors associated with occupational stress.

Results
Background characteristics of the respondents Concerning monthly income 197(50.1%) of them were between 2000-3500 ETB (Table 1).

Work-related and behavioral characteristics of respondents
Work experience of respondent's ranges from 1 to 34 years and 129(32.8%) of them have less than 7 years' experience. About 161(41%), 252(64.1%) and 213(54.2%) of respondents were from psychiatry ward, have rotating work shift and works for 39 up to 54 hours per week respectively. One hundred sixteen (29.5%) of participants were not satisfied with their job whereas one hundred forty (35.6%) of respondents were found to have type A personality. About 63(16%) of study subjects used substances in the past 3 months before data collection. Only 12(3%) and 4(1%) of health professional were found to have medical and mental illness respectively ( Table 2).
Prevalence of occupational stress among health care professionals A score greater than or equal to the median score of nursing stress scale was considered as occupational stress. The median score of a nursing stress scale for participants in this study was 43. Score 43 and above was considered as occupational stress. From a total 393 health care professionals, 184 of scored 43 and above on health professionals stress scale. The prevalence of occupational stress was found to be 46.8% with 95% CI (41.7, 51.7) (Figure 1). The most frequently reported source of stress in the workplace was found to be a conflict with other health professionals 222(56.5%) followed by conflict with supervisor 221(56.2%). One hundred ninety-five (49.6%) health professionals reported that death and dying issue were the source of stress for them (Figure 2).
Factors associated with Occupational Stress among respondents.
On bivariate analysis the independent variables with P-value < 0.2 were sex, marital status, having children, educational status, monthly income, work experience, working hours/ week, worksite, work shift, current substance use, job dissatisfaction and type A personality behavior. These variables were entered into a multivariable logistic regression to identify the risk factors for occupational stress. However, only worksite and job dissatisfaction were identified to be determinants of outcome variable after multivariable logistic regression.
The risk of developing occupational stress among health participants working in emergency OPD and forensic psychiatric unit were 3.5 (AOR = 3.48; 95% CI: 2.12, 12.08) and 9 (AOR = 8.99 95% CI: 1.25, 35.06) times higher as compared to participants working in Pharmacy/laboratory/office respectively. Dissatisfaction by one's job was identified to be a predisposing factor for stress at work among health care staffs. Those professionals dissatisfied by their job were 2.6 times more likely to develop occupational stress than those professionals satisfied by their job (AOR = 2.61; 95% CI: 1.563, 4.345) ( Table 3).

Discussion
Stress to a normal extent increases workers performance and life quality since people have to face and enjoy challenges in day to day life but if excessive and beyond the beneficial aspect, it imposes harm on an individual as well as organizations(28).. It will lead to complications which can be physiological (such as hypertension, heart diseases), behavioral such as substance abuse and emotional like depression (23).. Besides, it affects the efficiency of organizations, the stability of staff at the workplace as well as the worker's satisfaction in the job (10,21)..
The prevalence of occupational stress in this study was 46.8%. This is in agreement with a study in South Africa 51% (13) but higher than from Taiwan 17.5% (12),, Malaysia 33.3%, and Ethiopia 38%(15).. A study from Jordan revealed occupational stress among general physicians, dentists, pharmacists, and physician assistants was 33%, 32%, 25%) and 19% respectively (8) which is also lower as compared to the present study. Possible reasons may be measurement tools used, study population and setting. GHQ was used in Jordan, Taiwan, and Malaysia but nursing stress scale in the current study. Study subjects were general physicians, dentists and physician assistants for Jordan, laboratory technicians for Malaysia and nurses for Taiwan and Earlier Ethiopian study but in the current study almost all health professions were considered. Besides, the setting in the current study is a psychiatric hospital but non-psychiatric units in previous studies.
On the contrary, it is relatively lower than published studies in different countries like Northern Ireland 57.5% (29),, Ayub Medical College in Pakistan, 52%(30),, India, 73.5% (21) and Ethiopia, 58%(31).. A study in Taiwan showed that 66% of nurses, 61.8% of physician assistants, 38.6% of physicians had occupational stress (11).. This was also higher than the result of the current study. The sample size variation, difference in methods and organization culture, as well as social and cultural issues, might contribute to this. Besides this, the difference in risk factors between current and previous studies may cause this variation.
The most common source of stress in the workplace among study respondents were found to be a conflict with other staffs 222(56.5%) followed by conflict with supervisor 221(56.2%). This was in contrast to another study result in Ethiopia in which death & dying subscale, uncertainty about patient treatment and workload were most identified sources of stress with a mean score of 62.94 %, 57.72 % and 57.6 % respectively (31)..
The working unit was a risk condition for occupational stress as justified by professionals working in emergency OPD were at 3.5 time's higher risk as compared to health care staffs who work in Pharmacy/laboratory/office. This was supported by a study done in emergency department Nurses in Taiwan (32) anda study in Ethiopia whichshowed thatworking in emergency units and medical wards were associated with occupational stress (15).. A possible reason for this might be an emergency unit is mostly dealing with critical patients and professionals are uncertain of diagnosis and treatment of patients.
Working in a forensic psychiatric unit was also 9 times at higher risk as compared to health care staffs working in Pharmacy/laboratory/office. Findings of the current study showed that there was an opposite relationship between satisfaction in job and risk of occupational stress. A health care worker who was dissatisfied in their job was at 2.6 times higher risk of occupational stress as compared to professional satisfied with their job. This finding was supported by a study from southwest Ethiopia which concludes as there was a reciprocal relationship among occupational stress and job satisfaction (31).. Besides, a study done in Sao Paulo is also in line with this idea (33).. The possible reason might be dissatisfaction in the job may cause low self-esteem, hopelessness, poor interpersonal relationships and poor skill of coping from stress and will stigmatize them.
Socio-demographic variables such as age, sex, education, marital status, having children were not risk factors for occupational stress in this study. This is against the findings of studies in the USA (17) and the difference might be due to socio-cultural differences between professionals in the USA and Ethiopia.
However, using nursing stress scale for assessment of occupational stress in health professionals is a limitation of this study since no validated tool to asses stress for the health professional in Ethiopia. Additionally, it is difficult to explore the causal relationship between occupational stress and its risk factors since the study is crosssectional. Moreover, the shortage of studies in Ethiopia makes it difficult to compare this result with other studies in Ethiopia.

Conclusion
Occupational stress among health care professionals in this study was high (46.8%). This implies that it is a great public health concern. Working in the emergency department as well as the forensic psychiatry unit from work-related variables and dissatisfaction with one's job were risk factors significantly associated with occupational stress. Early screening of health professional for occupational stress and its risk factors has to be given   Tables   Table 1 Distribution of health care professionals by their background characteristics  Others*: catholic, jobha, wakifata    Sources of occupational stress among health care professionals working at ASMH