The effect of occupational stress on marital satisfaction and mental health in Iranian nurses

1 Introduction

Occupational stress (OS) can be defined as stressful situations experienced at workplace. Most people encounter such experiences during their work [1]. Nowadays, occupational stress has become of the most challenging issues that not only endangers the employees’ psychological and physical health, but also impose heavy costs on organizations [2]. Occupational stress and its consequences are estimated to cost American industry about 300 billion dollars annually. That is why it was labeled as the disease of the century [3].

Medical and health care professions such as nursing are among the most stressful professions as they are dealing with the people’s life [4, 5]. The American National Association of Safety Professionals introduced nursing as the first, among 40 stressful professions [6]. Delavand and et al. in a meta-analysis study, reported that prevalence of job stress in Iranian nurses was 69%, that this prevalence is very high and required special attention [7, 8]. However, Al Hosis et al. concluded OS in Saudi Arabia 34.2%.

Several factors increase the nurses’ professional stress. Shortage of nursing staff in proportion to the number of patients, high workload, shortages or lacking of needed equipment and facilities, caring of ill and dying patients, exposure to the suffering of patients and their families, contact with infectious patients, shift work, work related disruptions in personal life, increased expectations of patients and their families, unavailability of physicians in emergencies, encountering new medical diagnoses and therapies, working with the opposite gender and conflict with doctors, are only some of the stressing factors that affect nurses [9–13].

Occupational stress may negatively affect nurses and their performance. Evidence show that nurses who experienced more occupational stress made more working errors and had poor communication with patients and colleagues. Such stresses may make nurses aggressive, angry or depressed, and consequently would reduce their teamwork, ability to make appropriate decisions, and productivity. Occupational stress may also affect negatively on nurses’ social and family life and their marital satisfaction [14–17].

Several studies have reported that nurses experience high levels of occupational stress [18, 19]. Some studies have also conducted on the relationship of occupational stress and nurses’ psychological wellbeing, burnout [20], organizational commitment and job satisfaction [21], and their productivity [22]. Studies reported that severe stress may affect the individual’s physical and psychological health and consequently the person’s family life will suffer [10, 19]. However, few studies conducted on nurses’ marital satisfaction. Evidence show that, nurses with higher levels of psychological health have better relationships with their partners and this positively impact on their sexual and marital satisfaction [23, 24]. A study found that job-related stressors are more serious than other stressors such as financial and family problems [1]. Another study also showed that job stress negatively impacts on all aspects of nurses’ life [25].

Work and family are the two basic components of the individuals’ life and each one affects the other [26]. Such effects would be more profound in some professions such as nursing.

Although previous studies show the negative effect of occupational stress on mental health and marital satisfaction but, fewer studies in Iran have investigated the role of occupational stress components on mental health and marital satisfaction. This stress can be modified in a positive way when know how much and how affects this stress on marital satisfaction and mental health of nurses. Considering this issue is a universal concern to all managers and administrators in the area of health care, identifying the effective components of occupational stress on mental health and marital satisfaction can be considered in the preparation of nurses’ health promotion programs. So, this study aimed to investigate the relationship between occupational stress, mental health and marital satisfaction among nurses in selected hospitals governing by Shahid Beheshti University of Medical Sciences in Tehran, Iran.

2 Material and methods

This cross-sectional study was conducted in the last three months of 2016 on a random sample of nurses working in selected hospitals of Shahid Beheshti University of Medical Sciences in Tehran, Iran. University of Medical Sciences in Tehran, Iran. Sample size was estimated using the Cochran’s formula. Then, 196 samples were estimated to be needed based on the following parameters (α= 0.05, β= 0.15 and sampling error of 0.07). However, 245 samples were selected considering a 25% possible attrition. Sampling was conducted in two stages. Firstly, a list of all hospitals governed by Shahid Beheshti University of Medical Sciences (24 hospitals) was prepared. Then, 3 hospitals were selected randomly using a random number table. Afterward, the number of samples needed of each center was calculated based on the number of nurses in each hospital. Finally, the needed samples were selected randomly using the list of nurses in the selected hospitals. If any of selected nurses did not agree to participate in the study, another one was replaced using the same approach.

Inclusion criteria included bachelor’s degree in nursing, no second job, no history of known mental illness, no experience of crisis in one year and consent to participate in the study. Confused and incomplete questionnaires considered as exclusion criteria.

A four-part questionnaire was used for data gathering. The first section included of questions on demo-graphic variable (i.e. age, gender, education level, employment status, work experience, education level of spouse, job position, and the participant’s usual working shift).

The second part of the instrument was the 35 items hospital stress scale (HSS-35). This scale contains 35 items scored on a 5-choice Likert format (from 1 = never to 5 = always). The HSS-35 scale has the minimum and maximum scores of 35 and 175, respectively. Higher scores indicate higher levels of stress. This scale consists of eleven subscales including of role overload/workload (5 items), role underload/role incompetence (4 items), role incompatibility/role conflict (4 items), role ambiguity (4 items), relationships with superiors (3 items), relationships with colleagues (3 items), shift work (2 items), physical factors (3 items), chemical factors (2 items), biological factors (2 items) and ergonomic factors (3 items). The mean score of each subscale reflect the amount of stress measured by the subscale. The content validity of HSS-35 was previously confirmed and its reliability was measured using Cronbach’s alpha coefficient (α= 0.84) [27].

The Enrich Marital Satisfaction questionnaire (EMSQ) was used as the third part of the instrument. The EMSQ contains 47 items that scored on a 5-choice Likert scale (from 1 = strongly disagree to 5 =strongly agree). The EMSQ contains nine subscales (each with 5 items) including personality issues, marital relationships, conflict resolution, financial management, leisure activities, sexual relationships, marriage and children, relatives and friends, and religious orientation. Thirty-one items are scored inversely. The EMSQ has the minimum and maximum scores of 47 and 235, respectively. The content validity of the Persian version of EMSQ was previously confirmed and its reliability was measured using Cronbach’s alpha coefficient (α= 0.95) [28].

The Symptom Checklist-25 (Scl-25) mental health questionnaire was used as the fourth part of the instrument. This questionnaire contains 25 items that evaluate the individual’s psychological status in the past seven days. All items are scored on a 5-choice Likert scale (from 1 = none to 5 = very much). This questionnaire has the minimum and maximum scores of 25 and 125, respectively. The lower scores indicate higher levels of mental health. The Scl-25 has been translated into Persian by Najarian et al. and its content validity was confirmed. Also the reliability of the test was measured using Cronbach’s alpha coefficient (α= 0.90) [29].

When nurses agreed to take part in the study, the study instrument was given to them and they were asked to respond it carefully in a calm and private environment. Nurses were asked to put the completed questionnaire in a box that had been placed in the main lobby of each hospital. Questionnaires were collected from these boxes after 24 hours.

3 Results

From a total of 245 questionnaires distributed, 209 questionnaires were returned of which 200 were fully completed and were used in the analysis. From the 200 samples, 38.5% (77 cases) were males and 61.5% (123 cases) were females. The mean age of the subjects was 37.35±6.36 years.

The mean scores of nurse’s job stress; mental health and marital satisfaction were 104.11±16.42, 103.74±14.57 and 169.65±28.38, respectively. No significant association was observed between the mean age or work experience and job stress, marital satisfaction and mental health (P > 0.05).

In ANOVA, significant differences were observed between the mean scores of nurses, head nurses and supervisors in terms of job stress, marital satisfaction and mental health (p = 0.0001).

The mean score of occupational stress was higher in staff nurses then other subgroups, while, supervisors had higher marital satisfaction and mental health scores than staff nurses (p < 0.000). Significant differences were observed between the mean scores of occupational stresses in nurses with different education levels so that individuals with higher education levels, had lower stress scores (p = 0.001) (Table 1).

Using independent sample t-test, significant differences were observed between the mean scores of male and female nurses in terms of marital satisfaction and mental health. Male nurses had higher scores in marital satisfaction and mental health (p = 0.001). However, no significant difference was observed between the occupational stress mean scores in the two genders.

Inverse significant correlations were observed between the scores of job stress and mental health (r = –0.468, p = 0.001) and marital satisfaction (r = –0.517, p = 0.001). Then, nurses’ marital satisfaction and mental stress scores were decreased with an increase in score of occupational stress.

Inverse significant correlations were observed be-tween the scores in the majority of occupational stress subscales (except for the role incompatibility subscale) and marital satisfaction (Table 2). Also, inverse significant correlations were observed between the scores of the majority of occupational stress subscales (except for the role incompatibility subscale) and mental health (Table 2).

Multivariate regression analysis was used to investigate the effect of occupational stress components on marital satisfaction (Table 3). According to the results shown in Table 3, and based on the R² value, more than 0.74% of variation in marital satisfaction is explained by the components of occupational stress and the F value of 50.6 showed that the model is good fit for data at the significance level of 0.05.

As shown in Table 3, the four components of role compatibility, role ambiguity, relationships with superiors and ergonomic factors are the most important job-related stressors that could significantly affect nurses’ marital satisfaction.

In order to determine the contributions of the occupational stress components in predicting mental health, these components were entered in multivariate regression analysis as independent variables. Results in Table 4 show that the model is significant (F = 9.03, P < 0.001); and these components can predict 34% of the mental health variance (R² = 0.346).

As shown in Table 4, the three components of role incompatibility, physical and biological factors are the most important job-related stressors that could significantly affect nurses’ mental health.

This study aimed to investigate the relationship between job stress, mental health and marital satisfaction of nurses in hospitals of Shahid Beheshti University. This study showed an inverse relationship between job stress and nurses’ marital satisfaction. In other words, an increase in nurses’ job stress would result in a decrease in their marital satisfaction. This finding is consistent with the results of PeimanPak et al, Rostam et al. and Lee et al. [30–32]. In addition, in a qualitative study, Adib-Hajbaghery et al. have reported that occupational stress has negative impacts on all aspects of nurses’ family life [22].

Peimanpak has reported that high levels of job stress might negatively affect the nurses’ personal and family life, increase their conflicts with spouses, decrease their marital relationships and even would lead to divorce [32, 33]. It seems that job stress and burnout can decrease the nurses’ power to adapt with emotional and familial problems and consequently would lead to negative reactions such as censoriousness and criticism towards their spouses, other relatives and family members. In contrast, Story and Repetti have reported that marital dissatisfaction may exacerbate the effects of occupational stress. This may indicate that there is a reciprocal relationship between job stress and marital satisfaction, so that the problems in any of these two areas would affect the other [34].

In the present study, a significant inverse relationship was observed between job stress and mental health. This finding is consistent with results of some studies [35, 36] and is in contrast with Tehrani et al. who studied the relationship between job stress, mental health, personality type and stressful life events of the nurses worked in Tehran pre-hospital emergency medical system [37].

It seems that, increased levels of occupational stress would result in changes in body systems, including the endocrine system, which may consequently reduce the individual’s capacity of social adaptation and mental health [38]. Previous studies have also shown that occupational stress, not only causes physical illness in nurses, but predisposes them to psychosomatic and mental disorders [39, 40]. Shahrakivahed et al. have also reported that high levels of psychological health may inhibit or significantly decrease the level of occupational stress and its consequences [41]. Then, it can be concluded that the higher the level of nurses’ mental health, the better they will deal with job related stressors.

In the current study, a direct relationship was found between nurses’ mental health and their own marital satisfaction. This finding was in line with previous studies [32, 42]. Shahi et al. have also reported that having a psychological disorder may decrease the individual’s capability to establish a good relationship with others including their spouses, then, they would be unable to give and receive love, intimacy and gratitude. Such conditions would eventually lead to marital dissatisfaction [42].

There are some limitations in the present study. We used of self-report based on self-directed questionnaires. Responses to such instruments may be biased via providing some readymade responses. Perhaps using qualitative research methods may be helpful to explore the nurses’ lived experiences in this area. The study was conducted on a relatively small sample selected from 3 hospitals in one city. Then, the results might not reflect the situation in the total nursing population in Iran. Then, multicenter studies with larger sample size are suggested. Moreover, the study was a cross-sectional one. In a cross-sectional study we cannot assess a definite cause and effect relationship. In addition, findings of the present study might be affected by the number of females enrolled in this study; as they were nearly two-thirds of the participants and the mean occupational stress score were higher in females than in males while the mean marital satisfaction and mental health scores were significantly lower in females than in males. Furthermore, marital satisfaction is an interpersonal issue between a husband and his wife. Then the nurses’ spouses’ perceptions of the issue should be considered. This could be an important issue for further studies.

5 Conclusions

The results revealed that occupational stress plays a decisive role in nurses’ marital satisfaction and mental health. Due to the destructive effects of occupational stress on the people’s mental health, interpersonal relationships and on their efficacy in their job, establishment of some counseling services for nurses to be used by them periodically or by need, can help them to manage their stress level and better management of their family life problems. Moreover, in-service courses or workshops on stress management may help nurses to possess appropriate knowledge and skills on stress management. Such programs can train nurses how to positively balance their occupational and family roles. In such condition nurses will tend to engage in every role with equally high effort, devotion, attention and care.

Then they perhaps will tend to manage their job responsibilities more efficiently so that their work time does not cut into his or her allocated family time. Such abilities might consequently improve their social and family relationships and also would increase their levels of marital satisfaction.

Author contributions

Mohsen Adib-Hajbaghery approved the last version of article to be published, made a substantial contribution to the concept and design, and revised article critically for important intellectual content. Mohammad-Sajjad Lotfi made a substantial contribution to the concept, made drafted the article, analysis, and interpretation of data. Fatemeh Sadat Hosseini made a substantial contribution to the concept, design, and acquisition of data or analysis and interpretation of data.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.