579477 research-article2015
SJP0010.1177/1403494815579477Mental health problems in nursesT. Freimann and E. Merisalu
Scandinavian Journal of Public Health, 2015; 43: 447–452
Original Article
Work-related psychosocial risk factors and mental health problems amongst nurses at a university hospital in Estonia: A cross-sectional study
Tiina Freimann1,2 & Eda Merisalu2 1Tartu
University Hospital, Estonia, Department of Public Health, Medical Faculty, University of Tartu, Estonia, and of Public Health, Medical Faculty, University of Tartu, Estonia
2Department
Abstract Aim: Rapid changes in the Estonian health care system have placed extra pressure on the nursing profession, but the potential impacts of psychosocial changes have not been investigated. We aimed to explore the work-related psychosocial risk factors and their relationships with mental health problems (MHPs) amongst nurses at the university hospital in Estonia. Methods: A cross-sectional survey was undertaken amongst registered nurses at Tartu University Hospital (TUH). Psychosocial work factors and MHPs (stress, somatic symptoms, depressive symptoms and burnout) were measured using version two of the Copenhagen Psychosocial Questionnaire (COPSOQ II). Descriptive statistics and Pearson’s r correlation with sequential Bonferroni correction were used to analyse the data. Results: The analysis was based on 404 nurses (45% of the full-time working population of nurses). The highest mean scores recorded for the positive work-related psychosocial factors studied were meaning of work, role clarity, social relationships and mutual trust between employees. The highest scores for the negative factors studied were the demands for hiding emotions, work pace, cognitive and emotional demands. Stress and burnout showed the highest mean scores amongst the MHPs. Quantitative and emotional demands were positively related to all of the studied MHPs, while work pace and role conflicts had a positive correlation with stress and burnout. All of the studied negative psychosocial factors were significantly correlated with burnout. Conclusions: Work-related psychosocial risk factors such as quantitative demands (work load), emotional demands, work pace and role conflicts, had significant positive relationships with MHPs in nurses in Estonia, and may contribute to high levels of stress as well as burnout amongst nurses. Key Words: Psychosocial risk factors, mental health problems, stress, burnout
Introduction The International Labour Organisation (ILO) emphasises that the workplace is one of the key environments affecting workers’ health and wellbeing [1]. Rapid changes in the Estonian health care system over the past 20 years have placed extra pressure on the nursing profession, by significantly changing the nature and quality of their work. Nurses have had to adapt considerably to more demanding and technologically complicated working conditions. Previous studies and the European Agency for Safety and Health at Work recommend the use of surveys to
evaluate the possible health consequences, in terms of the psychosocial state of their staff, following changes at work organisations [2–4]. There is evidence that the prevalence of musculoskeletal pain among Tartu University Hospital (TUH) nurses is high [5]. Neck pain was associated with distressing somatic symptoms, emotional exhaustion and depersonalisation. Although psychosocial risk factors could influence mental health problems (MHPs) amongst TUH nurses, so far these risk factors have not been adequately investigated.
Correspondence: Tiina Freimann, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia. E-mail:
[email protected] (Accepted 8 March 2015) © 2015 the Nordic Societies of Public Health DOI: 10.1177/1403494815579477
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448 T. Freimann and E. Merisalu Systematic reviews have indicated associations between poor mental health amongst nurses and psychosocial risk factors, such as work overload, high job demands, low control/influence, leadership style of superiors, role conflicts and effort–reward imbalances [2,6–8]. Continuous exposure to stressful psychosocial factors at work can cause various MHPs in nurses, such as anxiety, burnout, depression and sleeping problems (2,9–11). Although previous studies have investigated the impact of psychosocial factors on mental health in nurses, they usually focused on a single health indicator or MHP [6,9] and analysed only a small number of risk factors [6]. There is a need for more thorough and sophisticated investigation of work-related psychosocial risk factors and MHPs in a single study. In the investigation presented here we explored a wide range of psychosocial work characteristics and their relationships with four mental health problems among university hospital nurses.
scales of psychosocial factors and MHPs included three or four items, but one scale – predictability – included only two items. All items were scored from 0 to 100 points (five response options 0, 25, 50, 75 and 100 and four response options 0, 33.3, 66.7 and 100) to make the scoring on the different scales comparable [13]. The total score on a scale was the mean of the scores of the individual items. Work organisation and job content were assessed differently from the original questionnaire, with four instead of five scales used: influence at work; possibilities for development; meaning of work; commitment to the workplace. The fifth scale – variation of work – was excluded because of low Cronbach’s alpha in the Estonian version of questionnaire. Other psychosocial domains were measured with the same number of scales as the original questionnaire [12]. Information about socio-demographic characteristics and work history was also collected. Statistical analysis
Method We performed a cross-sectional survey of nurses at Tartu University Hospital using an electronic questionnaire. All 906 full-time registered nurses, who had been employed at the hospital for at least a year, were invited to participate in the study. Three reminders of the survey were then sent to these nurses over a period of 6 weeks. The voluntary nature of participation was emphasised in the letter of invitation and through verbal communication. Approval for the study was obtained from the manager of the hospital and from the Ethics Review Committee on Human Research, University of Tartu.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS18.0). We calculated Cronbach’s alphas to assess the internal consistency of the psychosocial and mental health problem scales. Descriptive statistics were performed to calculate mean scores, standard deviations and 95% confidence intervals for all psychosocial factors and MHPs. Cross-sectional correlations between work-related psychosocial risk factors and MHPs were analysed using Pearson’s r correlation. Holm’s sequential Bonferroni correction was then used to account for multiple testing problems [14]. To compare the psychosocial work characteristics and MHPs with previous studies, we used the mean values and 95% confidence intervals.
Questionnaire
Results
The Copenhagen Psychosocial Questionnaire, version II (COPSOQ-II) was used to measure workrelated psychosocial factors and MHPs [12]. A licensed translator performed translation and backtranslation of the questionnaire. Cronbach’s alphas were calculated to assess the internal consistency of the scales for psychosocial factors and MHPs. In our study, psychosocial factors were assessed using 73 items grouped into 21 scales that covered the following four psychosocial domains: demands at work; work organisation and job content; interpersonal relationships and leadership; values at the workplace. To assess MHPs, we used 16 items grouped into the following four scales: stress; somatic stress symptoms; depressive symptoms; burnout. Most of the
Questionnaires were completed by 409 of the 906 nurses invited to take part in the study (a response rate of 45%). A total of 404 questionnaires were used in the analysis. Most of the nurses were women (98%) and their ages ranged from 23 to 69 years old with a mean age of 40. A large group of nurses (56.4%) had worked at the hospital for more than 10 years and one-fifth of the nurses were employed as nursing managers. Table I presents the mean scores, 95% confidence intervals and Cronbach’s alphas for self-reported psychosocial factors and MHPs. The psychosocial factors with the highest mean scores were: meaning of work; role clarity; social relationships at work; mutual trust between employees; demands for hiding
Study design and sample
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Psychosocial risks and mental health problems amongst nurses 449 Table I. Number of items, means, 95% confidence intervals and Cronbach’s alphas for work-related psychosocial factors and mental health problems in 404 nurses. Psychosocial factors and MHPs (scales)
Number of items
Mean
Demands at work Quantitative demands Work pace Cognitive demands Demands for hiding emotions Emotional demands
4 3 4 3 4
32.2 66.3 67.2 73.3 57.1
30.5–33.9 64.8–68.0 65.6–68.7 71.6–75.1 55.3–58.8
0.71 0.81 0.75 0.50 0.76
Work organisation and job contents Influence Possibilities for development Meaning of work Commitment to the workplace
4 4 3 4
33.3 68.6 80.2 63.7
31.3–35.4 67.1–70.2 78.7–81.7 61.7–65.6
0.74 0.75 0.78 0.73
Interpersonal relationships and leadership Predictability Rewards Role clarity Role conflicts Quality of leadership Social support from colleagues Social support from supervisor Social relationships at work
2 3 3 4 4 3 3 3
63.2 57.6 78.9 35.9 59.6 59.9 57.8 71.4
61.2–65.3 55.5–59.7 77.5–80.2 34.0–37.8 57.4–61.9 57.8–62.0 55.2–60.5 69.5–73.4
0.82 0.86 0.81 0.78 0.89 0.71 0.83 0.87
Values at the workplace Mutual trust between employees Trust regarding management Justice and respect Social inclusiveness
3 4 4 4
71.1 63.7 49.3 61.3
69.2–73.0 62.3–65.2 46.8–51.9 59.8–62.9
0.71 0.73 0.82 0.65
Mental health problems Stress Somatic symptoms Depressive symptoms Burnout
4 4 4 4
41.2 30.8 30.9 45.1
39.5–42.8 29.3–32.3 29.3–32.5 43.4–46.7
0.83 0.61 0.80 0.88
emotions; cognitive demands; work pace; emotional demands. Low mean scores were recorded for the influence on work organisation, and justice and respect at work. The mean scores for the four MHPs ranged from 30.8 to 45.1; the lowest score was for somatic symptoms of stress and the highest for burnout. A relatively high mean score was also occurred in the assessment of stress (41.2). The majority of the scales showed satisfactory Cronbach’s alphas, which ranged from 0.71 to 0.89 for scales of psychosocial work characteristics and MHPs. The following four scales had coefficients of less than 0.70: social support from colleagues (0.67); social inclusiveness (0.65); somatic stress symptoms (0.61); demands for hiding emotions (0.50). Table II shows the cross-sectional correlations between 21 psychosocial factors and four MHPs. After sequential Bonferroni correction, most of the 24 psychosocial factors statistically significantly correlated with burnout and stress (16 and 15 correlations, respectively). Fewer statistically significant correlations were found with depressive and somatic symptoms (10 and 8 correlations, respectively).
95% CI
Cronbach’s alpha
Psychosocial risk factors, such as quantitative and emotional demands, showed a positive correlation with all MHPs, while work pace was positively correlated only with stress and burnout; role conflicts correlated positively with stress, depressive symptoms and burnout. Positive indicators of interpersonal relations and leadership were negatively correlated with stress and (except for role clarity) burnout. Justice and respect, and trust regarding management also correlated negatively with stress and burnout. Social relationships at work, predictability, rewards and trust in management correlated with all studied MHPs. Discussion Work-related psychosocial risk factors and their relationships with four MHPs amongst nurses at a university hospital in Estonia were assessed in our study. Compared with earlier studies (Table III), nurses in our study scored lower than Danish and US nurses for some work-related risk factors, especially for quantitative demands and role conflicts [15,16].
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450 T. Freimann and E. Merisalu Table II. Pearson’s r correlations adjusted using sequential Bonferroni correction for psychosocial factors and mental health problems of a group of 404 nurses. Psychosocial factors (scales)
Stress
Demands at work Quantitative demands Work pace Cognitive demands Demands for hiding emotions Emotional demands
Somatic symptoms
Depressive symptoms
Burnout
0.38* 0.21* 0.10 0.06 0.27*
0.25* 0.08 0.04 0.05 0.19*
0.34* 0.03 0.08 0.06 0.25*
0.38* 0.33* 0.19* 0.20* 0.31*
Work organisation and job contents Influence Possibilities for development Meaning of work Commitment to the workplace
−0.12 −0.13 −0.17* −0.03
−0.09 −0.14 −0.09 −0.02
0.04 −0.10 −0.25* −0.01
−0.19* −0.04 −0.13* 0.01
Interpersonal relationships and leadership Role conflicts Role clarity Predictability Rewards Quality of leadership Social support from colleagues Social support from supervisor Social relationships at work
0.18* −0.14* −0.24* −0.24* −0.20* −0.19* −0.18* −0.30*
0.14 −0.08 −0.16* −0.19* −0.14 −0.17* −0.13 −0.23*
0.17* −0.23* −0.15* −0.16* −0.12 −0.13 −0.10 −0.22*
0.18* −0.08 −0.21* −0.30* −0.20* −0.17* −0.19* −0.29*
Values at the workplace Mutual trust between employees Trust regarding management Justice and respect Social inclusiveness
−0.16* −0.20* −0.25* −0.10
−0.14 −0.21* −0.19* −0.14
−0.13* −0.16* −0.12 −0.02
−0.12 −0.25* −0.25* −0.04
*Statistically significant p-values (p
