JOB STRESS AND ITS RELATED FACTORS IN NURSES WORKING AT EDUCATIONAL AND MEDICAL CENTERS: A LARGE STUDY FROM IRAN DURING THE COVID-19 PANDEMIC

ABSTRACT Introduction: Nurses are one of the most important elements of health care system that have been in a stressful situation during the Covid-19 pandemic. The aim of this study was to investigate the prevalence and sources of nurses' occupational stressand identify related factors during this period. Methods and Materials: This cross-sectional study was performed on 392 nurses of Rasht educational and medical centers in January to March 2021 selected with stratified random method. Demographic and occupational stress data (by Expanded Nursing Stress Scale questionnaire) werecollected. Data analyses performed by descriptive statistics and multiple regression models with SPSS software version 26. Results: The mean age of nurses were 37.8±8.8 years old. Stress was mild in 62% of nurses, moderate in 20% and severe in 2%. Death and dying situation (1/78±0/74), uncertainty concerning treatments (1.71±0.72) and workload (1.69±0.68), expressed higher occupational stress. Working in the intensive care units or emergency ward, higher education, excessive hours of work and female gender were independently predictors of more occupational stress and these characteristics determined 15% of the variance of stress scores. Conclusion: Stress related to the job during the Covid-19 pandemic is high, and stress in the workplace, especially in intensive care units and emergency ward, should be reduced and standard work shifts should be developed. Furthermore, training of stress management in situations of patients’ death and dying, high workload and uncertainty concerning treatment in pandemic conditions for at risk population of nurses should be done.  Key words: Occupational stress, Nurses, Covid-19, Guilan, Iran. EXTENDED ABSTRACT Introduction: Paying attention to the physical and mental health of the employees of an organization is as important as production and productivity, and effective management of an organization is not possible without paying attention to the mental health of the employees. One of the factors that endanger the mental health of employees is stress. Stress is a specific body reaction, a type of anxiety, stress, anxiety and fear (1, 2). Stress causes physical and psychological complications in people (3). Health care providers who experience both types of stress and emotion in their work environment are no exception to this issue and job stress and evaluation in this population is of particular importance (4). Nurses are one of the most important elements of the health care system that play an essential role in the continuity of care, promotion and maintenance of patients' health and need to pay attention to their health. The nursing profession is constantly dealing with life and death, human health and recovery. The National Institutes of Health ranks the nursing profession as one of the most stressful occupations between health occupations (5). With the onset of Corona disease and the prolongation of the pandemic period, conditions such as the high rate of transmission of the disease, lack of care equipment, especially at the beginning of the pandemic, and the increase in changing the behavior of the virus, increasing its transmission to young people, as well as re-infection of patients in later stages, have emerged as new stressors that can lead to a kind of persistent stress in nurses (2, 6). Studies in the Covid-19 disease pandemic indicate an increase in mental disorders, stress and tension prevalence in the nurses’ population (7-9). Study of Lee et al. showed 72% distress and a higher prevalence of anxiety and depression disorders in the Chinese health care workers (8). In a study of Jordanian nurses, a 68% prevalence of acute stress disorder was reported (9). Study of Sheikhbardsiri et al. in Kerman, Iran declared a moderate level of stress. This study reported that females, nurses with higher education and longer working hours stated more stress (10). Study of Khanmohammadi et al. which assessed the stress caused by the nursing job reported that 42% of the nurses working in the ward of patients with Covid-19 have moderate to severe occupational stress. Also, uncertainty about treatments and patients and their families are sources of the nurses’ occupational stress (11). As the most of the performed studies assessed general stress and not specific stress related to the occupation, therefore, considering the new and ongoing conditions of Covid-19 pandemic and the need to investigate the prevalence and source of job related stress in nurses, this study was conducted to determine the stress prevalence and its sources in this population and to identify job and demographic factors related to it. Methodology: The present study is a cross-sectional study on 392 nurses working in 7 educational and medical centers in Rasht in the period of January to March 2021. At this time, the city of Rasht was in the situation of Covid-19, so that the number of definitive new cases per 100,000 people was 10 to 24 and the overall epidemic trend was increasing. Inclusion criteria were being clinical nurse in the adult units and having at least a bachelor's degree and exclusion criteria were unwillingness to participate in the study. Nurses were selected randomly by a proportional stratified sampling process, using a list of nurses working in each hospital. After the approval of the ethics committee and the research deputy of Guilan University of Medical Sciences, data was gathered. Demographic and occupational information including age, gender, education level, marital status, number of years of work experience, employment status, type of work shift, number of shifts per month and amount of extra work hours per month were collected. Also the ENSS standard questionnaire presented by Gray-Toft and Anderson in 1981 and revised by French et al. in 2000 (12) was completed. Informed consent was taken from all participants. Frequency (percentage) and mean (standard deviation, median and range) were used to describe the demographic information and occupational stress of nurses. Normal distribution of quantitative variables was evaluated using the Skewness and Kurtosis statistics and Kolmogorov-Smirnov test. In the univariable analysis, student's t-test (or Mann-Whitney test), chi-square test, one-way analysis of variance (or Kruskal-Wallis test), Pearson correlation coefficient (or Spearman correlation coefficient) was used. In the multivariable analyses, multiple linear regression models were performed. The tests were performed at a significant level of 0.05, using SPSS software version 26. Result: Ninety-three percent of nurses were female and only 7 percent were male. 280 nurses (71%) were married. The mean and standard deviation of the age was 37.8 ± 8.8 years old. The average work experience of the studied nurses was 14 years. Only 6% of nurses did not work overtime per month, and the average number of nurses working overtime per month was 30 hours. Characteristics of the nurses are shown in Table 1. Table 1. Description of demographic characteristics and general occupational stress in the studied nurses (n=392) No. of participants (%) Average overall job stress (standard deviation) P-value Gender 0.073 Female 365(93) 1.55(0.63) Male 27(7) 1.33(0.39) Age in year, mean±SD (SD, range) 38(8.8, 22-64) 0.041** 20-29 92(24) 1.60(0.55) 0.289 30-39 108(28) 1.53(0.58) 40-49 142(38) 1.56(0.68) 50>= 37(10) 1.38(0.66) Education 0.120 Bachelor degree 348(89) 1.52(0.62) Master degree 44(11) 1.66(0.64) Marital status 0.369 Single 106(27) 1.49(0.62) Married 280(71) 1.55(0.61) Divorced/Widowed 6(2) - Job position in the ward 0.199 Nurse 316(81) 1.55(0.62) Head nurse 72(18) 1.50(0.61) Years of experience on the unit, median (range) 14(<1-14) 0.062** <5 94(24) 1.56(0.52) 5-15 145(38) 1.59(0.67) >15 148(38) 1.46(0/62) Shift worked 0.311 Day 92(24) 1.47(0.68) Day and Evening 26(7) 1.73(0.69) Night 12(3) 1.58(0.74) Rotating 258(66) 1.54(0.58) Number of worked shifts in the last month, median,(range) 22(4-60) 0.430 Extra worked hours in a month. median (range) 30(0-200) 0.029**. <= 30 hours 195(52) 1.51(0.64) 0.201 > 30 hours 181(48) 1.59(0.58) Type of employment contract 0.199 Permanent 247(65) 1.53(0.66) Candidate of permanent 41(10) 1.38(0.60) Temporary 93(25) 1.59(0.52) Type of unit 0.084 Internal 215(55) 1.52(0.57) ICU 63(16) 1.70(0.62) Emergency 17(4) 1.63(0.73) Surgical 46(12) 1.52(0.63) Other* 49(13) 1.38(0.75) If the total is different from 392, it is due to non-response, which was less than 7% of the data in all specifications. *Other items include operating room and nursing office. ** P-values ​​were reported from the correlation coefficient test of the overall occupational stress score with age (r = -0.105), work experience (r = -0.101) and extra workedhours (r = 0.112). In general, 85% (with 95% confidence interval: 81% to 89%) of nurses had different levels of occupational stress so that stress was mild in 62% of nurses, moderate in 20% and severe in 2%. Nurses in the subscales of death and dying situation, uncertainty concerning treatments, workload, patients and their families, problems with supervisors, conflict with the physicians, inadequate emotional preparation, problems with peers and discrimination,had the most to the least occupational stress, respectively. Based on univariable analyses and multiple regression models, data showed that nurses with younger age, higher education, less work experiences, excessive hours of work and females, nurses with temporary contract employment or nurses who work in the intensive care units or emergency wards, expressed more total occupational stress or one of the subscales (P<0.05, for all) (table 3). For total occupational stress, the mean score of overall occupational stress in women with a value of 1.55 ± 0.63 was significantly higher than the mean score of stress in men of 1.33 ± 0.39 (P = 0.051). Also, nurses with master degree expressed on average more occupational stress than nurses with bachelor degree (1.66 ± 0.64 vs. 1.52 ± 0.62 with P = 0.017). In addition, nurses working in intensive care units or emergency wards reported more stress than nurses in other wards (1.69 ± 0.64 vs. 1.50 ± 0.60 with P = 0.015). The data showed that the occupational stress score was higher with excessive hours of work and it is an independent predictor of nurses' occupational stress. These characteristics determined 15% of the variance of stress scores. Conclusion: Stress related to the job during the Covid-19 pandemic is high, and stress in the workplace, especially in intensive care units and emergency ward, should be reduced and standard work shifts should be developed. Furthermore, stress management training in patients’ death and dying situations, high workload and uncertainty concerning treatment in pandemic conditions in the at risk population of nurses should be done. Conflict of interest: The authors declare that there are no conflicts of interest regarding the publication of this manuscript.