Asian Journal of Psychiatry xxx (2014) xxx–xxx

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Somatic symptoms, perceived stress and perceived job satisfactionamong nurses working in an Indian psychiatric hospital

Sailaxmi Gandhi a,*, G. Sangeetha b,1, Nurnahar Ahmed c,2, S.K. Chaturvedi d,3

a Department of Nursing, National Institute of Mental Health & Neuro Sciences (Institute of National Importance), Near Wilson Garden, Hosur Road,

Bangalore 560029,

Karnataka State, Indiab National Institute of Mental Health & Neuro Sciences (Institute of National Importance),

Near Wilson Garden, Hosur Road, Bangalore 560029, Karnataka State, Indiac Department of Nursing, Lokpriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, Indiad Psychiatric Rehabilitation Services, Department of Psychiatry, National Institute of Mental Health & Neuro Sciences (Institute of National Importance), Near

Wilson Garden, Hosur Road, Bangalore 560029, Karnataka State, India

A R T I C L E I N F O

Article history:

Received 7 January 2014

Received in revised form 11 June 2014

Accepted 15 June 2014

Available online xxx

Keywords:

Somatic symptoms

Stress perception

Nurses

Job satisfaction perception

Psychiatric patients

Stress management

A B S T R A C T

Background: High stress perception by nurses caring for psychiatric patients can lead to somatic

symptoms which impact on their job satisfaction perception.

Objective: To assess and correlate the level of somatic symptoms, perceived stress and perceived job

satisfaction among the subjects.

Design: The authors used a descriptive correlation design to invite 150 nurses of both genders working

for more than one year with psychiatric patients. The Scale for Assessment of Somatic Symptoms

(Chaturvedi et al., 1987) and a Visual Analogue Scale (VAS) for stress and job satisfaction perception were

used to collect data.

Results: The nurses (128) reported mainly pain related (4.87 � 2.97) somatic symptoms. Somatic

symptoms positively correlated (r = 0.302) with stress perception and negatively correlated (r = �0.231)

with perceived job satisfaction, while perceived stress and perceived job satisfaction were negatively

correlated (r = �0.460, p = 0.000).

Conclusion: The results indicate a need for stress management interventions.

� 2014 Elsevier B.V. All rights reserved.

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo u rn al h om epag e: ww w.els evier .c o m/lo cat e/a jp

1. Introduction

Nurses are important members of the multi-disciplinary teamwho cater to the needs of psychiatric patients. The median numberof nurses working for mental health in India is only 0.05 per100 000 population as compared to the global median of 2.0 per100 000 population (WHO, 2005) which indicates the shortage ofnurses. In most Indian psychiatric hospitals, nurses have to work ina highly stressful environment where they face stressors some of

* Corresponding author. Tel.: +91 08026995322;

fax: +91 080 26564830/26562121; mobile: +91 09902763889.

E-mail addresses: sailaxmi63@yahoo.com, gandhicoach@yahoo.co.in

(S. Gandhi), sangeetha.canfnza@gmail.com (G. Sangeetha), anurnahar@gmail.com

(N. Ahmed), skchatur@gmail.com (S.K. Chaturvedi).1 Tel.: +91 08026995322; fax: +91 080 26564830/26562121;

mobile: +91 09535469591.2 Tel.: +91 09854341201.3 Tel.: +91 08026995289; fax: +91 080 26564830/26562121;

mobile: +91 09845472975.

Please cite this article in press as: Gandhi, S., et al., Somatic symptomworking in an Indian psychiatric hospital. Asian J. Psychiatry (2014)

http://dx.doi.org/10.1016/j.ajp.2014.06.015

1876-2018/� 2014 Elsevier B.V. All rights reserved.

which are shortage of nurses, unpredictable patient behaviour aswell as aggression and violence on the unit. Due to exposure topsychosocial risks, nurses develop depression, violent behaviourand other diseases (Robinson et al., 2005).

Accountability to the hospital as well as the profession also addsto the stress. When nurses are unable to cope with the stress, there

are possibilities that somatic symptoms such as palpitations,

feeling of fullness – gas in the stomach, giddiness, lethargy, fatigue,

reduced sleep and appetite as well as pain anywhere in the body

may present in them which in turn can become another stressor.

This vicious cycle can affect nurses’ perception of job satisfaction

negatively and may lead to rapid nursing turnover as well as be

detrimental to patient care.Kawono (2008) reported somatic symptoms among 1599 full

time Japanese hospital nurses such as fatigue among thoseworking in operating rooms, anxiety in those working in intensivecare units (ICU) and anxiety as well as depression among thoseworking in surgery and internal medicine. Milutinovic et al. (2012)evaluated stress levels of 1000 nurses working in intensive care

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units in health centres of Serbia and found that the nurses sufferedfrom headache, backache and fatigue. Doef et al. (2012) in a cross-sectional survey of 309 female nurses in private and publichospitals in Kenya, Tanzania and Uganda found that the EastAfrican nurses showed high levels of somatic complaints, andnearly one-third of the sample could be labelled as burned out.Vargas et al. (2005) assessed 109 nurses in a health facility in theDistrito Federal and reported a significant correlation betweenburnout and cardiovascular somatic symptoms (r = 0.348,p � = 0.01). Welsh (2009) identified predictors of depressivesymptoms in a sample of 150 medical surgical nurses. The primarysomatic complaints were fatigue or low energy (43%), pain in theextremities or joints (30%), trouble sleeping (29%), back pain (28%),and headache (18%). Somatic symptoms (b = 0.39, p < 0.01),occupational stress (b = 0.18, p < 0.05), major life events(b = 0.18, p < 0.05), and income (b = �0.15, p < 0.05) accountedfor 34% of the variance in nurses’ depressive symptom scores.Abdelrahim and Humaida (2012) found presence of psychosomaticsymptoms such as hypertension, headache, ulcers, bronchitis, backpain and eczema among 56 randomly sampled nurses in TabarjalHospital.

The studies mentioned so far are restricted to nurses workingwith patients without psychiatric illness. It is possible that workingin a psychiatric unit could be very stressful as the patientbehaviour is highly unpredictable. Death or violent preventableincidents (such as patients escaping from the unit, aggressiontowards other patients/staff, breaking hospital equipment) in theunit may directly impact on nursing care. Although physical workmay be less when compared to working in a trauma care unit,the emotional burden may be tremendous and very stressful. Theresearchers were unable to find published research on somaticsymptoms in nurses working with adult psychiatric patients whichled to the genesis of this study.

1.1. Aim

To explore somatic symptoms, perceived stress and perceivedjob satisfaction among nurses working with psychiatric patients.

1.2. Objectives

1. To assess the level of somatic symptoms, perceived stress andperceived job satisfaction among nurses working with psychi-atric patients.

2. To correlate somatic symptoms, perceived stress and perceivedjob satisfaction among nurses working with psychiatric patients.

1.3. Hypothesis

There will be a statistically significant correlation betweensomatic symptoms, perceived stress and perceived job satisfactionamong nurses working with psychiatric patients.

2. Materials and methods

2.1. Research design

A cross-sectional, descriptive correlation research design.

2.2. Participants

After approval by the Institute Ethics Committee and followinginformed consent as well as detailed explanation about therisks and benefits involved, 150 nurses of both genders workingin the Psychiatric Wing of a super-specialty hospital at

Please cite this article in press as: Gandhi, S., et al., Somatic symptomworking in an Indian psychiatric hospital. Asian J. Psychiatry (2014

Bangalore, India were invited to participate in this study. All thenurses accepted the invitation. They were all Indians with noethnic differences among them and had more than oneyear experience of working with psychiatric patients. Nursesworking in the casualty had to take care of patients with traumaticbrain injury and neurological disorders in addition to those withpsychiatric diagnosis. They were also included in the study.

2.3. Research tools

The Scale for Assessment of Somatic Symptoms (SASS,Chaturvedi et al., 1987), Visual Analogue Scale (VAS) for stressand job satisfaction perception as well as a socio-demographicperforma were used for data collection. The scale for assess-ment of somatic symptoms (SASS) was developed andstandardized by the last author (Chaturvedi et al., 1987;Chaturvedi and Sarmukaddam, 1988; Chaturvedi and Maguire,1998; Chaturvedi et al., 2006; Duddu et al., 2006; Chaturvediand Desai, 2013). This scale quantifies somatic symptoms onfour sub-scales: Pain related symptoms, sensory somaticcomplaints, non-specific somatic complaints and biologicalfunction related symptoms. The scale has 20 items, is easy toadminister and is rated on a scale of 1–3 (Criteria for severitywere: 1: mild – symptom of low intensity without affectingbiological symptoms (sleep, appetite, libido), social andoccupational functions; 2: moderate – symptom causes dis-turbances of sleep, appetite and libido but not of social oroccupational functions and 3: severe – symptoms causedisruption of biological, social and occupational functions). Ithas high test–re-test reliability (0.98, p < 0.01) and has beenused in several Indian studies (Chaturvedi et al., 1987;Chaturvedi and Michael, 1993; Chaturvedi and Maguire,1998). Nurses stress and job satisfaction perception wereassessed on a VAS of 0–100%. The VAS (Aitken, 1969) is aself-report device that basically measures variables that aresubjective such as stress perception and job satisfactionperception. It is a line that is 100 mm long with anchors ateach end that help indicate the extremes of subjective variables.It is a simple and valid measure that has been observed to beconsistent (Gift, 1989).

2.4. Analysis

The data obtained was analyzed using SPSS 16 with descriptivestatistics, t test and Pearson’s correlation coefficient and tested atp < 0.05 level of significance.

3. Results

3.1. Descriptives

Frequency distribution of the subjects based on socio-demo-graphic variables and on age and years of experience are shown inTables 1 and 2.

3.2. Nature of somatic symptoms

Magnitude of somatic symptoms are shown in Table 3.Paired t test showed that the nurses seemed to have more pain

related somatic symptoms than sensory somatic symptoms(t = 11.88, p = 0.000), more pain related symptoms than non-specific symptoms (t = 13.77, p = 0.000) and more pain relatedsymptoms than biological related symptoms (t = 14.10, p = 0.000)(Table 3).

The nurses reported somatic symptoms related with pain(4.87 � 2.97) such as headache, body ache, backache, abdominal pain

s, perceived stress and perceived job satisfaction among nurses), http://dx.doi.org/10.1016/j.ajp.2014.06.015

Table 2Frequency distribution of the subjects based on age and years of experience

(n = 150).

Variable Range Mean � SD

Age (years) 24–58 37.66 � 8.32

Years of experience 1–33 6.15 � 6.34

Table 1Frequency distribution of the subjects based on socio-demographic variables

(n = 150).

Variable f Percentage (%)

Gender

Female 118 78.7

Male 32 21.3

Marital status

Single 18 12.0

Married 130 86.7

Widowed 2 1.3

Education

GNM 82 54.7

B.Sc. 40 26.7

M.Sc. 9 6.0

Additional qualification (D.P.N.) 19 12.6

Chronic illness

No 121 80.7

Yes 29 19.3

Ward

Closed wards 25 16.7

Open wards 30 20.0

Special wards 27 18.0

Child psychiatry ward 10 6.7

Rehab ward 4 2.7

ICU 15 10.0

Casualty 22 14.7

Centre for Addiction Medicine 11 7.3

Family ward 6 4.0

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and pain in the extremities; sensory somatic symptoms (2.40 � 2.35)such as burning sensations, tingling/numbing sensations, palpita-tions, feeling of bloating up and heat and cold sensations; non-specificsomatic symptoms (2.03 � 2.26) such as weakness of mind (i.e.difficulty in doing mental tasks and mental fatigue) and body,tremors, lethargy and giddiness as well as biological relatedsymptoms such as (1.92 � 2.29) lack of sleep, appetite, libido,constipation and diarrhoea.

3.3. Severity of somatic symptoms

Severity of Somatic symptoms among the subjects are shown inTable 4.

Frequency distributions of somatic complaints according totheir severity were computed. On an average, the nurses reportedmildly severe somatic symptoms (11.21 � 8.12). There was only onenurse who did not report any somatic symptom at all. Most of them(128, 85.3%) had mild somatic symptoms. Moderate somaticsymptoms were reported by 21 (14%) of the nurses. None of themhad severe somatic symptoms.

3.4. Stress and job perception

Perception of stress and job satisfaction among the subjects areshown in Table 5.

Table 3Magnitude of somatic symptoms (n = 150).

Pairs Mean

Pair 1 Pain related symptoms 4.87

Sensory somatic symptoms 2.4

Pair 2 Pain related symptoms 4.87

Non Specific Somatic Symptoms 2.03

Pair 3 Pain related symptoms 4.87

Biological function related Symptoms 1.92

Please cite this article in press as: Gandhi, S., et al., Somatic symptomworking in an Indian psychiatric hospital. Asian J. Psychiatry (2014)

3.5. Correlations of somatic symptoms, perceived stress and job

satisfaction

There was a significant increase in somatic symptoms(r = 0.302, p = 0.000) when stress perception was high. The nursesperceived significantly low job satisfaction (r = �0.231, p = 0.000)with higher scores of somatic symptoms. When the nursesperceived significantly less stress (r = �0.460, p = 0.000), theirperception of job satisfaction was high (Table 6).

4. Discussion

4.1. Descriptives

Majority of the nurses (78.7%) were females. Female dominancein the nursing profession has been reported in other parts of theworld (Milutinovic et al., 2012; Welsh 2009). Most of the nurses inthis study were in the age group 24–58 years with mean age of37.66 � 8.32. Ahumada and Noriega (2010) reported that nurses’working in the children’s psychiatric hospital in their study were inthe age group of 19–67 years with mean age of 43 � 10.4.

It was found that only 12.6% nurses in the present study had anadditional professional qualification of DPN. In their study onphysical and mental health disorders associated with nursing at achildren’s psychiatric hospital, Ahumada and Noriega (2010) foundthat 20% of the nurses had specialized in psychiatric nursing. In thepresent study, the researchers found that nurses experience intaking care of psychiatric patients ranged from 1 to 33 years withmean experience of 6.2 years. Welsh (2009) reported that themedical-surgical nurses in his study had 10 years of experiencewith all of them having more than one year experience. Ahumadaand Noriega (2010) found that 90% of the nurses had 8 years ofexperience of working in the children’s psychiatric hospital. In thepresent study, 29 nurses (19.3%) reported that they were sufferingfrom chronic illness such as back pain, migraine, hypertension andscoliosis. Similarly, Humaida (2012) reported that of the 56 nursesin Tabarjal Hospital, 11 had hypertension. However, the nurses inthis study also suffered from other chronic diseases such as ulcers,bronchitis and eczema. It is possible that exposure to emotionalproblems of psychiatric patients led to somatic symptoms thatwere related more with pain.

4.2. Nature of somatic symptoms

Majority (85.3%) of the subjects in the present study seemed tohave mild somatic symptoms which were pre-dominantly pain

SD Paired ‘t’ value df p value

2.97 11.88 149 0.000

2.35

2.97 13.77 149 0.000

2.56

2.97 14.1 149 0.000

2.29

s, perceived stress and perceived job satisfaction among nurses, http://dx.doi.org/10.1016/j.ajp.2014.06.015

Table 6Perception of stress and job satisfaction among the subjects (n = 150).

Variable Range (%) Mean % � SD

Perception of stress 0–95 38.53 � 25.5

Perception of job satisfaction 30–100 81.67 � 15.17

Table 4Somatic symptoms among the subjects (n = 150).

Variable Range (%) Mean % � SD

Pain related symptoms 0–12 4.87 � 2.97

Sensory somatic symptoms 0–12 2.40 � 2.35

Non specific somatic symptoms 0–11 2.03 � 2.26

Biological function related symptoms 0–11 1.92 � 2.29

Total score 0–39 11.21 � 8.12

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related symptoms (4.87 � 2.97). The nurses reported that theysuffered from pain in the extremities, headache, backache, abdominalpain as well as whole body ache. These findings are supported byother studies (Welsh, 2009; Ahumada and Noriega, 2010; Milutinovicet al., 2012; Abdelrahim and Humaida, 2012). In Indian psychiatrichospitals, the nature of work in the closed wards, ICUs and casualty isquite stressful. Psychiatric patients in these wards are in the acutestage of illness, violent, aggressive, abusive, with suicidal/homicidaltendencies. In this study, 16.7% of the subjects were from the closedwards, 14.7% from the casualty and 10% from ICU. The physical andemotional stress is more here than in the open wards, rehabilitationward, child psychiatric ward and family ward. Nurses in casualty haveto also engage in a lot of physical work while caring for patients withtraumatic brain injury, neurological and neuro-surgical emergencies.This could possibly be the reason why the somatic symptoms seemedto be pre-dominantly pain related.

Sensory and non-specific somatic symptoms seemed to be lesspre-dominant although almost similar in occurrence. The nature ofsensory somatic symptoms (2.40 � 2.35) that these nurses seemedto be experiencing were burning sensations, tingling/numbingsensations, palpitations, feeling of bloating up as well as heat andcold sensations while the non-specific somatic symptoms(2.03 � 2.26) were weakness of mind (i.e. difficulty in doing mentaltasks and mental fatigue) and body, tremors, lethargy and giddiness.Similarly, Ahumada and Noriega (2010) observed that 12.7% of thenurses reported fatigue.

Biological related symptoms such as lack of sleep, appetite,libido, constipation and diarrhoea occurred in least (1.92 � 2.29)frequency. Similarly, Ahumada and Noriega (2010) in their studynoted that psychosomatic disorders in the nature of digestivesymptoms were reported by only 9.9% of the nurses and circulatorysymptoms by only 8.5% of the nurses.

4.3. Severity of somatic symptoms

The researchers found that the total mean somatic symptoms(11.21 � 8.12) were of mild severity. Violante et al. (2009) concludedfrom their study that the three subgroups of nurses (137) working inhospital wards for acute patients, units for long-term patients, andhome care for chronic patients had stress scores beyond the thresholdvalue of 17 for anguish (22.7 � 155), anxiety (22.3 � 15.8) and gastroenteric symptoms (19.0 � 17.8). Somatic symptoms of varyingseverity in nurses working in various settings have been reportedby Kawono (2008), Welsh (2009), Milutinovic et al. (2012), Humaida(2012) and Doef et al. (2012). The mean score on the SASS in our studywas 11.21 � 8.12 indicating that the subjects had mild somaticsymptoms which could be possibly attributed to perceived occupa-tional stress. Research carried out across countries reflect the

Table 5Severity of Somatic symptoms among the subjects (n = 150).

Variable f %

No somatic symptoms 1 0.7

Mild somatic symptoms 128 85.3

Moderate somatic symptoms 21 14.0

Severe somatic symptoms Nil 0.00

Please cite this article in press as: Gandhi, S., et al., Somatic symptomworking in an Indian psychiatric hospital. Asian J. Psychiatry (2014

presence of somatic symptoms of varying nature and intensity innurses working in various set ups. However, research in the area ofnurses working with psychiatric patients is apparently lacking.

4.4. Stress and job perception

Although the mean percentage of stress perception was38.53 � 25.5, the upper limit of the range was 95%. The NursingCouncil of India prescribes that all hospitals follow a nurse: patientratio of 1:5 in general wards and 1:3 in ICUs. Nurses work in threeshifts in this hospital. The wards are well staffed during the morningshifts. However, during the evening and night shifts only one nurse isposted in the open wards (where families stay with the patients)which have 50–60 patients census, two nurses are posted in theclosed wards which may have 40–60 patients and two nurses areposted in ICUs where there may be 10–15 patients. This may be thereason why some nurses perceive stress as high as 95%. Such a highperception of stress is quite disturbing. It indicates an urgent need forimplementation of stress management interventions as well as tomaintain optimal nurse: patient ratios during all shifts. In the presentstudy, perception of job satisfaction is very high (81.67 � 15.17) witha negative correlation between perception of job satisfaction andstress perception (r = �0.460, p < 0.01). Doef et al. (2012) investigat-ed job conditions, job satisfaction, somatic complaints and burnoutamong 309 female nurses in private and public hospitals in Kenya,Tanzania and Uganda and found that public hospital nurses had alower job satisfaction than private hospital nurses, but showedcomparable levels of somatic complaints and burnout. Contrastinglyin India, in the present study the researchers found that publichospital nurses had a higher job satisfaction which was probably dueto higher financial benefits

4.5. Correlations of somatic symptoms, perceived stress and job

satisfaction

There is a positive correlation (r = 0.302, p < 0.01) between totalsomatic symptoms score and perceived stress score while there isnegative correlation (r = �0.231, p < 0.01) between total somaticsymptoms and perceived job satisfaction. Although 9% of variancein the total somatic symptoms score can be attributed to stressperception, the remaining 91% remains unexplained. Similarly,although 4% of variance in the total somatic symptoms score can beattributed to perceived job satisfaction, the remaining 96% remainsunexplained. The correlation between perceived stress andperceived job satisfaction is significantly negative (r = �0.460,p < 0.01). Although 16% of variance in perceived stress can beattributed to perceived job satisfaction, the remaining 84% remainsunexplained. Although the correlation between these variables issignificant, it is possible that a large amount of variance remainsunaccounted as the correlation is spurious due to large sample size(n = 150) and clinically no real correlation exists between thesevariables. Hence, the findings of this study need to be treated withcaution. Hernandez-Vargas et al. (2005) found a positive correla-tion between scores on burnout and cardiovascular symptoms(r = 348, p£ = 0.01) among 109 nurses working in a health facilityin the Distrito Federal of Spain. Abdelrahim and Humaida (2012) ina descriptive study on 56 nurses in Tabarjal Hospital reported asignificant correlation between stress and psychosomatic com-

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plaints among nurses. These studies indicate that higher stresslevels may induce increasing occurrence of somatic symptoms.This makes it all the more vital that nurses learn to manageoccupational stress.

5. Recommendation

Further research can be conducted on somatic symptoms, stressperception and coping among nurses; outcome of stress manage-ment interventions; somatic symptoms among nurses in varioussettings and qualitative studies on nurses’ experience of painrelated symptoms may contribute to more hypotheses that can betested.

6. Limitations

Findings from this study need to be treated with caution asrandomization was not done, nurses with chronic illnesses wereincluded as subjects, and Hawthorne effect may have contributedto the findings as the subjects were working in the same place asthe first author (although they were given the option of not writingtheir names on the questionnaire). Although the nurses were askedto rate stress perception while working in the wards, otherstressors such as domestic stress could have influenced theirrating. Hence, stress from other sources too could have contributedto mild somatic symptoms in this group. Nurses working in thecasualty too were part of the study subjects. Although these nursestake care of psychiatric patients who come for emergency care,they also take care of neurological and neuro-surgical emergenciesand hence cause for the somatic symptoms in this group cannot besolely attributed to the psychiatric setting. Future large scalestudies with randomization may throw further light on the effectof somatic symptoms on quality of nursing care.

7. Conclusion

In this particular hospital where the study was carried out,nurses received comparatively higher salaries and other benefitssuch as sponsorship for higher studies, health care facilities forthemselves and their family as well as financial and leave benefitsfor participating in conferences. In spite of these facilities whichare not to be found in other hospitals across India, this group ofnurses had mild somatic symptoms and stress perception as highas 95%. The authors conclude from this study that stress perceptionseems to have a lasting impact on perceived job satisfaction andoccurrence of somatic symptoms. Proactive implementation ofstress management modules may prevent occurrence of somaticsymptoms and improve job satisfaction perception.

Funding

None.

Conflicts of interest

None.

Please cite this article in press as: Gandhi, S., et al., Somatic symptomworking in an Indian psychiatric hospital. Asian J. Psychiatry (2014)

Author contributions

Dr. Sailaxmi Gandhi performed the conceptualization, datacollection, compilation, preparation for analysis and manuscriptwriting. Dr. Sangeetha G. performed the data compilation,literature review and assisting in manuscript writing. Mrs.Nurnahar Ahmed performed the statistical analysis. Dr. S.K.Chaturvedi Edited the manuscript.

Acknowledgement

The authors thank administrative authorities for permittingdata collection and acknowledge the contributions of the studysubjects.

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