Discussion
This study used the OSI to determine the occupational stress among healthcare workers in the context of the COVID-19 pandemic in Nepal. Developed in 1982, this scale has been applied in various studies in both India and Nepal. After examining 368 subjects, the results indicated that the mean OSI score among healthcare workers was 149.56±22.01. However, it is noteworthy that this study focused exclusively on doctors and nurses in the hospital, while some previous studies included other health professionals with larger sample sizes.19 Additionally, several studies selected only nurses 2 20 21 or doctors.22
The findings of this study revealed a significantly higher mean OSI among female participants, married individuals, those working more than 1 year, working in rotating shifts, attending more than four night shifts in a month, participants working for 48 hours or more per week, those lacking support from other staff, participants with an alcohol drinking habit and those belonging to low-wealth quintile. The association between gender and occupational stress may be attributed to most of the participants being female nurses. In this study, there was no statistically significant difference in OSI with age and education. This finding is consistent with a study conducted in China during COVID-19 pandemic where, age and educational status had no significant association with stress among health workers.23 However, reports from Vietnam indicated that the rate of occupational stress among healthcare workers under 30 years old was 5.24 times higher compared with those over 30 years old (95% CI: 1.33 to 20.53, p value=0.019) before the pandemic.6 Studies from Germany2 and Ethiopia13 supported this finding, suggesting that young doctors and nurses face high job demands, long shifts, mental health issues and a lack of working experience. Educational status in this study did not show an association with the level of workplace stress, consistent with the study in Ethiopia.13 In contrast, a study in Vietnam concluded that health workers holding postgraduate degrees experienced less stress than those with bachelor’s or lower degrees.6 The reason may be that less educated individuals feel more pressure to become more professional and improve their skills to meet job demands. Occupational stress has shown a significant difference among nurses compared with doctors in this study, but no significant association in multiple regression, aligning with the results of studies conducted in Vietnam6 and Bangladesh.24 This could be attributed to the association between occupational stress and gender, as the majority of the professionals in this study were female nurses. The assessment of stress exclusively in the nurse population tends to yield higher stress levels than assessing stress in a population including both doctors and nurses. Comparable findings were noted in a study conducted among healthcare workers in Nepal and India during the COVID-19 pandemic. The study indicated that being women and working as a nurse were correlated with more pronounced mental health outcomes.25 26 This observation may be attributed to the substantial time nurses dedicate to patient care compared with other healthcare workers.
Additionally, factors such as increased job demands shift work, long-standing working hours and unpredictable duties among nurses could contribute to their heightened stress levels.
This study also supported the findings of research conducted in Iran2 and a systematic review and meta-analysis,27 indicating that being married is correlated with occupational stress among healthcare workers. In Nepalese context, married health workers have added responsibilities like managing household chores and taking care of children which is likely to contribute to occupational stress.
The current study did not show a significant association between the working department and stress levels among health workers. In contrast a study reported, ICU nurses assigned to COVID-19 units were more than twice as likely to express insufficient sleep and three times as likely to contemplate leaving their current department.28 Another study concluded that ICU workers were 4.5 times more likely to experience work stress before the pandemic.29 Discrepancies in these findings may be attributed to variations in sample size, country-specific contexts and workload disparities across different departments. Health workers working in rotating shift experienced more occupational stress. This is supported by the results of a study conducted in Saudi Arabia.19 This study showed that working in night shift had an association with occupational stress among health workers which is similar to the findings from Germany and Austria.30 Our study does reveal a significant association between social support and occupational stress. This finding is in line with the findings from the study in Italy, where stress related to COVID-19 partially mediated the connection between the absence of supervisor support and psychological distress.31 Also, the results from a study during COVID-9 showed that work stress can be mitigated by increasing social support and resilience32
This is also supported by the findings from the study in Bangladesh24 and Taiwan,33 which concluded that lack of peer support was linked with high occupational stress for the healthcare professional. This study concluded that work stress was more prevalent among individuals who consumed alcohol. This finding is consistent with a study conducted in Ethiopia, where cigarette smoking, chewing tobacco and alcohol consumption was associated with stress due to COVID-19 pandemic.34
In the multiple linear regression analysis, longer employment duration, working in rotating shift, higher number of night shifts, increased weekly work hours, lack of minimal support from colleagues and belonging to a low-wealth quintile were identified as independent factors associated with high occupational stress. Similar with the previous study,14 our study revealed that longer employment duration had a notable negative impact on stress. This may be attributed to the practice in hospitals, where healthcare workers with lengthier experience were typically assigned to care for and treat a larger number and/or more severe COVID-19 patients.23 The uncertainty or lack of clarity surrounding effective treatments for COVID-19 added to this stress. Also, longer work experience correlates with decision-making authority which could have contributed higher level of occupational stress.33 Occupational stress was also observed to be higher among those working for 48 hours or more per week. This result was consistent with global studies that showed the overwhelming workload among healthcare workers during the COVID-19 pandemic.14,35 Also, increase in daily working hours and number of working days per week increased the risk of work stress among healthcare professional.36 The associations observed in this study might have been strengthened due to the ongoing second wave of the COVID-19 pandemic in Nepal which posed an extra burden on all healthcare workers.37 This necessitated healthcare workers to take on additional shifts due to resource constraints, staff shortages and the increased risk of COVID-19 transmission among workers.
Strengths and limitations of the study
This study has investigated the factors contributing to occupational stress among healthcare workers. The selection of only one tertiary hospital with only doctors and nurses as sampled participants was a major limitation due to time constraints and COVID-19 restrictions. Personal factors that could influence the stress response of individual healthcare workers and prior history of stress, anxiety, depression and chronic diseases were not examined in this study. The sample size was drawn from a single tertiary hospital in Nepal, limiting the generalisability of the findings to healthcare workers across Nepal. This study did not assess the coping strategies adopted by healthcare workers to reduce their daily life stress. This study has not assessed any change of occupational stress compared with pre-COVID-19 period due to lack of baseline data. This suggests a need for more comprehensive, in-depth and multidimensional studies to understand occupational stress and identify the source of stressors in the healthcare setting. This study gains particular significance in the context of the COVID-19 pandemic, wherein healthcare workers have had to work under excess demand.
Policy implications
Healthcare workers represent the most suitable group for intervention programmes designed to prevent occupational stress. Government and health institutions can implement the following strategies to identify, intervene and prevent occupational stress among the health workforce:
The assessment and documentation of causes or sources of stress in the workplace, and developing strategies or remedies to improve working conditions.
Health institutions must ensure that workloads align with the worker’s capacity and facilitate healthcare workers in decision-making, taking breaks and understanding job stress.
Worksite improvements and stress intervention programmes should be conducted at the workplace to enhance the physical and psychological well-being of healthcare workers.
Identification and implementation of various coping strategies, as well as the promotion of healthy lifestyle, behavioural modification and the raising of mental health awareness among health professionals.
Conclusion
Based on the findings, it is evident that there are stronger associations between certain factors and occupational stress among healthcare workers. This underscores the crucial need to establish evidence-based measures to prevent occupational stress, promote conducive workplace settings and enhance the overall health of healthcare workers. These measures need to be enhanced in the context of pandemics like COVID-19 where there is an extra burden on the overall health system. Longer working experience, increased work hours, inadequate or no support from colleagues and a low-wealth quintile contribute to the development of stress among healthcare workers in the tertiary hospital. The adverse effects of occupational stress may manifest as reduced efficiency, diminished job performance, decreased initiative and interest in work, increased rigidity of thought, lack of concern for the organisation and colleagues and a loss of responsibility and loyalty to the organisation. Hence, understanding occupational stress and its associated factors among healthcare workers can assist decision-makers at the policy level in Nepal’s health system in addressing workplace stress and devising and implementing resilience strategies.