Occupational Stress in the Indian Army Oncology Nursing Workforce: A Cross-sectional Study.

OBJECTIVE: This cross-sectional, quantitative epidemiological study was aimed at finding out the degree of work-related stress among the staff nurses working in oncology.
METHODS: This study was conducted on 81 out of 100 oncology-trained nurses working in various oncology centers of Indian Army who consented to participate in it. It was carried out in five oncology centers of our organization where oncology-related facilities are available. Predesigned and pretested questionnaire covering their sociodemographic variables in part I and professional life stress scale by David Fontana in part II. The association between stress and various variables was found using Chi-square test.
RESULTS: Risk for professional stress was found more among unmarried young respondents of 20-30 years age group. No statistically significant association (P < 0.131) was found between department of posting and level of stress. Nurses reported that they had no time for rest, of whom 62.96% were suffering from moderate range of stress for a busy professional while only one admitted to have severe stress requiring remedial action. While 82.7% felt that they are able to achieve major objectives in life, 71.6% of them reported that they feel inadequately valued for their commitment at work.
CONCLUSIONS: The main nurses' occupational stressors were criticism, feeling of not being appreciated for hard work, and having time for self. This type of assessment should be carried out in all hospitals so that working conditions for this important component of health care can be improved.

Introduction

Stress has been regarded as an occupational hazard since the mid-1950s.[1] In fact, occupational stress has been cited as a significant health problem.[234] Work stress in nursing was first assessed in 1960 when Menzies[5] identified four sources of anxiety among nurses: patient care, decision-making, taking responsibility, and change. Nurses, having an important role in the health-care system, are considered to be members of a stressful job as a profession because they care for a stressful group comprising patients or those at health risk.[67] In the case of nurses working in oncology units, several circumstances such as critical decision-making, managing the treatment having serious side effects, patients’ issues of anger and noncompliance with treatment, monitoring patients having pain and suffering, terminal care, stressful situations experienced in connection with the death of patients, emotional difficulties with patients, and conflicts within the team can cause stress. Burnout syndrome often occurs as a result of chronic work stress seen in these units.[89]

Stress has been categorized as an antecedent or stimulus, as a consequence or response, and as an interaction. It has been studied from many different perspectives. For example, Selye[10] proposed a physiological assessment that supports considering the association between stress and illness. Conversely, Lazarus and Folkman[11] advocated a psychological view in which stress is “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.”

The quality of life of nursing employees in the workplace has been studied worldwide. Diverse work-related issues are notable across all of India, including unstable employment, inadequate workplace conditions, limited availability of equipment and materials that are essential to effectively improve the quality of care, overwork related to the scarcity of nursing staff, devaluation of the nursing profession.

We decided to conduct this study, especially in oncology nurses working in Indian Army. The working in army hospitals is quite different as compared to their civilian counterparts. Due to service requirement, there are frequent movements to various places, and on an average, the total tenure at a place is 3–4 years. This can result in prolonged and frequent separation from the family, and especially children leading to feeling of guilt and resulting in additional stress and anxiety among our respondents. This study was conducted to study the association between various variables such as age and work experience and stress levels among the nursing staff in oncology centers of Indian army so that prudent steps can be taken to improve their working conditions.

Methods

It is a cross-sectional, quantitative, epidemiological study conducted in five oncology centers over 3 months in the year 2017. The place of coordination for the study was Army Hospital Research and Referral, Delhi. It is a tertiary hospital. The study population comprised of oncology-trained nursing staff working in these hospitals. All the oncology-qualified nurses who consented for the study, working in the day or night shift were covered by consequential sampling technique; and all those who were on leave or not available at the time of data collection twice were excluded from the study. Thus, the total sample size of the study comprised of 81 out of total 100 female (81%) oncology-trained nurses. In our organization, all the nurses are females. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Data collection technique: interview technique was used as method to gather data and the questionnaires were filled by the individuals themselves. Predesigned and pretested and validated questionnaire in English was used. It had two parts:

Part I: Covering their sociodemographic variables and variables on their working environment, including attitude of the different category of working staff, salary, job condition, and so on

Part II: A specially designed closed-ended questionnaire developed by Professor David Fontana (1934–2010) a psychologist, which he had adapted from “Managing Stress,” published by the British Psychological Society and Routledge Ltd., 1989 was used.[7] It consists of a total of 24 questions, out of which 11 are yes/no questions, 2 are self-evaluative questions, 10 questions are multiple choice, and one question consists of 22 subquestions which are based on common features of life events, and the individual has to agree or disagree with each statement as the samples were well educated, English version of the questionnaire was used for the study. It has covered different variables such as personality perception by others, optimism for life, satisfaction to self and work, adjustment with the professional environment, and so on. A total score 60, was classified into:

0–15: Stress is not a problem in life

16–30: Moderate stress, which can reasonably be reduced

31–45: Stress is clearly a problem and needs remedial action

46–60: Stress is a major problem and something must be done.

Quality Assurances of the data collection: data were collected by the well-trained and well-qualified two primary investigators themselves. The Professional Life Stress Scale has been used by number of authors for assessing the stress related to various professionals including nurses in their studies in published world literature. It has a Cronbach's alpha reliability of 0.636 which is a significant level of reliability thus ensuring standardization of tool.[12]

Data analysis

All analysis was performed with SPSS for Windows, version 17.0, Chicago: SPSS Inc. and Chi-square test was used to find association among stress levels and other variables.

Results

The basic demographics are shown in Table 1. Maximum number of respondents (37.0%) were from 20 to 30 years of age group while 70.4% of them were legally married. Majority 33.3% had a long term of service experience of >20 years. The job satisfaction was expressed by 90.1% of participants while 9.9% were dissatisfied with their job conditions. On an average, 25.9% of respondents were working for 12 h a day although in rotation. Maximum number of respondents 93.8% were satisfied with the attitude of doctors, whereas 14.8% were dissatisfied with the attitude of civilian employees. Most of them showed satisfaction with the cooperation between various departments still 63.0% of them admitted to have moderate stress while one of the respondents had severe stress in our study.

Table 1

Demographic characteristics

Characteristics	n (%)
Age (years)
20-30	30 (37.0)
31-40	26 (32.1)
41-50	18 (22.2)
50-60	7 (8.6)
Marital status
Married	57 (70.4)
Unmarried	24 (29.6)
Sevice year
<10	32 (39.5)
10-20	22 (27.2)
>20	27 (33.3)
Department
ICU	13 (16.0)
Oncosurgery	21 (25.9)
Oncomed	20 (24.7)
Oncorad	12 (14.8)
Daycare	6 (7.4)
Oncology Operation Theatre	9 (11.1)
Duty hours per day
8 h	10 (12.3)
10 h	23 (28.4)
12 h	21 (25.9)
Duty h/n
12 h	27 (33.3)
Job condition
Unsatisfactory	8 (9.9)
Satisfactory	72 (88.9)
Excellent	1 (1.2)
Attitude of Medical Officers
Uncooperative	5 (6.2)
Cooperative	76 (93.8)
Attitude of other Nursing Officers
Uncooperative	3 (3.7)
Cooperative	78 (96.3)
Attitude of Nursing Assistants
Uncooperative	6 (7.4)
Cooperative	75 (92.6)
Attitude of other departments
Uncooperative	2 (2.5)
Cooperative	79 (97.5)
Attitude civilian employees
Uncooperative	12 (14.8)
Cooperative	69 (85.2)
Stress
No	29 (35.8)
Mild	51 (63.0)
Moderate	1 (1.2)
Severe	-

ICU: Intensive Care Unit, OT: Operation Theatre:, MO: Medical Officer, NO: Nursing Officer, NA: Nursing Assistants

Correlation between various factors and stress level has been shown in Table 2. Maximum number (20/81) in young and unmarried respondents in the age group of 20–30 years complained of moderate stress, but the association with age group did not reach a statistical significance (P = 0.346). Among married and unmarried groups, unmarried respondents complained more stress but without a significant (P = 0.12). Experience in their job did not matter as far as their stress levels were concerned statistically; however, 21/32 of respondents with 10–20 years of service experienced moderate stress. Maximum number of respondents working in surgical oncology wards complained of stress, but interdepartmental comparison did not reach a statistical significance (P = 0.131). Other factors such as job conditions, attitude of doctors, and civilian employees did not lead to statistical significance.

Table 2

Statistical correlation between various factors and stress levels

Factor	Stress			Total, n (%)	χ2	df	P
	Mild	Moderate	Severe
Age (years)
20-30	10	20	-	30 (37.0)	6.740	6	0.346
31-40	7	19	-	26 (32.1)
41-50	9	8	1	18 (22.2)
50-60	3	4	-	7 (8.6)
Marital status
Unmarried	11	12	1	24 (29.6)	4.244	2	0.120
Married	18	39	-	57 (70.4)
Service years
<10	11	21	-	32 (39.5)	2.666	4	0.615
10-20	7	15	-	22 (27.2)
>20	11	15	1	27 (33.3)
Department
ICU	5	8	-	13 (16.0)	15.036	10	0.131
Oncosurgery	8	13	-	21 (25.9)
Oncomed	9	11	-	20 (24.7)
Oncorad	6	6	-	12 (14.8)
Daycare	-	6	-	6 (7.4)
Oncology Operation Theatre	1	7	1	9 (11.1)
Job condition
Unsatisfactory	2	6	-	8 (9.9)	2.355	4	0.671
Satisfactory	26	45	1	72 (88.9)
Excellent	1	-	-	1 (1.2)
Attitude of Medical Officer
Uncooperative	2	3	-	5 (6.2)	0.099	2	0.951
Cooperative	27	48	1	76 (93.8)
Attitude of Nursing Officer
Uncooperative	-	3	-	3 (3.7)	1.833	2	0.400
Cooperative	29	48	1	78 (96.3)
Attitude of Nursing Assistant
Uncooperative	2	4	-	6 (7.4)	0.105	2	0.949
Cooperative	27	47	1	75 (92.6)
Attitude of other department
Uncooperative	-	2	-	2 (2.5)	1.206	2	0.547
Cooperative	29	49	1	79 (97.5)
Attitude of civilian employees
Uncooperative	2	10	-	12 (14.8)	2.543	2	0.280
Cooperative	27	41	1	69 (85.2)

ICU: Intensive Care Unit, OT: Operation Theatre, MO: Medical Officer, NO: Nursing Officer, NA: Nursing Assistants

Tiredness was complained by 46.9% of participants; however, 55.6% accepted that they feel satisfied at the end of the day and a majority 82.7% felt that they are able to achieve major objectives in life. Only 28.4% of our study participants felt that they are adequately rewarded for their commitment toward work [Table 3].

Table 3

Numbers and percentages of respondents in response to various questions

Question number	Question	Yes, n (%)
1	Two people discussing about you, feel positive	58 (71.6)
2	Seldom do anything right	21 (25.9)
	Feeling trapped	16 (19.8)
	Indigestion	30 (37.0)
	Poor appetite	24 (29.6)
	Difficulty to sleep	28 (34.6)
	Dizzy spells/palpitations	26 (32.1)
	Sweating without exertion	21 (25.9)
	Panic feelings	18 (22.2)
	Tiredness	38 (46.9)
	Feelings of hopelessness	21 (25.9)
	Faintness or nausea	11 (13.6)
	Extreme irritation	35 (43.2)
	Inability to unwind	16 (19.8)
	Waking regularly at night	25 (30.9)
	Difficulty in making decision	15 (18)
	Inability to stop thinking about problems	24 (29)
	Tearfulness	20 (24.7)
	Convictions that you just can not cope	13 (16.0)
	Lack of enthusiasm	16 (19.8)
	Reluctance to meet new people	13 (16.0)
	Inability to say “no”	32 (39.5)
	Having more responsibility than you can handle	28 (34.6)
3	Are you less optimistic	39 (48.1)
4	Do you enjoy watching sports	43 (53.1)
5	Getting up late at weekends without guilt	58 (71.6)
6	Can you speak your mind to: (a) your boss, (b) your colleagues, (c) family members	42 (51.9)
7	Who makes decisions: (yes) yourself, (no) someone else	75 (92.6)
8	When criticized by superiors at work feeling upset	33 (40.7)
9	Do you feel satisfied at the end of the	45 (55.6)
10	Unsettled conflicts with colleagues	9 (11.1)
11	Does the amount of work exceeds time	35 (43.2)
12	Clear picture of professional expectations	49 (60.5)
13	Enough time to spend on yourself	28 (34.6)
14	Find sympathetic ear for problems	64 (79.0)
15	Achieving major objectives in life	67 (82.7)
16	Bored at work	23 (28.4)
17	Looking forward to work	57 (70.4)
18	Feel adequately valued	37 (45.7)
19	Feel adequately rewarded	23 (28.4)
20	Superiors (a) hinder (b) help	11 (13.6)
21	Comparing 10 years ago with your professional achievements fulfilling	53 (65.4)
22	Rating yourself on a scale 5 (most like)	31 (38.3)

Overall analysis of this study suggested that 62.96% respondents had moderate range of stress with a score range of 16–30, for a busy professional while only one participant with a score of 34 accepted to have stress (31–45) which required remedial action. The respondent was sent on a holiday for 1 month, after proper counselling to find out any other factor leading to this type of stress [Table 4].

Table 4

Distribution of participants in relation to stress score rating

Scores	Number of respondents (%)	Conclusion
0-15	29 (35.8)	Stress is not a problem in life
16-30	51 (63.0)	Moderate range of stress for a busy professional
31-45	1 (1.2)	Stress is clearly a problem, and the need of remedial action is apparent
46-60	Nil	Stress is a major problem

Discussion

Quality of life in the workplace is a multidimensional concept that applies when the employee is able to cover the following personal necessities through employment or his or her own ventures: institutional support, security, and integration into his or her role at work and satisfaction related to this role, a sense of well-being obtained through his or her work and the personal development achieved, and the management of his or her free time.[13]

This study found that the nursing staff were moderately satisfied with their overall quality of life in the workplace. This finding is consistent with the results obtained in other related studies in which the majority of the nursing staff display moderate levels of satisfaction with their quality of life in the workplace.[1415] Taking quality of life in the workplace as a strong indicator of human experiences in the workplace and the degree of satisfaction experienced by the people who perform the work,[16] the strongest indicator of dissatisfaction observed was related to lack of appreciation and rewards for their commitment at work.

This study suggested that of participants having an experience of 10–20 years of service had moderate stress, whereas 55.6% of respondents with more than 20 years of service had moderate stress though it did not reach statistical significance. Only one of the respondent in all service brackets belonging to more than 20 years of service reported to have severe stress which can be due personal reasons also. This finding is consistent with the results of the study by Dargahi et al.[17] Sharhraky Vahed et al. also reported that employees with more than 20 years of experience had less stress than those with less work experience.[18] However, Nayeri et al. and Boonrod reported that they could not observe a significant relationship between stress levels and the length of work experience.[1920] One of the sources of occupational stress for nurses is shorter length of work experience. Thus, it seems that employees with greater work experience feel less occupational stress and more stability in their job.[18]

The current study could not reveal a statistical significant relationship between stress levels and marital status. However, in this study, unmarried staff had more level of stress when compared to married staff. Two other studies have shown that stress has no significant relationship with marital status.[1917] However, Khaghanizadeh et al. reported that 82% of married and 66% of single individuals had a moderate level of stress.[21] In this study, the QWL was higher in married nurses than single individuals although the difference was not statistically significant. This could perhaps be because married nurses receive greater emotional support from their spouses and this decreases their stresses, and thus, they experience a better job satisfaction.[18]

The results of the present study showed that there was no statistical significant correlation between age and stress levels; however, we observed that staff in younger age group 20–30 years experienced more stress when compared to their older counterparts. Two other studies also reported that there was no significant relationship between age and stress levels.[2022] These findings are not consistent with the report by Dehghan Nayeri et al., suggesting that there is a close correlation between age and stress levels.[19] On the other hand, Khaghani et al. reported that there is an inverse correlation between age and stress levels.[22] The present study showed that nurses’ quality of work life is at the moderate level.

In our study, 93.8% of the respondents were satisfied with the attitude of doctors. While in a study by Sharma et al.,[23] doctors attitude was perceived as a major factor leading to professional stress. They found that poor attitude of doctors led to 3-4 times more stress levels when compared with excellent attitude (odds ratio [OR] = 2.97 and OR = 3.97, respectively).

In the same study by Sharma et al.,[23] they found a significant association (P < 0.024) between department of posting and level of stress. Majority (43%) of the nurses posted in the emergency/Intensive Care Unit (ICU) were stressed out of whom 2% were severely stressed. It was found that the staff nurses posted in medicine, surgery, pediatrics, and gynecology were less stressed as compared with those posted in the emergency/ICU (OR = 0.32; 0.41; 0.54; 0.28 respectively). In our study, we found that maximum number of nurses (25.4%) working in oncosurgery complained of stress though it did not reach statistical significance (P = 0.131).

In a similar study by Monte et al. involving ICU nursing staff, they found that performing tasks with minimum time available, assisting family members of critical patients meeting the needs of family members, and facing death were the strongest stressing factors.[24]

In a study by Shah et al. in tertiary hospitals of Pakistan approximately 60% of nurses said that their job does not allow freedom to decide how they work. About 91/265 nurses disagreed with the statement there was much pressure of work by doctor. More than half 152 (57.4%) of nurses agreed that their job is very hectic. Majority 196 (74%) of nurses claimed that they have to attend many patients. Only 14% nurses strongly agreed to the fact their supervisor/senior nurse is not cooperative and unlike 69 (26.0%) told that there is pressure to learn new things in their job. Out of total nurses, 172 (64.9%) nurses stated that there are insufficient sleep and frequent call in their job. Totally 127 (47.9%) had stress due to high rates of deaths among patients in their hospital. Moreover, 27.5% (75) participants agreed or strongly agreed to report sexual harassment. Eighty-two nurses were diagnosed as severely job stressed, whereas 43 (34.4%) nurses had mild/moderate everyday life stress in that age group (P = 0.06).[25] While in our study, tiredness was complained by 46.9% of participants; however, 55.6% accepted that they feel satisfied at the end of day and a majority (82.7%) felt that they are able to achieve major objectives in life. Only 28.4% of our study participants felt that they are adequately rewarded for their commitment toward work. Overall analysis of our study suggested that 62.96% of respondents had moderate range of stress with a score range of 16–30, for a busy professional while only one participant with a score of 34 accepted to have stress (31–45) which required remedial action.

Nursing staff in oncology experiences similar problems, especially because they have been working with extreme workload and tensions associated with patients in terminal phase and their families. There are problems related to patient care procedures, insufficient protective measures during the preparation of antineoplastic agents. Most of the oncology nurses work in a night duty/shift basis, and the number of nurses working in various units is not adequate as well as their workload is increased by the demand for activities other than nursing such as creating patient's file, management of support services, and provision of supplies.

Limitations

The study is limited to a particular group of nurses, working in oncology, and army. Since army working atmosphere is quite different from civilian establishments, and hence, the results obtained cannot be generalized. Other limitation is the sampling method adopted is convenience sampling, and the sample size was restricted to 81, and hence, the conclusions cannot be universal.

Recommendations

All oncology units should be adequately staffed with provisions for the safety of the nursing staff working there

The nursing staff should be appreciated and adequately rewarded for their commitment toward work

They should be subjected to various stress relieving techniques things such as “Art of Living courses,” yoga, and meditation

Similar studies should be carried out in other departments also, to improve overall working conditions.

Conclusion

This research provides an initial step in understanding the work life of oncology nurses in an Indian Army setting. We found that most of them are satisfied with their working conditions, but there is dissatisfaction for lack of appreciation and rewards for their commitment toward work. We did not see their stress levels varying among various centers probably because of similar working conditions everywhere. Occupational stress is negatively related to the quality of care due to loss of compassion for patients and increased incidences of mistakes and practice errors. Thus, hospital managers should initiate strategies to reduce the amount of occupational stress among the nurses. They should provide more support to the nurses to deal with the stress. The authorities in the health-care system should develop strategies for improving the nurses work conditions so that, nurses will be able to perform better care for their patients.

In our organization based on this study, the working profile of all the oncology nursing staff was reviewed, and remedial steps were taken like we tried to rotate them more frequently from very busy to relatively less busier units. During working hours provisions were made to include some recreational activities such as yoga and board games in between to relieve the stress. The major step which had been taken was to increase the numbers by asking for fresh recruitments as suggested by the respondents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.