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Original Article

A Profile of Occupational Stress in Nurses

Aditi Prasad Chaudhari, Kaustubh Mazumdar, Yogesh Mohanlal Motwani, Divya Ramadas
Department of Psychiatry, Bhabha Atomic Research Centre Hospital, Mumbai, Maharashtra, India

Abstract
Background: Occupational stress is common in nurses. Stress can impact the health of the nurses leading to somatic complaints.
Aims and Objectives: (1) To determine the extent and causes of occupational stress among nurses at Bhabha Atomic Research Centre
Hospital. (2) To compare the stress levels among nurses depending on their years of experience. (3) To study any correlation between stress
levels and the extent of somatic complaints. Materials and Methods: Ninety‑seven staff nurses without any preexisting psychiatric illness
were evaluated for occupational stress using the Expanded Nursing Stress Scale. The extent of somatization was measured using the Patient
Health Questionnaire – 15, in a cross‑sectional study. Cronbach’s alpha, analysis of variance, and Spearman’s correlation co‑efficient test
were applied to the data. Results: An internal consistency of 0.945 was noted using Cronbach’s alpha. 51.5% nurses experienced mild, 34%
experienced moderate, and 2.10% experienced severe stress. Conflicts with supervisors, patients, and their families and workload were the
main causes of occupational stress while discrimination was the least affected domain. Nurses with 6–10 years of experience had maximum
stress. The stress levels correlated with the extent of somatic complaints. Conclusions: Occupational stress is prevalent in nurses. It may be
higher in nurses with lesser experience and it can be associated with somatic complaints.

Keywords: Nurses, occupational stress, psychosomatic complaints

Introduction illnesses such as depressive and anxiety disorders.[1] Therefore,

Professional stress is defined as a “pattern of emotional,
cognitive, behavioral, and physiological reactions to adverse
and harmful aspects of work content, work organization, and
the working environment.”[1] These harmful physical and
emotional responses occur when the requirement of the job
does not match the capabilities, resources, or needs of the
worker.[2] Nursing has always been recognized as a stressful
profession,[3,4] but this cannot be explained merely on the
basis of increased workload.[5] Research[6‑12] done in different
countries suggests that the causes of nursing stress could vary
from constant shift duties, interpersonal conflicts with peers,
seniors, patients, or doctors to performing tasks not related to
nursing and dealing with life‑threatening emergencies.
Occupational stress in nurses is significant for a number
of reasons. There is evidence to suggest that work‑related
stress decreases the quality of nursing and nursing care[1] and
increases the chances of making errors.[13] This could have an
adverse impact on patient care. Secondly, research has shown
that prolonged stress can not only trigger the development of
physical disorders of the musculoskeletal and cardiovascular
system[1] but also increase the vulnerability to psychiatric
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it can lead to poorer health in the nurses themselves. Finally,
professional stress is often a precursor to decreased job
satisfaction,[9] increased burnout,[14] absenteeism, and turnover
of nursing staff.[15] Nurses are the largest workforce in the
health‑care sector, and an unhealthy work environment is one
of the important factors contributing to worldwide nursing
shortage.[16]
The concept of nursing stress has, no doubt, been explored in
the Indian subcontinent with studies reporting a significant
stress among Indian nurses.[5,11,12,17] However, it is obvious
that stress in nurses has important implications not only
for the nurses themselves but also for the patients and
health‑care services. Thus, given the vast scope of the
subject, it is imperative that a much larger body of research
is warranted.
Address for correspondence: Dr. Aditi Prasad Chaudhari,
Department of Psychiatry, Bhabha Atomic Research Centre Hospital,
Anushaktinagar, Mumbai ‑ 400 094, Maharashtra, India.
E‑mail: aditidagaonkar@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Chaudhari AP, Mazumdar K, Motwani YM,
10.4103/aip.aip_11_18 Ramadas D. A profile of occupational stress in nurses. Ann Indian Psychiatry
2018;2:109-14.

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Chaudhari, et al.: Occupational stress in nurses
Aims and objectives
1. To determine the extent and causes of occupational
stress among nurses at Bhabha Atomic Research
Centre (BARC) Hospital
2. To compare the stress levels among nurses depending on
their years of experience
3. To study any correlation between stress levels and the
extent of somatic complaints.
Materials and Methods
Study sample
This was a cross‑sectional, observational study conducted at the
Department of Psychiatry, BARC Hospital, Anushaktinagar,
Mumbai. Individuals working as a staff nurse at BARC Hospital
for more than 1 year, in shift duties, willing to participate in
the study and not having a diagnosed, preexisting psychiatric
illness by self‑report were included in the study. The nurses
were informed of the research objectives and assured of the
confidentiality of their responses. A semi‑structured pro forma
was designed to collect the sociodemographic data. The pro
forma along with the study instruments were distributed to 120
consenting nurses in a survey method. Convenience sampling
was used. One hundred and five questionnaires were returned
but 8 were incompletely filled hence were excluded from the
study. Thus, 97 study pro formas were analyzed. This gave the
survey an overall response rate of 80.8%.
Study instruments
• The Expanded Nursing Stress Scale (ENSS):[18] This
scale was used to assess occupational stress in nurses. It
is an expanded version of the original 34‑item Nursing
Stress Scale. It has 57 items arranged in a five‑point
Likert response scale. The response options are 1 = never
stressful, 2 = occasionally stressful, 3 = frequently
stressful, and 4 = extremely stressful. In addition,
0 = does not apply, indicates that the person has never
faced such a situation in his/her work environment before.
This scale has nine subscales for the major sources of
stress commonly encountered in the nursing profession,
namely death and dying, conf lict with physicians,
inadequate preparation, problems with peers, problems
with supervisors, workload, uncertainty concerning
treatment, patients and their families and discrimination.
Factor analysis of this scale [1] has discerned three
factors: physical, psychological, and social working
environments. Physical working environment was
described by the subscale workload while psychological
working environment was described by the subscales of
death and dying, inadequate preparation, and uncertainty
concerning treatment. The third factor of the social
working environment was described by the remaining
five subscales, i.e., conflicts with physicians, problems
with peers, problems with supervisors, patients and their
families and discrimination. The internal consistency as
assessed by Cronbach’s alpha is 0.96 for the total scale
110
and that for the subscales ranges from 0.88 for problems
with supervisors to 0.65 for discrimination. The scale is
written in very simple English and so translation to local
language was not required. The mean individual score
was calculated by dividing the total score with the number
of items and the interpretation was done as follows:
• Up to 1.5 = None or minimal stress
• 1.6–2.5 = Mild stress
• 2.6–3.5 = Moderate stress
• >3.5 = Severe stress
• The Patient Health Questionnaire – 15 (PHQ – 15):[19]
This is a commonly used scale to assess the extent
of somatic complaints. It has 15 items in which the
respondent has to rate his or her somatic symptoms
on a three‑point scale (0 = not bothered at all;
1 = bothered a little; 2 = bothered a lot). The total
score can range from 0 to 30, with higher scores
indicating a greater severity of somatic symptoms.
The scores on the individual items are added to obtain
a total score which is interpreted as follows:
• 0–4 = Minimal
• 5–9 = Low
• 10–14 = Medium
• 15–30 = High.
Statistical methods
The data analysis was carried out using the IBM SPSS Statistics
for Windows, version 20.0, (Armonk, NY, IBM Corp.). The
sociodemographic data and prevalence of occupational stress
have been mentioned in terms of percentages. The scores on
the scales were checked for normal distribution using the
Shapiro–Wilk test. The scores on the scales and subscales
have been expressed in terms of mean, standard deviations,
and median scores with interquartile range. The scores on
the three factors of the scale were compared using the paired
t‑test. The scores on the ENSS have been compared among
nurses with different years of experience using the analysis
of variance (ANOVA). The correlation between occupational
stress and somatic complaints was assessed using the
Spearman’s correlation coefficient test. P =0.05 was regarded
as statistically significant.
Results
A total of 97 staff nurses were studied. The demographics of
the study population was as shown in Table 1.
The total individual scores on the ENSS were found to be
normally distributed (Shapiro–Wilk Sig = 0.105). They
ranged from 46 to 201, and the mean total score for the study
population was 124.06 ± 32.58.
The mean scores for each individual ranged from 0.81 to
3.53, and the individual mean score was 2.17 ± 0.57 which
corresponded to a mild level of stress.
The prevalence and severity of stress was as shown in Figure 1.
Thus, 87.6% nurses experienced stress.
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Chaudhari, et al.: Occupational stress in nurses

(t = 9.02; df = 96; Sig = 0.00; 95% Confidence interval – Lower

Table 1: Population demographics
0.403 and Upper 0.630).
Number Domain n (%)
Depending on the number of years of experience, the
1 Age (years) Range from 26 to 57
Mean age 38.5±7.21
nurses were divided into five groups, and the total scores
Age group on the ENSS for each group have been plotted in a graph
20‑30 12 (12.4) in Figure 2. The levels of occupational stress across the
30‑40 43 (44.3) groups were compared using ANOVA. It was found that the
40‑50 34 (35.1) groups differed significantly (F [4, 96] = 2.70 P = 0.032).
50‑60 8 (8.2) Post hoc least significant difference test showed that nurses
2 Sex with 6–10 years of experience had significantly higher
Males 10 (10.3) stress (Mean = 144.71 ± 28.7) as compared to nurses with more
Females 87 (89.7) than 15 years of experience (Mean = 114.6 ± 31.4).
3 Marital status
Married 91 (93.8)
The scores on the PHQ–15 were not found to be normally
Single 6 (6.2) distributed (Shapiro–Wilk Sig = 0.00). The mean score for the
4 Education study sample was 6.98+ standard deviation = 4.74. The median
General nursing and midwifery 80 (82.5) scores were 6.00 with an interquartile range of 7. These scores
BSc nursing 17 (17.5) correspond to a low level of somatic complaints.
5 Years of experience
The prevalence of somatic complaints was as shown in Figure 3.
<5 17 (17.5)
6‑10 14 (14.4) There was a significant positive correlation between
11‑15 22 (22.7) the scores on the ENSS and scores on the PHQ–15
16‑20 26 (26.8%) (Spearman’s rho = 0.347 P < 0.001) indicating that higher
>20 18 (18.5%) levels of stress were associated with increased somatic
complaints.
2.10%
Discussion
12.40% Of the 193 nurses working at BARC Hospital, 120 consented
for participation and the final analysis included data collected
34% from 97 nurses. This gave the study a margin of error of 7% and
a confidence level of 95%. The English version of the ENSS
scale was used, and valid psychometric properties were noted
within our study sample. The Cronbach’s alpha was used to
51.50% assess internal consistency. For the entire scale, the Cronbach’s
alpha was 0.945, and it was approximately 0.7 for all subscales
except discrimination wherein it was 0.514.
Exact comparison across studies is not possible due to the
Nil or Minimal Mild Moderate Severe use of different instruments and methodology. We noted that
87.6% of the nurses reported occupational stress, of which 34%
Figure 1: Severity of stress experienced moderate stress while 2.1% experienced severe
stress. Similar findings have been reported in a study by Bhatia
The causes of stress and the mean individual scores in each of et al.[5] in which 87.4% nurses found their jobs stressful with
the subscales were as shown in Table 2. 32.2% experiencing severe to extreme stress. In a study done
Among the three factors identified from the nine subscales, by Kane,[17] the prevalence of stress was found to be 73.59%
the mean score for stress was the highest in the physical in the study population. Both these studies had used different
working environment, i.e., 2.53 ± 0.71. The mean score on instruments to assess occupational stress. Research done by
the social environment was 2.04 ± 0.60 and psychological Shiv Prasad[12] in which the ENSS was used had reported that
environment was 2.02 ± 0.57. These two scores did not differ 92% nurses experienced stress, of which 52% had severe to
significantly from each other (t = −0.523; df 96; Sig = 0.602; very severe stress. All these findings unequivocally indicate
95% Confidence interval – Lower 0.118 and Upper 0.68). that there is a very high prevalence of occupational stress
among nurses in India.
However, the mean score on the physical working environment
was significantly higher than the social environment The mean individual score on the ENSS was 2.17 ± 0.57
(t = 10.33; df = 96; Sig = 0.00; Confidence interval – Lower which corresponded to a mild level of stress. Three studies
0.397 and Upper 0.586) and psychological environment from the Middle East have used the same scale and reported

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Chaudhari, et al.: Occupational stress in nurses

3
2.53 Minimal
39.20%
2.5

2 2.28 2.04
2.16 Low
1.98 30.90%
1.5
Medium
1 20.60%

0.5
High
9.30%
0
Upto 5 yrs 6 - 10 yrs 11 - 15 yrs 16 - 20 yrs > 20 yrs 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 45.00%

Figure 2: Mean score on the Expanded Nursing Stress Scale on Y‑axis Figure 3: Prevalence of somatic complaints
versus Years of Experience on X‑axis
constant. A recent analysis of the data from the INC and the
World Health organization by a private agency revealed that
Table 2: Causes of stress
India is short of 1.94 million nurses.[21] In most hospitals,
Number Domain Mean Percentage the nurses are often entrusted with several tasks such as
score±SD of nurses supervising the ward attendants, overseeing the housekeeping,
reporting stress laundry, beddings, repairs, and indents, attending numerous
1 Conflicts with supervisors 2.82±0.75 68.1 phone calls, and arranging for patient investigations,
2 Unreasonable demands from 2.56±0.80 59.8
referrals, discharges, and transfers, in addition to patient care.
patients and their families
3 Workload 2.53±0.71 56.7
Appropriate staffing not only leads to improved patient care
4 Limited experience with 2.13±0.63 32
but also facilitates allocation of fairer nursing workloads.[22] It
death and dying also helps nurses to regain confidence and control over their
5 Uncertainty regarding 2.10±0.67 31 working conditions.[22]
treatment
6 Conflicts with other 2.02±0.81 27.8
The causes of stress were compared only with those studies
health‑care professionals that have used the ENSS, for obvious reasons. In our study,
7 Inadequate preparation to 1.8±0.75 19.6 conflicts with supervisors, unreasonable demands from
deal with patient’s emotional patients and their families, workload and limited experience
issues with death and dying were the leading causes, while problems
8 Problems relating to peers 1.59±0.77 16.5
relating to peers and discrimination were the least common.
9 Discrimination 1.09±0.83 7.3
There is considerable variation in the findings reported across
SD: Standard deviation
studies. Problems related to peers and inadequate preparation
to deal with patient’s emotional issues have consistently
the mean scores to be much higher, i.e, 2.8 ± 1.4 in a study emerged as the least stressful issues in most studies.[1,8‑11]
from Jordan[9] and 2.5 ± 1.29 and 2.6 in two studies from This is similar to our findings. Death and dying have shown
Saudi Arabia.[8,10] Thus, the overall severity of stress was itself to be the biggest stressor in three studies [1,8,9] and
much milder in our study as compared to these studies. The among the leading causes in other studies.[11,12] Similarly,
reason for this discrepancy could be that these hospitals from conflicts with supervisors,[11] unreasonable demands from
the Middle East dealt mainly with oncology, neuroscience, patients and their families,[10] and workload[12] have also been
and transplants – departments known associated with high identified as top causes. Other stressors such as uncertainty
mortality and morbidity, whereas our study was conducted regarding treatment,[1,8,10,11] conflicts with other health‑care
in a general hospital setting. Furthermore, discrimination and professionals,[9] and discrimination[1,8] have been identified as
sexual harassment were high in their population, which was among the top four causes of occupational stress in different
negligible in our study. studies as cited. The primary reason for these differences is
Among the three main factors in the scale, the score on the setting in which the study is conducted. Our study was
the physical working environment was significantly higher conducted on nurses who were the employees of the central
than the scores on the psychological and social working government, working in a general postgraduate teaching
environments. A similar finding was reported by a Serbian hospital that caters to the employees of a central government
study.[1] This reflects the high workload faced by the nurses. As organization, availing a health‑care scheme. The nurses also
per the Indian Nursing Council (INC),[20] the nurse to patient avail the same health‑care services. Their salaries are on par
ratio is to be 1:5 in general wards and higher in specialty with pay commission standards. In addition, our organization
units. The present study collected data from nurses working also provides housing, transportation, and schools for the
in all different units of the hospital; hence, this ratio was not children. The scenario might not be the same for the nurses

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Chaudhari, et al.: Occupational stress in nurses
included in other studies. Nurses working in critical care and
superspecialty settings are faced with repeated experiences
of patient death and disability.[1,8,9] On the other hand, nurses
working in teaching hospitals cater to a very large number
of patients, leading to increased workload and increased
conflicts.[5] Nurses working in private hospitals very often
do not have a pay structure and job security compatible with
government hospitals, leading to higher stress and a different
set of occupational issues.[17] Exploring the role of possible
protective factors was beyond the scope of the present study;
however, this finding does provide an interesting direction
for future research. The disparity, nevertheless, highlights
the need for every organization to independently review the
causes of stress in an effort to take some remedial measures.
Extrapolating the findings of other studies may perhaps not
be an effective strategy for stress management.
In our study, nurses with 6–10 years of experience had
the highest stress, and this was significantly higher than
nurses with >15 years of experience. These findings are
in contrast with an Indian[11] study in which stress was not
associated with years of experience. An international study
from Saudi Arabia also reported no significant association
between levels of stress and years of experience.[23] However, a
study done in Serbia[1] reported that nurses in the age category
of 30–39 years experienced a higher stress level compared to
their younger or older coworkers, which is somewhat similar to
our findings. While more research is required to throw light on
this observation, it could be possible that the mid‑level nurses
have both an increased responsibility as well as an increased
workload which could have contributed to increased stress.
On the other hand, increased experience on the job may have
helped the senior nurses develop more protective mechanisms
to counter stress.
There is robust evidence to suggest that somatic complaints are
highly prevalent among nurses.[1,17,23,24] There was a significant
positive correlation between the severity of occupational
stress and somatic symptoms perceived by the nurses in our
study. Similar findings have been reported by Indian[17,25] as
well as international studies.[1,24] These findings do not imply
a singular and causal relationship between occupational
stress and somatic complaints. The relationship between
chronic stress and disease is intricate and can be influenced
by the type and severity of stressors, their persistence as well
as the person’s genetic vulnerability, personality factors,
psychosocial resources, and coping styles.[26] There is however
sufficient evidence to conclude that stress can contribute to
the precipitation, persistence, and perpetuation of various
psychosomatic ailments.[26] Efforts to alleviate stress could
therefore prove effective in enhancing health.
Conclusions
• About 87.6% nurses experienced stress
• About 51.5% nurses experienced mild stress and 34%
experienced moderate stress
Annals of Indian Psychiatry ¦ Volume 2 ¦ Issue 2 ¦ July-December 2018
• Common causes of stress were conflicts with supervisors,
unreasonable demands from patients and their families,
workload, and dealing with death and dying
• Nurses with 6–10 years of experience had maximum
stress
• 20.6% of the nurses reported moderate and 9.3% reported
a high level of somatic complaints
• There was a significant positive correlation between the
severity of stress and somatic symptoms.
Limitations
• The specific area of work (e.g., Intensive Cardiac Care
Unit, OT, and Casualty) was not considered
• Personal factors that could contribute to stress were not
considered
• It has all the limitations inherent to cross‑sectional studies.
Clinical implications
Nurses experience significant occupational stress and the
causes of stress can vary in different settings. Stress can have
an adverse impact on the health of the nurses. Hence, this issue
needs to be explored on a priority basis and the onus of this
effort must lie with the organization. A commitment to develop
targeted interventions at stress reduction could not only benefit
the individual nurse in particular but also our patients and the
health‑care services at large.
Acknowledgment
We would like to thank Matron, Assistant Matron and Nursing
staff of BARC Hospital for their kind cooperation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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