Work-related stress among nurses: a comparative cross-sectional study of two government hospitals in Ghana | BMC Public Health

Study design and study setting

This was a cross-sectional study among 248 nurses working in two government hospitals located in the Hohoe and Ho municipalities of the Volta region of Ghana. The Ho Municipality is bordered on the south by the Adaklu and Agotime Ziope Districts, on the north and west by Ho West District, and on the east by the Republic of Togo [21]. Whereas, the Hohoe Municipality shares a boundary with the Guan district of the Oti region to the north and the Afadzato south district to the south with only one government Hospital which is the VRH [22]. In the Ho Municipality of Ghana, there are four public hospitals namely HTH, Ho Municipal Hospital (HMH), Ho Polyclinic (HP), and the Volta Military Hospital (VMH) [21]. The HTH is a 320-bed referral healthcare facility staffed with 650 personnel, including 367 nurses and midwives [16]. The HTH is a major referral facility serving the region and neighbouring West African countries Strategically located to offer specialized healthcare to the Volta Region, it features approximately 20 major wards and units [16]. The VRA on the other hand has a bed capacity of 178 with 467 staff including 293 nurses and Midwives, and it is the referral point for very ill patients from other clinics and hospitals within and outside the Hohoe Municipality. Most of the referrals come from the eight northern districts of the region: Nkwanta North, Nkwanta South, Krachi East, Krachi West & Nchumuru, Kadjebi, Biakoye, Afadzato South, and Jasikan districts, including neighbouring Togo. Both hospitals primarily focus on curative care, including both clinical and preventive services such as health promotion. They provide 24-hour accident and emergency services, outpatient consultations, and inpatient care. The differences in hospital capacities and functions between HTH and VRH highlight the necessity of this study because the breadth and depth of services differ and may influence the nature of occupational stress experienced by nurses [23, 24]. Nurses in tertiary care settings like HTH might experience stress related to high patient acuity, complex cases, and the demands of specialized care. In contrast, nurses in secondary care settings like VRH might face stress due to resource limitations, high patient volumes, and the need to manage a wide range of medical conditions with fewer specialized resources.

Study population

The study included all nursing cadre such as Community Health Nurses, Professional nurses, Enrolled nurses, and Professional midwives from the VRH and HTH who are 18 and above. Inclusion criteria were registered nurses providing direct patient care with at least two (2) years of experience. Nurses on leave, in administrative roles, students, assistants, and interns were excluded.

Sample size

The sample size was determined using a Cochran formula [25]. The formula is given as n = (Z_α/2)²P (1-P) / е². Where, p = 0.10 is the prevalence of stress among nurses (Adzakpah et al., 2016), n = Sample size to be determined, е²=0.05, and Z_α/2 = 1.96. The sample size calculated was 138. To account for the response rate, we allowed a 5% non-response rate giving us a total sample size of 145. The estimated sample size was found to be less than 5% of their respective total populations (367 for HTH and 293 for VRH), obviating the need for a finite population correction (FPC) as per standard statistical practice [26]. Hence, this study estimated a sample size of 145 each for the two hospitals. However, 248 nurses returned the questionnaire giving a response rate of 85.5%. At VRH, all 145 administered questionnaires were administered, resulting in a response rate of 100%. At HTH, 103 out of 145 administered questionnaires were returned, yielding a response rate of 71%.

Sampling

At each hospital, permission was sought from the human resource directorate and access was granted to the staff nominal roll. The nominal roll was then re-arranged into the different departments. The proportion contribution of each department to the overall staff population was calculated and then used to determine how many subjects responded to the questionnaire for each department based on the sample size. Random number statistical tables were used to determine the respondents for each department to administer the questionnaire. In cases where the randomly selected staff was not available, a replacement was done with the same technique.

Study variables

Occupational stress was the main outcome variable in our study. It was derived as an index variable from the PSS questionnaire had 10 items. The questionnaire was designed by Cohen et al. (1983) to measure the degree to which situations in one’s life are appraised as stressful. In this study, the reliability coefficient of the scale for PSS scale was 0.71. It was measured on a 5-point Likert scale with responses ranging from 0 (Never) to 4 (Very often). The total score of the PSS ranged between 0 (No stress experiences and 40 (highest degree of stress experienced) [27].

The covariates included the respondents’ age, sex, religion, ethnicity, marital status, and years of work experience. This WOSS scale was used to measure the causes of occupational stress [13]. It is aimed at determining the causes of occupational stress among nurses in the two hospitals. Respondents were asked if: Engaging in an unfriendly relationship, Nursing ‘difficult’ patients, Harassment from aggressive relatives, Nursing patients without relatives, working with incompetent staff, and Inadequate delegation of responsibilities caused them to feel stressed. The response options for these questions were 1 indicating never, 2 indicating seldom, 3 indicating sometimes, 4 indicating frequently, and 5 indicating almost always. The reliability coefficient of the scale for WOSS scale was 0.82. A similar instrument was used in similar research by Adzapkah et al. (2016) in their study to determine the current level of occupational stress experienced by nurses and the most common occupational stressors [13]. A self-reported checklist or survey was used to assess the effects of occupational stress on the health worker’s health. The questionnaire includes three sections: physical effects, emotional effects, and psychological effects. Participants are asked to indicate whether they have experienced each effect by ticking the appropriate box, with “1” representing “Yes” and “2” representing “No”. Further, coping strategies for stress among Nurses were also measured. Participants in the study were asked to choose and rank the most often used stress management methods from a list shown to them.

Data collection procedure

Data was gathered using a standardized, closed-ended survey questionnaire study instrument which was adapted from a study by [13].

The mode of data collection was face-to-face for Nurses in the VRH (VRH). However, nurses from the HTH were selected and asked to complete the questionnaire and return on their own. Face-to-face interviews at VRH aimed to maximize engagement and response rates by allowing for direct interaction, clarifying questions in real time, and ensuring comprehensive data capture. Whereas, self-administered questionnaires at HTH were chosen to accommodate the structured environment and busy schedules of nurses to enhance data completeness and minimise social desirability bias. These methodological choices were made to mitigate biases specific to each approach, optimize resource utilization, and maintain methodological consistency across settings, thereby supporting robust comparisons of the effects of occupational stress in diverse healthcare environments.

Data analyses

Data were analysed with STATA version 17.0. Data were summarized into frequencies, means and standard deviation. The PSS scores were categorized where a total score of 0 to 13 represented low-stress prevalence, 14 to 26 signified moderate stress prevalence, and 27–40 represented high-stress prevalence [27]. The WOSS was graded by adding up the total number of points for each of the 15 questions and then dividing the total by 15. The score range for a subject is 145 to 15, with 145 being the highest and 15 being the lowest. The greater the score, the higher the level of occupational stress [13].

To establish the associations between variables, p-values less than 0.05 were considered statistically significant at a 95% confidence interval. A T-test was used to determine stressors that were significant at the hospitals from the two municipalities.

Ethical issues

Ethical approval for this study was sought from the Ethical Committee of the Ghana Institute of Management and Public Administration (GIMPA) and the University of Health and Allied Sciences (UHAS) for both HTH and VRH respectively. The protocol identification number GIMPA-REC A. [013] 21–22 and UHAS-REC A.9[75] 20–21. Furthermore, informed consent was acquired from each study participant before the commencement of work, with a guarantee of confidentiality and anonymity of the data, by ethical norms for medical research involving human subjects. The principal investigator enrolled 248 subjects and invited them to participate willingly with the option to withdraw at any time. Our research was carried out in conformity with the Helsinki Declaration’s ethical criteria [28].