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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 95-100

Stress among staff nurses: A hospital-based study

1 Department of Public Health Dentistry, Regional Institute of Medical Sciences, Dental College, Imphal West, Manipur, India
2 Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Tumkur, Karnataka, India
3 Department of Public Health Dentistry, SRM Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication2-Apr-2019

Correspondence Address:
Darshana Bennadi
Department of Public Health Dentistry, Sree Siddhartha Dental College and Hospital, Sri Siddhartha University, Tumkur, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_24_18

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Background: Stress can be described as a dynamic and reciprocal relationship between the person and the environment. Nursing is an occupation with a constellation of circumstances leading to stress. Work-related stress (occupational stress) can be damaging to a person's physical as well as mental status, which directly and indirectly affecting their quality and productivity of work. Hence, an attempt has been made with an aim to assess stress-perceived stress among staff nurses in Mysore city, India. Methodology: The descriptive cross-sectional study was conducted among 500 staff nurses selected from eight hospitals in Mysore City, India, using multistage sampling technique. Study duration was 5-month period and response rate was 100%. A structured questionnaire was administered to assess stress using Perceived Stress Scale (PSS) and Expanded Nursing Stress Scale (ENSS). Results: A cross-sectional study consisted of 500 staff nurses. Majority of the participants (467 [93.4%]) had diploma and 454 (90.8%) nurses worked on day shift. Nearly 277 (55.4%) had a moderate level of perceived stress and 249 (49.8%) had moderate occupational stress. Significant positive correlation (r = 0.144, P < 0.001) between ENSS and PSS. Conclusion: A positive correlation was found between perceived stress and occupational stress among staff nurses of Mysore City. This shows that those with general stress also have occupational stress.

Keywords: Nurses, occupation, perceived stress, stress

How to cite this article:
Kshetrimayum N, Bennadi D, Siluvai S. Stress among staff nurses: A hospital-based study. J Nat Sci Med 2019;2:95-100

How to cite this URL:
Kshetrimayum N, Bennadi D, Siluvai S. Stress among staff nurses: A hospital-based study. J Nat Sci Med [serial online] 2019 [cited 2022 Nov 27];2:95-100. Available from: https://www.jnsmonline.org/text.asp?2019/2/2/95/242159

  Introduction Top

Stress can be described as a dynamic and reciprocal relationship between the person and the environment. Stress, a term continually being redefined in the scientific study of disease and illness, is nevertheless a well-proven and important factor in etiology and maintenance of many inflammatory diseases. Selye defined stress as “response state of organism to forces acting simultaneously on body which, if excessive, i.e., straining the capacity of adaptive processes beyond their limits, led to diseases of exhaustion and death.”[1] Socioeconomic factor, type of occupation, daily schedule, competitive workload, emotional disturbances, etc., have led to increased stress levels in the modern lifestyle.[2] Stress may act alone or combine in groups and may exert effects at different stages of the life course. There have been multiple mechanisms proposed to relate pathogenic properties associated with stress including:[3]

  • A direct role for psychosocial stress through the central nervous system and autonomic nervous system
  • An indirect role of psychosocial stress through behavioral changes: psychosocial stress may have an indirect role through changes in the health behaviors. Stress may affect at-risk health behaviors such as smoking,[4] alcohol consumption, neglect of oral hygiene, or poor compliance with dental care.[3],[5] This influences not only the decrease of the frequency as well as the quality of the dental hygiene but also the increase of tobacco use, changes in food habits,[6] or overeating, especially a high-fat diet which then can lead to immune suppression through increased cortisol production,[3] leading to a diminution of the general health.

Stress, depression, and anxiety are not yet confirmed as absolute risk conditions but have been identified in some observational studies[7],[8],[9],[10],[11] as potential factors that may affect disease. The potential negative influence of stress on medical health in general and on specific diseases, in particular, has been subject of extensive research.

The stresses evaluated in this study were perceived stress and occupational stress measured by Perceived Stress Scale (PSS) and Expanded Nursing Stress Scale (ENSS), respectively.

Occupational stress was assessed because according to the WHO report, “Raising Awareness of Stress at Work in Developing Countries” in 2007,[12] and it is one of the most common forms of stress in developing countries as the socioeconomic states, social inequalities, and overpopulation forces employees to work based on job availability without a choice.

People with different jobs encountered different types and quantities of stress. Selye indicated that nursing is one of the most stressful professions.[6] Nursing is an occupation with a constellation of circumstances leading to stress.[13] Nurses were selected for the study because nursing is an occupation with a constellation of circumstances leading to stress. Stress affecting nurses across the globe has been convincingly documented in many literatures.[14],[15],[16],[17] Nurses in India are overburdened as the nurse-to-patient ratio is low (1:2250).[18] They are responsible – along with other health-care professionals – for the treatment, safety, and recovery of acutely or chronically ill, injured, health maintenance, treatment of life-threatening emergencies, and medical and nursing research. Nurses do not only assume the role of caregivers but are also administrators and supervisors of patients. These multiple work roles contribute to the significant amount of occupation-related stress among nursing staff, particularly those working at the bottom of the hierarchy such as staff nurses and nursing sisters, who end up sharing most of the work burden. Shift duties, time pressures, lack of respect from patients, doctors as well as hospital administrators, inadequate staffing levels, interpersonal relationships, death of patient, and a low pay scale significantly add to their stress levels.[19] These factors are intrinsic to nursing and are compounded by environmental factors such as difficult patients and their families, relationships with physicians, low institutional commitment to nursing, and the delivery of poor quality care.[13] Research has shown that nursing is a high-risk occupation in respect of stress-related diseases.[20] Hence study had assessed the stress among nurses by using Expanded Nursing Stress Scale [ENSS][21] and Perceived Stress scale [PSS].[22]

Stress-related studies were less among different occupations in Mysore city. Hence, an attempt had been made to assess the level of stress among staff nurses in Mysore city.

  Methodology Top

Research design

Descriptive, cross-sectional study was undertaken to assess the stress among staff nurses in Mysore city, India.

Duration of study

This cross-sectional study was conducted for a period of 5 months among the staff nurses in Mysore city.

Sample size and Sampling method

Sample size for the study was scientifically determined based on the data obtained from a recently published scientific article.[13] Study population was selected on the basis of multistage sampling technique. Moreover, for the selection of nurses from each of the hospital, the attendance register of the nurses was used. A list of hospitals in Mysore city was obtained from the district health office. Eight hospitals were shortlisted for the study by simple random sampling method because of logistics reasons and approached for permission to conduct the study. After the permission was granted, the nurses of these hospitals were considered for the study.

The proportional allocation was adapted to select equal proportion of nurses from each of the selected hospitals using the formula,

ni= n. Pi


Pi = Proportion of population included in strata i = Ni/N

n = Total Sample size required

Ni= Number of nurses in each stratum

N = Total population in all strata

ni= Number of nurses selected from strata.

[Table 1] shows the proportional allocation of staff nurses among selected hospitals.
Table 1: Proportional allocation of staff nurses among selected hospitals

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Nurses who were willing to participate and present on the study schedule day were included in the study. Those using anticonvulsive, immunosuppressive, calcium-channel blockers, pregnant, and nurses in management position were excluded from the study.

Permission and ethical clearance

The ethical clearance was obtained from Ethical Committee of Institution. Permission to conduct the study among staff nurses was then obtained from the directors of the respective hospitals. All the participants who were recruited for the study were explained about the purpose of the study. The research subjects were assured that the information collected from them will be kept confidential. Informed consent was then obtained from the participants.

Method of collection of data

Questionnaire consisted of questions regarding demographic and socioeconomic information (based on Modified Kuppuswamy Socioeconomic Status Scale),[23] questions concerning their medical history, diagnosed systemic diseases, and medications taken on a regular basis, history of tobacco, and alcohol consumption. Stress was measured using two stress scales: PSS[22] and ENSS.[21]

Perceived stress scale[22]

PSS is developed in 1983. It is one of the most helpful five-point Likert scales used to understand how different situations affect our feelings and our perceived stress. The PSS predicts both objective biological markers of stress and increased risk for disease among persons with higher perceived stress levels. For example, those with higher scores (suggestive of chronic stress) on the PSS fend worse on biological markers.

Expanded Nursing Stress Scale[21]

The scale is designed to measure nurse stress levels. The ENSS (French et al.) consists of 59 items with response options in a Likert-like format (1 = never stressful, 2 = occasionally stressful, 3 = frequently stressful, 4 = extremely stressful, and 5 = does not apply).

From pilot study sample, Pearson's correlation coefficient for the test–retest reliability of the PSS and ENSS was 0.83 and 0.78, respectively, showing good stability. The understanding of all the items in both questionnaires was found to be correct for all pilot subjects and no modifications were necessary. The participants who participated in the pilot study were not included in the main study. The questionnaire was administered to the participants and was explained by the investigator before the participants started answering it. On an average, it took 20 min to answer the questions.

Statistical analysis

Statistical analysis was done using computer with Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL, USA) version 17. The various parameters used for the purpose of analysis were frequencies, arithmetic mean, standard deviation, t-test, and analysis of variance. For the purpose of analysis, the individual scores were summed up to yield a total score. The range of PSS and ENSS scores was divided into stratified quartiles to develop an ordinal scale.[24],[25],[26] The stress score was stratified into low stress (first quartile), moderate stress (second and third quartiles), and high stress (fourth quartile). Probability levels at P < 0.05 were considered statistically significant.

  Results Top

The study was conducted to assess the stress and how it is perceived among the staff nurses in Mysore city. A total of 500 nurses were included in the study among that 93% were females and 7% were male staff nurses. Regarding marital status, 67% (n = 337) were married and 33% (163) were single. [Table 2] shows demographic details of the study population.
Table 2: Distribution of the subjects according to their age, gender, marital status, and monthly income

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Majority of the participants 467 (93.4%) had diploma, 454 (90.8%) nurses worked on day shift, 352 (70.4%) worked shift for 8 h, 383 (76.6%) had patient assignment of more than six patients, and 273 (54.6%) had work experience of 1–10 years [Table 3].
Table 3: Distribution of study subjects according to their nursing qualifications, usual shift most often worked, and usual length of shift, average patient assignment, and years of experience

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[Graph 1] shows majority of the participants (277 [55.4%]) had a moderate level of perceived stress and 249 (49.8%) had moderate occupational stress.

[Table 4] shows a significant positive correlation (r = 0.144, P < 0.001) between ENSS and PSS. There is a correlation between occupational stress and general stress.
Table 4: Correlations between Expanded Nursing Stress Scale and Perceived Stress Scale

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[Table 5] shows that females had significantly (P < 0.05) higher mean PSS stress score than males, but there was no significant difference between PSS score and age groups, marital and socioeconomical status.
Table 5: Mean Perceived Stress Scale scores and standard deviations for sociodemographic variables

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[Table 6] shows that mean PSS scores of participants with average patient assignment of 1–3 (21.00 ± 5.1) were statistically significant where no statistically significant difference between PSS score and nursing qualification, usual shift most often worked, usual length of shift, and their years of experience.
Table 6: Mean Perceived Stress Scale scores and standard deviations according to the nursing qualifications, usual shift most often worked, usual length of shift, average patient assignment, and years of experience

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[Table 7] shows that statistically significant difference (P < 0.001) was found between the mean ENSS score of all the age groups. However, no significant difference was found between ENSS scores and gender, marital and socioeconomical status.
Table 7: Mean Expanded Nursing Stress Scale scores and standard deviations for sociodemographic variables

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[Table 8] shows statistically significant difference between ENSS score and years of experience. Participants with <1 year of experience had the highest mean ENSS score of 126.04 ± 18.1.
Table 8: Mean Expanded Nursing Stress Scale scores and standard deviations according to the nursing qualifications, usual shift most often worked, usual length of shift, average patient assignment, and years of experience

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  Discussion Top

PSS was used to assess the perceived stress as it is a global appraisal scale Cohen et al., designed to measure the degree to which individuals found their lives to be unpredictable, uncontrollable, and overloading. The PSS was selected because it has been found to better predict stress-related psychological symptoms, physical symptoms, and health service utilization compared to commonly used life event scales.[23]

A significant positive correlation (r = 0.091, P < 0.05) was found between the total scores of ENSS scores and the PSS scores. When taken as categorical variable, it remained statistically significant (r = 0.144, P < 0.05). It indicates that the increase in the score of one scale also results in the increase in the other. Similar findings were found in a study conducted by Purcell et al.[27]

In our study, the mean score on the occupational stress was lower in the older age group of more than 56 years of age. This indicates that older nurses had significantly lesser occupational stress compared to the lower age groups. This finding is in line with the study conducted by Purcell et al.[27] and Shen et al.[28] This might have occurred since they are not skillful in coping than the older groups.

However, there was no significant difference between the perceived stress scores of all the age groups. A similar finding was seen in the study conducted by Purcell et al.[27]

The mean stress score on the nursing stress scale was not significantly different between the males (122.85 ± 13.17) and the females (123.24 ± 21.44). This finding is consistent with a study conducted by Watson et al.[17] and ALnems.[29]

No differences were observed on occupational stress and perceived stress by marital status. This finding of our study is consistent with the studies conducted by Sveinsdóttir et al.,[30] Bhatia et al.,[14] and Sharifah et al.[31]

However, contrary results were found in a study conducted by Shen et al.[28] were the separated/divorced nurses had higher stress compared to those who were married or single. Perceived stress was not significantly associated with socioeconomic status which was found in other study.[31]

In our study, the occupational stress score statistically significant difference (P < 0.001) with age groups and years of experience. This shows older people have the ability to overcome the stress with their experience. They will be well aware about the stress-related situation with their experience. Occupational stress showed no significant difference with the level of education. Contrary results to this finding were found in other studies conducted by Hamaideh et al.,[32] wherein association was found between the level of qualification, shift, and nursing stress. In a study conducted by Sveinsdóttir et al.,[30] occupational stress had no association with the level of occupational stress which was in line with our study. There existed a significant difference between the scores of the occupational stress and the years of experience with lesser score among the nurses who had experienced more than 30 years.

  Conclusion Top

Nurses had a moderate level of occupational and perceived stress. The study assessed significant positive correlation was found between the total scores of ENSS scores and the PSS scores. It indicates that the increase in the score of one scale also results in the increase in the other. The limitation of the study is that it should have been done with comparison group or association with stress-related disease. Further studies with a longitudinal approach relating stress and major oral disease should be conducted to establish a causal relationship between potential stress factors and any stress-related diseases. Studies using biochemistry markers, psychological assessment, and multiple measurements of variables should be considered to clarify the role of psychosocial factors and their mechanisms of action.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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