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ORIGINAL ARTICLE
Year : 2014  |  Volume : 21  |  Issue : 2  |  Page : 79-84  

Predictors of work-related stress among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia


1 Department of Family and Community Medicine, College of Medicine, University of Dammam, Kingdom of Saudi Arabia
2 Department of Family and Community Medicine, College of Medicine, University of Dammam, Kingdom of Saudi Arabia; Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Egypt

Date of Web Publication19-Jun-2014

Correspondence Address:
Huda M. Al-Makhaita
Department of Family and Community Medicine, College of Medicine, University of Dammam, P.O. Box 2955, Dammam 31432, Kingdom of Saudi Arabia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8229.134762

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   Abstract 

Introduction: Work-related stress (WRS) is an insidious and persistent part of everyday life related to the response of people to work environment. Nursing is a strenuous job and WRS is prevalent among nurses. The aim of this study was to estimate the prevalence of WRS among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia. Materials and Methods: A cross-sectional epidemiological study was conducted in 17 primary health care centers (PHCCs) representing the primary level of health care and  Medical Tower Complex (MTC) representing the secondary health care level in Dammam city. The total number of nurses included in the study was 637 nurses (144 in PHCCs) and (493 MTC). Data were collected using a self-administered questionnaire, which was developed based on the pertinent literature. It included two main parts: Sociodemographic and job characteristics of nurses and 31 WRS questions. Results: The overall prevalence of WRS among all studied nurses was 45.5%; 43.1% and 46.2% in primary and secondary levels, respectively. In the primary level, there was a statistical significant association between WRS and being married (85.5%), and having living three children and more (53.2%). Moreover, younger age group 20-<30 years (79.4%), Saudi nationality (86.8%), being married (74.6%), having nonbachelor degree (83.3%), work shifts (89.5%), and working in surgical department (46.5%) were the significant associating factors with the occurrence of WRS among nurses in secondary levels. Young age was the only predicting factor for WRS in primary care level. While being female, Saudi, married, with work shifts, and working in surgical department were found to predict WRS in the secondary level. Recommendations: Appropriate strategy in health care organization to investigate stress in health care settings is recommended. Moreover, interventional programs to identify, and relieve sources and effects of stress should be developed.

Keywords: Nurses, predictors, prevalence, Saudi Arabia, work-related stress


How to cite this article:
Al-Makhaita HM, Sabra AA, Hafez AS. Predictors of work-related stress among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia. J Fam Community Med 2014;21:79-84

How to cite this URL:
Al-Makhaita HM, Sabra AA, Hafez AS. Predictors of work-related stress among nurses working in primary and secondary health care levels in Dammam, Eastern Saudi Arabia. J Fam Community Med [serial online] 2014 [cited 2019 Oct 18];21:79-84. Available from: http://www.jfcmonline.com/text.asp?2014/21/2/79/134762


   Introduction Top


Stress is a pervasive and insidious part of everyday life and in the work environment. [1] According to United States National Institute for Occupational Safety and Health, job stress is defined as "the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, responses, or needs of the worker." [2] Work-related stress (WRS) is simply stress, which is caused or made worse by working. Job stress is a substantial and growing concern for workers, their advocates, employers, occupational health and safety regulators, and workers' compensation programs. [3] Different personality styles, gender difference, age, context, family history, emotional state, understanding of self and general social awareness will all influence each person's stress level. [4],[5] Usually, the effects of stress can be categorized as: Mental, physical, behavioral, and cognitive. Among the poor signs of WRS are the poor physical and mental health of the organization employees, poor attendance and less commitment to work, less productivity, distress and irritability and lastly the organization becomes less likely to be successful in a competitive market with poor image to stakeholders. [5],[6] Nursing is generally perceived as a stressful and demanding profession. There is substantial evidence that nursing is a stressful occupation, which can lead to disruptions in both psychological and physical health and can impair professional practice. There is a growing body of evidence, which validates that health care providers particularly nurses experience stress in the course of carrying out their work without exception. [7],[8],[9] Various studies have shown that nursing is a strenuous job and WRS is prevalent among nurses. [10],[11] The prevalence rates of stress among nursing staff vary across studies with researchers reporting rates of 29-40%. [12],[13],[14]

Many health professionals, in Saudi Arabia, are expatriates of various nationalities where Saudi physicians constituted 20% and Saudi nurses constituted 27% of the total number of physicians and nurses, respectively. [15]

By reviewing the literature and to the best of our knowledge, there was no available research that has investigated WRS and stress related work outcomes among nurses in different levels of health care in Saudi Arabia.

The aim of this study was to determine the prevalence of WRS and to find out the possible associated and predicting factors that affect WRS among nurses working in primary and secondary health care levels in Eastern Province, Saudi Arabia.


   Materials and Methods Top


Study design and sampling technique

A cross-sectional epidemiological study was carried-out in Dammam city; Eastern region of Saudi Arabia during January to May, 2013 G. The study sample included nurses working in the health facilities at primary and secondary health care levels, of all ages, both sex, Saudi and non-Saudi, and regardless of educational level or years of experience.

The total number of nurses included in the study was 637 nurses; 144 in primary health care centers (PHCCs) representing the primary level of health care and 493 in Medical Tower Center (MTC) representing the only secondary governmental health care level. They were selected by using the sample size equation described by Dahiru et al. [16] According to the number of nurses in PHCCs (270) and MTC (1070) with a prevalence rate of WRS among nurses of 30% as reported by Al-Hawajreh. [8]

Seventeen out of the 24 PHCCs were randomly selected and the MTC in Dammam. All nurses in the selected PHCCs as well as nurses working in medical and surgical wards, intensive care unit, accident and emergency, outpatient clinics, operating theater, burn unit, and a day surgery unit; at MTC were randomly selected by proportional allocation technique in both PHCCs and MTC.

Permission was taken from the concerned health authority to conduct the study. The objectives of the study were explained to the nurses involved in the study after which they gave their verbal consent to participate. Confidentiality of the information was strictly adhered to by assuring the nurses that no details about their status will be released and data will be used only for research purposes.


   Technical design Top


Data were collected by using a self-administered questionnaire, which was written in both English and Arabic. Internal consistency reliability was tested by Cronbach's alpha coefficient for the whole questionnaire with a value of 0.87. The questionnaire was composed of two main parts:

  • Sociodemographic and occupational characteristics such as age, sex, educational level, marital status, number of living children, years of experience, job position, department of work, working shifts, etc.
  • Occupational stress was assessed using occupational stress scale developed by Al-Hawajreh [8] which consisted of 31 items to identify the presence and sources of WRS. A scoring system was used ranged from 1 to 5 as follows: 1 (never), 2 (rarely), 3 (sometimes), 4 (often), and 5 (always) with a total WRS scale of 155. The total WRS scale was divided into two categories: Presence of WRS or absence of WRS according to the mean score of the total WRS (87.83 ± 17.75 standard deviation) that is, who were scored above the means was diagnosed as having WRS and those below the mean with no WRS.


Statistical analysis

The collected data were reviewed, coded, verified, and statistically analyzed using the Statistical Package for Social Sciences (SPSS) software version 16 (SPSS Inc., Chicago, Illinois, USA, 1998-2007). Descriptive statistics for all studied variables, Fisher's exact, and Chi-square tests were used. Logistic regression analysis was used to find the association between the characteristics of the nurses (independent variables) and WRS (dependent variable) and P < 0.05 was considered as significant throughout the study.


   Results Top


The mean age of studied nurses working in PHCCs and MTC in Dammam was 35.2 ± 8.2 and 28.6 ± 5.6 years, respectively with a high statistical significant difference (P < 0.001). Most of studied nurses working in either primary or secondary levels were Saudi (99.3% and 76.7%, respectively), females (91.7% and 86.4%, respectively) and married (80.6% and 64.5%, respectively) [Table 1].

The majority of studied nurses were staff nurses (85.4% in PHCCs and 88.4% in MTC) with a total experience of 10 years and more among 68.1% of nurses working in primary care compared to 17.6% among nurses working in secondary care with a statistical significant difference between the two levels (P < 0.001). However, 49.3% of nurses working in PHCCs and 9.5% of nurses working in MTC had current experience of the same duration (P < 0.001). None of the studied nurses working in primary care had postgraduate degrees, or having work shifts compared to 1.8% and 84.2% of nurses in secondary level, respectively [Table 1].
Table 1: Sociodemographic and job characteristics of studied nurses in primary and secondary health care levels


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The overall prevalence of WRS among all studied nurses was 45.5%; moreover, the prevalence of WRS among nurses working in primary and secondary health care levels was 43.1% and 46.2%, respectively [Figure 1].
Figure 1: Prevalence of work-related stress among studied nurses

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Work-related stress is more common among married nurses (85.5%, P < 0.05) and those with three or more children (53.2%, P < 0.01) and the difference was statistically significant [Table 2]. Moreover, younger age group 20-<30 years (79.4%, P < 0.05), Saudi nationality (86.8%, P < 0.001), married (74.6%, P < 0.001), qualifications, that is, nurses with nonbachelor degree (83.3%, P < 0.01), having work shifts (89.5%, P < 0.01), and working in surgical department (46.5%, P < 0.001) were the significant associating factors with the occurrence of work-related disease among nurses in secondary health care levels [Table 2].
Table 2: Association between sociodemographic and job characteristics of studied nurses and WRS according to levels of health care


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By studying the association between gender, monthly income, job position, postgraduate degrees, duration of total and current experience of nurses in both PHCCs and MTC with WRS among nurses, there was no any statistical significant association (P > 0.05).

[Table 3] represents the results of the logistic regression analysis of significant factors predicting the occurrence of WRS in primary and secondary care levels. Young age was the only predicting factor that was found to be independently and significantly associated with WRS in primary care level (odds ratio [OR] =0.473, 95% confidence interval [CI] =0.27-0.83), (P < 0.01). On the other hand, the following factors were found to be independently and significantly associated with WRS in secondary care level: female gender (OR = 0.663, 95% CI = 0.281-0.946), Saudi nationality (OR = −1.6, 95% CI = 0.096-0.368), married nurses (OR = 0.932, 95% CI = 1.635-3.94), presence of work shifts (OR = −1.2, 95% CI = 0.15-0.57), and working in surgical department (OR = 0.07, 95% CI = 0.869-1.00), (P < 0.001).
Table 3: Logistic regression analysis of significant factors predicting WRS among studied nurses in primary and secondary health care levels


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   Discussion Top


The sociodemographic features of the studied nurses showed that 73.2% in secondary health care level were aged 20-30 years compared with 25.7% in primary level, and the difference was statistically highly significant (<0.001). This may justify the higher percent (32.5%) of single nurses in secondary level [Table 1].

Work-related stress can occur specifically when a conflict arise from the job demands of the employees and the employees themselves; and if not handled properly, the stress can become distress. Occupational stress among health workers has been a matter of much scientific inquiry in literature in the past decades. High level of stress at work is a major factor to both physical and psychological health. [17],[18] The overall prevalence of WRS (45.5%) as well as its prevalence among nurses working in primary (43.1%) and secondary health care (46.2%) levels, in this study [Figure 1], were in agreement with other studies. [12],[14] However, Al-Hawajreh has reported lower prevalence (30%) of job stress among Jordanian Hospital nurses. [8] This higher level of stress among the studied nurses indicate that nursing has been shown to be a strenuous profession with nurses exposed to stress-provoking factors than other health care workers, and involving in providing help to people experiencing life crisis. [19] WRS, in this study, was significantly associated with younger age of nurses working only in MTC [Table 2] and was the only predicting factor for the occurrence of WRS among nurses working in PHCCs [Table 3], age was significantly related to occupational stress in several studies that reported consistent results, that is the younger the subjects, the higher levels of occupational stress. [10],[18],[19]

Furthermore, married nurses working in both MTC and PHCCs was significantly associated with WRS [Table 2]; moreover, married nurses were among the predicting factors of occurrence of WRS among MTC nurses [Table 3], similar finding were reported by other studies. [8],[18],[19] When the relation between total and current years of exposure and WRS was investigated in this study, no statistical significant association could be revealed. This finding is in agreement with Abd El-Fatah, [20] and Al-Hawajreh, [8] they could not revealed any significant association between the years of experience in nursing and job stress. [8],[20] However, the finding is incongruent with other study which showed a positive relationship between years of experience and job stress. [21] Although in several studies income has been introduced as associated factors related to occupational stress, [22],[23] the finding of the present study showed that income was not significantly associated with WRS among nurses in both PHCCs and MTC. Furthermore, the data of this study, in the MTC found that 89.5% of nurses who suffered from WRS had a working shifts compared to 79.6% without stress [Table 2] and the difference was statistically significant (P < 0.01). Moreover, presence of night shifts was among the predicting factors of occurrence of WRS among MTC nurses [Table 3], Botha and Pienaar stated that work schedule as working late shifts or overtime is one of the main contributors of occupational stress among employees. [22]

Moreover, other feature of job characteristic of the hospital nurses in this study showed that 46.5% of the nurses were working in surgical wards with a statistically highly significant difference between departments (P < 0.001) [Table 2]. This finding is not in - agreement with. Al-Hawajreh who reported that WRS stress was not statistically significant among nurses working in medical, surgical and other specialized hospital units. [8] Staff members of department dealing with many unpredictable challenges, including sudden death, violence, trauma, and overcrowding, on a daily if not hourly basis, have higher levels of stress and burnout than colleagues in other specialties. [24],[25],[26],[27],[28]

A Saudi study was done by Alomar 2003, on sources of WRS among the ministry of health hospital staff, Riyadh city, Saudi Arabia, showed that WRS was not influenced by educational level, marital status, gender and language. [29] In contrary to our results the previously mentioned study found that age and experience showed negative correlation with stress. [29]


   Conclusion and recommendations Top


The results of this study demonstrated high prevalence of WRS among the studied nurses in both primary and secondary health care levels. Young age, being married and having more than three children were the associating factors of WRS among nurses in primary level. Young age, female gender, Saudi nationality, married nurse, presence of working shifts and working in surgical department were the significant predictors of WRS among nurses in secondary level. Appropriate strategy in health care organization to investigate stress management in health care settings is recommended. Moreover, interventional programs to identify, and relieve sources and effects of stress should be developed including more training, support, and better work conditions.

 
   References Top

1.Leka S, Griffiths A, Cox T. Work Organization and Stress. Systematic Problem Approaches for Employers, Managers and Trade Union Representatives (Protecting Workers' Health Series No. 3). Geneva: Word Health Organization; 2003.  Back to cited text no. 1
    
2.National Institutes for Occupational Safety and Health. (NIOSH). Stress at Work. Cincinnati, OH: US Department Health and Human Services; 1999.  Back to cited text no. 2
    
3.Ugoji EI. Managing administrative stress in educational institutions: A study of selected Nigerian universities. J Niger Delta Res 2003;5:90-9.  Back to cited text no. 3
    
4.Vecchio RP. Organizational Behavior: Core Concepts. 4 th ed. Fort Worth: Dryden Press; 2000.  Back to cited text no. 4
    
5.Al-Yousuf M, Akerele TM, Al-Mazrou YY. Organization of the Saudi health system. East Mediterr Health J 2002;8:645-53.  Back to cited text no. 5
    
6.World Health Organization. The World Health Report 2000: health Systems: Improving Performance. Geneva: World Health Organization; 2000. p. 5.  Back to cited text no. 6
    
7.Rogers B. Clinical Practice in Occupational and Environmental Health Nursing. 2 nd ed. Saunders: United State of America; 2003.  Back to cited text no. 7
    
8.Al-Hawajreh K. Exploring the relationship between occupational stress and organizational commitment among nurses in selected Jordanian Hospitals. An-Najah Univ J Res (Humanities) 2011;25:1931-72.  Back to cited text no. 8
    
9.Huber D. What are the sources of stress for nurses? In: McCloskey JC, Grace H, editors. Current Issues in Nursing. 4 th ed. Louis: Mosby; 2000.  Back to cited text no. 9
    
10.Lee I, Wang HH. Perceived occupational stress and related factors in public health nurses. J Nurs Res 2002;10:253-60.  Back to cited text no. 10
    
11.Santos SR, Carroll CA, Cox KS, Teasley SL, Simon SD, Bainbridge L, et al. Baby boomer nurses bearing the burden of care: A four-site study of stress, strain, and coping for inpatient registered nurses. J Nurs Adm 2003;33:243-50.  Back to cited text no. 11
    
12.Gray-Toft P, Anderson JG. The nursing stress scale: Development of an instrument. J Behav Assess 1981;3:11-23.  Back to cited text no. 12
    
13.Sullivan EJ, Decker PJ. Stress Management. 3 rd ed. Tokyo: Addison-Wesley Publishing Hospital; 1993.  Back to cited text no. 13
    
14.Wong K. The effects of unanticipated work stressors on registered nurses. In: Humphrey J, editor. Human Stress: Current Selected Research. Vol. 4. New York: Ams Press; 2001.  Back to cited text no. 14
    
15.Ministry of Health (MOH), Kingdom of Saudi Arabia. Health Statistical Year Book. Dar Alhelal offset press; 2010, ISSN 1319-3228.  Back to cited text no. 15
    
16.Dahiru T, Aliyu A, Acne TS, Statistics in medical research misuse of sampling and sample size determination. Ann Afr Med 2006;5:S158-61.  Back to cited text no. 16
    
17.Ivancevich, JM, Matteson MT. Organizational Behavior and Management. 6 th ed. Boston, Mass: McGraw-Hill; 2002.  Back to cited text no. 17
    
18.Verhaeghe R, Vlerick P, De Backer G, Van Maele G, Gemmel P. Recurrent changes in the work environment, job resources and distress among nurses: A comparative cross-sectional survey. Int J Nurs Stud 2008;45:382-92.  Back to cited text no. 18
    
19.Tyson PD, Pongruengphant R. Five-year follow-up study of stress among nurses in public and private hospitals in Thailand. Int J Nurs Stud 2004;41:247-54.  Back to cited text no. 19
    
20.Abd El-Fatah M. Impact of organizational features of work environment on quality of nursing care and nurses commitment in critical care unit in selected hospital within Cairo governorate. Unpublished Dissertation. Doctoral Thesis Faculty of Nursing Cairo University; 2002.  Back to cited text no. 20
    
21.Wilson B, Laschinger HK. Staff nurse perception of job empowerment and organizational commitment. A test of Kanter's theory of structural power in organizations. J Nurs Adm 1994;24:39-47.  Back to cited text no. 21
    
22.Botha C, Pienaar J. South Africa correctional official occupational stress: The role of psychological strengths. J Crim Justice 2006;34S: 73-84.  Back to cited text no. 22
    
23.Sveinsdóttir H, Biering P, Ramel A. Occupational stress, job satisfaction, and working environment among Icelandic nurses: A cross-sectional questionnaire survey. Int J Nurs Stud 2006;43:875-89.  Back to cited text no. 23
    
24.Adeb-Saeedi J. Stress amongst emergency nurses. Australas Emerg Nurs J 2002;5:19-24.  Back to cited text no. 24
    
25.Adali E, Priami M. Burnout among nurses in intensive care units, internal medicine wards and emergency departments in Greek hospitals. Nurs Web J 2002;11:1-19.  Back to cited text no. 25
    
26.Potter C. To what extent do nurses and physicians working within the emergency department experience burnout? A review of the literature. Australas Emerg Nurs J 2006;9:57-64.  Back to cited text no. 26
    
27.Healy S, Tyrrell M. Stress in emergency departments: Experiences of nurses and doctors. Emerg Nurse 2011;19:31-7.  Back to cited text no. 27
    
28.Augusto Landa JM, López-Zafra E, Berrios Martos MP, Aguilar-Luzón Mdel C. The relationship between emotional intelligence, occupational stress and health in nurses: A questionnaire survey. Int J Nurs Stud 2008;45:888-901.  Back to cited text no. 28
    
29.Alomar B. Sources of work-stress among hospital-staff at the Saudi. J King Abdulaziz Univ 2003;17:3-16.  Back to cited text no. 29
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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