Occupational Stress in Nurse sAA —The Study Provided during the Urged Pandemic COVID-19 Quarantine Period

Introduction: Nursing is considered to be a complex and high demanding profession. A combination of high workplace demands, over-responsibility, and over-authority has been identified as a major source of occupational stress among nursing staff. Material and methods: Our study measured level of α-amylase in the saliva, non-invasive, reliable biomarker for stress expo-sure, of nurses using the Japanese device SALIVA AMYLASE MONITOR 2004. The questionnaire was considered to figure out how all 473 nurses from the Mongolian tertiary referral hospitals perceive and accept the stress. The Likert scale was used in measuring the questions. Participants were recommended not to eat any meal in the morning 8 - 10a.m. and after work for examination. The indicators were evaluated by cross-sectional research mod-el. Results: The amylase levels of nurses in the study ranged from 2 - 34 in the low stress group to a minimum of 16,083, while in the morning, the amylase levels in the medium group ranged from 2 - 105 to a maximum of 25,226 KU/L. The one-way ANOVA results revealed that the differences between the morning sAA level groups were statistically significant (F = 3.481, p = 0.032). Conversely, the evening sAA levels (F = 1.256, p = 0.286) had no statistical differences (F = 1.144), (p = 0.331). Occasionally, our study was conducted at the quarantine period of pandemic COVID-19, and we can see clearly that the nurses at National Center for Infectious Diseases are working hard under the urged stressed condition.


Background
Nursing is a stressful profession; accordingly, nurses are vulnerable to the effects of stress in their daily environment (McCraty, Atkinson, & Tomasino, 2003).
Work-related chronic stress leads to fatigue syndrome, lack of ability to work, which is exposed by emotional exhaustion, followed by an emotional numbness or a negative attitude towards oneself and others (Maslach, Schaufeli, & Leiter, 2001). It is impossible to wipe out work-related stress and stressors, but only effective coping techniques can help to reduce the stress caused outcomes (Benson, Beary, & Carol, 1974).
When stress is part of the work environment, it is difficult to control and can cause recurrent aggression, which in turn affects an individual's health and ability to act. In fact, sick leave is more common for people who suffer from work stress than other workers. Stressful work environments are prevalent among health professionals, and several studies have performed regarding the harmful effects of nursing workplace stress (Benson et al., 1974;Maslach et al., 2001;McCraty et al., 2003). The correlations between the workplace stressors and nurses' physical and mental health changes were determined in accordance with certain studies (Frantz & Holmgren, 2019). Nursing is considered to be a complex and highly demanding job. A combination of the high workplace requirements, over-responsibility, and over-authority has been identified as a major source of occupational stress among nursing staff (Burke, 2002;Gunkel, Lusk, Wolff, & Li, 2007;Wong, De-Sanctis, & Staudenmayer, 2007;Gunkel, Wolf, & Li, 2007).
In recent years, there have been a number of stressors, such as emotional instability, anxiety, and worry, due to a variety of factors, including social and economic conditions, drastic changes in science, technology, information, urbanization, and overcrowding. Nurses who have the closest contact with a client need to study stressful situations in their work.

Purpose
We aimed to study the workplace stress for nurses from the Mongolian tertiary referral hospitals during the pandemic COVID-19.

Objectives
In the frame of our doctoral dissertation, to determine if the Mongolian nurses perceived stress correlated to their salivary alpha amylase level regarding their working areas.
1) Before the sAA testing we asked the participants to have the Work Stress Profile Questionnaire of Rice to see how the Mongolian nurses perceive the workplace stress.
2) Check the sAA using the Japanese device Saliva Amylase Monitor 2004.

Materials and Methods
The study involved totally 473 nurses from the tertiary referral hospitals of Psychology The standard deviation (SD) and regression data, differences between the groups were revealed by Student's test, the statistical difference should be at р < 0.05.

Results
A total of 473 nurses were included in the study, including 121 NCTO, 89 NCMH, 146 NCID, and 117 NCC. Meanwhile, 46 administrative workers, 75 doctors, 208 nurse-midwives, 105 cleaners, and 46 organizational workers participated in our study, too. The general information of the study participants is demonstrated in Table 1. Table 1 illustrates that the gender 97.3% female and 2.7% male, but not the age and education statistical difference presents among the participants. However, we can see statistical significances in the working area/place and the years of working there. The nurse stress level is unified in Table 2.
We identified the nurses' stress at three levels: high, medium/normal, and low.  The stress level groups were classified by the hospitals: nurses from National Center of Traumatology and Orthopedics occupied the most percentage in the low stress group as well as in the normal stress group, their stress level was at 13.2% and 33.1%, correspondingly. Cancer nurses were categorized to the group of high stress level 76.1% (Table 3).
Moreover, they (cancer nurses) occupied the less percentage in the low and normal (19.7%) stress groups. The NCTO nurses cover the less percentage in high stress level 53.7%.
The findings expose that the traumatology nurses perceived stress level is low rather than the other hospitals. Conversely, the cancer nurses are the participants who are mostly suffered from the workplace stress. Nurse stress variability statistics also confirmed these results.
For instance, the occupational stress statistics of the nurses by hospitals revealed that the NCTO nurses have a lower stress level than other hospitals with 144,471 and the National Cancer Center has a higher stress level of 154,641 than other hospitals. However, the standard deviations demonstrate that the stress levels had gone up and down: the most fluctuated group was the NCTO nurses and the least one was National Cancer Center (Table 4).
We examined whether the nurse stress levels differ regarding the work-related stress level groups by one-way ANOVA and the statistical real differences (F = 3.071), (p = 0.028) were confirmed (Table 5).
In order to evaluate the Workplace stress we added all the corresponding scores to each questions and organized in following three levels: Using CROSSTABS analyzing method we attempted to figure out the WPS questionnaire with the participants' sAA stress scores (See Table 6).
In accordance with the salivary alpha amylase statistics, the morning sAA levels were 2 -34 (at least 16,083 KU/L) and 2 -105 (the highest 25,226 KU/L) in the low and normal stress groups, correspondingly (Table 7).

Discussion
Various of the scientists, for instance, Weiman (1978), Holmgren (Frantz & Holmgren, 2019) (1990 and Rice (1999) have been developed different self-administered questionnaires in order to identify the workplace stress in its early stages; by the early detection, the person or the organization can be prevented or avoid from the numerous unpleasant consequences such as sick-leave, physiological and psychological illnesses, work burnout, and other organizational expenses. Nevertheless, we chose the Rice (1999) WPS self-esteemed questionnaire because we considered that our study participants will categorized to relatively healthy, i.e. they never complain on being sick and leave the work. Furthermore, we decided that it would be reasonable if the participants assess themselves whether they are in a work-related stress by reading and getting idea what can be called workplace stress indeed (Rice, 1992). It is clear that women dominate nursing around the world, however regardless of the work environment, requirements, or workload, regardless of gender all are exposed to workplace stress. The results of our study agree that it depends only on individuals. Our study gave proof that due to ANOVA the gender differences on workplace stress is absent (F = 0.404), (p = 0.525) statistically.
According to literatures, workplace stress is often treated by the gender of nurses, but the results vary. Certain researchers noted that there is no gender difference in work stress (Wong et al., 2007), and others claimed that female nurses are more vulnerable to various occupational stresses than men (Gunkel et al., 2007). Moreover, some researchers figured out that female nurses are more intended to psychological stress, meanwhile the men are tend to physiological stressors (Burke, 2002).
If correlate the age with workplace stress, it would cover the personal issues as the perception, the experiences, the adapting abilities and etc.
According to our study, when working stress is related to the age of snurses, the lowest percentage was in the low-stress group, 4.0% in the 31 -40 age group, the lowest in the middle group, and 16.2% in the 31 -40 age group, and the highest in the high-stress group a small percentage was identified as 55.9% in the 18 -24 age group. This suggests that the stress levels of nurses in the 18 -24 age group are lower than in other age groups, while the stress levels of nurses in the 31 -40 age group are higher than in other age groups.
The results of this study are similar to the results of a 2013 study by Finnish researchers as well as Mauno that found that young nurses are less exposed to workplace stress than older nurses (Mauno, Ruokolainen, & Kinnunen, 2013).
We agreed with the global studies that the nurses at younger age are less exposed to the work stress because they are working in fellowship system and they are always relying on co-workers help.
Particular researchers, such as Takase, Teraoka, and Yabase, suggested in a 2016 study that nurses over the age of twenty-five who want to keep their workplaces are more stressed than middle-aged and older nurses (Takase, Teraoka, & Yabase, 2016). The statistically significant differences in the stress levels (F = 1.923) and (p = 0.105) regarding the nurses' education levels were refuted when we examine it by ANOVA. And the result is agreed with Kim Oliver study findings (2007) (Oliver, 2007).

Conclusion
1) The results revealed that the work-related stress is at high level among the nurses regarding their work places.
3) Occasionally, our study was conducted at the quarantine period of pandemic COVID-19, and we can see clearly that the nurses at National Center for Infectious Diseases are working hard under the urged stressed condition.