What Really Stresses Out Nurses in Iranian Hospitals?
The weight of human life rests heavily on the shoulders of those in blue scrubs, but what happens when that weight becomes too much to bear?
Imagine making life-or-death decisions while navigating complex hierarchies, comforting grieving families, and working long hours with minimal resources. This is the daily reality for many nurses at Guilan University of Medical Sciences, where research has uncovered a complex web of stress factors affecting those who dedicate their lives to caring for others.
Recent studies have revealed that nursing is considered one of the most stressful professions globally, with work stresses creating negative effects on both health and quality of life 1 . In Iran's medical centers, this stress has become a significant concern, potentially overshadowing nursing performance and reducing caring behaviors that are crucial for patient recovery 1 .
The significance of nursing stress extends far beyond individual discomfort. Research demonstrates that job stress has a direct negative effect on nurses' quality of life, potentially reducing their caring behaviors and impacting patient outcomes 1 . Stressed nurses are more likely to make errors, become less vigilant in their duties, and ultimately leave the profession—creating a vicious cycle of understaffing and increased stress for those who remain 4 .
93.4%
of nurses had contact with COVID-19 cases
42%
had relatives infected with COVID-19
A study examining the psychological impact of COVID-19 on Guilan's nurses found particularly alarming statistics: female nurses, those working in COVID-19 designated hospitals, and those with insufficient personal protective equipment showed significantly higher rates of anxiety and depression 8 . This highlights how external crises exacerbate existing stress factors, creating perfect storms that threaten both healthcare provider wellbeing and patient safety.
In a crucial investigation into this phenomenon, researchers conducted a cross-sectional survey design study involving nurses working in hospitals associated with Guilan University of Medical Sciences 1 . This research aimed to quantify job stress levels and examine their correlation with quality of life and caring behaviors among nurses.
The study employed several validated instruments to capture the multifaceted nature of nursing stress:
A 57-item scale measuring nine specific dimensions of stress, from death and dying stressors to discrimination 1 .
Assessing both physical and mental health status through 12 targeted questions 1 .
Measuring perceptions of caring through 25 core questions about nursing practice 1 .
Researchers used availability sampling to select 115 nurses with at least one year of work experience and direct patient contact, ensuring participants understood the realities of nursing practice 1 .
The results painted a concerning picture of nursing life in these medical centers. The mean total score for job stress was 2.77 (on a scale where higher scores indicate more stress), while quality of life averaged 56.64 and caring behavior 38.23 1 .
Most significantly, statistical analysis revealed:
Perhaps most strikingly, univariate linear regression showed that job stress alone could predict 27.9% of the changes in quality of life scores and 4.9% of the changes in caring behaviors 1 .
| Variable | Mean Score | Standard Deviation | Possible Range |
|---|---|---|---|
| Job Stress | 2.77 | 0.54 | 0-4 |
| Quality of Life | 56.64 | 18.05 | 0-100 |
| Caring Behavior | 38.23 | 9.39 | Not specified |
The Expanded Nursing Stress Scale broke down stress into nine specific dimensions, revealing which aspects of nursing life created the greatest burden:
| Stress Dimension | Description | Number of Items in Scale |
|---|---|---|
| Death and Dying Stressors | Stress related to patient death and end-of-life care | 7 |
| Conflict with Physicians | Tensions and disagreements with doctors | 5 |
| Inadequate Emotional Preparation | Feeling unprepared for emotional demands | 3 |
| Problems with Peers | Issues with fellow nurses and colleagues | 6 |
| Problems with Supervision | Difficulties with managers and supervisors | 7 |
| Workload | Excessive work demands and time pressure | 9 |
| Uncertainty Concerning Treatment | Doubts about treatments and procedures | 9 |
| Patients and Their Families | Challenges in dealing with patients and relatives | 8 |
| Discrimination | Experiences of unfair treatment | 3 |
The Guilan study confirmed what many healthcare professionals have long suspected: stress doesn't just affect nurses—it affects their patients too. The negative correlation between job stress and caring behaviors suggests that as stress increases, the very compassion that drew many to nursing begins to erode 1 .
This phenomenon aligns with broader research indicating that job-related stress has been linked to "loss of compassion for patients and increased incidences of practice errors" 1 . When nurses are overstretched and emotionally drained, their ability to provide the thoughtful, attentive care that facilitates healing becomes compromised.
Additionally, the strong relationship between stress and reduced quality of life creates a vicious cycle: stressed nurses experience declining mental and physical health, further diminishing their capacity to manage job pressures effectively 1 .
The research demonstrates a clear causal chain: high stress levels lead to reduced quality of life for nurses, which in turn diminishes their capacity for compassionate care, ultimately affecting patient outcomes and satisfaction.
The already concerning situation appears to have worsened during the COVID-19 pandemic. A separate study focusing on nurses in Guilan hospitals during April 2020 revealed that:
| Risk Factor | Association with Anxiety | Association with Depression |
|---|---|---|
| Female Sex | OR = 3.27 | OR = 4.62 |
| Working in COVID-19 Hospital | OR = 1.82 | Not significant |
| Suspected COVID-19 Infection | OR = 2.01 | OR = 3.44 |
| Insufficient Protective Equipment | OR = 2.61 | OR = 1.86 |
Significantly higher risk for anxiety (3.27x) and depression (4.62x)
Strongly associated with anxiety (2.61x) and depression (1.86x)
Increased risk for anxiety (2.01x) and depression (3.44x)
Moderately associated with anxiety (1.82x)
For those interested in the methodological aspects of this research, the following tools were essential to collecting and analyzing the data:
| Research Tool | Function | Key Characteristics |
|---|---|---|
| Expanded Nursing Stress Scale (ENSS) | Measures job stress across 9 dimensions | 57-item scale using 6-point Likert format |
| Quality of Life Questionnaire (SF-12) | Assesses health-related quality of life | 12 questions measuring physical and mental health |
| Caring Dimension Inventory (CDI-25) | Evaluates perceptions of caring behaviors | 25 items on 5-point Likert scale |
| Availability Sampling Method | Participant selection technique | Non-probability sampling based on accessibility |
| Univariate Linear Regression | Statistical analysis method | Predicts relationship between independent and dependent variables |
While the numbers tell a compelling story, the real impact lies in the daily experiences of nurses. The stress dimensions identified in the Guilan study represent very real challenges: the emotional toll of losing patients, the frustration of conflicts with physicians, the exhaustion of chronic understaffing, and the moral distress of feeling unable to provide ideal care 1 4 .
This research adds to a growing global recognition that nurse well-being isn't a luxury—it's an essential component of functional healthcare systems. Studies from North America and Europe similarly show that stressful work environments and inadequate staffing predict emotional exhaustion and intent to leave the profession 7 .
The findings from Guilan University of Medical Sciences highlight an urgent need for systemic interventions to address nursing stress. The significant percentage of quality of life changes predicted by job stress alone (27.9%) suggests that organizational and environmental modifications could substantially improve nurse well-being 1 .
As the global healthcare landscape continues to evolve, the lessons from Guilan's nurses remind us that caring for those who care for others isn't just ethical—it's essential for maintaining quality healthcare systems capable of serving all who need them.
The next time you encounter a nurse, remember the complex challenges behind the uniform. Supporting these healthcare professionals through evidence-based workplace improvements might be one of the most important investments we can make in public health.