Occupational stress and job performance among Iranian hospital nurses: A cross-sectional survey

Abstract

BACKGROUND:

Occupational stress is one of the most important factors affecting nurse performance. However, there is a lack of data about the association between occupational stress and performance.

OBJECTIVE:

The aim of this study was to determine the occupational stress level and its association with job performance in hospital staff.

METHODS:

This cross-sectional study was conducted among 400 hospital staff of Tehran University of medical sciences in 2018. Subjects completed the World Health Organization Health and Work Performance questionnaire (WHO HPQ) for demographic and occupational characteristics, and the Short Form of Copenhagen questionnaire.

RESULTS:

The demand and individual interface domain received the highest and the lowest score of occupational stress respectively. We found that the median for absenteeism distribution was 16 hours and, in our study, less than 10 % of the nurses had low performance. Working in intensive care units, fewer night shifts, higher income, higher levels of vitality, and social support could decrease absenteeism. In addition, staff who felt more supported and reported lower emotional demands had higher performance.

CONCLUSION:

Since higher levels of social support could have positive influences on reducing absenteeism and improving performance, it is recommended that hospital managers should be encouraged to use educational programs, coping behaviors, and effective interventions to improve social support. Financial incentives are a factor that could also be used to reduce absenteeism.

Keywords

Occupational stress nurse work performance absenteeism presenteeism

1 Introduction

Occupational stress has become one of the most important issues in workplace health, specifically in developing countries [1]. Work-related stress could be defined as staff response to situations where work demands are not matched to the employees’ abilities and knowledge, which can result in grueling challenges that are difficult to cope with. Stress is present in many work circumstances, but it is worse in a situation where there is a lack of support from the supervisors and colleagues [2].

According to the International Labor Organization (ILO), occupational stress is widespread among all categories of workers, and industries all over the world [2]. Occupational stress is estimated as the largest occupational health problem in the United Kingdom [3]. The prevalence of occupational stress in Iranian midwives was 70 % [4].

The consequences of occupational stress are not only seen in the mental and physical state of staff, but it can cause harmful repercussions on companies, organizations, and governments that could lead to financial consequences [5]. The health care industry is one of the most hazardous occupational settings. There are different types of hazards in this sector including physical, chemical, mechanical, biological or psychosocial, with potential adverse health effects [6].

Hospital staff must deal with life-threatening conditions in addition to heavy workloads, inadequate staffing, work shifts, threat of malpractice litigation, exposure to infectious diseases and needle stick injuries, role ambiguity, interpersonal conflicts with other staff, conflict between work and family roles and responsibilities, dealing with difficult or seriously ill patients, all of which contribute to stress [7].

Prolonged exposure to these psychosocial hazards is related to different types of reactions, such as psychological (emotional instability, depression) and physical consequences (headaches, gastrointestinal problems, cardiovascular diseases). Furthermore, it could have a negative impact on workers’ attitudes and behavioral culture. The consequences of work-related stress in the health care industry are difficulties in communicating with seriously ill patients which can contribute to quality of care, relationships with coworkers can contribute to adverse clinical care that affects patients, and judging the seriousness of a potential emergency [8]. Research by Fachruddin et al. indicated that work overload is a main cause of stress among nurses [9]. According to Chaudhari’s survey work load, conflicts with supervisors and their families, unreasonable demands from patients were the main factors of nurses’ occupationalstress [10].

Since HCWs have a key role in hospitals, measuring and managing their performance could be achieved by detecting absenteeism and presenteeism. Absenteeism in the health industry is defined as the loss of scheduled time due to work absence, and could be attributed to having more than necessary leaves. Extrinsic factors such as work load and shift times would affect the absenteeism behavior of nurses [11]. Absenteeism reduces the quality of patient care and performance of health care workers by making an unhealthy working environment due to the psychological stress [12].

Presenteeism refers to the lack of performance and full function of employees in the workplace. Even though the employee is present at the workplace, he could not perform his duties and lost productivity. Presenteeism has recently determined as a major factor that affects organizational performance [13].

According to a Chinese study, the public service motivation was reduced in hospital staff with level of job stress, which in turn leads to poor job performance [14]. Another survey showed the negative impact of job stress on nurses’ performance [15]. In spite of the increasing research on psychosocial hazards and their effects on performance in developed countries, there is a need to explore the psychosocial hazards and their consequences on performance among health care workers in developing countries. Although some studies have already been carried out on stress in nurses and their findings may offer useful insight into occupational stress, there is a lack of data about the association of occupational stress and performance and this concerning subject is not well documented in Iran.

The aim of this study was to examine the occupational stress level and its association with job performance in HCWs (health care workers) in a university hospital in Iran (Tehran province) during 2018.

2 Methods

Hospital management agreed to data collection methodology before nurses were approached. The baseline study population comprises of 400 HCWs. The inclusion criteria of the study were work experience of more than 6 months and the participant’s agreement for joining the study. The exclusion criteria consisted of suffering from a neurologic disorder (e.g. multiple sclerosis, amyotrophic lateral sclerosis, neuropathies), psychological diseases (e.g. depression, biphasic mood disorder, schizophrenia) and the use of psychiatric drugs.

2.1 Data collection

This study was conducted using a survey questionnaire in order to examine the levels of occupational stress, and its association with nurse job performance. The survey questionnaires were personally administered to each participant. The questionnaires consist of three parts: The first part containing demographic information (age, gender, marital status, number of children and smoking status), and occupational characteristics (working history, employment type, job title, working unit, shift work, educational level, and income).

The second part includes a self-report instrument, the world health organization health and work performance questionnaire (WHO-HPQ) for measuring absolute absenteeism, and presenteeism [16]. We used the validated Persian version of the WHO-HPQ questionnaire, which factor analysis showed acceptable validity (Cronbach’s alpha was > 0.73 for all scales) [17].

Absenteeism is scored in terms of lost working hours per month; a higher score indicates a higher amount of absenteeism. The measure of absenteeism is expressed in raw hours, with a negative lower bound (if the person works more than expected) and an upper bound equal to the number of hours the respondent is expected to work. Presenteeism is conceptualized as a measure of actual performance in relation to possible performance [16].

Presenteeism is a ratio of self-rated job performance and the rated performance of colleagues in the same or similar job. To obtain this ratio the participants are asked to rate the usual performance of their colleagues at the same or similar jobs on a scale from 0 to 10, where 0 is the poorest and 10 is top performance. Then they are asked to rate their own job performance over the past 28 workdays. The 0.25 ratio is the worst relative performance, and 2.0 is the best performance [16].

The Copenhagen Psychosocial Questionnaire I (COPSOQ-I) was used for the assessment of occupational stress [18]. The short form of this questionnaire consisted of 44 items with 5-point Likert scale (0 = never, 25 = seldom, 50 = sometimes, 75 = often, and 100 = always) which high values shows a high level of the item that has been measured. This questionnaire consists of 18 scales (quantitative demand, emotional demand, demand for hiding emotions, influence at work, possibility for development, degree of freedom, meaning of work, commitment to workplace, predictability, quality of leadership, social support, feedback at work, sense of community, insecurity at work, job satisfaction, general health, mental health and vitality) covering five domains (job demand, job content and work organization, interpersonal relations and leadership, person-work interface level, and health and wellbeing). The number of each scale calculated through calculating the average of the related questions. A higher score indicates more unpleasant psychosocial condition in the workplace [19]. In addition, three-dimension labels were defined as follows: green (scores: 60–100): most favorable for health; yellow (scores: 40–60: intermediate; red (scores 0–40): most unfavorable for health. The Validated Persian version of this questionnaire was used to assess occupational stress [20]. The Cronbach’s α of the Persian version was between 0.75 and 0.89 and test-retest reliability ranged from 0.75 to 0.89 [21].

All questionnaires were collected and entered into an electronic database and completeness of data was checked. Questionnaires with missing data were excluded.

2.2 Data analysis

Data were analyzed using the SPSS software version 21, and statistical significance was set at a P-value of < 0.05. The results were presented as mean (standard deviation) and number (percentage) for quantitative and qualitative variables, respectively. The variables that were found to be related to absenteeism and performance in the univariate analysis were entered into a multivariable linear regression model. Two separate linear regression analysis was used to investigate the association between demographic, occupational characteristics, stress scales with absenteeism and performance as the two main outcomes.

3 Results

The baseline characteristics of the study population are presented in Table 1. The majority of the population was female, about two-thirds of the participants (76.3%), more than half of them were married and in their early thirties (mean age: 31.4years).

Table 1
Baseline characteristics of study population (n:400)

Continuous variables Mean (SD) Min-max

Age 31.4(6.7) 20–59

Working years 7.27(5.9) 1–33

Shift /months 7.37(6.6) 0–30

Income 2.7(0.78) 1–8

BMI 24.2(3.2) 16.53–39.34

Categorical variables n(%)

Gender Male 95(23.8)

Female 305(76.3)

Marital status Single 167(41.8)

Married 233(58.3)

Employment type Contract 247(61.8)

Formal 153(38.3)

Job title Nurse 328(82)

Technician 72(18)

Educational degree <master 34(8.5)

> = master 366(91.5)

Working unit Intensive care units 215(53.8)

General units 185(46.3)

Continuous variables	Mean (SD)	Min-max
Age	31.4(6.7)	20–59
Working years	7.27(5.9)	1–33
Shift /months	7.37(6.6)	0–30
Income	2.7(0.78)	1–8
BMI	24.2(3.2)	16.53–39.34
Categorical variables		n(%)
Gender	Male	95(23.8)
	Female	305(76.3)
Marital status	Single	167(41.8)
	Married	233(58.3)
Employment type	Contract	247(61.8)
	Formal	153(38.3)
Job title	Nurse	328(82)
	Technician	72(18)
Educational degree	<master	34(8.5)
	> = master	366(91.5)
Working unit	Intensive care units	215(53.8)
	General units	185(46.3)

The mean history of the working years of the participants was 7.27 years. Our participants reported that they have approximately 7-night shifts per month. About 62 % of them were contract workers. Most of them work as nurses and regarding their education; most of them had completed a master’s degree (Table 1).

After measuring the occupational stress using the short form of Copenhagen questionnaire the highest score was in the first domain of the five domains (Demand; Type of production and task) and the lowest score was obtained in the fourth domain (individual interface) (Fig. 1).

Fig. 1

Distribution of the 18 scales of the Copenhagen Psychosocial Questionnaire (COPSOQ).

According to Fig. 2, which has been presented the different scales of occupational stress, emotional demand was ranked as the highest value (62.9) and sense of community received the lowest (2.5) in contrast.

Fig. 2

Average scores and standard deviations of the Copenhagen Psychosocial Questionnaire domains (mean(SD)).

The median for absenteeism distribution was 16 hours with a minimal value of –174 and the maximal value of 280; in our study, about 42.3% of the nurses were not involved in absenteeism. The median score for presenteeism was 1.12 with a minimal and maximal score of 1 and 1.28, respectively.

According to the linear regression analysis, test result report for absenteeism shows that working in general units in comparison with ICU; B: 23.614, CI95 %(2.701, 44.528), standard error: 10.620; p value: 0.027 was associated with higher absenteeism. Lower income; B: 1.639, CI95 % (0.103–3.175), standard error: 0.78, p value: 0.049, higher shifts per month; B: –13.741, CI95 % (–27.445,–0.038), standard error: 6.959, p value: 0.037 and lower social support; B: –0.679, CI95 % (–1.161,– 0.197), standard error: 0.245, p value: 0.006 and vitality; B: –1.001, CI95 % (–1.805,– 0.197), standard error: 0.408, p value: 0.015 were related with increased rate of absenteeism (Table 2).

Table 2

Relationship between different factors (demographic, work related and occupational stress) and absenteeism with linear regression

Variables	B	SE	Beta	P value	Confidence interval 95%
					Lower bound	Upper bound
(Constant)	54.352	56.252		0.335	–56.420	165.125
Age	0.270	0.796	0.022	0.735	–1.297	1.838
Sex	18.033	14.088	0.091	0.202	–9.710	45.775
Working unit(general/ICU)	23.614	10.620	0.147	0.027	2.701	44.528
Job title	32.501	17.006	0.132	0.057	–0.988	65.991
Educational degree	–34.698	25.102	–0.092	0.168	–84.130	14.734
Income	–13.741	6.959	–0.126	0.049	–27.445	–0.038
Shift per months	1.639	0.780	0.140	0.037	0.103	3.175
Quantitative demand	–0.075	0.349	–0.014	0.829	–0.762	0.611
Emotional demand	0.122	0.271	0.031	0.652	–0.412	0.656
Possibility for development	0.512	0.298	0.122	0.087	–0.076	1.100
Meaning of work	0.230	0.298	0.056	0.441	–0.357	0.817
Predictability	0.197	0.312	0.050	0.528	–0.417	0.811
Social support	–0.679	0.245	–0.187	0.006	–1.161	–0.197
Mental	0.344	0.435	0.080	0.430	–0.512	1.200
Vitality	–1.001	0.408	–0.240	0.015	–1.805	–0.197

B: The slope of the line is b(y = ax+b) the value of prediction by independent variable. Beta: estimated coefficients of the explanatory variables. SE: standard error. R²: 0.124; standard error of estimate: 78.49.

As shown in Table 3 higher social support (B:0.006; p value < 0.001) has positive effect on performance, in contrast with emotional demand (B: –0.004; p value < 0.05) which led to lower performance.

Table 3

Relationship between different factors (demographic, work related and occupational stress) and performance with linear regression

Variables	B	SE	Beta	P value	Confidence interval 95%
					Lower bound	Upper bound
(Constant)	1.814	0.353		0.000	1.119	2.509
Age	–0.001	0.006	–0.013	0.834	–0.012	0.010
Sex	0.016	0.091	0.011	0.857	–0.163	0.195
Working unit	–0.080	0.076	–0.066	0.292	–0.230	0.070
Job title	0.013	0.112	0.008	0.908	–0.207	0.233
Educational degree	0.150	0.167	0.056	0.370	–0.178	0.478
Income	–0.067	0.046	–0.086	0.146	–0.157	0.023
Quantitative demand	0.003	0.002	0.075	0.230	–0.002	0.008
Emotional demand	–0.004	0.002	–0.138	0.034	–0.008	0.000
Social support	0.006	0.002	–0.214	0.000	–0.009	–0.003
Insecurity	–0.001	0.001	–0.054	0.354	–0.003	0.001
Mental	–0.005	0.003	–0.144	0.116	–0.011	0.001
Vitality	0.003	0.003	0.103	0.255	–0.002	0.009

B: The slope of the line is b(y = ax+b) the value of prediction by independent variable. Beta: estimated coefficients of the explanatory variables. SE: standard error. R²: 0.072; standard error of estimate: 0.429.

4 Discussion

The aim of this study was to examine the occupational stress level and its correlation with job performance in health care workers. In our study population, the demand domain including quantitative, emotional demand and demand for hiding emotion received higher scores (red zone) which are relevant in connection with human service work. Similar to our study, high percentage of psychological demands was shown in the red area [22]. The results of some studies showed that job related factors were more associated with job stress in contrast with demographic factors [23]. Jobs with patients and relatives and also coworkers were determined as source of violence among nurses [24]. Another study mentioned a high level of emotional exhaustion and personal accomplishment among nurses [25]. Therefore, high level of job stress can be expected due to the key roles of nurses in the healthcare system such as providing life-saving care, long shifts and high turnover of patients and supportingphysicians.

We found the lowest scores (green zone) for the sense of community, commitment to the workplace and meaning of work. Organizational commitment is important because subjects with high work commitment are emotionally linked to their workplace; also, affective and high job commitment was negatively related to turnover intention [26]. Nurses who were more satisfied with their job had more organizational commitment [27]. Since HCWs are among the high-ranking occupational groups that provide public health services, they feel more committed to their workplace and try to be less absent from work. Interventions aimed at stressors or coping were found to be effective to decrease the hospital staffs’ occupational stress [28].

The median for absenteeism distribution was 16 hours; this means that an average nurse in our sample was absent for almost two full days at work in the last months. Our findings were different from the survey that was conducted in Croatia that the median absenteeism distribution of nurses was 32 hours per month [29]. Similar to our findings (24 days/person per year), Tripathi et al. reported the overall absenteeism (days/person) 27.7 per year [30].

In our study, absenteeism was related to some occupational factors including; working ward, excess of night shifts and income. The average absenteeism hours of intensive care units were lower than general units. Some articles found that high rates of absenteeism in intensive care units due to the workload, and another study showed higher frequency of absenteeism in intensive care units due to the health problems [31]. Similar to our results, there was no increase rate of absenteeism in intensive care units. Dynamics of people management, teamwork, interpersonal relationship and enough knowledge regarding workload could be assumed as the contributing factors [32]. The intensive care nurses tended to be more motivated and satisfied with their work as they perceived their work environment more closely matching their practice model and also feel that their work is important for the community [33].

Excess of night shifts resulted in absenteeism that could be due to the employees’ fatigue. In a study conducted among Italian nurses, it was shown that night rotations could be a significant item for absenteeism because shift work has a negative effect on physical and psychological wellbeing, so they tend to be absent more often [34]. A retrospective observational study which was conducted in 32 wards of a hospital [35].

Absenteeism was related to inadequate salary, because financial pressures could lead to look for a supplemental income [36]. Some studies showed the related factors with absenteeism were health problem, working environment, family responsibilities, job stress, job dissatisfaction, workload, female gender and increasing age [37, 38].

Nurses involved in absenteeism (57.7 %) had slightly higher levels of stress in two domains of stress; social support and vitality, when compared to those not involved in absenteeism. These results are comparable with the study in Croatia that found higher levels of stress in nurses who had experienced absenteeism [29].

Social support is an important issue for staff, not only concerning the feeling of job satisfaction but for reducing health and emotional complaints. Social support from a supervisor seems to have priority over a colleague’s support [39]. Teamwork is highlighted in nursing profession, nurses need to work together to manage the patient needs and efficient outcomes are expected due to the teamwork a nursing unit, also the importance of colleague’s support in nursing staff cannot be denied because nursing is teamwork in its nature and cooperation of members is a key factor in achieving healthcare goals [40].

In our study, less than 10 % of the nurses (7.1%) had lower performance in comparison to others (presenteeism lower than 1) which is an appropriate range for this occupational group. Since nurses as human service workers are highly engaged in high levels of job demand including physical and psychological demands, and so, at times, it would be hard for them to focus on their work and perform efficiently, and these factors could lead to decreased performance [41]. A study among 457 workers showed that frustration at work is associated with the occupational stress [42]. Another research found that thirty-nine out of 572 (6.82 %) respondents reported lower job performance [29]. A study by Teraoka in 13 health care facilities showed that coping behavior and occupational performance had a negative relationship with occupational dysfunction [43]. We did not detect any association between demographic variables, occupational factors and decreased performance.

According to our results, the performance had a negative association with emotional demands. job demands produce a psychological reaction, which affect nurses’ job performance. When the emotional demands are high, the staff couldn’t have an effective attention due to the involvement in greater effort, which in turn decline performance [41]. Our study has investigated that social support influence nurses’ job performance. These results are consonant with the findings of Cho et al.’s study that suggested social support could play a key role in improving workers’ performance level by improving the individual’s ability to cope with stressful situations and dealing with stress [44]. Implementing social support can improve workplace performance [45].

5 Limitations

This study has a few limitations. According to the cross-sectional design of the study, it is not possible to make causal inferences on the reported factors associated with performance. In addition, collected data were based on employees’ subjective self-report, which may be affected by recall bias. Furthermore, self-report response biases due to the social desirability could be considered. Our findings may only be relevant for employees working in a teaching hospital, so it limits its generalizability. Further research in more health care sectors could help to omit the limitations of this study.

6 Recommendations

The need for enhanced training and support for health care workers to manage their emotional demands has been recognized. But due to the nature of nursing work it doesn’t seem to be easy to decrease emotional demands but it would be possible to use approaches to reduce its negative consequences. One of these approaches could be improving social support. Since higher levels of social support could have positive influences on reducing absenteeism and improving performance it would be necessary to use educational programs, coping behaviors, and effective interventions in the organization. There are different ways of social support which include emotional support such as creating an atmosphere that makes the employee feel comfortable and understood also practical support could be given by taking actions to help others. Another useful way is information support by promoting staffs’ knowledge and providing useful instructions by clarifying their tasks in order to prevent role ambiguity and role conflicts and in addition by implementing efficient working schedules for nurses with appropriate days off andshift work.

7 Conclusion

It was found that the most important domain of occupational stress was the demand domain. Emotional demand has a negative impact on performance but increasing social support will improve nurses’ performance. Nurses who work in intensive care units experienced less absenteeism; also, higher a number of night shifts and lower-income were related to absenteeism. Regarding occupational stress; higher levels of vitality and social support were protective factors against absenteeism.

Ethics statement

The data were kept anonymous and the hospital had no access to completed surveys or raw data. The study was approved by the Ethics Committee of Tehran University of Medical Sciences.

Informed consent

All study participants signed the informed consent form.

Footnotes

Acknowledgment

The authors thank the participating health care workers at TUMS for their cooperation.

Conflict of interest

The authors declare that they have no competing interests.

Funding

No financial support was received for this study.

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