BIOLOGICAL, ENVIRONMENTAL AND OCCUPATIONAL HEALTH SCIENCES 
SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA, LEGON 
 
DETERMINANTS OF WORKPLACE STRESS IN THE HEALTH SECTOR: A 
CASE STUDY OF NURSES AT THE TEMA GENERAL HOSPITAL 
 
BY 
DORCOO KWAME CHRISTIAN JNR. 
10288063 
 
 
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE 
AWARD OF THE MASTER OF SCIENCE IN OCCUPATIONAL HYGIENE 
DEGREE 
 
 
 
 
 
JULY, 2016 
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TITLE PAGE 
BIOLOGICAL, ENVIRONMENTAL AND OCCUPATIONAL HEALTH SCIENCES 
SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA, LEGON 
 
DETERMINANTS OF WORKPLACE STRESS IN THE HEALTH SECTOR: A 
CASE STUDY OF NURSES AT THE TEMA GENERAL HOSPITAL 
 
 
BY 
 
DORCOO KWAME CHRISTIAN JNR. 
10288063 
 
 
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE 
AWARD OF THE MASTER OF SCIENCE IN OCCUPATIONAL HYGIENE 
DEGREE 
 
JULY, 2016 
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DECLARATION 
 
I, Dorcoo Kwame Christian Jnr. declare that this Thesis, with the exception of quotations 
and references contained in published works which have all been identified and 
acknowledged, is entirely my own work, and it has not been submitted either in part or 
whole for another degree elsewhere. 
STUDENT: DORCOO KWAME CHRISTIAN JNR. 
SIGNATURE …………………………………………………….. 
DATE………………………………………………………………. 
 
SUPERVISOR: DR MAWULI DZODZOMENYO 
SIGNATURE………………………………………………………. 
DATE……………………………………………………………….. 
 
 
 
 
 
 
 
 
 
 
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DEDICATION 
This project is dedicated to the Almighty God for His wonderful protection over me 
throughout the study of this course. 
This work is also dedicated to my mother, Beatrice Tekpor, for her support, prayers and 
encouragement throughout the period of my study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGEMENT 
Thanks be to God for the grace and favour I received from him to complete this programme.  
Writing this thesis was a very big academic undertaking which I might not have been able to 
undertake, let alone complete it without the supervision, guidance and advise from a number 
of people who deserve particular mention. 
I would first like to express my deep and sincere gratitude to my supervisor, Dr. Mawuli 
Dzodzomenyo. His wide knowledge and logical way of thinking have been of great value to 
me. His understanding, encouragement and personal guidance have provided a good basis 
for my thesis. I want to thank Dr. Arko Mensah for his early morning motivations on how to 
go about our thesis either before or after he lectures, and also all the other lecturers who 
helped me to make this thesis a reality. 
I also want to acknowledge the Dean of the School of Public Health for making sure we 
learnt MENDELY and STATA  to aid us in our research and also my Head of Department, 
Professor Fobil, for accepting me into the course. 
My warmest appreciation goes to all the staff of Tema General Hospital, including the 
medical director and all the various nurse managers for their cooperation in the 
administration of my questionnaires. I will make special mention of Mrs Emelia Koranteng 
of the Labour Ward, Vincent of the Fevers Unit, Delasi of the In-Service Training 
Department, Selasi of the Paediatric Medical Ward for their immense support.  
Finally I acknowledge the numerous authors whose works have been cited in this book. 
 
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ABSTRACT 
Stress is the body's way of responding to any form of demand placed on it. Job stress is 
experienced in relation to the day-to-day work required of nurses. Examination of stress is 
necessary because work stress is associated with fair or poor physical and mental health as 
well as a reduction in overall performance levels. This study was carried out to assess the 
prevalence of stress among nurses, identify the facility related factors contributing to stress 
and the coping mechanisms adopted by nurses to reduce stress. A descriptive cross-sectional 
study design was employed in this study. A total of 198 nurses at the TGH were randomly 
sampled from a total of 399 for the study. The stress component of the DASS scale was used 
to measure stress levels among the nurses. Data was analysed with STATA version 13 
software. The prevalence of stress among the nurses was 99% with 45%, 30%, 20% and 4% 
having extremely severe, severe, moderate and mild stress respectively. No statistically 
significant relationship was found between demographic characteristics of nurses and their 
level of stress: age, sex, professional rank, level of education, marital status, years of 
working experience. Facility related factors contributing to stress among nurses were poor 
interpersonal relationship (mean=3.712, SD=1.052), role at work (mean=3.402, SD=1.067), 
level of control (mean=3.364, SD=0.984) and change (mean=3.164, SD=0.957). The high 
prevalence of stress among the nurses in this study suggests the need for multisectoral 
concerted efforts to address stress associated with the nursing profession. The factors 
contributing to stress among nurses provide a strong indication of the need for improvement 
in nursing management and leadership practices.  
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 TABLE OF CONTENTS 
TITLE PAGE ............................................................................................................................ i 
DECLARATION ..................................................................................................................... ii 
DEDICATION ........................................................................................................................ iii 
ACKNOWLEDGEMENT ...................................................................................................... iv 
ABSTRACT ............................................................................................................................. v 
TABLE OF CONTENTS ........................................................................................................ vi 
LIST OF TABLES .................................................................................................................. ix 
LIST OF FIGURES ................................................................................................................. x 
LIST OF ABBREVIATIONS ................................................................................................. xi 
CHAPTER ONE ...................................................................................................................... 1 
INTRODUCTION................................................................................................................ 1 
1.1 Background to the Study ....................................................................................... 1 
1.2 Problem Statement ................................................................................................. 4 
1.3 Conceptual Framework ......................................................................................... 5 
1.4 Justification of the study ........................................................................................ 8 
1.5 Research Questions ............................................................................................... 9 
1.6 General Objective .................................................................................................. 9 
1.7 Specific Objectives .............................................................................................. 10 
CHAPTER TWO ................................................................................................................... 11 
LITERATURE REVIEW ................................................................................................... 11 
2.0 Introduction ......................................................................................................... 11 
2.1  Stress .................................................................................................................... 11 
2.2 Workplace Stress ................................................................................................. 11 
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2.3 Stress among Nurses ............................................................................................ 13 
2.4 Factors Contributing to Stress among Nurses ..................................................... 15 
2.5 How Nurses Cope with Stress ............................................................................. 20 
2.6 Summary .............................................................................................................. 23 
CHAPTER THREE ............................................................................................................... 25 
METHODOLOGY ............................................................................................................. 25 
3.0 Introduction ......................................................................................................... 25 
3.1 Study Design ....................................................................................................... 25 
3.2 Study Location ..................................................................................................... 25 
3.3 Study Population ................................................................................................. 26 
3.3.1 Inclusion Criteria ............................................................................................. 27 
3.3.2 Exclusion criteria ............................................................................................. 27 
3.4 Variables .............................................................................................................. 27 
3.5 Sample Size Calculation ...................................................................................... 28 
3.6 Sampling Procedure ............................................................................................. 28 
3.7 Data Collection Tool ........................................................................................... 29 
3.8 Quality Control .................................................................................................... 30 
3.9 Pre-Test of the Questionnaire .............................................................................. 31 
3.10 Data Processing and Analysis ............................................................................. 31 
3.11 Ethical Consideration .......................................................................................... 32 
CHAPTER FOUR .................................................................................................................. 34 
RESULTS .......................................................................................................................... 34 
4.0 Introduction ......................................................................................................... 34 
4.1 Demographic Characteristics of Respondents ..................................................... 34 
4.2 Prevalence of Stress among Nurses ..................................................................... 37 
4.3 Association between Demographic Characteristics of Nurses and Levels of 
Stress 37 
4.4 Facility Related Factors Contributing to Stress among Nurses ........................... 41 
4.5 Coping Mechanisms adopted by Nurses to reduce Stress ................................... 45 
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CHAPTER FIVE ................................................................................................................... 47 
DISCUSSION .................................................................................................................... 47 
5.0 Introduction ......................................................................................................... 47 
5.1 Demographic Data ............................................................................................... 47 
5.2 Prevalence of Stress among Nurses ..................................................................... 49 
5.3 Demographic Characteristics of Nurses and their Relationship with Levels of 
Stress 51 
5.4 Facility Related Factors Contributing to Stress among Nurses ........................... 51 
5.5 Coping Mechanisms adopted by Nurses to reduce Stress ................................... 55 
CHAPTER SIX ...................................................................................................................... 57 
CONCLUSION AND RECOMMENDATIONS ............................................................... 57 
6.0 Introduction ......................................................................................................... 57 
6.1 Conclusion ........................................................................................................... 57 
6.2 Implications of the Study ..................................................................................... 58 
6.2.1  Implications for Research ................................................................................ 58 
6.2.2  Implications for Policy Making ....................................................................... 58 
6.2.3  Implications for Practice and Management ..................................................... 59 
6.2.4  Implications for Education ............................................................................... 59 
6.3  Limitations of the Study ...................................................................................... 59 
6.4 Recommendations ............................................................................................... 60 
REFERENCES ...................................................................................................................... 62 
APPENDIX A: QUESTIONNAIRE ..................................................................................... 68 
APPENDIX B:  CONSENT FORM ...................................................................................... 73 
APPENDIX C:  ETHICAL APPROVAL LETTER .............................................................. 76 
APPENDIX D:  INTRODUCTORY LETTER ..................................................................... 77 
 
 
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LIST OF TABLES 
Table                             Page 
Table 4.1: Demographic Characteristics of Respondents ...................................................... 35 
Table 4.2:  Relationship between Age, Sex and level of stress ............................................. 38 
Table 4.3:  Relationship between professional rank and level of stress ................................ 39 
Table 4.4:  Relationship between educational status and level of stress ............................... 40 
Table 4.5:  Relationship between marital status, years of work experience and level of stress
 ............................................................................................................................................... 41 
Table 4.6:  Facility related factors contributing to stress among nurses ................................ 43 
Table 4.7:  Relationship between facility related factors contributing to stress and level of 
stress ....................................................................................................................................... 44 
Table 4.8:  Stress coping mechanisms ................................................................................... 46 
 
 
 
 
 
 
 
 
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LIST OF FIGURES 
Figure                                    Page 
Figure 1.1: Conceptual framework on stress and coping strategies ........................................ 6 
Figure 3.1:Areal map showing the location of Tema General Hospital within the Tema 
Metropolis .............................................................................................................................. 26 
Figure 4.1: Professional rank distribution of respondents ..................................................... 36 
Figure 4.2: Prevalence of stress ............................................................................................. 37 
 
 
 
 
 
 
 
 
 
 
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LIST OF ABBREVIATIONS 
HCW - Health Care Workers 
ILO - International Labour Organization 
OSH - Occupational Safety and Health 
WHO - World Health Organization 
WPS - Workplace Stress 
TGH - Tema General Hospital 
GHS-ERC - Ghana Health Service – Ethical Review Committee 
 
 
 
 
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CHAPTER ONE 
INTRODUCTION 
1.1 Background to the Study 
Stress is the body's way of responding to any form of demand placed on it. This occurs in 
response to either negative or positive experiences. According to McVicar (2003), stress is 
“a subjective phenomenon based on individual perceptions, producing positive (eustress) 
and negative (distress) perspectives” (p. 640). In situations where a person finds it difficult 
to deal with stressors such as difficult life situations, problems and goals, stress occurs 
(Videbeck, 2007). The effects of stress can be physical, emotional and / or cognitive. 
Everybody can, to some extent, cope with stress. However, people do not have similar 
reactions to similar stressors at the same time (Timby, 2008). 
Historically, stress has been classified as a stimulus or a response to situation.  Many studies 
have been carried out on stress and many frameworks and perspective have been made 
concerning stress. Selye (1976), one of the pioneers of the concept of stress suggested a 
physiological assessment of stress by considering the association between stress and illness. 
In addition, Lazarus and Folkman (1984) also posited a psychological view whereby stress 
is viewed as a kind of relationship between a person and his or her environment which is 
perceived as demanding and exceeding the resources or the capacity of the individual to 
handle hence compromising one’s health or well-being.   
According to Lazarus and Folkman (1984), one only experiences stress in situations that are 
perceived as exceeding ones’ ability to handle. Stress is experienced only when situations 
are appraised as exceeding one’s resources. This indicates that an individual may perceive 
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additional responsibilities or tasks placed on him or her as a threat whilst others may take it 
as a challenge. Role stress ensues when an individual experiences incongruity between his 
or her own perception about the nature of the role and the actual nature of the role (Lambert, 
Lambert & Ito, 2004). Role strain occurs due to negative reaction in the event of role stress.  
This is manifested as frustration, with burnout occurring as an outcome. Burnout comprises 
depersonalization, emotional exhaustion, and a reduction in ones’ personal accomplishment 
(Maslach & Jackson, 1986). As a part of life, stress is known to generate negative or positive 
consequences. Stress has a positive influence by serving as a form of motivation towards 
progress and the creation of more awareness and initiative. On the other hand, stress has a 
negative influence when it results in feelings of rejection, distress and depression (Mehta & 
Chaudhary, 2005). 
Work related stress among nurses is as a result of the daily routine and demands placed on 
nurses (Shields & Wilkins, 2006). This has raised a lot of concerns among researchers in 
various organizations because of the impact that workplace stress has on the performance of 
employees. Within the health sector, employees are at a greater risk of stress and stress 
related illness by virtue of the nature of their work and their work environment. Prolonged 
stressful situations leads to burnout which nurses are particularly perceived to be susceptible 
(Zaghloul, 2008). Assessment of workplace stress is important due to its link with poor 
mental and physical health as well as reduced performance (Shields & Wilkins, 2006). 
Nursing as a profession, comprises the delivery of humane, empathetic, proficient and moral 
care, in work environments often characterised by inadequate resources coupled with 
increasing responsibilities. According to Zaghloul (2008), the nursing profession is 
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demanding. Some imbalance exists between the provision of quality nursing care and how 
nurses cope with the stressful nature of the work environment in which they work (Kalliath 
& Morris, 2002). According to Lowe (2006), health workers in general have higher levels of 
workplace stress compared to other category of workers. Nurses who experience high levels 
of job strain and distress at work are likely to experience poor health (Shields & Wilkins, 
2006). The most common cause of stress among Ghanaian nurses is the long working hours 
they endure, financial challenges they face and the stress associated with the death of a 
patient (Dapaah, 2014).  
When stress is too much, it affects one’s health physically and emotionally. In situations 
where nurses manage to deal with the stress associated with their profession, there is less 
absenteeism, excessive workloads are managed well, they live healthier and longer life and 
there is some form of stability of the nursing workforce and quality nursing services are 
provided. Nurses’ success or failure at the job is also linked to their ability to successfully 
manage stress. The emotions of nurses can affect others, especially their clients and stress, to 
some extent, affects the way they interact with others. When nurses are able to manage their 
stress effectively, then they will be they have a positive impact on the lives of people around 
them.  
With less stress, nurses are able to spend quality time together and contribute positively to 
the outcome of their patients. There is therefore the need for health service administrators 
and management to assess the contributory factors in workplace stress among nurses for 
necessary action to be taken in order to ensure a stable and continuous nursing workforce at 
various health care institutions.  
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1.2 Problem Statement 
Nursing is undoubtedly a stressful profession due to the frequent direct and continual 
exposure of nurses to persons going through a lot of pain, agony and suffering, and the need 
to give attention and emotional support to these patients.  This exposes nurses to various 
stressors (Lambert & Lambert, 2008).  
Stress among nurses is mainly as a result of the demand for physical labour, exposure to 
suffering and emotional demands from patients and their families, unstable work hours, the 
shift system of work interactions with colleagues, patients and their families and other health 
professionals. Continual exposure to situations like this is likely to lead to feelings of 
irritability, depression and disappointment (Preto & Pedrão, 2009). 
Most nurses suffer psychological and physical effects of stress (Nursing Times Career, 
2014). Many types of physical ailments have been linked with stress. These include high 
blood pressure, heart attack, heart disease, peptic ulcer, headache, pain in the neck, asthma, 
cancer, to mention but a few (Mehta & Chaudhary, 2005). The onset of psychological 
ailments such as depression has also been associated with stressful life events  (Hammen, 
2005), including sleep problems (Harvey, Jones & Schmidt, 2003). In Ghana, the Ministry 
of Health (MoH) is not ignorant of the plights faced by nurses and has tried to help address 
the problem, but according to Offei and Quansah (2009), the MoH could not successfully 
identify where to begin. 
Although literature on the causes of stress among nurses is available, not many studies have 
been carried out on the prevalence of stress among nurses in Ghana. The recent study on 
stress among nurses in Ghana was carried out by Dapaah (2014) on the causes of stress 
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among nurses in the Greater Accra Region. 
Through observation and personal interviews, the researcher has noticed that nurses 
complain of workplace stress. In addition to their stresses, some nurses complain of other 
stressors such as family responsibilities, traffic situations in town, high cost of living, 
combining school with work or doing extra work. Others also experience work related stress 
such as increased workload, shortage of resources at work and conflict with other staff 
members. Personal communication with some of the nurses reveals some of the nurses 
openly confessing frustration with work and the desire to move out of the clinical area. This 
therefore poses a negative rebound effect on the quality of nursing care. This has motivated 
the researcher to conduct this study to explore work-related stress among nurses. 
1.3 Conceptual Framework 
The model for this study was adapted from (Teye, 2011) which was based on the general 
socio-cognitive theory (Bandura, 1986, Osipow, 1998, Cooper & Bright 2001). The figure 
represents the general theoretical model of the stressor, coping and stress. It gives the clear 
indication that the extents to which stressors within an organization generate stress 
responses are based on the effectiveness of stress coping strategies. The arrows linking 
organisational stressors to coping strategies and then to stress give the indication that there is 
not direct relationship between the stressor and the stress response, but rather coping serves 
as a link between them. Secondly, the severity of occupational stressors, in addition to 
coping strategies and stress response has been shown to depend on the age of employees, 
their marital status, their rank, level of educational and sex.  
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Below the framework are the explanations of the various organisational stressors. 
Organisational stressors 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1.1: Conceptual framework on stress and coping strategies 
 
Demand  
a. Workload,  
b. Work design 
patterns  
c. Work environment 
 
Control 
a. Opinion 
b. Autonomy at work 
 
Relationship 
a. Nature of work 
environment 
b. Behaviour of staff 
r 
 
 
Support 
a. Encouragement 
b. Sponsorship  
c. Availability of 
resources  
d. Equitable wages/ 
salaries  
e. Guidance 
 
Change  
a. Management of 
organizational change  
b. Communication of 
change in the 
organisation. 
 
Coping strategies  
 
 
 
Stress level 
a. Normal 
b. Mild 
c. Moderate 
d. Severe 
e. Extremely severe  
 
Demographic Factors 
a. Age 
b. Educational level 
c. Rank 
d. Marital status 
e. Sex 
 
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Factors relating to the workload, design of work patterns and the work environment 
comprises work demand.  Secondly, the extent to which an employee had a say or is 
recognized in an organisation has an effect on the way the individual works and this is 
referred to as control.  This comprises the extent to which an employee is allowed to make 
contribution to decision making at the workplace.  
Support involves encouragement from management, staff and superiors (Zhang & Zhu, 
2008). This includes among other things the availability of the necessary resources, in 
addition to better wages. According to Sanders (2013), support comprises the availability of 
all assistive devices required to make work comfortable and safe and the needed guidance 
from superiors.  
With regard to relationship, it comprises the existence or otherwise of a positive work 
environment. Where there is no positive work environment, the end product is conflict 
which encourages unacceptable behaviour. Relationship includes promoting positive 
working to avoid conflict and dealing with unacceptable behaviour. Role is the extent to 
which employees have an understanding of their role in the organisation and how the 
organisation make sure they do not have conflicting roles. 
Finally, the nature and frequency of change in management, in addition to how change is 
communicated and implemented, can to some extent be stressful. This in general comprises 
how change within the organisation is managed and communicated among staff within the 
organisation. 
Workplace stress has been categorized into five subgroups according to the stress 
component in the Depression, Anxiety and Stress Scale (DASS). This includes normal, mild, 
moderate, severe and extremely severe stress levels. Coping strategies adopted in response 
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to stress situations include problem focused coping, reappraisal, avoidance coping and 
emotional coping. 
1.4 Justification of the study  
The Tema General Hospital (TGH) is the largest public health institution located in the 
Tema Metropolis. It serves as the main referral point for all other clinics/ hospitals in the 
Tema Metropolis. The Hospital has a total of ten (10) wards with a bed capacity of 294. The 
Tema General Hospital provides a 24 hour specialist and general services on both out-
patient and in-patient basis. Since the inception of the NHIS in 2003, a total of about 
207,329 Out-Patient Department (OPD) cases were handled by medical personnel of the 
TGH in 2008 as against 180,814 cases in 2007 representing a 14.6% increase. This statistics 
shows that the OPD cases keeps on increasing and as a result poses a lot of work demand on 
nurses.  
The nurse to patient ratio is really a challenge in the health sector left alone TGH and this is 
a major stressor in the profession. There is also a growing concern about the quality of 
service rendered by nurses (Offei & Quansah, 2009). Nurses have major roles to play in the 
provision of timely and quality services, but according to Offei and Quansah (2009) high 
levels of occupational stress tend to impact negatively on performance.  
It is therefore essential to study the prevalence of stress and the coping strategies among 
nurses as it will help sensitize the Ministry of Health, their staff and all stakeholders on the 
need to take necessary actions to address the issue of workplace stress among nurses and 
introduce better ways of coping with stress. It will also help in the formulation of 
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appropriate health and safety work policies and regulations necessary to reduce stress to 
normal levels among health care workers in general. 
Findings from the study will also serve as material that will be reviewed by future 
researchers as literature when carrying out similar studies. Recommendations for future 
studies based on the findings from this study will encourage more research on the area of 
workplace stress and its management among health workers in Ghana. The ultimate 
beneficiary of these interventions as a result of the findings will be the healthcare worker 
(Nurses). 
1.5 Research Questions  
1. What is the prevalence of stress among nurses at the Tema General Hospital?  
2. Do demographic factors contribute to stress levels among nurses?  
3. What are the facility related factors contributing to stress among nurses?  
4. How do nurses cope with stress?  
1.6 General Objective 
The general objective of the study is to determine the prevalence of stress among nurses at 
the Tema General Hospital and to assess the factors contributing to this situation. 
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1.7 Specific Objectives 
The specific objectives of the study are to: 
1. Assess the prevalence of stress among nurses at the Tema General Hospital  
2. Assess demographic factors and their association with stress among nurses.  
3. Identify the facility related factors contributing to stress among nurses  
4. Describe the coping mechanisms adopted by nurses to reduce stress.  
 
 
 
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CHAPTER TWO 
LITERATURE REVIEW 
2.0 Introduction 
This chapter presents a review of literature for the study. This includes a general overview 
of stress and workplace stress. In addition, previous studies on stress among nurses, factors 
contributing to stress at the workplace and coping strategies adopted by nurses to deal with 
stress are also included in this chapter.  
2.1  Stress 
Stress is referred to as a mixture of related experiences, reactions and outcomes produced by 
various different situations or circumstances that have different effects on each and every 
individual (Manktelow, 2005). According to McGowan (2001), stress occurs when one is 
faced with events or encounters that they perceive as dangerous to their physical or 
psychological well-being. Job stress is described as unhealthy physical and emotional 
reactions that occur when there is incongruity between job requirements and the abilities, 
resources, in addition to the needs of a worker. Stress is generally defined as undue, 
inappropriate or exaggerated response to a situation (Roohafza, Sarrafzadegan, Sadeghi, 
Talaei, Talakar & Mahvash, 2012). Workplace stress is also referred to as the non-specific 
negative response of the body to workplace demands placed on it.  
2.2 Workplace Stress 
Stress became a known concept in nursing due to data gathered form patients and literature 
gathered from empirical studies which indicated the link between stress and health. The 
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Spielberger State-Trait (STP) model of occupational stress (Spielberger, Vagg, & Wasala, 
2003), views stress as a complex process comprising three major components. These 
components are; (1) the sources of stress experienced within the work environment, (2) how 
these stressors are appraised by the employee and (3) emotional reactions that these stressors 
generate when perceived as a threat.  
The STP model of occupational stress places more focus on two major workplace stressors 
which include pressure from the demands at the workplace and the lack of support 
(Spielberger et al., 2003). The impact of individual differences and personality traits on 
ones’ stress response is also recognized by the STP model. In this model, occupational stress 
is described as an arousal process involving the mind and body as a result of physical and/ or 
psychological demands that the work place places on the individual. Anxiety and anger is 
said to occur as an emotional response when the stressor is perceived as a threat to the 
individual. Severe and persistent anxiety and anger leads to physical and psychological 
strain which may result in adverse behavioural consequences (Spielberger et al., 2003).  
Employees are believed to assess their work environment based on the severity and the 
frequency of specific workplace demands and the nature and level of support they receive 
from co-workers and supervisors as well organisational features such as organizational 
policies and procedures. The inability of an individual to identify the frequency with which a 
particular stressor occurs is believed to contribute to overestimation of the effects of highly 
stressful situations that seldom occur in addition to underestimating effects of events that are 
moderately stressful and occur frequently.  
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2.3 Stress among Nurses 
Using a brief version of the Job Stress Scale, Filha, Costa and Guilam (2013) conducted a 
study on occupational stress among nurses in Campo Grande in Brazil. The aim of the study 
was to determine the association between nurses’ job stress and their self-rated health at 
emergency units in public health facilities. This was a cross-sectional study that involved 
134 nursing personnel from nine public health units comprising 12 nurse assistants, 21 
registered nurses and 101 nurse technicians. Data was collected using a self-administered 
questionnaire and the Chi-square test and multivariate analysis were carried out using SPSS 
(version 13.0). 
In this study, passive work was found to be common among 43% of the women and high 
strain work was found to the common among 32.5% of the men. Younger staff, below 35 
years of age, had high strain (43.4%). However, the rest of the age ranges had passive work 
being common among them (p = 0.005). Low demand and low control was common among 
workers who had family income of up to 3.4 minimum salaries, with university level 
education, or who were suffering from chronic illness. Respondents who had higher income, 
had gone through more schooling and were single experienced work with high strain 
however, this was not statistically significant. Employees who were new at the work place 
had greater high strain compared to those who had worked in the place for a longer time. A 
significant association with passive work was found among workers who did more on-call 
night duties, unspecified working hours, and did extra on-call duties every week. Those who 
were dissatisfied with work and had less social support had high strain at work but no 
significant difference was observed in relation whit their satisfaction with life.  
In a cross-sectional survey, Rothmann, van der Colff and Rothmann (2006) carried out a 
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study on occupational stress of nurses in South Africa. Random samples of 1780 participants 
were taken which included 980 professional nurses and 800 enrolled and auxiliary nurses 
from seven of the nine provinces of South Africa. Using the Spielberger State-Trait (STP) 
model of occupational stress, the Nursing Stress Indicator (NSI) was developed and used to 
collect data. 
Severe workplace stressors found in this study included watching of patients suffering, 
increasing demands from patients, carrying out ward or unit stock control, health risks 
associated with coming into contact with patients, the inability of superiors and management 
to recognize the good work done, some staff issues including staff shortage, lack of staff 
motivation, time constraints to perform required tasks and lack of commitment to work by 
colleagues. Among these stressors, health risks associated with contact with patients, the 
lack of recognition by management and superiors for good work in addition to insufficient 
staff were highest stressors.  
Comparing differences between professional nurses and then enrolled and auxiliary nurses 
showed that professional nurses experienced more stress as a result of the fear of making 
mistake at the workplace. Furthermore, professional nurses had more stress as a result of 
disputes with colleagues and medical practitioners concerning patients’ treatment plan.   
Milutinović et al. (2012) carried out a cross-sectional study to assess stress among critical 
care nurses in Intensive Care Units (ICU), and the relationship between nurses’ perception 
of stress and the physical and psychological manifested.  
Separate analysis revealed the existence of significant differences in nurses’ perception of 
individual stressful situations in relation to their age, marital status, and level of education. 
In situations such as death or dying and increased workload, married nurses experienced 
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higher stress levels compared to the nurses who were divorced or not married. Younger 
nurses also experienced higher stress levels compared to older nurses. 
In a descriptive cross-sectional study in Portugal, Rodrigues and Ferreira (2011) investigated 
stressors in nurses working in intensive care units. A total of 235 nurses from two Intensive 
Care Units located in Porto, Portugal, took part in the study. The aim of the study was to 
assess the stressors associated with nurses working in intensive care units. A self-developed 
structured questionnaire was used to collect data and the Interpersonal Work Relations Scale 
in addition to the Nurse Stress Index were adopted and used to measure stress and work 
relations among the nurses. Higher levels of stress were noticed among nurses within the 
early stages of their carrier.  Secondly, poor physical work structure was also found to lead 
to higher stress levels. According to Rodrigues and Ferreira (2011), worse interpersonal 
relations among nurses led to higher levels of stress among nurses. Nurses who experienced 
poor interpersonal relationship with their managers viewed the dimension "Support and 
Organizational Involvement" as a stressor. 
2.4 Factors Contributing to Stress among Nurses 
The sources of stress among nurses are related to the nature of the nursing profession. 
Among the stressors associated with the nursing profession is the intense work environment 
nurses find themselves and the extended working hours they endure, in addition to running 
of shifts on weekends, night shifts and working on holidays. Sources of stress in the working 
environment of nurses include new technology, nature of work conditions, extra work load, 
shift work system, ambiguous and conflicting roles in addition to the responsibility of 
persons that nurses have to bear (Arnold, Cooper & Robertson, 1998). According to 
Ruggiero (2003), the shift work system among nurses could be related to the stressful nature 
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of the profession, which he described as mentally and physically demanding.  Intense 
emotional support needed by patients and families simultaneously is yet another burden of 
stress placed on nurses.  
Nurses’ exposures to pain and suffering of their clients and the physically and mentally 
traumatic life events that are witnessed by nurses at work each day can contribute to stress 
among nurses (Cohen-Katz et al., 2005). These issues can finally result in emotional 
exhaustion among nurses. Research shows that psychological distress extends beyond the 
victims of trauma (Collins & Long, 2003). According to Dunkley and Whelan (2006), health 
care workers, including nurses are exposed to emotional and spiritual stress as they 
constantly witness patients undergoing suffering, pain and trauma. This, as described by 
Pearlmann and Saakvitne (1995) involves a transformation of the experience of the patient 
to the carer as he or she attends to the patient, which they termed vicarious traumatization. 
French, Lenton, Walters and Eyles (2000) came up with nine sub-scales of workplace 
situations that places demand on nurses. These workplace situations are; conflict and 
misunderstandings with physicians, lack of adequate preparation, relationship problems with 
colleagues, issues with supervisors, discriminatory attitudes at the workplace, too much 
workload, difficulty in arriving at the decision concerning treatment of patients, the task of 
having to deal with death and dying patients, and putting up with patients and their families. 
In addition, intra-professional and inter-professional conflicts also continue to be an 
important source of stress for nurses. Inter-professional conflict, particularly among nurses 
and physicians, appears to be a big problem (Bratt, Broome, Kelber & Lostocco, 2000). The 
issue of poor interpersonal conflict among health professionals has also been confirmed by 
research findings which show evidence of bullying (Kivimaki, Elovainio, & Vahteera, 
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2000). 
The stressful nature of the work environment, in addition to poor interpersonal relationships 
among nurses and other health professionals, the stressful nature of the nursing profession, 
other organizational factors, various roles that nurses have to play, and their personal 
characteristics have been found to be the major causes of stress to nurses. The major 
determinants of emotional exhaustion were increased demands on the job, staff shortage, 
lack of carrier advancement opportunities, lack of autonomy at the workplace and work 
overload (Moustaka & Constantinids, 2010).  
The Demand-Control Model describes stress in the workplace as due to the imbalance 
between psychological demands and the level of control that an individual has over his or 
her work, and this can have adverse effect on the health of workers. Therefore, the greater 
the demand that work places on an individual and the less control one has over his/her work, 
the higher the risk that one will become physically or psychologically stressed (Karasek & 
Theorell, 1990). Among the main causes of workplace stress among nurses was their lack of 
preparation in addressing emotional needs of their patients and this leads to anxiety among 
the nurses (Sveinsdottir, Biering & Ramel, 2006). 
Dapaa (2014) carried out a descriptive study to assess the causes of stress among nurses in 
the Greater Accra Region of Ghana. She employed a descriptive survey design and 369 
nurses working in government facilities within the Greater Accra Region were sampled. 
However, the convenient sampling technique was used to select participants for the study, 
which might contribute to bias in the sample selection process. The nurses comprised of 108 
(29.3%) males and 261 (70.7%) females. 
Majority (73.3%) of them had more than 15 years’ of work experience in nursing. The life 
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events theory which explains how individuals and the environment in which they live in 
effect each other was used to guide the study. The use of theory in research helped to give 
meaning to the findings of the study since the findings were presented and discussed under 
the constructs of the theory. 
Data was analysed quantitatively using frequencies, mean distributions and standard 
deviations. The mean score on the factors contributing to stress among the nurses was 3.96, 
which suggested that the nurses confirmed that the key items listed in the questionnaire 
actually contributed to stress among nurses. The major factor contributing to workplace 
stress among the nurses in the study was the number of hours spent at work (M=3.890, SD= 
1.158). This was then followed by financial difficulties (M=3.863, SD=1.184). The third 
source of workplace stress among nurses that was revealed in the study was the death of 
patients (M=3.855, SD=1.202). However, the least source of workplace stress among the 
nurses in the study was a lack of control over their work (M=2.965, SD=1.271). 
Using a modified version of the new UK Health and Safety Executive’s (HSE) Management 
Standards (MS) model of stress, Yeboah, Ansong, Antwi, Yiranbon, Anyan and Gyebil 
(2014) carried out an empirical analysis on the determinants of workplace stress among 
healthcare professionals at the Komfo Anokye Teaching Hospital in another study in Ghana. 
An examination of the relationships between 6 main organisational factors (demand, control, 
support, relationships, change, and role conditions) and the level of stress among healthcare 
professionals was carried out in a teaching hospital. A total of 453 health care professionals 
at the Komfo Anokye Teaching Hospital took part in the study.  
Yeboah et al. (2014) found that all 6 elements (thus demand factors, control factors, support 
factors, relationships factors, change factors and role factors) that were assessed had a 
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significant impact on the stress levels of employees. However, their impact on the health 
professionals was not in the same way. Specialist physicians, general practitioners or family 
physicians, and registered nurses, with the exception of nurse supervisors and nurse 
managers, had a higher risk of work stress that was relative to that of other health care 
providers. 
In the southern region of Brazil, Urbanetto, Silva, Hoffmeister, Negri, da Costa and de 
Figueiredo (2011) carried out a cross-sectional study on workplace stress among nursing 
staff using the Demand-Control Model. However, the model does not explain the variations 
and aspects related to the object of study. The staff comprised of nurses, nurse technicians 
and nurse auxiliaries. The aim of the study was to identify workplace stress according to the 
Job Stress Scale and to compare it with socio-demographic and occupational variables of 
nursing workers. A convenient sample of 388 participants took part in the study. 
Out of this, 153 worked the Intensive Care Units (ICUs), 56 worked in Surgical Centres, 91 
were from hospitalization units and 88 worked in emergency units. The Job Stress Scale was 
used as the data collection tool for the study. The nature of work of the nurses was classified 
into job demand (high and low demand) and job control (high and low control). After that, 
Demand - Control quadrants were classified into ‘high strain jobs’ (indicating increased 
psychological demand coupled with workplace control); ‘active jobs’ (indicating increases 
psychological demand and more control); ‘passive jobs’ (indicating reduced psychological 
demand coupled with reduced control) and ‘low strain jobs’ (indicating reduced 
psychological demand in addition to increased control). The total number of health 
professionals who had low psychological demand was found to be significantly (p<0.001) 
higher. Moreover, the total number of health professionals who had low control was found 
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to be significantly high (p=0.006).  
Using non-adjusted logistic regression, findings showed that auxiliary nurses or health 
technicians, health workers who have had more than 15 years’ work experience, and health 
workers with low social support had positive association with and were more likely to be 
classified as being in the high strain quadrant. Secondly, health workers who were nursing 
technician or nurse auxiliaries were more likely to be in the passive job quadrant. However, 
health workers who have had more than 15 years’ work experience were more likely to be in 
the active job quadrant. Among those with a lower chance of being placed in the active job 
quadrant were health workers hospitals or those working in the intensive care unit.  
2.5 How Nurses Cope with Stress 
The extent to which nurses experience occupational stress is determined by the success of 
stress coping mechanisms adopted by the nurses to be able to cope with stressors related to 
their job situation (Sveinsdottir et al., 2006). Coping strategies include problem focused 
coping (which involves the act of confronting or dealing directly with the source of stress); 
reappraisal (thus reflecting on the import of actions taken to deal with workplace stress); 
avoidance coping (thus actions taken to avoid or get one distracted from the problem at 
hand); and then emotional coping (thus actions geared towards addressing or controlling 
how one responds emotionally to stressful situations). If nurses are able to manage their 
stress well, they will be able to have a more positive impact on the lives of people around 
them and the stressors form other persons will have less negative effect on them (Dapaa, 
2014). 
Spielberger and Vagg (1999) posited that successful identification of the main sources of 
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stress at ones workplace provides two fold benefits for both employees of an organization 
and the management of that organization. First of all, it helps to be able to identify certain 
changes at the work place that are needed to help bring down the level of stress among 
employees and help increase productivity. Secondly, it promotes the planning and 
development effective interventions required to lessen the negative effects associated with 
organizational stress.  
Coping has been identified as one of the stabilizing factors that help individuals to be able to 
psychologically and socially adapt to stressful situations. According to Robin (2002), the 
way one actually responds to any stressful situation in the environment is as important as the 
situation itself. Sources of stressors can be social, physiological or it can be from the 
environment.  
The way people cope with stress can be described as positive or negative coping. It can also 
be described as reactive (that is, how one reacts to his or her thoughts and feelings) or active 
(that is direct actions taken to address stressful situations or events that one faces). However, 
active or reactive ways to coping with stress can be either positive or negative an, this 
depends on the peculiar nature of the situation and the nature of the response to the stressor 
(Shields, 2001). There exist many ways that people adopt to be able to cope with various 
stressors. Literature on stress shows that people in general actually adopt more than one 
approach to dealing with stressful situations in their life rather than resigning to only one 
way (Lazarus, 1993). 
Various techniques that are learned by people and used to relieve tension, reduce stress and 
to calm down are referred to as positive coping strategies. Examples of these positive coping 
strategies include deep breathing exercises and relaxation techniques (Fortinash & Holoday-
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Worret, 2004). These strategies, if applied appropriately, help people to be able to 
successfully adapt to stressful situations. These can either be therapeutic and non-
therapeutic. Therapeutic coping strategies are the coping strategies that are geared towards 
assisting the individual in the acquisition of insight, gaining of confidence to face reality, 
and to mature emotionally (Timby, 2008). Coping strategies adopted in a particular situation 
depend on individual differences among people, past experiences or the nature of the 
situation (Heerwagen & Diamond, 1992). 
Callaghan, Tak-Ying and Wyatt (2000) found that the most frequently used coping strategy 
among nurses were venting to, giving and receiving social support. They identified certain 
harmful coping strategies that nurses adopted. These coping strategies included smoking, the 
excessive use of drugs or other medicinal substances and the consuming of alcohol. Hope, 
Kelleher and O’Connor, 1998) also posited that nurses resort to eating of food in order to 
cope with stress. According to Sullivan (1993), coping strategies that were found to have 
been adopted by nurses to relief their stress and level of dissatisfaction included, but it was 
not limited to, problem solving techniques, acceptance of responsibility, having positive 
thoughts about situations in live and avoiding stressful situations entirely.  
In a study entitled “Nursing and Coping with Stress”, Laal and Aliramaie (2010), assessed 
how Iranian nurses coped with stressful situations (thus with regard to the application of 
both positive and negative coping strategies) and its relationship with how nurses cope and 
the health outcome of nurses. In this cross-sectional study, a total of 100 nurses working in 
the Tohid and Besat Hospitals of Sanandaj City in Iran were selected for the study. The 
Adolescent Coping Orientation for Problem Experiences (A-COPE) questionnaire was 
adopted and used in this study to assess coping strategies used by the nurses.  
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The positive coping strategies found to be used by the Iranian nurses included listening to 
music, buying of books, cassettes or tapes, going on shopping spree with friends and family, 
watching of movies at home or at the cinema, spending time to read books, singing or 
composing songs, having enough rest, going for hiking including other sporting events. 
In addition to that, making of table arrangements at work, engaging in repair and some 
construction works at home, taking part in group games, participating in conferences or 
attending concerts, going for excursions to parks, mountainous areas in addition to having 
some quiet time for reflection at a quiet place. Some other activities used to relief stress 
were spending time to play with pets, praying or meditating and carrying out relaxation 
exercises, engaging in gardening or painting activities, having a good bath, spending time to 
chat with friends and colleagues about the problems one is facing, paying visit to family and 
friends, playing chess or computer games and getting oneself occupied with home chores.  
Negative coping strategies that were found among the Iranian nurses included having 
disputes, engagement in profanity or the use of insults, yelling at others and making of 
negative speeches about self, taking of tea or coffee in excess, intake of alcohol in excess, 
smoking, abuse of abuse, having suicidal ideations, impatience, reckless driving, eating too 
much or not eating enough food, social isolation distancing oneself from others, negative 
expectations about self, crying spells, nail biting and tossing of objects.  
2.6 Summary  
The review of literature shows that the nursing profession is indeed a stressful one. 
However, there are varying degrees of stress and its prevalence among the various studies 
that have been carried out so far. This may be attributed to the different scales used to assess 
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stress levels of nurses in the various studies. Various models and stress scales such as the 
STP model of occupational stress, the NSI scale, the ENSS and the Interpersonal Work 
Relations Scale. However, none of the studies adopted the stress component of the DASS 
scale to assess levels of stress among nurses. Furthermore, just a few studies carried out by 
Dapaa (2014) and Yeboah et al. (2014) in Ghana focused on stress among nurses which 
suggests limited studies in the area of workplace stress among nurses. This study is therefore 
needed to close this gap.  
 
 
 
 
 
 
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CHAPTER THREE 
METHODOLOGY 
3.0 Introduction 
This chapter presents the methods employed in the study.  This includes the research design 
and a description of the setting in which the study was carried out. The chapter also 
describes how the sample size was determined, the sampling technique, data collection tool 
and technique, data analysis and ethical issues.  
3.1 Study Design 
A descriptive cross-sectional design was employed in this study. Descriptive designs 
describe what actually exists, determine the frequency with which it occurs, and categorizes 
the information (Burns & Grove, 2005). This design was employed to assess the prevalence 
of stress among nurses at the Tema General Hospital. 
3.2 Study Location 
This study was carried out at the Tema General Hospital. The Tema General Hospital is the 
largest public health institution located in the Tema Metropolis. It serves as the main referral 
point for all other clinics/ hospitals in the Tema Metropolis. The Hospital has a total of ten 
(10) wards with a bed capacity of 294. The Tema General Hospital provides a 24 hour 
specialist and general services on both out-patient and in-patient basis. The services, 
department and units available are; Internal Medicine, General Surgery, Obstetrics and 
Gynaecological Care, Paediatrics, Reproductive and Child Health Care/ Family Planning, 
Accidents and Emergency Services, Theatre, Prevention of Mother-to-Child Transmission 
(PMTCT)/ Voluntary Counselling and Testing (VCT). The specialist clinics/ units available 
are; Eye Clinic, Dental Clinic, Diabetic Clinic, Sickle Cell Clinic, Public Health, Weekly 
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Dermatology Clinic, ENT (ear, nose and throat) Clinic, Chest Clinic, Hypertensive Clinic, 
Anaesthetic Clinic, Antiretroviral treatment and prevention of mother-to-child transmission 
(ART/PMTCT) clinic. 
In addition, the hospital has the following support services; Laboratory/ Blood Bank, 
Radiology/ Ultrasound Scan, Pharmacy, Physiotherapy and electrocardiogram E.C.G 
(electrocardiogram). Other facilities in the hospital are Staff Rest Room, Catering/ Canteen, 
Mortuary, Laundry/ C.S.S.D (central sterilization service department service), Stores and 
Supplies and then Estate Department. The location of the Tema General Hospital within the 
Tema Metropolis is shown in the map below.  
 
Figure 3.1:Areal map showing the location of Tema General Hospital within the Tema 
Metropolis 
3.3 Study Population 
A target population comprises a group of individuals or subjects which serve as the main 
focus of a scientific query from which a sample is selected for a study (Castillo, 2009). The 
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target population for this study was nurses working at the Tema General Hospital. 
3.3.1 Inclusion Criteria 
The criteria for inclusion comprised of all categories of nurses employed at the Tema 
General Hospital. Nurses who have had at least one year experience in nursing and were 
willing to participate qualified for inclusion into the study. 
3.3.2 Exclusion criteria 
Student nurses on affiliation programmes and rotation nurses were excluded from the study. 
Nurses who had less than one year work experience at their current workplace were also 
excluded.  
3.4 Variables 
i. Dependent variable;  
a. Stress  
ii. Independent variables are;  
a. Demographic factors: Age, Sex, Educational status, Marital status, Rank, 
b. Stress coping strategies  
c. Work-related demands  
d. Work-related control  
e. Work-related support  
f. Work-related relationship  
g. Workplace Role  
h. Change  
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3.5 Sample Size Calculation 
Sample size was calculated using the model proposed by Glen et al. (1992): 
 
Where: 
n = Sample size required 
N = Total number of nurses at TGH (399) 
P = estimated proportion of people with stress (0.5) 
A = Precision desired around P to be estimated, (0.05) 
Z = Confidence level critical value (1.96 for 95% confidence) 
 
 
 
 
 
3.6 Sampling Procedure 
Stratified and simple random sampling techniques were used to select participants for the 
study. The stratified sampling technique is a form of probability sampling technique which 
involves the stratification of the target population into various cadres out of which individual 
subjects are then selected. This was carried out by subdividing the nurses based on their 
rankings, out of which a portion from each group was selected using the simple random 
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sampling technique. 
The simple random sampling technique is a type of sampling involving a selection at 
random from a list of the population of research interest (Robson, 1996). In applying the 
simple random sampling technique, ward managers in the hospitals were asked to provide 
the total number of registered nurses in their wards on each time the researcher visited the 
wards. The researcher then used the fish bowl technique to select the registered nurses on 
duty on each of the visits. This technique was to ensure that all the registered nurses in the 
wards or various cadres had equal chance of being selected for the study. 
3.7 Data Collection Tool 
A structured questionnaire was used to collect the data. The questionnaire had four main 
sections. The first section had 7 items on the demographic characteristics of respondents 
(age, sex, professional rank, educational level, ward/ unit, marital status, and number of 
years practicing). The second section was a 14 item stress component of the Depression 
Anxiety and Stress Scale (DASS) with five rankings (normal, mild, moderate, severe and 
extremely severe stress). This was used to assess the stress levels of the nurses.  
Normal stress represents no stress. It is the everyday stress that people generally encounter, 
but are able to cope with to the extent that it poses no threat to their health. Mild stress 
represents just a minimal level of stress which poses no danger and usually requires no 
treatment. Moderate level of stress represents increasing level of stress which may affect 
one’s physical health and, the person may require some form of psychological assistance. 
Severe stress refers to high levels of stress that threatens one’s physical health and requires 
both physical and psychological treatment. Extremely severe stress represents the highest 
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level of stress and burnout which is an imminent threat to one’s health and requires 
immediate attention.  
Total scores from 0-14 represented normal stress; scores 15-18 represented mild stress; 
scores 19-25 represented moderate stress; scores 26-33 represented severe stress and; scores 
34 and above represented extremely severe stress (DASS).  
The third section was a 16 item scale on 6 facility related factors contributing to stress with 
5 rankings. Demand, control, support, relationships, role and change all had 2, 3, 5, 2, 2, and 
2 items respectively.  
The fourth section was a 13 item scale on coping with stress with 5 rankings. Coping 
strategies include relationship, self-care, social support and cognition had 3, 4, 3 and 3 items 
respectively.  
Recreation involves distraction from stressful events and a form of relief outside work 
environment. This involves forms of leisure activities and entertainment. Self-care 
represents healthy activities such as exercise, rest and sleep, good nutrition, avoidance of 
harmful substances such as illicit drugs and alcohol and the practice of relaxation 
techniques. Good interpersonal relationship with family and friends, as well as social 
groups, represents social support. This serves as an avenue for help, comfort and relief. 
Cognitive coping involves problem solving techniques such as planning, setting of priorities 
and effective time management.  
3.8 Quality Control 
Quality control was ensured by carrying out a pre-test of the data collection tool at the Ridge 
Hospital in Accra to ensure consistency of the findings. Training of two research assistants 
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was done to provide assistance with the data collection process. Data collection was done by 
the researcher and the trained assistants to ensure that the process was carried out 
effectively. All participants were duly informed about the study. All filled questionnaires 
were cross-checked 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-Test of the Questionnaire 
A pre-test of the questionnaire was carried out at the Ridge Regional Hospital. This was carried 
out on ten (10) nurses. The questionnaire was then reviewed and necessary amendments done 
based on the responses before the actual data collection process. This was to help eliminate 
unnecessary questions and rephrase ambiguous ones to ensure consistency of the findings. 
3.10 Data Processing and Analysis 
Data collected was analysed using the STATA (Version 13). After initial collection of data, 
the questionnaire was coded using the STATA and data from each questionnaire entered into 
the software. All entries made were then edited to eliminate errors after which the data was 
processed. Descriptive analysis of demographic data was carried out using frequencies, 
means and standard deviations which were then presented in the form of frequency 
distribution tables and bar graphs.  
Stress level was also analysed descriptively, with the frequencies and percentages illustrated 
in a bar chart. The 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. 
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Factors contributing to stress and coping strategies were also analysed descriptively using 
frequencies, means and standard deviations which were then presented in the form of 
frequency distribution tables.  
Means scores on facility related factors contributing to stress among nurses were calculated 
by summing up the scores under all the items under each factor (demand, control, support, 
relationships, role and change) and finding the mean score for each facility related factor for 
each individual. The average of all the individual means for calculated for each factor for 
each individual was then calculated to get the mean score on each facility related factor for 
the entire sample.  
3.11 Ethical Consideration 
Ethical approval to carry out the study was sought from the Ghana Health Service Ethical 
Review Board. Permission to conduct the study was obtained from the Tema General 
Hospital administration by sending an introductory letter to formally introduce the 
researcher to them. Each participant was also provided a written informed consent to sign to 
indicate their willingness to participate in the study. 
No form of coercion was employed to lure the participants into taking part in this study. The 
purpose, benefits and potential risks for taking part in this study were duly explained to all 
the participants. All participants were informed that they can opt out of the study any time 
they wish without having any negative effect on their status at work.  
Anonymity was ensured by assigning numbers to each of the questionnaires filled by the 
respondents in place of their names. No one was allowed to write his or her name on the 
questionnaire. The questionnaires were also administered to the participants individually to 
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ensure privacy. In order to ensure confidentiality, all information provided were kept safety 
under lock and was only be accessible to the researcher and the supervisor. 
 
 
 
 
 
 
 
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CHAPTER FOUR 
RESULTS 
4.0 Introduction 
This chapter presents the results of the study and is divided into sections. The first section 
reports the demographic characteristics of participants. The rest of the sections present the 
results according to the objectives of the study. 
4.1 Demographic Characteristics of Respondents 
Eighty six (43.4%), of the respondents were between 31-40 years and 78 (39.4%) were 
between 20-30 years. Majority, 158 (79.8%) of the respondents were females. Eighty six 
(43.4%), of them had diploma and 85 (42.9%), had a bachelor’s degree. However, 21 
(10.6%) of them had a master’s degree. Others, 6 (3.0%), had post basic certificates in 
various nursing specialties such as critical care, ophthalmic and paediatric nursing. Majority, 
105 (53%), of the respondents were married and 86 (43.4%) were single. Majority, 163 
(82.3%), of the nurses were registered general nurses, followed by health assistants 11 
(5.6%) and midwifes 11 (5.6%). The average years of working experience among the 
participants was 7.7 years (SD= 5.97). Detail analysis is shown in table 4.1 below.  
 
 
 
 
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Table 4.1: Demographic Characteristics of Respondents 
Variable  Frequency (n) Percent (%) 
Age 20-30 years 78 39.4 
 31-40 years 86 43.4 
 41-50 years 23 11.6 
 51-60 years 11 5.6 
 Total 198 100 
    
Sex Male 40 20.2 
 Female 158 79.8 
 Total 198 100 
    
Educational status Diploma 86 43.4 
 Degree 85 42.9 
 Masters 21 10.6 
 Other 6 3.0 
 Total 198 100 
    
Marital status Single 86 43.4 
 Married 105 53 
 Separated 3 1.5 
 Widowed 4 2.0 
 Total 198 100 
    
Category of Nurse Community health nurse 1 0.5 
 Critical care nurse 2 1 
 Health assistant clinical 4  2 
 Midwife 11 5.6 
 Ophthalmic nurse 11 5.6 
 Paediatric nurse 1 0.5 
 Public health nurse 5 2.5 
 Registered general nurse 163 82.3 
 Total 198 100 
 
 
 
 
 
 
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The respondents comprised 66 (33.3%) nursing officers (NO), 61 (30.8%) staff nurses, 26 
(13.1%) senior staff nurses (SSN), 22 (11.1%) senior nursing officers, 20 (10.1) principal 
nursing officers (PNO) and 3 (1.5%) deputy directors of nursing service (DDNS). This is 
shown in figure 4.1 below.  
 
Figure 4.1: Professional rank distribution of respondents  
 
 
 
 
 
 
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4.2 Prevalence of Stress among Nurses  
As shown in Figure 4.2 below, majority, 88 (45%) of the respondents had extremely severe 
stress, followed by 60 (30%) with severe stress, 40 (20%) with moderate stress and 8 (4%) 
with mild stress. Only 2 (1%) had normal stress. Thus placing the prevalence rate of stress at 
99%.  
 
Figure 4.2: Prevalence of stress 
 
4.3 Association between Demographic Characteristics of Nurses and Levels of 
Stress  
Another objective of the study was to assess the association between stress levels and 
demographic variables (age, sex, rank, marital status, educational status, years of work 
experience).  Years of work experience was categorized into two (1-10 years and More than 
10 years).  
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The Chi-square statistics was used to test the relationship between age and sex category and 
level of stress among nurses, both of which are categorical variables. The Chi-square 
statistics shows that there is no statistically significant association between the age category 
of nurses and their level of stress (X2= 17.729, p= 0.139). This indicated that the level of 
stress among nurses is not determined by the age category in which they belong.  
The Chi-square statistics also showed that there was no statistically significant association 
between sex and level of stress among nurses (X2= 7.845, p= 0.079). This indicated that the 
level of stress among nurses was not determined by the age category in which they 
belonged. Detail analysis is shown in Table 4.2 below. 
Table 4.2:  Relationship between Age, Sex and level of stress  
Variable  Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Extremely 
severe n (%) 
Chi-
square 
test  
P-
value 
Age  20-30 0 (0%) 4 (50%) 19 (47.5%) 26 (43.3%) 29 (33%) 17.729 0.139 
 31-40 1 (50%) 3 (37.5%) 14 (35%) 24 (40%) 40 (50%)   
 41-50 0 (0%) 0 (0%) 7 (17.5%) 6 (10%) 10 (11.4%)   
 51-60 1 (50%) 1 (12.5%) 0 (0%) 4 (6.7%) 5 (5.7%)   
         
Sex Male 0 (0%) 0 (0%) 4 (10%) 12 (20%) 24 (27.3%) 7.845 0.097 
 Female 2 (100%) 8 (100%) 36 (90%) 48 (80%) 64 (72.7%)   
 
 
 
 
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Levels of stress among nurses were also compared with their professional rank using the 
Chi-square statistic. The Chi-square statistics showed no statistically significant association 
between professional rank and level of stress among nurses (X2= 19.591, p= 0.484). This 
meant that the stress level of nurses was not affected by their professional rank. This is 
shown in Table 4.3 below. 
Table 4.3:  Relationship between professional rank and level of stress  
Rank Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Extremely 
severe n (%) 
Chi-square 
test  
P-value 
SN 0 (0%) 1 (12.5%) 14 (35%) 21 (35%) 25 (28.4%) 19.591 0.484 
SSN 0 (0%) 0 (0%) 3 (7.5%) 8 (13.3%) 15 (17%)   
NO 2 (100%) 3 (37.5%) 12 (30%) 17 (28.3%) 32 (36.4%)   
SNO 0 (0%) 2 (25%) 5 (12.5%) 7 (11.5%) 8 (9.1%)   
PNO 0 (0%) 2 (25%) 6 (15%) 7 (11.7%) 5 (5.7%)   
DDNS 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (3.4%)   
 
The relationship between education and stress level among nurses was assessed with the 
Chi-square statistic. No statistically significant association was found between highest level 
of education and level of stress among nurses (X2= 13.999, p= 0.599). This means that the 
stress level of nurses is not influenced by their highest level of education. This is shown in 
Table 4.4 below. 
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 Table 4.4:  Relationship between educational status and level of stress  
Education Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Extremely 
severe n (%) 
Chi-
square test  
P-value 
Diploma 0 (0%) 1 (12.5%) 16 (40%) 29 (48.3%) 40 (45.5%) 13.999 0.599 
Degree 2 (100%) 6 (75%) 18 (45%) 23 (38.3%) 36 (40.9%)   
Masters 0 (0%) 1 (12.5%) 3 (7.5%) 6 (10%) 11 (12.5%)   
Others 0 (0%) 0 (0%) 3 (7.5%) 2 (3.3%) 1 (1.1%)   
 
The marital status of nurses and years of work experience were also compared with the level 
of stress among nurses using the Chi-square statistic. However, there was no statistically 
significant association between marital status and level of stress among nurses (X2= 12.403, 
p= 0.414). This implies that the marital status of nurses does not influence their level of 
stress.   
Secondly, no statistically significant association was also found between years of work 
experience and level of stress among nurses (X2 =5.186, p= 0.269). This means that the 
stress level of nurses is not determined by the number of years they have practiced nursing. 
This is shown in Table 4.5 below. 
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Table 4.5:  Relationship between marital status, years of work experience and level of 
stress  
Variable  Normal 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Extremely 
severe  
n (%) 
Chi-
square 
test  
P-
value 
Marital 
status 
Single 0 (0%) 3 (37.5%) 17 (42.5%) 33 (55%) 33 (37.5%) 12.403 0.414 
 Married 2 (100%) 5 (62.5%) 22 (55%) 23 (38.3%) 53 (60.2%)   
 Separated 0 (0%) 0 (0%) 1 (2.5%) 2 (3.3%) 0 (0%)   
 Widowed 0 (0%) 0 (0%) 0 (0%) 2 (3.3%) 2 (2.3%)   
         
Years 
of work 
First 10 
years 
1 (50%) 7 (87.5%) 27 (67.5%) 49 (81.7%) 72 (81.8%) 5.186 0.269 
 More than 
10 years 
1 (50%) 1 (12.5%) 13 (32.5%) 11 (18.3%) 16 (18.2%)   
 
4.4 Facility Related Factors Contributing to Stress among Nurses 
Facility related factors contributing to stress among nurses that were measured included 
demands at the workplace, level of control, support, interpersonal relationships, role at work 
and change at the workplace.  
The results showed that interpersonal relationship (mean =3.712, SD =1.052) had the highest 
mean scores which indicate that poor relationship with others at work was the highest 
contributing factor to stress among nurses in the hospital compared to others.  
Role (mean =3.402, SD =1.067), Control (mean = 3.364, SD =0.984), Change (mean 
=3.164, SD =0.957), Support (mean =2.869, SD =0.812), had moderate mean scores. This 
indicated the average contributory effect that these facility related factors had on stress 
among nurses.  
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The factor with the lowest mean score was Demand (mean =2.141, SD =0.928). This 
indicates that the extent to which demands placed on nurses at the work place affect their 
stress levels is low. Details of the analysis are shown in Table 4.6 below.  
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Table 4.6:  Facility related factors contributing to stress among nurses 
Factors Minimum Maximum Mean SD 
Demand (Total score)   2.141 0.928 
The workload at work is too much 1 5 2.08 0.958 
There is too much pressure at work 1 5 2.20 1.007 
Control 1 5 3.364 0.984 
I am not involved in any decision making at work 1 5 3.03 1.117 
I am not allowed to make decisions on my own at work 1 5 3.36 1.116 
I am not recognised as important at work 1 5 3.70 1.134 
Support (Total score)   2.869 0.812 
There is lack of encouragement from management  1 5 3.10 1.265 
There is no sponsorship at work 1 5 3.03 1.272 
I lack resources and materials needed to work 
effectively and efficiently 
1 5 2.95 1.134 
My salary is not satisfactory 1 5 2.15 1.256 
There is no provision of guidance at work 1 5 3.13 1.126 
Relationships (Total score)   3.712 1.052 
Conflict with colleagues and/ or other health team 
members 
1 5 3.24 1.242 
Poor relationship with management and/ or superiors 1 5 3.51 1.121 
Role (Total score)   3.402 1.067 
I have conflicting roles with colleagues and other 
members of the health team 
1 5 3.33 1.184 
I am uncertain about what I am supposed to accomplish 
in my work 
1 5 3.47 1.224 
Change (Total score)   3.164 0.957 
There is slow pace of change in the organization 1 5 3.17 1.065 
Changes in organizational policies and mode of 
operation are poorly communicated to the staff 
1 5 3.11 1.063 
 
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A Pearson product-moment correlation was run to determine the relationship between 
facility related factors contributing to stress and levels of stress among nurses. 
Results of Pearson’s correlation showed that there was a strong but significant negative 
correlation between stress and work demand (r = -0.280, n = 198, p < .001) and role (r = -
0.283, n = 198, p < .001). This showed that the lower the demand placed on nurses at work 
and the less defined their roles are, the more stressed they become.  
The test also showed a strong but significant negative correlation between stress and control 
(r = -0.158, n = 198, p < .05) and, relationship (r = -0.203, n = 198, p < .05). This implies 
that the less control nurses have at work and the poorer the relationship they have with other 
staff at work, the more stressed the nurses become.  
Furthermore, there was negative but weak correlation between stress and support (r = -
0.049, n = 198, p >.05) and change (r = -0.025, n = 198, p >.05). This indicates that 
workplace support and change does not have any significant impact on nurses’ level of 
stress. Details of the analysis are shown in table 4.7 below.     
Table 4.7:  Relationship between facility related factors contributing to stress and level 
of stress 
Variables                      Age 
 r   p- value (2-tailed) 
Demand -0.280 0.000 
Control  -0.158 0.026 
Support  -0.049 0.493 
Relationship -0.203 0.004 
Role  -0.283 0.000 
Change 0.025 0.726 
 
 
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4.5 Coping Mechanisms adopted by Nurses to reduce Stress 
Coping mechanisms that nurses used to reduce stress were assessed. These included 
recreation, self-care, social support and cognition.  
The results showed that Cognition (mean =2.958, SD =0.889), Recreation (mean =2.662, SD 
=0.722) and Social support (mean =2.646, SD =0.840) had the highest mean scores in 
relation to coping mechanisms in stress reduction. This implies that nurses most of the time 
engage themselves in recreational activities to relax themselves, seek social support in times 
of difficulty as well as employ cognitive strategies such as planning and avoidance 
techniques to deal with stressful situations.  
The coping mechanism with the lowest mean score was Self-care (mean =1.969, SD =0.568) 
compared to other coping mechanisms. This means that nurses often neglect themselves 
without paying much attention to their own health. Detail analysis is shown in Table 4.8 
below. 
 
 
 
 
 
 
 
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Table 4.8:  Stress coping mechanisms 
Coping Mechanism Minimum Maximum Mean SD 
Recreation 
 
  2.662 0.722 
When I need a leave I take one 1 5 2.62 1.091 
 I am able to do what  I want to do in my 
free time 
1 5 2.84 1.078 
 I hardly watch television  1 5 2.53 0.975 
Self-care 
 
  1.969 0.568 
When I’m relaxing, I frequently think 
about work    
1 5 2.64 1.065 
I get regular physical check-ups 1 5 2.31 0.984 
I exercise regularly  (at least 20mins.,3 
times a week) 
1 5 2.46 1.152 
I practice relaxation techniques 1 5 2.43 1.039 
Social support   2.646 0.840 
If I need help at work ,I know who to 
approach 
1 5 3.04 1.202 
My working environment is not friendly 1 5 2.08 1.306 
In times of difficulties there is someone to 
talk to. 
1 5 2.83 1.162 
Cognition   2.958 0.889 
I can establish priorities  for  the use of my 
time        
1 5 2.97 1.108 
Once they are set, I am able to stick to my 
priorities 
1 5 2.94 1.055 
I have techniques to help avoid being 
distracted 
1 5 2.96 1.087 
 
 
 
 
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CHAPTER FIVE 
DISCUSSION  
5.0 Introduction 
This chapter presents the discussion of the findings with related literature. The first section 
is a discussion of the demographic characteristics of the respondents. The subsequent 
sections comprise a discussion of the results according to the objectives of the study.  
5.1 Demographic Data 
A total of 198 nurses took part in this study. They were mainly young nurses from 20-40 
years old (82.8%) with an average working experience of 7.7 years. This is consistent with 
the average age of nurses in Ghana which is said to be between 25 to 35 years (GHS annual 
report, 2013). Nurses within this young age bracket are usually active and may be involved 
in multiple tasks at work which might place some strain on them. This can be linked to Filha 
et al. (2013) in Brazil who found that younger staffs below 35 years of age are predominated 
with work with high strain.  
Majority (79.8%) of them were females which suggest that females continue to dominate the 
nursing profession. This is similar to the findings of Dapaa (2014) who found that female 
nurses in the Greater Accra Region of Ghana comprised 70.7% of his study sample. Nursing 
begun as a female oriented profession and still continues to be predominantly dominated by 
females. This is consistent with the findings by Meadus and Twomey (2011) that although 
some appreciable numbers of men are entering the nursing profession, the increase in the 
percentage of men in nursing has not been significant. The gender imbalance in nursing is 
also perpetuated by the increasing exit of males from the nursing profession compared to 
their female counterparts (McLaughlin, Muldoon & Moutray, 2010). 
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The current study found that 87.9% of the respondents were registered general nurses and 
midwifes. Among them 30.8% were staff nurses. More than half of the respondents (57.5%) 
were nurses in the senior grade (senior staff nurses, nursing officers and senior nursing 
officers) whilst those in the penultimate grade (principal nursing officers and deputy 
directors of nursing service) were just a few (11.6%). This explains why majority of them 
were in the young age bracket. Moreover, staff nurses and nurses in the senior grade are 
mostly responsible for the day to day activities on the wards or in their various units and are 
more likely to bare the main physical and psychological burden of workload on the job 
compared to those in the penultimate grade. However, those in the penultimate grade are 
also mainly involved in administrative activities and are liable to the stress associated with 
the day to day nursing administrative activities.  
Majority of nurses in Ghana enter the profession at the diploma level with a few entering the 
profession at the degree level. However, 43.4% of the nurses in this study had diploma and 
42.9% had a bachelor’s degree in nursing which suggest that most of the nurses with 
diploma had advanced in the academic ladder of their profession to acquire a degree. This 
can be linked to the recent proliferation of private universities offering two year regular top 
up and three years sandwich top up courses for nurses with diploma to acquire a degree in 
nursing. A few of them remaining had master’s degree (10.6%) in nursing which shows that 
that nurses still continue to climb higher the academic ladder in their profession (The Future 
of Nursing, 2010). This implies that more Ghanaian nurses are motivated to progress in their 
carrier which predicts a brighter future for the nursing profession in the country.   
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5.2 Prevalence of Stress among Nurses  
Undoubtedly, the nursing profession is characterized by a variety of stressful situations 
which makes nursing a stressful occupation (Lambert & Lambert, 2008). According to 
Shields and Wilkins (2006) job related stress is associated with the 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. Videbeck (2007) posited 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 
(Zaghloul, 2008). This places the nurses in this current study at risk of reduction in their 
overall performance at work (Shields & Wilkins, 2006). 
The findings from this study revealed that 45% and 30% of the nurses had extremely severe 
and severe stress respectively. It shows that majority of the nurses (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 (Spielberger et al., 2003).  
According to Shields and Wilkins (2006), nurses experiencing higher levels of stress are 
more likely to experience poor health. This implies that the nurses in this current study are 
vulnerable to stress related physical and psychological conditions due to the stressful nature 
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of the profession. Lowe (2006) posited 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 capacity to adapt to stress, however, responses to 
stress among people are never the same (Timby, 2008). Persons with such high level of 
stress are prone to many types of physical ailments. These include hypertension, various 
form of heart diseases, peptic ulcer in addition to body discomfort such as headache and 
bodily pains (Mehta & Chaudhary, 2005). In addition to these physical problems, 
psychological conditions such as depression (Hammen, 2005) and sleep problems (Harvey 
et al., 2003) are also associated with increased levels of stress. This highlights the 
vulnerability of nurses to these stress related conditions.  
Twenty percent (20%) of the nurses had moderate stress and 4% had mild stress. However, 
this is likely to rise to higher stress levels if the work situation remains unchanged. Nurses 
play a key role in the provision of adequate, timely and quality health care services however, 
the stress experienced at work affects their output, which is a matter of growing concern 
(Offei & Quansah, 2009). The danger of stress in the nursing profession within the country 
calls for multilateral concerted efforts to address the situation in order to save the lives of the 
life savers. According to Offei and Quansah (2009), the Ministry of Health in Ghana is not 
unaware about the stressful situation that nurses face at work. However, attempts to provide 
resources to help nurses cope with stress associated with their work situation have not been 
fruitful.  
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5.3 Demographic Characteristics of Nurses and their Relationship with Levels of 
Stress  
The study also investigated the relationship between stress among nurses and their age, sex, 
rank, marital status, educational status, and years of work experience. Findings from the 
study showed no statistically significant relationship between the age category of nurses, 
sex, professional rank, level of education, marital status, years of work experience and level 
of stress among nurses. This means that no difference was found in the levels of stress 
among male and female nurses, married and unmarried nurses, junior and senior nurses and 
nurses with lower and higher academic qualification. This indicates that stress permeates all 
aspects of the nurses irrespective of ones’ rank and years of work experience in the 
profession in addition to other factors such as sex, age, marital status and level of education.  
Similar to this finding, Filha et al. (2013) found no statistically significant difference in the 
stress levels among marital status and level of education of nurses in Brazil.  
 On the contrary, Milutinović et al. (2012) in their study on stress levels of nurses found 
significant differences in the levels of stress levels in relation to age, marital status, and 
education level among critical care nurses. This might be due to the fact that their study was 
based on a section of nurses – critical care nurses – and not nurses in general.  
5.4 Facility Related Factors Contributing to Stress among Nurses 
According to Lambert and Lambert (2008), nurses are confronted with a variety of stressors. 
Demands at the workplace, level of control, support, interpersonal relationships, role at work 
and change at the workplace are key factors within the workplace environment that 
influences the level of stress among employees. This can be linked to sources of stress that 
are encountered in the work environment as indicated by Spielberger et al. (2003) in the STP 
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model of occupational stress. This is suggestive of the diverse ways, events or circumstances 
that lead to stress (Manktelow, 2005). 
 
The current study found that the main contributor to stress among nurses at the workplace 
was poor interpersonal relationship (mean =3.712, SD =1.052). Interpersonal relationship 
had a strong but significant negative correlation with stress among the nurses (r = -0.203, n 
= 198, p < .05) which underscored the fact that poor interpersonal relationship at work is a 
significant contributor to stress among nurses. Similarly, Bratt et al. (2000) found that inter 
and intra-professional conflict still remains an important source of stress for nurses. With 
regard to poor workplace relationship factors, inter-professional conflict between nurses and 
physicians was found to be a major problem at the workplace.  
 
Among nine sub-scales of workplace situations identified by French et al. (2000) to 
contribute to stress among nurses, conflict with physicians, problems with peers, problems 
with supervisor and discrimination were four items within the sub-scales that lead to 
interpersonal relationship at work. In their study in Portugal, Rodrigues and Ferreira (2011) 
noticed that as the interpersonal relationship at work got worse, stress levels among the 
nurses rose up to higher levels.  
 
Contrary to the finding of the current study, Rothmann et al. (2006), in their cross-sectional 
survey in South Africa found 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. However, they also noticed that, to 
some extent, significantly higher scores on stress were observed among nurses in South 
Africa due disagreement between nurses and medical practitioners or colleagues concerning 
the treatment of a patient.  
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This means that misunderstandings, contentions, and lack of cohesion among nurses abound 
in the profession leading to strained relations between nurses and their colleagues, superiors 
and subordinates. The existence of positive interpersonal relationship among nurses and 
others at the workplace make them spend quality time together and contributes to quality 
care for their patients.  However, strained relations among employees in general make them 
uncomfortable working with each other. According to Preto and Pedrão (2009), continual 
exposure of nurses to strained relationships between colleagues, superiors and other health 
professionals is likely to lead to feelings of irritability, depression and disappointment. It 
also creates feelings of distress and rejection (Mehta & Chaudhary, 2005). This serves as a 
great impediment to work and happiness. As a result of this, nurses are likely to feel hurt and 
unhappy at work. They are unlikely to collaborate well with each other causing more 
frustration and mental stress at work.  
The second group of facility related factors that contributed to stress among the nurses in 
this current study were; role at work (mean =3.402, SD =1.067), level of control (mean = 
3.364, SD =0.984), workplace changes (mean =3.164, SD =0.957) and support at work 
(mean =2.869, SD =0.812). Role at work includes the level of understanding that employees 
have about their role in the organisation in addition to how the organisation makes sure there 
are no conflicting roles among their staff. In this current study, nurses understanding of role 
at work had a strong but significant negative correlation with stress among nurses (r = -
0.283, n = 198, p < .001) which indicates that poorly defined roles and role confusion 
significantly contributes to stress among nurses. Lambert et al. (2004) posited that in the 
event of incongruity between expected roles and actual roles being carried by an employee, 
role stress develops. This is likely to result on frustration and burnout at work which 
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underscores the need for nurse managers to employ the needed management skills in 
assigning roles to nurses in various grades and categories in order to avoid role strain.  
Secondly, level of control includes the level of autonomy that one has over some aspect of 
the workplace. This also includes how much employees are recognized in an organization 
and the extent to which their views or opinions are heard. In this current study, level of 
control at work had a strong but significant negative correlation with stress among nurses (r 
= -0.158, n = 198, p < .05) which showed that nurses with less control at work become more 
stressed up. Therefore, lack of control among nurses at the workplace is likely to make them 
loose their sense of initiative and make them feel unimportant at work which can be 
stressful. However, in a study in the Greater Accra Region of Ghana, Dapaa (2014) found 
that nurses’ lack of control at the workplace was the least source of workplace stress among 
the nurses.  
Furthermore, the spate of change within the workplace environment can be stressful 
depending on the rate and level of involvement of the staff in decisions concerning the 
change process. Sudden changes effected in the work environment of nurses such as 
redeployment, sudden change in shift and frequent reshuffling of nurses to other wards, units 
of department can be stressful.  
Support involves the provision of necessary resources needed to make work easy and 
comfortable (Sanders, 2013). It also involves assistance from both management and staff 
(Zhang & Zhu, 2008). Lack of support at work increased the level of stress among the 
nurses. This finding confirms that of Filha et al. (2013) in Brazil where low social support 
among nurses contributed to increased levels of stress.  
 
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Although nursing is known as a generally demanding profession (Zaghloul, 2008), the 
nurses perceived demand as the least facility related factor that contributes to workplace 
stress (mean =2.141, SD =0.928). This might be an indication that the nurses have become 
used to the stressful routine at work and did not consider it as a stressor anymore. However, 
a comparison between workplace demand and the stress level of the nurses showed a strong 
but significant negative correlation between stress and work demand (r = -0.280, n = 198, p 
< .001). This can be linked to Ruggiero (2003) who found that workplace stress among 
nurses could be related to variables of shift work that are physically and mentally 
demanding. The Demand-Control Model explains that greater demands placed on 
individuals at the workplace makes them have less control over their work which places 
them at a higher risk of becoming physically or psychologically stressed (Karasek & 
Theorell, 1990).  
5.5 Coping Mechanisms adopted by Nurses to reduce Stress 
With regard to coping mechanisms employed by nurses to reduce stress, cognition, 
recreation and social support emerged as the main forms of coping mechanisms the nurses 
used to deal with the stressful situations at work. This suggests the various ways that the 
nurses adopt to help relieve the stress experienced at work. This confirms the findings by 
Lazarus (1993) that people tend to use a number of different coping approaches rather than 
just one. Sveinsdottir et al. (2006) posited that the extent to which each nurse copes with the 
stress experienced at work is a main indicator of occupational stress in nursing. However, 
Kalliath and Morris (2002) highlighted the existence of some imbalance between the 
provision of high quality care and the way nurses cope with stressful situation in their 
working environment.  
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In the current study, the nurses engaged themselves in recreational activities to relax 
themselves, seek social support in times of difficulty as well as employ cognitive strategies 
such as planning and avoidance techniques to deal with stressful situations. Social support 
involves accessing and receiving support and encouragement from friends and family. This 
can be linked to Callaghan et al. (2000) who found that giving and receiving social support 
were the most frequently used coping strategy among nurses. Similarly, Laal and Aliramaie 
(2010) reported positive coping strategies among nurses where recreational activities, 
seeking social support from friends and family among others were reported in Iran.  
Better stress coping strategies make nurses to positively affect people around them whereas 
poor coping strategies makes nurses to negatively affect people around them (Dapaa, 2014). 
Effective stress management practices among nurse promotes punctuality at work, effective 
handling of demands at work, facilitates healthier and longer life, increases the quality of 
productivity and promotes healthier and longer life among nurses.  
However, the least coping mechanism employed by the nurses in this study was self-care. 
The use of self-care involves activities such as good nutrition, regular exercise, routine 
medical review to mention but a few. This means that nurses often neglect themselves 
without paying much attention to their own health.  
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CHAPTER SIX 
CONCLUSION AND RECOMMENDATIONS 
6.0 Introduction 
This chapter focuses on conclusions of the study, implications of the finding for research, 
policy, practice and education. Also included in this chapter are the limitations of the study 
and recommendations based on the findings of the study.  
6.1 Conclusion 
Conclusively, stress and burnout are well documented to affect work output and quality of 
work among employees. The findings from the study on the prevalence of stress revealed a 
high (99%) prevalence of stress among the nurses at the Tema General Hospital. This 
suggests the need for multilateral concerted efforts to address stress associated with the 
nursing profession. Analysis of the relationship between stress among nurses and their 
demographic characteristics showed no significant differences in the age category of nurses, 
their sex, professional rank, level of education, marital status, years of work experience and 
nurses’ level of stress. However, these differences were evident in other studies.  
Facility related factors contributing to stress among nurses were poor interpersonal 
relationship, poorly defined roles at work, workplace demand and low level of control. 
These factors confirm the findings from previous studies. This gives a strong indication of 
the need for improvement in nursing management and leadership practices. 
General coping mechanisms adopted by the nurses to manage their stress included cognitive 
actions involving effective planning and priority setting, engaging in recreational activities 
and seeking social support which were positive. However, the neglect of self-care among the 
nurses is a matter of concern.   
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6.2 Implications of the Study 
The findings of this study have implications for the occupational safety among nurses and 
health care management in general. The implications are grouped into practice and 
management, policy making, education and research. 
6.2.1  Implications for Research 
The findings from the study on facility related factors contributing to stress among nurses is 
a strong indication of poor nurse management practices. This implies that nursing research 
in Ghana needs to pay more attention on nurse management and leadership styles among 
nurses. Understanding more about the nurse management practices and leadership styles 
among Ghanaian nurses through research will help determine any flaws in nurse 
management practices and any areas in nursing management and leadership that need to be 
improved.    
6.2.2  Implications for Policy Making 
This study has significant implications for policy making in the area of health care services 
for nurses and health workers in general. The high prevalence of stress among the nurses 
shows that most of the nurses are not aware about their condition. This implies that majority 
of the nurses have not had any stress screening exercise for some time. These nurses are 
likely to end up suffering from stress related chronic conditions that will eventually affect 
their work output and quality of service delivery. The Ghana Health Service makes 
provision for health facilities to provide medical screening for their staff. However, 
psychological screening is most often than not left out. An innovative policy intervention is 
thus needed to ensure regular psychological screening of all Ghana Health Service staff, 
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especially nurses and midwives, in addition to training and employment of clinical 
psychologists in all hospitals and polyclinics in the country to provide psychological 
services for the staff.  
6.2.3  Implications for Practice and Management 
The study found that poor interpersonal relationship among nurses at work was a major 
facility related factor contributing to stress among nurses. This implies that nurse managers 
might not have sufficient knowledge and competence to improve communication among 
their staff and provide a conducive work environment for addressing interpersonal issues 
among their staff and to foster good interpersonal relations among their staff. This provides 
a strong indication of the need for training of current and future nurse managers on nurse 
management practices to promote conducive work environment for their staff.  
6.2.4  Implications for Education 
Findings from the study on the high prevalence of stress among nurses indicate that nursing 
is a stressful profession especially in Ghana. This implies that the training of nurses and 
midwives in both health training schools and universities should include substantial 
information on stress and stress management practices. There is therefore the need for 
curriculum review to ensure that stress and stress management be treated as a major course 
in the training of nurses and midwives. 
6.3  Limitations of the Study 
Research studies in general, aim to produce findings that can be applied in other settings. 
However, no study can provide findings that are universally generalizable (Khan, 2012). 
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This study was conducted in one general hospital in only one region in Ghana to determine 
the prevalence of stress among nurses and the facility related factors contributing to their 
stress. However, this may not necessarily represent the holistic situation among nurses in 
Ghana. 
As part of some limitations associated with using a self-administered questionnaire, the 
tendency for nurses to miss out on reporting their real life or lived experiences at their work 
place cannot be ruled out.  
6.4 Recommendations 
Based on the findings of the study, the following recommendations were made; 
1. Due to the high prevalence of stress among the nurses, management of the Tema 
General Hospital should, as a matter of urgency, carry out medical screening on all 
their nurses for stress related physical conditions for early detection and treatment. 
The hospital authorities also need to engage the services of a clinical psychologist to 
provide stress relief intervention and counselling for their nurses.  
2. There is the need for health service administrators, medical directors and nurse 
managers to organize periodic medical and psychological health screening for their 
staff, especially nurses. This will help with early detection and treatment of stress 
and stress related medical conditions that may affect the health and work output of 
their staff.  
3. Poor interpersonal relationship at work emerged as a major contributing factor to 
stress among nurses. Nurse managers need to take the necessary steps to resolve 
issues and improve upon interpersonal relations among their staff in order to provide 
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a serene and conducive work environment that is free of tensions among nurses and 
their colleagues. This will help eliminate, if not possible, reduce to the barest 
minimum the stress associated with poor interpersonal relationship at the workplace.  
4. Nurse managers should make concerted efforts to assign staff to roles that they are 
able to do best, allow their staff to have some level of control or autonomy, involve 
their staff in decisions regarding changes at the workplace and provide them with the 
necessary support and encouragement at work.  
5.  The study revealed that nurses neglect self-care practices at the expense of their own 
health. Nurses need to promote their self-care by making time for themselves to 
implement the positive lifestyle practices such as regular exercise and good nutrition, 
that they educate their patients on.   
6. The Ghana Health Service in collaboration with health service administrators and 
directors should organize periodic workshop for their staff on stress and stress 
management practices. This will help update their knowledge on current stress and 
stress management practices to help them deal the stress associated with their work.  
7. Future researchers in the field of occupational health should replicate this study all 
the regional hospitals in Ghana in order to provide holistic view of the subject.  
 
 
 
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REFERENCES 
Arnold, J., Cooper, C. L., & Robertson, I. T. (1998). Work psychology- understanding 
human behaviour in the workplace (3rd ed.). London: Prentice Hall. 
Arnold, J., Cooper, C. L. (1989). Work psychology- understanding human behaviour 
in the workplace. London: Prentice Hall. 
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. 
Callaghan, P., Tak-Ying, S.A. & Wyatt, P.A. (2000). Factors related to stress and coping 
among Chinese nurses in Hong Kong. Journal for Advance Nursing. 31(6), 1518-
1527. 
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. 
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. 
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 
Dunkley, J., & Whelan, T. (2006). Vicarious traumatization: Current status and future 
directions. British Journal of Guidance & Counselling, 34(1), 107-116. 
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. 
University of Ghana http://ugspace.ug.edu.gh
63 
 
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. 
Hammen, C. (2005). Stress and depression. Annu. Rev. Clin. Psychol.,1:293–319. 
Harvey, A.G., Jones, C. & Schmidt, D.A. (2003). Sleep and posttraumatic stress disorder: a 
review. Clin. Psychol. Rev., 23:377–407. 
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. 
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. 
Kalliath, T. & Morris, R. (2002). Job satisfaction among nurses: A predictor of burnout 
levels. J. Nurs. Adm., 32, 648–651. 
Karasek, R. & Theorell, T. (1990). Healthy work: stress, productivity and the 
reconstruction of working life. New York: Basic Books. 
Khan, J. A. (2012). Research methodology. New Delhi: APH Publishing Corporation. 
Kivimaki, M., Elovainio, M. & Vahteera, J. (2000). Workplace bullying and sickness 
absence in hospital staff. Occupational and Environmental Medicine 57: 656 – 
660. 
Laal, M. & Aliramaie, N. (2010). Nursing and Coping With Stress. International 
University of Ghana http://ugspace.ug.edu.gh
64 
 
Journal of Collaborative Research on Internal Medicine and Public Health, 
2(5), 168-181. 
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. 
Lowe, G. S. (2006). Creating healthy health care workplaces in British Columbia: Evidence 
for action. Vancouver, BC: Provincial Health Services Authority. 
Manktelow, J. (2005). Mind Tools: Essential Skills for an Excellent Career. Mind Tools 
Ltd: London. 
McGowan, B. (2001). Self-reported stress and its effect on nurses. Nursing Standard 15: 
33-38. 
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. 
McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of 
Advanced Nursing, 44(6), 633-642. doi:10.1046/j.0309-2402.2003.02853. 
Meadus, R.J. & Twomey, J.C. (2011). Men student nurses: the nursing education 
experience. Nurs Forum, 46(4):269-79. 
Mehta, R.S. & Chaudhary, R.N. (2005). Job related stress among the nurses working in critical 
care areas at BPKIHS, Nepal. Nursing and Midwifery Research Journal, 1(2), 70-76 
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. 
University of Ghana http://ugspace.ug.edu.gh
65 
 
171-180. DOI: 10.2478/10004-1254-63-2012-2140. 
Moustaka, E. & Constantinidis, T. C. (2010). Sources and effects of Work-related 
stress in nursing. Health Science Journal. 4:4. 
Pearlman, L., & Saakvitne, K. (1995). Treating therapists with vicarious traumatization 
and secondary traumatic stress disorders. In C. R. Figley (Ed.), Compassion 
Fatigue: Coping with secondary traumatic stress disorder in those who treat the 
traumatized. New York: Brunner-Routledge. 
Preto, V.A. & Pedrão, L.J. (2009). Stress among nurses who work at the intensive care 
unit. Rev Esc Enferm USP., 43(4):838-45 
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. 
Selye, H. (1976). The Stress of Life. (2nd Ed.). New York: Mcgraw-Hill. 
Shields N. (2001). Stress, active coping, and academic performance among persisting and 
non-persisting students. Journal of Applied Bio-behavioural Research, 6(2), pp. 
University of Ghana http://ugspace.ug.edu.gh
66 
 
65-81. 
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. 
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. 
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. 
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.  
Twumasi, P. A. (2005) Medical systems in Ghana: A study in medical sociology. Ghana: 
Publishing Corporation Assembly Press 
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. 
University of Ghana http://ugspace.ug.edu.gh
67 
 
Videbeck, S.L. (2007). Psychiatric Mental Health Nursing (4th edtn.). 
Lippincott Williams & Wilkins.  
Yeboah, M.A., Ansong, M.O., Antwi, H.E., Yiranbon, E., Anyan, F. & Gyebil, F. (2014). 
Determinants of Workplace Stress among Healthcare Professionals in Ghana: An 
Empirical Analysis. International Journal of Business and Social Science 5(4), 
140-151. 
Zaghloul, A.A. (2008). Developing and Validating a Tool to Assess Nurse Stress. J Egypt 
Public Health Assoc. 83 (3), 223-227 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX A: QUESTIONNAIRE 
Dear Sir/ Madam, 
I am conducting a study on the prevalence of stress among nurses and how nurses cope with 
stress. I will be grateful if you could spend a little of your time to complete this 
questionnaire. There are no right or wrong answers. Any information provided is private and 
confidential. This study is only for academic purposes. Your participation in this study is 
entirely voluntary. Please feel free to answer the questions below. 
INSTRUCTION: Please tick [√] your choice of answer in the boxes below or write in the 
spaces provided.  
Section A: Demographic Data 
1. Age 20-30 years [ ] 31-40 years [ ] 41-50 years [ ]  
 51-60 years [ ]  
2. Sex:   Male [ ]  Female [ ] 
3. Rank:  SN [ ]  SSN [ ]  NO [ ]  
  SNO [ ]  PNO [ ]  DDNS [ ] 
4. Educational status: Diploma [ ] Degree  [ ]   
    Masters  [ ] PhD  [ ]  
 Other (specify) _____________________________________________ 
5. Ward/ Unit: ___________________________________________________ 
6. Marital Status: Single [ ]  Married [ ] Separated [ ]  
  Widowed [ ]  Divorced [ ]    
 Other (specify) _____________________________________________ 
7. Number of years in nursing:  _____________years  
8. Shift type : Morning ( )  Afternoon ( )  Evening ( ) 
 
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Section B: Level of stress  
Please read each statement and circle a number, 0, 1, 2 or 3, to indicate how much the 
statement applied to you over the past week. There are no right or wrong answers. Do not 
spend too much time on any statement. 
The rating scale is as follows: 0- Did not apply to me at all; 1- Applied to me to some 
degree, or some of the time; 2- Applied to me to a considerable degree, or a good part of 
time; 3- Applied to me very much, or most of the time. 
 Stress 0 1 2 3 
9.  I found myself getting upset by quite trivial things 0 1 2 3 
10.  I tended to over - react to situations 0 1 2 3 
11.  I found it difficult to relax 0 1 2 3 
12.  I found myself getting upset rather easily 0 1 2 3 
13.  I felt that I was using a lot of nervous energy 0 1 2 3 
14.  I found myself getting impatient when I was delayed in 
any way (e.g. Traffic, being kept waiting) 
0 1 2 3 
15.  I felt that I was rather easily offended 0 1 2 3 
16.  I found it hard to wind down 0 1 2 3 
17.  I found that I was very irritable 0 1 2 3 
18.  I found it hard to calm down after something upset me 0 1 2 3 
19.  I found it difficult to tolerate interruptions to what I do 0 1 2 3 
20.  I was intolerant to anything that kept me from getting on 
with what I was doing 
0 1 2 3 
21.  I could see nothing in the future to be hopeful about 0 1 2 3 
22.  I was worried about situations in which I might panic 
and make a fool out of myself 
0 1 2 3 
 TOTAL     
 GRAND TOTAL  
 
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Section C: Factors contributing to stress  
Please indicate in the table below how often you experience the following stressful 
situations at work. Please read the statements carefully and tick [√] the answer from the 
corresponding box that best describes your choice of response. The rating scale is as 
follows: 1 – Never; 2 – Rarely; 3 – Sometimes; 4 – Often; 5 – Always.  
Sources 5 4 3 2 1 
Demand      
23.  The workload at work is too much      
24.  There is too much pressure at work      
Control      
25.  I am not involved in any decision making at work      
26.  I am not allowed to make decisions on my own at 
work 
     
27.  I am not recognised as important at work      
Support      
28.  There is lack of encouragement from management       
29.  There is no sponsorship at work      
30.  I lack resources and materials needed to work 
effectively and efficiently 
     
31.  My salary is not satisfactory      
32.  There is no provision of guidance at work 
 
     
 
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Relationships      
33.  Conflict with colleagues and/ or other health team 
members 
     
34.  Poor relationship with management and/ or 
superiors 
     
Role      
35.  I have conflicting roles with colleagues and other 
members of the health team 
     
36.  I am uncertain about what I am supposed to 
accomplish in my work 
     
Change      
37.  There is slow pace of change in the organization      
38.  Changes in organizational policies and mode of 
operation are poorly communicated to the staff 
     
 
 
 
 
 
 
 
 
 
 
 
 
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Section D: Coping with stress 
Please indicate in the table below what you do to manage stress 
 Never      
True 
Occasionally    
True 
Often      
True 
 Usually          
True 
Most Of The 
Time True 
1 2 3 4 5 
Recreation 
39.  When I need a leave I take 
one 
     
40.  I am able to do what  I want 
to do in my free time 
     
41.  I hardly watch television       
Self 
42.  When I’m relaxing ,I 
frequently think about work    
     
43. I get regular physical check-
ups 
     
44. I exercise regularly  (at least 
20mins.,3 times a week) 
     
45. I practice relaxation 
techniques 
     
Social support 
46. If I need help at work ,I 
know who to approach 
     
47. My working environment is 
not friendly. 
     
48.   In times of difficulties there 
is someone to talk to. 
     
Cognition  
49. . I can establish 
priorities  for  the use of my 
time        
     
50. Once they are set, I 
am able to stick to my 
priorities 
     
51.  I have techniques to help 
avoid being distracted 
     
THANK YOU!!! 
 
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APPENDIX B:  CONSENT FORM 
Title: DETERMINANTS OF WORKPLACE STRESS IN THE HEALTH SECTOR: A 
CASE STUDY OF NURSES AT THE TEMA GENERAL HOSPITAL 
Principal Investigator: Dorcoo Kwame Christian Jnr 
Address: College Of Health Sciences, School Of Public Health, Department of Biological, 
Environmental and Occupational Health, University Of Ghana, Legon.  
Email: ckdorcoojnr@gmail.com 
Telephone: 0244124205/0206617661 
NB: YOU CAN CALL HANNAH FRIMPONG (0507041223) - GHS-ERC 
ADMINISTRATOR FOR FURTHER CLARIFICATION IF NEED BE. 
Introduction: The title of this study is “Determinants of workplace stress in the health 
sector: A case study of nurses at the Tema General Hospital”. Stress is the body's way of 
responding to any form of demand placed on it. This occurs in response to either negative or 
positive experiences. 
According to McVicar (2003), stress is “a subjective phenomenon based on individual 
perceptions, producing positive (eustress) and negative (distress) perspectives” (p. 640). 
Stress occurs when a person has difficulty dealing with stressors such as life situations, 
problems and goals (Videbeck, 2007). The main objective of this study is to determine the 
prevalence of stress among nurses at TGH. 
You are being invited to participate in this study undertaken by Dorcoo Kwame Christian 
Jnr, a student of University Ghana pursuing an MSc Occupational Hygiene at the School of 
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Public health. This form is intended to seek your consent to participate in the study. This 
consent form contains information about the study and in other to ensure your understanding 
about participating you are being encouraged to read and sign. Prior to conduct of the study, 
you will be required to furnish us with some information about yourself. 
The study poses no risk whatsoever to participant. You are being asked to answer 
questionnaire which will take about 20 minutes of your time to complete. You may 
voluntarily decline to answer any question and also decline involvement at any level of the 
survey. Participant who consents to take part in the study will not be given any monetary 
compensation. No direct benefit to participant, however, information provided could be used 
to develop strategies to reduce or handle stress in the healthcare sector which could be 
beneficial in the future. 
 
Confidentiality 
This study has been reviewed and approved by the ethical review committee of Ghana 
health services. Information provided will be stored in secured place such as locked 
cabinets. Data will be entered into SPSS for coding and analysed with STATA and 
electronic files accessible by only Principal investigator and research supervisor. Participant 
personal identification such as names and address will not be written on questionnaire. 
However, each questionnaire will be given a unique identification number. 
If you have any questions and concerns, we will be more than happy to answer and address 
then now or later at your convenient time. You may contact me on the telephone number 
provided and email address. 
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PARTICIPANT CONSENT FORM 
 
I ……………………………………………………….. Have been thoroughly briefed on the 
entire methodology and significant of the ongoing study which is being conducted by 
Dorcoo Kwame Christian Jnr. On my own free will, I hereby consent to be part of the study, 
based on my understanding of what the study entails. 
 
I am doing this on condition that under no circumstances should my references be made to 
my actual identity to any other person(s) after providing all the information requested from 
me for this particular study as promised by the researcher. 
 
 
Respondent signature/ Thumbprint. ……………… Date ……………………………… 
 
 
 
 
Researcher signature ……………………………….Date ……………………………….. 
 
 
 
 
 
 
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APPENDIX C:  ETHICAL APPROVAL LETTER 
 
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APPENDIX D:  INTRODUCTORY LETTER 
 
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