Background: Nurses among the health care providers play a vital role in the success of the health care system. Their continuous hours of working and the existing lacunae in regard to their mental health in the current study setting, this study was conducted to elicit if the nurses are posed to any such mental health risks and perceive any stress?
- To determine the prevalence of psychological distress and the perceived stress among the study subjects.
- To assess the factors associated with psychological distress and perceived stress.
Materials and Methods: This is a cross-sectional study conducted among all the nursing staffs at our tertiary care centre for 2 months. A predesigned and pretested semi-structured self-administered questionnaire including general health questionnaire (GHQ)-12 and perceived stress scale (PSS)-10 were used to collect the data and to asses psychological distress and perceived stress considering the cut-off scores of a minimum of 12 and 19, respectively. Data were entered into Microsoft Excel 2010 and analyzed using the SPSS software version 20.0, Armonk, NY, USA: IBM Corp.
Results: The mean age of the participants was 24.4 ± 3.7 years. Mean GHQ-12 score was 11. As per the scores, the cutoff of at least 12 was found in 35% of the respondents indicating the prevalence of psychological distress among 35.0% and as per the screening tool PSS-10 used, majority of the study subjects (93.0%) perceived moderate level of stress with a median score of 19.
Conclusion: Nearly one-third of the nursing personnel were under psychological distress and almost the entire nursing faculty perceived moderate level of stress.
Keywords: General health questionnaire -12, nursing, perceived stress scale, perceived stress scale-10, psychological distress
|How to cite this URL:|
Shruthi M N, Veena V, Seeri JS. Prevalence of psychological distress and perceived stress among nursing staff in a tertiary care center, Bengaluru. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=357064
| Introduction|| |
Stress from work can have varied negative effects. As a matter of fact, it is even ubiquitously present among nursing professionals. Nursing is a dedicated profession that demands both good physical and mental health for their inherent nature of work. They are exposed to many stressors, namely irregular job shifts or night shifts, unpredictable postings, paperwork, interpersonal conflict within the healthcare team, decreased social perception and respect, lucrative remunerations abroad, reduced time for family and inadequate family support which lead to failure of various physiological functions, and emotional exhaustion due to the changes in circadian rhythm and overproduction of adrenaline and cortisol.,,, Above all, they also form the largest working force in health care.
The prevalence of mental health problems (anxiety and depression) among nurses is also noted to be high. Kishore et al. have reported the prevalence of anxiety, depression, and stress among 63.3%, 56.05%, and 36.17%, respectively. Divinakumar et al. noted psychological distress among 21% and 48.3% had high stress levels.
Such chronic stress leads to increased absenteeism, individual intent to leave a profession, burnout, reduced patient satisfaction, and diagnosis and treatment errors. Moreover, stressful work environments pose risks to the mental health of health care workers and substance abuse, suicide, anxiety, and depression are reported as the psychological distress outcomes.,
General health questionnaire (GHQ) being a commonly used instrument for assessing mental health and detecting various sources of distress for workers, a shortest version of it, i.e., GHQ-12 has been used as it is the most commonly used, seems particularly appropriate for research, clinical, and health intervention in caregivers.,
In order to assess the stress among nurses, Perceived Stress Scale (PSS)-10 English version was used as it is short and shown to be a valid and reliable instrument.
With this above background, this study was conducted to determine the prevalence of psychological distress, the perceived stress among the study subjects, and to elicit the factors associated with psychological distress and perceived stress.
| Materials and Methods|| |
This is a cross-sectional study conducted among the nursing staff working in a tertiary care setting located in urban Bengaluru for a period of 2 months. An ethical approval was obtained from the Institutional Ethics Committee before initiating the study.
Assuming the prevalence of 50% mental distress and nearly 50% estimated prevalence of stress levels among nursing females, 20% relative precision, and 5% alpha error, the sample size was estimated to be 100.
Using purposive sampling, all the study subjects who were working as nursing faculty in our tertiary care setting and were available during two visits were included and the nursing students if any were found to be posted in the ward were excluded from the study. The subjects who mentioned that they were already under treatment for any psychiatric illness were excluded from the analysis.
After obtaining the permission through proper channel, a meeting was held and a convenient date was fixed to collect the data. The data were collected among the nursing staffs of all the three shifts of morning, evening, and night. Those who were not available at the time of the interview were attempted to retrieve with two visits.
After obtaining a written informed consent, the data were collected using a predesigned and pretested semi-structured self-administered questionnaire. Questionnaire contained sociodemographic details such as age, gender, religion, stay, family type, and chronic illness and its treatment along with the GHQ 12 and PSS-10 English version with Cronbach's alpha of 0.90 and 0.78, respectively, from the existing literature.,
The GHQ was initially devised by Goldberg and Bridges to screen for psychiatric illnesses in the primary care setting which has been later validated by the World Health Organization. The GHQ 12 was used to assess the current mental health of the participants and it focuses on two major areas – The inability to carry out normal activities and the appearance of new and distressing incidents.,, The original version of PSS scale was developed by Sheu et al., PSS – 10. Questionnaire is a valid tool which can be applied to a wide range of settings, to different subject types and includes items measuring reactions to stressful situations as well as the measures of stress.,,
Each item in the GHQ 12 was rated on a four-point scale (less than usual, no more than usual, rather more than usual, or much more than usual). We have used the Likert method of scoring (0, 1, 2, and 3) with score range at 0–36. Scores up to 12 were considered normal and a score of 12 and more than 12 was considered as an evidence of psychological distress.
PSS-10 has 10 questions/statements in it and the respondents were asked to indicate their level of agreement with a given statement. We used a five-point Likert-type rating scale, ranging from never (0) to very often (4); the scores of four positive items (4, 5, 7, and 8) were reversed. The total scores ranged from 0 to 40, with higher scores indicating higher stress level., Though, PSS is not a diagnostic tool, it can be used as a first screening tool to identify individuals with heightened stress levels. As it is not a diagnostic toll, there are no defined no cutoff scores to indicate higher stress levels. However, higher scores are said to indicate a higher level of perceived stress., An arbitrary scores of cutoff of 0–13 as low, 14–26 as moderate, and 27–40 as high perceived stress were defined in our study. General Health Questionnaire (GHQ-12) items and Perceived Stress Scale are represented in [Table 1].
Data were entered into Microsoft Excel 2010 and analyzed using SPSS (version 20.0 for Windows; SPSS Inc., Armonk, NY: IBM Corp). Results were expressed in descriptive statistics such as proportions, mean or median, standard deviation or interquartile range. The Mann–Whitney U-test and Kruskal–Wallis test were used in two-group comparisons and in more than two group comparisons, respectively. The Chi-square test was used to express the association of different variables with the GHQ scores and PSS scores. The significance threshold for all statistical analyses was P < 0.05.
| Results|| |
Most of them, i.e., 82% of the study population belonged to the age group of ≤25 years, majority of them were females (97%). The mean age of the participants was 24.4 ± 3.7 years and it ranged from a minimum of 20 years to a maximum of 40 years. Maximum (82.0%) of them stayed in the hostel, 85% belonged to Hindu religion were from nuclear families (91.0%) and belonged to upper socio-economic status (SES) according to modified B G Prasad Scale (96.0%). Only 11% reported of illnesses such as headache (2/11, 18.2%), hypothyroidism (2/11, 18.2%), rheumatic heart disease (1/11, 9.1%) insomnia (1/11, 9.1%), refractive error (1/11, 9.1%), weakness (1/11, 9.1%), and allergic rhinitis (1/11, 9.1%). Nearly 50.0% were on regular treatment/corrections for hypothyroidism, rheumatic heart disease, refractive error, and allergic rhinitis [Table 2].
Forty percent of the study population worked under the major departments (general medicine, general surgery, obstetrics and gynecology, and pediatrics) while 35% worked under emergency departments (intensive care unit [ICU]/neonatal ICU/casualty/labor room), only about 18% and 7% worked under minor departments (ophthalmology, ENT, orthopedics, dermatology, radiology, and psychiatry) and OT and other departments such as floor supervisor, nursing superintendent, and deputy nursing superintendent, respectively. Most of them (64.0%) worked in the morning shifts and 14% and 22% worked in the afternoon and night shifts, respectively [Table 3].
|Table 3: Descriptive statistics for general health questionnaire-12 items and summary scores (n=100)|
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Majority of the study population responded not more than usual according to four-point Likert scale for items under GHQ-12. Seventeen percent reported that they are under stress much more than usual and 13% each felt unhappy and depressed much more than usual and also losing confidence. Mean GHQ-12 score was 11. As per the scores, the cutoff of at least 12 was found in 35% of the respondents indicating the prevalence of psychological distress among 35.0% [Table 3].
The maximum response given by study subjects was almost never for the items under PSS-10 according to the five-point Likert scale. As per the screening tool PSS-10 used, majority of the study subjects (93.0%) perceived moderate level of stress with a median score of 19 [Table 4] and [Graph 1].
|Table 4: Descriptive statistics for Perceived Stress Scale items and summary scores (n=100)|
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The association of psychological distress with various sociodemographic characteristics, namely age, gender, religion, stay, type of family, SES, and self-reported illnesses was not found to be statistically significant (P > 0.05).
Although psychological distress was slightly more among nursing staffs working in minor departments (44.4%) compared to those working under major departments, i.e., 38.3% and under emergency departments (25.7%) and among those working in morning shifts (39.1%) compared to afternoon and night (39.1%) shifts, the associations were not statistically significant (P > 0.05) [Table 5].
|Table 5: Psychological distress among study participants based on the general health questionnaire 12 and its association with various sociodemographic and work characteristics|
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[Table 6]a,[Table 6]b,[Table 6]c indicate that the perceived stress scores were slightly more among subjects aged <24 years, males, Hindus, those staying in hostel, those belonging to nuclear family and upper socioeconomic status and those with illnesses known to them, those working in night shifts and morning shifts and under major departments. However, the differences in scores among the groups were not statistically significant (P > 0.05) [Table 6]a,[Table 6]b,[Table 6]c.
| Discussion|| |
In the current study, we determined the psychological distress, perceived stress among the study subjects, and also elicited the factors associated with psychological distress and perceived stress.
In this study, majority of belonged to the age group of ≤25 years and were females and the mean age of the participants being 24.4 ± 3.7 years which is similar to the study by Kshetrimayum et al. where majority of the study subjects were in the age group of <24 years and females.
In the present study, majority of the study subjects worked under the major departments followed by emergency departments and minor departments, whereas according to Masa Deh et al. study, majority of nurses worked in emergency rooms, medical surgical wards followed by ICU, oncology, and psychiatry settings. The difference may be due to different hospital settings and patient load based on which staffs are posted in different departments.
In this study, most of the nurses (64.0%) worked in the morning shifts and 14% and 22% worked in the afternoon and night shifts, respectively, which is similar to the study findings of Kshetrimayum et al.
According to our study, psychological distress was found in 35.0% of the study subjects which is in-line with the study findings of Altinoz and Demir i.e., 35.7% were at risk for mental disorder. Although the cutoff of 4 has been used in Altinoz and Demir, the maximum score was 12 in theirs and ours was 36 and the cutoff of 12 was used which are comparable. Balajee et al. have recorded a prevalence of psychological distress among those who were normal (healthy controls) and those with noncommunicable diseases as 35.4% and 50.8%, respectively. However, there has been no overall prevalence mentioned in theirs as it was a comparative study. Psychological distress was slightly more among nursing staffs working in minor departments (44.4%) compared to those working under major departments and under emergency departments, but the associations were not statistically significant similar to the study conducted by Masa Deh et al., who showed psychological distress to be more among psychiatric nurses and low among nurses working in emergency departments. The reason that the nurses working in emergency departments reporting less stress could be due to experience, more skills, less nurse to patient ratio, and regular training sessions which has not been elicited in the current study. Nurses working in the working in morning shifts (39.1%) showed slightly higher psychological distress compared to other shifts which was not statistically significant similar to the findings of Kshetrimayum et al.
Majority of the study subjects (93.0%) perceived moderate level of stress with a median score of 19 which is similar to the findings of Kshetrimayum et al., Bodke and Dhande, and Asturias et al., in their study noted that majority of the nurses felt moderate level of perceived stress.,,
Perceived stress scores were slightly more among subjects aged <24 years, males, Hindus, those staying in hostel, those belonging to nuclear family and upper socioeconomic status and those with known illness, those working in the night and morning shifts and under major departments; however, the differences in scores among the groups were not statistically significant (P > 0.05), whereas according to Kshetrimayum et al., 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 similar to this study.
Limitations of the study
The WHO validation study of GHQ for screening mental illness in general health care has shown that a threshold of 12 using the Likert scoring (0, 1, 2, and 3) had a sensitivity of 79% and specificity of 77% and is an inherent limitation of the study. The consideration of factors such as years of experience, skills, and new appointments would throw some light on eliciting the factors associated with psychological distress and perceived stress among the study subjects which is a limitation. With the adoption of purposive sampling in the current study, there might be selection bias which limits its generalizability.
| Conclusion|| |
The psychological distress among the study subjects according to GHQ-12 was found to be 35% which attributes to more than 1/3rd of them. All of them perceived some amount of stress but 93.0% of the study subjects were having heightened stress levels as per the PSS-10 scale scores.
Hence, it can be considered that it is important to continuously monitor the stress levels using such screening tools among the largest work force in the health care field. Those subjects can be recommended to undergo further diagnosis by referring them to the specialty services and could be managed accordingly. It also highlights that it is important to implement certain stress management programs and facilitate our nursing professionals to develop and build their coping skills and abilities to lead a better life and also contribute efficiently to the workplace.
The authors immensely thank the interns who actively helped in collecting the data and contributing in the successful completion of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Community Medicine, BGS Global Institute of Medical Sciences, # 67, BGS Health and Education City, Uttarahalli Road, Kengeri, Bengaluru - 560 060, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]