Prevalence and Associated Factors of Psychological Distress Among Nurses in public Hospitals, Southwest, Ethiopia: A Cross-Sectional Study Design

Background: Psychological distress is broadly dened as a state of emotional suffering characterized by symptoms of depression and anxiety combined by other somatic symptoms like; insomnia, headaches, and lack of energy that is likely to vary across different areas. Therefore, this study aimed at assessing the prevalence of psychological distress and its’ associated factors among nurses in public hospitals, Southwest Ethiopia, 2017/18. Method: An institutional-based cross-sectional study was conducted in public hospitals, Southwest Ethiopia from February 1 st , 2018 to April 1 st , 2018. The total number of nurses who fulll the inclusion criteria were enrolled. Data was collected using the predesigned tool like Self-Reporting Questionnaire version 20 (SRQ 20). Data were entered using EPI INFO version 7 and was exported to statistical packages for social science (SPSS) version 21.0 for analysis. Bivariate and multivariate logistic regression was employed and odds ratio with 95% condence interval was used to assess the degree of association between variables. Variables with a P-value of less than 0.05 were considered as statistically signicant. Result: A total of 282 eligible nurses were enrolled in the study with mean age of 28.71 [SD ±7.047]. The prevalence of psychological distress among nurses was 78(27.7%). Predictor variables like; [AOR= 10.13, 95% CI (1.85, 55.41)], work experience [AOR= 4.98, 95% CI (1.59, 15.568)], interaction with staffs [AOR= .305, 95% CI (.117, .796)], fatigue [AOR= 2.54, 95% CI (1.072, 6.02)], social support [AOR= .189, 95% CI (.075, .474)], perfectionism [AOR= 5.697, 95% CI (1.449, 22.39)] and insomnia [AOR= 3.82, 95% CI (1.52, 9.579)] were found to be strong predictor variables for psychological distress. Conclusion: This study revealed that a considerable proportion of nurses had psychological distress.


Introduction
The study was conducted in public hospitals located in zones of Southwest Ethiopia. These are Mizan-Tepi University Teaching Hospital, Gebretsadik Shawo General Hospital, and Tepi General Hospitals, which are located in Benchi-Maji Zone, Kefa Zone, and Sheka Zone respectively. Mizan-Tepi University Teaching Hospital has located 561 km from the capital city Addis Ababa and 844 km from the regional city Hawasa. Gebretsadik Shawo Hospital is found in Bonga town and located 464 km from Addis Abeba and 739 km from regional city Hawasa. Tepi General Hospital is found in Tepi and located 611 km from Addis Abeba. All of these hospitals have immunization departments, delivery ward, inpatients wards, outpatient departments, antenatal and post-natal clinic. Currently, Mizan-Tepi University Teaching Hospital is expected to provide service for more than 829,000 populations. While Gebretsadik Shawo General Hospital and Tepi General Hospitals are expected to provide care for more than 500,000 populations. Mizan-Tepi University Teaching Hospital, Tepi General Hospital, and Gebretsadik Shawo General Hospital have 106, 94, and 82 nurses respectively whose work experience is one or more years.

Study Participants
To be included, participants had to ful l the following criteria: (1) have a minimum of year work experience in the same workplace or a similar health setting, (2) age 18 years and older and (3) being nurse and working in public hospitals. But those who were critically ill and unable to give response during data collection time were excluded.

Data collection tools and procedure
The data was collected using a self-administered questionnaire by six trained health professionals' and three supervisors. The questionnaire was pretested among 5% of the sample size in health centers which were out of the study settings. The coherence and skipping pattern of the questionnaire were corrected after the pretest.
For psychological distress (anxiety, depression, and somatization), the Self-Reporting Questionnaire version 20 (SRQ 20) was used, which was developed by World Health Organization (WHO) for low and middle-income countries including Ethiopia [30,31]. It has a "YES" or "No" questions and can be used as a self-administered or interviewer-administered questionnaire [32]. SRQ 20 is a 20 item questionnaire commonly used to screen anxiety, depression, and somatization symptoms [33]. We used the cut-off point 8 based on the nding from the validation study of SRQ-20 which gave the highest sensitivity and speci city [32].
To assess social support, Oslo Social Support Scale was used. Oslo Social Support Scale Score is ranged from 3-14 with a score of 3-8 = poor social support; 9-11 = intermediate social support; and 12-14 = strong social support [34].
For perfectionism, a self-assessment perfectionism screening test was used. It has "yes" if it's generally true and "no" if it's generally not true. Five or more yes answers suggest a signi cant problem with perfectionism. This is a screening test [35].
Sleep disturbance was measured by the Athens insomnia scale (AIS). The AIS is an 8-item self-reported questionnaire that indicates insomnia within the past month and scores each ranging from 0 to 3 (0 score equals better and 3 is worst). The total score greater than or equals to 6 indicates insomnia [36,37].

Data analysis
The data was entered using EPI INFO version 7 and was exported to statistical packages for social science (SPSS) version 21.0 for data cleaning and analysis. Bivariate logistic regression was done to see the degree of association between independent variables (socio-demographic, organizational related factors, psycho-social related factors), and dependent variable (psychological distress) were assessed. Variables with a P-value of < 0.05 were recruited for multivariate analysis to control the effects of confounding. Finally, the results considering a con dence level of 95% and P-value of < 0.05 were taken as strong predictors for psychological distress. The results were presented in the form of tables, gures, and summary statistics.

Socio-Demographic Characteristics of the Respondents
A total of 282 eligible nurses were included in the study with a 100% response rate. Among the respondents, most of 125 (44.3%) was in the age range of 25-29 years with a mean age of 28.71 [SD ± 7.047], more than half of participants 144 (51.1%) were female, 91 (32.3%) were Amhara by ethnicity, 120 (42.6%) were currently single, 158 (59.6%) had diploma educational status, 157 (58.6%) were orthodox religion members followed by protestant 34.3%. Concerning the respondents' working years of experience in the current health institution, most 138 (48.9%) of them had 1-3 years of experience [ Table 1].  The prevalence of psychological distress among nurses was 78(27.7%) with 95% CI (22%, 33%).

Factors associated with psychological distress
Based on bivariate analysis variables like; age, job title, year of experience, interaction with staff, fatigue, social support, perfectionism, and insomnia were the factors found to be signi cantly associated with psychological distress.
After adjusting for possible confounders with multivariate analysis; job title, work experience, interaction with staff, fatigue, social support, perfectionism, and insomnia were found to be strong predictor variables for psychological distress.

Discussion
The aim of this study was to identify the prevalence of psychological distress and associated factors. In addition to this, the ndings of this study will have a signi cant role towards overcoming of the problems associated with psychological distress among nurses, like; job dissatisfaction and lack of energy which negatively affects their perception of the quality of life and health services in the workplace and the relationship with the patient and family [38]. Conversely, nurses with their job satisfaction increases showed reduced psychological distress [39].
In this study, the prevalence of psychological distress was 78(27.7%) with 95% CI (22%, 33%), and this study was found to be low when it is compared with a study done in Nigeria 44.1% [20]. The possible explanation for the difference in prevalence may be due to the difference in study setting, study population, tools, and methodological differences. For instance, in a study conducted in Nigeria, the tool named General Health Questionnaire (GHQ-12)was used whereas, the Self-Reporting Questionnaire version 20 (SRQ 20) was used in our study.
In contrast to the other study, this study was found to be higher compared with the studies conducted in different areas, wherein Norwegian 13% [40], in Sri Lanka 21% [41], in Addis Ababa, Ethiopia 11.7% [42], and in another study conducted in Addis Ababa, Ethiopia 17.7% [43].
This discrepancy might be for the reason that there might be a difference in a study setting, study population, tools, and methodological differences. Another possible explanation might be due to the nature of their work that nurses are more prone to experience psychological distress than the general population in the community.
Different independent predictor variables associated with psychological distress were identi ed in this study.
In this study, the job title was found to be signi cantly associated with psychological distress. The odds of having psychological distress were almost 10 times more likely in those participants with a job title of staff nurse as compared with a head nurse. This might be due to the fact that those nurses in the position of staff nurse may experience more distress and less job satisfaction because they spend more time with patients. Conversely, nurses working in managerial positions, generally have more professional experience and a higher level of education, which factors can help them to cope with different stressors and also increase job satisfaction [44].
Work experience was also found to be signi cantly associated with psychological distress. Participants whose working experience was 6-10 years were almost 5 times more likely to have psychological distress than those participants with experience of 1-3 years. This nding also noted in London that year of work is associated with psychological distress [45]. This might be explained by those nurses who worked for a long duration of time in the health setting are more subjected for emotional exhaustion, lack of energy, and general fatigue which in turn leads to the experience of psychological distress [46].
This study found interaction with other staff members was also another predictor variable for psychological distress. Nurses with good interaction with other staff members were 30.5% times less likely to be psychologically distressed as compared with their counterparts. This nding is in line with the study conducted in Virginia, USA [47], and in Texas [48]. This is due to the fact that nurses with good interaction among staff and family members have a chance to discuss and seek solutions for the issues which interfere with their stability and motivation for work. In contrast to this, poor interaction can negatively affect their physical as well as mental health [49].
In this study, fatigue among nurses was considered as a signi cant variable for psychological distress.
Participants with fatigue were 2.5 times more likely to have psychological distress as compared with their counterparts. This is supported by a study from Iran [50] and Rhine-Main-Region, western Mid-Germany [51]. This might be for a reason that nurses with fatigue are commonly experienced with a devastating sense of drowsiness, lack of energy, and impaired cognitive and/or physical functioning, which may lead to a health problem, decrement of performance, increased risk of injury/accident, and low personal achievement, which possibly experience psychological distress [52][53][54].
Social support was found to be another factor associated with psychological distress in this study. Those participants with intermediate social support were 18.9% times less likely to have psychological distress than those with poor social support. This nding is also supported by the study conducted in China [55] and in Sri Lanka [41]. A plausible explanation to this could be the fact that nurses with good social support can have good mental and physical health [56][57][58], where this leads to the good cognitive function and performance of concentrated health care procedure which nally increases the quality of health care services [59].
Besides, this study investigated that participant with perfectionism was a predictor variable for psychological distress. Participants with perfectionism were almost six times more likely to develop psychological distress than their counterparts. This nding was supported by the study conducted in the United States Western University, USA [60]. This is due to the fact that perfectionism is a driving force of negative stress in some nurses [61]. Because perfectionist nurses who were more concerned about faults, obsessed with higher quality of work, and had more worries about their capabilities regarding the patient care are more prone to be psychologically distressed [62][63][64].
Insomnia was also another important predictor variable in this study. The odds of having psychological distress were almost 4 times more likely in those participants with a minor problem with sleep as compared with those participants with normal sleep. This is supported by the study conducted in Finland [65], in the USA [66], and in Samara, Ethiopia [67]. The reasonable justi cation could be the fact that nurses with sleep problem become disoriented for their work and further it increases the likelihood of subsequent psychological distress [68][69][70].

Conclusion
This study revealed that a considerable proportion of nurses had psychological distress. Job title, work experience, interaction with staff, fatigue, social support, perfectionism, and insomnia were found to be strong predictor variables for psychological distress. Therefore, strong social support, upgraded working status, and good interaction with staff should be encouraged among nurses working in the health setting to cope up with different stressors.

Limitation
Even though this study contributes as an input for the policymakers towards the decrement of the psychological distress among nurses, it has its own limitations. First, since a cross-sectional study design was implemented, it can't establish cause-effect relationship between the predictor variables and dependent variables. Second, the tools used to assess psychological distress was not validated in Ethiopia. Finally, other health professionals were not included, which limited us not to compare nurses with other health professionals.
List of abbreviations Ethics approval and consent to participate The study was approved by the research standing committee of Mizan Tepi University, college of health science with a reference number CHS/0246/15/19. In addition to this, permission letter was taken from each hospital administration o ce. After explaining the objectives of the study, written consent was obtained from each study participant. Then after data was collected with strict privacy and assuring con dentiality.

Consent for publication
Not applicable Availability of data and materials The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Email: Alex.sayihalem2012@gmail.com Competing interests