• 20.09.2018 Administrator UMB

    Multi-criteria decision analysis of occupational stress among healthcare professionals in Nigeria

    Amole BB.1A-E,, Adebiyi SO.2A-E, Dakare O.3D-F* 

     

    1. Department of Accounting and Business Administration, Distance Learning Institute, University of Lagos, Nigeria.
    2. Department of Business Administration, University of Lagos, Lagos. Nigeria.
    3. Department of Business Administration, School of Management and Social Sciences,               Pan-Atlantic University, Lagos, Nigeria.

    ______________________________________________________________________________

     

    A-Conceptionandstudydesign;B-Collectionofdata; C-Dataanalysis; D-Writingthepaper;

    E-Reviewarticle; F -Approvalofthefinalversionofthearticle

     

     

    ABSTRACT

    ______________________________________________________________________________

     

     

    Introduction:Stress among healthcare professionals has become a major issue in healthcare organizations operating at the domestic, international and global fronts. This profession however, requires people to be physically, emotionally and mentally alert, in order to care for other people.

    Purpose:To ascertain stress factors among healthcare professional in Nigeria. In order to rank and establish causal relationships among the various stress factors using the Multi-Criteria Decision Making methods (MCDM).

    Materials and methods:A validated AHP-based questionnaires was used to conduct a survey of 386 healthcare professionals from two tertiary teaching hospitals in South-west, Nigeria, using proportional quota sampling procedure.

     

    Results:The results reveal that relationship factor has the most significant impact on the stress of healthcare professionals with an Eigen vector of 0.3531. It finds also that the role factor has the least significant criterion, having an Eigen vector of 0.0778. At the global level of ranking the alternative decision occupational stress factor, speed of change has the highest priority, the least being financial problems.

    Conclusions:In comparison with others, the health care profession is highly stressful, due mainly to the fact that it has a higher rate of psychological distress. Keeping this in mind, this study has examined what determines occupational stress among healthcare professionals in teaching hospitals in Nigeria.

    Keywords:Occupational stress, Health care professionals, MCDA, AHP, Healthcare service delivery, Nigeria

     

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    DOI:10.5604/01.3001.0012.1121

     

     

     

    *Corresponding author:

    Dakare Olamitunji, Ph.D., Department of Business Administration,   School of Management and Social Sciences,      

    Pan-Atlantic University,  Lagos, Nigeria, e-mail: odakare@pau.edu.ng,  Tel: 234 8023600188  

     

    Received: 08.01.2018

    Accepted: 16.02.2018

    Progress in Health Sciences

    Vol. 8(1) 2018  pp 113-125

    © Medical University of Białystok, Poland

     

    INTRODUCTION

     

                    The pressure at the workplace is unavoidable, due to the demands of the contemporary work environment. However, work environment pressures may be positive or negative, considering the degree of pressure. Pressure may be acceptable to an individual or not depending on the situations, magnitude and the capacity to cope. Often times, it may keep workers on the alert, even motivates them to achieve what they would not achieve ordinarily or learn in the process depending on the availability of resources and personal characteristics. Nevertheless, when pressure becomes excessive or otherwise unmanageable, it may become negative, thereby leading to stress [1].

                    Stress among healthcare professionals has become a major issue in healthcare organizations operating at the domestic, international and global fronts. This profession however, requires people to be physically, emotionally and mentally alert, in order to care for other people. Mistakes by healthcare professionals are hardly allowed, because they may be disastrous and irreversible. Healthcare professionals are therefore required to be in a stable and perfect state of mind, with no worries and anxieties [2].

                    Meanwhile, the causes and effects of job-related stress have been widely acknowledged within the extant literature and academic researchers. The reason for this acknowledgement is that most workers, in their line of duties, may have experienced stress in one way or another [3]. Much of the extantresearch studies on occupational stresshave also demonstrated that healthcare-related professions can result in excessive stress levels [4,5]. Upon the recognition that healthcare profession is a stressful one, Somaz and Tuglan [6] however, pointed out workload, job duplications, inadequate resources, physical environment, inadequate allocation of job, psychological environment, among others, as responsible for stress. Nonetheless, much of the prolific research on occupational stressamong healthcare professionalshas concentrated on developed and developing countries, using different methodology. However, this phenomenon has global appeal as evidenced in studies within Delhi [7], Iran [8], Ghana [9], Taiwan [10], India [11],Ghana [12], Dubai [13]. The aforementioned empirical review however, shows that studies have been undertaken to assess stress factors among healthcare professionals across developed and developing countries, using different methodology, however, similar studies do not exist in Nigeria and also no study has sought to rank and establish causal relationships among the various stress factors affecting the healthcare professional.

    Consequently, this research study is necessary because it provided evidence that stress factors among healthcare professional are numerous but they are all treated with equal importance in prior research. The study also represents one of the few formal research studies to focus on West Africa region and the first one to focus on pairwise comparison for ranking and establishing causal relationships among the various occupational stressfactors affecting the healthcare professionals in Nigeria using theMulti-Criteria Decision Making methods (MCDM). Hence, the study proposed a framework based on cause and effect relationship among occupational stress factors. It thus offers a novel perspective.Similarly, this study has also provided empirical evidence that, in practice, prioritization of stress factors among healthcare professional will advance the understanding of both practitioners and academics to know which stress factors act as causes to other stress factors, or which stress factors lead to other stress factors in order to stimulate research driven policy for its management.

                    Ultimately, the purpose of this research study is to ascertain the influence of stress factors among healthcare professionals in Nigeria and to rank and establish causal relationships among the various stress factors using the Multi-Criteria Decision Making methods (MCDM).

                    The term “stress” has become an amorphous term since there are numbers of research studies on the subject with different definitions of stress. The implication of this, that stress is a multidimensional concept, its definition then depends largely on the focus of the particular research study undertaken. For instance, The National Institute of Occupational Safety and Health [14], Health and Safety Executive [15], Howard [16], Moustaka & Constantinidis [17], Radhakrishnan & Jins [18] among others, defined stress to encompass the physical, mental, psychological and emotional pressures on the individual(s) which result from the interaction with the environment which they live, that are alleged as hurting and/or beyond their adaptive aptitude and having threats to human wellbeing.

                    However, as earlier mentioned in this study, numerous empirical studies have been conducted on stress factors among healthcare professionals in various contexts. Bhatia et al. [19] in their study on comparative analysis of occupational stress among nurses in two tertiary care hospitals in Delhi found that  the  most  significant  stressors  in the case of the

    causes of stress were high level of skill requirement of the job, while the least significant stressor was the helpfulness of the supervisors. In the same way, Saranbadi et al. [8] conducted a study on employee occupational stress among Military hospital personnel in Iran.  The Cross-sectional survey design was employed. The results of the study show that there is a higher stress level among healthcare employees compared to their administrative counterparts, which depicts that working conditions in military health settings are even more stressful for clinical staff. Also, from the findings of the study, no significant effect was identified for other demographic and professional characteristics, including age, sex, marital status, educational level, and work experience either between entire employees, or between clinicians.

                    Rita et al. [9] also carried out a comparative study at Ridge and Pantang hospitals in Ghana, in order to find out the main causes of stress among nurses in both hospitals and their level of job satisfaction.  The results of study reveal that the main causes of stress are the same for both sampled, except workload which is higher in Ridge hospital.  It also found out that there was a weak negative correlation relationship between work stress and job satisfaction in the two Hospitals. In Taiwan, Pan [10] also conducted a study to identify the determinant of nurses’ capabilities of stress using the Analytic Hierarchy Process model (AHP) in two regional hospitals in southern Taiwan. This study identified stress factors and classified them according to their order of importance. Four factors were identified as the second level of hierarchy. Of these, family factor was considered the most important, followed by personal attributes. The top three sub-criteria that enhanced nurse’s stress-coping capability are children’s education, good career plan, and healthy family.

                    For Gulavani and Shinde [11] the results of their study show that there is no significant relationship between occupational stress,job satisfaction and age, sex, professional education, and year of experience.Yeboah et al. [12] also examined the relationships between six key organizational factors, namely: demand, control, support, relationships, change, and role conditions. To do this, they analyzed the data collected from 453 healthcare professionals working in a teaching hospital in Ghana, using the three sequential steps in linear regression analysis. This helped to identify the causes of stress among human resource personnel sampled. The overwhelming finding in their study is that six elements significantly impact on employee stress with differential influences. They called for a model like the AHP, which will not only estimate the influence of major factors (criteria), but contribute to each component (sub-criteria). In the long run, this helped to arrive at a comprehensive assessment of occupational stress influences of health professionals.

                    Furthermore, Khan and Khurshid [13] conducted an empirical study on the impact of workplace stress of employees among hospitals’ staff in Dubai. A total of 150 employees working in various healthcare centers and hospitals in UAE were surveyed. The results of the study show that workplace has negative impact on employees’ well-being and the impact was found to be weak. The findings of the study suggested that an increase in workplace stresses will reduce wellbeing of employees. Also, the researchers recommend that in order to reduce the impact of stress on employees’ well-being, organizational support, family support and social support are essential.          

                    Although, in the above empirical review, studies have been undertaken to assess stress factors among healthcare professional across developed and developing countries, using different methodology, similar studies do not exist in Nigeria. To be precise, there has not been any know study that mobilize the Multi-Criteria Decision Making methods in order to assess occupational stress among healthcare professionals in Nigerian teaching hospitals. It can thus be said that the interest of this paper in situating the MCDM model within the context of Nigerian healthcare experience is seminal. Since, little stress situation can have positive effects by energizing employees towards achieving both personal and organizational goal, conversely unnecessary stress can seriously and undesirably impact an employee’s health and job performance from time to time [20].

     

    MATERIALS AND METHODS

     

                    The cross-sectional design was used in the selected teaching hospitals in South-west, Nigeria. The Lagos University Teaching Hospital (LUTH), Lagos, Nigeria, and Olabisi Onabanjo University Teaching Hospital (OOUTH), Ogun-state, Nigeria were purposively selected to guarantee easily access to information. The population of this study comprises all doctors and nurses in the selected teaching hospitals in South-west, Nigeria. The total population of the healthcare professional in the selected teaching hospitals is 5917. The choice of the healthcare professionals (doctors, nurses and other healthcare professionals) for the study is necessitated by the fact that they are recognized as the closest tertiary caregiver to numerous patients and patient relatives in the teaching hospital.  Additionally, the quota sampling technique was used. This helped to determine the percentage of respondents from each of the hospitals, so as to ensure effective representation.

     

    Meanwhile, 16% (975) of the total respondents were healthcare professional of OOUTH while 84%  4,942) of the respondents were healthcare professional of LUTH. 

    The researchers depended on the widely adopted formula developed by Cocharan [21] to determine appropriate sample size, based on the population from 5, 917 health professionals.

     

     

     

    Where:  n = sample size; N = population size; Z = standard normal variable (z = 1.96 at 95% confidence level); P = proportion or degree of variability = 50%; e = the level of precision = 5%.

     

              

     

     

    The appropriate sample size for the population of this study is approximately 361.  This is clearly less than the standard sample size of 384 being proposed for population that is unknown by the [21]. In order to guide against incomplete entries/low response rate which are the main disadvantage of questionnaire as an instrument for data collection, the researchers administered more questionnaires than the determined sample size. The copies of questionnaire administered were 400. The quota sampling of the healthcare professional of the hospitals under study would be used to determine the number of copies of questionnaire to be administered to each of the hospitals as well as the categories of health care professionals

     

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    Table 1. Quota sampling of the health care professionals

    Health care professionals

    OOUTH

    LUTH

    TOTAL

    Quota Sampling

    Copies  of questionnaire administered

    Doctors

    203

    1112

    1315

    22%

    22%  of 400 = 88

    Nurses

    236

    1417

    1653

    28%

    28%  of 400 = 112

    Others

    536

    2413

    2949

    50%

    50%  of 400 = 200

    Total

     

     

    5917

     

                          400

     

     

                    Table 1 shows that 22%, 28% & 50% of the copies of questionnaire were given to doctors, nurses and other categories of health professionals in that order.The present study adapted and modified the causes of stress identified by in the new UK Health and Safety Executive’s (HSE) Management Standards (MS) model, taking it as the key measurement in organizing questionnaire. This is in response to growing concern in the extant literature that the General Health Questionnaire has been the major device for evaluating the causes of stress, since it helps organizations to manage potential sources of work-related stress [12,13].

    The management standards had identified six key factors that  cause stress, namely: Demands factors: this includes issues such as workload, work patterns and the work environment.; Control factors – how much say the person has in the way they do their work.; Support factors – this includes the encouragement, sponsorship and resources provided by the organisation, line management and colleagues; Relationships factors – this includes promoting positive working to avoid conflict and dealing with unacceptable behavior; Role factors – whether people understand their role within the organization and whether the organization ensures that they do not have conflicting roles;and Change factors – how organizational change (large or small) is managed and communicated in the organization.

                    The factors were used in formulating the AHP-based questionnaire for pairwise comparison by respondents.  Figure 1 below shows the hierarchical model of the occupational stress factors among healthcare professionals.

     

     

    Determinants of occupational stress factors among healthcare professionals

    Demand factor

    Relationship factor

    Control factor

    Support

    factor

    Change

    factor

    Role

    factor

    Shortage of resources

    Shortage of staff

    Work overload

    Long working hours

    Time pressure

    Unfriendly

    Supervision

    Lack of Motivation

    Lack of appreciation

    Poor work ethics

    Lack of reward

    Lack of recognition

    Unfriendly

    Work environment

    Lack of support

    Financial problems

    Encouragement

    Sponsorship

    Financial

    Incentive

    Understanding roles

    Conflicting roles

    Responsibility

    Speed of change

    Communication

    Change leadership

    Figure  1.Hierarchical structure of Occupational stress, as adapted from UK Health and Safety Executive’s (HSE) and theManagement Standards (MS) model of stress

     

     

    RESULTS

     

                Four hundred (400) copies of questionnaire were administered. Out of these, three hundred and ninety (390) were returned, indicating 97.5% of the administered copies of the questionnaires. In all, 98.9% were found to be useful for analysis. It is necessary to note that analysis was done based on the total number of retrieved questionnaires that were found to be useful and valid.  

    The demographic characteristics of the respondents reveal  that 139  (36%)  of  the  respondents  were  males,  while  247  (64%)  were females. Two hundred and sixty-six (266) or 69% of them were between 31 - 50 years of age, while 23 (6%) were within the age bracket of 21-30 years. Similarly, 27 (7%) were above the age of 60 years. In regard to the educational level of respondents, 259 (representing 67%) are B. Sc./MBBS  degree holders. Also, an assessment of the working experience of respondent shows that 290 (65%) had put in 6-15years into labor. Also, eighty four (84) of them were doctors, 108 nurses and 194 respondents (50%) fall under the category of other healthcare professionals. All respondents experience work related stress in one way or another. Likewise, Sixty-eight percent (68%) of the respondents revealed that their experience of stress lasted for 2 to 3 weeks, 17% for a month and 15% lasted just within a week. While the stress lasted, it negatively affected the labor input and ultimately the service delivery of an average health worker. 

     

    Comparison matrices

                    This  section  of  the  study  presents  information  on  the  comparison  matrix  derived  from  the questionnaires administered  to respondents.  Two thousand, seven hundred and two (2702) comparison matrices were obtained from 386 respondents (health care professionals) in the two   teaching hospitals selected purposely for this study.  These include   matrixes for each level of the hierarchy and the reversed judgment matrices when consistency ratio (CR) is >10 %.

                 For AHP analysis, each comparison matrix must be reduced to 1 for each level of the hierarchy.  Therefore, the 2702 matrices were later reduced to seven (7) comparison matrices as shown Table 2.

    This was done by using 1/386 ratio, since it is assumed that health care professionals are likewise knowledgeable about their occupational stress factors in the selected teaching hospitals.

     

     

     

     

    Table 2. Reduced matrix for determinants of occupational stress factors among health care professionals

    CRITERIA

    Demand factor

    Relationship factor

    Control factor

    Support factor

    Role factor

    Change factor

    WEIGHT

    Demand factor

    1.0000

    0.4105

    0.3708

    0.2252

    1.9928

    0.2653

    0.0956

    Relationship Factor

    2.4359

    1.0000

    1.7790

    4.0000

    3.6000

    2.4000

    0.3531

    Control factor

    2.6972

    0.5621

    1.0000

    0.3409

    0.2205

    2.3429

    0.1536

    Support factor

    0.4072

    0.2500

    2.9335

    1.0000

    0.1223

    2.4000

    0.1616

    Role factor

    0.5018

    0.2778

    0.7275

    0.3527

    1.0000

    0.5079

    0.0778

    Change factor

    3.7695

    0.4167

    0.4268

    0.4167

    1.9688

    1.0000

    0.1582

    λmax = 6.3204

    CI = 0.0605

    CR = 0.0484

     

     

             

    The values found in the last column of Table 2, as denoted by weight, are also known as eigenvector which a direct physical meaning in the interpretation of AHP result. The values determine the participation or weight of those criteria relative to the total results of the goal. Based on the occupational stress factors identified, relationship factor has the weight of 35.31%, relative to the goal. This indicates that a positive evaluation of this factor contributes approximately five times more than that of the role factor (7.78%).             

     

     

    Following the procedure of AHP, there is a need to check for data inconsistencies. The reason for this is to capture enough information to determine whether the health care professionals have been consistent in their choices. The inconsistency index is based on maximum lambda, which is calculated by summing the product of each element in the eigenvector (weight) by the respective column total of the original comparison matrix.  Table 3 demonstrates the calculation of the maximum eigenvalue, also called maximum lambda, denoted as (λmax).

     

     

     

    Table 3. Calculation of the maximum eigenvalue of the six criteria,with respect to goal which states determinant of occupational stress factors among health care professionals

    Criteria

    Demand factor

    Relationship factor

    Control factor

    Support factor

    Role factor

    Change factor

    Eigen vector

    0.0956

    0.3531

    0.1536

    0.1616

    0.0778

    0.1582

    Total sum

    10.8116

    2.9171

    7.2376

    6.3355

    8.9044

    8.9161

    Maximum eigenvalue

    {(0.0956*10.8116) + (0.3531*2.9171) + (0.1536*7.2376) + (0.1616*6.3355) + (0.0778*8.9044) + (0.1582*8.9161)}=  (1.0336 + 1.0300 + 1.1117 + 1.0238 + 0.6928 + 1.4105) = 6.3024

     

     

     

    The test of consistency is done using the formula: 

    CI = (λMax-n)/(n-1); 

    CI = (6.3024 – 6)(6-1)

         = 0.3024/5

         = 0.0605

                        In order to verify the Consistency Index (CI), Saaty [23] prescribes what is called the Consistency Ratio (CR), which is determined by dividing the Consistency Index (CI) by Random Index (RI).

    The matrix will be considered consistent if the resulting ratio is less than 10%.

    The Random Index value is fixed and based on the number of evaluated criteria. In the case of occupational stress factors of health care professionals, the Consistency Ratio for the initial group criteria is

    CR=    CI/RI = 0.0605/ 1.25

    = 0.0484 = 4.8% approx. 5%

                       The AHP model employed for this study has three levels, namely: The goal, the criteria, and   alternatives. The healthcare professionals of the teaching hospitals under study were able to pairwise the occupational stress factors in the order of importance and as they affect their functionality and healthcare service delivery. The analysis of the different levels is shown in Table 4.

    Table 4 majorly consist of seven sections in which the first section denoted as part 1 displays average composite priority and relative reference ranking of the criteria with respect to main goal. However, the remaining six sections fall under part 2 of the table 6 displays average composite priority and relative reference ranking of the decision alternatives with respect to each criterion.

    The part 1 of the table 5 presents the priorities of the criteria with respect to the main goal of the study, which is to determine the level of occupational stress among healthcare professional inealthH Nigerian teaching hospitals.      

    This is done by considering six identified causes of stress, adopting appropriate stress models like the new UK Health and Safety Executive’s (HSE) and theManagement Standards (MS).  Based on the perception and pairwise comparison of the occupational stress factor among healthcare professional, the most affected factor is that of relationship factor, with a priority of 0.3531.

     Support factor has 0.1616 of priority. Likewise change factor has a priority of 0.1582.

    While control factor has a priority of 0.1582, the priority of demand factor is 0. 09956.

    The least is the role factor that has a priority of 0.0778.

    However, the first section of part 2 of table 4 shows the perception of healthcare professionals, with regards to decision alternatives of the demand factors, using the composite priorities.

    The most affected factor of this alternative under the demand factor is shortage of resources, with a priority of 0.2458.

    This is followed by the work load, with a priority of 0.2413.  

    Next is the shortage of staff, with a priority of 0.2249, followed by the pressure of time with priority of 0.1670.

    The least affected of the alternative is the long working hours, with priority of 0.1271.

    Since the shortage of resources was the most affected factor among the alternatives of the demand factor, it may stop the healthcare professionals from achieving an extra role performance, by losing motivation, commitment and disengagement from the system. To resolve this, there is need for   health care managers to provide more   resources for the health care professional. This will help to assuage or eliminate stress in their work place, so that improved performance can be guaranteed.  In addition, the second section of part 2 displays the perception of healthcare professionals with regards to decision alternatives of the relationship factors using the composite priorities. The most affected factor of this alternative under the relationship factor is lack of appreciation, with a priority of 0.2753. This is followed by the unfriendly supervisors/boss, with a priority of 0.2563. Next is lack of motivation, with a priority of 0.2104.

               While lack of reward has a priority of 0.1472, poor working ethics occupies the least, with 0.1126 priority value.                         

    In considering the perception of healthcare professionals with regards to decision alternatives of the control factors using the composite priorities. The most affected factor of this alternative under control is lack of support from the principal officers of the hospitals, with a priority of 0.3289.

    The next is unfriendly working environment, having a priority of 0.3040. Closely following this is the lack of recognition, which has 0.1549 of priority. No Personal growth has a priority of 0.1546, while that of individual financial problem is 0.0576. 

                    Also, the fourth section of part 2 of the table 4 reveals the perception of healthcare professionals with regards to decision alternatives of the support factors using the composite priorities.

    The most affected factor of this alternative under support is encouragement, with a priority of 0.5204. Sponsorship has a priority of 0.3124 that of financial incentives is 0.1672. It is evident form the result that more than halves 52% of the contribution to stress through lack of support due to lack of encouragement.

    The management of human and facilities in the healthcare sector should encourage their workers always as the healthcare professionals value it most as support factor than can help to reduce the stress on the job.

                     Moreover, the fifth section of part 2 reveals the perception of healthcare professionals with regards to decision alternatives of the role factors using the composite priorities.

    The most affected factor of this alternative understanding is the roles to be performed, with a priority of 0.4899. This is followed by the responsibility that has a priority of 0.2690.

     The least affected factor goes to conflict roles, having a priority of 0.2411. This result is reflecting the Nigeria perspective on the role factors as criteria of occupational stress among healthcare professionals. Recruitment workers into hospitals should be based on merit as it is evident from the result that lack of proper understanding of what is expected at work may influences stress more than conflict at work.

                    The last section of the part 2 shows the perception of healthcare professionals with regards to decision alternatives of the change factors using the composite priorities. The most affected factor of this alternative unawareness is the speed of change, with a priority of 0.7143.

    Communication has a priority of 0.2067, while change leadership is the least affected, cornering only a priority of 0.0789.

    Furthermore, local priorities (weights) were derived for each of the occupational stress criteria and decision alternatives, with respect to decision criteria, as presented in table 5.

    Table 6 shows the individual local weight of occupational stress factors denoted as criteria  and  the  local  weight  of  the  decision  alternatives  with respect  to  the stress factors criteria. These local weights of the decision criteria and alternatives were subsequently used to calculate the total weight or global weight/priority.

    From the result, shortage of resources to work with by healthcare professions is the most dangerous stressor with highest local priority of 0.2458, leading all other alternatives.

    This is in line with the psychological view of stress as posited by Lazarus and Folkman [22] been the relationship between an employee and the working environment. As the employee assessed by the person as demanding his or her resources and threatening his or her wellbeing. The resources available for healthcare professionals are in limited supply or at times obsolete in terms of meeting the modern days healthcare service delivery thereby constituting stress to the healthcare professionals.

     Figure 2 vertical bar chart denotes the pictorial diagram of the decision alternatives of occupational stress. It is the global priority of each of the alternatives.

     From the chart, it can be seen that the alternative speed of change has the longest bar, with priority of 0.1130. This is followed by lack of appreciation, with priority of 0.0966. Unfriendly supervisors or boss has a priority of 0.0905. Encouragement has 0.0841.

    Lack of motivation and reward respectively has priorities of 0.0743 and 0.0505. The priority of sponsorship and lack of support from healthcare management is 0.0505.

     Likewise, unfriendly working environment, poor work ethics, understanding roles, and communication have priorities of 0.0467, 0.0398, 0.0381 and 0.0327, in that order.

    As can also be deciphered from the chart, the shortest bar is that of financial problems as an alternative, with a priority of 0.0088. Long working hours follows, with a priority of 0.0121.

    The priorities of change of leadership, time pressure, conflicting roles, responsibility, shortage of staff, work load, shortage of resources, no personal growth and lack of recognition, and financial incentives are 0.0125, 0.0154, 0.0188, 0.0209, 0.0215, 0.0231, 0.0235, 0.0238 and 0.0270, in that order.

    These priorities were summed up into one, and as a consequence, they satisfy the law of probability.

     

     

     

    Table 4. Combined composite priority and relative reference ranking of the criteria and decision alternatives

     

    Determinant of Occupational stress factors among healthcare professionals

    PART 1

     Criteria to Goal

    Demand

    Relationship

    Control

    Support factors

    Role factors

    Change factors

    Pooled average composite priority

    0.0956

    0.3531

    0.1536

    0.1616

    0.0778

    0.1582

    Relative reference ranking

    5th

    1st

    4th

    2nd

    6th

    3rd

     

    PART 2

      Decision alternatives to criteria

     

    Decision alternatives with respect to Demand factors

     

     

    Shortage of resources

     

    Shortage of staff

     

    Workload

     

    Long working hours

     

    Time pressure

    Pooled average composite priority

    0.2458

    0.2249

    0.2413

    0.1271

    0.1670

    Relative reference ranking

    1st

    3rd

    2nd

    5th

    4th

     

     

     

    Decision alternatives with respect to Relationship factors

     

    Unfriendly supervisors

     

    Lack of motivation

     

    Lack of appreciation

     

    Poor work ethics

     

    Lack of reward

    Pooled average composite priority

    0.2563

    0.2104

    0.2753

    0.1126

    0.1472

    Relative reference ranking

    2nd

    3rd

    1st

    5th

    4th

     

     

     

    Decision alternatives with respect to Control factors

     

    Lack of recognition

     

    No personal growth

     

    Unfriendly working environment

     

    Lack of support

     

    Financial problems

    Pooled average composite priority

    0.1549

    0.1546

    0.3040

    0.3289

    0.0576

    Relative reference ranking

    3rd

    4th

    2nd

    1st

    5th

     

     

    Decision alternatives with respect to support factors

    Encouragement

    Sponsorship

    Financial incentives

    Pooled average composite priority

    0.5204

    0.3124

    0.1672

    Relative reference ranking

    1st

    2nd

    3rd

     

     

    Decision alternatives with respect to Role factors

    Understanding roles

     

    Conflicting roles

    Responsibility

    Pooled average composite priority

    0.4899

    0.2411

    0.2690

    Relative reference ranking

    1st

    3rd

    2nd

     

     

    Decision alternatives with respect to change  factors

     

    Speed of change

    Communication

    Change leadership

    Pooled average composite priority

    0.7143

    0.2067

    0.0789

    Relative reference ranking

    1st

    2nd

    3rd

                   

     

     

     

     

     

    Table 5. Tabular presentation of the decision criteria and alternatives local priority

     

    Criteria

     

    Local Priority

     

    Alternatives

     

     

    Local Priority

    Demand factor

    0.0956

    Shortage of resources

    0.2458

    Shortage of staff

    0.2249

    Work overload

    0.2413

    Long working hours

    0.1271

    Time pressure

    0.1610

    Relationship factor

    0.3531

    Unfriendly supervisors

    0.2563

    Lack of motivation

    0.2104

    Lack of appreciation

    0.2735

    Poor work ethics

    0.1126

    Lack of reward

    0.1472

    Control factor

    0.1536

    Lack of recognition

    0.1549

    No personal growth

    0.1546

    Unfriendly working environment

    0.3040

    Lack of support

    0.3289

    Financial problem

    0.0576

    Support factor

    0.1616

    Encouragement

    0.5204

    Sponsorship

    0.3124

    Financial Incentive

    0.1672

    Role factor

    0.0778

    Understanding roles

    0.4899

    Conflicting roles

    0.2411

    Responsibility

    0.2690

    Change factor

    0.1582

    Speed of change

    0.7143

    Communication

    0.2067

    Change of leadership

    0.0789

     

     

             

     

     

    Table 6. Tabular presentation of decision alternatives with their corresponding global weight

     

    Decision Alternatives

     

    Global weight

     

     

    Ranking

     

     

    Decision Alternatives

     

    Global weight

     

    Ranking

    Shortage of Resources

    0.0235

    16th

    Unfriendly working environment

    0.0467

    9th

    Shortage of staff

    0.0215

    18th

    Lack of support

    0.0505

    7th

    Work load

    0.0231

    17th

    Financial problems

    0.0088

    24th

    Long working hours

    0.0121

    23rd

    Encouragement

    0.0841

    4th

    Time pressure

    0.0154

    21st

    Sponsorship

    0.0505

    7th

    Unfriendly supervisors

    0.0905

    3rd

    Financial Incentives

    0.0270

    13th

    Lack of motivation

    0.0743

    5th

    Understanding roles

    0.0381

    11th

    lack of appreciation

    0.0966

    2nd

    Conflicting roles

    0.0188

    20th

    Poor working ethics

    0.0398

    10th

    Responsibility

    0.0209

    19th

    Lack of reward

    0.0520

    6th

    Speed of Change

    0.1130

    1st

    Lack of recognition

    0.0238

    14th

    Communication

    0.0327

    12th

    No personal growth

    0.0238

    14th

    Change leadership

    0.0125

    22nd

     

     

     

    Figure 2.  Bar chart of the decision alternatives of the occupational stress and their corresponding global weight 

     

     

     

    DISCUSSION

     

    The study demonstrated a multi-criteria decision-making analysis for pairwise comparison of occupational stress criteria and alternatives thereby revealing the healthcare profession perspective as well as research driven policy directions in its management in Nigeria. The results revealed that financial factor came out to be  a least factor influencing stress of healthcare professionals, contrary to the wide believe that brain drain in the health sector is majorly influenced by financial inducement. No amount of studies conducted on different aspect of occupational stress will be too much since studies have suggested that stress and health are strictly connected [24,25]. Among the five alternatives under the control factor criteria, lack of support is highly prioritised as most influencer of occupational stress among healthcare professionals in Nigeria. This result corroborates the findings of Van-der-Colff and Rothmann [26], using different methodology (factor analysis) in South Africa found out that lack of support from contemporaries at work serve as source of stress for professionals in their working environment. This shows that support from co-workers serves as hygiene factors that employees consider necessary if their working environment (hospitals) will stimulate the best from employees (healthcare professionals).

                    On the demand factor criteria, shortage of resources, work overload and shortage of staff takes

     

     

    substantial seventy percent (70%) among all the factors influencing stress of healthcare professionals in the hospitals. This is in line with submission of Somaz and Tuglan [6] that workload, job duplications, inadequate resources, among others are responsible for stress. Although using a different methodology, AHP pairwise comparison was able to assign weight to each of factors as they influences demand factor as a criteria stress and ultimately the occupational stress of healthcare professionals in the hospitals. AHP is used in this study owing to it arguably the most well-known and widely used multi-criteria method, which has firm theoretical underpinnings and has been used successfully to help people make better decisions in a wide variety of complex circumstances [27,28], such as the occupational stress management of healthcare professionals in a developing nation like Nigeria.

                    The results of the study also point out that lack of appreciation and unfriendly supervisor as most stressors with over 50% contribution to relationship stress related factor. This is indicating the training needs for Managers in the health sector for effective motivation of colleagues thereby bring out the best from all categories of healthcare professionals in their role of managing peoples health and life. In all, this study present a comprehensive assessment of occupational stress influences of health professionals in the hospitals using AHP where all categories of healthcare professionals (experts opinion) are duly represented as respondents in the pairwise comparison and judgment process.

                    The present study however, has the following limitations. First, a unique contribution of this study is ascertain stress factors among healthcare professional in Nigeria and to rank and establish causal relationships among the various stress factors using the Multi-Criteria Decision Making methods (MCDM). There is the need for further empirical work to test the degree to which the findings can be generalized to other industries and countries. Second, the study conducted a survey of only healthcare professionals: future work can be carried out to validate the findings using statistical methods and taking a large sample of respondents.

     

    CONCLUSIONS

     

    1. In comparison with others, the health care profession in Nigeria is highly stressful, mainly to the fact that it has a higher rate of psychological distress.
    2. The results reveal that relationship factor has the most significant impact on the stress of healthcare professionals.
    3. It finds also that the role factor has the least significant criterion.
    4. At the global level of ranking the alternative decision occupational stress factor, speed of change has the highest priority, the least being financial problems.

     

    Conflicts of interest

    The authors declare that they have no conflicts of interest.

     

     

    REFERENCES 

     

    1. World Health Organisation. Work organisation and stress, protecting workers. Health Series. 2003; 3:1-25.
    2. Familoni OB. An overview of stress in medical practice, Afr Health Sci 2008 Mar;8(1):6 –7.
    3. Cooper C, Dewe P. Driscoll M. Organisational stress. Thousand Oaks; C.A: Sage; 2001.
    4. Rafati F, Shafiee N. The effect of job stress on physical health - Mental Nurse. J Nurs   Midwifery 2002;(4)3:14-7.
    5. Kerr R, McHugh M, McCrory M. HSE Management Standards and stress-related work outcomes. Occup Med 2009 Dec;59(8):574–79.
    6. Somaz WH, Tulgan B. Performance under   pressure:  Managing   stress   in   the Workplace. Canada: HRD Press Inc; 2003; 7-8p.
    7. Awoniyi E, Griego O, Morgan G. Person-environment fit and the transfer of training Int J Train Dev 2002 Mar;6(1):25-35.
    8. Sarabandi A, Hazarati H, Keykha M. Occupational stress in Military health settings: A questionnaire-based survey. IJHR 2012;(1)2:103-8.
    9. Rita AA, Artindanbila S, Portia MP, Abepuoring P. The causes of stress and job satisfaction among nurses at Ridge and Pantang hospitals in Ghana. International IJASS. 2013;3(3):762-71.
    10. Pan FC. Using analytic hierarchy process to identify the nurses with high stress-coping capability: Model and application. Iran J Public Health 2014 Mar;(43)3:273-81.
    11. Gulavani A, Shinde  M. Occupational stress and job satisfaction among nurses. IJSR. 2014 Apr; (3)4:733-40.
    12. Yeboah MA, Ansong MO, Antwi HA, Yiranbon E, Anyan F, Gyebil F. Determinants of workplace stress among healthcare professionals in Ghana: An empirical analysis. IJBSS. 2014 Mar;5(4): 140-51.
    13. Khan N, Khurshid S. Workplace stress and Employee wellbeing: Case of Healthcare Staff in UAE. ESJ 2017;(13)5:217-26.
    14. National Institute for Occupational Safety & Health (NIOSH). Stress at work. Cincinnati OH: US Department of health and human services, Public Health Service. Center for Disease Control and Prevention. 1999; 99 – 101p.
    15. Health and Safety Executive (HSE). Tackling stress. The management standards approach Sudbury: HSE Books. 2005.
    16. Howard F. Managing stress or enhancing well – being: Positive psychology’s contribution to clinical supervision. Austral Psychol 2008; (43)29:105-13.
    17. Moustaka E, Constantinidis TC. Sources and effects of work-related stress in nursing. Health Sci J 2010;4:210-6.
    18. Radhakrishnan R, Jins JP. A study on gender differences in stress faced by life insurance marketing employees. Asia Pac J Manag 2012;8: 77-85.
    19. Bhatia N, Kishore J, Anand T, Jiloha RC. Occupational stress amongst nurses of two tertiary care hospitals in Delhi. AMJ 2010 Jan;3(11):731-8.
    20. Sharma E. Role stress among doctors. J Health Manag 2005;7(1):151-6.
    21. Cochran WG. Sampling techniques. 3rd edition. New York: John Wiley & Sons; 1997.
    22. Lazarus RS, Folkman S. Stress appraisal and coping. New York: Springer; 1984.
    23. Saaty TL. Fundamentals of decision making and priority theory with analytical hierarchy process. Pittsburgh: RWS Publications; 2000.
    24. Burke M. Managing work-related stress in the district nursing workplace. Br J Community Nurs 2013 Nov;18(11):535-38.
    25. Farquharson B, Bell C, Johnston D, Jones M, Schofield P, Allan J, Ricketts I, Morrison K, Johnston M. Nursing stress and patient care: real-time investigation of the effect of nursing tasks and demands on psychosocial stress, physiological stress, and job performance: study protocol. J Adv Nur 2013 Oct;69(10):2327-335.
    26. Van-der-Colff JJ, Rothmann S. Occupational stress of professional nurses in South Africa. J Psychol Africa 2013;(24)4:375-84.
    27. Golden BL, Wasli EA, Harker PT. The analytic hierarchy process: Applications and studies. New York: Springer Verlag; 1989.
    28. Vaidya OS, Kumar S. Analytic hierarchy process: An overview of applications. EJOR 2006 Feb; 169(1):1–29.