A Cross-Sectional Study Examining the Factors that Influence the Perception of Stress Among Intensive Care Unit Nurses in Jordan

1. INTRODUCTION

Identifying the factors that influence perceived stress is a focus of research on mental health [1-3]. Stress, a normal response arising when facing challenges, is characterized by negative emotional, physical, and behavioral responses due to an individual’s inability to cope. Perceived stress reflects the relationship between people and the environment, which they appraise as endangering or overtaxing their resources, and it may impact their well-being [4]. Previous studies have indicated that healthcare providers’ work environments and sociodemographic characteristics are significantly correlated with their stress [5-7]. Work can be demanding and stressful for nurses working in acute care settings, such as emergency departments and intensive care units (ICU) [8]. ICU nurses experience a significant level of stress owing to end-of-life care, complex life-support procedures, and painful interventions during patient care [9]. The prevalence of stress among nurses and ICU nurses is approximately 9–68% and 68.29% globally, respectively, and varies across different countries [10, 11].

Multifaceted work-related stressors can disrupt nurses’ physical and mental wellbeing, increase stress, and decrease work productivity [12, 13]. Psychological resilience constitutes a nurse's ability to adapt to or cope positively with perceived stress as a coping strategy [14, 15]. Resilience predicts depression, anxiety, and stress [16] and protects nurses from mental health distress [17]. Furthermore, it is considered an essential and effective method for overcoming various challenges and stressors, including work-related difficulties [16, 18].

Correlational studies on job performance, stress, and resilience have revealed a negative relationship between job performance and stress, a positive relationship between resilience and stress, and a moderately positive relationship between stress and resilience [18]. Peñacoba et al. reported that a higher perception of self-efficacy was associated with increased resilience and a lower perception of stress [19]. Additionally, increased resilience was associated with improved physical health and mental well-being. Similarly, Talebian et al. reported a positive relationship between resilience and moral distress, indicating that ICU nurses used resilience as a coping strategy when moral distress increased [20]. Psychological empowerment of ICU nurses significantly improved after resilience training compared with before the intervention [8, 21].

Furthermore, research findings indicate correlations between job performance, perceived stress, and resilience among ICU nurses. Ta’an et al. found a negative correlation between job performance and stress, and a positive correlation between resilience and stress [18]. Another study reported that nurses experienced moderate levels of stress but demonstrated high levels of resilience, with a significant relationship observed between stress, resilience, and turnover intention [22]. During the pandemic, the relationship between stress and resilience among ICU nurses had a psychological impact on nursing. Almegewly et al. found that although nurses in the critical care unit reported stress, there was no correlation between stress and resilience; furthermore, 64% of participants indicated moderate levels of stress [23].

Although significant stress levels were noted in the emergency room (ER), most neonatal intensive care unit (NICU) nurses reported feeling extremely stressed. Nurses had high confidence in their ability to manage issues related to infection. Almegewly et al. reported that even after the number of COVID-19 cases dropped, most nurses still experienced moderate-to-high stress levels linked to the pandemic and demonstrated reasonable resilience [23]. Aqtam et al. reported that most ICU nurses experienced high stress levels and low resilience. Aqtam also found negative correlations between stress and resilience, as well as between nurses’ stress subscales and resilience [6].

Hence, examining nurses’ stress and resilience is essential for understanding how workplace challenges impact perceived stress, which can vary based on psychological resilience. Stressors may lead to mental health issues, such as fear, depression, and anxiety, among ICU nurses [6]. Previous studies have mainly examined stress levels among ICU nurses and their coping strategies. However, few studies have addressed work-related stressors in relation to stress and resilience among ICU nurses in Jordan, using the PSS-10 and CD-RISC-10 scales concurrently. This study aimed to explore the relationship between perceived stress, psychological resilience, and sociodemographic variables of ICU nurses in Jordan, identify predictors of perceived stress, and assess the model for accuracy.

2. METHODS

3. RESULTS

3.5. Prediction Accuracy Analysis

The Mean Absolute Error (MAE), Root Mean Square Error (RMSE), and Mean Absolute Percentage Error (MAPE) were used to evaluate the accuracy of multiple linear regression models. These metrics conveyed how far the predicted values were from the actual values (stress raw score).

Table 5 presents the results of the multiple regression analysis. The MAE prediction model predicted stress scores deviate by approximately 2.54 units from the actual values. However, the RMSE prediction error was approximately 3.31 units, which was considered a small prediction error. Additionally, the MAE and RMSE prediction models were lower than the MAE and RMSE of the baseline model, which indicated that the model performed better than estimating the average perceived stress score; furthermore, including predictors improved prediction accuracy. Hence, our model predicted that stress scores would deviate from the actual stress scores by 10.20% (MAPE=10.20%).

Table 4.

Stressors Contributing to Perceived Stress Among ICU Nurses	Unstandardized Coefficients		Standardized Coefficients	t-value	P-value	95.0% Confidence Interval for B		Unique Variance explained	VIF
	B	Std. Error	Beta			Lower Bound	Upper Bound
Participants work extra hours in the ICU (Yes vs No)	2.800	0.531	0.313	5.277	<0.001	1.753	3.846	8.35	1.173
Comfortable work environment (No vs Yes)	2.116	0.559	0.230	3.783	<0.001	1.013	3.219	4.28	1.235
Shift work (16 vs 8 hours)	1.728	0.554	0.198	3.119	0.002	0.635	2.821	2.92	1.350
Marital status (Married)	Reference
Marital status (Others)	2.209	0.716	0.186	3.086	0.002	0.797	3.621	2.86	1.213
Marital status (Single)	1.334	0.560	0.145	2.381	0.018	0.229	2.439	1.69	1.240

Note: F(5,194)=27.972, p<0.001 R-square 0.419, adjusted R-square 0.404.

Table 5.

Models	MAE	RMSE	MAPE
Prediction model (model with predictors)	2.54	3.31	10.20%
Baseline model/ Benchmark (stress mean score =27.68, SD=4.37, critical t value=1.97, N=200)	3.50	4.35	----

Note: 95% prediction interval (19.05-36.31) Sample Mean ± t × Sample SD × , MAPE (10-20%) good accuracy.

The 95.0% Prediction Interval (PI) for individual nurses’ stress scores was constructed and between 19.05–36.31, which indicated that the regression model with included predictors predicted individual nurses’ stress scores within that range 95.0% of the time; this indicated that if a nurse was randomly selected, a stress score would likely fall within this interval and prediction interval extended 8.63 units above and below the mean prediction. (mean lower bound: mean upper bound =8.63).

4. DISCUSSION

This study revealed the relationship between perceived stress and psychological resilience among nurses. Furthermore, the impact of demographic and work stressor variables on stress levels was explored. A statistically significant inverse relationship was observed between perceived stress and psychological resilience. These findings implied that the more resilient nurses became, the less they experienced stress at work.

Our findings of an inverse relationship between perceived stress and resilience levels were supported by previous literature. Saravanan et al. reported that ICU nurses exposed to prolonged stress experienced emotional exhaustion and burnout [31]. Furthermore, they implied that lack of resilience was inversely related to stress and burnout. Vahedian-Azimi et al. found that stress and burnout were associated with decreased emotional and physical well-being [32]. Moreover, they demonstrated that resilience was an important factor in promoting emotional and physical well-being, which could be negatively affected by high levels of stress and burnout.

Results revealed that age and work experience had positive and significant impacts on perceived stress. These findings implied that older and more experienced nurses reported higher levels of stress and aligned with those of Guttormson et al., who reported that nurses experienced moderate to high stress levels due to long hours of exposure to COVID-19 in 2020 [33]. They also implied that exposure was positively correlated with high stress levels. Healthcare personnel who worked during the pandemic reported high levels of stress, anxiety, and depression, and the main characteristics linked to psychological distress were being male, married, and older than 40 years [34]. Thus, experienced and older nurses were more exposed to traumatic events, which resulted in their high perceived stress in this study.

Based on these findings, female nurses were more susceptible to perceiving stress levels compared with male nurses. Current literature has not addressed the possible reasons why women experience higher levels of stress compared with their male counterparts. Possible explanations could include work-life balance challenges. Future researchers should explore the possible reasons why female nurses experience higher stress levels than male nurses.

A significant relationship was observed between perceived stress and marital status. Single nurses and those divorced or widowed exhibited higher stress levels than married nurses. Fadillah et al. reported that inadequate time spent with family members owing to being busy may lead to higher stress levels among nurses [35]. However, in this study, single and divorced nurses experienced higher levels of stress. These findings implied that reduced stress levels among married nurses may be attributable to the presence of a strong family support system.

Workplace conditions also impacted nurses’ stress. Nurses who worked 16-hour shifts reported higher stress levels compared with those who worked eight-hour shifts. Based on the regression analysis, extra hours were the strongest predictor of perceived stress. These results were consistent with those of Mousazadeh et al., who reported that increased workload raised stress levels and resulted in job dissatisfaction [36]. Therefore, ICU nurses who worked 16-hour shifts or extra hours perceived higher stress, likely due to work overload. Consequently, these nurses were more likely to be dissatisfied with their jobs due to elevated stress levels.

Nurses who reported that their work environment was uncomfortable also experienced higher stress levels. Furthermore, nurses who reported equipment shortages reported increased stress. Although we did not ask participants which equipment was lacking, nurses may have perceived stress because they felt their health and patient safety were at risk, were unable to provide optimal care, and had to constantly improvise. This is consistent with a previous study [33], which linked the absence or lack of personal protective equipment to mental health issues.

This study emphasized stress among ICU nurses, an issue that demands the attention of hospital management. The potential of sociodemographic variables to predict perceived stress was further explored. Variables that showed significant results in the bivariate analysis (age, gender, experience in ICU, marital status, work shift, working extra hours, comfortable work environment, and equipment availability) aligned with those reported in other studies [37, 38]. This study identified the sociodemographic variables that predicted perceived stress. Working extra hours, comfortable work environment, work shift, and single or other marital status collectively contributed 40.4% to the overall perceived stress score, suggesting that these variables significantly impacted the differences observed in the dataset, while the remaining 59.6% of variability was explained by other variables not considered in the analysis. Specifically, perceived stress from working extra hours, a comfortable work environment, being divorced or widowed, and being single accounted for an additional 8.35%, 4.28%, 2.86%, and 1.69% of the variance, respectively. These variables emerged as predictors of perceived stress and could potentially be mitigated through resilience.

ROC analysis was used to evaluate the accuracy of the multiple linear regression models and the performance of the perceived stress scale. The multiple linear regression model predicted perceived stress scores 95.0% of the time, with up to 85.0% sensitivity and 78.0% specificity. Hence, it efficiently predicted perceived stress. An area under the curve (AUC) of 0.90 indicated excellent diagnostic accuracy. Hosmer and Lemeshow’s classification of AUC of 0.5, 0.7–0.8, 0.8–0.9, and >0.9 was considered no discrimination, acceptable, excellent, and outstanding, respectively [39]. This suggested a 90% chance that perceived stress would correctly discriminate between individuals who were stressed and those who were not stressed.

5. LIMITATIONS

Despite providing significant insights into the relationship between stress, resilience, and contributing factors, this study has some limitations and gaps. First, data were self-reported, which may have introduced response biases, as participants could have misreported their stress levels. Second, the causal mechanisms underlying the relationship between demographics and work environment conditions were not extensively evaluated. Third, this study was conducted in a single setting, which may limit the generalizability of the findings to other contexts.

Furthermore, two gaps were identified. First, there was a lack of qualitative data to understand how nurses perceived and coped with stress. Second, the study did not provide a conclusive explanation for why women experienced higher levels of stress. Additionally, as a cross-sectional study, it cannot establish causality and is susceptible to various biases, including sample selection bias. Further analysis is required to clarify the association between gender and higher stress levels among nurses.

Lastly, this study used convenience sampling. The disadvantage of using a convenience sample is that it may not reflect the larger population, undermining the validity and generalizability of the results. The first researcher was present in the room during data collection and ensured that all items in the questionnaires were marked, which would be considered biased.

6. IMPLICATIONS FOR CLINICAL PRACTICE AND RECOMMENDATIONS

Perceived stress and resilience in nursing should be assessed to identify areas for improvement. Limiting excessive working hours and adequate staffing should be implemented in hospital settings to reduce perceived stress levels. Additionally, improving working conditions, such as providing adequate resources, could help reduce stress among nurses.

Future studies should conduct longitudinal studies to determine the impact of stress reduction tailored towards promoting resilience on stress levels. In addition, qualitative methods, such as interviews and focus groups, may be useful to determine nurses’ experiences and how they cope with stress. Qualitative analysis may also help establish the underlying reasons why certain factors, such as gender, influence stress levels.

CONCLUSION

This study explored the relationship between perceived stress, resilience, and work environmental factors among nurses. Results revealed that perceived stress levels were high and psychological resilience was low. Perceived stress was inversely correlated with psychological resilience. Factors such as being older, having more workplace experience, being female, divorced/widowed, working 16-hour shifts, working extra hours, being in an uncomfortable environment, and facing a shortage of equipment were significantly associated with higher stress levels. In regression analysis, nurses’ age, workplace experience, and facing a shortage of equipment had no significant effect on perceived stress scores. Future studies aimed at enhancing nursing resilience and well-being are recommended.

Although this study provides valuable insights into perceived stress and resilience, certain limitations remain, including the reliance on self-reported data and a sample confined to ICUs in three hospitals. Future studies should consider additional factors affecting nurses’ perceptions of stress, such as sleep patterns, dietary habits, physical activity, and caregiving responsibilities for infants or toddlers at home. Moreover, research should include other medical professionals working in ICUs, not only registered nurses with bachelor’s degrees.

REFERENCES