This study aims to compare the stress determinants between hospital and non-hospital nurses. The principal findings are: (1) not much difference in household stressors between both groups, (2) hospital nurses significantly had higher level of workplace stressors, (3) the level of stress were higher among hospital nurses, (4) shift work is associated with higher household and workplace stressors among hospital nurses, (5) nurse manager in hospital setting is associated with higher level of workplace stressors and stress, (6) marriage is associated with higher household stressors among nurses in both groups, (7) older age and junior are associated with higher stress level among non-hospital nurses, (8) both workplace and household stressors significantly associated with stress status with 40% explained variance. Overall, hospital nurses, were at higher risk of having workplace stressors, household stressors, and stress.
The hospital nurses had significantly higher stress level in spite of similar prevalence of stress status. This finding is consistent with the evidence from another geographical region such as Saudi Arabia [39] and Australia [40] which reported higher stress level among hospital nurses. It could be due to the higher level of all components of workplace stressors and several aspects of household stressors among hospital nurses in our study which explained 40% of variance in stress level. This is supported by previous finding which found that stress level was significantly and positively correlated with all components of workplace stressor among nurses [40]. Previous studies also reported that hospital nurses may face higher stressors related to workload, death and dying, and conflict with family members or colleague [27–29]. The stressors could also be implicated by shift work which could adversely impact social, personal, family and occupational life [41–42] and made complicated by marriage life [39, 42–43].
Shift work is significantly associated with higher stress level among nurses; however, the significant association is diminished when workplace setting is considered. This is consistent with study by Lin et al. (2015) that reported higher stress level among nurses who work in shift [44]. The diminishing effect could be due to the differential level in proportion of nurses involved in shift work between two groups. The nature of nursing work in hospital around the clock exposed a higher proportion of them to shift work which is associated with stressors and stress. Our study further emphasize that shift schedule is associated with higher risk of having both household and workplace stressors among hospital nurses. This is supported by a study by Ferri et al. (2016) which concludes that shift work, particularly rotating shift work, is a potential stressor for nurses [45]. This finding imply that those involved in shift schedule, particularly hospital nurses, should be given high priority in stress intervention, and the intervention itself should include evaluation and improvement of shift schedule design. For instance, Lin et al. (2015) reported that two days-off after night shift will improved the stress level among nurses who involve in rotating shift work [44].
We also found that nurse managers in hospital setting is associated with higher level of workplace stressors and stress. This could be due to the heavier workload, inadequate resources, and role conflict in fulfilling the demands from their subordinate and superior [46–47]. In contrast, older age and junior are associated with higher stress level among non-hospital nurses. This is consistent with finding among community health nurses in China and Saudi Arabia [39, 43] which may be explained by low work ability and overstretched among older workers [48] and lower training or competency among junior workers [43]. Nevertheless, all these postulations need to be confirmed in future study as previous studies did not conduct a comparative study to enable statistical measurement of significant difference.
Our study extent the previous knowledge that prove differential in mental health status and its determinants between hospital and non-hospital nurses. For instance, a study by Dor et al. (2018) found that hospital nurses had a significantly higher level of emotional exhaustion and depersonalization as compared to community nurses [28]. Previous study by Starc (2018) found that nurses from secondary level of healthcare reported higher level of stressors related to dealing with death, working with difficult patients, exposure to infection, working at night, lack of personnel, and working hours as compared to nurses from primary care [49]. Our findings also suggest that working condition for all nurses is not similar, thus, necessary adjustment to accommodate the demands of hospital and non-hospital work should be carried out to ensure a healthy working condition and lower risk of stress.
The workplace stressors and stress level are significantly higher among hospital nurses. It is thus necessary to put high priority in intervening stress among hospital nurses. Intervention should be initially conducted by identifying the root causes of workplace and household stressors such as shift work which could affect work and family life. Further intervention such as schedule redesign should be initiated, and its efficacy should be tested. Apart from hospital nurses, targeted intervention should also focus on high risk group such as managerial nurse group in hospital setting and older workers and junior at non-hospital setting. Finally, the intervention should consider both aspect of household and workplace stressors as both can significantly influence the level of stress among nurses in both hospital and non-hospital setting.
This study has several limitations. First, the use of self-reported data exposes the result to common method bias [50] and social-desirability bias [51]. However, the use of validated questionnaire and guarantee in anonymity may reduce such biases [50–51]. Second, this study is limited to female nurses and thus cannot be generalized to the male nurses. Third, study was conducted in Malaysia and may not represent other geographical region which has different work system or social culture.