|Year : 2011 | Volume
| Issue : 1 | Page : 39-44
Evaluation of work place stress in health university workers: A study from rural India
Badrinarayan Mishra1, SC Mehta2, Nidhi Dinesh Sinha3, Sushil Kumar Shukla4, Nadeem Ahmed5, Abhishek Kawatra1
1 Department of Community Medicine, Pravara Institute of Medical Sciences, PMT, Loni, Maharashtra, India
2 Department of PSM, Yardigardi Medical College, Ujjain, MP, India
3 Department of Prosthodontics, Rural Dental College, Pravara Institute of Medical Sciences, PMT, Loni, Maharashtra, India
4 Department of Community Medicine, Rural Medical College, Etawa, UP, India
5 Department of Community Medicine, Rohilkhand Medical College and Hospital, RMCH, Bareilly, UP, India
|Date of Submission||11-Jan-2010|
|Date of Acceptance||08-Feb-2011|
|Date of Web Publication||12-May-2011|
Department of Community Medicine, Rural Medical College, Pravara Institute of Medical Sciences, PMT, Loni, Maharashtra
Source of Support: Management of Pravara Medical Trust, Conflict of Interest: None
| Abstract|| |
Background: Healthcare providers being over-worked and under staffed are prone to poor mental health. Unhealthy work place compounds it further. Aims: This study was aimed at to assess the mental health status of a medical university employee with special reference to work place stressors. Settings and design: A cross-sectional study was designed and carried out at a Rural Health University. Materials and Methods: Both the General Health Questionnaire (GHQ)-12 and Holmes-Rahe Scale were used to evaluate 406 participants. Statistical analysis: Multivariate analysis, correlation, and ANOVA by SPSS 11.0. Results: The minimum age of the participant was 19 years and the maximum 64 years, with an average age at 35.09 years. On the GHQ scale 239(58.9%) recorded psychiatric morbidity out of which 201(49.5%) had moderate and 38(9.3%) severe morbidity. Doctors were the highest stressed group (P ≤ 0.04). Prominent work environmental stressors were poor departmental reorganization, lack of cohesiveness in department, difficult superiors and juniors (P ≤ 0.001, Pearson correlation). Stressors associated with work organization and work nature were: noninvolvement in departmental decision making and lack of proper feedback; along with; work load, lack of clarity in job, and a erratic work schedule (P ≤ 0.001 on Pearson correlation). Harassment, favoritism, discrimination, and lack of self-expression (P ≤ 0.003) were other factors responsible for work dissatisfaction. Conclusions: A high stress level was detected in the study population. The principal stressors were work environment related. Poor work culture was found to lead to job dissatisfaction among majority.
Keywords: Employees, health university, occupational stress
|How to cite this article:|
Mishra B, Mehta S C, Sinha ND, Shukla SK, Ahmed N, Kawatra A. Evaluation of work place stress in health university workers: A study from rural India. Indian J Community Med 2011;36:39-44
|How to cite this URL:|
Mishra B, Mehta S C, Sinha ND, Shukla SK, Ahmed N, Kawatra A. Evaluation of work place stress in health university workers: A study from rural India. Indian J Community Med [serial online] 2011 [cited 2020 Aug 11];36:39-44. Available from: http://www.ijcm.org.in/text.asp?2011/36/1/39/80792
| Introduction|| |
Stress can be defined as a interstate which can be caused due to physical demands on the body or by environmental and social situations which are evaluated as potentially harmful uncontrollable or exceeding our sources for coping. 
Job stress is defined as "The emotional, cognitive, behavioral and physiological reaction to aversive and noxious aspects of work, work environments, and work organizations. It is a state characterized by high levels of arousal and distress and often by feelings of not coping." 
Under normal circumstances, the reaction mechanisms of employees should enable them to find new balances and responses to new situations. Stress is, therefore, not necessarily a negative phenomenon. Some stress, therefore, is normal and necessary. However, if stress is intense, continuous, or repeated, if the person is unable to cope or if support is lacking, then it becomes a negative phenomenon leading to physical illness and psychological disorders. ,,
There are study reports of mental health assessment and psychiatric morbidity in different health manpower groups such as doctors, nurses, and other paramedics. Most of these studies are carried out in isolation. , A holistic view on stress assessment encompassing the entire health (medical) university work force is rarely reported.
Further, studies probing work place stressors in relation to factors such as work environment, work organization, and nature of work are far and few. In this backdrop, we planned to conduct the reported study in a Rural Health (Medical) university with the following points in mind. We presumed that the health university workforce could represent a particularly vulnerable occupational group. Thus, we hypothesised to record a high level of stress and low psychosocial health in the study participants.
| Materials and Methods|| |
Aim of the study
The study was aimed at exploring different stress factors operating at workplace of a rural health university by using internationally established guidelines, i.e. GHQ-12 (General Health Questionnaire-12) and Holmes-Rahe Scale.
The objectives of this study were:
- To estimate the prevalence of psychiatric morbidity.
- To determine different work place stressors of mental health in university workers.
- To categorize the stressors as per their source of origin and severity.
- Make necessary recommendations for their elimination.
This prospective point prevalence study was carried out from March to May 2008. It was carried out in a health university located in remote and inaccessible part of western Maharashtra state of India. This place though well-known for its educational marvels is aptly coined as "a place among no where" as it lacks rail and major roadways connectivity. 
The sample size was calculated by using the formula P = 4PQ/L,  where P-the prevalence of the condition was taken at 40% and L-the allowable error was taken at 05. Thus a sample size of 406 was found valid.
Eligible study participants were selected by a systemic random method. Ethical clearance was sought from the Institutional Ethical committee and written consent was obtained from eligible study participants.
Eligibility was assessed by the following inclusion and exclusion criteria.
Age: 18-65 years.
Sex: both sexes (males and females).
Subjects giving valid written consents.
Subjects in the permanent muster of the university.
Persons free from severe mental illness.
Frank and diagnosed cases of psychoneurosis.
Persons not in the permanent muster of the university.
Persons out side the employable age group, i.e. 18-65 years.
MSW (medicosocial workers) trained in psychosocial work were employed in data collection.
Data entry and analysis
Data were computer-coded and analyzed using the Statistical Package SPSS 11. Analyses included cross-tabulations, bivariate correlation establishment, and other relevant tests.
| Results|| |
General demographic profile
From a study universe of 1250 employees, 406 subjects were enrolled. There were 253(62.3%) males and 153(37.7%) females with a maleto-female ratio of 1.65:1. Study population was divided in to three occupational groups: unskilled (fourth class and logistic employees), skilled (paramedics and clericals), and professionals (doctors). Their respective presentation in the study were as 101(24.9%), 136(33.5%), and 169(41.6%). The average age for the unskilled group was at 37.97 years, that of the professionals at 35.73 years, and skilled manpower at 32.15 years. The detail demographic profile of the population is presented in [Table 1].
It was evaluated by two internationally acclaimed standards, i.e. General Health Questionnaire (GHQ)-12 and Holms-Rahe scale.
- GHQ-12 evaluations: GHQ scoring pattern of 0, 1, 1, and 2 was used. The cut-off point of no morbidity was defined as scores "less than 4". Participants with scores ≥4 were diagnosed to have moderate psychiatric morbidity and ≥8 as severe psychiatric morbidity.  On this scale, the prevalence of psychiatric morbidity was recorded at 58.9%, i.e. 239 out of 406. From this 201 (49.5%) registered moderate and 38(9.3%) severe morbidity. Profession wise doctors recorded the highest prevalence of psychiatric morbidity at 106/169(62.8%) followed by skilled manpower at 84/136(61.8%) and unskilled at a low value of 49/101(48.5%). There was significant difference in psychiatric morbidity between professionals and skilled groups vs. unskilled groups (P < 0.05). Prevalence of different stressors in study population as per GHQ 12 criteria was presented in [Figure 1].
- Holmes-Rahe evaluation: Here stressors were subclassified to job-related stressors, personal stressors, physical stressors, and psychological stressors. They were scored in a scale of 0, 1, 2, 3, and 4; indicating increasing severity. Cutoffs for moderate stress was at 90 to ≤110 and severe stress at ≥110. On this scale, the average score of the population came out to be 96.1 while the range varied from 67 to 146. We detected a total 264(65%) with psychiatric morbidity; out of which 217(53.4%) had moderate and 47(11.6%) severe morbidity.
Occupational stress profile
For calculation of job-related stress by Holmes-Rahe scale, a standard cut off score of 16 was adopted. Here the result demonstrated a range of 13-43 with an average score at 23.22. Out of the total 406 study participants; 356(88.4%) reported existence of moderate and 20(5%) severe stress at work place.
The level of job satisfaction is directly proportional to the level organizational and departmental growth. The reported study demonstrated a high level of present job dissatisfaction by Pearson (P ≤ 0.001, df = 6, χ2 = 21.7) in all study groups. An in-depth analysis of factors associated with job dissatisfaction is presented in [Table 2].
|Table 2: Multivariate analysis of factors related to job dissatisfaction by GHQ 12 (tests of between-subjects effects)|
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Occupational stressors profile
We tried to subclassify job stressors into three groups: stressors related to nature of work, work organization and work environment.
- Work related: Here factors relating to the nature of job and their contribution in generating occupational stress were analyzed. It was found that work load, lack of clarity in job, and a erratic work schedule showed high significant association with stress (P ≤ 0.001 on Pearson correlation).
- Work organization related: The organization lays down policy and practice guidelines. Its responsibility in maintenance of stress-free work place is paramount. In addition to proper work assignment and distribution it also should provide adequate feedbacks to its employees and encourage their participation in its day today functioning. Our concluded study observed that noninvolvement in departmental decision making and lack of proper feedback were very significant stressors (P ≤ 0.001-Pearson correlation).The correlations of work and organization related factors are presented in [Table 3].
|Table 3: Pearson correlations (two-tailed) for work organization related stressors|
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- Work environment related: The above all functioning (work culture) of any organization is guided by organizational policies and departmental functioning. Stress-free work environment is a product of good interpersonal relationship and adherence to a standard protocol. We observed that poor departmental reorganization, lack of cohesiveness in department, difficult superiors and juniors were major stressors (P ≤ 0.001-Pearson correlation), other factors such as credits taken by seniors for work done by juniors, harassment, discrimination, and favoritism at the departmental level were also significantly correlated to stress (P ≤ 0.05-Pearson correlation).
On analysis of job stressors with respect to different study groups, i.e. professionals, skilled, and unskilled by Pillai's Trace Multivariate Tests, it was observed that all study groups experienced significant stress for the variables under study. Pillai's trace multivariate tests results for unskilled groups were: value = 0.958, F = 299.120, sig. at P = 0.000; skilled groups were: value = 0.961, F = 255.036, sig. at P = 0.000; and professionals were: value = 0.969, F = 235.549, sig. at P = 0.000 for all job-related study variables. Furthermore, the three study groups were intercompared with respect to the lowest stressed group, i.e. unskilled subjects. Here issues such as departmental cohesiveness (P < 0.02) and difficult superiors (P < 0.01) were significant job stressor in professionals and difficult superiors (P < 0.01), difficult juniors (P < 0.05), and departmental groupism (P < 0.04) were significant job stressor for skilled workers. [Table 4] depicts the details of these observations.
|Table 4: Work place-related stress parameter estimates in different study groups|
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| Discussion|| |
Health care providers are a known risk group for mental health aberrations.  The scenario in care providing sectors and Health University are different. In addition, health care delivery employees are burdened by educational and administrative commitments. Therefore, it is logical to perceive that the stress level is likely to be high.
For valid estimation of the research objectives two reliable and authentic formats were adopted. They were GHQ (general Health Questionnaire) 12 and Holmes-Rahe scale. GHQ 12 is a self-administered test originally developed by Goldberg to assess mental health status of individuals in a general population and in primary health care settings. ,, It is a frequently used screening test for assessment of psychiatric morbidity in different settings including health care sectors. Holmes-Rahe scale recorded a sensitivity of 0.75 and specificity of 0.68. ,,
Recorded observations of our study were in the line of proposed hypothesis. The general stress level detected by both study formats were at a high level, i.e. 58.9% and 65%, respectively. The nearest available evidence showed a stress level in doctors and nurses, i.e. at 67% and 58.6%, respectively. 
Logically people exposed to such a high level of stress in general are required to have stress-free work environment. However, in reality the work place of them is severely stress prone. Our study recorded occupational stress prevalence of 93.3%. This was in fact very high in comparison to data from available literature where the highest record showed a prevalence of 67% among doctors. 
The main responsibility for maintaining a healthy work place is that of the organization. A clean and clear job policy with proper feedback and individual recognition are basic mandates for organizational success.  However, when the organization is new and trying to come out with a standard policy, these aspects are usually overlooked. In our study, the above factors were found lacking. This may be due the comparatively new concept of Health University in India.
Good work culture and interpersonal relationships are prerequisites to healthy work environment. When this is in jeopardy, it reflects as occupational stress. Work environmental stressors had a significant role in occupational stress generation in our case. Poor work culture is a disturbing problem with many Indian institutions. ,,,,
To conclude we may remark that emergence of higher education sector in the form of health universities are a relatively new focus of concern. There is strong evidence to believe its workforce could represent a particularly vulnerable occupational group.
The psychological health of the respondents of the reported study was considerably lower than that found in other studies which have used the same measures. It was evident that a substantial number of its staffs are experiencing a high degree of pressure at work from a number of different sources. The impact of departmental climate and the factors those could be viewed as preventable has led to causation of stress for many. Such a high level of stress can be individually and organizationally disadvantageous.
Internal validity and limitations of the study
Accurate data generation was assured by employing MSWs trained in psychosocial work in data collection. These MSWs were blinded to the study objectives. Use of established formats such as GHQ-12 and Holms-Rahe Scale were aimed at minimizing bias and confounding. Neutrality was also observed by blinded data analysis. In spite of these efforts we still believe a better result could have been achieved by better matching of the population in respect to age, sex, and occupation.
A valid sample size and adequately control of bias and confounders speaks about the genuineness of the study results. This can act as a base for further evaluation and comparison of results by other researchers in similar setups.
Future scope of the study
Central governments, state governments, and local organizations should encourage further research in the field of workplace stress in Health Universities. The concept of Health University is new in India. A liberal policy approach by statutory bodies such as University Grant Commission has led to a sharp rise in their numbers. This puts the demands for studies of this nature at high end.
We observed some controllable stress factors which should have not occurred in a professional high-stressed work setup. These can be mitigated by changes in policy which asks for attaching disincentives and fines for those who encourages activities on the line of regional and local groupism. Work culture can be improved by making people accountable and encouraging cross strata participation on daily functioning of the departments.
- There is a recent boom of health universities in India by liberal government policy.
- This has created a unique work scenario where employees work as health care providers, teachers, and administrators.
- Our study reported strong association of stress with avoidable factors such as lack of departmental involvement, job satisfaction, and opportunity for self-expressions which reflect unhealthy work culture.
- Other significant factors were work load, lack of clarity in job, and erratic nature of work.
Health care providers as a group experience a high stress level.
A lack of professional approach at work places compounds this problem further.
| Acknowledgments|| |
We thank all study participants for their honest participation. We are also thankful to the management of Pravara Medical Trust for providing financial support and encouragement for the study.
| References|| |
|1.||Delva MD, Kirby JR, Knapper CK, Birtwhistle RV. Postal survey of approaches to learning among Ontario physicians implications for continuing medical education. Br Med J 2002;325:1218. |
|2.||Kirby JR, Delva MD. Approaches to learning at work and workplace climate. Int J Training Dev 2003;7:31-52. |
|3.||Deary IJ, Blenkin H, Agius RM, Endler NS, Zealley H, Wood R. Models of job-related stress and personal achievement among consultant doctors. BrJ Psychol 1996;87:3-29. |
|4.||Newble DI, Entwistle NJ. Learning styles and approaches: Implications for medical education. Med Educ 1986;20:162-75. |
|5.||McManus IC, Richards P, Winder BC, Sproston KA, Styles V. Medical school applicants from ethnic minorities: Identifying if and when they are disadvantaged. BrMed J 1995;310:496-500. |
|6.||McManus IC, Winder B, Paice E. How consultants, hospitals, trusts and deaneries affect pre-registration house officer posts a multilevel model. Med Educ 2002;36:35-44. |
|7.||McManus IC, Winder BC, Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet 2002;359:2089-90. |
|8.||Fox RA, McManus IC, Winder BC. The shortened Study Process Questionnaire: An investigation of its structure and longitudinal stability using confirmatory factor analysis. Br JEduc Psychol 2001;71:511-30. |
|9.||Kirby JR, Delva MD, Knapper CK, Birtwhistle RV. Development of the approaches to work and workplace climate questionnaires for Physicians. Eval Health Prof. 2003;26:104-21. |
|10.||Smith R. Why are doctors so unhappy? Br Med J 2001;322:1073-4. |
|11.||Dollard MF. Introduction, Context, theories and intervention In Occupational stress in the service professions London: Taylor and Francis; 2003. p. 1-42. |
|12.||Chambers R. Supporting GPs. Br Med J 2003;326:100. |
|13.||Maslach C, Schaufeli WB, Leiter MP. Job burnout. Ann Rev Psychol 2001;52:397-422. |
|14.||Mishra BN, Sinha ND, Gupta M. A comparative evaluation of stress factors among Rural University employees and local residents. Pravara Med Rev 2008;2:3-7. |
|15.||Mishra BN, Arif S. Evaluation of effects of religious faith and its effect on health. Ind J Prev Soc Med 2009;38:123-8. |
[Table 1], [Table 2], [Table 3], [Table 4]
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