Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11817 The relationship between mental workload and nurse stress levels in hospitals Zahid Fikri,1 Adelia Bellarifanda,1 Sunardi Sunardi,1 Muhammad Rosyidul ‘Ibad,1 Khikmatul Mu’jizah2 1Nursing Department, Universitas Muhammadiyah Malang, Malang; 2Nursing Department, Rajekwesi College of Health Sciences, Bojonegoro, Indonesia Abstract High mental workload implies significant mental resources and can lead to increased cognitive stress and fatigue. Nurses have the responsibility of managing a wide range of nursing care tasks, awhich frequently involve addressing anxiety, handling patient complaints, and managing patient defense mechanisms, all of which can lead to increased stress levels. This study aimed to identify the relationship between mental workload and the stress level of nurses in the Hospital Malang City. The research utilized a cross-sectional study design. The sampling technique employed was Total Sampling, involving 96 inpatient nurses at the hospital. Data collection involved the use of two questionnaires: the National Aeronautics and Space Administration Task Load Index (NASA-TLX) and the Perceived Stress Scale (PSS-10). Data analysis in this study was conducted using Pearson Correlation. The results indicated a positive relationship between mental work- load and nurses’ stress levels, supported by a significant p-value of 0.002 and a correlation coefficient of 0.312. A high mental work- load can impact the level of job-related stress experienced by nurses. Effective stress management skills can help individuals mitigate this impact. Introduction Job stress is a serious problem faced by nurses in carrying out their professional duties.1,2 High levels of stress in nurses’ jobs can negatively impact their well-being as well as the quality of care provided to patients.3–5 Several studies have been conducted to understand the impact and factors associated with the work stress of nurses.6–8 Nursing workload is all activities or activities carried out by nurses during their duties in a nursing service unit. Workload includes both physical and mental workload.9 Mental workload is the difference between the workload and the maxi- mum capacity of a person’s mental load.10,11 Nurses must be responsible for physical, administrative, and comprehensive nurs- ing care tasks such as dealing with anxiety, complaints, and patient defense mechanisms resulting in stress levels.12,13 The level of mental stress among nurses indicates that they often operate in highly demanding work environments. Several factors can influence their workload and self-esteem. Nurses who share living spaces, have fewer years of work experience, possess younger professional qualifications, earn lower incomes, hold non-management positions, exhibit lower psychological capital, and adopt negative coping styles are more likely to experience low workload and low self-esteem. Conversely, higher psychological capital and positive coping styles tend to be associated with medi- um and high workloads and high self-esteem.14 The issue of burnout is prevalent in Europe, with health and social service workers (nurses) experiencing 43% of cases, teachers experienc- ing 32%, and the rest distributed among administrative and man- agement professionals, as well as those in the legal and policy sec- tors.15 An imbalance in mental workload, where certain tasks or cognitive demands are disproportionately higher than others, can result in various negative consequences, including stress and burnout, reduced performance, decreased job satisfaction, physi- Correspondence: Zahid Fikri, Nursing Department, Universitas Muhammadiyah Malang, Malang, Indonesia. E-mail: zahid_fikri@umm.ac.id Key words: mental workload; nurse; stress level. Contributions: ZF, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; AB, conceptualization, investigation, methodology, valida- tion, and writing – original draft, review and editing; SS resources, inves- tigation, and writing –review and editing; ss formal analysis, validation, writing – review and editing; MRI, resources, supervision, and writing – review and editing; KM, resources, investigation, and writing –review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received eth- ical approval from the Health Research Ethics Commission, Faculty of Medicine, Universitas Muhammadiyah Malang, based on ethical certifi- cate E.5.a/216/KEPK-UMM/XI/2022. During the research, the researcher pays attention to the ethical principles of information to con- sent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgement: we would like to thankful to our research team, who have worked hard in this research, Hospital Malang City, which has pro- vided facilities and all health workers who helped this research and all patient who became research respondents. Received: 15 September 2023. Accepted: 17 November 2023. Early access: 14 December 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11817 doi:10.4081/hls.2023.11817 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11817] [page 53] Non -co mmerc ial us e o nly cal health problems, interpersonal issues, diminished creativity and innovation, and increased turnover.16 Nurses regularly experience a variety of work-related stres- sors, including long hours, time constraints, meeting patient needs, irregular schedules, and a lack of professional support.17–20 These demanding job conditions can profoundly affect the mental health and overall quality of life of healthcare professionals.21–23 Previous research has shown that the constant stress these professionals experience can have a negative impact on their psychological well- being.24,25 Poor mental health among healthcare providers can compromise their professional effectiveness and significantly impact the quality of care they offer to patients, ultimately nega- tively influencing patient health.17,24,26 Therefore, nursing leaders and managers are increasingly interested in the health status of nurses. The negative impact that will arise from the increased work- load is that the nurses’ emotions will arise which are not controlled and are not what the patient expects.27 If the stress experienced by nurses is too great, it will have an impact on performance which begins to decline, because it can hinder nurse performance.28 In addition, nurses will lose the ability to control it or be unable to make decisions in their work and their behavior becomes erratic. The most extreme impact that may occur to nurses and the services provided is performance becomes zero, nurses experience distrac- tion, become sick, and are no longer strong enough to work, become hopeless, leave or refuse to work.28 Hospital and care administrators should identify specific workload and teamwork issues and provide solutions to reduce the psychological burden on caregivers.29 This study aimed to determine the relationship between mental workload and stress levels experienced by nurses, by analyzing workload and work stress, it will be able to improve the quality and quantity of health services. In addition, it can increase effective- ness in the provision of nursing care. Materials and Methods Study design The design of this study was correlation study with a Cross Sectional Study approach. The research was conducted on December 15 to December 29, 2022. Sample and settings The population of this study were inpatient nurses at Hospital Malang City. The research sample was all inpatient nurses at Hospital Malang City with a total of 96 respondents using a total sampling technique. The inclusion criteria for respondents were as follows: the nurse currently works at Hospital Malang City; the nurse has a minimum education level of a diploma (DIII) in nurs- ing; the nurse has at least 1 year or more of work experience in hospital nursing; and the nurse falls within the age range of 21-60 years. Variables and instruments The independent variable is mental workload as measured by the National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire. There are 6 main indicators, namely Mental demand (MD), Physical demand (PD), Temporal demand (TD), Performance (P), Frustration level (FR).30 This min- imum and maximum value is 0-100 with the categories Mild (0- 29), Moderate (30-49), Severe (50-79), Very Severe (80-100).31 The dependent variable of this study is the stress level measured by the PSS 10 (Perceived Stress Scale) questionnaire. There are 10 questions with mild category values (1-14), moderate (15-26), and severe (> 26).32 The instrument in this study used a questionnaire with the Perceived Stress Scale 10 (PSS 10) method. PSS 10 is the only empirically established general stress assessment index. For each question, must choose from the following alternatives: 0 = never, 1 = almost never, 2 = sometimes, 3 = quite often, 4 = very often. Then, the scores are added for each item to get a total score. The total score is represented as a stress score. Individual scores on PSS 10 can range from 0 to 40, which are grouped into 3 groups. The independent variable is mental workload as measured by the National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire. The dependent variable of this study is the stress level measured by the PSS 10 (Perceived Stress Scale) questionnaire. Data collection Primary data was collected using a prepared questionnaire. Before the questionnaires were distributed to be filled in by respondents, the researcher explained the procedures for filling out the questionnaires to the nurses. This is so that when filling out the questionnaire nothing is missed and no one experiences misunder- standings. Secondary data was obtained from recording and report- ing from hospital management. The data is in the form of: the num- ber of inpatient room nurses, nurse absences, and the number of inpatient room patients. Data collection was carried out offline by distributing questionnaires. Data were analyzed using SPSS soft- ware (Statistical Package for Social Science) version 25. Data analysis used the Pearson correlation test. Data were analyzed using the Pearson correlation test with a significance level <0.05. Data analysis Univariate analysis in this study was mental workload and stress level. The bivariate test uses the Pearson Correlation test to determine the level or closeness of the relationship between two variables on an interval or ratio scale under normal distribution conditions with significant value < 0.05. Ethical clearance The research has received ethical approval from the Health Research Ethics Commission, Faculty of Medicine, University of Muhammadiyah Malang, based on ethical certificate E.5.a/216/KEPK-UMM/XI/2022. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. Results Data collection in this research was carried out by distributing questionnaires directly. The data presented in the questionnaire consists of the respondent’s personal data and questions related to the mental workload and stress experienced by the respondent. A description of the characteristics of respondents in Table 1 based on age was obtained by 53 respondents or 55.2% who were aged 26-35 years. The description of the characteristics of respon- dents based on gender was obtained by 77 respondents or 80.2 per- cent who were female. A description of the characteristics of respondents based on the type of room obtained by 51 respondents or 53.1% working in different types of ward rooms from the pedi- atric ward, surgical ward, and internal medicine ward. The descrip- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 54] [Healthcare in Low-resource Settings 2024;12:11817] Non -co mmerc ial us e o nly tion of the characteristics of the respondents based on the length of working hours was obtained by 63 respondents or 65.6% who worked for 7 hours. Description of the characteristics of respon- dents based on the level of patient dependence obtained 62 respon- dents or 64.6% of patients have a partial level of patient depend- ence. Description of the characteristics of respondents based on years of service obtained 41 respondents or 42.7% have worked for 1-5 years. Description of the characteristics of respondents based on the number of patients handled in 1 day obtained 67 respon- dents or 69.8% treated > 15 patients in a day. Based on Table 2, nurses with an average score of Mental Needs 182.5, Physical Needs 155.9, Time Needs 151.6, Performance 163.1, Effort Level 168.0, Frustration Level 97.8. It can be concluded that inpatient nurses have greater mental needs compared to other indicators. The description of mental workload from 96 respondents obtained 3 people or 3.1% had light mental workload, 22 people or 22.9% had moderate mental workload, 58 people or 60.4% had heavy mental workload, and 13 people or 13.5% have a very heavy mental workload. Based on the results of the study, it was found that the average value for negative statements was 8.56 and the average value for positive statements was 9.35, similar to the results of the study, namely that inpatient nurses experienced moderate work stress with the results of 72 respondents or 75 %. The description of work stress from 96 respondents obtained 22 people or 22.9% had light work stress, 72 people or 75.0% had moderate work stress, and 2 people or 2.1% had heavy work stress (Table 3). Pearson correlation test results between mental workload and work stress obtained a correlation coefficient of 0.312 with a sig- nificance value of 0.002. These results show a significance value of less than 0.05 (sig <0.05) so that it is stated that there is a signi- ficant positive correlation between mental workload and work stress, meaning that the heavier the mental workload of nurses will have a significant effect on the heavier the work stress of nurses, and conversely, the lighter the mental workload of the nurse will have a significant effect on the lighter the nurse’s work stress. The strength of the correlation was measured using the correlation coefficient obtained at 0.312, where these results indicate that the strength of the correlation between mental workload and work stress is at a low level (Table 4). Discussion The age characteristics of nurses who experience very heavy mental workload, it is dominated by nurses who are 26-35 years old, as many as 8 respondents. This is closely related to the matu- rity or maturity level of a person.33 The older a person is, the more mature he will be, the maturity of his soul and more capable of car- rying out his duties and responsibilities.34 As you get older, your ability to make decisions, think rationally, be wiser, be able to con- trol your emotions, be more tolerant, and be open to the views or opinions of others will increase so that your stress resistance will increase.35 Individuals who have longer work experience tend to be more resistant to the pressures experienced in work, than individuals with shorter working tenure because they have less experience. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Data on respondent characteristics. Characteristics n % Ages <25 years old 35 36.5 26-35 years old 53 55.2 36-45 years old 5 5.2 >45 years old 3 3.1 Sex Female 77 80.2 Male 19 19.8 Room Surgical 4 4.2 Medical 7 7.3 Pediatric 8 8.3 Surgical, Medical 4 4.2 Medical, Pediatric 2 2.1 Surgical, Medical, Pediatric 20 20.8 Others 51 53.1 Work durations <7 hours 4 4.2 7 hours 63 65.6 >7 hours 29 30.2 Patient dependency level Minimal 25 26.0 Partial 62 64.6 Total care 9 9.4 Working period <1 years 16 16.7 1-5 years 41 42.7 5-10 years 25 26.0 >10 years 14 14.6 Number of patients in 1 day 5-10 patients 3 3.1 10-15 patients 26 27.1 >15 patients 67 69.8 Total 96 100 Table 2. Description of mental workload. Statistics KM KF KW P TU TF (mental needs) (physical needs) (time needs) (Performance) (effort level) (frustration level) N 96 96 96 96 96 96 Mean 182.5 155.9 151.6 163.1 168.0 97.8 Median 180.0 150.0 150.0 150.0 150.0 40.0 St. deviation 99.2 109.5 83.4 119.5 114.6 114.2 Minimum 0 0 0 0 0 0 Maximum 500 450 400 450 450 400 [Healthcare in Low-resource Settings 2024;12:11817] [page 55] Non -co mmerc ial us e o nly Tenure of work is related to the experience of a worker in dealing with problems at work.36 Nurses with a tenure of <10 years usually have more work problems than nurses with a tenure of >10 years. Another factor affecting mental workload is the patient-to-nurse ratio, namely the large number of patients that must be handled by nurses. When the number of nurses and the number of patients to be treated is not balanced, it will cause something called mental workload. The results of the research show that inpatient nurses at Hospital Malang City mostly manage >15 patients per day per individual. Based on the results of the study, it was found that inpatient nurses experienced moderate work stress. Job stress is a form of a person’s response, both physically and mentally, to a change in his environment that is felt to be disturbing and causes him to be threatened.37 The main factors that cause job stress are intrinsic, work, demands from outside the organization/work, limited time to do work, frustration, changes in job types, and individual charac- teristics such as personality, skills, values and needs, years of serv- ice, age, and education.38 Humans are instinctively born as individuals who always try to adapt to the changes that occur. Similarly, with high levels of stress, the more diverse ways of coping with stress are develop- ing. Efforts to overcome stress are theoretically termed stress management.39 Stress management is a series of programs to con- trol and regulate stress which aims to identify the causes of stress and know techniques for managing stress so that people are better at handling stress in life. One of the factors that health workers have in stress resilience is self-motivation, the high level of work- load felt by the workforce requires them to adapt to the circum- stances that occur, encouraging the workforce to adapt to over- come the stress they experience due to demands.40 In line with the results of the study, the adaptation of a good nurse will minimize the incidence of heavy work stress, even though in the research results, inpatient nurses at Hospital Malang City have a heavy mental workload, inpatient nurses at Hospital Malang City can manage to stress well so that the level of stress experienced by nurses still at medium level. The results of the correlation test showed a significance value of p=0.002 (sig < 0.05) so it was stated that there was a significant positive correlation between mental workload and work stress, meaning that the heavier the mental workload of nurses would have a significant effect on the heavier the work stress of nurses, and vice versa the lighter the mental workload of the nurse will have a significant effect on the lighter the work stress of the nurse. The strength of the correlation was measured using the correlation coefficient obtained at 0.312, where these results indicate that the strength of the correlation between mental workload and work stress is at a low level. This level indicates that stress can occur, one of which is influ- enced by the way individuals respond to pressure obtained at work.41 Individuals who can control external pressure well can avoid stress. Mental workload is not the only thing that can affect work stress, another thing in the form of individual differences is associated with an individual’s ability to handle stress because there are individuals who can handle stress well, while others feel overwhelmed due to stress. Individual difference factors consist of perception, work experience, social support, and personality.42 This is similar to the results of a study that showed that most of the inpatient nurses at Hospital Malang City experienced a heavy mental workload, but most only had moderate levels of work stress. Inpatient nurses at Hospital Malang City are dominat- ed by nurses who have worked for 1-5 years and nurses aged 26- 35 years, this can help nurses handle stress well so that the level of work stress that appears is only at a moderate level. This study has several limitations, In this study, researchers were unable to examine directly respondents because the Head of the Nursing Department at Aisyyah Islamic Hospital gave access only to entrust the questionnaire sheets to each Head of Room. This research was carried out only in 1 installation, namely the inpatient installation, it was not carried out in other installations such as the emergency unit or Intensive Care Unit. Moreover, the researcher also did not examine further other factors related to the respondent’s mental workload, for example the distance between the place of residence and the work location and other work per- formed by nurses outside the hospital, causing limitations in dis- cussing the results of the study. Conclusions In conclusion, this study highlights the significant impact of mental workload on the stress levels of nurses working in a demanding hospital environment. The positive relationship observed underscores the importance of recognizing and address- ing mental workload as a crucial factor in understanding and man- aging work-related stress among nurses. This study emphasize the need for healthcare institutions to prioritize strategies and interven- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 56] [Healthcare in Low-resource Settings 2024;12:11817] Table 4. Pearson correlation test results. Mental Workload Stress levels Mental Workload Pearson Correlation 1 .312** Sig. (2-tailed) .002 N 96 96 Stress levels Pearson Correlation .312** 1 Sig. (2-tailed) .002 N 96 96 Table 3. Description of stress levels. Favorable Unfavorable N 96 96 Mean 8.56 9.35 Median 9.00 9.00 St. deviation 4.384 2.726 Minimum 0 4 Maximum 19 16 Non -co mmerc ial us e o nly tions that reduce mental workload among nurses. 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