1Department of Paediatric Nursing, College of Nursing, University of Warith Al- Anbiyaa, Karbala, Iraq
2Department of Psychiatric and Mental Health Nursing, College of Nursing, University of Warith Al-Anbiyaa, Karbala, Iraq
3Radiological Techniques Department, College of Health and Medical Techniques, University of AL-Zahraa for Women, Holy Karbala, Iraq
4Department of Maternity Nursing, College of Nursing, University of Warith Al- Anbiyaa, Karbala, Iraq
5Department of Basic Science, College of Nursing, University of Warith Al-Anbiyaa, Karbala, Iraq
*Corresponding Author’s Email: kholoud.ha@uowa.edu.iq
Background: Paediatric nurses experience distinct mental and physical challenges on the job, adding to the widespread problem of healthcare worker stress. The negative effects on health, productivity, and patient care can result from nurses experiencing high levels of stress, few studies have looked at the prevalence of stress among Iraqi paediatric nurses, despite the fact that this population has higher rates of stress overall. Objective: The study aimed to find out stress levels and recognise the causes of stress among paediatric nurses. Methods: Descriptive cross-sectional study design, conducted in the Educational Karbala Hospital for Children in the Holy City of Karbala in Iraq, and the researcher used a questionnaire which consists of two parts, socio-demographic for the study sample: age, educational level etc. In addition, the expanded nursing stress scale (ENSS) to measures the sources and frequency of stress experienced by the nurses. A total of 300 nurses randomly selected were recruited. Results: Indicated that the common paediatric nursing personnel assessed their job stress as moderate (87.7%), but the nurse had more stress related to the patient’s death. In addition, there are no significant differences in job stress (p ≥ 0.05) in relation to the rest of the demographic variables. Conclusion: Researchers found that all those nurses have a moderate level of job stress. Current study recommended to find ways to decrease the prevalence of job stress among paediatric nurses, as treating the difficulties inside and outside the workplace in order, to decrease the stress for those nurses’ group, foster a positive work environment and Ensure Clear Job Role Definitions.
Keywords: Iraq; Job; Nurses; Paediatric; Stress
There is growing interest in analysing and understanding the different sources of workplace stressors. Furthermore, substantial evidence indicates that nursing is perceived as a highly stressful occupation within the health care sector, with numerous studies documenting elevated stress levels among nurses (Al Sabei et al., 2023). The nursing job is highly intricate and demanding, exposing nurses to various conditions that might impact their physical and emotional health. Nurses often encounter patients with terminal illnesses and in critical situations (Goudarzian et al., 2024). Paediatric nurses must deliver developmentally suitable care and meticulously address patient and family concerns. The intricate responsibilities of paediatric nurses necessitate unwavering attention to detail to deliver exceptional patient care (Hendy et al., 2023). Stress constitutes a significant risk factor for paediatric nurses, potentially resulting in substandard care (Glawing et al., 2024). Nurses' health and capacity to handle demands at work were both negatively impacted by workplace stress (Pangarkar et al., 2023). Research indicates that nursing is among the most challenging professions.
Occupational stress affects workers' perceptions of events and work pressures, thereby influencing their mental health. Stress diminishes judgment, focus, and decision-making capabilities (Jeon, Yun & Kim, 2024). It diminishes care quality and increases the likelihood of errors. Nurses may experience guilt regarding illnesses that afflict them due to their profession. Nurses may experience significant guilt when managing multiple issues in patient care (Quesada-Puga et al., 2024). Job stress harms physiology, psychology, and behavior, including job performance. While limiting stress, such as conflicting roles and work anxiety, cannot be overcome, challenger stress, such as task load and time pressure, can be utilized to further nursing careers (Yu et al., 2024). In addition, Unsatisfactory work performance and insufficient nursing care adversely affect the wellness of patients (Bian et al., 2023). Compared to nurses in other words, paediatric nurses are particularly vulnerable to mental health issues and professional stress (Bhagat et al., 2025; Fang et al., 2020). Limited research has investigated stressors among paediatric nurses with differing years of experience.
This study identifies specific characteristics contributing to occupational stress amongst paediatric nursing staff, including exhaustion, age, and problems in the work environment. Comprehending these stressors is essential for formulating specific therapies to enhance the wellness of nurses’ overall job fulfilment. In addition, Burnout, which can result in lower job performance, lower-quality medical care, and higher turnover rates, is strongly predicted by job stress. Healthcare companies may prevent burnout and preserve an additional reliable workforce by treating stress (Keykha, Alinejad-Naeini & Peyrovi, 2025). Whereas the paediatric nurses are essential in providing care for patients who are at risk. Reducing work-related stress can improve their capacity to deliver compassionate, superior treatment, which will eventually improve patient outcomes (Huang et al., 2025).
The study employed a descriptive cross-sectional design.
The study was conducted at the Educational Karbala Hospital for Children in Iraq. The research sample comprised 300 nurses working at the hospital, selected through a random sampling method.
The study included individuals who were not participating in any program related to work stress management or control. Additionally, individuals diagnosed with chronic diseases were also excluded from participation in order to minimize potential confounding factors that could influence the study outcomes.
Part two: Expanded nursing stress scale (ENSS) (Abu Ruz et al., 2018; French et al., 2000) has been tested for both validity and reliability (> 0.70) in various nursing populations, including paediatric and clinical settings, and it contains 57 items, each representing a different source of stress; which is a validated tool for measuring the frequency and intensity of stress experienced by nurses in different clinical situations. The ENSS seeks to identify the sources and levels of stress experienced by nurses in their professional practice, thereby aiding researchers in understanding critical stressors and facilitating the implementation of supportive interventions.
The nurses’ Job stress was classified based on the mean score (MS) of their answers to the items of the Job stress questionnaire, the range scores was divided into stratified quartiles to develop an ordinal scale The stress score was stratified into low stress (first quartile: 0 – 1), moderate stress (second and third quartiles: 1.01 – 2; 2.01 - 3), and high stress (fourth quartile: 3.1 - 4). Probability levels:
Average (MS = 0 - 1) is considered low job stress. Average (MS = 1.01 - 3) is considered moderate job stress. Average (MS = 3.1 - 4) is considered high job stress.
The questionnaire was distributed to the respondents, and they were asked to answer the questionnaire electronic, where the data collected between 13th February 2024 to 15th April 2024.
The statistical analysis utilised in this study included descriptive statistics such as frequency (N), mean (M), standard deviation (SD), and percentage (%) to summarize the data. To examine differences in job stress based on demographic variables with two groups, an independent samples t-test was employed. For demographic variables with more than two categories, a one-way analysis of variance (ANOVA) was conducted. A p-value of ≤ 0.05 was considered the threshold for statistical significance, indicating meaningful differences between groups.
The research obtained ethical clearance from the Ethics Committee of the College of Nursing at Warith Al-Anbiyaa University, Iraq with reference number 356 on 8th December 2023.
The results of the data analysis presented methodically:
Table 1: Socio- Demographic Data for the Study Sample
Variables | |||
% | |||
Gender | Male | 165 | 55.0 |
Female | 135 | 45.0 | |
Total | 300 | 100 | |
Education | Diploma | 96 | 32.0 |
Graduation | 191 | 63.7 | |
Postgraduate | 13 | 4.3 | |
Total | 300 | 100 | |
Workplace | ICU | 33 | 11.0 |
CCU | 28 | 9.3 | |
Other | 239 | 79.7 | |
Total | 300 | 100 | |
Martial statues | Married | 171 | 57.0 |
Unmarried | 113 | 37.7 | |
Widowed | 9 | 3.0 | |
Divorced | 7 | 2.3 | |
Total | 300 | 100 | |
Requirements in Clinic Area | M | SD | Level |
Performing operations that cause agony to patients | 1.95 | 0.994 | Moderate |
Criticism by a physician | 1.89 | 1.207 | Moderate |
Feeling unprepared to assist with a patient's family's emotional demands | 1.65 | 1.091 | Moderate |
Difficulty discussing issues in the workplace candidly with other staff members. | 1.84 | 1.261 | Moderate |
Conflict with a supervisor | 1.99 | 1.301 | Moderate |
Breakdown of computer | 1.89 | 1.378 | Moderate |
Inadequate information from a physician regarding the medical condition of a patient | 1.91 | 1.215 | Moderate |
Patients making unreasonable demands | 2.36 | 1.190 | Moderate |
Being sexually harassed | 2.00 | 0.000 | Moderate |
Feeling powerless when a patient doesn't improve | 2.22 | 1.247 | Moderate |
Conflict with a physician | 1.94 | 1.172 | Moderate |
A patient asking a question can't answer | 1.92 | 1.201 | Moderate |
Lack of workplace sharing of experiences and feelings with others | 1.78 | 1.271 | Moderate |
Floating to understaffed units/services | 2.14 | 1.251 | Moderate |
Unpredictable staffing and scheduling | 1.91 | 1.282 | Moderate |
A physician prescribing what seems to be an unsuitable treatment | 1.74 | 1.282 | Moderate |
Families of patients making irrational requests | 2.29 | 1.285 | Moderate |
Experiencing discrimination because of race or ethnicity | 2.00 | 0.000 | Moderate |
Discussing dying with a patient | 1.90 | 1.397 | Moderate |
Fear of making a mistake in treating a patient | 2.13 | 1.295 | Moderate |
Feeling unprepared to help a patient emotionally | 1.83 | 1.255 | Moderate |
Lack of opportunity to voice my unfavourable feelings toward patients to unit staff | 1.77 | 1.256 | Moderate |
Problems dealing with a nurse or nurses in my current work context | 1.84 | 1.215 | Moderate |
Difficulty in working with a particular nurse (or nurses) outside my immediate work setting | 1.78 | 1.246 | Moderate |
Too little time to comfort emotionally the sufferer. | 1.81 | 1.274 | Moderate |
A medical emergency without a doctor | 2.14 | 1.390 | Moderate |
Attribution of blame for any adverse outcomes | 2.11 | 1.403 | Moderate |
Experiencing discriminations on the basis of sex | 1.87 | 1.406 | Moderate |
The death of a patient | 2.51 | 1.317 | Moderate |
Patient treatment disagreement | 2.01 | 1.243 | Moderate |
Table 2 presents the mean (M), standard deviation (SD), and level of job stress perceived by paediatric nurses in relation to various clinical requirements. The highest stressors were associated with patient’s death, unreasonable demands, and emotional strain when patients did not improve.
Table 3: Assessment of Job Stressors and Perceived Stress Levels among Paediatric Nursing Staff
Bedtime Resistance | M | SD | Level |
Feeling adequately trained for what have to do | 1.81 | 1.169 | Moderate |
Unsupportive immediate supervisor | 2.02 | 1.333 | Moderate |
Disapproval by a supervisor | 2.00 | 0.000 | Moderate |
Too little time to finish nursing tasks | 1.90 | 1.301 | Moderate |
Not knowing what to tell a patient or family about their condition and treatment | 1.83 | 1.313 | Moderate |
Being the one that has to deal with patients' families | 2.03 | 1.253 | Moderate |
Managing violent patients | 2.21 | 1.306 | Moderate |
Exposure to safety and health dangers | 2.26 | 1.280 | Moderate |
Your close patient's death | 2.36 | 1.352 | Moderate |
Decision-making for a patient without a doctor | 1.94 | 1.219 | Moderate |
Being in charge with insufficient experience | 1.95 | 1.247 | Moderate |
Deficiency of support by administrators | 2.16 | 1.284 | Moderate |
Too many non-nursing jobs, such clerical | 2.20 | 1.264 | Moderate |
Insufficient staff to cover the unit | 2.29 | 1.275 | Moderate |
Ambiguity concerning the operation and functionality of specialized laving equipment | 2.04 | 1.260 | Moderate |
Having to deal with abusive patients | 2.26 | 1.241 | Moderate |
Too little time to meet patient families' demands | 1.88 | 1.264 | Moderate |
Being responsible for things can't control | 2.00 | 1.336 | Moderate |
Physician absent when patient dies | 1.97 | 1.428 | Moderate |
Managing Doctors' work | 1.91 | 1.378 | Moderate |
Insufficient support from other health administrators | 2.07 | 1.270 | Moderate |
Trouble working with opposite-sex nurses | 1.82 | 1.186 | Moderate |
System requirements for patient classification | 1.86 | 1.231 | Moderate |
Dealing with patient family abuse | 2.21 | 1.266 | Moderate |
Watching a patient suffer | 2.39 | 1.282 | Moderate |
Criticism by nursing administration | 2.22 | 1.328 | Moderate |
Working during breaks | 2.28 | 1.223 | Moderate |
Not knowing if patients' families would report poor care | 1.83 | 1.267 | Moderate |
Decision-making under pressure | 1.80 | 1.257 | Moderate |
Table 3 summarises the mean (M), standard deviation (SD), and level of stress experienced by paediatric nurses across different job stressors. The most stressful situations included watching patients suffer, patient death, and managing insufficient staffing.
Both table 2 and 3 show the average mean and the job stress level perceived by the paediatric nursing in each phrase of the scale. Where the average mean for all phrases showed that there was an average level of job stress in each phrase.
However, the phrases related to ‘patient’s death’ and ‘suffering’ had the highest mean values, indicating that these situations were perceived as more stressful by the nurses, with (M ± SD = 2.51 ± 1.317) and (M ± SD = 2.39 ± 1.282), respectively. Conversely, the phrases "Feeling unprepared to help a patient emotionally" and "A physician prescribing what seems to be an unsuitable treatment" had the lowermost mean values, indicating that these phrases were professed as less stressful by the nurses by (M±SD = 1.65±1.091) and (M±SD =1.74±1.282) respectively.
The phrases "patient’s death and suffering" are likely to be more stressful for nurses because they involve direct confrontation with patient suffering and death. Dealing with these situations can be highly emotional and emotionally draining, leading to increased levels of job stress. On the other hand, the phrases " Feeling unprepared to help a patient emotionally" and "A physician prescribing what seems to be an unsuitable treatment" may be less traumatic because they do not involve direct confrontation with patient suffering. Rather, these phrases may relate to concerns about competence or conflicts with colleagues, which may be less stressful than dealing with patient suffering and death.
Table 4: Levels of Occupational Stress and Its Distribution within the Sample
Total Job Stress Level | f | % | M | SD | Assessment |
Low | 27 | 9.0 | 2.01 | 0.668 | Moderate |
Moderate | 263 | 87.7 | |||
High | 10 | 3.3 | |||
Total | 300 | 100 |
Table 4 evaluates nursing staff job stress in this study. The results show moderate job stress (M±SD = 2.01±0.668). The majority of nursing staff (87.7%) perceived their job stress at a Moderate level. Additionally, 9% of them perceived it at a low level, while only a small percentage (3.3%) perceived it at a high level.
Table 5: Job Stress and Demographics of Sample
Variables | N | M | SD | T / F | df | p value |
Gender | T = 0.547 | 298 | 0.585 | |||
Male | 165 | 1.99 | 0.684 | |||
Female | 135 | 2.03 | 0.651 | |||
Education | F = 1.568 | (2, 297) | 0.210 | |||
Diploma | 96 | 1.95 | 0.771 | |||
Graduation | 191 | 2.00 | 0.625 | |||
Postgraduate | 13 | 2.29 | 0.351 | |||
Workplace | F = 1.874 | (2, 297) | 0.155 | |||
ICU | 33 | 2.04 | 0.526 | |||
CCU | 28 | 2.24 | 0.357 | |||
Other | 239 | 1.98 | 0.709 | |||
Marital status | F = 0.515 | (2, 297) | 0.672 |
Married | 171 | 2.01 | 0.681 | |||
Unmarried | 113 | 2.04 | 0.642 | |||
Widowed | 9 | 2.19 | 0.585 | |||
Divorced | 7 | 1.84 |
T: T test for The Independent sample; F: One Way Anova test,
Table 5 showed no significant differences in job stress (p ≥ 0.05) related to the rest of the demographic variables.
Paediatric nurses encounter mental, physical, and organizational obstacles on their job, according to this study that takes a nursing and healthcare management stance. It recognises that care for children is delicate and that dealing with worried families may be emotionally taxing, making paediatric nursing an inherently challenging profession. Factors like high patient acuity, emotional commitment to patients, long shifts, and personnel shortages frequently make these stresses even worse.
Due to job stress's impact on nurses' quality of life and care behaviours, job stress in paediatric nursing staff must be studied. Research shows that job stress affects nurses' physical and emotional health, job productivity, and treatment quality. The result of our research reveals according to the Table 1, that more than half of the participants were male nurses, and the majority of them were working at other places than the NICU and NCCU. One possible reason for the higher representation of male nurses in this study may be related to the overall gender distribution within the nursing profession. On the other hand, Okechukwu (2025) the stress experienced by paediatric nurses is not specific to a particular department or unit but rather is prevalent across various areas of nursing practice.
The existing study discovered in Table 2 that the majority of paediatric nursing staff perceived their job stress at a moderate level. The result corresponds with Zhang, Zhou and Xia (2025) that found more than half of paediatric nurses had empathy exhaustion in their work. In addition, another study done in Egypt (Ibrahim, Zakaria & Abdel-Ghani, 2023) revealed, that most staff nurses had moderate stress and more than half had poor performance on the job. Alharbi et al., (2023) found the stress impacted over fifty percent of the paediatric nurses polled. In addition, Wali et al., (2023) in Saudi Arabia, the findings revealed a contrasting outcome, with the majority of nursing staff involved in the study reporting high levels of stress.
This finding aligns with the broader understanding that the nursing profession is inherently associated with high stress levels, largely due to various job demands and environmental factors (Alraimi & Shelke, 2023). Consequently, previous research has found modest job stress, as does this study. Several studies have examined occupational stress and characteristics within clinical nurses. The current study revealed no significant differences in job stress (p ≥ 0.05) related to the rest of the demographic variables. While Shdaifat et al., (2023) found a strong relation between the level of job stress and emotional impact of the nurses, which are mostly related to females more than males, they reported a low level of stress, where higher levels of empathy fulfilment are being associated with reduced stress on the job.
Another study found relation between the stress level and workplace (Kabir & Razia, 2020). The medicine and emergency room nurses showed more occupational stress than nurses in different departments. In addition, a study by ( Yıldırım et al., 2017), examined the relationship between job experience and stress levels, showing that new nurses were more stressed. These data demonstrate the complex relationship between demographics and clinical nurses' occupational stress. A study explored the relationship between job stress and demographic data among nurses in clinical areas, where the researcher found a significant correlation between age and job stress levels among nurses, with younger nurses reporting higher levels of stress (Bai & Ravindran, 2019).
Job stress is viewed in this research as a systemic problem that affects patient safety, staff retention, and overall healthcare quality, as well as an individual burden for nurses. From this vantage point, it is critical to comprehend and alleviate occupational stress in order to provide a nurturing workplace that encourages nurses to be healthy, boosts their clinical performance, and guarantees the best possible results for patients.
The primary limitation is that nurses are relatively busy with their work. In addition, this study has several limitations; First, the cross-sectional design prevents causal inferences. Second, self-reported data may be subject to bias. Third, the sample was limited to reducing generalizability. Finally, unmeasured confounders (e.g., institutional policies) could influence stress levels. Future longitudinal or mixed-methods studies are recommended.
The findings of this study highlight those nurses working in Educational Karbala Hospital for Children in the Karbala city in the Holy of Karbala city, experience moderate levels of job stress without in relation to their demographics data. This indicates that while their stress levels are not critically high, they are still significant enough to potentially impact their well-being, job satisfaction, and quality of patient care. Several factors likely contribute to this stress, including the emotional demands of caring for sick children, high workloads, long shifts, and the pressure to maintain precision in a sensitive healthcare environment. Addressing these stressors is essential to ensure nurses’ mental and physical health, reduce burnout, and improve retention rates in paediatric nursing. This study found that nurses working in paediatric hospitals in Iraq experience moderate levels of job stress, suggesting a need for targeted interventions to improve their well- being and work conditions.
However, to gain a deeper understanding of job stress in this setting, future research should expand in several key directions. Multi-center investigations across different hospitals in Iraq would provide a more representative and diverse sample, reduce regional biases and offer broader insights. Additionally, including other healthcare professionals such as physicians, therapists, and technicians who work with paediatric patients would allow for a comparative analysis of stress levels across roles, identifying unique challenges faced by different team members. In addition, analysis of stressors, such as the impact of conflict and security issues, by looking into how current hostilities and safety concerns in Iraq impact paediatric nurses' job stress. Furthermore, examine how Iraqi cultural and social characteristics affect paediatric nurses' job stress. By broadening the scope of research in these areas, healthcare policymakers and hospital administrators can develop more effective, evidence-based interventions to support paediatric nurses and other medical staff. Addressing job stress not only enhances the well-being of healthcare workers but also improves patient care quality, ensuring a more resilient and sustainable healthcare system in Iraq.
The study results recommend the following measures to alleviate clinical paediatric nurses' stress on the job by the following points: establishing programs to manage stress should be implemented by hospitals; these programs should include mindfulness training, relaxation methods, and professional counselling services that are specifically designed for paediatric nurses. In addition, reducing workload and preventing burnout requires adequate nurse-to-patient ratios. Besides providing emotional and psychological assistance, including peer groups, debriefing sessions following critical incidents, and access to psychologists to assist nurses in managing the emotional challenges related to paediatric care. Furthermore, encouraging the equilibrium between professional responsibilities and personal well-being.
The authors declare that they have no competing interests.
The authors extend deepest gratitude to the paediatric nurses for their participation in this study, as their contributions were crucial for the successful completion of the work. Additionally, this communication is specifically directed to the managers of the Educational Karbala Hospital for Children in Karbala City, Iraq with appreciation conveyed to each individual among them.
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