Work-Related Stress and Associated Factors Among Nurses Working in Public Hospitals of Addis Ababa, Ethiopia: A Cross-sectional Study

Abstract

Work-related stress is a pattern of reactions to work demands unmatched to nurses' knowledge, skills, or abilities; these challenges exceed their ability to cope, resulting in burnout, turnover, and low quality patient care. An institution-based cross-sectional study of 343 nurses was conducted in public hospitals of Addis Ababa in 2012. Data were collected by pretested and self-administered questionnaires using a nursing stress scale. One hundred twenty-one (37.8%) (95% confidence interval: 34.3 to 39.1) nurses reported experiencing occupational stress. Significant associations were found between nurses' stress and gender, work shift, illness, marital status, and worksite or unit. Prevalence of work-related stress was higher than expected and opportunities exist for stake holders to design stress reduction and management programs for nurses. [Workplace Health Saf 2014;62(8):326-332.].

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326 Copyright © American Association of Occupational Health Nurses, Inc.
Globally, the costs of work-related stress are es-
timated to be approximately $5.4 billion each
year (Health and Safety Executive, 2010), sec-
ond to the most frequent occupational health problem,
low back pain, and estimated to affect one in three em-
ployees (Health and Safety Executive 2010, 2011).
Work-related stress can be related to anxiety, depres-
sion, insomnia (Wong, Leung, So, & Lam, 2001), and
physical illness. Chronic stress can increase the risk of
heart disease (European Foundation for the Improvement
of Living and Working Conditions, 2007) and weaken
the immune system, thus decreasing resilience to illness
(Health and Safety Executive, 2011).
Stress also affects quality of life and work, including
overall well-being, social relationships, and family life. In
addition, stress can result in work absences, higher turnover,
early retirement, lower productivity, and lower quality of
services or products (European Foundation for the Improve-
ment of Living and Working Conditions, 2007; Health and
Safety Executive, 2011). Researchers suggest that nurses
suffer from high levels of work-related stress, jeopardiz-
ing nurses’ health and patients’ lives, undermining quality
of services, and increasing the cost of health care (Dollard,
LaMontagne, Caufield, Blewett, & Shaw, 2007). Stress also
has been cited as one reason for turnover (McVicar, 2003),
resulting in negative effects on services and quality and con-
tinuity of care (Department of Health and Children, 2002).
One study has shown that 41% of hospital nurses were dis-
satisfied with their jobs and 22% planned to leave their po-
sitions in less than 1 year due to workplace stress (Blaug,
Kenyon, & Lekhi, 2011). Even though developed countries
are known for health care that affects nurses, insufficient evi-
dence exists in Ethiopia about this problem.
The findings of this study enhance the body of
knowledge about nurses’ work-related stress; the data
may also serve as a baseline for future studies and assist
health care agencies to develop strategies to reduce work-
related stress and its consequences.
ABSTRACT
Work-related stress is a pattern of reactions to work demands unmatched to nurses’ knowledge, skills, or abilities; these
challenges exceed their ability to cope, resulting in burnout, turnover, and low quality patient care. An institution-based
cross-sectional study of 343 nurses was conducted in public hospitals of Addis Ababa in 2012. Data were collected by
pretested and self-administered questionnaires using a nursing stress scale. One hundred twenty-one (37.8%) (95%
confidence interval: 34.3 to 39.1) nurses reported experiencing occupational stress. Significant associations were found
between nurses’ stress and gender, work shift, illness, marital status, and worksite or unit. Prevalence of work-related
stress was higher than expected and opportunities exist for stake holders to design stress reduction and management
programs for nurses. [Workplace Health Saf 2014;62(8):326-332.]
Work-Related Stress and Associated Factors
Among Nurses Working in Public Hospitals of
Addis Ababa, Ethiopia: A Cross-sectional Study
Selamawit Zewdu Salilih, MSc; Amanuel Alemu Abajobir, MPH
ABOUT THE AUTHORS
Ms. Salilih is Lecturer and Researcher, and Mr. Abajobir is Lecturer and
Researcher, Debremarkos University, Debremarkos, Ethiopia.
Submitted: September 27, 2013; Accepted: May 27, 2014; Posted online:
August 5, 2014
The authors have disclosed no potential conflicts, financial or otherwise.
The authors thank Amanuel Mental Specialized Hospital and the Uni-
versity of Gonder for their financial support, and the study participants and
data collectors.
Correspondence: Amanuel Alemu Abajobir, MPH, Health Sciences Col-
lege, Debremarkos University, P. O. Box 269, Debremarkos, Ethiopia. E-
mail: abajobir6@gmail.com
doi:10.3928/21650799-20140708-02

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WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 8, 2014
METHODS
An institutional-based cross-sectional study was
conducted in public hospitals of Addis Ababa in 2012.
All nurses working in all Addis Ababa public hospitals
were the study population.
Sample and Sampling Procedure
The sample for this study was selected by using a
single population proportion formula and a 95% confi-
dence interval (CI) with the proportion of work-related
stress to be 50%, absolute precision to be 5%, and 10%
non-respondents. Accordingly, the total sample size was
343 nurses.
Sampling Technique
Proportionate systematic random sampling was used
to select study participants from all public hospitals in Ad-
dis Ababa (Table 1). The records of nurses in each hospital
were used to identify potential study participants; study
participants were selected randomly using record identi-
fication numbers. Independent variables included socio-
economic, demographic, and work-related variables. The
dependent variable was work-related stress among nurses.
Operational Definitions
Work-Related Stress. Nurse stress was rated from 0
(never stressed) to 3 (very frequently stressed); the score
of 1 or higher was considered as work-related stress.
Substance Use. Use or consumption of any substance
such as alcohol, cigarettes, shisha, and hashish, regardless
of the amount and frequency of use for the past 3 months.
Type A Personality. According to Maeda’s Question-
naire for Type A Behavior Pattern, a total score of 17 or
higher was considered as type A personality.
Staff Job Satisfaction. Satisfaction was defined as
the extent to which respondents like (satisfied) or dislike
(dissatisfied) their jobs. In this study, nurses who an-
swered “yes” were assumed to be satisfied with their job.
Instruments and Data Collection
The Institutional Review Board of the Amanuel Men-
tal Specialized Hospital and the University of Gonder ap-
proved this study. Self-administered pretested question-
naires were used to collect data from selected nurses. The
questionnaires included sociodemographics and ques-
tions related to work environment, substance use, illness,
type A personality, and stress.
The Nursing Stress Scale (NSS) has been used
worldwide over the past 20 years to measure stress among
nurses. The scale includes 34 questions designed to mea-
sure the frequency and sources of occupational stress ex-
perienced by nurses in various hospital units. The scale
has seven subscales and identifies seven major sources
of stress; one factor relates to stress from the physical
environment; four factors from the psychological envi-
ronment; and two from the social environment of the hos-
pital. The tool uses ratings from 0 (“never”) to 3 (“very
frequently”), according to perceived occurrence in their
workplaces. Values 1 (occasionally stressful) and above
were assumed to indicate occupational stress.
The type A behavior pattern was assessed via a set of 12
questions adopted from a study conducted in Japan (Maeda’s
Questionnaire for Type A Behavior Pattern). A total score of
17 or greater indicated a type A behavior pattern.
Data Quality Assurance
A pretest was conducted using 10% of the sample
to assess instrument simplicity, flow, and consistency.
To improve the validity and reliability of the instrument,
questionnaire modifications were made giving due atten-
tion to the language. Data collectors and supervisors were
trained. Data completeness and consistency were checked
by the investigators. Data cleaning and editing resulted in
missing values being removed from statistical packages.
Data Processing and Analysis
Descriptive summaries were used to present results.
Logistic regression was used to test associations between
variables and to control possible confounders. The degree
of associations between independent and dependent vari-
ables were assessed using odds ratios with 95% CIs.
RESULTS
Of the 343 sample nurses, data were collected from
320 nurses (response rate: 93%) (Table 2). Two-thirds of
the participants (66.9%) were females. The ages of the re-
spondents ranged from 20 to 60 years; the mean age was
31.9 ± 8.9 years and 165 (51.6%) were married. Among
the respondents, 162 (50.6%) of the nurses had children.
Most (88.1%) respondents were Christian and Amhara
(ethnicity) (44.7%). One hundred ninety-one (59.7%) of
the nurses held diplomas in nursing. Ninety-five (29.7%)
of the respondent nurses earned between $79.00 and
$105.00 per month (U.S. dollars).
According to the findings, Ministry of Health,
Addis Ababa Health Bureau and nursing stake
holders should design stress management
programs for nurses that include the proac-
tive identification of stress and the evaluation
of stressors at work areas. All hospitals and
nursing administrators should take responsibil-
ity for the health and well-being of staff mem-
bers by reducing stressful situations, resched-
uling shifts, and recruiting adequate nurses
to decrease workloads. Furthermore, support
systems such as counselling services and
self-help groups should be made available to
nurses. In terms of perceived stress, this study
is the first step in developing a perceived
stressor profile for nurses in Ethiopia; it is
recommended that the study be expanded to
all provinces of the country. Qualitative studies
should assess the context of nurses’ stress.
Applying Research to Practice

328 Copyright © American Association of Occupational Health Nurses, Inc.
Distribution of Respondents by Work-Related and
Behavioral Characteristics
Many of the nurses were selected from medical
wards (61 [19.1%]), surgical wards (55 [17.2%]), and
emergency units (46 [14.4 %]) (Figure 1). Most of the
nurses had worked in St. Paulos (22.2%) and Tikur An-
bessa (17.5%) Hospitals (Figure 2).
More than two-thirds (71.6%) of the nurses worked ro-
tating shifts. The work experience of nurses ranged from 1
to 35 years; 191 (59.7%) of the respondents reported having
less than 7 years of experience. One hundred twenty-eight
participants (40%) worked 51 to 65 hours per week and 98
(30.6%) of the nurses worked 35 to 50 hours per week.
Less than half (48.4%) of the nurse respondents re-
ported being satisfied with their jobs and approximately
1 in 10 had experienced illnesses. Approximately 5%
and 38% of the nurses reported histories of substance
use and type A personality, respectively (Table 3).
The mean NSS score for the study participants
ranged from 0.15 to 2.68. Scores of 1 and above indi-
cated work-related stress. From a total of 320 nurses, 121
of them scored 1 (occasionally stressed) or above on the
NSS. Therefore, the prevalence of work-related stress in
this sample was 37.8% (95% CI: 34.3 to 39.1).
The descriptive analysis showed that the most fre-
quently reported sources of stress at the workplace were
“workload” (142 [44.4%]) and emotional issues related
to patient death and dying (130 [40.6%]). One hundred
nineteen (37.2%) nurses reported that conflict with a
TABLE 1
Sampling Procedure of Nurses
Working in Public Hospitals of
Addis Ababa, 2012
Hospital
Total
Number
of Nurses
Selected
Nursesa
Zewditu Memorial
Hospital
142 29
Ras Desta Damtewu
Hospital
102 21
Dagmawi Minilik
General Hospital
159 32
Yekatit 12 Referral
Hospital
193 39
Gandi Memorial Hospital 135 28
St. Petros TB Specialized
Hospital
58 12
Tikur Anbesa Teaching
Specialized Hospital
295 60
St. Paulos Referral and
Teaching Hospital
344 70
Amanuel Mental
Specialized Hospital
116 24
ALERT Hospital 135 28
Total 343 1,679
aSelected number of nurses based on the total number of
nurses.
TABLE 2
Distribution of Socioeconomic and
Demographic Characteristics of
Nurses Working in Public Hospitals
of Addis Ababa, Ethiopia, 2012
Variable
Frequency
(n = 320) %
Age (years)
≤ 25 104 32.5
26 to 34 108 33.8
35 to 44 70 21.9
≥ 45 38 11.9
Sex
Male 106 33.1
Female 214 66.9
Religion
Christian 282 88.1
Muslim 38 11.9
Ethnicity
Amhara 143 44.7
Oromo 83 25.9
Tigrie 56 17.5
Gurage 33 10.3
Others 5 1.6
Marital status
Single 145 45.3
Married 165 51.6
Widowed/divorced/separated 10 3.1
Child rearing
No 158 49.4
Ye s 162 50.6
Educational status
Diploma 191 59.7
Degree 129 40.3
Monthly salary (in US $)
53 to 78 122 38.1
79 to 105 95 29.7
106 to 131 41 12.8
> 131 62 19.4

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WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 8, 2014
supervisor and other nurses made their jobs stressful
(Figure 3).
Factors Associated With Work-Related Stress Among
Nurses
Binary logistic regression was used to test associa-
tion between variables. On bivariate analysis, the factors
with a p value of less than .20 were sex, marital status,
work shift, illness, work site, religion, work hours, and
substance use.
To control for possible confounders, the research-
ers used multivariate analysis to look for associations
between independent variables and stress. All variables
with p values less than .20 in bivariate analysis were in-
cluded in the multivariate analysis and p values less than
.05 were considered significant.
The multivariate analysis demonstrated that sex,
marital status, work shift, illness, and working unit/site
were significantly associated with stress.
Female nurses were twice as likely to suffer from
work-related stress than their male counterparts (adjusted
odds ratio [OR]: 2.47, 95% CI: 1.28, 4.77). Widowed and
divorced nurses were 10 times more likely to experience
occupational stress than married nurses (adjusted OR:
10.11, 95% CI: 4.56, 15.17). The relatively wide CI was
due to the small sample size.
Study participants who work rotating shifts were four
times more likely to experience occupational stress than
those working fixed shifts (adjusted OR: 4.613, 95% CI:
2.19, 9.71). Those respondents who reported illness were
2.7 times more likely to have experienced occupational
stress than those without illness (adjusted OR: 2.75, 95%
CI: 1.06, 7.12).
Compared with nurses working in psychiatry
units, nurses who worked in medical wards were three
times more likely to report occupational stress (adjust-
ed OR: 3.40, 95% CI: 1.16, 9.93) and nurses working
in emergency units were eight times more likely to re-
port occupational stress (adjusted OR: 8.16 , 95% CI:
2.52, 16.46). Those nurses working in surgical wards
reported 0.18 times less stress than nurses working in
psychiatry units (adjusted OR: 0.18, 95% CI: 0.05,
0.69) (Table 4).
DISCUSSION
Stress results when demands outweigh resources. A
moderate level of stress or “Eustress” is motivating and
considered normal and necessary. If stress is intense, con-
tinuous, and repeated, it becomes a negative phenomenon
or “distress,” which can lead to physical illness and psy-
chological disorders (Sadock & Sadock, 2007).
Prevalence of work-related stress in this study was
37.8 per 100 full-time workers, higher than the study in
Temerloh, Pahang, Malaysia (Rosnawati & Robat, 2008)
that reported the prevalence of work-related stress to be
25 per 100 full-time workers. A possible reason for this
difference may be using different tools and a convenience
sample that can increase error.
The findings of this study were lower than those of
a study conducted in India that revealed 73.5% of nurses
suffer from work-related stress (Kane, 2009). Differences
between the two studies may be due to varying bench-
marks for the NSS.
A study at the Isfahan University of Medical Scienc-
es hospitals in Iran (Mehrabi, Pravin, Yazdani, & Rafat,
2007) reported that most of the nurses (73.4%) experi-
enced greater stress than in this study. This variation may
be due to organizational differences because the Iranian
study was conducted only in a teaching hospital, whereas
the current study included all types of hospitals.
The number of nurses reporting work-related stress
in this study was higher than the stress (17%) reported
in a study about nurses in Taiwan (Aoki, Keiwkarnka,
& Chompikul, 2011); the reasons for the difference
may be tools used or study setting, which included
only psychiatry units. A study at a teaching hospital
in Malaysia found that the prevalence of work-related
stress among medical and surgical ward nurses was
49.3% (Mojoyinola, 2008); the difference between this
and the current study may be due to differences in tools
Figure 1. Worksite (unit) of nurses working in public hospi-
tals of Addis Ababa, Ethiopia, 2012. OR = operating room;
OPD = outpatient department; ICU = intensive care unit
Figure 2. Percentage of study participant nurses by hospi-
tal, Addis Ababa, Ethiopia, 2012.

330 Copyright © American Association of Occupational Health Nurses, Inc.
used and the limited participants from the medical and
surgical ward.
According to this study, female nurses were more
stressed than males; this may be due to female nurses be-
ing working mothers who bear a greater and more dif-
fuse workload than men, or all women, because they have
multiple roles in the family and society.
A significant association was found between stress
and marital status in this study. Nurses who were wid-
owed or divorced were more stressed than married nurses.
This finding is supported by the Malaysian (Hamaideh,
Mrayyan, Mudallal, Faouri, & Khasawneh, 2008; Kane,
2009) and Taiwanese studies (Shen & Cheng, 2005).
Researchers also reported a significant association
between work shift and stress in this study; nurses who
worked rotating shifts were more stressed than nurses
who worked fixed shifts. This finding is consistent with
a Jordanian research study that reported that work shift
was the best predictor of nurses’ stress (Hamaideh et al.,
2008). Working evenings and nights leads to poor quality
of sleep, resulting in drowsiness, fatigue, limited concen-
tration, and errors resulting in stress. However, working
on weekends and holidays creates stress for nurses be-
cause they often miss social or family activities.
A significant association between working units and
work-related stress was found in this study. When com-
pared to those nurses who work in psychiatric units/wards,
nurses who work in medical wards and emergency units
were stressed more. This finding may be due to nurses
working on medical wards and emergency units, suffer-
ing from heavy workloads, caring for critical patients, and
with little time for nurses to support each other emotion-
ally. This finding is supported by an Irish study (McCarthy,
Power, & Greiner, 2010) that explored medical wards and
emergency department nurses who were perceived to expe-
rience higher stress levels than other nurses.
Respondents who reported illness were more likely
to report occupational stress than those without illness,
even though this research did not differentiate temporal
relationships. This result is supported by Seyle’s research,
the first to demonstrate a correlation between stress and
illness (Health and Safety Executive, 2011).
Descriptive analysis indicated that “workload” was the
most frequent source of stress for nurses. This finding should
be interpreted cautiously because the data were subjective
and based on nurses’ reports. Looking at individual items
on the workload subscale, “not enough staff to adequately
cover unit” was the most frequently selected item, followed
by “not enough time to complete all my nursing tasks.”
TABLE 3
Distribution of Work-Related and
Behavioral Characteristics of Nurses
Working in Public Hospitals of
Addis Ababa, Ethiopia, 2012
Variables
Frequency
(n = 320) %
Work shift
Fixed 91 28.4
Rotating 229 71.6
Work experience (years)
1 to 7 191 59.7
8 to 14 56 17.5
15 to 21 38 11.9
22 to 28 22 6.9
29 to 35 13 4.10
Work hours per week
35 to 50 98 30.6
51 to 65 128 40.0
66 to 80 84 26.3
> 81 10 3.1
Staff job satisfaction
Yes 155 48.4
No 165 51.6
Illness
Yes 38 11.9
No 282 88.1
Substance use
Ye s 17 5.3
No 303 94.7
Type A personality
Yes 121 37.8
No 199 62.2
Figure 3. Stressors at the workplace for nurses working in
public hospitals of Addis Ababa, Ethiopia, 2012.

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WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 8, 2014
These findings were supported by a South African
study (Makie, 2006) that reported greater sources of
stress as “not enough staff to adequately cover unit” and
consistent with an Indian study that explored causes of
stress and found the greatest cause of stress to be “jobs
not finished in time because of shortage of staff and over-
time.” Similiar to other developing countries, Ethiopia
suffers from a shortage of nurses (i.e., 2 nurses for 10,000
people) (Mojoyinola, 2008), which increases nurses’
workload. In addition, nurses engage in many non-nurs-
ing activities such as paperwork, management, and super-
vision, which can add stress.
The second most reported nurse stressor was “emo-
tional issues related to patient death and dying.” These
findings are supported by studies in Malaysia and Jordan
that revealed major sources of stress were “work load”
and “death and dying” (Blaug et al., 2011).
Death, by its nature, is stressful and a source of suf-
fering; therefore, nurses may be stressed when they are
faced with the deaths of patients. Additionally, because
of the increased workload, nurses may not have enough
time to support each other emotionally in these situations.
Nurses in this study reported that work-related stress
was high; almost one in three nurses working in public
hospitals was stressed at work. Significant associations be-
tween nurses’ stress and work shift, working unit, gender,
marital status, and illness status were found. No significant
associations were found between stress and work experi-
ence, child rearing, substance use, age, or monthly salary.
IMPLICATIONS FOR PRACTICE
According to these findings, Ministry of Health and
Addis Ababa Health Bureau and Nursing stake holders
should collaborate to design stress management programs
TABLE 4
Binary Logistic Regression Analysis of Work-Related Stress and Associated
Factors Among Nurses Working in Public Hospitals of
Addis Ababa, Ethiopia, 2012 (n = 320)
Variable Yes No COR (95% CI) AOR (95% CI)
Sex
Male 27 79 1.00 1.00
Female 94 120 2.29 (1.37, 3.83)a2.47 (1.28, 4.77)
Marital status
Single 50 95 0.86 (0.54, 1.37) 0.94 (0.50, 1.74)
Divorced/widower 9 2 7.40 (1.54, 35.38)a10.11 (4.56, 15.17)
Married 62 102 1.00 1.00
Work shift
Fixed 21 70 1.00 1.00
Rotating 100 129 2.58 (1.48, 4.49)a 4.61 (2.19, 9.71)
Illness
Ye s 25 13 3.44 (1.71, 6.92)a2.75 (1.06, 7.12)
No 96 186 1.00 1.00
Work unit
Medical ward 42 19 5.52 (2.06, 14.76)a3.40 (1.16, 9.93)
Intensive care unit 9 7 3.21 (0.89, 11.60) 1.78 (0.40, 7.85)
Emergency 36 13 6.92 (2.45, 19.52)a8.16 (2.51, 16.45)
Pediatrics 5 16 0.78 (0.21, 2.85) 0.54 (0.12, 2.31)
Operation room 8 26 0.76 (0.24, 2.40) 0.69 (0.20, 2.38)
Surgical 6 49 0.30 (0.09, 0.99) 0.18 (0.04, 0.69)
Outpatient department 5 27 0.46 (0.13, 1.62) 0.27 (0.07, 1.05)
Maternity 2 22 0.22 (0.04, 1.20) 0.19 (0.03, 1.08)
Psychiatry 8 20 1.00 1. 00
COR = crude odds ratio; CI = confidence interval; AOR = adjusted odds ratio
aSignificant at p < .20.

332 Copyright © American Association of Occupational Health Nurses, Inc.
for nurses that include the proactive identification and
evaluation of stressors in work areas. All hospitals and
nursing administrators must take responsibility for the
health and well-being of their staff by reducing stressful
situations. They should reschedule shifts and recruit ad-
equate nurses, decreasing workloads. Furthermore, sup-
port systems such as counselling services and self-help
groups should be made available to nurses. Qualitative
studies should assess the context of nurses’ stress.
In terms of perceived stress, this study is the first step
in developing a perceived stressor profile for nurses in
Ethiopia; it is recommended that the study be expanded
to all of the provinces of the country.
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