Premenstrual Syndrome's Impact on Work-Related Quality of Life Among Jordanian Nurses.

Premenstrual syndrome (PMS) is a common clinical condition that occurs in most women during their reproductive years. [ 1 ]. The American College of Obstetricians and Gynecologists (ACOG) defines it as "a clinical condition characterized by the cyclic presence of physical and emotional symptoms unrelated to any organic disease that appear during the 5 days before menses in each of the three prior menstrual cycles and disappear within 4 days of the onset of menses without recurrence until at least cycle day 13" [ 2 ]. A key aspect of PMS is that the timing and intensity of the symptoms may be severe enough to interfere with regular daily activities. [ 3 ]. According to epidemiological studies, up to 80% of women can experience a variety of irritating PMS symptoms [ 1 ]. Moreover, there are more than 200 related symptoms of PMS [ 3 ] that vary from psychological to behavioral to physical, including headache, mastalgia, bloating, backache, mood changes, anxiety, anger, irritability, lack of interest, change in sleep pattern, change in appetite, and several more symptoms [ 1 , 4 ]. PMS is responsible for causing deterioration in health from physical to psychosocial aspects [ 4 ]; it can affect women themselves, their families, and their societies [ 5 ]. Furthermore, it has an effect on the nation’s development through high levels of psychological instability and a reduction in women’s daily achievements [ 6 ]. In aggregate, PMS can engender challenges spanning approximately 3,000 days throughout a woman's reproductive lifespan [ 5 ]. Furthermore, PMS-related somatic and mood symptoms may be associated with a decrease in the quality of life of affected women [ 7 ]. PMS can have a negative impact on physical activities and social life, as well as interfere with personal relationships and work performance, lowering the overall quality of life [ 8 ]. Many studies have found that moderate-to-severe PMS symptoms can have a negative impact on women's work performance through increased absence and lower productivity, resulting in a decrease in women's quality of life [ 3 ]. Previous research defined work-related quality of life for working women as an employee's perception of physical and mental aspects of their working circumstances and factors related to the work environment [ 9 ]. Nurses are known to have a high workload and a poor working environment, with regular night shifts [ 10 ]. The environment also offers inadequate physical security due to regular contact with people’s diseases and needs and sustained interaction with colleagues and patients’ families [ 10 ]. Furthermore, their clinical duties are often critical. Hard and demanding work, occupational hazards, and a sense of job satisfaction all have an impact on their lives. Consequently, nurses are more susceptible to PMS [ 9 ]. Being present at work while sick is referred to as "sickness presenteeism," which can affect health and work productivity [ 11 ]. Sickness presenteeism is becoming a worldwide occupational health challenge in all occupations [ 11 ]. The severity of PMS was found to have a strong relationship with presenteeism [ 5 ]. The purpose of this study is to evaluate the impact of PMS on work-related quality of life among Jordanian nurses. By analyzing the effects of PMS on nurses' quality of life, this study hopes to open up conversations about how best to manage PMS in the workplace. This could potentially lead to better working conditions, improved work-life balance, and greater recognition of the physical and mental strain that PMS can cause. Despite the critical importance of nurses’ work and the impact their quality of life has on their patients, very few studies on PMS and work-related quality of life among nurses have been conducted. This study could contribute to a better understanding of PMS symptoms and highlight the negative impact of PMS on the quality of life. It may help raise nurses’ awareness of the importance of treating symptoms and thus avoiding negative consequences. It may influence policy decisions, bringing the working environment in health facilities more in line with the health needs of female nurses.

This study had 210 participants. Their mean age was 34.88 years (SD = 5.20), they were mostly married (86.2%), and 65.2% lived in a city. In terms of job specifications, the majority of participants (n = 118, 56.2%) were registered nurses with bachelor's degrees (n = 115, 54.8%), worked 41.07 (SD = 4.94) hours per week on average, and 59% worked night shifts. Also, 11.4% used combined oral contraceptive pills (COCP), 7.6% smoked cigarettes, and 18.6% smoked waterpipes. Table 1 contains a detailed description of the participants' characteristics. Anger and irritability were the most commonly reported effective symptoms of PMS, followed by somatic symptoms such as muscle and joint pain. It demonstrated that PMS had a significant impact on nurses' family relationships and social activities. COCP, combined oral contraceptive pills; DM, diabetes mellitus; HTN, hypertension; SD, standard deviation; BMI, body mass index The majority of participants (61%) began menstruating between 12 and 14 years of age with a regular cycle (77.1%) and a medium flow (n = 144, 68.6%). Almost half (47.6%) reported a family history of PMS. As shown in Table 2 , 60.5% of women had experienced PMS. The overall WRQoL mean score was 67.47 (SD = 15.20). This study discovered a significant association of PMS with age, night shift work, COCP use, smoking, dysmenorrhea, and family history, as shown in Tables 3 - 5 . PMS, premenstrual syndrome The chi-square test was used. *Statistical significance was achieved at p < 0.05. COCP, combined oral contraceptive pills; DM, diabetes mellitus; HTN, hypertension; PMS, premenstrual syndrome The independent sample t-test was used. *Statistical significance was achieved at p < 0.05. PMS, premenstrual syndrome; SD, standard deviation the chi-square test was used. *Statistical significance was achieved at p < 0.05. PMS, premenstrual syndrome The WRQoL scores of participants differed statistically in four of the six WRQoL subscales: job and career satisfaction, control at work, home-work interface, and stress at work. There was a significant difference in mean total WRQoL score between the two groups, with nurses with PMS having a lower mean total WRQoL score (mean = 65.47, SD = 15.38) than nurses without PMS (mean = 70.54, SD = 14.47), as shown in Table 6 . The independent sample t-test was used. *Statistical significance was achieved at p < 0.05. PMS, premenstrual syndrome; SD, standard deviation; WRQoL, Work-Related Quality of Life scale Using the backward selection method, the regression model identified job and career satisfaction and workplace stress as significant predictors of PMS after controlling for the effects of other variables (age, use of COCP, family history, and dysmenorrhea). Those who were more satisfied with their jobs and careers were less likely to have PMS (AOR = 0.92, p = 0.026, 95% CI = 0.85, 0.99), while those who were more stressed at work were more likely to have PMS (AOR = 1.2, p = 0.036, 95% CI = 1.01, 1.42). After controlling for the effect of other variables in the model, the model revealed that one year of age increase reduces the risk of PMS by 0.90 (p = 0.002, 95% CI = 0.84, 0.96). Moreover, nurses who used COCP were 5.18 (p = 0.018, 95% CI = 1.33, 20.17) times more likely to have PMS than nurses who did not. Moreover, having a first-degree relative with PMS increases the risk of PMS by 2.52 times (p = 0.012, 95% CI = 1.23, 5.18). In addition, severe dysmenorrhea was associated with an 11.78-fold increase in the risk of PMS (p = 0.002, 95% CI = 2.48, 56.02), as shown in Table 7 . *Statistical significance was achieved at p < 0.05. AOR, adjusted odds ratio; CI, confidence interval; COCP, combined oral contraceptive pills

In this study, 60.5% of nurses reported having PMS. A study of Turkish nurses reported that 38.1% of them suffered from PMS [ 9 ]. PMS prevalence is associated with a variety of factors, including sample size, participant characteristics, and differences in culture. Differences in diagnostic tools, as well as its diagnoses, have quite a broad range of definitions and cut points. [ 9 , 15 ]. There was no significant relationship between PMS and job title in terms of job history. This is because all staff, including registered nurses, midwives, assistants, and practical nurses, are assigned an equal workload. The educational level of the participants was unimportant because they were all educated in nursing colleges at various levels and were assumed to be aware of the PMS condition. A study of working women in Thailand, on the other hand, found that those with higher education had more PMS than those with lower education. In contrast to our study, half of the participants had only completed primary or secondary school [ 16 ]. Furthermore, experience duration was found to be significantly related to PMS, with a high prevalence in those with less than 10 years of experience. This finding is consistent with the age results, which show that PMS is more prevalent in younger nurses. Additionally, working hours had no effect on the presence of PMS, whereas night shifts did. These findings show that despite working the same number of hours each week, those who worked night shifts had more PMS. These findings are consistent with the findings of a study that investigated the relationship between sleep and PMS and discovered that women with PMS have a higher rate of poor-quality sleep [ 17 ]. Furthermore, a Korean study found that sleep time variability and poor sleep quality exacerbated nurses' PMS symptoms [ 18 ]. Nurses' sleep quality deteriorates as a result of working night shifts, increasing the risk of PMS. PMS detrimentally affects an individual's quality of life. It has been shown to have an impact on all aspects of a woman's life, including daily activity, social life, study, and work productivity [ 3 , 8 , 19 ]. Our findings back up what others have discovered. In nurses suffering from PMS, the WRQoL score was significantly lower. PMS has a significant impact on working women [ 5 ]. Furthermore, because of their difficult working conditions, female nurses are more susceptible to PMS [ 9 ]. Because it is an indicator of job satisfaction, nurses' work ability is an important aspect of the quality of their work life. Work ability has been shown to be significantly related to WRQoL score, implying that tracking WRQoL and nurses' work ability would assist hospitals in determining their status and taking steps to improve working conditions [ 20 ]. As a result, nurses suffering from PMS experience a wide range of symptoms that can impair their ability to work. In our study, we discovered that working the night shift increases the risk of developing PMS in nurses, which can lead to a decrease in WRQoL. A study found that nurses who did not work night shifts had a significantly higher quality of work life [ 21 ]; thus, night shifts, PMS, and WRQoL form a vicious circle. New regulations are required to improve the quality of life for female nurses at work. Reducing the number of night shifts, for example, can help female nurses with PMS have a better working experience. Control at work and stress at work were found to be significantly associated with PMS, and stress at work was found to be a predictor of it in the logistic regression. PMS is a sensitive subject for women. According to one study, it is difficult to disclose the reason for needing rest due to PMS symptoms, and many managers did not believe that PMS symptoms were a valid reason for taking time off from work [ 5 ]. Furthermore, having a male manager may heighten the embarrassment of reporting PMS as a reason for sick leave. Even if the manager was female but did not have PMS, nurses may feel unsupported [ 5 ]. All of these factors can lead to nurses feeling out of control at work and increasing their stress levels, causing PMS symptoms to exacerbate the problem. Furthermore, nurses reported that PMS has an impact on their relationships with their families as well as their social activities. This is consistent with a significant reduction in the home-work interface scale in PMS nurses. When nurses fail to balance work and home responsibilities, their ability to get the most out of either domain is jeopardized. Job and career satisfaction were also significantly associated with PMS. Logistic regression discovered an inverse relationship between them. It is possible to conclude that hospitals' inability to achieve job satisfaction for female nurses with PMS is due to their having to work long hours, meeting unforeseen work demands, a lack of manpower, and, more specifically, their job dissatisfaction [ 14 ]. Our findings should be considered by healthcare executives who are responsible for improving their employees' work-related quality of life. Female nurses may be subject to additional regulations. Measures are needed, for example, to reduce sleep time variability and improve sleep quality, which can reduce workplace stress. Listening to nurses to determine their needs and involving them in decision-making can also increase a sense of control at work. Reducing restrictions on female nurses' sick leave and staff shortages can enhance nurses' satisfaction. To achieve work-life balance and focus on increasing that balance qualitatively, colleagues and managers must consider each nurse's life circumstances individually and create a supportive environment in which nurses can strive for a better work-life balance. This would allow nurses to sustain their desired level of productivity while also increasing their satisfaction at work and at home. According to the current study, PMS is quite common among Jordanian nurses, with a negative impact on their work-related quality of life. The most commonly reported effective PMS symptoms were anger and irritability, followed by muscle and joint pain. It was discovered that PMS had a significant impact on nurses' family relationships and social activities. Furthermore, various demographic and menstrual characteristics were discovered to be significantly associated with PMS. Logistic regression models discovered that increasing age, family history, using COCP, and having severe dysmenorrhea are all risk factors for PMS. Furthermore, it was discovered that workplace stress has a direct relationship with PMS, whereas job and career satisfaction have an inverse relationship with PMS. Limitations There are several limitations of this study. We are cognizant of the possibility of self-report bias since the information used in this study was based on participant self-reports of their symptoms (under- or over-reporting of PMS symptoms). The results also cannot be applied to all industries because different work circumstances may exist that interfere with work-related quality of life because the study was only conducted in the public sector.

Overall, nurses with PMS are dissatisfied with their career opportunities, face excessive pressure at work, experience increased stress at work, have a work-life balance, are less involved in decisions that affect their lives, and have little sense of control at work. As a result, the work-related quality of life decreases. We recommend increasing nurses' awareness of the disease, its symptoms, and effects on WRQoL. In order to take appropriate action, the study should be widened to encompass all female health care workers in both the public and private sectors to identify the differences. Policymakers should also be educated about the disease in order to persuade them to consider enacting or passing new legislation.

Design, sample, and settings Data were collected using a cross-sectional design from a convenience sample of 210 nurses working in the Jordan Ministry of Health hospitals (Princess Basmah Teaching Hospital, Princess Bade'a Teaching Hospital, and Princess Rahma Teaching Hospital). Female nurses between the ages of 18 and 45 years were our inclusion criteria. A diagnosis of depression or another mental illness, a diagnosis of a gynecological disease such as endometriosis, or pregnancy were all exclusion criteria. Instruments The data were collected from participants using a self-reported questionnaire (see Appendix) on Google Forms. It consists of the following three sections. Demographic Factors and Menstrual Characteristics This section included the sociodemographic and menstrual characteristics of the participants. Lifestyle factors were included and developed in accordance with existing literature [ 12 ], with some modifications tailored to the culture of the selected population. Premenstrual Symptoms Screening Tool The premenstrual symptoms screening tool (PSST) was used, which reflects and "converts" categorical Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) standards into a ranking scale with levels of intensity [ 13 ]. The instrument consists of 14 PMS symptoms with a rank of four levels: not at all, mild, moderate, or severe. In addition, five other items were added regarding interference in daily life activities due to symptoms (work efficiency or productivity, relationships with co-workers, relationships with family, social life activities, and/or home responsibilities). The following standards should be found for a diagnosis of PMS [ 13 ]: no less than one of the first four symptoms should be moderate to severe, no less than four symptoms must be moderate to severe, and no less than one of the standards about daily life function impairment should be moderate to severe. The reliability of the tool in our study was tested, and Cronbach’s alpha coefficient was 0.95. Work-Related Quality of Life Scale This tool was used to measure the work-related quality of life among Jordanian nurses. It includes 24 items on a 5-point Likert scale (from 1 = "strongly agree" to 5 = "strongly disagree") and six subscales: General Well-Being (GWB), Home-Work Interface (HWI), Job Career Satisfaction (JCS), Control at Work (CAW), Working Conditions (WCS), and Stress at Work (SAW). Each subscale score is determined by calculating the average of the item scores contributing to that factor, with the scores reversed for the three negatively phrased items (questions 7, 9, and 19). The 24th item is not used in the calculation as it is used to evaluate the reliability and validity of the scale. The overall Work-Related Quality of Life Scale (WRQoL) score is determined by calculating the sum of the six subscale scores; as the scores increase, the work-related quality of life also increases [ 14 ]. The reliability of the tool in our study was tested, and Cronbach’s alpha coefficient for the overall scale was 0.91. To ensure accuracy and validity, all questionnaire sections have been translated into Arabic and validated by professionals in public health. Informed consent and ethical approval A consent form was obtained from each nurse who met the eligibility criteria. The informed consent has information explaining the study purpose, procedure, and participant’s rights. The nurses were assured that their participation was voluntary and that they could withdraw at any time without any explanation. Also, the nurses were assured that their responses would be kept confidential and not shared with anyone, and only the researcher could access the data. Ethical approval was obtained from the Jordan Ministry of Health (approval number: 18687). Statistical analysis Statistical Package for Social Sciences (SPSS) Version 25 (IBM Corp., Armonk, NY) was used for data entry, cleaning, and analysis. The mean and standard deviation were used to describe the continuous variables, and frequencies and percentages were used for the categorical variables. Participants were divided into two groups according to the presence or absence of PMS, and then demographics, menstrual history, and WRQoL scores were compared using the chi-square test and t-tests. Multivariable logistic regression was used to assess the potential relationship between the study variables and the PMS variable. A p-value of 0.05 or less was considered statistically significant. Adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were presented.