LEVELS AND SOURCES OF STRESS AMONG NURSE WORKING IN MEDICAL AND PSYCHIATRIC HOSPITAL: A COMPARATIVE STUDY NAUMAN QAMAR BSN, Master of Science in Nursing, M.phil Behavioral Sciences, M.Sc Psychology, Bachelors of arts, Bachelors of education.

Introduction The present study is carried out to make a comparison about level of stress experienced by nurses in Medical and Psychiatric Hospitals. A structured self-report survey was used to collect data on basic demographic characteristics, perceived stress and amount of stress caused by work related stressors. A formal permission for data collection was taken from the superintendent of each hospital. The possible association of overall stress levels obtained from SPSS with the different independent variables (age, marital state, work shift, type of ward, and educational level) was evaluated using t-test and one sample ANOVA test. Relationship of nursing specialty with perceived stress level was further explored by Multiple Linear Regression Analysis. Work-related stress levels of psychiatric and non-psychiatric nurses in five domains of DCL were also contrasted using independent sample t-test. Two tailed test were used in all the analyses with the significance level set at 0.05.

Need of the study Stress in nursing profession has been identified as an endemic issue. Stress influences the physical and psychological health of nurses and also reduces their efficiency (Kane, P. P., 2009). Nursing has been identified as an occupation. This suffering not only impairs nurses’ own health but also impact their ability to deliver care to patients (Gholamzadeh, S., Sharif, F., & Rad, F. D., 2011).

The current study attempts to discover the association of demographic factors with stress and also contribution of work related factors towards perceived stress among nurses. Additionally researcher would attempt to have insights into comparison of levels of stress and sources of stress among the nurses working in medical and psychiatric hospitals.

Materials and Methods Research Design: A descriptive correlation cross sectional research design was employed in this current study. Sample Study sample constituted of 134 subjects with 49 nurses from one psychiatric hospital and 85 medical nurses from three multispecialty hospitals of Lahore.

Data Collection A structured self-report survey was used to collect data on basic demographic characteristics, perceived stress and amount of stress caused by work related stressors. A formal permission for data collection was taken from the superintendent of each hospital. Study subjects were recruited by approaching the nurse manager within the nursing facility and requesting her permission and her assistance in gathering the desired data from the staff members. The individuals conducting the study distributed the questionnaires personally to each willing participant explaining the purpose of the study, motivating and assuring respondents’ anonymity and confidentiality. Participation by subjects was kept entirely voluntary and there was no inclusion or exclusion criterion.

Sampling Technique In this research a purposive non-probability sampling method was employed considering the accessibility issues and complexity of probability techniques for selection, to select wards/units and then sample subjects from respective wards/units. In order to make the two samples comparable and homogeneous, wards/units in multispecialty hospitals expected to have extremely low or extremely high stress levels were excluded from study. For example the wards which are proved to have significantly raised levels of stress among nurses compared to other wards in hospital such as Emergency ward, ICU ward were excluded from survey. Similarly the wards which exhibit prominently lower levels of stress like OPD were also not included in survey. As the sample of non-psychiatric nurses was taken from general hospitals, they belonged to various different wards which included medical wards of different specialties. However since all the wards in psychiatric hospital were seen not to have any considerable differences in terms of workloads, patient flow, staff shortage and other factors which form basis for stress differences among nurses working in same hospital, sample was obtained from nurses in all the wards available at the time of survey.

Study Variables Dependent (Criterion) Variable In this study criterion variable is Perceived Stress among psychiatric and non-psychiatric nurses, which is of primary concern. Independent (Predictor) Variables In this study predictor variables include socio- demographic variables including nursing speciality, gender, age, marital status, hospital ward/unit where employed, qualification, type of shift, years of experience, children bearing status and husband’s status of employment. Other work related predictors are patient demands, organizational and managerial issues, staffing, future concerns and job satisfaction.

Research Instruments A self-report questionnaire survey was employed in this research as data collection tool. The questionnaire was designed in three sections to suit the purpose of the study and items of questionnaire were selected based on the literature review. The questionnaire has three parts comprising of 54 items. Questionnaire was translated into Urdu by a professional translator considering the understand ability issues of prospective target population. Assessment measures included a basic demographic information sheet within the first page of the questionnaire, following a Perceived Stress Scale and DCL Stress Scale which are discussed below.

Statistical Analysis The Statistical Package for Social Sciences (SPSS) VERSION 17.0 was used to generate descriptive and inferential statistics. Once the survey was received from the participants, the data was immediately coded and entered into SPSS. Descriptive statistics namely frequencies and percentages were utilized to describe the sample characteristics and comparison between demographics of two groups was made using chi-square test and Independent sample t-test. The normality of distribution for continuous variables was evaluated using Kolmogorov-Smirnov test and Shapiro-Wilk test. The possible association of overall stress levels obtained from PSS with the different independent variables (age, marital state, work shift, type of ward, and educational level) was evaluated using t-test and one sample ANOVA test. Relationship of nursing speciality with perceived stress level was further explored by Multiple Linear Regression Analysis. Work-related stress levels of psychiatric and non-psychiatric nurses in five domains of DCL were also contrasted using independent sample t-test. Two tailed test were used in all the analyses with the significance level set at 0.05.

Results

Psychiatric Nurses (n=49) Table 1. Demographic Characteristics of Respondents by Nursing Speciality (Psychiatric Nurses and Medical Nurses) Demographic Characteristic The Whole Sample (n=134) Psychiatric Nurses (n=49) Medical Nurses (n=85) Sta tist ics N % P- Val ue Marital Status of Respondents Unmarried 65 48.5 14 28.6% 51 60. 0% <.0 1 Married/Widowed/Divorced 69 51.5 35 71.4% 34 40. 0% Qualification Nursing Diploma 22 44.9% 43 50. 6% .11 7 Graduates (BSN/Post RN-BSN/B.A/BSc) 56 41.8 25 51.0% 31 36. 5% Masters and above 13 9.7 2 4.1% 11 12. 9% Current Shift of Duty Morning 72 53.7 28 57.1% 44 51. 8% .59 2 Evening 62 46.3 21 42.9% 41 48. 2% Child bearing status Yes 72.86 80.0% 23 65. 7% .28 2 No 19 27.14 7 20.0% 12 34. 3% Mean SD P-Value Age Psychiatric Nurses 35.78 9.00 <.01 Medical Nurses 28.66 6.33 Years of Experience 13.34 8.86 6.68 5.17

Nursing Specialty Statistical analysis revealed that nurses working in general hospitals in medical wards were experiencing significantly higher stress as compared to nurses working in psychiatric hospital (mean=23.45 vs. mean 17.61, p<0.05). Although medical nurses reflected higher average stress score, both categories indicate low to moderate levels of stress.

Comparison between Medical and Psychiatric Nurses for Work-related Stress and Stressors: The fourth major objective of this research was to assess whether intensity of work related stress differ between psychiatric and medical nurses for aggregate work related stress and in different domains of work related stress individually. DCL stress score was used as DV and nursing speciality as IV. A series of t-tests were conducted to compare the different sources of nursing stress between the two specialties within workplace environment. The means and standard deviation of DCL total and factor scores of two speciality groups are reported in table 4. No significant difference was found between the two groups on DCL total score (mean=53.78 vs. mean=46.82, p>0.05). However the differences were found to be significant between psychiatric and medical nurses on three sources of work related stress namely, Staff related issues (mean=10.61 vs. mean=13.44, p<0.05), Future prospects (mean= 4.29 vs. mean=6.02, p<0.05) and Job satisfaction (mean=4.22, mean=5.52, p<0.05). This implies that respondents working in medical speciality have higher mean scores on these three dimensions than their counterparts working in psychiatric hospital. An important point to notice here is that both nursing specialities scored highest in the domains of “patient care” and “organizational and managerial issues”, though the difference between the two groups in these domains was insignificant.

Table 5. Difference in Mean DCL Stress Scores on 5 Dimensions Between Psychiatric and Medical Nurses DCL Stress Dimensions Nursing Speciality Psychiatric Nurses Medical Nurses P-Value Mean Standard Deviation Patient Care 13.35 7.38 12.69 5.94 .599 Organizational and Managerial Issues 14.35 7.92 16.11 6.55 .168 Staff Related Issues 10.61 6.30 13.44 5.77 .009** Future Prospects 4.29 4.38 6.02 4.27 .026* Job Satisfaction 4.22 3.39 5.52 3.20 .029* Overall DCL Score 46.82 26.23 53.78 21.72 .101 Note. *p < .05, **p < .01.

Discussion/Conclusion This study was aimed at exploring potential indicators of perceived stress among nurses and also to determine and contrast the work related stressors between psychiatric and medical nurses working in some major hospitals of Lahore. Findings of this study provided some important insights into areas of occupational stress among nursing staff. Though aggregate levels of stress were found to be low among nursing staff but keeping in mind that any degree of stress is harmful to nurses, to the organization and to the quality of patient care; stress management programs and culturally sensitive interventions should be developed. Though a comparison of work related stressors between medical and psychiatric nurses identified three areas with significant differences including staff related issues, future prospects and job satisfaction, it must not be ignored that the two groups of nursing speciality scored highest in the areas of patient care and managerial and organizational issues as sources of stress. So, hospital management should concentrate on these two areas particularly, to reduce the nursing stress caused by workplace factors. This research also identified a grave need to educate and acknowledge nurses for work-related stress and its management by incorporating this knowledge into their curriculum.

Recommendations for Future Research As aforementioned, exploration of various potential indicators and multi- category variables was constrained by small sample size in this study; the future researchers are recommended to use a larger sample size to dig out more information. This study was confined to the investigation of few aspects of stress among nurses and was limited to population working only in public hospitals. Future research should explore not only new dimensions of nursing stress e.g. coping mechanisms but should also include private hospitals to make a meaningful comparison between public and private institutions. As perception of stress and stressors is subjective in nature, and is prone to be measured inaccurately by the use of a structured questionnaire, it is suggested that future research should incorporate qualitative methods to obtain deeper information pertaining to stress and related areas. This study was limited to psychiatric nurses working in a psychiatric hospital and excluded nurses who work in psychiatric wards in general hospitals. To formulate effective interventions for stress management it is necessary that future researchers should address these nursing areas also. To date, most of the researches encompassing measurement of stress and identification of stressors have been conducted in western countries and a little is known about Pakistani nurses in this perspective. It is encouraged that more researches should be conducted in Pakistan to explore this area in order to take into account the impact of cultural differences.

Acknowledgements I wound like to thank TAU for giving me this opportunity as well as my Coordinator for helping me and guiding me in all the possible ways. I would like to thank and acknowledge the efforts of my mother who always pushed me in each step of life.