Work-related stress in intensive care unit night shift nurses: A cross-sectional analysis of prevalence and determinants

A descriptive cross-sectional research design was employed in this study. This design was suitable for the research aim, as it allowed for the assessment of work-related stress and associated factors among ICU night shift nurses at a single point in time, providing a snapshot of the current state without requiring follow-up. The approach enabled efficient data collection from a relatively large sample within a limited timeframe.

This study was conducted at the ICUs of Main Mansourah University Hospital, Convalescence Hospital, and the Internal Medicine building. These units provide direct care for all critically ill patients. Across sites, the number of ICUs ranged from three to ten, and bed capacity ranged from 14 to 40 beds. These units are well-equipped with advanced monitoring and life support technology and provide direct care to critically ill patients in general surgical, respiratory, neurosurgical, and neurological ICUs, as well as the stroke unit. The nurse-patient ratio in these ICUs typically ranged from 1:2–1:1, depending on the type of ICU and the patients’ conditions.

A convenience sample of 362 ICU nurses was recruited from the selected ICUs. Despite its limitations, this approach provided valuable insights into examining work-related stress and associated factors among ICU night shift nurses. Data were collected between January 10, 2025, and April 30, 2025. The inclusion criteria were nurses directly involved in patient care, with at least one year of experience in the ICU, and a willingness to participate in the study. Exclusion criteria included nurses in administrative roles, those on leave, and those not working night shifts. Participants who met the inclusion criteria were approached in person within their ICUs, where the study purpose and procedures were explained. Nurses who agreed to participate and signed written informed consent provided their official email addresses and subsequently received a Google Form link through which data were securely collected via email to prevent duplicate entries and ensure only eligible participants responded. This approach facilitated efficient, confidential, and contactless data collection. In accordance with the principle of voluntariness, all participants who completed the questionnaire were considered to have given their informed consent, and they were free to withdraw from the study at any time during the study period. The final sample size reflected the number of eligible and willing participants available during the study period. It exceeded the calculated sample size (= 277) using an Excel calculation sheet [25,26]:

Where n is then corrected for the population size (N = 450) as n*=nNn+(N−1). Where P is the assumed population proportion (= 0.35), d is the margin of error (= 0.05), α is the significance level (= 0.05), β = 0.20 (i.e., statistical power = 80%), Zα_/2 and Z_β (1.96 and 0.845, respectively) are the standard normal values.

One tool was utilized to collect data after reviewing recent relevant literature [27–29].

Part I: Nurses’ Demographic Data Sheet: This section was used to gather information about nurses’ age, gender, educational level, years of work experience in the ICU, current position, working hours, and attendance at training courses on stress management.

Part II: Revised Nursing Stress Scale (RNSS): This tool was adapted from Pavek et al. [27]. The Revised Nursing Stress Scale is a valid and reliable tool recommended for assessing the frequency and significant sources of stress experienced by nurses. The RNSS consisted of a total of 66 items and nine subscales as follows: death and dying, conflict with providers, inadequate preparation, problems with peers, problems with supervisors, workload, uncertainty concerning treatment, patients and their families, and discrimination. Each item was measured using a unipolar 4-point Likert scale to measure the frequency of occupational stressors as experienced by the participant. Likert scale responses consisted of never (0), occasionally (1), frequently (2), and very frequently (3). Total scores ranged from 0 to 198, with higher total scores representing higher levels of perceived. Total RNSS scores were first transformed into Sten scores (scale from 1 to 10). Sten scores were then classified into low (1–4), moderate (5–6), and high scores (7–10) [2,30]. The RNSS demonstrated acceptable to excellent internal consistency reliability (αs ≥ 0.73 and ω ≥ 0.80). This tool was translated into Arabic using a forward-backward translation technique to ensure cultural equivalence. Permission to use the RNSS was obtained from the author.

The RNSS was translated using a standard forward-backward translation technique to ensure linguistic accuracy and cultural relevance. Two independent bilingual translators first translated the original English version into Arabic (forward translation). Another set of translators, blinded to the original, then back-translated the Arabic version into English. The back-translated version was compared with the original to identify discrepancies. An expert panel of critical care nursing professionals reviewed all versions for clarity, cultural appropriateness, and contextual relevance. Revisions were made based on their feedback to improve comprehensibility and applicability in the local nursing context. This rigorous process ensured semantic, idiomatic, experiential, and conceptual equivalence between the original and translated instruments.

The reliability analysis shows that all subscales of the RNSS have acceptable to excellent internal consistency, with Cronbach’s alpha values ranging from 0.708 to 0.942. The overall RNSS scale has a very high reliability (α = 0.967), indicating that the instrument is highly consistent in measuring work-related stress among ICU nurses. These support the use of the RNSS in this population.

Before starting the data collection, a pilot study was conducted with 36 nurses, representing 10% of the overall sample, to test the feasibility, applicability, and simplicity of the translated tool. The participants who were involved in the pilot study were excluded from the main study. Participants provided feedback on the clarity of language, response options, and the relevance of items to their work environment. Minor adjustments were made based on pilot findings to enhance the tool’s usability without changing the core content or structure.

Ethical approval for this study was obtained from the Research Ethics Committee of the Faculty of Nursing, Mansoura University (Ref. No. 0696). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained from the study nurses after they were informed of the study’s aim and nature. Participants were assured of their voluntary participation and the right to withdraw from the research at any time without facing any consequences. They were also informed that their personal information was encrypted and kept confidential, and that the observed practice would not be taken into account in their annual appraisal.

The researcher collected data from January to June 2025. Before data collection, the researchers introduced themselves to the participating nurses in each unit, described the purpose and nature of the study, and invited them to participate in the study. Official email addresses were obtained from participants who agreed to participate. After securing all necessary approvals, the study questionnaire was converted into a user-friendly Google Form. The link to the form was then sent to participants via their official email addresses. This secure online platform facilitated efficient and confidential data collection.

The data were analyzed using the Statistical Package for Social Sciences (SPSS), version 21.0. Chronbach’s α was obtained as a measure of reliability. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the data. For age and education categories with very low frequency, pooling was performed with other categories, resulting in two categories for each (Age: < 30 years, ≥ 30 years; Education: less than bachelor’s, bachelor’s or higher). The distribution of stress scores (total RNSS scores and the subscale scores) was assessed graphically using boxplots and standard probability plots. Where the normality assumption was met (death and dying, problems with supervisors, patients, and their families ‘ workload, and discrimination), an independent samples t-test was used to test differences in mean scores among levels of independent variables with two categories (age, gender, having children, and education). In comparison, one-way ANOVA was carried out to test differences among levels of variables with three or more categories (marital status, work experience, and number of night shifts per week). For dependent variables where significant deviations from normality were detected (conflict with providers, inadequate preparation, problems with peers, and uncertainty concerning treatment subscales), the non-parametric Mann-Whitney U test and Kruskal-Wallis test were used instead of the t-test and One-Way ANOVA, respectively. Multiple pairwise comparisons were performed using Tukey’s test for One-way ANOVA and Dunn’s procedure with Bonferroni adjustment for the Kruskal-Wallis test.

No significant relationship (P > 0.05) was found between work stress and any of the following variables: age, marital status, education, having children, or the number of weekly night shifts. A significant relationship (P < 0.05) was found with gender concerning death and dying, patients and their families, and discrimination, where females had higher average stress scores in all three domains (Table 4).

For marital status, a significant relationship was found only with the “inadequate preparation” subscale (P = 0.041), where single nurses had a higher average score (7.841) than married (6.59) and divorced or widowed nurses (6.44). A significant relationship (P = 0.023) was also found between work experience and “inadequate preparation”. Nurses with less than 5 years of experience had higher average stress scores in this subscale than nurses with 5–10 years of experience and nurses with more than 10 years of experience, as shown in Table 5. No significant relationship (P > 0.05) was found between work experience and the other stress scales or the overall RNSS score. However, the relationship was substantial (P = 0.057) with “uncertainty concerning treatment,” where nurses with less than 5 years of experience had higher average scores than those with more years of experience, as presented in Table 5.

The study has several limitations. First, its cross-sectional design limits the ability to establish causal relationships between variables. Future research is warranted to include intervention-based studies and longitudinal designs. Furthermore, the use of a convenience sample from a single hospital network limits the generalizability of the findings to other settings. Second, data were collected using a self-report questionnaire, which may be subject to response bias.

Third, the absence of qualitative data limited deeper exploration of nurses’ lived experiences and perceptions. Additionally, essential variables such as organizational support, workplace culture, burnout, job performance, leadership style, and coping strategies were not addressed, although they may also influence stress levels. Future research is recommended to incorporate longitudinal and mixed-methods approaches, include these additional variables, and expand the scope across multiple hospitals and regions to enhance the applicability and depth of the findings.

Conclusion: Work-related stress is highly prevalent among ICU nurses working night shifts, primarily driven by heavy workloads and interpersonal challenges. Stress levels vary significantly by gender and years of experience, underscoring the need for organizational interventions, such as staff support programs, training, effective shift management, flexible scheduling, and psychosocial support, to mitigate stress and improve the quality of care.

Based on the current findings, the following are recommended. Healthcare organizations should implement targeted stress management programs for ICU night shift nurses to reduce work-related stress and its negative impact on well-being and patient care quality. Strategies such as cognitive-behavioral training, mindfulness, peer support groups, and workload adjustments can help nurses enhance their coping skills and resilience. Nursing education programs should incorporate training on recognizing stress, developing effective coping mechanisms, and practicing self-care strategies to promote overall well-being. Ongoing professional development and workshops focusing on mental health and stress reduction are crucial for preparing nurses for the high demands of ICU environments. Moreover, further studies should adopt longitudinal designs to explore the progression of work-related stress and evaluate the effectiveness of intervention programs over time. Research expanding to multiple hospitals and diverse healthcare settings will improve the generalizability of findings. Additionally, investigating organizational culture, leadership styles, and individual coping strategies can provide a holistic understanding of factors influencing nurse stress and burnout.

All relevant data are within the paper and itsfiles. Supporting Information