A systematic review and meta-analysis of  Job stress among Iranian nurses

DOI: https://doi.org/10.21203/rs.2.24414/v1

Abstract

Background: Job stress is the most important factor in reducing organizational productivity. Therefore, this study aimed to identify prevalence of job stress among nurses in Iran.

Methods: This study was conducted using a meta-analysis. All published articles on prevalence of job stress among nurses in Iran until July 2018 were searched and collected using PubMed, Web of Science, Science Direct, CINAHL, PsychInfo, Scopus, Magiran, IranMedex and SID and Bibliography section of the retrieved papers and related journals. Finally, 22 empirical studies were reviewed using Comprehensive Meta-Analysis software.

Results: The overall prevalence of job stress in Iranian nurses was 49.5% (95% CI 41.9%-59.1%). The highest job stress was recorded in Tehran in 2016, 96.4% (95% Cl: 90.3%-98.7%) and the lowest job stress was found in Kashan in 2011, 2.5% (95% Cl: 6.0%-1.0%). Significant statistical correlation was observed between job stress, year and sample size (p<0/05).

Conclusion: job stress affects about half of nursing staff in Iran; thus, managers and policymakers should take serious measures to reduce prevalence of job stress among nurses.

1. Background

Hospital is a social system that plays a critical role in preserving and promoting the health of the community by using facilities and human resources (1). The ultimate goal of the hospital is to effectively and efficiently meet the health needs of the community (2).Working in the hospital requires direct contact with patients and clients throughout the day. This resulting interactions increases the psychological pressure on health care workers, including nurses (3). Nursing is classified as a stressful profession due to the ongoing contact with sick people, incurable diseases, and deaths (4). Moreover, a high proportion of nurses work in different shift work. Although some nurses tolerate shift working conditions comfortably without issues, many others face with serious problems such as stress (5).

Stress is very common in the present century. It is linked to many diseases and is a main reason for absenteeism in healthcare centers (6). The National Institute of Occupational Safety and Health defines stress as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, and needs of the worker (7). Occupational stress is the physical and psychological strain, which happens when there is inconsistency between the objective or cognitive demands of the work environment and the individual compatibilities (8).

Job stress occurs when expectations of an individual exceed their authorities and abilities, which leads to personal problems, inability to work, and disruptions in organizational performance (9). Nursing is one of the most stressful professions and its multitude of stressors in negatively affect the staff. It is very demanding and practitioners experience many ups and downs from the time they begin their studies until they retire. Working long shifts, working in more than one shift, and mandatory or voluntary overtime are some of the factors that affect nurses’ job satisfaction (10).

On the other hand, job stress increases work-related incidents, delays, and absenteeism, hypertension and cardiovascular diseases thus reducing productivity, organizational commitment, and the quality of care (10–11). In Iran, 80% of health system workers are nurses. In addition, 80% of the works in hospitals is done by them (12).The American National Institutes of Health (NIH) ranked nursing as 27th among 130 most stressful jobs due to mental health problems. Nurses experience stress like the patients and are often faced with stressors that they cannot adapt to (13). In fact, Job stress among nurses can impact on their performance in all aspects (14).

Studies have shown the prevalence of job stress in nurses is higher than that of the whole population, although it may vary among different countries as well as nursing specialties (15).For example, in Iran, the highest level of stress (43.2%) was reported among hospital nurses who had to do shift work (16). Ghasemi et al also conducted a study in Zanjan and reported the prevalence of job stress among nurse was 57.4% (17). In U.S, 20% of intensive care unit and general care nurses in various hospitals were found to suffering from anxiety and stress (18). In Singapore, a survey showed 21% of nurses in a general hospital had anxiety disorders (19).

Although different studies have been published on the prevalence of job stress among Iranian nurses in hospitals (20–22), the question of what the overall prevalence of stress among Iranian nurses is, still remains unanswered. On the other hand, it is essential to review and integrate the results of published studies to help hospital managers and policymakers make evidence-based decisions. Therefore, the purpose of the present study was to systematically review the studies conducted on job stress in nurses of Iranian hospitals.

2. Method

This research was a meta-analysis of studies on job stress in nurses.

2.1 Search strategy

Articles published in databases such as PubMed, Web of Science, CINAHL, PsychInfo, ScienceDirect, Scopus, Magiran, IranMedex, and Scientific Information Database (SID) were identified until July 2018. Google Search and Google Scholar were also used to search for relevant articles. Search strategy included the use of Persian and English keywords and a combination of these terms. PRISMA guidelines were used to direct the reporting process (Fig. 1) (23). The search strategy was as follows: “Prevalence” AND (“Job stress” OR “occupational stress” OR “work related stress”) AND “Nurses” AND “hospital” AND “Iran”. Search strategy is reported in Appendix 1. In addition, the reference lists of the articles were examined to identify other relevant articles that did not shown up in database searches.

2.2 Inclusion and Exclusion criteria

We selected studies if they were:

- Observational studies (cross-sectional, case control, cohort investigations) examining the prevalence of job stress among Iranian nurses;
- Studies published in Persian and English language;
- Studies published by July 2018;

We excluded studies if they were:

- Studies designed as books, randomized clinical trials (RCTs), case-report investigations, case series, qualitative studies, gray literature,, dissertations, and editorials;
- focus on other groups such as physicians, midwives, and student
- unavailability of the full-text articles
- Studies reporting overlapping results;
- Studies whose results were not clear, and in which the possibility of calculating the prevalence was not provided.
 
2.3 Quality evaluation

One of the researchers extracted the required data after agreeing on selected studies. Disagreements were resolved by discussion. Finally, Data were selected from each study based on the title of the article, the name of the first author, the year of publication, sample size, methodology, location of study, and prevalence of job stress and an Excel spreadsheet was used for data entry.

The STROBE checklist was used to evaluate the quality of the reviewed articles (24). The checklist contains 22 items and examines various aspects of the methodology such as sampling methods, variables measurement, statistical analysis, adjusting confounders, study objectives, and characteristics of validity and reliability measurement tools. This checklist has a maximum score of 44. The articles were divided into three categories: low (0–15), medium (16–30) and high (31–44) (Table 1). Article quality was rated independently by the researchers using the scale’s scoring table and their eventual disagreements were resolved by discussion. Titles and abstracts of the articles that were identified through database searches were assessed by the researchers using the inclusion and exclusion criteria to obtain a list of articles for meta- analysis. The full texts of identified articles were obtained. The recovery rate for these articles was 100 percent.

2.4 Analysis

Data were analyzed using the Comprehensive Meta-Analysis software. I2 was used to test for study heterogeneity. The heterogeneity was divided into three categories of < 25% (low heterogeneity), 25–75% (moderate heterogeneity), and > 75% (high heterogeneity). The results indicated the heterogeneity of the studies (I2 = 96.37) and thus a random effects model was used to synthesize their results (25). The funnel plot and Egger’s test were used to assess the potential for publication bias (26) and the results showed that publication bias was not statistically significant (P = 0.10) (Fig. 2).

Finally, the effect of variables that could be the potential sources of heterogeneity was examined using the meta-regression technique. Point estimation of job stress prevalence in nurses was calculated in forest plots at the 95% confidence interval, where the size of the box indicates the weight of each study and the lines on its sides represent the 95% CI (Fig. 3).

 

3. Results

In total, 25 eligible articles were selected based on steps of PRISMA statement (Table2). Most of these studies were conducted in 2010, 2011, and 2012. More than half of these studies were published after 2010. Most studies were done in training hospitals in Tehran, Isfahan, and Hamedan. The design of most included studies was cross-sectional.

In the present research, the prevalence of job stress in nurses across Iranian hospitals was found to be 49.5 percent based on the random effects model (40.5-58.6 percent: 95% CI). The highest prevalence of nursing job stress was 96.4 percent (90.3-98.7 percent: 95% CI) in Tehran as reported in Kammar (2016) (5), while the lowest prevalence of nursing job stress was 2.5 percent (1.0-6.0 percent: 95% CI) in Kashan as reported in Bahrami (2011) (37).

The results were broken down based on sample size and region of study, which is shown in Table 3. Nursing job stress was more prevalent in southern regions of Iran compared to other regions. On the other hand, job stress was more prevalent in sample sizes smaller than 150.

To examine the factors that caused heterogeneity, variables such as year of publication and sample size were incorporated in the meta-regression model. Based on the results of analysis in Table 4, there was a significant relationship between year of publication, sample size, and nursing job stress prevalence.

The results of reviewed studies revealed that the prevalence of nursing job stress has increased by 0.03 percent each year. The review covered the period until July 2018, and most of the studies were conducted after 2010.

4. Discussion

The purpose of this study was to determine the prevalence of nursing job stress in Iranian hospitals until July 2018. By searching 6 databases, 22 relevant articles were identified. Based on a random effects model, the prevalence of nursing job stress in Iranian hospitals was found to be 50.5 percent, which is less than the value reported in Mwinga (2015) in Zambia (93 percent) (47), but higher than the value reported in Aoki (2011) in Thailand (26.2 percent) (48) and Al Hosis et al. (2013) in Saudi Arabia (34.2 percent) (49). The results of different studies suggest that the prevalence of nursing job stress varies by countries. Therefore, it is necessary to interpret the present findings with caution. It is also important to note that the research are based on the results of 22 studies, while the researches in other countries are based on one or two studies.

In this research, prevalence of nursing job stress was shown to decrease by 0.009 percent for each increase in the sample size by one person. This indicates that studies with small samples are prone to bias and may not provide valuable insights for healthcare managers and policymakers. Therefore, studies on prevalence of nursing job stress must ensure a representative sample size and the use of appropriate sampling methods.

A closer look at the prevalence of nursing job stress in these studies showed that it has increased in recent years. This could be due to the application of the study quality control process and selection of fewer studies from the period before 2010 due to poor quality. It must be noted that prior to 2010, fewer studies examined the prevalence of job stress in nurses and used incomplete methodologies. Therefore, increase in nursing job stress in the last few years may simply be due to an increase in stressors in the workplace rather than better documentation with more scientific methodologies (50, 17). Although the number of studies conducted before 2010 was less than those conducted afterwards due to qualitative screening, it must be noted that prevalence of stress in nurses is indeed increasing despite the implementation of different programs such as strategic planning, accreditation, and quality improvement. Perhaps one of the most important factors that have been overlooked by most healthcare managers and policymakers is the issue of increased nursing workload following the implementation of these programs (50–51).

This study showed that nursing job stress is more prevalent in the southern regions of Iran compared to other regions of the country. One of the reasons for this finding may be the fact that working in southern regions is harder due to bad and warm weather and the problems it causes, thus putting more work pressure and stress on nurses. As an example, in Iran, Mazloum et al showed Excessive heat can make problems such as heat exhaustion, neurological symptoms and psychological stress and reduced productivity in employees (52).

In recent years, a number of studies have been conducted on nursing job stress in Iranian hospitals. However, the results of these studies showed large dispersion and heterogeneity. Another key factor may be the instruments that have been used to measure job stress in nurses. Due to the development of different questionnaires, nursing job stress is measured differently. Therefore, differences between the results of the reviewed studies can be, in part, due to differences in the instrument used to measure this variable. For example, the Occupational Stress Questionnaire has been used in Osipow, Krishna, Stimer, and Steinmetz. Overall, there is no a comprehensive questionnaire for measuring job stress among nurses. Thus, there is a need for developing a comprehensive questionnaire for Iranian hospitals

Nursing job stress has been investigated in a limited number of Iran’s provinces. This shows that these studies have not been comprehensive, and this gap can be filled in future research.

One of the strengths of this study was a comprehensive and systematic research on important medical sites. On the other hand, it was studied the potential sources of heterogeneity by meta-regression and subgroups-analyses. However, this study had some limitations. One of the limitations of this study was the high heterogeneity of the reviewed studies. Moreover, these studies lacked sufficient information for measuring nursing job stress based on average age and hospital department.

5. Conclusion

Job stress at any level can be an inevitable problem in health-related professions. This can lead to higher medical errors and lower quality of care. Therefore, healthcare managers and policymakers must prevent this by adopting appropriate strategies such as increasing welfare facilities, reconsidering job descriptions for different nursing grades, providing support, increasing nurses’ involvement in the decision-making process, improving communication between managers and nurses, and teaching problem solving skills.  Conducting qualitative studies of job stress would give a better view of job stress and related factors among nurses in hospitals.

Abbreviations

The American National Institutes of Health (NIH), Scientific Information Database (SID), randomized clinical trials (RCTs),  Confidence Intervals (CI).

Declarations

ORCID:  Mahnaz Afshari: https://orcid.org/0000-0003-1349-2588

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Tables

Table 1. The STROBE Statement—checklist of items that should be addressed in reports of observational studies.

Item number

Recommendation

Title and Abstract

1

(a)

Indicate the study's design with a commonly used term in the title or the abstract

(b)

Provide in the abstract an informative and balanced summary of what was done and what was found

Introduction

 Background/rational

2

Explain the scientific background and rationale for the investigation being reported

 Objectives

3

State specific objectives, including any prespecified hypotheses

Methods

 Study design

4

Present key elements of study design early in the paper

 Setting

5

Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection

 Participants

6

(a)

Cohort study—Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up

Case–control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control selection. Give the rationale for the choice of cases and controls

Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants

(b)

Cohort study—For matched studies, give matching criteria and number of exposed and unexposed Case–control study—For matched studies, give matching criteria and the number of controls per case

 Variables

7

Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable

 Data sources/measurement

8 a

For each variable of interest, give sources of data and details of methods of assessment (measurement).
Describe comparability of assessment methods if there is more than one group

 Bias

9

Describe any efforts to address potential sources of bias

 Study size

10

Explain how the study size was arrived at

 Quantitative variables

11

Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen, and why

 Statistical methods

12

(a)

Describe all statistical methods, including those used to control for confounding

(b)

Describe any methods used to examine subgroups and interactions

(c)

Explain how missing data were addressed

(d)

Cohort study—If applicable, explain how loss to follow-up was addressed Case–control study—If applicable, explain how matching of cases and controls was addressed Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy

(e)

Describe any sensitivity analyses

Results

 Participants

13

(a)

Report the numbers of individuals at each stage of the study—e.g., numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed

(b)

Give reasons for non-participation at each stage

(c)

Consider use of a flow diagram

 Descriptive

14

(a)

Give characteristics of study participants (e.g., demographic, clinical, social) and information on exposures and potential data confounders

(b)

Indicate the number of participants with missing data for each variable of interest

(c)

Cohort study—Summarise follow-up time (e.g., average and total amount)

 Outcome data

15

Cohort study—Report numbers of outcome events or summary measures over time
Case–control study—Report numbers in each exposure category, or summary measures of exposure Cross-sectional study—Report numbers of outcome events or summary measures

 Main results

16

(a)

Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (e.g., 95% confidence interval). Make clear which confounders were adjusted for and why they were included

(b)

Report category boundaries when continuous variables were categorized

(c)

If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period

 Other analyses

17

Report other analyses done—e.g., analyses of subgroups and interactions, and sensitivity analyses

Discussion

 Key results

18

Summarise key results with reference to study objectives

 Limitations

19

Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias

 Interpretation

20

Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence

 Generalisability

21

Discuss the generalisability (external validity) of the study results.

Other information

 Funding

22

Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based.


Table3: Subgroup analyses of the included studies

variable

 

No. studies

Prevalence 95% CI

I2

P

Sample size

<150

10

77.0% (63.3-86.7)

93.99

0.0001

>150

14

30/3% (23.4-38.3)

95.13

0.0001

=150

1

64.9% (57.0-72.1)

0.000

0.0001

regional

center

 

 

97.20

0.0001

9

46.0%(29.6- 63.4)

south

7

60.2%(45.4-73.4)

94.07

0.0001

north

3

56.7 % (37.8-73.8)

93.03

0.0001

west

5

44.8% (27.7-63.2)

96.13

0.0001

 

 

 

Table4: Results of meta-regression

P.V

T

SE

Point estimate

Variable

0.001

0.66

0.009

0.03

year

0.007

1.16

0.003

-0.009

sample

Appendix 1

Appendix 1. Search strategy in PubMed/MEDLINE and ISI/Web of Sciences Search strategy for PubMed/MEDLINE

#1 Prevalence(Tiab)

#2 Frequency(Tiab)

#3 Epidemiology(Tiab)

#4 #1 OR #2 OR #3

#5 job stress(Tiab)

#6 work related stress(Tiab)

#7 occupational stress(Tiab)

#8 #5 OR #6 OR #7

#9 Nurses(Tiab)

#10 Iran(Tiab)

#11 #4 AND #8 AND #9 AND #10

Search strategy for ISI/Web of Sciences

#1 TS=(Prevalence* OR Frequency* OR Epidemiology)

#2 TS=( job stress* OR work related stress* OR occupational stress)

#3 TS=(Nurses)

#4 TS=(Iran)

#5 #1 AND #2 AND #3 AND #4