University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON FACTORS INFLUENCING STRESS AMONG PSYCHIATRIC NURSES AT THE ACCRA PSYCHIATRIC HOSPITAL BY PRISCILLA AMA KYEREME (10168529) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE. JULY, 2018 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Priscilla Ama Kyereme declare that this is my own original work. It was written independently by me under the supervision of Dr. Emmanuel Asampong. Where views and ideas of others have been used, they have duly been acknowledged. It has not been submitted to any other institution for any award of a degree or any other qualification, in what so ever nature either in full or part. ……………………………………… …………………………. PRISCILLA AMA KYEREME DATE (STUDENT) …………………………………. ….….…………………. DR. EMMANUEL ASAMPONG DATE (ACADEMIC SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work first and foremost to God Almighty for his grace and favour that has made this possible. Secondly to my family to my mother Margaret Azong and father Stephen Kofi Kyereme, my sister Gifty Alegsi and husband Godwin Ampofo and finally to my Aunty Emma Agabser and her husband Mr. Kingsley Abutima for their immense support and prayers which has made this work a success. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am grateful for the immense contributions of several people who helped me complete this study, without their help I probably wouldn’t have been able to. I take this occasion to direct my heartfelt appreciation and gratitude to the following people: I want to first to express my profound and genuine appreciativeness to Dr. Emmanuel Asampong, who supervised this work for his immense support, advice, and academic guidance. I also extend a word of thanks to Dr Maya and Dr. Ogum Alanga of the Department of Population, Family and Reproductive Health, School of Public Health, for their advice, guidance and support. To Mr. Philip Govule for his help and support. My sincerest gratitude goes to all the staff of the Accra Psychiatric Hospital, including the Medical director, the administrator, and to all the heads of the various wards of the Accra Psychiatric hospital for their warm reception and cooperation in the administration of my questionnaires and to all the psychiatric nurses who took part in this study. God richly bless and reward you immensely. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: Mental Health Professionals have been known to have stressful work settings. Psychiatric nurses have been particularly identified consistently with an enormous level of stress which has been known to destroy their performance, job satisfaction and their overall attitude to work. Harmful effects of work-related stress are poor health care service delivery, dissatisfaction with one’s job, poor attendance to work, mental health diseases, and mortality occurring at a fast rate, including deaths from suicide and stress-related diseases like cardiovascular diseases, diabetes, and hypertension etc. Psychiatric nurses should be in a healthy form and state of mind without any form of apprehensions and worries for them to execute their duties effectively and well. The study sought to assess factors influencing stress among mental health or psychiatric nurses at the Accra psychiatric hospital in Accra Ghana. Methodology: A quantitative cross-sectional study design. Random sampling method was the method used to select one hundred and fifty five (155) psychiatric nurses, from the Accra psychiatric hospital for the study. The Mental Health Professionals Stress Scale (MHPSS) questionnaire was used for data collection. Descriptive, bivariate Fisherman’s exact Chi square test, Pearson’s correlation coefficient and linear regression were used for data analysis. Results: The study’s findings revealed that most of the psychiatric nurses (75%) at the Accra Psychiatric hospital were stressed due to their work. The study also revealed that there was no statistically significant relation between socio- demographic characteristics of psychiatric nurses and their level of stress. Age, sex, marital status, and years of working experience were found not to influence stress in this group. iv University of Ghana http://ugspace.ug.edu.gh It was also found out that workload was a major factor that influenced stress among psychiatric nurses at the Accra Psychiatric hospital. Lack of resources, client related difficulties and home-work conflict were however found not to influence stress in the psychiatric nurses at the Accra Psychiatric hospital. Conclusion: To minimize the level of stress in psychiatric nurses at the Accra Psychiatric hospital there is the need for measures to be taken and policies put in place like training more psychiatric nurses, building more psychiatric hospitals and reducing the number of patients handled by nurses to ensure that workload at the Accra psychiatric hospital is reduced to the barest minimum to improve upon the physical and the mental wellbeing of psychiatric nurses and the wellbeing of their patients. v University of Ghana http://ugspace.ug.edu.gh Table of Contents DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENT .............................................................................................................. iii ABSTRACT .................................................................................................................................. iv LIST OF FIGURES ....................................................................................................................... ix LIST OF ABBREVIATION ............................................................................................................ x DEFINITION OF TERMS ............................................................................................................. xi CHAPTER ONE ............................................................................................................................. 1 1.0 INTRODUCTION ..................................................................................................................... 1 1.1 BACKGROUND ................................................................................................................... 1 1.2 PROBLEM STATEMENT .................................................................................................... 5 1.3 CONCEPTUAL FRAMEWORK ........................................................................................... 8 1.4 JUSTIFICATION ................................................................................................................ 10 1.5 RESEARCH QUESTIONS .................................................................................................. 11 CHAPTER TWO .......................................................................................................................... 13 2.0. LITERATURE REVIEW ....................................................................................................... 13 Introduction ............................................................................................................................... 13 2.1. Stress .................................................................................................................................. 13 2.2 Work Related Stress ............................................................................................................. 14 2.3 Sources of work related stress .............................................................................................. 15 2.4 Stress Reactions ................................................................................................................... 16 2.5 Factors influencing work- related Stress in Mental Health professionals............................... 17 CHAPTER THREE ....................................................................................................................... 27 3.0 METHODOLOGY .................................................................................................................. 27 Introduction ............................................................................................................................... 27 3.1 Study Design ....................................................................................................................... 27 3.2 Study Area ........................................................................................................................... 27 3.3 Study Population .................................................................................................................. 28 3.3.2 Exclusion criteria ........................................................................................................... 28 vi University of Ghana http://ugspace.ug.edu.gh 3.4. Study Variables ................................................................................................................... 29 i. Dependent variable ......................................................................................................... 29 ii. Independent variables...................................................................................................... 29 3.5 Sample Size ......................................................................................................................... 29 3.6 Sampling method and Data collection process ...................................................................... 30 3.7 Data Collection Tool ............................................................................................................ 31 3.8. Quality Control ................................................................................................................... 31 3.9. Pre-testing of research instruments ...................................................................................... 32 3.10 Data Analysis ..................................................................................................................... 32 3.11 Ethical issues .................................................................................................................. 33 CHAPTER FOUR ......................................................................................................................... 35 Introduction ............................................................................................................................... 35 4.1 Socio-demographic characteristics of respondents ................................................................ 35 CHAPTER FIVE .......................................................................................................................... 58 5.0 DISCUSSION ......................................................................................................................... 58 Introduction ............................................................................................................................... 58 5.3. Influence of workload, client related difficulties, lack of resources and homework conflict Work-related stress theories and literature has identified a number of factors as influencing stress at the workplace in the various professions of mankind the world over. ......... 63 5.5. Relationship between Home-work interface and stress ........................................................ 65 5.6. Relationship between lack of resources and stress. .............................................................. 67 5.7. Relationship between client-related difficulties and stress ................................................... 67 CHAPTER SIX ............................................................................................................................. 69 6.0 CONCLUSIONS, LIMITATIONS, AND RECOMMENDATIONS ........................................ 69 Introduction ............................................................................................................................... 69 6.1 Conclusions ......................................................................................................................... 69 6.2 Limitations of the study ....................................................................................................... 71 6.3 Recommendations ................................................................................................................ 72 REFERENCE ............................................................................................................................... 73 APPENDICES .............................................................................................................................. 88 APPENDIX B: CONSENT FORM ............................................................................................... 91 APPENDIX C: ETHICAL APPROVAL LETTER ........................................................................ 94 vii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4. 1.Socio-demographic characteristics, Gender, age, marital status of respondents……………………………………………………………………………….….36 Table 4. 2 Self-reported Stress among Psychiatric nurses…………………………………..37 Table 4.3. The relationship between socio demographic characteristics and self-reported stress……………………………………………………………………………………….…38 Table 4.4 Table on relationship between years of experience and stress………………….....40 Table 4.5 Workload. Mean and standard deviation results on workload…………………….43 Table 4. 6 Correlation between stress and workload…………………………………………44 Table 4.7 Stress and client related difficulties………………………………………….……43 Table 4.8 Correlation between stress and client related difficulties………………………....44 Table 4.9 Stress and lack of resources………………………………………………….……46 Table 4.10 Correlation between lack of resources and stress………………………………..47 Table 4.11 Stress and homework conflict………………………………….. ……………….49 Table 4.12 Correlation between homework conflict and stress……………………………..50 Table 4.13 Logistic regression analysis showing the relationship between stress and workload ………………………………………………………………………………………………52 Table 4.14 Model summary of logistic regression analysis…………………………………53 Table 4.15 logistic regression analysis showing the variables not in the equation…………54 viii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1. Conceptual framework of the study (Adapted from Hassard, Teoh, Visockaite, Dewe, & Cox, 2017). ...................................................................................................................... 8 Figure 4. 2 Pie chart of workload................................................................................................... 42 ix University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATION ERC - Ethical Review Committee GHS - Ghana Health Service ISR - Institute for Social Research MHN - Mental Health nurses MHPSS - Mental Health Professional Stress Scale MHP - Mental health professionals NHIS - National Health Insurance Scheme OSH - Occupational Safety and Health O.P.D - Out Patient Department R.C.H - Reproductive and child health V.I.P - Very important personality WHO - World Health Organization WPS - Workplace Stress x University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS ITEM DEFINITIONS Distress - Is extreme anxiety, sorrow or pain Eustress - Positive stress or good stress that motivates a person to perform Home- work conflict - Is the Contradictory burdens of work and home Work- related stress - Is the reaction many or a lot of people have if faced with work strains and burdens which does not correspond to their awareness and skills to cope. Stress - The mental, physical, emotional and Behavioral Reaction to any perceived demand Stressors - Are factors that have main effect on our attitudes, logic of wellbeing, conduct, and wellbeing. Rehab Alcoholicnous - Rehab for Alcohol Abuse xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 BACKGROUND Psychiatric nurses are trained to provide a wide range of mental health services to patients and families in a variety of settings. Psychiatric nursing is unreservedly stressful. The psychiatric nurse’s duties include, guiding patients on their journey to mental wellness, they diagnose patients’ conditions and their cause, interview patients about symptoms and complaints, determine whether a psychiatric illness has a physiological or emotional basis, screen patients for physical illness and analyze reasons for psychiatric illness, they also do assessment of risk factors for mental illness evaluations, provide a range of therapies to patients in their care, conduct individual, group or family counselling sections and administer drugs to patients, monitor drug use and document treatment results and they are also responsible for case management. The levels of work related stress among psychiatric nurses are extraordinarily high because apart from experiencing stress in general nursing like bureaucracy and paperwork, they also face additional stressors due to the nature of their work that is the care of the mentally ill, difficult and violent patients or clients. Self-fulfilment and job satisfaction are important factors that serve as motivators for mental health workers especially psychiatric nurses, who often have high expectations of their own wellbeing, that of their patients and the efficacy of their work. Disparities between these ideas and working conditions can result in negative and heightened expectations which can lead to cynicism about the efficiency of their work. 1 University of Ghana http://ugspace.ug.edu.gh Stress is the expressive and bodily tension produced by people’s reactions to burdens and demands from the surroundings or environment of the world. Stress responses well known to us are tautness, petulance, failure to focus, thwarting and diverse physical indications that consist of headache and a fast heartbeat (Cooper, 2012). Stress is grouped into two that is positive and negative stress. Eustress which is referred to as positive or good stress gives one the chance or ability to gain something; it serves as a stimulus for the highest form of achievement. The process of hormonal gesticulation, the sense of harm arrays off an instinctive reaction pattern, known as the fight-or-flight reaction, this positions people to encounter a task or run away from it. A traumatic experience, whether an outward occurrence like the abrupt presence of a scorpion in your way or an inside happenings like the dread of your business collapsing or going bankrupt due to financial challenges activates a flood of hormones, including adrenaline and cortisol, that rushes within the body, moving heartbeat and the flow of blood, organizing fat and sugar for rapid vigor, directing responsiveness, arranging strengths for achievement, and many more. Usually it takes several hours for the body to settle down when the stress reaction has been generated. Negative stress has to do with a person encountering social, organizational and emotional challenges he or she cannot handle. Distress is excessive nervousness, sadness and hurt a person may come into contact with due to some intimidating circumstances or settings. Lifesaving as the stress response is, it is designed to resolve temporary, severe complications, not prolonged troubles such as daily hardships encountered or work challenges. Persistent or constant stimulation of the stress reaction, a characteristic of contemporary life, can have damaging physical and psychological effects, including heart disease and depression. 2 University of Ghana http://ugspace.ug.edu.gh Work-related stress according to the definition of the world health organization (WHO,2017) is the reaction humans have when faced with work hassles and burdens that are beyond and above their understanding and capacities and which fights or defies their capacity to cope (Leka & Jain, 2010). The Management Standards 2010 defines work related stress as an outward structural influence or inducement which effects bodily, sensitive and mental uneasiness in a worker or employee in an organization (Shirom, Toker, Berliner, & Shapira, 2008). The hassles, worries and difficulties of present time work environment make Workplace demands and pressures inevitable. Conventional demands and pressures apparent to a person, can help motivate workers to be vigilant, inspired, and ready to labour and study, based upon the absence of means and individual physiognomies. Nevertheless, once that burden turns out to be extreme and insurmountable it may result in severe forms of stress. Stress can harm employees or workers' wellbeing and eventually work outcome. Deprived work institutions lead to Work-related stress. Poor work conditions consist of the way jobs and work structures are planned, the way they are regulated, the absence of regulation over work procedures, poor administration, substandard working environments, and want of a helping hand from coworkers and superiors. Findings from research has revealed that excessive difficulties and burdens beyond an employee or workers’ awareness and capabilities, is the greatest stressful type of work. Stress is also explained by a dynamic relationship between the individual and their working environment, and is time and again determined by the presence of a difficult person- environment fit and the sensitive responses that structure these connections. Essential to this method is the part that environmental causes, predominantly the part that psychosocial and structural influences, perform in work related stress. Work-related stress is 3 University of Ghana http://ugspace.ug.edu.gh widely documented as one of the key modern-day difficulties confronting job-related wellbeing or welfare. Consequently there is the need for stress prevention measures at the workplace (Leka & Jain, 2010). The work atmosphere, job environment, and the characteristics of work itself have significant impact on wellbeing (Dixon, 2000). Stress has undesirable impact on the somatic and psychological wellbeing of professionals (Rugulies et al., 2007) . Proof stipulates that, Stress can cause increased depression, reduced job fulfillment, disturbed individual interactions, poor state of wellbeing and mental health care, truancy, psychological suffering, emotional healthiness complications and advanced degrees of death, with death from suicide and stress-related diseases (Maslach, Jackson, & Leiter, 1997). When people are unprotected from risk factors at work stress reactions may develop. These may consist of reactions such as, reduced devotion and sensitivity, amnesia, feeling tensed or exasperated, violent, spontaneous actions, making blunders, upsurge in heart rate, blood pressure and hyperventilation. (Borritz et al., 2005) . If stress continues for a long period of time, extensive effects may develop which can disturb various parts of the body like the joints, heart, kidney, stomach, reproductive organs, pancreas, brain and nervous system, muscle and the intestines which can result in mental illnesses, heart diseases, hypertension, stroke, and diabetes, etc. In conclusion Work systems, culture, structures, communication and workplace relationships have important effects on the emotional and mental wellbeing of psychiatric nurses. Steps must be taken to manage and minimize the high levels of stress in this group by replacing stressful workplace conditions. Stress management interventions must be provided for individual psychiatric nurses. Interventions for managing stress must address organizational challenges as well as problems faced on the job by individual nurses for it to be successful. 4 University of Ghana http://ugspace.ug.edu.gh 1.2 PROBLEM STATEMENT Work related stress levels among psychiatric nurses in Ghana are extraordinarily high because apart from experiencing stress in general nursing like bureaucracy and paperwork, they also face additional stressors due to the nature of their work that is the care of the mentally ill, difficult and violent patients or clients. World health organization estimates that out of the 29.6 million people living in Ghana, 650,000 are suffering from a severe mental disorder and a further 2,166,000 are suffering from a moderate to a mild mental disorder. The increase in mental illnesses has serious implications for psychiatric nurses. There is the greater need for more psychiatric nurses in the country. Currently in Ghana the number of mental health professionals is shockingly very low, the few psychiatric hospitals are relentlessly overcrowded, community and rehabilitative care are nonexistent, there is limited resources and the law on mental health has not changed for over thirty years now. This is all due to scarce funding, stigma of persons and families living with mental illnesses, low death toll of mental illness and the government’s indifference towards mental health care. Self-fulfillment and job satisfaction are important factors that serve as motivators for mental health workers especially psychiatric nurses, who often have high expectations of their own wellbeing, that of their patients and the efficacy of their work. Disparities between these ideas and working conditions can result in negative and heightened expectations which can lead to cynicism about the efficiency of their work. Work systems, culture, structures, communication and workplace relationships have important effects on the emotional and mental wellbeing of psychiatric nurses. Steps must be taken to manage and minimize the high levels of stress in this group by replacing stressful workplace conditions. Stress management interventions must be provided for individual 5 University of Ghana http://ugspace.ug.edu.gh psychiatric nurses. Interventions for managing stress must address organizational challenges as well as problems faced on the job by individual nurses for it to be successful. Although, a number of researches have been conducted on factors influencing stress among mental health workers in other parts of the world, few researches have been conducted with regards to the issue in Ghana. Mental health professionals’ especially psychiatric nurses are severely overworked and under resourced in Ghana due to scarce staff resources, poor organizational structures and processes, lack of resources and client related difficulties. There are less than fifteen psychiatrist and a very few number of psychologist and the number of psychiatric nurses are not enough for a population of twenty nine point six (29.6) million people in Ghana, the psychiatric nurse patient ratio is not very proportional as there are more patients to a nurse which is beyond their capacity and what they can handle and bare. More mental health professional’s especially psychiatric nurses, structures and equipment are needed in Ghana to make mental health work effective and efficient and bearable for those in the profession. This research was therefore conducted to identify factors that influence stress among mental health nurses or psychiatric nurses at the major psychiatric Hospital in Ghana that is the Accra psychiatric hospital. If stress in psychiatric nurses must be reduced or minimized, proper funding sources must be created for mental health care in Ghana to provide for all mental health needs and resources. Psychiatric nurses training and education must be made very cheap and affordable so that more people can be trained and recruited into the profession, mental health personnel and non-governmental organizations must work to increase awareness of mental illness, delivery of service and mental health care must be improved and cost effective. 6 University of Ghana http://ugspace.ug.edu.gh The government and the ministry of health must work to provide equal access to mental health treatment for all Ghanaians. 7 University of Ghana http://ugspace.ug.edu.gh 1.3 CONCEPTUAL FRAMEWORK For this study the conceptual framework consisted of work-related stress, socio-demographic characteristics of respondents and the factors that influenced work-related stress in respondents. Independent variables Dependent variables Workload Work pressure Working long hours Too many clients/patients Work related Stress Lack of resources Lack of adequate staffing Inadequate equipment supplies Lack of financial resources Client related difficulties Difficult client/patient Dealing with death/suffering Socio-demographic Homework conflict characteristics Taking work home Age Inadequate time for Sex friendship Marital Status Not having time with Years of working experience family Figure 1. Conceptual framework of the study (Adapted from Hassard, Teoh, Visockaite, Dewe, & Cox, 2017). 8 University of Ghana http://ugspace.ug.edu.gh CONCEPTUAL FRAMEWORK NARRATIVE: FACTORS THAT INFLUENCE STRESS IN MENTAL HEALTH NURSES. Stress has been recognized as a result of a multifaceted set of active occurrences and also as an effect of a direct process. Previous literature and hypotheses on the relationships among study variables (workload, lack of resources, client related resources, homework conflict pressure, socio demographic factors and Work related stress have collectively given rise to the conceptual framework of this study, as shown in Figure 1. To recognize the relationship between stress and associated factors, Hassard, Teoh, Visockaite, Dewe, & Cox, 2017 identified several exposure factors that influence stress which are work related, these consist of, workload, client related difficulties, lack of resources, home-work interface, etc. Unstructured administration and organization of the work environment could result in work related stress. The foundations and supervision of stress due to work, both include methods and systems employed in the design, management and organization of the work. Literature reviewed on stress has identified a number of causes of stress known as the ‘psychosocial hazards’, this often includes, those stressors central to the job, inadequate funds, violent and difficulties patients, workload, administrative structure and environment, and homework conflict. Stress procedure was summarized in the framework to illustrate, stress levels, factors influencing stress and individual characteristics of respondents. Stress responses may occur if a person is exposed to risk factors at the work place. Individual socio demographic physiognomies such as age, gender, work experience, marital status, can have an impact on a person’s capability to manage the stress. These features can both lessen the special effects of threat influences at the work place and, eventually, the knowledge of stress. The health effect of psychosocial threats and work-related stress can affect an individual’s wellbeing, and can also disturb the output and resiliency of the organization. 9 University of Ghana http://ugspace.ug.edu.gh Managing stress at the work environment could benefit the psychiatric nurses, the psychiatric hospital, patients and the society at large (Hassard et al., 2017). Studies conducted the world over has revealed that workload, lack of resources, homework conflict and client related difficulties are factors if present at the workplace can lead to stress and so they are the independent variables that are linked or connected to the dependent variable stress. Age, sex, marital status and years of working experience are also variables that can lead to stress. Literature has revealed that high levels of workload can lead to high levels of stress, handling difficult and violent patients on daily bases can lead to stress. Lack of resources for one to work with makes work very difficult and can lead to stress and homework conflict which has to do with combining the pressures of the home with that of the workplace can lead to stress if not well balanced. The conceptual framework was designed to show the link between these factors and stress. 1.4 JUSTIFICATION If stress in mental health or psychiatric nurses is to be minimized or reduced, it is imperative to explore analytically what influences stress in this group. This study was therefore very important because findings would help identify and address factors that influence stress among psychiatric nurses which could lead to the mental wellbeing and better health of the mental health nurses, their patients/clients and the society as a whole. When factors that influence stress in mental health nurses are identified and tackled psychiatric nurses would be able to execute their work well, thereby ensuring their own health and wellbeing and that of their patients. 10 University of Ghana http://ugspace.ug.edu.gh This research is of enormous benefit for the reason that it would serve to make available knowledge, evidence and assist in the direction and reserve of information for regulatory bodies, governmental and non-governmental organizations and other similar organizations in the prevention of stress in psychiatric nurses. Findings of the study could also help in framing proper health and safety policies and regulations at the various psychiatric hospitals in the country. 1.5 RESEARCH QUESTIONS Some questions formulated out of the main theme of this study are; 1. What factors influence stress among psychiatric nurses? 2. What association exist between workload and stress among psychiatric nurses? 2. What client-related difficulties influence stress among psychiatric nurses? 3. What work-related stress levels do psychiatric nurses face due to lack of resources? 4. What home-work conflict factors influence work-related stress among psychiatric nurses? 11 University of Ghana http://ugspace.ug.edu.gh STUDY OBJECTIVES General Objective The general objective of this study was; To identify factors that influence stress among psychiatric nurses at the Accra Psychiatric hospital. Specific Objective The Specific objectives of this study were; 1. To assess if workload influenced stress among mental health or psychiatric nurses. 2. To determine if client-related difficulties influenced stress among psychiatric nurses. 3. To examine if lack of resources, influenced stress in psychiatric nurses. 4. To determine if home-work conflict is a factor that influenced stress among psychiatric nurses. 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0. LITERATURE REVIEW Introduction This section presents literature reviewed for the study. The literature reviewed helped to explain stress and the issues that influenced Work related stress in psychiatric or mental health nurses. This included a general overview of stress, work-related stress, sources of stress. In addition to this there was a review of previous studies on stress among nurses and the factors that influenced work related stress in mental health nurses. 2.1. Stress A research on Stress by Brun (2008), provides scientific evidence based on risk factor prevention. He states that stress is a major problem in mental health workers and found out those factors influencing stress affects their level of job performance, success of their interactions with their patients, job satisfaction and their own health. Work related stress occurs because of growing burdens due to workload, monetary and administrative controls, and the demands of the nature of the nurse’s work. According to Butler (1993) in a study on stress he states that Psychological stress is the perception of pressure which presses, pushes, pulls and exerts pressure on people. A number of Persons can feel “crushed” through the want to create a life altering choice. People can have a sense of been “smashed” by an adversity, or “stretched” to the point of “splitting”. Each person or individual may describe stress in relation to the demands and burdens they experience from things occurring in their environment. Scholars talk of the presence of stress 13 University of Ghana http://ugspace.ug.edu.gh due to abysmal test results or a looming deadline for a key examination. Fathers and mothers talk of the difficulties of bringing up teenage boys and girls besides the economic burdens of keeping a family. Educators lament about the demands of keeping a professional Stability, working to hold onto the highest level of responsibilities associated with classroom teaching. Professionals like Doctors, nurses, lawyers, and therapists strive and work hard to meet the unending strains of patients and clients. In every stage of our lives and in every profession human beings go through stress in one way or the other. Stress is part of the human life, but constant, continuous stress can result in severe health complications if not controlled and minimized. 2.2 Work Related Stress Leka & Jain (2010), in a research on health influence on psychosocial hazards at work have stated that psychosocial hazards happen concurrently with work-related stress experience They found out that for most workers in Europe, more than a half of the people, felt they were influenced by occupational stress at the work place (EU-OSHA, 2002). The Fourth European Working Conditions survey revealed that, most workers from different other countries reported that their wellbeing is at risk due to occupational stress. In most of the Countries in the European Union (EU), the rate of stress was assessed from three to four percent (3% to 4%) gross national product, costing them billions of monies lost yearly (Levi, 2002). On countrywide bases, it was projected that work-related stress illnesses are accountable for the cost of many operational days annually in the United Kingdom, costing companies an estimated millions of money and humanity in its entirety billions of lost money that can never be retrieved. In the 1990,s in Sweden, fourteen percent (14%) of employees on continuing 14 University of Ghana http://ugspace.ug.edu.gh sick absence stated the purpose for this to be stress and psychological strain with a related average budget of sick absence from work of billions of money. In a recent report it was found out that in France occupational stress-related diseases cost the people millions (Brun, 2008). In addition, longitudinal researches and methodical assessments has shown that stress at the work place is linked to cardiovascular diseases, downheartedness, and musculoskeletal conditions (MSDs) and reliable indications show that extraordinary career loads, little regulation, and work remuneration imbalance are threat issues for psychological and somatic wellbeing complications, resulting in additional pressure on public expenditure for bigger budgets on healthcare. (Kortum, Leka, & Cox, 2010). 2.3 Sources of work related stress A study conducted by Tyler & Cushway (1992) states that there are several forms of stressors experienced by people. Several are biological (toxins, heat, cold), while others are psychological (threats to self-esteem), and for others sociological (Children, family, friends, love relationships, unemployment, and death of loved ones), and still others philosophical (time schedule, a person’s mission to be alive on earth). Irrespective of the stressor, often times signs of the body’s response is the same. Stressors often shared in our lives involve the adjustment to change or the encounter with every day pressures, demands and hassles. Dewe, Driscoll, & Cooper (2012) established that additional burdens and irritations a person experiences in his or her life, leads to greater chances that he or she would develop physical or psychological illness. Cooper viewed more hassles as equivalent to more stress and consequently, more illness and disease. 15 University of Ghana http://ugspace.ug.edu.gh In their studies Lazarus & Cohen(2001), found out that everyday troubles a person experience are a threat to his or her health. Lazarus considers these day-to-day occurrences as detrimental to health due to the fact they happen quiet frequently. 2.4 Stress Reactions Cooper (2012) states that Hans Seyle in his previous work, the principal work issued in his standard manuscript “The Stress of Life” summarizes stress reactions as a three-phase procedure labelled the common adaptation syndrome. The principal Stage is the Alarm Reaction. The body displays the variations typical of the main exposure to a stressor, and if the stressor is adequately robust (severe burns, extremes of temperature), may result in death. The subsequent Stage is the Stage of Resistance. Resistance arises if persistent contact with the stressor is attuned with adaptation. The bodily signs distinctive of the alarm reaction stage have essentially gone extinct and opposition increases beyond average. The last stage is the Stage of Fatigue. This follows a long-continued contact with the stressor, after that the body becomes in tuned, in the end adaptation dynamism is drained. The symptoms of the alarm response recur, but now they are permanent and the individual dies (Rosch, 2015). In a research by Hassard et al (2017) it was found out that Stress responses may possibly end if individuals are bared to risk influences at the work place or in the working environment. Stress responses can consist of psychosocial and/or physical dangers, and may perhaps be demonstrative, mental, behavioural and physical in natural surroundings. Individual physical features such as character, beliefs, objectives, age, sex, level of education and personal circumstances can impact one’s capacity to handle the stress response. These features can one way or the other aggravate or improve the special effects of threat influences at the work place and, in the end, the experience of stress (Murphy, 2002). 16 University of Ghana http://ugspace.ug.edu.gh The health effect of psychosocial dangers and work-related stress spread out past a single individual health, and can also lead to the efficiency and elasticity of the society. Numerous effects connected to stress and a deprived psychosocial working surroundings disturbs and reduces output that is work fulfillment, determination, Routine, revenue or income, presence, absenteeism, attendance and work obligation (Rabin, Feldman, & Kaplan, 1999). 2.5 Factors influencing work- related Stress in Mental Health professionals Cushway & Tyler(1996), conducted a study of clinical psychologists and revealed that issues linked with the healing procedure, such as the pain and sufferings of patients and insecurity, were stressors. To add to his, the causes of the stress found in other health professionals or individuals, for example workload and administrative factors, were also recognized. Psychiatrists seem to have the greatest suicide proportions in the midst of or compared to their other colleague doctors (and an enormous measure of research conducted on psychiatrists in internships established the fact that there were reported cases of the highest number of mental health illnesses in addition to not finishing their internships. An early study by Cushway ( 1992), which invented the slogan ‘beginning psychiatry syndrome’ which stands to mean or states that whatever was observed as temporal neurotic warning signs and psychosomatic disorders in psychiatrist, were worrying but obligatory or needed foundational capabilities in the growth of the psychiatrists. Cushway (1992), also established that high degree of fifty nine percent (59%) of stress was found in her study of clinical psychology students, which was substantially greater than that for other reported groups. According to Maslach et al(1997) in a study on stress they detected that two main possible causes of stress for the psychiatric nurses are client interactions and organizational and 17 University of Ghana http://ugspace.ug.edu.gh managerial influences, using open-ended questions, they asked psychiatric nurses to reveal the main causes of stress at the work place or environment and a key stressful episode in the previous days. They found ‘inadequate funds, inadequate resources and inadequate or staff shortage’ to be the major cause of stress but, once queried to remember the major stressful instance in the previous days, the biggest proportion mentioned a fierce or disturbing incident with mental health clients or patients. A research by Philip, Driscoll, & Cooper(2012) found out that, even though several of the difficulties of psychiatric nursing appeared to be shared in general nursing and basic to nurses in general (e.g. workload due to shortage of staffs ), they encountered additional stress because of the violent nature of their clients or client-related problems and the special effects could be worsened by the kind of work they do, that is, the treatment and ensuring of the wellbeing of the mentally ill. (Sibbald et al., 2000). According to Edwards & Harrison(1993) in a study they identified five stress influences related to the healing responsibilities of psychotherapists in the administration of their duties or work at the private and public sectors : keeping with the healing bond, scheduling, expert uncertainty, work over involvement and individual exhaustion. Cushway & Tyler (1994), found out in their studies of clinical psychologists, that causes linked to the healing responsibilities, such as a patients pain and sufferings and lack of self- confidences, were stressors. To add to this, the factors that influenced stress identified in other professional individuals, for instance amount of work and structural problems, were also recognized. A study conducted in Ghana by Assibi, Atindanbila, Prudence, & Abepuoring (2013) on the causes of stress and job satisfaction among nurses at the Ridge and Pantang hospitals in Accra Ghana, revealed that all the factors that influenced or caused stress (bereavement and 18 University of Ghana http://ugspace.ug.edu.gh the loss of a loved one, clash or fights with physicians, scarce sensitive training, problems with peers, and problems with superiors, the amount of workload, indecision regarding treatment, client and household and the level of judgment) were the same in both Hospitals. However, workload was found to be higher at Ridge Hospital compared to Pantang hospital. In a study by Healy & McKay (1999) , observed causes of stress and contentment was studied at the work place in the midst of one hundred and twenty one (121) mental health workers, and they recognized five factors that were gotten or developed from causes of work related stress matters (i.e., responsibilities, meagre sustenance, patients, impending duties, and workload), workload accounted for seventy percent (70%) of the total influences or causes. Stress from “workload” was connected with sensitive fatigue.(Nielsen, Randall, Holten, & Gonzalez, 2010). The nursing profession is characterized by a variety of stressful situations which makes nursing a very stressful occupation (Healy & McKay,1999) . According to Gibb, Cameron, Hamilton, Murphy, & Naji (2010) job related stress is associated with day-to-day workplace activities of nurses. The prevalence rate of stress among the nurses in this current study stands at 99% with different percentages at various levels. This is suggestive of the stressful nature of the nursing profession among the respondents. A study by Luszczynska et al (2009) found out that when people face difficulty dealing with difficult and challenging situations, stress develops. It implies that difficult and challenging situations permeate the nursing profession which is a threat to the physical, emotional, and cognitive wellbeing of the nurses. Continuous high prevalence of stress among the study sample also makes them susceptible to burnout. This places the nurses at risk of reduction in their overall performance at work. The findings from this study revealed that forty five percent and thirty percent (45% and 30%) of the nurses had extremely severe stress. It shows 19 University of Ghana http://ugspace.ug.edu.gh that majority of the nurses seventy five (75%) recorded high levels of stress thus providing a strong indication of the dangerously stressful nature of the nursing profession. If the severity of the stress level of the nurses persists, the physical and psychological strains that may arise are likely to have adverse behavioural consequences on the nurses (Tyler & Cushway, 1995). According to a study by White(2009), nurses suffering from greater levels of stress are more likely to experience reduced wellbeing. This implies that nurses are vulnerable to stress related physical and psychological conditions because of the demanding nature of their occupation. Gibb et al(2010) stated that individuals in health occupations have higher levels of work related stress compared with all other occupations. Everybody in one way or the other has the ability to adjust to stress, nonetheless, reactions to stress among people are never the same. Houdmont (2012) states that Persons with high level of stress are prone to many types of somatic diseases. These include hypertension, various forms of heart diseases, peptic ulcer in addition to body discomfort such as headache and bodily pains. In addition to these mental complications, psychological conditions like depression and sleep problems are also associated with increased levels of stress (Eberhart & Hammen, 2010). This highlights the vulnerability of nurses to these stress related conditions. In a study conducted by Rabin et al(1999) , it was discovered that Twenty percent (20%) of nurses had moderate stress and four percent 4% had mild stress. This is likely to rise to higher stress levels if the work situation remains unchanged. Nurses perform a key part in the delivery of adequate, timely and quality health care services, however, the stress experienced at work affects their output, which is a matter of growing concern. The danger of stress in the nursing profession calls for multilateral concerted efforts to address the situation in order to save the lives of the life savers. Attempts should be made to provide resources to help nurses cope with stress associated with their work. 20 University of Ghana http://ugspace.ug.edu.gh Edwards, Burnard, Coyle, Fothergill, & Hannigan(2001) in a study which used semi- structured interviews to survey stress and management in a sample of twenty two (22) female team listed psychiatric nurses working in the four important parts of three individually owned hospitals. They established that complications with clients accounted for thirteen percent (13%) of the generally stressors that psychiatric nurses come across. Specifically, patients’ chronicity and habit were recognized as causes of stress. Dawkins et al. developed the Psychiatric Nurses Occupational Stress Scale (PNOSS) to ascertain causes of stress explicitly in psychiatric nurses. In an interview on telephone forty three (43) psychiatric nurses were surveyed. They were systematically selected from the staff of a huge psychiatric hospital. The findings of the study were that destructive patient characteristics accounted for nine percent (9%) of stressors and bodily harm from clients were also precisely stressful for nurses. A study by Braaten(2000) tested work-related stress and breakdown in seventy eight (78) psychiatric nurses employed in eight critical admissions wards, the results of the findings of the study revealed that ferocious occurrences, possible suicide and surveillance are the most common stressors in relation to patient upkeep. He also found out that the greatness of such stressful experiences was influenced by two factors: scarcity of workforce resources to withstand reasons at a harmless level, and psychiatric nurses’ opinion of the absence of sympathetic and provision from hospital supervision. The outcome of this study proposed that the type of patient services that psychiatric nurses render may be a key source of stress. A study conducted by Acquaye( 2007) on causes of stress among nurses evaluated the sources of stress among nurses in the Greater Accra Region of Ghana. The research method employed for the study was a descriptive investigation into the issue, and questionnaires were distributed to respondents to ask for respondents’ view with respect to the issue under study. The findings revealed that the most principal effect of stress was the long hours spent or used by nurses in carrying out their duties. 21 University of Ghana http://ugspace.ug.edu.gh Shirom et al(2008) used a self-report instrument to measure stress in nurses’ working in a special psychiatric hospital. They theorized that the consequences of psychological sufferings, anxiety and depression as the consequence of the association between job strains, provision, and controls. Their study discovered three major kinds of job demands: organizational demands (such as “involvement in seminar meetings” and “report patients’ development to medical staff”), patient administration (“continually observe patients” and contrary burdens (such as being required to “undertake work I consider unnecessary” and “work with patients I am afraid of”). Patient regulatory loads were high compared with organizational and contrary loads. Cushway & Tyler (1996), conducted Studies on mental health professionals and have revealed that studies based on this group have been comparatively few. Mental health professionals’ inputs and efforts have conventionally been viewed as an undesirable and unimportant work. Nonetheless there is an increasing buildup of evidence to propose that psychiatric nurses could have specific susceptibilities and stresses. Studies have revealed that Psychiatrists seem to manifest or show the utmost level of suicide proportions compared to their colleague other doctors and a great measure of studies of mental health specialist in internships has established the fact that a great degree of mental health difficulties are faced by psychiatrist, who are unable to finish their internship but drop out of school.. (Cushway & Tyler, 1996). Studies of a range of psychiatric nurses indicated that these nurses encounter to a certain degree diverse stressors which are not unique from the stressors their coworkers face. Psychiatric nurses face additional problems apart from being faced with stressors distinctive in general nursing. Several researches conducted in the UK and the USA and the world over have indicated that the biggest causes of stress in psychiatric nurses are the interactions between them and their clients or patients who are violent and difficult to handle due to their 22 University of Ghana http://ugspace.ug.edu.gh illness, workload, organizational and structural factors, such as ‘inadequate funds and inadequate staff’, ‘difficult nature of their work, which has to do with the upkeep and wellbeing of people with mental disabilities and homework conflict (Sibbald, Enzer, Cooper, Rout, & Sutherland, 2000). 2.6 Psychiatric nursing and stress Generally researches carried out the world over has revealed high levels of stress among psychiatric nurses which indicates the fact that the psychiatric nursing profession is a stressful profession and that they are stressed to the nature of their work. A study conducted by Gibb et.al (2010) revealed a higher level of work- related stress among psychiatric nurses in Scotland at a (90%) stress rate. Dorcoo (2016) who conducted a research in Ghana found a high level of stress among psychiatric nurses at a (99%) stress rate. (Zaghloul (2008) in his study found out that the psychiatric nursing profession is particularly susceptible to stress and burnout as psychiatric nurses encounter a lot of difficulties in the course of their work. According to Shields and Wilkins (2006) job related stress is associated with the day-to-day workplace activities of nurses. Travers & Cozens (2007), found out that in the nursing profession, a fierce or troublesome incident with patients, inadequate resources and the shortage of staff’ were the major sources of stress in mental health nurses. A study by Sutherland & Cooper (1990), found out that even though a lot of the complications of psychiatric nursing seemed to be a shared problem in nursing in general (e.g. Work overload due to inadequate staff), the consequences may be heightened by the 23 University of Ghana http://ugspace.ug.edu.gh duties they carry out and the services they render to patients as responsibility of mental health nurses, in the care of the mentally ill and demanding patients or clients. Videbeck (2007) in a study found out that when people face difficulty dealing with difficult and challenging situations, stress develops. This indicates that demanding, difficult and challenging environments and situations characterize the mental health nursing profession. This poses a threat to the physical, emotional, and cognitive wellbeing of the nurses. Prolonged and high incidence of stress among them makes them susceptible to more serious and incurable diseases (Zaghloul, 2008). A study by Hassard and Cox (2013) revealed that Stress responses could be a consequence of people been exposed to hazard influences at the workplace. This can consist of psychosocial and/or physical hazards, and may be sensitive, intellectual, behavioural and/or physiological in nature. These may take into account mental reactions: such as, reduced attention and perception, forgetfulness; emotional responses: such as, feeling nervous or irritated; behavioural reactions: such as, aggressive, impulsive behaviour or making mistakes; physiological responses: such as, increase in heart rate, blood pressure and hyperventilation. According to Shields and Wilkins (2006) in a study they conducted, nurses suffering from greater levels of stress are further likely to experience reduced wellbeing. The health effect of psychosocial threats and work-related stress spreads further than individual health, and can also disturb the efficiency and resiliency of an individual. Lambert and Lambert (2008), in their studies found out that nurses in carrying out the duties of their profession, are faced with a variety of stressors like organizational structures, workload, homework conflict, lack of resources etc. 24 University of Ghana http://ugspace.ug.edu.gh A study conducted by Spielberger et al (2003), revealed sources of stress that are encountered in the work environment and stated that factors such as organizational structures, workload, lack of resources and homework conflict influenced stress in workers. The findings of Chaufeli and LeBlanc (2014), who investigated the influence of workload on exhaustion and work outcome among nurses, revealed that workload influenced stress in nurses. Karasek &Theorell, postulated that, extreme job hassles or pressures both physical and psychosocial can have an effect on stress altitudes (especially psychological strain). In a study conducted by Kortum (2012), it was found out that in mental health care services stress is at an all-time high level among psychiatric nurses due to the great strains of workload. Study findings of Lundstrom. (2002), Feldman & Kaplan (2009), identified homework conflict as a factor that influenced stress in nurses. Studies conducted by Borritz (2005), Braaten (2000), and Ballenger & Schmitz (2018) all indicated the fact that lack of resources influenced stress in nurses. Rothmann et al (2006), in their cross-sectional survey in South Africa found out that health risks associated with physical contact with patients, lack of recognition for good work done, and shortage of staff were the main factors contributing to stress among nurses at the workplace. Jack et al (2018) conducted a study on the challenges of psychiatric nursing specialty: education and practice in Nigeria and found out that the current mental health care system in Nigeria continues to struggle with providing adequate care and services to all that require it due to limited resources, stigma of persons and families living with mental illness, biases 25 University of Ghana http://ugspace.ug.edu.gh from other professional team members and the complexities of treatment of many of those individuals that suffer from mental illness. Mental health nurses, also referred to as psychiatric nurses, are impacted by these same biases, limited resources, and complexities in their role. A study by Fournier (2011) on the status of mental Health care in Ghana, West Africa and the signs of progress in the Greater Accra Region, has revealed that there are very few psychiatric hospitals in the country which is centered in the south with the other parts of the country lacking mental health care. The study also revealed that there is overcrowding and pressure on the three major psychiatric hospitals with the very few psychiatric nurses overburdened with workload. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY Introduction This chapter represents methods carried out for conducting the study. This includes the study design, study area, study variables and study population. This section also describes how the sample size was determined, the sampling technique, data collection tool and process, analysis of data and ethical issues. 3.1 Study Design A quantitative Analytical cross sectional design was employed for the study. This method was chosen as the most suitable design because respondent’s outlooks and thoughts were sought on their real experience on factors that influenced work- related stress. 3.2 Study Area The Accra Psychiatric Hospital was the area chosen to conduct this study. Accra psychiatric hospital is located at Adabraka a suburb in Accra. The Hospital is operational for the care, management, cure, welfare, training and recovery of the mentally ill. The hospital has the ability to house six hundred 600 clients at regular bases. The Accra Psychiatric hospital strives to make available the top practice in psychiatric care to mental patients by means of a committed work force of health experts in a patient-friendly surroundings and to nurture corporation with other stakeholders in providing excellent health service. Conversely, this is 27 University of Ghana http://ugspace.ug.edu.gh not the situation as the hospital continues to be packed with a swelling population and consequently a mounting call on the inadequate services. The hospital provides facilities such as OPD services, Clinical Psychology services, Electro Convulsive Therapy, 24hr Pharmacy, Social Work Services, Community Psychiatry Nursing, Rehab Alcoholicnous (Rehab for Alcohol Abuse), VIP wards, special school for the mentally challenged, public education, teaching & research, in- service training unit. 3.3 Study Population All psychiatric nurses at the Accra Psychiatric hospital were the target population for this study. There are about four hundred (400) mental health nurses at the Accra psychiatric hospital working in the various wards of the hospital. 3.3.1 Inclusion Criteria The standards for inclusion in the study was all mental health or psychiatric nurses, males and females alike within the ages of twenty (20) and fifty (50) years, with one (1) year to thirty years (30) working experience. 3.3.2 Exclusion criteria Ward assistants, general nurses, and all other workers in the Accra psychiatric hospital were excluded from the study. 28 University of Ghana http://ugspace.ug.edu.gh 3.4. Study Variables i. Dependent variable The dependent or outcome variable was: Work - related stress ii. Independent variables The independent variables were:  Socio-demographic characteristics of respondents; Age, Sex, Marital status, years of working experience.  Workload  Client related difficulties  Home - work conflict  Lack of resources 3.5 Sample Size A total sample size of 155 mental health nurses or psychiatric nurses was derived using the sample size calculation formula designed by Fisher et al. (1998) as detailed below. n = (Z2 p q)/d2, 𝒁𝟐 ∗ 𝑷(𝟏 − 𝒑) (𝒁𝟐 ∗ 𝒑𝒒) 𝐧 = = 𝒅𝟐 𝒅𝟐 𝟏. 𝟗𝟔𝟐 ∗ 𝟎. 𝟗𝟐 ∗ 𝟎. 𝟎𝟖) 𝐧 = 𝟎. 𝟎𝟓 Calculated sample size is 155 with 20% non-response rate added. 29 University of Ghana http://ugspace.ug.edu.gh Where n = sample size or minimum sample size required. Z = Standard normal deviation at required confidence level of 1.96 (at 95% alpha risk expressed in Z score). P = Estimated prevalence (0.92) by using estimated prevalence of stress in a study in Ghana by (Acuaye,2007) on job satisfaction, occupational stress and mental health among nurses in the Greater Accra Metropolis. d= desired precision of margin of error = Degree of accuracy= 0.05 (5%). q: 1-p. P = 0.92, therefore q=1-0.92=0.08 A twenty (20%) for non-response rate was considered and added to this sample size. The total number of psychiatric nurses sampled for the study was = 155 psychiatric nurse. 3.6 Sampling method and Data collection process Random sampling method was used to select 155 mental health nurses or psychiatric nurses for the study. Nurses are assigned to different wards at the Accra psychiatric hospital like the children’s, female, male, VIP wards etc. Names of all psychiatric nurses at the various wards were obtained and numbered. Random numbers were generated and those whose numbers come up were selected to take part in the study. Data was collected at the Accra Psychiatric hospital over a two week’s period. All the various wards of the hospital were visited and questionnaires were distributed to nurses whose names came up during the random sampling. Questionnaires were distributed to the morning, afternoon and evening shift nurses who made up the 155 psychiatric nurses. 30 University of Ghana http://ugspace.ug.edu.gh 3.7 Data Collection Tool In this research the Mental Health Professionals Stress scale a technique for detecting causes of stress for mental Health professionals was administered to psychiatric nurses at the Accra Psychiatric hospital. The factors or elements that make up the MHPSS was founded on the outcomes of earlier studies of mental health professionals and by identifying seven important factors that influenced stress in this group ( Cushway & Tyler,1996). The questionnaire was in two parts; the first part was about the socio-demographic characteristics of participants and asked for information about the respondents’ age, gender, marital status, and years of work experience. A particular question which followed after the background information requested respondents to rate to what level they felt a sense of being stressed as a result of their present job. In order to identify their self-reported stress levels, Participants were asked to rate ‘stress level’ on a five-point likert scale from 1 (‘not stressed at all’), 2(not stressed), 3 (neither), 4 (stressed) to 5 (‘very stressed’). The second part of the questionnaire was the Mental Health Professionals Stress Scale (MHPSS) a 42 item scale with seven (7) subscales. But for the purpose of this study it was reduced to a 24 item scale with four (4) subscales that identified ‘Sources of stress at work’ such as (i. Workload, ii. client related difficulties, iii. Lack of resources, and iv. Home-work conflict). Each of the items is answered on a five-point likert scale, scored from 1. Strongly disagree, 2. Disagree, 3. Neither, 4.Agree, 5. Strongly Agree. 3.8. Quality Control Quality control was worked on by carrying out a pre-test of the data collection tool at the Pantang Hospital in Accra to ensure consistency of the findings. 31 University of Ghana http://ugspace.ug.edu.gh Data collection was done for a period of one week by the researcher to make sure that the process was done effectively and questions were answered correctly by explaining things to participants and making amendments to difficult and confusing questions. Participants were duly informed about the study and asked to willingly participant in the study. Questionnaires filled were marked or given numbers to ensure that they were complete in order to reduce the number of missing data. Double entry of data was carried out and data cleaning done to minimize errors. 3.9. Pre-testing of research instruments The study tool or questionnaire was pre-tested at the Pantang hospital in Accra. The hospital was chosen because it has the same characteristics as that of the Accra psychiatric hospital because it is also a psychiatric hospital where mental health professionals, nurses are available and can easily be reached. A total of 10 psychiatric nurses answered the mental health professional stress scale (MHPSS) questionnaire. This pilot study was conducted to test the validity or the extent to which the test measured what it was intended to measure and reliability or the stability or the consistency of the questionnaire. This helped to eliminate unnecessary questions and rephrase ambiguous ones to ensure consistency of findings. 3.10 Data Analysis Raw scores of data collected were directly entered into and coded by the statistical product and service solutions (SPSS) version 23 software for data analysis. Descriptive analysis of demographic data was carried out. Frequencies, percentages, mean and standard deviation (SD), minimum, maximum and ranges were calculated. This was presented in the form of frequency distribution tables. 32 University of Ghana http://ugspace.ug.edu.gh The prevalence of Stress among mental health nurses was also analyzed descriptively, with frequencies and percentages. The fisherman’s exact Chi-square statistic was used to test association between stress levels of nurses and their demographic data using a P value of < 0.05 as the statistically significant value. It was also used to determine whether mental health nurses were stressed or not stressed due to factors such as workload, client related difficulties, home-work conflict and lack of resources and to test if there is an association and if it’s significant. The Pearson’s correlation test was run to test if there was a relationship between stress and workload, stress and client related difficulties, stress and lack of resources and stress and homework conflict. Finally, logistic linear regression analysis was run to determine the strength of the relationship or association between stress and workload, client related difficulties, lack of resources and homework conflict 3.11 Ethical issues Ethical clearance and permission was sought from the Ghana Health Service Ethical Review Board before the commencement of the study. Permission was also sought from the management of the Accra psychiatric hospital where the study was conducted before the study commenced. The study objectives and procedures as well as possible risk/ benefits associated with participating in the study were carefully explained in English to the psychiatric nurses before the study began. Possible hazards related with participating in the study was the emotional strain that having to answer sensitive questions and giving personal information about the way one feels can have 33 University of Ghana http://ugspace.ug.edu.gh on the individual. They were given the assurance that the study was not meant to harm, but to create awareness to better their condition of service. The profits linked with taking part in this study was that, the study served as an outlet for participants to express their bottled up emotions to the problems they face at the workplace which helped improve their mental wellbeing. The study also created the awareness that when the research was conducted it could help solve most of the problems they face at the workplace. Participants felt they were very important and needed for the success of the study. Participants were able to contribute their quota for the betterment of conditions of service at their work place and this gave them a very high sense of self-worth. To ensure confidentiality and privacy names of respondents were not provided, so information obtained could not be traced to any individual person. Participants had options not to answer questions they felt invaded their privacy. Participants took part in the study after written informed consent was obtained. Questionnaires were administered to those who agreed to participate and satisfied the inclusion criteria. They were informed that their participation was voluntary and they had the right to stop at any point in time in the study. Forms from each participant were kept under lock and the electronic data was locked with a password known to the principal investigator to prevent access to unauthorized people. 34 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS Introduction This chapter presents information on main results of the study and further provides appropriately brief analysis of this information. The results have been discussed with tables reflecting each objective of the study that is: influence of workload, client related difficulties, lack of resources, and homework conflict on stress. Additional discussions in this chapter include summary, conclusions, recommendations and limitations of the study. The results of the analysis are presented in the following order. First, the socio demographic profile of mental health professional (Table 1). Next, the prevalence of self-reported stress is sought (Table 2) is presented by gender. 4.1 Socio-demographic characteristics of respondents First the researcher sought to understand the socio demographic factors, of respondents in general. The main socio demographic information sought was the age, sex and marital status of participants. Other related information was the profession of the respondents and their years of experience. The socio-demographic information is useful to understand the respondents holistically and if need be later relate some of the socio demographic variables with the main variables being studied in addition to its use in controlling for other extraneous valuables. Sample consisted of one hundred and fifty five (155) psychiatric nurses. Majority 96(61.9%) of the respondents was females. The respondents were aged between the ages 22 - 41 and 35 University of Ghana http://ugspace.ug.edu.gh majorities (43.2%) were from the age group 25-29. Out of the 155 respondents 83(53.5%) were single, and 72(46.5%) of them were married. The mean values for each variable are listed as follows: stress (Mean = 3.8, SD=1.1), workload (Mean=20.9, SD=4.2), client related difficulties (Mean=19.9, SD = 3.2), homework conflict (Mean =15.9, SD = 4.12), lack of resources (Mean =36.2, SD = 2.8). This indicated the average, influential effect that these factors had on stress among nurses. Table 4.1. Socio-demographic characteristics, Gender, age, marital status of respondents. Sex Frequency Percent% Female 96 61.9 Male 59 38.1 Distribution according to Age 20-24 13 8.4 25-29 67 43.2 30-34 53 34.2 35-39 18 11.6 40-44 4 2.6 Profession Psychiatric nurse 155 100 Marital Status Single 83 53.5 Married 72 46.5 Years of work experience 1-3 6 4 4 1 . 3 4-6 59 38.0 7-9 20 12.9 10-11 12 7.8 Total 155 100.0 36 University of Ghana http://ugspace.ug.edu.gh Prevalence of Stress among Psychiatric Nurses The prevalence of Self-reported assessment of stress (SRS) as perceived by the mental health nurses was determined. A self-reported feeling of being stressed was sought from the respondents; the nurses were asked the extent to which they felt stressed in their current job as mental health professionals. Results as presented in Table 4.2 below showed a prevalence of self-reported stress of up to 75% among all mental health nurses sampled with 25% reporting not being stressed at all. Overall most mental health nurses at the Accra Psychiatric hospital reported that they were stressed due to their work at a prevalence rate of 75% meaning that there is a high prevalence rate of stress among nurses at the Hospital. Table 4. 2 Self-reported Stress among Psychiatric nurses Prevalence of Stress Frequency Percent (%) Stressed 48.4 75 Very stressed 26.4 41 Not stressed 25.2 39 Total 155 100.0 37 University of Ghana http://ugspace.ug.edu.gh Relationship between Socio Demographic characteristics of Professionals and Perceived Levels of Stress The researcher assessed association between stress levels and socio-demographic variables (age, sex, profession, marital status and years of work experience). Years of work experience were first classified into 4 categories (1-3, 4-6, 7-9, 10-12) was later re-categorized into two levels, (below 9 years and then 10 and above years) to determine if working for long time had some influence in the stress levels. The results are presented below. Table 4.3. Relationship between socio demographic characteristics and self-reported stress Self-reported Stress levels Not X2 P-Value Variables Stressed Stressed Total Sex of the Respondent Male 49 (42.2) 10 (25.6) 59 (38.1) 3.412 0.065 Female 67 (57.8) 29 (74.4) 96 (61.9) Marital Status Married 56 (48.3) 16 (41.0) 72 (46.5) 0.617 0.432 Single 60 (51.7) 23 (59.0) 83 (53.5) Age Category 20-40 80 (69.0) 27 (69.2) 107 (69. 0) 0.001 0.975 40> 36 (31.0) 12 (30.8) 48 (31.0) Years of experience and stress 1-3 50(78.1) 14(21.9) 64(100.0) 1.304 0.750 4-6 44(74.6) 15(25.4) 59(100.0) 7-9 14(70.0) 69(30.0) 20(100.0) 10-12 8(66.7) 4(33.3) 12(100.0) Total 116(74.8) 39 (25.2) 155(100.0) 38 University of Ghana http://ugspace.ug.edu.gh The table as presented represents the frequencies and percentages showing association between the years of experience and presence or absence of stress. Over all the stress level is 75% across mental health professionals in Accra. It was found out that as the number of years of experience increases stress levels among the mental health professionals reduces. The results indicate a bigger stress level among those with working experience of one to three (1- 3) years of working experience of up to 78.1% compared to those stressed in the other age groups (78% Vs 74% Vs 70% and then 66.7% among the 10-12 years age). More female were reported stressed compared to male and younger respondent (20-40) were stressed compared to older respondents above 40 years. The Chi-square statistics was used to test relationship between age, marital status, and sex, professional and finally years of experience characteristics of the respondents and level of stress among the mental health professionals, all these were treated like categorical variables. The Chi-square statistics shows that there is no statistically significant association between all the socio-demographic variables of; - age category, sex category or marital status of the mental health professionals and their level of stress For Sex (X2(N=155)= 3.41, p=0.065), marital status (X2 (N=155)= 0.62, p=0.432), Age (X2(N=155), p=0.975) and profession, (X2(N=155)= 0.847, p= 760). The Fishers exact test (Chi-square) statistics also shown no statistical significant association between years of experience and their level of stress, with a chi square result of (X2(N=155)= 1.304, p=0.750). Although from the table 4.2 it can be visibly seen that proportion of stress varied across the sex, marital status, age, profession or even years of experience, the result of the chi-square statistics show these difference observed were not significant at 0.05 level of significance. This indicates that the level of stress among mental health profession in this 39 University of Ghana http://ugspace.ug.edu.gh study was not determined by the age category, sex, marital status of the person and profession or even the years of experience at 0.05 level of significant among the mental health professionals in Accra. While applying the concept of the Odds, the researcher reanalyzed the years of experience by re-categorizing the age ranges into only 2 categories above 10 years and below 2 years of experience. A cross tabulation was carried out to study and understand the possible relationship between years of experience and stress. Table 4.4 Relationship between years of experience and stress. Years of experience (2 categories) Self-reported Health Status Total Stressed Not Stressed OR CI 0-9 years 108 (93.1) 35 (89.7) 143 (92.3) 0.668 (0.184-2.286) 10 years and above 8 (6.9%) 4 (10.3) 12 (7.7) Total 116 (100.0) 39 (100.0) 155 (100.0) Results show that having an experience of at least 10 years decreases the odd of being stressed up by about 34% compared with the group who have an experience of less than 9 years in their work (OR=0.668, CI= 0.184-2.286). Hence having more experience of more than 10 years is likely to decrease the level of stress generally compared to where there is no experience in the mental health job. Nonetheless the overall results showed that there generally was no significant relationship between stress and respondents years of working experience meaning that one’s years of influence didn’t influence stress in the psychiatric nurses. 40 University of Ghana http://ugspace.ug.edu.gh Objective 1. Assessment of Workload as a Factor That Influences Stress in the psychiatric nurses The first objective of this study was to assess if workload had 3.43an influence on stress among nurses at the Accra psychiatric hospital. A series of test and analysis was done to achieve this goal. First the mean and standard deviation of responses to questions pertaining to workload was calculated and the result in the table below showed that overall the psychiatric nurses at the hospital felt that there was generally workload with a mean and standard deviation of the responses with regards to workload(mean= 3.43,SD=1.14). After this a Pearson’s correlation test was run to ascertain correlation between stress and workload. The correlation result was (r=0.31, p=<0.001). This results indicated that there was a statistically strong correlation between stress and workload with a p value of less than 0.05(p=0.001 p 0.05) meaning that the relationship is weak .Furthermore a chi square statistics test was run and the results also indicated that there was no relationship between stress and lack of resources with the chi square results of (X2=14.989, p =0. 25), , indicating that there was no relationship between stress and lack of resources and that psychiatric nurses at the Accra Psychiatric hospital were not stressed due to lack of resources. Finally a logistic regression analysis was performed to determine if there was a linear relationship between stress and lack of resources and to determine the strength of the relationship, the result was that since there was a weak relationship between stress and lack of resources the analysis eliminated the equation on lack of resources from the logistic regression results, because there was no linear relationship between them .this indicated that psychiatric nurses had no lack of resources but had resources to work with and this didn’t contribute to stress in them. The results are presented below in the following tables. 48 University of Ghana http://ugspace.ug.edu.gh Stress and Lack of resources Lack of resources as a factor influencing stress among mental Health nurses was assessed. These factors included: Lack of adequate staffing, Lack of financial resources for training courses/workshops, Shortage of adequate equipment/supplies is stressful, Lack of adequate cover in potentially dangerous environment, Poor physical working conditions stresses me up, inadequate clerical/technical backup. The results showed that generally most psychiatric nurses disagreed with the notion that there was lack of resources with a mean and standard deviation result of (mean = 4.37, SD =1.80). A summary of the results are as follows. Table 4.9 Stress and Lack of resources LACK OF RESOURCES Min Max Mean SD a) Not having enough time with family 1 5 3.53 0.956 b) Inability to separate personal from professional role 1 5 2.47 1.065 c) Taking work home 1 5 2.22 0.948 d) Relationship with spouse/partner affects work 1 5 2.26 1.168 e) Work emphasizes feelings of emptiness and/or isolation 1 5 2.41 1.062 f) Inadequate time for friendships/social relationships 1 5 3.09 1.321 Lack of Resources (Total) 2.66 1.09 49 University of Ghana http://ugspace.ug.edu.gh Correlation between lack of resources and stress The Pearson correlation coefficient test was used to determine the relationship between stress and lack of resources and the result was (r = 0.139. p =0.085) indicating that there was no significant correlation between lack of resources and stress. The fishers chi square test also gave a result of (X2=14.989, p =0. 25). This result showed that there was no significant relationship between stress and lack of resources. Lack of resources was found not to influence stress in psychiatric nurses. Table 4.10. Correlation between lack of resources and stress Correlations Stress Lack of resources Stress Pearson Correlation 1 .139 Sig. (2-tailed) .085 N 155 155 Lack of resources Pearson Correlation .139 1 Sig. (2-tailed) .085 N 155 155 50 University of Ghana http://ugspace.ug.edu.gh Objective 4. To determine if home-work conflict is a factor that influenced stress among psychiatric nurses. The fourth objective of this study was to determine if homework conflict influenced stress among psychiatric nurses at the Accra psychiatric hospital. A series of test and analysis were run to achieve this goal. First of all the mean and standard deviation of responses to questions pertaining to homework conflict was calculated and the results as in the table below showed that overall the psychiatric nurses at the hospital reported that they generally didn’t experience homework conflict, which is the conflict between the demands of work and that of the home. That is their response disagreed with the notion that homework conflict was a factor that influenced stress among them, with a mean and standard deviation of the responses with regards to homework conflict as (mean =2.66, SD =1.09). A Pearson’s correlation test was run to determine the correlation between stress and homework conflict. The correlation result was ((r = 0.147, p = 0.069), indicating that there was statistically a weak correlation between stress and homework conflict with a p value greater than 0.05(p=0.07> p 0.05) meaning that the relationship is weak .Furthermore a chi square statistics test was run and the results also indicated that there was no relationship between stress and homework conflict with the chi square test results of (X2 =0.981, P=0.995), , indicating that there was no relationship between stress and homework conflict and that psychiatric nurses at the Accra Psychiatric hospital were not stressed due to homework conflict. Finally a logistic regression analysis was performed to determine if there was a linear relationship between stress and homework conflict and to determine the strength of the relationship, the result was that since there was a weak relationship between stress and homework conflict the analysis eliminated the equation on homework conflict from the logistic regression results, because there was no linear relationship between them .this 51 University of Ghana http://ugspace.ug.edu.gh indicated that psychiatric nurses had no homework conflict or that they didn’t experience any homework conflict. The results are presented below in the following tables. Homework conflict Homework conflict as a factor influencing stress among mental Health nurses was assessed. These factors included: Not having enough time with family, Inability to separate personal from professional role, Taking work home, Relationship with spouse/partner affects work, Work emphasizes feelings of emptiness and/or isolation, and Inadequate time for friendships/social relationships. The results showed that generally most clients disagreed with the notion that there was homework conflict with a mean and standard deviation of (Mean 2.66, SD 1.09). Meaning that psychiatric nurses reported that they didn’t experience homework conflict, so homework conflict was not a factor that influences stress in them. Table 4.11. Stress and Homework Conflict HOMEWORK CONFLICT Min Max Mean SD a) Not having enough time with family 1 5 3.53 0.956 b) Inability to separate personal from professional role 1 5 2.47 1.065 c) Taking work home 1 5 2.22 0.948 d) Relationship with spouse/partner affects work 1 5 2.26 1.168 e) Work emphasizes feelings of emptiness and/or isolation 1 5 2.41 1.062 f) Inadequate time for friendships/social relationships 1 5 3.09 1.321 Homework conflict Total 2.66 1.09 The result showed that generally most clients disagreed with the notion that there was homework conflict with mean and standard deviation of (mean =2.66, SD =1.09). 52 University of Ghana http://ugspace.ug.edu.gh Correlation between stress and Home-work- conflict. Analysis was run to determine the correlation between stress and homework conflict. The results of the Pearson correlation test was (r = 0.147, p = 0.069), indicating that there was no significant positive correlation between stress and homework conflict. That is homework conflict didn.t influence stress among the mental health nurses at the Accra psychiatric hospital. The fishers Exact chi square test was also run and the result was (X2=25.808, p=0.69), indicating that there is no significant relationship between homework conflict and stress, affirming that homework conflict didn’t influence stress. Table 4.12. Correlation between Home-work- conflict and stress Correlations Stress Homework conflict Stress Pearson Correlation 1 Sig. (2-tailed) N 155 Homework conflict Pearson Correlation .147 1 Sig. (2-tailed) .069 N 155 155 53 University of Ghana http://ugspace.ug.edu.gh Logistic regression analysis showing the relationship between stress and workload. A logistic regression analysis was run to obtain the best model fit to explain variability in the dependent variables occurring as a result of predictor variables. More than one explanatory variable that is workload, client related difficulty, homework conflict and lack of resources, were put into the model to see their level of contributions towards the dependent variable work stress. The result of the binary logistic regression model for the mental health professional study is presented in Table 4.9 below. The dependent variable ‘Stress’ as a Binary variable was assigned value of ’1’ if the respondents reported stress and ‘0’ if no stress’. A value less than one imply that individuals in that category have a lower probability of reporting self as having stress than individuals in the reference category, the reference category has been entered in all cases except rare circumstances as 0. Composite scores from responses for the other variables derived from views on factors that contributed to stress. These composite scores were a cumulative effect of responses that follow responses to questions in a Likert scale for each factor sought. Before first step (block 0), the intercept-only model is fitted and individual score statistics for the potential variables are evaluated; Only 1 predictor was able to fit well by the model. The Hosmer-Lemeshow tests was carried out based on the null hypothesis that predictions made by the model fit perfectly with observed group memberships. A chi-square statistic was computed for the model fit comparing the observed frequencies with those expected under the linear model. The results for model 2 indicate a non- significance of (X2 =0.981, P=0.995). Hence model fits perfectly well. In the logistic regression the explanatory variables that is workload, client related difficulty, homework 54 University of Ghana http://ugspace.ug.edu.gh conflict and lack of resources, and the extent to which the model explained the variability in the dependent factor was assessed. The result was a beta component Exp (B) of 1.208., meaning mental health professionals with much workload are 1.2 times more likely to be stressed compared to those with no workload or that professionals with much workload have 1.2 times the risk of been stressed compared to those with no workload. Table 4.13. Logistic regression analysis showing the relationship between stress and workload. Variables in the Equation 95% C.I. for B S.E. Wald df Sig. Exp (B) E X P(B) Lower Upper Step 1a workload .189 .052 13.366 1 .000 1.208 1.092 1.337 composite Constant -2.736 1.033 7.016 1 .008 .065 a. Variable(s) entered on step 1: workload composite. 55 University of Ghana http://ugspace.ug.edu.gh Represents a model summery of the logistic regression analysis. For the final model that was fit, the Nagelkerke R2 was used as shown in table summary below; the value is 0.144, which indicates that 14.4% of the variability in the dependent variable stress was explained by the explanatory variables (workload). Only one factor was able to fit well. This explains how much workload influences stress. The result was R square (0.144) which means that workload is explained as having a 14.4% chance of causing stress in mental health nurses. Table 4.14. Model summary of the logistic regression analysis Model Summary Step -2 Log likelihood Cox & Snell R Nagelkerke R Square Square 1 159.010a .097 .144 a. Estimation terminated at iteration number 5 because parameter estimates changed by less than .001. 56 University of Ghana http://ugspace.ug.edu.gh A logistic regression analysis showing the variables not in the Equation. This table represents Variables not in the equation because they didn’t have a significant relationship with stress. Client related difficulty (p = 0.75), lack of resources (p = 0.65) and homework conflict (p = 0.06) were eliminated from the equation because the relationship was very weak. This means that client related difficulties, lack of resources and homework conflict were found not to be factors that influence stress in mental health nurses or psychiatric nurses. Table 4.15. Logistic regression analysis showing the variables not in the Equation. Variables not in the Equation Score Df Sig. Step 1 Variables Client related difficulties .101 1 .750 Lack_of_resources .207 1 .649 Homework_conflict 3.462 1 .063 Overall Statistics 3.473 3 .324 57 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION Introduction The findings of the study are presented in this chapter with related literature. This study sought to identify factors that influenced stress among psychiatric nurses and to determine if factors such as workload, client related difficulties, lack of resources and homework conflict influenced work-related stress among mental health nurses at the Accra Psychiatric hospital. 5.1 Prevalence of stress in psychiatric nurses Mental Health professional’s especially psychiatric nurses have been long equated with greater levels of work-related stress compared to their other colleagues working in the health sector in general (Hassard et al., 2017). The current study findings report work-related stress level among the psychiatric nurses at 75% among which 26.5% reported being very stressed. This finding showed a very high stress level generally. However some other studies by Gibb et.al (2010) and Dorcoo (2016) have revealed a higher level of work- related stress among psychiatric nurses in Scotland and Ghana at a (99%) stress rate respectively. Difficulties in dealing with challenging circumstances often are related to higher levels of stress. This is particularly so to professionals constantly handling and dealing with difficult, physical, emotional and psychological issues much as is found in the psychiatric profession. High levels of stress prevalence make the mental health profession in general and psychiatric nurse profession particularly susceptible to stress and burnout (Zaghloul, 2008). 58 University of Ghana http://ugspace.ug.edu.gh Work-related stress is one of the most important present-day challenges confronting professional health and wellbeing. According to Shields and Wilkins (2006) job related stress is associated with the day-to-day workplace activities of nurses. Mental health nurses are confronted with extra burdens in addition to being exposed to the stressors characteristic of the general nursing profession, this is consistent, with the findings of Travers & Cozens(2007), who found out that a fierce or troublesome incident with patients, inadequate resources and the shortage of staff ’ were the major source of stress in mental health nurses. This finding is also linked to Sutherland & Cooper (1990) who found out that even though a lot of the complications of psychiatric nursing seem to be a shared problem in nursing in general (e.g. Work overload due to inadequate staff), the consequences may be heightened by the duties they carry out and the services they render to patients as responsibility of mental health nurses, in the care of the mentally ill and demanding patients or clients. Work related stress among mental health nurses is presently the main worry in health strategy. Literature shows that stress represents several psycho-social circumstances which have a tendency to produce harm or affect a person’s behavior, including physical and mental illnesses in mental health nurses. Videbeck (2007) found out that when people face difficulty dealing with difficult and challenging situations, stress develops. This indicates that demanding, difficult and challenging environments and situations characterize the mental health nursing profession. This poses a threat to the physical, emotional, and cognitive wellbeing of the nurses. Prolonged and high incidence of stress among them makes them susceptible to more serious and incurable diseases (Zaghloul, 2008). 59 University of Ghana http://ugspace.ug.edu.gh Results from this current study revealed that 48.4% and 26.5% of the mental health nurses were stressed and very stressed respectively. Majority of the nurses (75%) reported that they were stressed. This provides a strong indication of the dangerously stressful nature of the mental health nursing profession. Hassard and Cox (2013) found out that Stress responses could be a consequence of people been exposed to hazard influences at the workplace. This can consist of psychosocial and/or physical hazards, and may be sensitive, intellectual, behavioural and/or physiological in nature. These may take into account mental reactions: such as, reduced attention and perception, forgetfulness; emotional responses: such as, feeling nervous or irritated; behavioural reactions: such as, aggressive, impulsive behaviour or making mistakes; physiological responses: such as, increase in heart rate, blood pressure and hyperventilation. If stress responses stay on for a very long passage of time, this can end in more harmful, everlasting, and less adjustable health results: like protracted fatigue, burnout, musculoskeletal problems or cardiovascular disease. Individual features such as character, standards, objectives, age, sex, level of knowledge and household conditions can impact one’s capacity to survive. These individualities can either surge or decrease the outcomes of hazard causes at work and, in turn, the consequence of stress. According to Shields and Wilkins (2006), nurses suffering from greater levels of stress are further likely to experience reduced wellbeing. The health effect of psychosocial threats and work-related stress spreads further than individual health, and can also disturb the efficiency and resiliency of an individual. There are lots of issues to address and special problems to tackle to help reduce stress in psychiatric nurses such as lack of resources, lack of funding and the very low funds allocated to the mental health sector, the very few staff workforce, and the lack of structures or 60 University of Ghana http://ugspace.ug.edu.gh psychiatric hospitals in the country. The government of Ghana must provide more funds to the ministry of health, and the ministry of health must brace itself to help solve these problems to help mitigate the very high levels of stress in mental health workers for their own wellbeing and that of their patients. 5.2 Socio-demographic characteristics and its association with stress among psychiatric nurses The study assessed association between stress levels and socio-demographic characteristics or variables such as (age, sex, marital status and years of work experience) of the respondents, and found out that there was no statistically significant association between the variables age category, sex category or marital status, years of experience of the psychiatric nurses and their level of stress. This indicated that the level of stress among mental health nurses was not determined by the age category in which they belonged, their sex or marital status. Linked to these findings, Filha et al (2013) found no statistically significant difference in the stress levels with regards to marital status and years of experience of nurses in Brazil. On the other hand Milutinović et al (2012) in their research on stress levels of nurses found significant differences in the stress levels with regards to its relationship to age, marital status, sex and education. The socio-demographic individualities of respondents in this study specified that most the respondents were females, this result is expected with regards to psychiatric nurses as the profession is predominately a female dominated profession, with its associated difficulty in combining work, married and family life which is not very easy as found out in a research by (Hassard, Teoh, Visockaite, Dewe, & Cox (2017) that the mental health profession is faced with diverse health hazards at the work place. Most of the mental health nurses were females 61 University of Ghana http://ugspace.ug.edu.gh making up (61.9%) of the respondents suggesting that females dominant the nursing profession. This is in accordance with the outcomes of a study carried out by Kada (2010) who found out that increase in the proportion of males in the nursing profession has not been significant, even though a considerable number of men are entering the nursing profession, an increasing number of males are moving away from the nursing profession, compared to their female counterparts, this has led to the gender imbalance in the nursing profession, Reeve, Shumaker, Yearwood, Crowell, & Riley (2013). This current study found out that there was no statistically significant correlation between the sex of the respondent and the level of stress experienced by the psychiatric nurses due to their work. Findings showed that there are predominantly young aged psychiatric nurses in the profession. Young mental health nurses due to their physical strength, abilities and capabilities, perform diverse, multiple and difficult tasks are the workplace and are often loaded with a lot of activities, which poses health hazards and puts a strain on them, leading to serious health problems like cardiovascular diseases, diabetes, hypertension, mental illnesses. This can be linked to Felomi (2017), who found that younger staffs below 35 years of age are predominated with work with high strain in Nigeria. 62 University of Ghana http://ugspace.ug.edu.gh 5.3. Influence of workload, client related difficulties, lack of resources and homework conflict. Work-related stress theories and literature has identified a number of factors as influencing stress at the workplace in the various professions of mankind the world over. For the purposes of this study workload, client related difficulties, lack of resources and homework conflict were selected as factors to be investigated to determine if it influenced stress in psychiatric nurses. The increasing demand for good physical shape or healthy working conditions, produces a hospital environment in which direct care provider wellbeing and wellbeing have become crucial, planned significances for hospitals. Research conducted well, under the right circumstances could assist to detect and order key influences on place of work ferocity and disrupting actions, and improved understanding of how uninterrupted care providers working conditions influence health, family, and work outcomes. The model of occupational stress suggest diverse ways, events or circumstances that lead to stress Manktelow (2005) and some others are as mentioned above. Lambert and Lambert (2008), in their studies found out that nurses in carrying out the duties of their profession, are faced with a variety of stressors. Organizational structures, workload, homework conflict etc., are key issues that influenced the level of stress among workers at the work place. This is in agreement with the research carried out by Spielberger et al (2003) about the sources of stress that are encountered in the work environment and stated that factors such as organizational structures, workload, lack of resources and homework conflict influenced stress in workers. 63 University of Ghana http://ugspace.ug.edu.gh The Pearson’s correlation coefficient test was run to determine the relationship between stress and the factors that influence stress like workload, client related difficulties, lack of resources and homework conflict. The results of the correlation test showed that there was a statistically significant positive correlation between stress and workload with a person’s correlation of (r = 0.31, P < 0.00), indicating that as workload increases there is a corresponding increase in the levels of stress experienced by mental health nurses which also means that much workload can increase the level of stress in mental health workers. However it was found out that there was no statistically significant relationship between stress and lack of resources, stress and client related difficulties and stress and homework conflict, this is contrary to most findings that lack of resources, homework conflict and client related difficulties influence stress at the workplace like studies conducted by Cooper (2012) Leka (2010), Lazarus (2012) and many others. 5.4. Relationship between Workload and stress Work overload is extraordinary levels of demand and of time pressure, which is continually subject to deadlines on an individual. Leka, Griffiths & Cox (2003).Workload in the nursing occupation is influenced by the levels of staffing and the situations of clients or patients, the design of the system of the nurses’ work. The type of nursing job or specialty determines the level of workload. To link components and their patient consequences in relation to nursing staffing, the nurse-patient ratio can be used. High workloads in the nursing profession, at all and unit levels have an undesirable influence on patient health outcome and wellbeing. Professional level workload is linked to various nursing outcomes, such as stress, health hazards, absenteeism and job dissatisfaction. Increased number of nurses at all levels and in a unit and or reducing the number of 64 University of Ghana http://ugspace.ug.edu.gh clients/patients assigned to each nurse can help mitigate the high stages of stress in the midst of psychiatric nurses. This present study found out that the major factor that influenced stress in mental health nurses at the Accra psychiatric hospital was workload with a mean and standard deviation of (Mean= 3.43, SD=1.14). Workload had a statistically strong positive correlation with stress among psychiatric nurses (r = 0.31, P < 0.01), this revealed that as workload increased, stress also increased in psychiatric nurses, meaning that there was generally workload at the Accra psychiatric hospital which has led to high levels of stress among the mental health nurses. Finally a logistic regression test of (Exp (B) of 1.208), means that mental health nurses with much workload are 1.2 times more likely to be stressed compared to those with no workload. This corresponds to the findings and theories that workload was a factor that influenced stress at the workplace. This finding is also consistent with the findings of Chaufeli and LeBlanc (2014), who investigated the influence of workload on exhaustion and work outcome among nurses, and found out that workload, influenced stress in nurses. Karasek &Theorell, postulated that, extreme job hassles or pressures both physical and psychosocial can have an effect on stress altitudes (especially psychological strain). Kortum (2012) found out that in mental health care services stress is at an all-time high level among psychiatric nurses due to the great strains of workload. 5.5. Relationship between Home-work interface and stress Home-work conflict is the Contradictory hassles of work and home, low support at home, double career challenges that individuals encounter. (Williams,2014). 65 University of Ghana http://ugspace.ug.edu.gh The theory of the applied Stress/Health Model is about caregivers of persons with mental or behavioural disabilities. Problems such as nonattendance to work, fatigue at work, and wasted prospects for career promotion are some of the challenges psychiatric nurses face. Negative hazards of home-work conflict include low output or job performance and life satisfaction, health implication like high blood pressure, cardiovascular diseases, physical and psychological strain, burnout, and serious sickness like diabetes and mental illnesses. Alliance (2014). In present, modern and contemporary times there has been growing worry of how contradictory hassles at work and at home affects an individual’s mental health Carson, Fagin, Oliver, & Kuipers. (2013). This present study found out that generally most mental health nurses disagreed with the notion that there was homework conflict, with a mean and standard deviation of (Mean 2.66, SD 1.09). Home-work conflict had a weak correlation with stress with a Pearson correlation coefficient of (r = 0.147, p = 0.069), and a fishers Exact chi square test of (X2=25.808, p=0.69), indicating that homework conflict was found not to influence stress in the mental health nurses at the Accra Psychiatric hospital. This is contrary to study findings of Lundstrom. (2002), Feldman & Kaplan (2009) who identified homework conflict as a factor that influenced stress in nurses. 66 University of Ghana http://ugspace.ug.edu.gh 5.6. Relationship between lack of resources and stress. Studies on work-related stress have identified lack of resources as a factor that influenced stress in workers. Studies conducted by Borritz (2005), Braaten (2000), and Ballenger & Schmitz (2018) all indicated the fact that lack of resources influenced stress in nurses. Lack of resources has to do with factors such as the lack of necessary adequate equipment/supplies, inadequate staffing, and lack of financial resources for training courses/workshops, poor physical working conditions, inadequate clerical/technical backup. When these things are not available for workers to carry out their duties effectively this can lead to work related stress. Work related stress theories, models and research findings indicate that lack of resources has influence on stress. This present study’s findings revealed that most psychiatric nurses disagreed with the notion that there was lack of resources with a mean and standard deviation result of (mean = 4.37, SD =1.80). There was a weak correlation between stress and lack of resources with a Pearson correlation coefficient of (r = 0.139. p =0.085). The fishers exact chi square test result was (X2 =14.989, p =0. 25). This indicated that lack of resources didn’t influence stress in mental health nurses at the Accra psychiatric hospital. This is contrary to most findings that indicate that lack of resources influenced stress like Murphy (2002), Paul (2015), Lazarus (2010) and many others. 5.7. Relationship between client-related difficulties and stress Client-related difficulties have to do with the difficult nature of psychiatric nurse’s profession in that they have to handle violent and difficult patients when carrying out their duty. Psychiatric nurses are sometimes beaten, insulted, and assaulted by their patients. This can be 67 University of Ghana http://ugspace.ug.edu.gh a source of stress to psychiatric nurses. Client related difficulty has to do with factors such as physically threatening clients/patients. Difficult and demanding patients,etc. The findings of this study revealed that most mental health nurses at the Accra psychiatric hospital disagreed with the notion that there was client-related difficulties with a mean and standard deviation of (mean = 3.32, SD =1.88). A Pearson correlation test result of (r = 0.158, p = 0.05) showed that there was a weak positive relationship between stress and client related difficulties. Fishers Exact chi square test result was (X2=17.652, p=0.277), indicating that Client related difficulties was found not to influence stress in mental health nurses at the Accra psychiatric hospital. This finding is Contrary to that of Rothmann et al (2006), in their cross-sectional survey in South Africa found out that health risks associated with physical contact with patients, lack of recognition for good work done, and shortage of staff were the main factors contributing to stress among nurses at the workplace. Workload was found in this current study as the main factor that influenced stress in psychiatric nurses at the Accra psychiatric hospital due to the shortage of nurses, overcrowding at the hospital with the few nurses available been over loaded with work and pressures that are above them. More psychiatric nurses must be trained by the government, stress management interventions must be introduced to individual psychiatric nurses to help them manage their levels of stress, the government of Ghana and the ministry of health must allocate more funds to the mental health sector and build more psychiatric hospitals in all the regions of the country. This will help minimize the high levels of stress among psychiatric nurses, ensure their wellbeing and the wellbeing of their patients or clients. 68 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.0 CONCLUSIONS, LIMITATIONS, AND RECOMMENDATIONS Introduction This chapter focuses on the, conclusions, limitations and recommendations of the study. 6.1 Conclusions Psychiatric nurses, in addition to being vulnerable to the stressors characteristic in general nursing, face further difficulties due to factors such as client related difficulties, workload, lack of resources, homework conflict, administrative structures and many other factors. The aim of the study was to assess the prevalence of stress among mental health nurses at the Accra psychiatric hospital, to find out if the socio-demographic characteristics of the respondents had an association with stress and finally to determine if factors such as workload, client related difficulties, lack of resources and homework conflict influenced stress among them. The findings of the present study revealed that majority of the mental health nurses were stressed at a prevalence rate of (75%) due to their work. There was no statistically significant relationship between stress and the socio-demographic characteristics of the respondents. This means that age, sex, marital status and years of working experience did not have any influence on stress in the psychiatric nurses. 69 University of Ghana http://ugspace.ug.edu.gh It was also found out that Workload was a key factor that caused stress in psychiatric nurses and that the increase in workload led to an increase in stress at the Accra Psychiatric hospital, which means the high rate of stress was due to workload. Client related difficulties, lack of resources and homework conflict were found not to influence stress in mental health workers at the Accra psychiatric hospital. The results of the Pearson’s correlation analysis showed that there was a statistically significant strong positive correlation between stress and workload. But there was a weak correlation between stress and client related difficulties, stress and lack of resources and stress and homework conflict, this means that these factors didn’t have any influence on stress in the psychiatric nurses. The results of the linear regression analysis of the study revealed that psychiatric nurses with much workload were 1.2 times more likely to be stressed compared to those with no workload. 70 University of Ghana http://ugspace.ug.edu.gh 6.2 Limitations of the study A cross-sectional study design was employed for this study and this might not effectively or efficiently be capable of disclosing the several variances in the variables under study compared to the case of a longitudinal study which takes time and is able to disclose differences that exist or variance in the variables. The tendency for psychiatric nurses not to express or reveal their true feelings, real life or lived experiences at their work place is very high due to fear of been identified if they give any negative information and this can affect the authenticity of the research findings. The findings of the research may not in actual fact be the real situation on the ground among mental health nurses or psychiatric nurses, as the study was conducted in a psychiatric hospital in the Greater Accra region in Ghana and does not represent all psychiatric nurses. 71 University of Ghana http://ugspace.ug.edu.gh 6.3 Recommendations Based on the findings of the study, the following recommendations were made; 1. The government of Ghana should increase the health budget. Ghana health service allocates a mere, debatable 0.5-3.4% of the health budget to mental health sector which is very unreasonable and must be increased. 2. Psychiatric specialty training and education should be made easy, affordable and attractive to motivate nursing students choose psychiatric nursing as a future career, which will help increase psychiatric nurses staff strength and reduce much workload on the few available. 3. Mental health personnel and non-governmental organizations must work to increase awareness of mental illness, delivery of service and mental health care must be improved and made cost effective. 4. The government of Ghana and the ministry of health must work to provide equal access to mental health treatment for all Ghanaians by making funds available for the construction of more psychiatric hospitals in the country. 5. Stress management interventions and counselling for all psychiatric nurses, Seminars, conferences, workshops and symposia should be organized regularly to expose psychiatric nurses to the factors that influence stress and to also improve the coping expertise for nurses to be able to manage stress. 6. More researches should be conducted in the area of mental health to help identify other stressors in the mental health profession which will go a long way to help mitigate the high levels of stress among this group. 72 University of Ghana http://ugspace.ug.edu.gh REFERENCE Abor, P. A., Abekah-Nkrumah, G., & Abor, J. (2008). An Examination of Hospital Governance in Ghana. In:Leadership in Health Services , 21(1), 47-60. Acquaye, A. (2007). Job satisfaction, occupational stress and mental health among nurses in the Greater Accra Metropolis, 1–102. Adams, I., Darko, D., & Accorsi, S. (2004,). Malaria – A Burden Explored. In: Bulletin of Health Information 1(1). Alem A, Jacobsson L, Hanlon C (2008) Community-based mental healthcare in Africa: mental health workers’ views. World Psychiatry 7: 54-57. Alliance, W. (2014). Developing a mentally healthy workplace : A review of the literature. Antoniou & C.L. Cooper (2000) Research companion to organizational health psychology Cheltenham, UK: Edward Elgar. Aspinwall, L. G., & Tedesch, R. G. (2010). The value of positive psychology for health psychology: Progress and pitfalls in examining the relation of positive phenomena to health. Annals of Behavioral Medicine, 39(1), 4-15. Arnold, J., Cooper, C. L. (1989). Work psychology- understanding human behaviour in the workplace. London: Prentice Hall. Arnold, J., Cooper, C. L., & Robertson, I. T. (1998). Work psychology- understanding human behaviour in the workplace (3rd ed.). London: Prentice Hall. Assibi Rita, A., Atindanbila, S., Prudence Portia, M.-N., & Abepuoring, P. (2013). the Causes of Stress and Job Satisfaction Among Nurses At Ridge and Pantang Hospitals in Ghana. International Journal of Asian Social Science, 3(3), 762–771. 73 University of Ghana http://ugspace.ug.edu.gh Ballenger-browning, K. K., & Schmitz, K. J. (2018). Predictors of Burnout Among Military Mental Health Providers, 176(March 2011), 253–260. Borritz, M., B??ltmann, U., Rugulies, R., Christensen, K. B., Villadsen, E., & Kristensen, T. S. (2005). Psychosocial Work Characteristics as Predictors for Burnout: Findings From 3-Year Follow Up of the PUMA Study. Journal of Occupational and Environmental Medicine, 47(10), 1015–1025. Bower, J. E., & Suzanne, C. S. (2004). Stress management, finding benefit, and immune function: positive mechanisms for intervention effects on physiology. Journal of psychosomatic research (2004): 56(1), 9-11. Bowman, R. E., Beck, K. D., & Luine, V. N. (2003). Chronic stress effects on memory: sex differences in performance and monoaminergic activity. Hormones and behavior, 43(1), 48-59. Braaten, D. (2000). Occupational stress in mental health counselors, (May). Bratt, M.M., Broome, M., Kelber, S. & Lostocco, L. (2000). Influence of stress and nursing leadership on job satisfaction of paediatric intensive care unit nurses. American Journal of Critical Care 9: 307 – 317. Bruckner TA, Scheffler RM, Shen Yoo J, Chisholm D, Morris J, et al, (2011) The mental health workforce gap in low- and middle-incomecountries: a needs-based approach. Bulletin of World Mental Health 89:184-194. Brun, J. (2008). Work-related stress: scientific evidence-base of risk factors, prevention and costs. Skinuto S Mreže, 1–10. Butler, G. (1993). Definitions of stress. Occasional Paper (Royal College of General Practitioners), (61), 1–5. Callaghan, P., Tak-Ying, S.A. & Wyatt, P.A. (2000). Factors related to stress and coping 74 University of Ghana http://ugspace.ug.edu.gh among Chinese nurses in Hong Kong. Journal for Advance Nursing. 31(6), 1518-1527. Calnan, K., & Kelloway, E. K. (2012). Workplace Violence. The Encyclopedia of Criminology and Criminal Justice. Canadian coalition for high blood pressure prevention and control, laboratory centre for disease control at Health Canada (2012). heart and Stroke Foundation of Canada." CMAJ: Canadian Medical Association Journal, 160(9), 546-550. C.E.P. (2011). Workplace stress in nursing workers from an emergency hospital: Job Stress Scale analysis. Rev. Latino-Am. Enfermagem, 19(5):1122-1131. Cahoon, S. L. (2003). Burnout among Canadian physicians. Lethbridge, Alta.. University of Lethbridge, Faculty of Management. Caplan, R. P. (1994). Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. BMJ: British Medical Journal, 309(6964), 1261-. Charnley, E. (1999). Occupational stress in the newly qualified staff nurse. Nursing Standard, 13(29), 33-36. Cohen, A., & Margolis, B. (1973). Initial psychological research related to the Occupational Safety and Health Act of 1970. American Psychologist , 28(7), 600. Cohen, L., Manion, L., & Morrison, K. (2007). Research methods in education (5th ed.). London and New York Collins, S., & Long, A. (2003). Too tired to care? The psychological effects of working with trauma. Journal of Psychiatric and Mental Health Nursing, 10, 17-27. Cordes, C., & Dougherty, T. (1993). A review and integration of research on job burnout. Academy of Management Review, Cited in O'Driscoll, M. P. and Cooper, C.L. (1996)., 18, 621-656. 75 University of Ghana http://ugspace.ug.edu.gh Cox, T. (2000). Chair’s address: European Academy of Occupational Health Psychology: Present and Future.Occupational health psychology: Europe (2000),1473-0200, Cushway, D. (1992). Stress in clinical psychology trainees. British Journal of Clinical Psychology, 31(2), 169–179. Cushway, D., & Tyler, P.A (1996). Stress in clinical psychologists. The International Journal of Social Psychiatry, 42(2), 141–149. Cushway, D., & Tyler, P. A. (1996). Development of a stress scale for mental health professionals, 279–295. Dapaah, A.K. (2014). Causes of stress among nurses in the Greater Accra Region. International Journal of Research In Social Sciences. 3 (8), 74-81 Delaney KR, Shattell MM (2012) Registered nurse workforce trends for new entrants age 23- 26: Hope for the psychiatric nursing workforce shortage. Issues in Mental Health Nursing 33: 340-341. De Lange, A. H., Taris, T. W., Jansen, P., Kompier, M. A., Houtman, L. I., & Bongers, P. M. (2003). The very best of the millennium”: Longitudinal research and the Demand- Control-(Support) Model. Journal of Occupational Health Psychology, 8, 282–305. De Lange, A. H., Taris, T. W., Jansen, P., Kompier, M. A., Houtman, L. I., & Bongers, P. M. (2010). On therelationships among work characteristics and learning‐related behavior: Does age matter? Journal of Organizational Behavior, 31(7), 925-950 Dempsey A, Ribak J (2012) The future of the psychiatric mental health clinical nurse specialist. Nursing Clinics 47: 295-304. Dewe, P. J., Driscoll, M. P. O., & Cooper, C. L. (2012). Handbook of Occupational Health and Wellness, 23–39. Dewe, P. J., Driscoll, M. P. O., & Cooper, C. L. (2012). Theories of Psychological Stress at Work. In Handbook of Occupational Health and Wellness, Handbook in Health, Work, 76 University of Ghana http://ugspace.ug.edu.gh and Disability (pp. 23–39). Dewe, P. J., O’ Driscoll, M. P., & Cooper, C. L. (2012). Theories of Psychological Stress at Work. In Handbook of Occupational Helth and Wellness, Handbook in Health, Work, and Disability (pp. 23–39). Dixon, J. (2000). Social Determinants of Health by Michael Marmot and Richard Wilkinson - Book Review. Health Promotion International, 15(1), 87–92. Donahue, D. (2010). Stress and medical malpractice: Organizational risk assessment and intervention. Journal of Applied Psychology, 13, 235-246. Dunkley, J., & Whelan, T. (2006). Vicarious traumatization: Current status and future directions. British Journal of Guidance & Counselling, 34(1), 107-116. Dupré, K. E., Barling, J., & Dawe, K.-A. (2014). Harm to those who serve: Effects of direct and vicarious customer-initiated workplace aggression. Journal of interpersonal violence: Eberhart, N. K., & Hammen, C. L. (2010). Interpersonal Style, Stress, and Depression: An Examination of Transactional and Diathesis-Stress Models. Journal of Social and Clinical Psychology, 29(1), 1–15. Edwards, J. R., & Harrison, R. V. (1993). Job demands and worker health: Three- dimensional reexamination of the relationship between person-environment fit and strain. Journal of Applied Psychology, 78, 628–648. Edwards, D., Burnard, P., Coyle, D., Fothergill, a, & Hannigan, B. (2001). A stepwise multivariate analysis of factors that contribute to stress for mental health nurses working in the community. Journal of Advanced Nursing, 36(6), 805–813. Everly, G. S. (1986). An introduction to occupational health psychology. In P. A. Keller & L. G. Ritt (Eds.), Innovations in clinical practice: A source book, Vol. 5 (pp. 331–338). Sarasota, FL: Professional Resource Exchange 77 University of Ghana http://ugspace.ug.edu.gh Fairbrother, K., & Warn, J. (2003). Workplace dimensions, stress and job satisfaction. Journal of managerial psychology , 18(1), 8-21. Farber, B. A. (2014). Tailoring treatment strategies for different types of burnout, . In 106th Annual Convention of the American Psychological Association, August 14–18. ED 424 517. San Francisco California: AmericanPsychological Association Filha, M.M.T., Costa, M.A. & Guilam, M.C.R. (2013). Occupational stress and self-rated health among nurses. Rev. Latino-Am. Enfermagem, 21(2):475-83. Folami, F. F. (2017). Gender Inequality and Role-strained among Male Nursing Students in Selected Nursing Institution , Lagos , Nigeria, 5(6), 214–219. Fortinash, K.M. & Holoday-Worret, P.A. (2004). psychiatric mental health nursing (3rd edition). St. Louis: Mosby press. French, S.E., Lenton, R., Walters, V. & Eyles, J. (2000). An empirical evaluation of an expanded nursing stress scale. Journal of Advanced Nursing 32: 473 – 480. Gibb, J., Cameron, I. M., Hamilton, R., Murphy, E., & Naji, S. (2010). Mental health nurses’ and allied health professionals’ perceptions of the role of the Occupational Health Service in the management of work-related stress: How do they self-care? Journal of Psychiatric and Mental Health Nursing, 17(9), 838–845. Gureje O, Lasebikan VO, Kola L, Makanjuola VA (2006) Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of MentalHealth and Well-Being. British Journal of Psychiatry 188: 465-471. Hammen, C. (2005). Stress and depression. Annu. Rev. Clin. Psychol.,1:293–319. Happell B (2009) Influencing undergraduate students’ attitudes toward mental health nursing: acknowledging the role of theory. Issues in Mental Health Nursing 30: 39-46. Harvey, A.G., Jones, C. & Schmidt, D.A. (2003). Sleep and posttraumatic stress disorder: a review. Clin. Psychol. Rev., 23:377–407. 78 University of Ghana http://ugspace.ug.edu.gh Hassard, J., Teoh, K. R. H., Visockaite, G., Dewe, P., & Cox, T. (2017). The Cost of Work- Related Stress to Society: A Systematic Review. Journal of Occupational Health Psychology. Healy, C., & McKay, M. (1999a). Identifying sources of stress and job satisfaction in the nursing environment. Australian Journal of Advanced Nursing, 17(2), 30–35 6p. Healy, C., & McKay, M. (1999b). Identifying sources of stress and job satisfaction in the nursing environment. The Australian Journal of Advanced Nursing : A Quarterly Publication of the Royal Australian Nursing Federation, 17(2), 30–35. Heerwagen, J. & Diamond, R.C. (1992). Adaptation and coping: Occupant response to discomfort in energy efficient buildings. Proceedings of ACEEE, Summer study on energy efficiency in buildings, Berkeley, CA: ACEEE. 10: pp. 83-90. Health and job stress amongst GPs participating, or not, in a rural out-of -hour cooperative. Family Practise, 22, 275-279. Herbert, J. F. (1980). Burn-Out: The High Cost of High Achievement. Anchor Press. Heyman I (2012) Challenging misconceptions about mental healthnursing. Nursing Times 108:16-17. Hoekstra HJ, van Meijel BB, van der Hooft-Leemans TG (2010) Anursing career in mental health care: Choices and motives of nursingstudents. Nurse Education Today 30: 4-8. Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11,213–218. Hope, A., Kelleher, C.C. & O’connor, M. (1998). Lifestyle practices and the health promoting environment of hospital nurses. Journal of Advanced Nursing. 28; 438-447. Houdmont, J. (2012). Coping with Work Stress. P. Dewe, M. O’Driscoll and C. Cooper, 2010. Published by Wiley Blackwell, Chichester. ISBN:. Stress & Health: Journal of the 79 University of Ghana http://ugspace.ug.edu.gh International Society for the Investigation of Stress, 28(2), 175–176. Hunter L, Weber T, Shattell M, Harris BA (2014) Nursing Students Attitudes about Psychiatric Mental Health Nursing. Issues Ment Health Nurs 35: 29-34. International Labour Organization-ILO. (2013). International Labour Organization-ILO (2013) Global Employment Trends 2013, Recovering from a Second Jobs Dip. International Labour Office Publication-Geneva, Switzerland. Jack-Ide IO, Amiegheme FE, Ongutubor KE (2016) Undergraduate Nursing Students' Mental Health and Psychiatric Clinical Experience and Their Career Choice in Nursing: Perspectives from the Niger Delta Region of Nigeria. J Ment Disord Treat 2: 116 Jack-Ide IO, Onguturbo KE, Ameigheme FE, Afolayan JA (2018) The Challenges of Psychiatric Nursing Specialty: Education and Practice in Nigeria. J Ment Disord Treat 4: 157 Jandackova, V. K., Paulik, K., & Steptoe, A. (2012). The impact of unemployment on heart rate variability: The evidence from the Czech Republic. Biological psychology, 91(2), 238-244. Karasek, R. & Theorell, T. (1990). Healthy work: stress, productivity and the reconstruction of working life. New York: Basic Books. Kalliath, T. & Morris, R. (2002). Job satisfaction among nurses: A predictor of burnout levels. J. Nurs. Adm., 32, 648–651. Karl, D., & Fischer, M. (2013). Prevention and Communication: A Most Effective Tailored Treatment Strategiesfor Burnout. Burnout for Experts. Springer US, 185-200. Kristensen, T., Borritz, M., Villadsen, E., & Christensen, K. (2005). The Copenhagen Burnout Inventory: A new tool for the assessment of burnout. Work & Stress, 19, 192- 207. Kortum, E., Leka, S., & Cox, T. (2010). Psychosocial risks and work-related stress in 80 University of Ghana http://ugspace.ug.edu.gh developing countries: health impact, priorities, barriers and solutions. International Journal of Occupational Medicine and Environmental Health, 23(3). Lambert, V. A., & Lambert, C. E. (2008). Nurses’ workplace stressors and coping strategies. Springfield: MDRR Press Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer Lazarus. R.S. (1993). Coping Theory and Research: Past, Present, and Future. Journal of Psychosomatic Medicine, 55, 234-247. Lazarus, R. S., & Cohen-Charash, Y. (2001). Discrete emotions in organizational life. In Emotions at Work: Theory, Research and Applications for Management (pp. 45–81). Leka, S., & Jain, A. (2010). Health impact of psychosocial hazards at work: an overview. Chemistry & …, 126. Lehrer, S., Montazem, A., Ramanathan, L., Pessin-Minsley, M., Pfail, J., Stock, R. G., & Kogan, R. (2009).Bisphosphonate-induced osteonecrosis of the jaws, bone markers, and a hypothesized candidate gene.Journal of Oral and Maxillofacial Surgery 67(1), 159- 161. Lundstrom, T. (2002). Organizational and environmental factors that affect worker health, 93–106. Lunn B (2011) Recruitment into psychiatry: An International challenge.Australian and New Zealand Journal of Psychiatry 45: 805-807. Luszczynska, A., Benight, C. C., Cieslak, R., Kissinger, P., Reilly, K. H., & Clark, R. A. (2009). Self-Efficacy Mediates Effects of Exposure, Loss of Resources, and Life Stress on Posttraumatic Distress among Trauma Survivors. Applied Psychology: Health and Well-Being, 1(1), 73–90. Maslach, C., Jackson, S. E., & Leiter, M. P. (1997). Maslach Burnout Inventory: Third edition. Evaluating stress: A book of resources. 81 University of Ghana http://ugspace.ug.edu.gh McGowan, B. (2001). Self-reported stress and its effect on nurses. Nursing Standard 15: 33- 38. McLoughlin. M., Armstrom P, Byrne M, Heaney D, O’Brien N., & Murphy A. W.(2005) McLaughlin, K., Muldoon, O.T. & Moutray, M. (2010). Gender, gender roles and completion of nursing education: a longitudinal study. Nurse Educ Today, 30(4), 303-7. Mikkelsen, A., Øgaard, T., & Landsbergis, P. (2005). The effects of new dimensions of psychological job demands and job control on active learning and occupational health. Work & Stress , 19(2), 153-175. Mills, R. (1995). Realizing Mental Health: Toward a new Psychology of Resiliency. Sulberger & Graham Publishing, Ltd. Milutinović, D., Golubović, B., Brkić, N. & Prokeš, B. (2012). Professional Stress and Health among Critical Care Nurses in Serbia. Arh Hig Rada Toksikol, 63, pp. Moustaka, E. & Constantinidis, T. C. (2010). Sources and effects of Work-related stress in nursing. Health Science Journal. 4:4. Murphy, L. R. (2002). Job stress research at NIOSH: 1972-2002. Historical and Current Perspectives on Stress and Health., 1–55. Newton, T., & Handy, J. F. (1995). Managing stress: Emotion and power at work. Sage, 1995. Nielsen, K., Randall, R., Holten, A.-L., & Gonzalez, E. R. (2010). Conducting organisational- level occupational health interventions: What works? Work and Stress, 24(3), 234–259. Nuhu FT, Yusuf AJ, Akinbiyi A, Fawole JO, Babalola OJ, et al. (2010) The burden experienced by family caregivers of patients with epilepsy attending the government psychiatric hospital, Kaduna, Nigeria. Pan Afr Med J 5: 16. Paul J. Rosch, M.D., F. A. C. P. (2015). Hans Selye: Birth of Stress. The American Institue of Stress, 1–4. 82 University of Ghana http://ugspace.ug.edu.gh Pandey, S., Gaur, S. P., & PestonjeeD.M. (2013). Methodological Issues in Stress Research: Challenges,Concerns, and Directions. Stress and Work: Perspectives on Understanding and Managing Stress, 323 Quick, J. C., & Tetrick, L. E. (2010). Handbook of occupational health psychology(2nd ed.), Washington, DC: American Psychological Association. Quick, J., Murphy, L., Hurrell, J. J., & (Eds.). (1992). Work and well-being: Assessments and instruments for occupational mental health. . Washington, DC: American Psychological Association. Rabin, S., Feldman, D., & Kaplan, Z. (1999). Stress and intervention strategies in mental health professionals. The British Journal of Medical Psychology, 72 ( Pt 2), 159–69. Robin, W.L. (2002). A Comparison of Perceived Stress Levels and Coping Styles of Junior and Senior Students in Nursing and Social Work Programs. In Doctor of Education Dissertation. College of Graduate Studies, Marshall University. Rodrigues, V.M.C.P. & Ferreira, A.S.S. (2011). Stressors in nurses working in Intensive Care Units. Revista Latino-Americana de Enfermagem, 19(4), pp. 1025-32. Roohafza, H., Sarrafzadegan, N., Sadeghi, M., Talaei, M., Talakar, M., & Mahvash, M. (2012). The effectiveness of stress management intervention in a community-based program: Isfahan Healthy Heart Program. ARYA atherosclerosis, 7 (4), 176. Rothmann, S., van der Colff, J.J. & Rothmann, J.C. (2006). Occupational stress of nurses in South Africa. Curationis, 29(2): 22-33. Rugulies, R., Christensen, K. B., Borritz, M., Villadsen, E., Bültmann, U., & Kristensen, T. S. (2007). The contribution of the psychosocial work environment to sickness absence in human service workers: Results of a 3-year follow-up study. Sartorius N (2007) Stigma and mental health. Lancet 370: 808-810. Sedgeman, J. (2005). Health Realization/Innate Health: Can a quiet mind and a positive 83 University of Ghana http://ugspace.ug.edu.gh feeling state be accessible over the lifespan without stress-relief techniques? Med. Sci. Monitor Health Realization/Innat, 11(12), 47-52. Selye, H. (1976). The Stress of Life. (2nd Ed.). New York: Mcgraw-Hill. Serca C, Ayala RA, Bracke P (2015) How does stigma influence mental health nursing identities? An ethnographic study of the meaning of stigma for nursing role identities in two Belgian psychiatric hospitals.Int Journal of Nursing Stud 52: 307-316. Settersten, R. A. & Mayer, K. U. (1997). The measurement of age, age structuring and the life course. Annual Review of Sociology, 23, 233-261. Schulze B (2007) Stigma and mental health professionals: a review of theevidence on an intricate relationship. International Review of Psychiatry 19: 137-155. Shaufeli, W. M., & Maslach, C. (2009). Burnout: Thirty-five years of research and practice. Career Development International, 14, 204-220. Shields N. (2001). Stress, active coping, and academic performance among persisting and non-persisting students. Journal of Applied Bio-behavioural Research, 6(2), pp. Shields, M., & Wilkins, K. (2006). Findings from the 2005 National Survey of the Work and Health of Nurses. Ottawa, ON: Health Canada and Canadian Institute for Health Information Shirom, A., & Melamed, S. (2005). Does burnout affect physical health? A review of the evidence. (In A.S.G. Shirom, A., Toker, S., Berliner, S., & Shapira, I. (2008). The Job Demand-Control-Support Model and stress-related low-grade inflammatory responses among healthy employees: A longitudinal study. Work and Stress, 22(2), 138–152. Sibbald, B., Enzer, I., Cooper, C., Rout, U., & Sutherland, V. (2000). GP job satisfaction in 1987, 1990 and 1998: lessons for the future? Family Practice, 17(5), 364–371. 84 University of Ghana http://ugspace.ug.edu.gh Sinclair, R. (2009). The future of OHP: The experts speak (Part I). Society for Occupational Health PsychologyNewsletter, 5, 11-13. Somaz, W. H., & Tulgan, B. (2003). Performance Under Pressure: Managing Stress in the Workplace.Canada.HRD Press Inc, 7-8. Spence, J. D., Barnett, P. A., Linden, W., Ramsden, V., & Taenzer, P. (1999). Lifestyle modifications to prevent and control hypertension. 7. Recommendations on stress management. Canadian Hypertension Society, Spielberger, C.D. & Vagg, P.R. (1999). Job Stress Survey: Professional manual. Odessa, FL: Psychological Assessment Resources Spielberger, C.D., Vagg, P.R. & Wasala, C.F. (2003). Occupational stress: Job pressures and lack of support. In J.C. Quick & L. E. Tetrick (Eds.), Handbook of occupational health psychology. Washington, DC: American Psychological Association. pp. 185-200. Strümpfer, D. J. (2003). Resilience and burnout: A stitch that could save nine. South African Journal of Psychology, 33(2), 69-79. Sullivan, P.J. (1993). Occupational stress in psychiatric nursing. Journal of Advance Nursing. 18; 591-601. Sveinsdottir, H., Biering, P., & Ramel, A. (2006). Occupational stress, job satisfaction, and working environment among Icelandic nurses: A cross-sectional questionnaire survey International Journal of Nursing Studies, 43(7):875-89. Tarnini, B. K., & Kord, B. (2011). Burnout Components as Predictors of Job & Life Satisfaction of University Employees. Indian Journal of Industrial Relations , 47(1). The Future of Nursing (2010), Leading Change, Advancing Health. The Institute of Medicine of the National Academies 2010. Available at www.iom.edu/Reports/2010/The-future- of-nursing-leading-change-advancing-health.aspx. Accessed July, 2016. Thornicroft G, Ros D, Kassam A, Sartorius M (2007).Stigma: Ignorance,prejudice and 85 University of Ghana http://ugspace.ug.edu.gh discrimination? British Journal of Psychiatry 190: 192-193. Timby, B.K. (2008). Fundamental nursing skills and concepts. USA, Philadelphia. Urbanetto, J.S., Silva, P.C., Hoffmeister, E., Negri, B.S. da Costa, B.E.P. & de Figueiredo. Tracy, S. J. (2000). Becoming a Character for Commerce Emotion Labor, Self- Subordination, and Discursive Construction of Identity in a Total Institution. Management Communication Quarterly 14(1), 90-128 Tyler, P., & Cushway, D. (1992). Stress, coping and mental well???being in hospital nurses. Stress Medicine, 8(2), 91–98. Tyler, P., & Cushway, D. (1995). Stress in nurses: The effects of coping and social support. Stress Medicine, 11(1), 243–251. Van der Bijl, H., & Oosthuizen, P. (2007). Anxiety, depression, health attitudes and coping strategies in doctors and teachers in a Cape Town setting. South African Journal of Psychiatry, 13(2), 46-51. Videbeck, S.L. (2007). Psychiatric Mental Health Nursing (4th edtn.). Lippincott Williams & Wilkins. Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, et al. (2007) Worldwide use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental healthsurveys. Lancet 370: 841-850. Weinberg, A. & Creed, F. (2000, Feburary). Stress and Psychiatric Disorder in Healthcare Professionals and Hospital Staff. The Lancet, 35, 76-79. White, G. (2009). Managing Employee Performance and Reward: Concepts, Practices, Strategies - Edited by John Shields. Industrial Relations Journal, 40(2), 173. Willems, E. A. (2014). Stress among Social Work Professionals in Mental Health Care 86 University of Ghana http://ugspace.ug.edu.gh Settings. World Health Organization (2009) Improving Health Systems and Services for Mental Health Mental Health Policy and Service Guidance Package. Geneva. Zaghloul, A.A. (2008). Developing and Validating a Tool to Assess Nurse Stress. J Egypt Public Health Assoc. 83 (3), 223-227. Zhang, Q., & Zhu, W. (2008). Exploring emotion in teaching: Emotional labor, burnout, and satisfaction in Chinese higher education. Communication Education, 57(1), 105-122. 87 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX A: QUESTIONNAIRE MENTAL HEALTH PROFESSIONALS STRESS SCALE (MHPSS) Profession/Position: (1. Psychiatrist 2. Psychologist 3. Psychiatric nurse) Sex: Male / Female Marital Status: Single / Married Work Experience…………………… Age…………………………………… Please kindly read each statement and circle number 1, 2, 3, 4, 5 that applies to you. Thank you. To what extent do you feel stressed as a result of your present job? 1. Not stressed at all 2. Not stressed 3. Neither 4. Stressed 5. Very stressed. Part 2. 1. Strongly disagree 2.Disagree 3. Neither 4.Agree 5. Strongly Agree Subscale I: Workload a) Too much work to do 1 2 3 4 5 b) Too many different things to do 1 2 3 4 5 c) Not enough time to complete all tasks satisfactorily 1 2 3 4 5 d) Too many clients/patients 1 2 3 4 5 e) Working too long hours 1 2 3 4 5 f) Not enough time for recreation 1 2 3 4 5 88 University of Ghana http://ugspace.ug.edu.gh Subscale II: Client-related difficulties 1. Never 2. Rarely 3.Occasionally 4.Frequently 5. Very frequently a) Terminating with clients/patients 1 2 3 4 5 b) Dealing with death or suffering 1 2 3 4 5 c) No change or slowness of change in clients/patients 1 2 3 4 5 d) Difficult and/or demanding clients/patients 1 2 3 4 5 e) Physically threatening clients/patients 1 2 3 4 5 f) Managing therapeutic relationships 1 2 3 4 5 Subscale IV: Lack of resources 1. Strongly Disagree 2.Disagree 3.Neither 4.Agree 5. Strongly agree a) Lack of adequate staffing 1 2 3 4 5 b) Lack of financial resources for training courses/workshops 1 2 3 4 5 c) Shortage of adequate equipment/supplies is stressful 1 2 3 4 5 d) Lack of adequate cover in potentially dangerous environment 1 2 3 4 5 e) Poor physical working conditions stresses me up 1 2 3 4 5 f) Inadequate clerical/technical backup 1 2 3 4 5 89 University of Ghana http://ugspace.ug.edu.gh Subscale VI: Home-work conflict 1. Almost never true 2. Usually not true 3. Occasionally true 4. Usually true 5. Almost always true a) Not having enough time with family 1 2 3 4 5 b) Inability to separate personal from professional role 1 2 3 4 5 c) Taking work home 1 2 3 4 5 d) Relationship with spouse/partner affects work 1 2 3 4 5 e) Work emphasizes feelings of emptiness and/or isolation 1 2 3 4 5 f) Inadequate time for friendships/social relationships 1 2 3 4 5 90 University of Ghana http://ugspace.ug.edu.gh APPENDIX B: CONSENT FORM Psychiatric Nurses CONSENT FORM Form number [ ] Project Title FACTORS INFLUENCING STRESS IN PSYCHIATRIC NURSES IN ACCRA. Name and address of principal investigator Priscilla Ama Kyereme, Department of Social and Behavioral Sciences, University of Ghana, Accra, Legon Mobile: 0232269848 Email Address: prxylla@gmail.com Institution affiliated to School of Public Health, University of Ghana Legon, Accra Introduction I am Priscilla Ama Kyereme, a student from the School of Public Health, University of Ghana conducting a research on Factors Influencing Stress in psychiatric nurses in Accra. PLEASE kindly spare some few minutes to complete the questionnaire. All information entered will be treated as confidential and no one will be able to trace any information to you. 91 University of Ghana http://ugspace.ug.edu.gh Procedure The study seeks to assess the level of stress in psychiatric nurse and to investigate or determine factors that influence stress in this group. Selection of participants was by random sampling and voluntary. Participants were made to complete questionnaires and returned to the principal investigator. Risk and Benefit You may feel uncomfortable answering some of the questions however, it would be helpful for the purpose of the study to identify factors that influence stress and may help improve organizational structures, policies, to reduce the level of stress in psychiatric nurses. Right to refuse Your consent to participate in this study is voluntary you are not under any obligation to participate, and you are at liberty to withdrew from the study at any point in time. I will appreciate it if you do complete it. Anonymity and confidentiality Be assured that any information given would be used purely for the purpose of research. Any information given would be treated with utmost confidentiality. Your ideas and suggestions will help in designing structures and policies that could help reduce factors that influence stress in psychiatric nurses in the various psychiatric hospitals. 92 University of Ghana http://ugspace.ug.edu.gh Your right as a Participant This research has been reviewed and approved by the Ethical Review Committee of the Ghana Health Service. If you have any questions about your rights as a research participant you can contact the ethical review coordinator on 233 (0) 243235225 or 0507041223 (Ms. Hannah Frimpong). Voluntary agreement form for Psychiatric Nurses. The above document describing the benefits, risk procedures for the research topic “factors influencing stress in psychiatric nurses in Accra” I have read and I understand. I have been given an opportunity to ask any questions about the research. I agree to take part as a participant. Name……………………………………………………..Date……………………………… ………. Signature ……………………………………………………………………………………………… Interviewer’s statement I……………………………………………………… the undersigned, have explained to the subject in the language he/she understands and the subject has agreed to take part in the study. Signature………………………………………………………………………………… of interviewer………………………………………Date……………………………………........ 93 University of Ghana http://ugspace.ug.edu.gh APPENDIX C: ETHICAL APPROVAL LETTER 94