The cost of caring: understanding occupational stress among nurses at Mulago National Referral Hospital

Background: Occupational stress is prevalent among nurses, particularly in resource-constrained settings, where high patient volumes, limited institutional support, and societal pressures exacerbate strain. In Uganda, nurses at tertiary referral hospitals face compounded challenges, yet empirical evidence on multilevel determinants of stress is limited. This study applied the Job Demands-Resources-Support (JDRS) framework to examine health system, patient-related, and community-level factors influencing occupational stress among nurses at Mulago National Referral Hospital (MNRH). Methods: A facility-based cross-sectional study was conducted from April to June 2024, enrolling 231 nurses through availability sampling. Occupational stress was measured using a self-reported binary indicator, and explanatory variables captured job demands, control, and support per the Job Demand-Control-Support (JDCS) framework. Descriptive statistics summarized variables, while bivariate and domain-specific multivariable logistic regression analyses were used to examine adjusted associations with occupational stress within health system, patient-related, and community-level domains. Results: Occupational stress prevalence was 64.5%. In domain-specific multivariable analyses, caregiver-related challenges were associated with higher odds of stress (aOR = 1.3, 95% CI: 1.02-1.57), while participation in continuous professional development-based programs (aOR = 0.3, 95% CI: 0.12-0.98) and lack of hospital accommodation (aOR = 0.2, 95% CI: 0.04-0.80) were associated with lower odds. Counterintuitive inverse associations were also observed for inadequate staffing and exposure to aggressive patient behavior, likely reflecting adaptation, selection effects, or residual confounding. Gender-related stressors were similarly inversely associated with stress (aOR = 0.7, 95% CI: 0.52-0.88). Conclusion: Nurses at MNRH experience high occupational stress driven by complex interactions of job demands, limited resources, and societal pressures. Effective stress mitigation requires integrated interventions addressing structural capacity, professional development, and social valuation of nursing. Future research should employ longitudinal and mixed-methods designs to disentangle the dynamics of occupational stress in high-demand, resource-limited environments.