Single-item measures of stress during work- and private time in healthcare workers

Abstract

BACKGROUND:

While the psychosocial work environment within the hospital sector is a topic of great debate, surveys assessing stress often do not differentiate between stress related to work- and private life. Identifying risk factors associated with these domains of daily life would help improve policies as well as target relevant treatment options. Therefore, the aim of this study was to evaluate associations between stress during to work- and private time with Cohen’s Perceived Stress Scale (CPSS).

METHODS:

Perceived stress was assessed by the full version of CPSS (scores 0–40) as well as by two single-item questions related to stress related to work- and private life, respectively. Associations between these single-items and CPSS were modelled using general linear models controlling for lifestyle factors.

RESULTS:

Overall, stress due to both work- and private time was strongly associated with CPSS scores. In the full population (n = 3,600), “never experiencing stress” during both work- and private time was associated with low stress scores (6.0, 95%CI 5.1–6.9). “Never experiencing” work-related stress but experiencing private time stress “very often” was associated with high stress scores (22.4, CI 19.8–25.1). Likewise, experiencing work-related stress “very often” but “never experiencing” private time stress was also associated with high stress scores (22.2, CI 20.3–24.2). Lastly, Spearman’s r between the full CPSS and the two single-item questions about work- and private time stress were 0.62 (p < 0.0001) and 0.52 (p < 0.0001), respectively, while the two items were only weakly correlated (r = 0.32).

CONCLUSION:

The present study shows that perceived stress due to both work and private time is strongly associated with Cohen’s Perceived Stress Scale scores. The results illustrate the feasibility of using single-item questions related to work- and private time in identifying domain-specific risk factors for psychosocial stress.

Keywords

Biopsychosocial hospital psychometrics work environment nurse Cohen’s perceived stress scale

1 Background

Psychosocial stress constitutes a major socioeconomic issue and arguably one of the biggest modern-day challenges in a fast-tracked society; often resulting in severe negative health consequences for the individual [1 –4]. Indeed, in addition to being associated with numerous indicators of poor health (e.g. obesity, type-II diabetes, depression, anxiety and persistent pain) [5 –9], stress is the second-most frequently reported work-related health issue; affecting approximately 22%of workers in Europe [10].

Referring to the biopsychosocial model of health as proposed by Engel [11], the causes of stress can be related to biomedical-, psychological- and social aspects of both work- and private life. For instance, excessive job demands, low control, low social support, role- ambiguity and conflict, low development possibilities and job-insecurity are all factors known to influence the individual’s perceived level of work-related stress [10]. Defining stress as an individual experience with levels of homeostatic disruption and accompanying coping strategies varying greatly between individuals, it is typically measured and quantified by subjective psychometric questionnaires; Cohen’s Perceived Stress Scale (CPSS) [12] arguably being the most utilized. In the effort to identify specific risk factors, however, it is important to recognize that CPSS does not inherently differentiate between stressors related to work- and private life, respectively.

Specifically, among healthcare workers, it is well known that this subgroup of the working population experience a high prevalence of musculoskeletal disorders as well as a current and future shortage of workers [13, 14]. Thus, effective methods to accurately investigating the organizational context of this job group –primarily in terms of the local work environment and the inherent stressors within –constitutes an important area of research as numerous organizational physical- and psychosocial factors have been shown to influence the health and workability of healthcare workers [15 –20]. Therefore, the primary aim of this study was to investigate if two single-item questions on stress related to work- and private life, respectively, are associated with perceived stress, with the hypothesis that stressors related to both domains of life are independently reflected in these items.

2 Methods

2.1 Study design and participants

This study is a cross-sectional analysis of data obtained from a large-scale questionnaire survey among Danish healthcare workers (N = 3,600) during the Spring of 2016, investigating associations between physical and psychosocial factors related to the work environment on outcomes related to musculoskeletal pain and injury [21, 22]. Using this survey, we have previously reported associations between perceived stress and low-back pain among healthcare workers [18, 23]. Table 1 describes the study participants’ demographic characteristics, including baseline information from the full sample of healthcare workers as well as from a sensitivity analysis of female nurses (N = 2,047).

Table 1
Demographics of included participants

All Nurses

Variable Mean SD % Mean SD %

N 3,600 2,047

Female 86 100

Age (y) 45.8 11.4 45.5 11.0

BMI 25.1 4.7 25.0 4.8

Smoking (yes) 9.1 8.8

Education:

Nurse 58.9 100

Doctor 13.8

Healthcare assistant 7.5

Therapist 6.5

Other 13.3

	All	Nurses
N	3,600			2,047
Female			86			100
Age (y)	45.8	11.4		45.5	11.0
BMI	25.1	4.7		25.0	4.8
Smoking (yes)			9.1			8.8
Education:
Nurse			58.9			100
Doctor			13.8
Healthcare assistant			7.5
Therapist			6.5
Other			13.3

3 Instruments

3.1 Cohens perceived stress scale

The Perceived Stress Scale by Cohen [12] is a widely-used psychometric instrument for the subjective measurement of stress. Items were designed to show how unpredictable, uncontrollable, and overloaded respondents find their current lives, and includes a few direct queries about current levels of perceived stress. Importantly, the questions are of a general nature and relatively free of content specific to any subpopulation. Each item is rated on a 5-point Likert scale ranging from “never” to “almost always”. Positively worded items are reverse scored, and the ratings are summed, with higher scores indicating higher levels of perceived stress. Normative values [mean (SD)] among the general population are 12.1 (5.9) for men and 13.7 (6.6) for women, respectively. Thus, A score of ∼13 –not adjusting for gender or age –is considered average, and stress scores above 20 indicate high stress [12, 24].

3.2 Questions related to work- and private life

Two single-item questions were constructed to encompass stressors related to work- and private time, respectively; rated on a 5-point Likert scale ranging from “never” to “very often”.

The questions were as follows:

“How often within the last month have you felt stressed because of your private life?”

“How often within the last month have you felt stressed because of your work life?”.

3.3 Statistics

Associations between perceived stress during work- and private time and CPSS scores were modelled using general linear models (Proc GLM, SAS version 9.4), with the latter as the dependent variable. The analysis was controlled for gender, age, education, BMI, and smoking habits. Because female nurses represent the largest occupation among healthcare workers and therefore in this sample, a sensitivity analysis among this subgroup was also performed. Estimates are presented as least square means and 95%confidence intervals (CI).

3.4 Ethics approval and consent to participate

According to the Danish National Scientific Ethics Committee, questionnaire surveys not pertaining to biological material does not require registration. Consent to participate is given by the participant when he/she replies to the questionnaire.

4 Results

Among all healthcare workers, we report CPSS scores [mean (SD)] of 12.8 (5.8). Further, 2.8%and 2.1%replied that they “very often” experience stress related to work- and private time, respectively. Conversely, 17.0%and 22.7%reported that they “never” experience stress related to work- or private time, respectively. Similar results were found among the subgroup of female nurses; with 2.5%and 1.9%experiencing work- and private time stress “very often”, respectively (Table 2). Figure 1 provides a visual representation of the associations between the two single-item questions and CPSS scores for all healthcare workers.

Table 2
Stress scores for all healthcare workers (N = 3,600) and the subgroup of female nurses (N = 2,047) using CPSS and the two single-item questions related to work- and private life stress. Values are presented as mean (SD) or point-prevalence

All Nurses

Stress Mean SD % Mean SD %

CPSS score 12.8 5.8 12.8 5.8

Work

Never 17.0 17.0

Rarely 33.0 33.4

Sometimes 36.1 35.5

Often 11.2 11.6

Very often 2.8 2.5

Private

Never 22.7 22.5

Rarely 37.5 37.7

Sometimes 30.1 30.6

Often 7.6 7.4

Very often 2.1 1.9

Fig. 1

Visual representation of CPSS scores (0–40, vertical) and associated ratings of perceived stress during work (grey)- and private time (black). Values are presented as least square means.

In the full sample of healthcare workers, there was a main effect of perceived stress during work (p < 0.0001), private time (p < 0.0001), as well as a significant interaction between stress during work- and private time (p < 0.0001) and CPSS scores. Importantly, the correlation coefficients (Spearman’s r) between the full CPSS and the two single-item questions about work- and private time stress were 0.62 (p < 0.0001) and 0.52 (p < 0.0001), respectively, with the mean value of the items showing an even stronger correlation with the full CPSS (0.72, p < 0.0001). Further, the items related to work- and private time stress were only weakly correlated (r = 0.32), indicating two individual constructs.

Table 3 shows the estimates of the interaction between stress during work- and private for CPSS scores: “Never experiencing stress” during both work- and private time was associated with low CPSS scores (6.0 [95%CI 5.1–6.9]), whereas experiencing stress “very often” in both domains was associated with high scores (26.0 [95%CI 23.2–28.8]).

Table 3

CPSS scores related to perceived stress during work- and private time in the full sample of healthcare workers. Values are presented as least square means and 95%confidence intervals

Private	Work
	Never	Rarely	Sometimes	Often	Very often
Never	6.0 (5.1–6.9)	8.9 (7.9–9.8)	10.8 (9.8–11.8)	14.8 (13.5–16.1)	22.2 (20.3–24.2)
Rarely	7.4 (6.4–8.4)	10.3 (9.5–11.2)	13.7 (12.8–14.5)	18.0 (17.0–19.0)	23.8 (22.1–25.6)
Sometimes	10.3 (9.2–11.5)	12.7 (11.8–13.6)	15.3 (14.5–16.2)	18.6 (17.5–19.7)	23.0 (21.4–24.5)
Often	14.2 (12.0–16.4)	16.9 (15.7–18.0)	17.1 (16.0–18.2)	21.8 (20.6–23.1)	23.9 (21.4–26.5)
Very often	22.4 (19.8–25.1)	20.6 (18.8–22.4)	19.8 (17.9–21.7)	25.0 (22.6–27.5)	26.0 (23.2–28.8)

^*Adjusted for gender, age, education, BMI, and smoking.

In the sensitivity analysis of female nurses, similar findings were obtained: There was a main effect of perceived stress during work (p < 0.0001), private time (p < 0.0001), as well as a significant interaction between stress during work- and private time (p < 0.0001) for CPSS score (Table 4). “Never experiencing stress” during both work- and private time was associated with low CPSS scores (6.1 [95%CI 5.5–6.7]), whereas “very often” experiencing stress during both work- and private time resulted in the highest score (31.0 [95%CI 26.6–35.3]). Finally, experiencing stress “very often” in either one of the domains was associated with CPSS scores above 20.

Table 4

CPSS scores in relation to frequency of experienced stress during work- and private time among female nurses. Values are presented as least square means and 95%confidence intervals

Private	Work
	Never	Rarely	Sometimes	Often	Very often
Never	6.1 (5.5–6.7)	8.4 (7.6–9.2)	10.9 (10.0–11.7)	14.8 (13.6–16.1)	22.2 (19.8–24.6)
Rarely	7.9 (7.0–8.8)	10.3 (9.8–10.8)	13.8 (13.2–14.3)	18.2 (17.3–19.1)	23.5 (21.3–25.7)
Sometimes	10.6 (9.4–11.8)	13.1 (12.5–13.8)	15.4 (14.9–15.9)	18.6 (17.7–19.6)	21.8 (20.1–23.6)
Often	14.5 (12.2–16.7)	16.3 (15.1–17.4)	17.5 (16.4–18.6)	21.9 (20.5–23.2)	24.5 (21.2–27.9)
Very often	27.8 (22.4–33.1)	22.4 (20.3–24.6)	21.6 (19.3–23.9)	25.2 (22.7–27.7)	31.0 (26.6–35.3)

^*Adjusted for age, education, BMI, and smoking.

5 Discussion

This study reports strong associations between two single-items related to perceived stress during work- and private time and CPSS scores among Danish healthcare workers as well as in a subgroup of female nurses. In the present analyses, “very often” experiencing work- and private time stress corresponded to high CPSS scores; i.e. 26.0 and 31.0 for the two samples, respectively. Importantly, based on the relatively strong correlations to the full CPSS and because the two included items were only weakly correlated, this study indicates the possibility of identifying domain-specific stressors with simple measures.

The strategy of utilizing single-item questions in survey research has gained popularity in quantitative and qualitative studies alike [25 –30], the implementation of which have been ranging from quantifying levels of physical activity among university staff [31] to identifying the association between a single measure of stress and the prospective risk of severe musculoskeletal injury among industrial forest workers [27]. Arguable, this increasing- and widespread use is not without merit, and the approach may prove increasingly valuable in aspiring epidemiological research: For example, using 4 sets of independent data across borders and occupations, Elo et al. reports satisfactory content-, criterion- and construct validity for a single-item measure of work-related stress [26]. Similarly, using a large prospective cohort, Littman et al. found good validity and reliability for 2 single-item measures of psychosocial stress [25]. Further, when comparing different question formats (i.e. branch, grid or single-item), the latter is likely to achieve the highest response rates [32]. Given that most questionnaire surveys average a response-rate of about 50%[33, 34], continuous use and development of this approach is likely to increase the representatives of future population-based surveys.

Collectively, the notion that single, concise questions hold the potential to contribute to or even replace longer self-reported measures in survey research echoes throughout the literature [28 , 35]. However, while the present study highlights the potential of identifying domains-specific stressors, the brain and hormonal system do not discriminate between origins of stress and the same physiological response (i.e. increased levels of cortisol and catecholamines) is therefore expected [36 –40]. In addition to a range of clear-cut physiological ailments [6 –8], high levels of cortisol is associated with smaller hippocampi [41] as well as stress-induced remodeling of the amygdala and prefrontal cortex [42].

In short, persistent stress –regardless of origin–constitutes a complex issue affecting both physiological, psychological and behavioral aspects of wellbeing, with a broad array of immunological, cardiovascular, musculoskeletal- and mental health ramifications known to follow [43–48 , 55]. Therefore, survey-based research plays an important role in accurately identifying risk factors related to both work- and private life, with the over-arching goal of improving recovery and management of psychosocial stress originating from both domains.

5.1 Strengths and limitations

To our knowledge this is the first study to demonstrate associations between CPSS and two single-item questions about work- and private time stress. Inherent limitations of self-reported questionnaire surveys include recall-, non-response, and common-method bias [49 –51], and it may be argued that it is difficult for the individual to accurately pinpoint whether the cause of their stress is (mainly) due to work- or private life. Further, due to the demographic characteristics of the population, generalizability remains to be determined. Contrariwise, the fact that the sensitivity analysis of 2,047 female nurses showing similar results as the total sample, speaks to the robustness of the presented associations. Finally, using Cohen’s Perceived Stress Scale [12] is a noteworthy strength as it is highly utilized method of evaluating stress with acceptable psychometric properties [52, 53].

6 Conclusion

The present study shows that two single-item questions on perceived stress related to work- and private time, respectively, are strongly associated with the full version of Cohen’s Perceived Stress Scale. Further, the results indicate that the use of individual questions related both aspects of daily life is feasible; subsequently enabling the identification of suitable and domain-specific intervention strategies.

Conflict of interest

The authors declare that they have no competing interests.

Funding

Author LLA obtained a grant from the Danish Working Environment Research Fund, Arbejdsmiljøforskningsfonden, grant number 26-2015-09 / 20150064698.

Author contributions

LLA designed the study and obtained the funding. All authors contributed to planning of the analyses and interpretation of the results. LLA performed the statistical analysis. KJ and JV drafted the manuscript and all co-authors provided critical feedback. All authors approved the final version.

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, Sundstrup

, Andersen

, The psychosocial work environment and perceived stress among seniors with physically demanding jobs: The SeniorWorkingLife Study. International Journal of Environmental Research and Public Health. 2021:18:7437. doi:10.3390/ijerph18147437.

	All			Nurses
Variable	Mean	SD	%	Mean	SD	%
N	3,600			2,047
Female			86			100
Age (y)	45.8	11.4		45.5	11.0
BMI	25.1	4.7		25.0	4.8
Smoking (yes)			9.1			8.8
Education:
Nurse			58.9			100
Doctor			13.8
Healthcare assistant			7.5
Therapist			6.5
Other			13.3

	All			Nurses
Stress	Mean	SD	%	Mean	SD	%
CPSS score	12.8	5.8		12.8	5.8
Work
Never			17.0			17.0
Rarely			33.0			33.4
Sometimes			36.1			35.5
Often			11.2			11.6
Very often			2.8			2.5
Private
Never			22.7			22.5
Rarely			37.5			37.7
Sometimes			30.1			30.6
Often			7.6			7.4
Very often			2.1			1.9

Single-item measures of stress during work- and private time in healthcare workers

Abstract

BACKGROUND:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1 Background

2 Methods

2.1 Study design and participants

Table 1 Demographics of included participants All Nurses Variable Mean SD % Mean SD % N 3,600 2,047 Female 86 100 Age (y) 45.8 11.4 45.5 11.0 BMI 25.1 4.7 25.0 4.8 Smoking (yes) 9.1 8.8 Education: Nurse 58.9 100 Doctor 13.8 Healthcare assistant 7.5 Therapist 6.5 Other 13.3

3.1 Cohens perceived stress scale

3.2 Questions related to work- and private life

3.3 Statistics

3.4 Ethics approval and consent to participate

4 Results

5.1 Strengths and limitations

6 Conclusion

Conflict of interest

Funding

Author contributions

References

Table 1
Demographics of included participants

All Nurses

Variable Mean SD % Mean SD %

N 3,600 2,047

Female 86 100

Age (y) 45.8 11.4 45.5 11.0

BMI 25.1 4.7 25.0 4.8

Smoking (yes) 9.1 8.8

Education:

Nurse 58.9 100

Doctor 13.8

Healthcare assistant 7.5

Therapist 6.5

Other 13.3