Occupational Stress, Strain, and Coping among Nursing Personnel: A Hospital-Based Cross-sectional Study

Introduction

A sense of mental or bodily strain is referred to as stress. It can be triggered by an event or idea that makes a person upset, furious, or anxious. The body's response to a challenge or demand is known as stress. Stress may be beneficial in brief spurts, such as when it aids in avoiding danger or meeting a deadline. Stress, on the other hand, can be harmful to an individual's health, if it lasts for an extended period of time.

Occupational stress is defined as harmful physical and emotional responses that arise when job requirements do not meet the worker's, capabilities, resources, and needs.¹ Reviews suggest that individuals and organizations are largely affected by occupational stress. Despite this, it affects all employed professionals; the burden is too high among health care providers.²³⁴ Occupational stress is a leading cause of tardiness, absenteeism, hypertension, musculoskeletal illnesses, cardiovascular disorders, and drug abuse.⁵⁶⁷⁸⁹ Furthermore, it is a major cause of mental health issues, injuries, and staff turnover.⁶¹⁰¹¹ It also reduces organizational commitment, job satisfaction, quality of care, and organizational productivity.^{12131415161718} Occupational stress is a second work-related problem next to low back pain.¹⁹ Occupational stress affects at least 3 million people throughout the world, with 28% of employees in the European Union suffering from it. It is also to blame for 50 to 60% of losses on working days.²⁰ In the United States, occupational stress affects roughly 83% of workers, resulting in 120,000 fatalities in 2019.²¹ Occupational stress is predicted to cost between $221.13 million and $187 billion, according to a systematic study and meta-analysis, with 70 to 90% of productivity losses.²²

The magnitude of occupational stress among health care professionals ranges from 27 to 87.4%.^72324252627 According to studies performed in Ethiopia, among health care professionals, 37.8 to 68.2% of health care professionals experienced occupational stress.²⁸²⁹ Nursing is a stressful profession³⁰ that necessitates the expenditure of energy on several levels. The job can be physically taxing, with high levels of muscular–skeletal tension resulting in numerous aches and pains. Mentally, nurses must be alert, conduct drug calculations, and respond to vital queries from patients and families. Emotionally, the impact is felt when they empathize and assist others, as well as the toll of working in an environment filled with pain and suffering. The nurses' work environment is often characterized by resource constraints, poor staff support, and organizational change, which add to the energy expended.³¹

Personal strain is considered the result of occupational stressors, according to Osipow and Davis (1988). Personal strain manifests itself in vocational, physical, interpersonal, and psychological strains.³² Strain is described as an individual's response to stress, which can include psychological strains like depression or anxiety as well as physical and biologic strains like illness. Strain is the result of stress or the negative consequences of stressful events.³³ Many authors have hypothesized that coping resources regulate stress–strain correlations. The research and subsequent model of Osipow and Spokane (1984) proposed a closed system. In this closed system, occupational stress, strain, and coping resources interact (interactional approach). Differences in coping resources would attenuate the ensuing strain if occupational stresses were equal for two people. As a result, a high level of occupational stress does not always imply strain. An accurate strain prediction can only be made by taking into consideration the amount of coping resources available.³⁴ Stress is linked to health problems in at least two ways, according to research. First, changes in attitudes and behaviors related to maintaining a healthy condition are linked to the perceived stressful event and the resultant strain. These changes can either limit health-promoting behaviors like exercise, self-care, and relaxation or lead to the development of health-threatening behaviors like smoking, excessive drinking, or drug abuse.³² Menzies was the first to evaluate occupational stress in nursing, identifying four causes of anxiety among nurses: patient care, decision-making, accepting responsibility, and change.³⁵ The nurses' role has long been regarded as stress-filled based on physical labor, human suffering, staffing, and interpersonal relationships that are essential to the work nurses do.³⁶

According to a study done by Sharma et al, the risk of professional stress due to a poor and satisfactory doctor's attitude was found to be approximately 3 and 4 times higher than with an excellent attitude of doctors toward the staff nurses. A statistically significant association was found between the department of posting and the level of stress. Nurses claimed they didn't have time to rest, and 42% of them were stressed out. The nurses who felt that the job was not tiring were found to be less stressed than those who perceived the job as tiring.³⁶ Occupational stress in nursing personnel affects their health and increases absenteeism, attrition rates, injury claims, infection rates, and errors in treating patients. Thus, this study aimed at finding out the areas of occupational stress, personal strain, and coping resources used by nurses.

Methodology

A hospital-based cross-sectional study with a purposive sampling technique was undertaken with registered nurses and nursing officers in one of the superspecialty tertiary care hospitals in Bengaluru, Karnataka, India in the years 2022 to 2023. The sample size was calculated assuming 42% of the prevalence of occupational stress among nurses using the calculator.net. A total of 73 nurses were required among the available 90 nurses with a 95% confidence level and a 5% margin of error to estimate the occurrence of occupational stress among nurses. Finally, 77 nurses with different roles and responsibilities were included in the study and nurses with less than 6 months of experience were excluded from the study.

This study was approved by the Institutional Ethical Committee members of SSNMC Hospital with the reference number SSNMC/IEC/2022/23/129 on October 26, 2022. Before the data collection, a consent sheet was prepared in English with a description of the study impact and attached to the front page of the questionnaires.

The revised version (structured questionnaire) of the Occupational Stress Inventory (OSI-R) scale was used to assess occupational stress among nurses. OSI-R is a concise measure of three dimensions of occupational adjustment: occupational stress, psychological strain, and coping resources. The inventory is divided into three sections: (1) ORQ (occupational role questionnaire): 6 scales, 10 items per scale; (2) PSQ (personal strain questionnaire): 4 scales, 10 items per scale; and (3) PRQ (personal resource questionnaire): 4 scales, 10 items per scale. For the ORQ and PSQ scales, high scores suggest significant levels of occupational stress and psychological strain, respectively (>70T: presence of maladaptive stress; 60T to 69T: mild levels of maladaptive stress and strain; 40T to 59T: within the normal range; and <40T: relative absence of stress and strain). For the PRQ scale, high scores indicate highly developed coping resources (<30T: significant lack of coping resources, 30T–39T). Mild deficits in coping skills (40T–59T: average coping resources and strong coping resources). Interview technique was used to administer the tool to each participant for 30 to 40 minutes by the investigator.

Formal permission was obtained from the hospital authority and from the ethical committee members. The data were collected from October 2 to November 31, 2022, and the researchers collected the data. The nurses from different specialties were requested to respond to the questionnaires through pen and paper with a consent form attached. The instructions were written on the front page and were also given orally. The participants were informed that it will take around 30 to 40 minutes to complete the answers, not to use any material for reference purposes, and not to discuss with other nurses and colleagues to determine the correct answer.

Data quality was assured by proper pretesting of the questionnaires, which was done at a nursing home far from the original research site with a total of 10% of the total participants, to ensure that the questionnaires were easily understood and clear by the participants. Moreover, the participants were asked to ask for any doubts they had while filling out the questionnaires.

The descriptive statistics were presented with the mean, standard deviation, frequency, and percentage. Furthermore, to check the association between demographic variables and stress, strain, and coping resources, chi-square analysis was used. After the data collection, the data were exported from an Excel sheet to the Statistical Package for Social sciences version 16, which was used for analysis and interpretation.

Results

A total of 77 nursing professionals participated in this study. Majority of the study participants (67 [87%]) were female, and 46 (59.7%) of them were in the age group of 20 to 30 years. With regard to the designation majority, 51 (66.2%) of the nursing personnel were working as staff nurses. Furthermore, nurses were mostly equally divided into different specialties for the smooth running of patient care. However, in this study, we have seen the majority of 23 (29.9%) of the nurses working in different wards, administration, and the outpatient department section (Table 1).

The data suggest that the highest number of nurses are suffering from maladaptive and mild maladaptive stress under the ORQ, and the mean score was 63.53, which is above average, whereas PSQs also show that the majority of the nurses are suffering from deliberating and interpersonal strain (IS), and the mean score is 62.20. However, the PRQ shows that there are strong coping skills among nurses, and the mean score (55.09) falls within the normal range (Fig. 1).

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Fig. 1 Mean score of OSI-R. OSI-R, revised version Occupational Stress Inventory.

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Regarding the ORQ role overload, 25 (32.5%) of the individuals exhibited a mild level of maladaptive stress, compared with 44 (57.1%) of the participants who reported normal stress levels. Most of the 46 individuals (59.7%) experienced mild maladaptive stress in terms of role insufficiency. In addition, among nurses working in various settings, role ambiguity (RA) 63 (81.8%), role boundary 31 (40.3%), and physical environment (PE) 55 (71.4%) are associated with the largest number of cases of maladaptive stress. However, the data also demonstrate that a very small proportion of nurses who completed the ORQ do not experience any occupational stress.

In PSQ, the data show that the majority of 35 (45.5%) of the nurses are suffering from vocational strain (VS) and 32 (41.6%) of them are suffering from IS. However, the data also suggest that 41 (53.2%) of the study participants are within the normal range of psychological strain (PSY) and physical strain, 55 (71.4%).

The PRQ data show that recreational coping, 45 (58.4%), and self-care coping (SC), 39 (50.6%), have the highest number of nurses. It shows that the majority of them have strong coping resources. However, 52 (67.5%) of the study participants fell under average coping and social support (SS). Furthermore, in regard to rational coping, the majority of them, 47 (61%), have an average coping style (Table 2).

The association between gender and ORQ was found to be statistically significant in the area of PE (χ2 = 14.702; p = 0.001). Furthermore, the designation of the nurse and ORQ questionnaires were also found to be significant in the area of responsibility (R) (χ2 = 85.364; p = 0.000) and PE (χ2 = 23.469; p = 0.009) of the working area at the p ≤ 0.05 level. This shows that gender and the positive working environment in hospitals have a tremendous impact on reducing stress levels and to reduce burnout. However, other demographic variables, such as age and different specialties in the hospital, were found to be statistically nonsignificant. Therefore, the results show that even though some wards in the hospital have much more intense work compared with other wards, the positive environment can lead to less stress (Table 3).

A significant association was found between gender and VS (χ2 = 7.796; p = 0.050) under the PSQ at the p ≤ 0.05 level. However, other variables such as age, designation, and specialty were found statistically nonsignificant. Therefore, the data suggest that age, personal designation, and different specialties do not have that much of an impact on personal strain compared with different genders (Table 4).

In the subscale PRQ of OSI-R, the factor gender was associated with SC (χ2 = 11.198; p = 0.011) and SS (χ2 = 10.366; p = 0.016) coping skills at the p ≤ 0.05 level (Table 5).

Discussion

Globally, nurses play a critical role in illness prevention, public health, research and development, and diagnosis and treatment. Every day, around the clock, they provide treatment for patients in many areas of expertise. Consequently, one of the biggest issues facing many nurses is work stress. According to recent research, nurses are far more likely to develop cardiovascular diseases, an unhealthy lifestyle, depression, longer working hours, less sleep duration, diabetes, and fatigue.^3233353738 Therefore, this study was formulated to determine the occupational stress, strain, and coping strategies among nurses in a multispecialty hospital.

The probability of mild maladaptive stress and strain among nurses is indicated by the mean scores on the ORQ and PSQ in our study. Similar results were noted in Zhang et al's investigation.³⁴ The PRQ mean score indicates that nurses had strong coping resources, which is consistent with findings from research done by Hashim et al.³⁹ This study found that the two main factors contributing to occupational stress among nurses were RA and PE on the ORQ. Among nurses, RA is one of the best indicators of occupational stress. Charkathat Gorgich et al⁴⁰ made comparable findings. A further factor influencing work stress is the PE. Najimi et al⁴¹ discovered in their study that one of the primary causes of occupational stress is the PE. Nurses' occupational stress was found to be influenced by both vocational and IS, as measured by the PSQ in our study. In Wu et al's⁴² investigation, a similar finding was made. The major job stressor that predicted burnout among medical professionals in their study was VS. Interpersonal relationships were shown to be the most prevalent source of occupational stress among nurses in another study conducted by Santana et al,⁴³ which is in line with the results of this study. The majority of the nurses in our study had strong strategies for coping, and recreational and self-care coping were the most often employed strategies for coping. Wu et al's⁴⁴ study produced similar findings, demonstrating the proactive benefits of self-care and recreation as coping mechanisms against occupational stress.

In this study, the demographic variables “gender” and “designation of nurses” were linked to the PE and responsibility in the ORQ. The findings of the study are corroborated by Najimi et al.⁴¹ In their study, for female nurses, the job environment was the most significant source of job stress, but for male nurses, it was the responsibility and the job environment. The study outcomes are similar with the study done by Hashim et al³⁹ indicating job stress among senior and head nurses, where there is more stress due to the nursing profession and work-related issues. Gender and VS were shown to be significantly associated in the PSQ. Gender was also significantly associated in PRQ with coping mechanisms for self-care and SS. Compared with male nurses, female nurses employed more SS strategies for coping, according to research by Pino and Rossini.⁴⁴ This is consistent with the results of this study.

Recently, India suppressed China to become the most populated country in the world. Therefore, it has become more important to improve the health system, health delivery, world-class hospitals, the improvement of tertiary care hospitals, nursing homes, primary health centers, community health centers, and other health facilities. Nowadays, more and more people are shifting themselves to urban areas compared with rural areas to get better health facilities and high-quality health care providers. As per recent data, around 3.514 million nurses are currently working in India,⁴⁵ which is relatively low in terms of the nurse–patient ratio, according to the World Health Organization. Therefore, the work pressure is continuously building up among the Indian nurses in different specialties. Moreover, lack of SS, long working hours, low salary, patients' behavior, more incoming patients, nurse–patient ratio, imbalanced work life and personal life, negative physical and mental health, and negative emotional health are also contributing factors in increasing job stress among nurses, which also aggravates the suicidal tendency among nurses, which is a cause of concern.

Psychological intervention should be performed among nurses to improve mental health and also to improve patient care by removing negative thoughts from the nurses' minds. We have seen that most of the previous research done under OSI-R questionnaires has a positive correlation with SS, which gives us a clear picture of how most of the nurses, irrespective of countries, face challenges in terms of a lack of SS systems. Stress leads to poor productivity at work and poor work–life balance and leads to poor quality of care, which has an impact on patients. Thus, it is the responsibility of health care organizations, hospitals, and nursing homes to provide the best organizational support and to initiate strategies to reduce occupational stress among nurses. The findings of the present study may help health care policymakers and hospital authorities design a comprehensive health care system to reduce occupational burden among nurses.

Conclusion

India is going through a massive urbanization project in different sectors in both urban and rural areas. During coronavirus disease 2019, the health care infrastructure and human resources have collapsed, along with the shortage of nurses and doctors around the world, including India. However, during the time of the human existence crisis, nurses came forward and gave life to the needy, while many other health care departments were shut down. In India, we expect a rise in incoming patients in the hospital. Therefore, scientific development, research, community engagement, health care researchers, management, and SS groups should come together to find a new way to manage stress in the workplace, mainly in hospital settings, and to fight negative emotions, depression, burnout, work pressure, and psychological pressure. A proper health care systematic approach is a dire need currently in India, which could pave the way to having a better health care setting with high-value nurses.

Limitations

The study has a small sample size, and the study was limited to all nurses in one hospital. Hence, the data generated from this research cannot be generalized to other nurses who are working in different hospitals.