REDUCING THE JOB-RELATED STRESS AMONG NURSING OFFICERS IN A BASE HOSPITAL, SRI LANKA

Introduction: Stress is a one of risk factors affecting all health categories including nursing officers. Objective: To implement a Mindfulness Base Stress Reduction (MBSR) intervention for nursing officers at base hospital Horana Sri Lanka. Methodology: Intervention study with randomizing nursing officers for two groups (i.e., control group and intervention group) was conducted in Base hospital, Horana. A sample of 96 nursing officers was randomized to two groups. Prior to randomization, baseline stress level was assessed by Expanded Nursing Stress Scale (ENSS). A six-week mindfulness-based stress reduction (MBSR) package was implemented for intervention group. Similar to the baseline assessment, effectiveness of the MBSR package was assessed following the implementation in both groups. Student t test was used to compare intervention and non-intervention group. Initially, 48 participants were selected for each arm. Out of the remaining participants, 42 in non-intervention group and 41 in the intervention group were completed the post intervention assessment, successfully. Results: Several aspects of stress were improved with the intervention. As examples, perception of stress due to issues of inpatient care including procedure painful to patient (p =001), The death of a patient with whom you develop with a close relationship ( p<0.001)), Physician(s)not being present when patients dying ( p =0.001), watching the patient suffer( p <0.001), were significantly improved in the intervention group. Conclusion: Result of present study shows benefits of MBSR intervention to reduce perception of stress among nursing officers. The MBSR package is recommended for other hospitals.


ISSN: 2320-5407
Int. J. Adv. Res. 9(01), 573-580 574 individual reasons and family reasons, etc. The managements of health care organization and the clients demand high quality service may lead to stress.
Although the Sri Lankan evidences are scattered and scanty, work relatedstress(WRS), burn-out and reduce empathy are probably a major problem among health care workforce. In fact in Europe 28% of workers suffer work related stress(European Union & European Foundation for the Improvement of Living and Working Conditions, 1997)The WRS is a serious condition which affects all compartment of health including physical, mental, social and spiritual health (Sheldon et al., 2007).Psychological stress is usually developed when person faces excess environmental demand than his or her adaptive capacity. WRS is associated with severe illness including cardiovascular Diseases (Fishta -Backe,2015) There are several techniques for stress management. "Mindfulness meditation" which originally came from "Theravada tradition of Buddhism" is used by some organizations to cope stress among their workersKabat-Zinn, J. 1982; Dunne,2015). "Mindfulness" is kind of practice or training which increase awareness of his/her movement, thoughts, and emotions (Bishop, 2004;Weilgosz et al.,2019)There are evidences that "Mindfulness Based Stress Reduction" (MBSR)as cost effective for stress reduction (Lengacher et al., 2015).
Assessing the stress level is important to understand the stress level and the effectiveness of the intervention. Stress levels have assessed using different study instruments. As an example, stress level among nursing officers have assessed by "Nursing Stress Scale" (Gray-Toft , Anderson, 1981).However, it is argued that the stresses are provoked by changing of health care setting and working environment which is not reflected in NSS Therefore, Expanded Nursing Stress Scale(ENSS) have developed with necessary modifications (Milutinovic et al., 2012;Sarafis,p et al., 2016).This study aim to assess the effectiveness of an intervention package to reduce job related stress among nursing officers at a secondary care government hospital in Sri Lanka.

Methodology:-
This randomised control intervention study was conducted at the government hospital, Horana, Sri Lanka. The hospital comprised of 501 beds for the inward care with multi-specialties. The study target to nursing officers in the hospital (wards= 157, clinics and out-patient"s department = 16, special units -91). MBSR based intervention was designed. Out of the total number of nursing officers, 147 consented for the study, 96 nursing officers were randomly selected for the study based on the estimated sample. The study comprised of three phases as the (1) initial baseline survey on perception of stress, (2) implementation of the MBSR and (3) assessment of the effectiveness MBSR. The study flow is graphically shown in figure 1. Initial baseline survey on perception of stress (i.e., pre-assessment):Allselected nurses for the study was requested to complete the(i.e., self-administered) questionnaire. The questionnaire included ENSS which face validated to Sri Lankan context by an expert panel. ENSS comprised of 57 terms. Each question had Likert-scale with five points. Each response of an item measures the stress level as "(1) Never stressful", "(2) Occasional stressful", "(3) Frequently stressful", "(4) Extremely stressful" and "(5) not applicable".
Implementation of the MBSR: Once the baseline survey was completed, the study group was randomised as (1) intervention group and (2) non-intervention group. Intervention package was included several sessions of instructions, skills development and introduction of newer techniques of mindfulness. Each session limited to a period of two hours. Contents of the sessionsincluded "sitting meditation"," bodyscan","Hatha Yoga" and "threeminutes breathing space". Further, walking meditation, relaxation exercise and breathing exercise techniques was also used for the programme. Each session was limited for 30 minutes with using the practical sessions. Audiovisual materials were used as appropriate. Table1 gives the content of intervention. The second session was conducted after three days and all the other sessions were conducted one week apart. This event is also a meditation which make attention to body and breath 5 loving kindness meditation A concept of Buddhism also which promote the kindness and empathy (3) Assessment of the effectiveness MBSR:One month after implementation of the intervention, effectiveness of the MBSR was assessed with the questionnaire used for the base line survey. Post-assessment questionnaire was administered to both intervention and control group.
Ethical clearance was obtained from University of Colombo Sri Lanaka.

Results:-
Total of 90 (non-intervention group = 47 and intervention group = 43)nurses completed the questionnaire at the preassessment. Following the intervention, 83 nurses (non-intervention group = 42 and intervention group = 41) were completed the questionnaire (i.e., post assessment). All nurses completed the post assessment questionnaire (n = 42) were attended all the sessions of the MBSR package.
In terms of age, civil status, qualifications, service period, and social support, intervention and non-intervention group were not different (table 2 and table 3).   It could be noticed that a considerable number of factors are different between intervention and non-intervention group after the intervention. Out of the factors assessed related to patient care (n = 15), nine factors were significantly different. Out of the factors assessed related to nursing care (n = 7), two factors were significantly different. Out of the factors assessed related to emotional needs of the patients (n =7), three factors were significantly different. Out of the factors assessed related to issues with administration (n =12), seven factors were significantly different. Out of the factors assessed related to issues with working environment (n =13), three factors were significantly different.

Disscussion:-
Mindfulness is bringing attention on one's experience of the present moment without judgment or attachment to outcomes. It encourages individuals to make changes in their thoughts, feelings and bodily responses (Botha,Gwin, Purpora, 2015). These interventions help the individuals toskilfully adapt of unpleasantthoughts, feelings, situations and events(Raj-Kumarp2018).Mindfulness is practice or developing skill of self-awareness in Buddhist teachingVipassana" (Dunne,2015). It is also called insight meditation.Sri Lankan follow "Theravadi" tradition of Buddhists, "Vipassana" is a known thing to them. However this type of MBSR programmes came from Western scholars.Kabat-Zinn (1982) developed the Mindfulness-Based Stress Reduction (MBSR) program, which is a clinical program to facilitate adaptation to medical illness.
At present both western type MBSR programmes and Mindfulness programmes conducted by Buddhist monks are in rising popularity in Sri Lanka. Applicability of Mindfulness practices has been realizing by Sri Lankan organizations especially in education sector. Sri Lankan health sector also has made some isolated efforts especially in private sector.
In the present study, as estimated by the sample size, 96 nursing officers were randomized to two groups. Prior to the intervention, stress level was assessed and repeated after the intervention. The intervention attempted to assess the effectiveness of an intervention package among nursing officers in a government hospital. Pre assessment of the nursing officers was followed by six-week intervention. The intervention includes Mindfulness Based Stress Reduction programme.
Due to time factor and some administrative issues this study was limited 6 weeks instead of 8.However some previous studies also varied in duration too.
The range of intervention may be eight week(2.5 hour sessions a week,four week(30 minute session per week) 10 month programme(2.5 hour session per month) This was due to the limitation of practicality and resources. Nevertheless, some of the previous studies had limited to four weeks. Patricia et al (2008) have done study among nursing officer which consists of four week programme sessions of 30 minutes and daily practice of fifteen minutes. This study also has been shown reduction of stress.
We have used professional trainer who has vast experiences in conducting MBSR programmes in private sector companies and International Schools to conduct MBSR intervention.
Comparison of the two groups by their selected socio-demographic characteristics (table 2) and the social support (table 3) showed that there was no significant difference between two groups. Therefore, the differences in the factors in the post intervention could be attributed to the impacts of the intervention.
As significant association is seen in many variables of ENSS( According to previous studies, drop out rate of MBSR intervention is less than 20% (Kabat-Zinn, 1982). Dropout rate in the present study including the non-intervention group was 16%. Probably this shows the affinity of nursing officers to involve in a research project of this nature. Importantly, it shows the potential for scaling up the similar intervention for other health care institutions.
Present study selected the both intervention group and non-intervention group from the same hospital. Selection of the control from the same hospital may likely to contaminate the intervention package content with the participants of control group (i.e., non-intervention group) which leads to reduce the estimate of impact of intervention. However, selection of the control from the same hospital is important to identify a group with same level of institutional impact for the stress.
The stress among health care workers is not uncommon. Perhaps, stress has a negative impact on the physical health, mental health and social heath. Nursing officers are important category of health care team which is generally exposed to stress due to their nature of work and working environment. Growing demand of the health care industry which increases the indoor and outdoor patient caring leads to increase work load. MBSR offers non-invasive cost effective and internationally well-established model for reducing stress among nursing officers. Basis of mindfulness practice is to help people to alter their perception for painful thoughts and emotions. As described earlier, the results of the present study show the success of the intervention.

Reccomendations:-
As this intervention is a non-invasive and cost effective method, it can be introduced to other institutions. Further studies are suggested to other curative settings and other health professional categories to explore benefits of MBSR