TITLE: STRESS-RELATED INHIBITORS AND THEIR CONTRIBUTION TO

MENTAL WELLNESS OF NURSES IN PUBLIC HOSPITALS: A CASE OF EMBU

LEVEL-5 HOSPITAL

Margaret Gatavi Njeru

PSC-4-0067-1/2021

Kenya Methodist University

Department of Theology, Religious Studies, and Counseling
Code Title: Concept Paper
Course Code: DPCP 920
First Trimester 2023
 Table of Contents
1.0 Background of Research............................................................................................................4
1.1 Statement of the Problem.......................................................................................................5
1.2 Purpose of Research...............................................................................................................6
1.3 Scope of the Study.................................................................................................................6
1.4 Research Objectives...............................................................................................................6
2.0 Theoretical and practical Relevance of the Research................................................................6
2.1 Theoretical Framework..........................................................................................................6
2.1.1 Organizational Inhibitors.................................................................................................8
2.1.2 Physical Work Environment Inhibitors...........................................................................8
2.1.3 Colleagues.......................................................................................................................8
2.1.4 Care Recipients................................................................................................................8
2.1.5 Intrinsic factors................................................................................................................9
2.2 Conceptual Framework..........................................................................................................9
2.2.1 Research Variables..........................................................................................................9
2.2.2 Research Hypothesis (Null Hypothesis)........................................................................10
2.3 Relevance of the Study........................................................................................................11
3.0 Summary of Relevant Literature.............................................................................................11
3.1 Introduction..........................................................................................................................11
3.2 Prevalence of mental disorders among nurses in health sector............................................11
3.3 Stress-related Inhibitors and mental health among nurses...................................................14
3.1.1 Physical work environment...........................................................................................14
3.1.2 Care recipients...............................................................................................................15
3.1.3 Organizational...............................................................................................................17
3.1.4 Colleague.......................................................................................................................18
3.1.5 Intrinsic Factors.............................................................................................................20
3.5 Strategies and mechanisms for managing factors causing mental health disorders among
nurses.........................................................................................................................................21
3.6 Research Gaps......................................................................................................................23
4.0 Proposed Research Design, Methods/Procedures....................................................................23
4.1 Proposed Research Philosophy........................................................................................23

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 4.2 Research Design...................................................................................................................23
4.3 Data Collection....................................................................................................................24
4.3.2 Questionnaire Design....................................................................................................24
4.3.3 Sampling techniques......................................................................................................25
4.3.4 Sample population and sample size...............................................................................25
4.4 Data Analysis.......................................................................................................................26
4.5 Ethical Considerations.........................................................................................................26
5.0 Timeline...................................................................................................................................26
6.0 References................................................................................................................................28
Appendices....................................................................................................................................33
Appendix I: Questionnaire Survey.............................................................................................33
List of Figures and Tables

Figure 2.1: The Therapeutic Engagement Stress Theory (TEST) model........................................7

Figure 2.2: Conceptual Model.......................................................................................................10

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1.0 Background of Research
Nursing is one of the careers in the healthcare sector that has exposed many workers to
mental health problems due to availability of many stressful factors within the working
environment. According to CDC (2022), nurses' working environmental factors such as huge
workloads, unfavorable working environment, and work-life balance affect their work-out put
and health. Additionally, Sasidharan & Dhillon (2021) claimed healthcare workers are
continuously exposed to continuous stress that leads to psychological, physical, and cognitive
symptoms. Nurses experience higher anxiety levels and more psychological pressure leading to
depression and other mental disorders because of these factors (Garcia-Iglesias et al., 2022). The
presence of these factors not only affects the delivery of safe and quality care but also impacts
the health and well-being of nurses and their families. Governments and other stakeholders in
health are more concerned with improving patients' health, with little attention being given to
nurses, especially regarding mental health and occupational risks. Also, increasing population
and emerging healthcare issues, workplace complexities, and unpredictable changes in the
healthcare sector with new daily routines are other sources of mental health disorders among
nurses. The above factors have contributed to rising cases of mental health disorders facing
nurses in healthcare settings. However, these factors continue to cause threats to the health and
well-being of nurses, and their contributions and causes have not been completely established in
order to come up with approaches and interventions to manage them.
Stress in the Nursing Practice
Stress among nurses is yet to receive extensive research despite causing significant
impacts on the practice of nursing by affecting various aspects of personal and work life. Stress
has an effect on nurses' mental and physical health that affects patient outcomes. Stress has been
identified by researchers as an occupational health hazard affecting the practice of nursing
(Morris, 20220. As such, it is paramount to learn what causes stress and strategies to manage it
among nurses. Stress is caused by different conditions at both individual and organizational
levels. The nursing shortage has been termed one of the major causes of nurse burnout and
fatigue, which leads to corresponding stress. Moreover, long shifts at work have been found to be
the most common nurse stressors. Other factors such as non-conducive working environment,
under-resourced healthcare facilities, and non-cooperative patients and their families have been
associated with increasing levels of stress among nurses. On the other hand, understanding these

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factors calls for a need to implement solutions to manage stress among nurses. A survey
conducted by the American Nurses Association identified a number of integrating individual-
focused approaches to assist nurses in coping with stressful conditions (American Nurse
Association, 2023). Also, organizational-focused strategies have been proposed to help reduce
workplace environmental inhibitors that lead to stress.
Mental Health
Mental health is one of the serious health problems facing healthcare professionals across
the world. The emergence of the Covid-19 pandemic was one of the reasons that led to the rise of
mental health disorders among nurses in both private and public healthcare settings. Li et al.
(2021) noted the pandemic exposed many healthcare workers to undergo psychological stress
that affected their well-being. Also, Sahebi et al. (2021) claimed that the Covid-19 pandemic
affected both the mental and physical health of frontline health workers with the majority being
diagnosed with stress-related disorders irrespective of their having no history of psychological
illness. The existence of psychological stress disorders affected nurses from all corners of the
world. Kwobah et al. (2021), who studied the response to Coronavirus among Kenyan healthcare
workers, found out they were at greater risk of mental health illness, with results showing more
than 30% of workers were diagnosed with depression and another 36% suffered from
generalized anxiety (Kwobah et al., 2021). The prevalence of mental health and psychological
disorders among nurses in third-world countries is higher than those in developing and
developed countries. According to Jaguga & Kwobah (2020), the rapid rise of the pandemic in
Sub-Saharan Africa, with Kenya being among the most affected, calls for a need to study the
trend and establish a guide for responding to mental health problems among healthcare workers.
It emerges that some factors, such as work environment and individual factors play a key role in
determining the level of satisfaction of nurses.
1.1 Statement of the Problem
Mental health is recognized as a key challenge affecting the nursing profession. Evidence from
numerous studies conducted on this problem shows stress among nurses has been threatening
their health leading to the high prevalence of mental disorders. According to Baye, Demeke, &
Birhanu (2020), stress in the nursing profession is caused by internal factors within the
individual's workplace and external factors outside the workplace associated with a relationship
with family, friends, and the community. The increasing prevalence of mental health disorders in
the nursing profession is associated with negative work outcomes, such as reduced quality of
nursing care and negative impacts on the health and well-being of individual nurses (Søvold et

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al., 2021). Stress is termed the main cause of mental health disorders in nurses and emerges from
a wide range of factors. Work-related factors have been known to contribute a lot to nursing
professional stress (CDC, 202. The following research will investigate contributions of stress-
related inhibitors toward mental health disorders in nursing. The main inhibitors studied are the
physical work environment; care recipients; organization; colleagues; and intrinsic factors.
1.2 Purpose of Research
The purpose of this study is to find out the contributions of stress-related inhibitors on
the mental health of nurses in public health hospitals.
1.3 Scope of the Study
As much as research on mental health disorders among nurses in the health care sector
has been widely conducted, the study on same targeting nurses from third-world countries,
especially after the emergence of the Covid-19 pandemic, is limited and poorly understood. Also,
the relationship between mental health disorders among nurses in public health and private
health organizations has not been fully established.
The scope of the study will be limited to nurses working in level five hospitals in Embu
County. The study will aim at collecting data from 100 nurses working at Embu level five
hospital. Embu County has been selected for this study because there are few studies on this
topic.
1.4 Research Objectives
The main objective of this study is to determine the contributions of stress-related inhibitors on
mental health disorders among nurses in public health hospitals.
The specific objectives are:
1) To find out the causes of the prevalence of mental health disorders among nurses in
public health organizations
2) To determine stress-related factors affecting nurses’ mental health in healthcare
organizations.
3) To determine the contributions of stress-related inhibitors on the mental health of nurses
4) To recommend strategies and approaches for overcoming stress inhibitors among nurses
in their workplaces.

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2.0 Theoretical and practical Relevance of the Research
2.1 Theoretical Framework
The framework most relevant for this study will be the Therapeutic Engagement Stress
Theory (TEST). According to Rippon et al (2020), TEST demonstrates the level of stress
experienced by a healthcare provider is determined by the perceived therapeutic capacity to
engage with individuals exhibiting behaviors that challenge their work output. The framework is
applicable in this research because it assists in specifying factors inhibiting nurses' ability to
successfully deliver quality and safe care in public health hospitals and establish support
mechanisms for reducing work-related stress inhibitors. Nurses often engage with environments
and individuals whose actions challenge their ability to work effectively. These are behavior
inhibitors and are grouped into five categories. These are physical work environment; care
recipients; organization; colleagues; and intrinsic factors (see fig. 2.1). In each of these
categories, there are factors that reduce healthcare providers' ability to engage therapeutically
with patients especially when their behaviors are challenging effective care delivery. Moreover,
there are strategies in each of the five categories capable of supporting healthcare staff in
delivering interventions capable of assisting care recipients, and this help reduce work-related
stress. As such, the model will be significant in identifying and helping to determine the role of
stress-related factors on nurse mental health in Embu Level Five Hospital.

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Figure 2.1: The Therapeutic Engagement Stress Theory (TEST) model

INHIBITORS FACILITATORS
Physical Work
Environment Physical Work
Environment

Organizational
Organizational

Colleagues Work-Related Stress Colleagues

Care Recipients Care Recipients

(Clients) (Clients)

Intrinsic Factors Intrinsic Factors

2.1.1 Organizational Inhibitors

Healthcare organizations often partner with other organizations to improve quality of
services. The level of collaboration between nurses and partnering organizations may affect the
work output of care providers. Also, partnering organizations may trigger challenging situations
that affect care providers' outcomes. Rippon et al. (2020) argued lack of effective
communication between care providers and partnering organizations might affect the workplace
network making it hard for nurses to therapeutically engage with patients and colleagues causing
stress.
2.1.2 Physical Work Environment Inhibitors
The working environment of care providers may inhibit their behaviors leading to stress.
Public healthcare organizations in Kenya are known to offer poor working standards to their
staff. Also, a lack of adequate resources, such as protective equipment and a non-conducive
working environment, may trigger behaviors that lead to the onset of work-related stress. In most
situations, the physical work environment, such as distractions due o noises, poor settings

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inwards, and other operational areas, and the inability of nurses to engage freely with patients
may inhibit the capacity of care providers to offer quality therapeutic services.
2.1.3 Colleagues
Factors within the colleagues' category that inhibit care providers' behavior include
increased workloads due to some colleagues failing to perform their duties accordingly, burnouts
because of colleagues lacking required expertise especially in emergency and critical condition
areas, and social loafing. Rippon et al. (2020) argued lack of balanced contribution among
colleagues in the workplace elicits injustice perceptions leading to an increased burden on other
care providers, which negatively affects staff motivation and could cause work-related stress.
Also, colleagues who undermine the work of their fellow care providers, especially those
working on the front and encountering challenges experience behavioral changes that cause
work-related stress.
2.1.4 Care Recipients
Factors that inhibit care recipients' contribution to stress among nurses include low-
motivated recipients and recipients not willing to accept the therapeutic process. Sometimes care
recipients may not have enough motivation to continue with a treatment intervention and this
causes work-related stress among caregivers. Some causes of poor acceptance of intervention
include recipients suffering from chronic diseases and having little faith in getting well. In such
scenarios, healthcare givers may experience work-related stress upon noting the therapeutic
intervention offered to recipients does not provide the expected outcome. Additionally, poor
nurse-patient relationships may result in stress among caregivers.
2.1.5 Intrinsic factors
Intrinsic factors such as experiencing challenging situations with patients and worrying
about the future of the career/profession may inhibit a caregiver's ability to experience work-
related stress disorders. Stress occurs when a caregiver experiences repetitive negative thoughts
about an experience, especially among nurses prone to critical health situations. For example,
nurses who take care of Covid-19 patients in isolation rooms experience repetitive thoughts that
cause stress disorders (Levi & Moss, 2022). Also, personal limitations and lack of self-awareness
are associated with increasing stress-related conditions. Nurses experience challenges related to
work-life balance that end up affecting their psychological well-being leading to stress.

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 The TEST model establishes strategies for overcoming stress inhibitors among healthcare
providers. Organizational inhibitors could be managed using organizational facilitators such as
partnering and sharing knowledge, positive engagement with care providers, and post-incident
debriefs. Physical work environment facilitators include designing a workplace that is conducive,
having adequate resources for caregivers, and improving workplace structures. Also, collegial
facilitators, such as having informal debriefs and emotional responses among colleagues, help
manage colleague inhibitors. Care recipient facilitators including motivating patients and having
sources of knowledge and learning help overcome care recipient inhibitors. Finally, intrinsic
facilitators like the reflection of challenging situations and openness to personal limitations help
reduce levels of work-related stress (Rippon et al, 2020).
2.2 Conceptual Framework
The Therapeutic Engagement Stress Theory model of stress will help in developing the
conceptual framework for the study. The model identifies dependent, independent, and
intervening variables. The identification of variables will aid in creating the conceptual model.
2.2.1 Research Variables
The research will be guided by these variables
Dependent Variables
Mental Health Disorders among nurses [e.g., stress, anxiety, PTSD, and depression]
Independent Variables
Stress-Related Inhibitors [Physical work environment; Care recipients; Organizational;
Colleagues; and Intrinsic factors)
Intervening Variables
 Type and department of caregiving
 Type of colleagues
 Level of motivation of patients
 Work-life balance

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Figure 2.2: Conceptual Model

Independent Variables
Stress-Related Inhibitors Intervening Factors
Physical work environment Dependent Variables
Care recipients Mental Health Disorders among nurses [Stress, anxiety, depression
Type and department of nurse
Organizational Type of colleagues
Colleagues Level of motivation of patients
Intrinsic factors Work-life balance

2.2.2 Research Hypothesis (Null Hypothesis)

H1: Stress is directly related to the high prevalence of mental health disorders among nurses
working in public hospitals.
H2: Stress-related inhibitors (Physical work environment; Care recipients; Organizational;
Colleagues; and Intrinsic Factors) contribute directly to mental health disorders among nurses.
H3: Mental health disorders affect nurses' well-being, performance, and overall healthcare
outcome.
H4: Introducing strategies to manage stress-related inhibitors will help to reduce mental health
disorders among nurses.
2.3 Relevance of the Study
The study on the contributions of stress-related inhibitors towards the mental health of
nurses in public health organizations in Embu County will help gain more understanding about
mental health disorders, their causes, and approaches to manage them. The high prevalence of
mental health disorders among nurses is becoming a threat to the industry. The research will be
relevant to future nurses and their employers in terms of helping identify key triggers/inhibitors

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to mental health disorders and determining methods of managing these conditions to safeguard
the future career and well-being of nurses.
3.0 Summary of Relevant Literature
3.1 Introduction
The following section reviews the literature on stress-related inhibitors among nurses working in
public health care organizations. The section is divided into four sub-sections. These are:
prevalence of mental disorders among nurses in the health sector;
3.2 Prevalence of mental disorders among nurses in the health sector
Mental disorders have been present among nurses and other healthcare workers for
decades. PTSD is one of the most common mental health disorders affecting nurses all over the
world. According to Liu et al. (2022), unpredictable changes in nurses' daily working
environment, including emerging healthcare challenges and individual demands, put nurses at
higher risks of stress. Liu and colleagues studied the relationship between symptoms of PTSD
and job stress and thinking. The authors used a cross-sections study targeting 351 mental health
nurses from Public Hospitals in China. Structured questionnaires were used to collect data. The
main variables related to job stress measured were workload and time pressure, interpersonal
relationships and management issues, resource and environmental problems, and professional
and career issues. Data were analyzed using descriptive statistics. The study found out more than
18% of participants suffered from PTSD, with thinking styles such as anarchic, monarchic, and
external playing a vital role in predicting the effects of job stress as causative agents for PTSD
(Liu et al., 2022). The findings above provide theoretical bases for developing an effective
approach to studying contributions of stress-related inhibitors toward nurses' mental health. The
variables used in Liu and colleagues' research, such as time pressure and workloads,
interpersonal relationships, and resources, will be considered in the study.
On the other hand, the research will rely on literature regarding the experiences of
healthcare workers working in labor-intensive areas and their exposure to stressors and trauma.
One study by Shigemura et al. (2021) will be of greater significance in helping to identify the
traumatic experiences of healthcare workers who responded to the Covid-19 pandemic. The
study identified risks that healthcare workers get exposed to when treating patients with life-
threatening diseases like the Corona Virus. The experiences of patients dying every hour and
others suffering due to lack of oxygen lead to psychological and emotional effects that have a

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potential impact on the practitioner's health. In this study, Shigemura et al. (2021) suggested the
provision of mental health support among all healthcare workers and advocating for community
and organizational well-being. The study will play a vital role in recognizing variables associated
with stress among nurses.
Moreover, research conducted by Brahmi et al. (2020); Saladino, Auriemma &
Campinoti (2022) also assists in understanding the trauma experienced by healthcare
professionals during the Covid-19 pandemic period. The study investigated the impacts the
Covid-19 pandemic has on the psychological well-being of healthcare professionals. Doctors and
nurses experienced new situations that led to extreme distress, and some became traumatized.
The systemic review was used to carry out the study with selected sources from PubMed, Google
Scholar, PsycINFO, and electronic journals utilized to research the problem. Information
analyzed from the sources revealed healthcare workers experienced traumatizing events due to
isolation, experiences with critically ill patients, and a lack of empathy for dying patients. The
findings are essential for this study, but more focus will be paid to nurses working in public care
organizations.
The prevalence of mental health disorders among nurses and other healthcare providers
has been rising in developing and third-world countries. According to Muzammil & Lopes
(2020), developing nations are experiencing a struggle to manage rising cases of mental health
among healthcare providers and the community. The reduced quality of mental health nursing
has caused this increase. Mulatu et al (2020) studied the prevalence of symptoms that are
common to mental illness among healthcare workers from Ethiopia during the pandemic. The
study used a quantitative research design and self-administered surveys to collect data about the
demographics and symptoms of mental disorders of participants. A total of 420 respondents
formed the sample size. The main symptoms investigated were those related to anxiety,
depression, distress, and insomnia. The tests were done using PHQ-9, ISI, GAD-7, and IES-R
tools. The data were analyzed using the Chi-square test and regression analysis to determine the
relationship between variables. Findings from the study showed a high prevalence of mental
disorder symptoms among healthcare workers. The prevalence of depression was higher,
followed by anxiety, insomnia, and distress recorded the lowest prevalence. Also, participants'
demographics, such as gender and marital status, affected the prevalence of mental health. For
example, married female workers had a higher prevalence than single female workers. Moreover,

13
workers in the frontline position suffered more symptoms compared to other workers (Mulatu et
al., 2020). The findings above shows increasing prevalence of mental disorders is mostly caused
by depression and anxiety among healthcare workers. The outcome will be used to identify key
factors leading to depression and anxiety among nurses.
Also, healthcare workers from third-world countries are prone to many factors that
increase workers’ ability to suffer mental illnesses. The emergence of the Covid-19 pandemic led
to many researchers studying the effect of the pandemic on mental illness among healthcare
workers. Shah et al. (2021) investigated the occurrence of mental health disorders among
healthcare workers in Kenyan hospitals during the Covid-19 pandemic. The authors aimed to
determine the impact of Covid-19 on the mental health of healthcare workers in sub-Saharan
Africa. A cross-sectional study was conducted between August and November 2020, targeting
workers from three main hospitals in Kenya. The research was supported by the fact that
hospitals in most of Africa have a weak healthcare system, and the pandemic introduced
additional health burdens to workers. Data regarding symptoms of anxiety, insomnia, depression,
burnout, and distress were gathered and measured using standardized questionnaires. The study
collected data from 433 participants and found more cases of anxiety, depression, distress,
burnout, and anxiety among each participant. The rate was higher among frontline nurses, and
females suffered more instances of depression. Also, a lack of adequate resources was associated
with an increasing rate of depression among healthcare workers. The study recommended an
introduction of strategies to assist nurses in coping with mental health symptoms (Shah et al.,
2021). The study outcome reveals the increasing rise of mental health problems among nurses in
African countries has been caused by poor health working conditions and a lack of adequate
resources to address emerging health issues.
3.3 Stress-related Inhibitors and mental health among nurses
3.1.1 Physical work environment
Mental disorders have become common among healthcare workers, with nurses being the
most affected profession. According to Karanikola et al. (2022), nurses stand a higher risk of
suffering from work-related traumatic stress disorders. Mental disorders among health care
workers are associated with a number of causes, some related to nurses while others to the
working environment. Karanikola and colleagues conducted a study to find out work-related
stress responses among nurses working in the Covid-19 setting. The aim of the study was to

14
investigate the relationship between work-related stress inhibitors and demographic factors,
stress response, and psychosocial hazards. Gabra et al. (2022) noted nurses who offered care to
patients during the Covid-19 pandemic experienced major psychological and physical burdens
that affected their psychological well-being. In their research, Karanikola and colleagues utilized
s descriptive and cross-sectional study where data was collected for two months between April
and May 2020. The target participants for the research were 380 nurses working in healthcare
organizations in Cyprus, and data was collected using survey questionnaires. The outcome of this
study showed 233 out of 380 surveyed nurses experienced work-related traumatic stress.
Moreover, there was a positive correlation between traumatic symptoms and distress and
emotional exhaustion among nurses. Findings from this research will play a vital role in
establishing factors leading to the emergence of psychological stress disorders among nurses and
their association with individual factors including demographics and workplace environment.
Moreover, exposure to physical working conditions is more likely to expose nurses to
stress, leading to mental disorders. According to Lee et al. (2020), there have been a number of
studies conducted on mental health disorders among nurses, but less has been known about their
prevalence, the factors leading to their emergence, and the impact of the disorder on individual
employees' personal and career life. Hao et al. (2021) used a similar approach to Lee to find out
the prevalence and risk factors associated with mental health among healthcare workers. The
study identified the Covid-19 pandemic as the main cause of increasing mental health issues
among nurses over the past two years. Lee and colleagues conducted a systemic review of the
literature to identify the views of other researchers on this issue. However, their study compared
the prevalence of mental health before and after the pandemic. It was known that most nurses
who worked on the front line during the pandemic suffered from work-related stress and have
been diagnosed with post-traumatic stress disorder. Lee et al. (2020) systemic review targeted
literature from a number of databases, including Google Scholar and PubMed, while relying on
guidelines for identifying studies on PTSD. The outcome of the systemic review showed a high
number of occupational post-traumatic stress disorders were reported before and after the
pandemic. The main risk factors associated with these disorders included poor working
conditions, the presence of psychiatric symptoms during the time of the traumatic event, a
history of mental disorders among nurses, and personality and interpersonal relationships. The
findings revealed health care workers are highly vulnerable to post traumatic stress disorders

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(Lee et al., 2020). These results will be utilized in this research to relate risk factors with current
working conditions in Embu level five hospital to help identify key interventions that would
assist in managing nurses' well-being.
Nurses working in health care organizations in third-world countries are known to suffer
more from mental disorders. The high prevalence has been related to the type of working
conditions and individual private factors. Kahenda (2022) claimed the prevalence of stress,
depression and anxiety is high among healthcare workers in Kenya with one out of every four
midwives suffering depression. The statistics above call for a need to find out key causes of
mental health disorders and their associated problems. Kabunga & Okalo (2021) investigated
post-traumatic disorders and their associated predictive factors among frontline nurses in Uganda
during the second wave of the Covid-19 pandemic. A cross-sectional study targeting 601 nurses
was conducted between the months of May and June 2021. A PTSD checklist-Civilian was used
to assess the prevalence of post-traumatic stress. Results from this study revealed a 65.7%
prevalence rate for post-traumatic stress disorder among nurses. These outcomes demonstrated
Covid-19 was a contributing factor towards an increasing number of nurses diagnosed with
PTSD. The high rate was associated with a number of patients, workplace, and industry factors.
According to Kabunga & Okalo (2021), the Ugandan healthcare has been suffering from poor
human resources, poor management, and poor working conditions that challenged the outcome
of nurses during the pandemic.
3.1.2 Care recipients
Care recipients play a vital role in the health and well-being of nurses. The type of
relationship developed between the nurse and the care recipient determines how well the nurse
copes with the stressful work environment. A research by Keykaleh et al (2018) to investigate
the relationship between patient safety and nurse stress highlighted on the importance of
observing safety in the nursing practice. According to the study, poor relationship between the
nurse and the care recipient will lead to increased job stress that may eventually cause mental
health problems among nurses. Moreover, the lack of coordination between the patient and the
nurse, especially when adhering to specified medication affects nurses' work output that could
cause anxiety and stress. Baye (2020) when studying factors contributing to work-related stress
among nurses revealed nurses taking care of patients suffering from chronic diseases are more
likely to record higher prevalence of stress in their work stations.

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 Also, care recipients are known to cause stress on healthcare providers depending on their
ailing conditions and the type of care they need. Aisa et al (2021) conducted a study to
investigate stress levels on healthcare providers taking care of critically-ill patients. The study
was conducted targeting patients’ diagnoses of Covid-19 and who had been placed under
intensive care observation. According to Lee et al (2022), outbreak of pandemics is associated
with heightened levels of psychological stress among healthcare providers. Also, there are
additional factors contributing to distress among workers including challenges dealing with high
numbers of care receivers. Aisa and colleagues conducted a cross-sectional multicenter study to
collect data from 1649 healthcare workers selected from 59 countries. The study utilized a web-
based questionnaire with 27 questions for measuring perceived stress and assessment of stress
levels. Also, the questionnaire included questions for identifying factors related to stress,
sociodemographic characteristics, and psychological support available at the workplace. The
study outcome showed nurses working on critically ill patients in the intensive care recorded
high stress levels. Female healthcare workers working in busy facilities and in remote areas
showed higher prevalence than their male colleagues. Also, the study revealed lack of
psychological support among healthcare workers operating in intensive care contributed to
increasing levels of stress (Aisa et al. 2021). The study findings implied healthcare providers
experience psychological disturbances when dealing with patients requiring immediate and strict
observation, which is a major factor contributing to stress.
The relationship created between the patient and the healthcare provider during the
delivery of care determines the work output and psychological well-being of the provider. Nurses
have reported many instances where patients have physically engaged them in their lines of duty,
which interferes with their normal operations. The conflict between the nurse and the patient, or
family of the patient has a negative impact on performance and well-being. Alshehry (2022)
investigated the claim above to determine the relationship between nurse-patient conflict and
work competence. Nurses require a safe workplace environment to provide competent care and
record good patients outcomes. However, nurses are facing many challenges, especially with
inadequate resources and poor health conditions leading to conflicts with patients and their
families. Conflict between nurses and patients/or family of patients is a global problem and has
been associated with poor work outcomes among nurses. In their study, Alshehry investigated
320 nurses from Saudi Arabia between December 2019 and January 2020. The study utilized the

17
Health Professionals Education in Patient Survey and the Healthcare Conflict Scale to identify
the relationship between the level of conflict and nurses' competence and well-being. The study
results revealed the level of conflicts was determined by the type of healthcare and the gender of
the provider. Nurses who recorded high nurse-patient conflict lacked motivation and trust, which
reduced their confidence levels, eventually affecting the competence and causing a negative
psychological well-being (Alshehry 2022). The above findings shows the behavior, attitude, and
character of care recipient determines the perceived level of trust and motivation that a nurse
gets; hence, determining their well-being and competences.
3.1.3 Organizational
Organizational factors such as availability of resources and nurse-support programs are
known to influence the performance of nurses in a healthcare setting. Mental health problems
continue to pose significant threats to the health and livelihood of healthcare providers. Mealer et
al. (2009) investigated post-traumatic stress disorder and burnout syndrome. The aim of this
study was to find out common types of mental disorders affecting nurses and their causative
agents, including work and non-work related activities. Target participants for the research were
Nurses from the University of Colorado hospital. Data was collected using questionnaires
between July 2007 and February 2008. Main validated surveys employed in data collection were
Hospital Anxiety and Depression Scale (HADS), PTSS-10, Maslach Burnout Inventory (MBI)
and Post-traumatic Diagnostic Scale (PDS). The outcome from this research showed nurses who
worked in intensive care unit and high risk ICU for outpatients showed high prevalence for
psychological symptoms. Out of the 322 nurses, 16% had high levels of anxiety, 13% responded
positively to depression. Moreover, organizational-related triggers were identified to accelerate
symptoms of PTSD including nightmares because of experiences with suffering patients and
anxiety (Mealer et al., 2009). The findings from this study will be of important use. The use of
validated surveys for measuring anxiety is highly recommended for this study and will be
considered when collecting data.
Additionally, the research will review literature from Hamed, Elaziz, & Ahmed (2020)
who studied prevalence and predictors stress, burnout syndrome, anxiety, and depression among
nurses. Hamed and colleagues noted hospitals have become one of the most challenging
workplaces with employees having different assignments and facing different cases each day.
Nurses are most likely to experience stress because of huge workloads, making them vulnerable

18
to psychiatric disorders. Hamed et al (2020) conducted a cross-sectional study targeting 181
nurses operating in Al Zahraa University Hospital in Cairo, Egypt. The study focused on
identifying the prevalence of psychological disorders in African hospitals. According to Zwane
et al (2022), nurses experience many challenges when working in poor settings especially in
under-developed and developing countries. Hospital Anxiety Depression Scale, Davidson
Trauma Scale, Proactive Coping Inventory, and Maslach Burnout Inventory were used to collect
data from participants. Research outcomes revealed there was a high prevalence of psychiatric
symptoms among nurses. Out of 181 nurses surveyed, 79% responded positively to depression
while 64% showed signs of anxiety. Additionally, the prevalence of PTSD was at 19.9%.
Moreover, the rate of burnout was high among nurses with 68% of participants showing burnout
syndrome. These findings revealed anxiety, depression, and burnout syndrome are very common
among nurses and higher in countries where healthcare infrastructure are yet to be developed.
The study plays a key role in the investigation of psychological trauma and stress among nurses
because it provides a good background for studying variables that affect nurse performance in
third-world countries.
3.1.4 Colleague
Colleagues in the workplace determine how their fellow workmates perform their duties
and deliver expected outcomes. Working relationships among employees are long termed as
crucial determinants of the overall performance and well-being of an employee. Negative
workplace relationships are associated with poor work output and reduced performance. Tran et
al (2018) carried out a study to investigate how health workplace relationships including positive
employees' behavior affect their performances. According to Wei et al. (2018), nurses are more
likely to perform well in a healthy work environment because apart from being safe it empowers
them to carry out their duties with a lot of satisfaction. Tran and colleagues study applied an
integrated model to identify primary performance drivers of nurses. A questionnaire survey was
administered to 303 nurses from selected hospitals in Vietnam and a structural equation
modelling approach applied to study the data. The study outcome revealed a positive workplace
relationship increases the performance of workers y improving their commitment to duties,
increased perception of social impact, and decreased reports of job stress. Also, the relationship
between other leaders and senior members of the staff has a similar effect (Tran et al., 2018).

19
The findings above are essential in determining the role of colleagues in nurse psychological and
social well-being.
Also, the behavior of colleagues in the workplace determines the health and well-being of
other nurses. The lack of proper training and skills in dealing with some health issues may lead
to only a few members being called upon, which causes fatigue and burnout leading to stress.
Nurse shortage is an issue affecting healthcare organizations across the globe and one of the key
contributors to burnout among nursing professionals. High levels of burnout causes poor service
delivery, low empathy, and low quality of care. Pyne et al (2020) researched the relationship
between burnout and work satisfaction in the nursing profession targeting nurses from South
Africa. The study used a cross-section research with the aid of the Copenhagen Burnout
Inventory and a job satisfaction questionnaire to determine the relationship between variables. A
total of 127 nurses were involved in the study. The outcome from the research showed majority
of nurses experience burnout because of work-related factors. The burnout leads to low job
levels of job satisfaction. Also, it was noted women nurses are largely affected by the work-
related burnout than male employees (Pyne et al., 2020). With these findings, it is possible to
determine factors within the working environment that contribute to burnout. The following
study will establish the contribution of nurse colleagues to work-related burnout and its impact
on the psychological well-being of affected nurses.
The type of healthcare facility and the availability of resources will influence the level of
job satisfaction and performance of a healthcare worker. Nurses in public hospitals are used to
huge workloads because of a high number of patients and limited staff, which increase the level
of workload stress. Kewa, Mutuku-Kioko, & Lewa (2017) carried out a research to determine
workload stress and performance of nurses in public hospitals in Kenya. The study aimed at
establishing the effect of workplace on morale, clinical outcome, and performance of nurses.
Nurses were selected from all six levels of government hospitals in Nairobi County, and a
sample of 845 nurses used to collect data. Inferential and descriptive statistics were used to
analyze data from questionnaires directed to the study sample. The outcome of this study
revealed the performance of nurses is affected by load stress. The study found out lack of
adequate resources such as poor staffing, lack of skilled nurses, and lack of modern equipment
were among factors increasing workload stress among nurses (Kewa et al., 2017). The findings

20
above play a key role in the identification of work colleagues as a key factor determining the
work output and well-being of nurses.
3.1.5 Intrinsic Factors
Stress among nurses has been associated with geographical factors with nursing
professionals in developing and under-developing countries recording high prevalence. Mental
health disorders have been found to be common in third world countries, especially in Africa.
The following part of the review will target workers in African countries to establish the
prevalence of psychological trauma and work-related stress disorders. Afulani et al. (2021)
conducted a study to investigate physiological burnout and stress among healthcare workers in
the maternity section. The study was based on the evidence that stress and burnout was becoming
a major health crisis affecting nurses across the world. The authors noted there have been limited
studies to address stress and burnout among healthcare providers in Sub-Sahara Africa, and more
so in maternity wards. The study targeted 101 maternity providers composing of 62 nurses, 23
support staff, and 16 clinical officers. Data was collected using a mixed methodological
approach and results analyzed with a multilevel linear regression model. The outcome of the
research showed more than 80% of participants had moderate to high stress levels while 65%
experienced burnout. Also, it was noted that female healthcare providers had a higher prevalence
compared to male providers (Afulani et al., 2021). The results are vital in this research because
they have included a new element, participants' gender, which will be used to study stress-related
inhibitors and their role in mental health among nurses.
Additionally, nurses' worries about emerging health issues such as pandemics are
associated with increasing stress levels. Kwobah et al (2021) who investigated frequency and
associated factors related to stress and depression among nurses in Kenyan health care
organizations established that depression was higher and caused by worries related to contracting
the Covid-19 disease. The findings were analyzed from data collected using online surveys
targeting1259 health care workers in Kenya (Kwobah et al, 2021). The outcome from two studies
show poor working conditions and personal factors are common causes of mental health among
nurses working in health care organizations in third-world countries. However; data on causative
factors associated with public health organizations is limited, influencing the need for this
research.

21
3.5 Strategies and mechanisms for managing factors causing mental health disorders
among nurses
Mental health disorders have a major impact on the performance and work output of
nurses. The following section aims to review the literature on approaches and practices that have
been employed by various organizations and governments to manage and minimize the
prevalence of mental health disorders among nurses. Quality healthcare is needed for the growth
and prosperity of the society. Mental health and other psychological disorders affecting nurses
and health care workers have affected the delivery of quality and safe care. Shah et al. (2021)
while investigating the prevalence of mental health disorders among healthcare workers during
the Covid-19 pandemic found out the highest number of workers was found to have been
affected by mental health. The article called upon governments and other stakeholders to
introduce cost-effective mitigation measures to assist in curbing the burden of mental health
among nurses.
Additionally, the study will review literature on the contributions of natural disasters and
pandemics to mental health problems among nurses. Specific focus will be paid on the SARs and
Covid-19 pandemics that had a significant impact on the outcome of nurses and other healthcare
workers. One study to be reviewed is the research by Palmer et al. (2022) on public health
emergency and psychological distress among healthcare workers during the Covid-19 pandemic.
Palmer et al (2022) argued pandemics and other natural disasters create stressful events for
healthcare workers like nurses working in the frontline and affects their psychological and social
well-being. In this study, Palmer and colleagues conducted a scoping review targeting a body of
literature that assesses the effectiveness of mental health interventions for healthcare workers at
the organizational level. It was found out that there is limited research that addresses methods
used by organizations to address mental health prevention and mitigation measures for healthcare
workers during times of disaster and pandemics. Findings from this systemic review will play a
key role in evaluating the relationship between rising cases of stress in nurses working during
Covid-19 pandemic.
Another research by Riedel et al (2021) will contribute towards understanding mental
health disorders among nurses during pandemics. The study aimed at evaluating mental health
disorders among nurses in the era of Covid-19 and provide a coping strategy to overcome future
scenarios. Social and health workers are among the employees who have carried a huge burden

22
during the Covid-19 pandemic as they sacrifice their time, energy, resources, and life to ensure
the safety of patients as they try to control the virus. Kock et al (2021) claimed any approach to
support their (nurses) well-being should be a priority considering they experience psychological
and emotional challenges in their lines of duty. In their study, Riedel et al (2021) investigated
risk factors associated with the development of mental health disorders and their research scope
was based on the United States and compared with 16 countries to find out the one that reported
the highest number of health workers with traumatic events. The study found out there was a
lack of early intervention measures to prepare nurses for conditions during the pandemic. It
recommended an implementation of a therapeutic intervention and health coping skills to help
nurses manage the negative impacts of the pandemic (Riedel et al, 2021). The results above are
influential in identifying coping mechanisms for nurses in under-developed countries like Kenya
that experience more challenges compared to the U.S and other developing nations.

23
3.6 Research Gaps
The review of literature has assisted in identifying ideas, knowledge, and theories applied
by past researchers. However, there are some weaknesses in these findings that form our research
gaps. First, researchers tend to use a generalized idea of studying mental health and stress. Most
studies relied on effects of mental health and stress on job satisfaction and performance. It was
hard to identify the major causes of the stress in most studies, which has formed the basis for the
current research. Second, the type of data and method of data collection used in the literature
created some gaps and affected the reliability of results. The use of empirical studies did not
bring out the real nature of the situation since most data was collected from secondary sources.
The following study will use a quantitative research method to collect primary data from
participants. Finally, there was minimal use of theoretical approaches and many studies relied
only on answering research questions. The following study will apply the TEST model to study
stress-related inhibitors and their contributions to the mental health of nurses.
4.0 Proposed Research Design, Methods/Procedures
4.1 Proposed Research Philosophy
The study will apply the positivism research philosophy. According to Tsung (2016), the
positivist research philosophy claims factual knowledge acquired through observation and
measurements are the only trusted one. Under the positivism philosophy the researcher carries
the role of collecting and interpreting data using an objective approach. The philosophy is very
applicable in a quantitative research because it relies on quantifiable observations that produce
statistically analyzed results. Moreover, the philosophy is highly structured and suitable for
studying large samples. Also, it distances the researcher's personal knowledge about the
phenomenon from the study. The guiding principles of a positivist research are: the aim of the
research is to explain and predict; common sense cannot be used to generate research outcomes;
and the study should be observed empirically using the human senses (Tsung, 2016). An
inductive reasoning is applied in a positivist research to develop hypotheses that are tested during
the research.
4.2 Research Design
The study will make use of a quantitative research design to meet research purpose of
investigating stress-related inhibitors and their contributions towards mental health disorders in
nurses at Embu level five hospital. A quantitative research design is one of the most commonly

24
used to generate knowledge and understanding of the social world by studying a group of
participants. According to Creswell (2014), social scientists recommend the quantitative research
design as the best for observing a phenomenon and issues affecting people in the society.
Additionally, it has been utilized to learn behaviors and attitudes that identify skills from
participants. Therefore, it is selected as the most appropriate for identifying prevalence, causes,
and approaches for managing stress among public health nurses in Embu County.
Additionally, the study will employ a technique for conducting research that is in
agreement with the quantitative research approach. A descriptive research design is the most
preferred technique. According to Salkind (2010), descriptive research enables the researcher to
describe a phenomenon to make readers understand the sense of its existence and effects it has
on a society. As such, I chose this technique because I will be able to explain the causes of stress
among the target population, and their association with the society.
4.3 Data Collection
The study will correct raw data using primary research. Questionnaire surveys will be the
most appropriate tools for collecting study data. It is one of the widely applied method of data
collection in a quantitative research and best for determining attitudes and perspectives of
respondents towards the research problem (Creswell, 2014). Moreover, the method is more
appropriate for this study because it makes it possible for the researcher to understand the
internal thoughts of respondents. Questionnaire surveys are easier and cheaper to administer and
more appropriate for a large and diverse population because they allow for generalization of
results. However, questionnaires may affect the outcome of the study because they may fail to
integrate important information about the phenomenon because they restrict respondents from
making any adjustments on questions. Also, survey questionnaires are associated with bias
because people might provide false information because there is no scrutiny of respondents and
answers provided.
4.3.2 Questionnaire Design
The study will administer survey questionnaires online to the targeted sample size.
Questionnaires will be divided into 3 main parts. The first part will be a "screening questions"
section composed of YES or NO answers. The second part will contain questions designed in a
Likert Scale ranging from 1 (Totally Agree) to 5 (Not Agree). The third part will aim at
determining the demographic characteristics of participants. Questionnaires will be administered

25
to the target population online through the internet. Online questionnaires were selected for this
research because the internet has become a rich domain for conducting survey research because
of its ability to reach diverse people. It is possible to access unique populations located at
different parts of the world who meet the criteria for the sample size (Wright, 2017).
Questionnaires will be designed using Survey Monkey software. The link generated will be
shared to the selected sample size. The questionnaire targets nurses from Embu level five
hospital.
4.3.3 Sampling techniques
The research will apply a probability sampling technique. A probability sampling
technique gives every member of the population equal chances to be selected for data collection.
A systematics sampling method will be applied to select the sample size. According to
McCombes (2022), systematic sampling lists each member of the population with a number and
individuals selected at a regular interval.
4.3.4 Sample population and sample size
The target population for the study are nurses from Embu level 5 hospital. According to
current data from Ministry of Health, Embu County has approximately 400 nurses working in
Embu level five public hospital (Ministry of Health, 2020). The majority of nurses are female,
therefore, the sampling method used will ensure equal representation of all genders. The sample
population will undergo a systematic sampling to find the sample size. The selected population is
400 participants (n=400). All individuals in the 4th position will be chosen. The outcome of
sampling will generate a sample size of 100 nurses.
Moreover, all nurses that will take part in data collection will be subjected to the
following information:
a) Social demographic data including sex, age, marital status, experiences in their
departments, working areas, and their level of cooperation with patients.
b) A Hospital Anxiety Depression Scale (HADS) [English Version] will be used to
explore the presence of anxiety and depression symptoms among nurses.
c) Davidson Trauma Scale (DTS)-English Version, A self diagnostic scale for
evaluating post traumatic stress disorders (PTSD)

26
 d) Maslach Burnout Inventory (MBI) [English Version], a self-report scale to assess
depersonalization (DP); Emotional Exhaustion (EE); and Personal Accomplishment
(PA).
4.4 Data Analysis
Data will be analyzed using statistical analysis with the help of the SPSS (Version 21.0).
The data will be entered in the form of numbers and presented as mean and standard deviation.
Also, ANOVA test will be used to compare different groups of participants. Also, the Binary
logistic regression analysis will help in prediction the relationship between variables.
4.5 Ethical Considerations
The study observes high levels of ethical considerations. The first step in the ethical
consideration will be acquiring an ethical approval from the research department and the
institution ethic's board that gives authority to conduct the research. Secondly, I will collect and
fill out an information sheet and consent form that will be sent to selected participants to read,
fill, and sign. The consent form describes to participants, among other things, the purpose of the
study, aims, and objectives, data collection techniques, roles of each individual participant, and
expectations. All participants will be required to fill out the consent form and no one will be
allowed to take part in interviews without a dully filled and signed form. Moreover, respondents
will let to know their rights such as right to skip a question and right to withdrawal from the
research. Finally, the study will observe high levels of privacy and confidentiality. No participant
will be identified physically and no one is required to provide information that may show their
identity. All participants will be identified with an anonymous code and it will be used in the
entire process of data collection and analysis. Moreover, the respondents will be assured that the
information they give is only used for the purpose of the study and will be stored securely to
avoid misuse.

5.0 Timeline
Week
Activities w1 w2 w3 w4 w5 w6 w7 w8 w9 w10 w11 w12 w13 w14 w15 w16
Topic Selection
Topic Submission
Writing Concept Paper

27
Submit Concept Paper
Proposal Writing
Participant
recruitment
Data Collection
Data Analysis
Report Writing
Presentation
Report Submission

28
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Appendices
Appendix I: Questionnaire Survey

34