Chapter Two:

REVIEW

20

CHAPTER TWO: REVIEW

The professional nurse is concerned with helping people get well and keep well,

and since many factors contribute to the well-being of the individual, the activities of

nurses cover a wide range. A nurse may give bedside care to the sick or emergency care

after accident or disaster. She or he may be a staff member or a director of a hospital

nursing service, working in one of the various clinical specialities such as surgery,

psychiatry, tuberculosis, paediatrics. She may participate or assist in nursing, medical or

related research projects. She may be a staff nurse, or a director or a consultant in a

public health or industrial nursing service. She may teach health to individuals or groups

or direct a health education program where she will use public speaking, writing, and

preparation of exhibits. She may be an instructor or a director in a school of nursing or in

the nursing division of a college or university. She may be the expert nurse member of a

surgical operating team. These are some of the varied activities open to the professional

nurse today. Professional nursing is a well-developed aptitude for using scientific

knowledge and technical skills to answer the physical, psychological and emotional

health needs of people (Laird, 1947).

According to 2001 population norms, there is still a shortage of 4,477 primary

healthcare centres and 2,337 community healthcare centres in India. India would require

1.75 million beds by 2025. Over 6800 more hospitals are needed in India to provide basic

health facilities to people in rural areas. The various hospitality brands have started

aggressive expansion in the country. Some of the companies that are planning to expand

include Anil Ambani’s Reliance Health, Hindujas, Sahara Group, Apollo Tyres and

Panacea Group. There is a shortage of 3,50,000 nurses in India, partly because many

qualified nurse’s leave for better prospects abroad. The private sector provides 60 per

cent of all outpatient care in India and as much as 40 per cent of all in-patient care. The

cause of low recruitment, migration, attrition and drop-outs due to poor working

conditions. The quality of nurse training is also poor affecting their ability to take

21

advantage of job opportunities within and outside the country. Poor training is due to the

non-adherence to teacher: student norms, inadequate infrastructure, insufficient budget,

inadequate clinical facilities and insufficient hands-on training for students. There are

about 74% private sector hospitals and 26% is government sector hospitals in India.

India’s medical tourism business is predicted to generate USD2.4 billion a year by 2012

and is growing at 30 per cent a year. The occupation ratio for private hospitals in Delhi is

between 70-90%. There are approximately 523 hospitals in Delhi out of which 380 are

private hospitals. The nurse supply is of ratio approximately only two out of one

thousand. Thus there is an urgent need to study the need for increasing the number and

their work efficiency, for which it is important for us to know the problems which they

face and motivate people to enter into nursing profession. The current study intends to

explore the various dimensions of career development, stress experienced in nursing

profession and their association with work family conflict for all the four groups

namely, male nurses working in private hospitals, female nurses working in private

hospitals, male nurses working in government hospital nurses and female nurses working

in government hospitals.(Doshi,2010)

Before one goes onto the details of analysis, a review previous work conducted in this

domains is presented in the sections below.

Career development in nursing profession

Reilly and Orsak (1991) conducted a study on career stage analysis of career and

organizational commitment in nursing. The purpose of this study was to identify and

compare the characteristics of commitment specifically appropriate for hospital nurses so

that they may be used as a basis for future research on fostering commitment in nurses.

Four dimensions of commitment specifically relevant to hospital nursing were identified:

career, affective-organizational, continuance, and normative. The Organizational

Commitment Questionnaire (OCQ) was used to measure career commitment and three

components of organizational commitment (affective-organizational, continuance, and

22

normative). The sample consisted of male and female staff nurses. The 22-item Maslach

Burnout Inventory (or MBI; Maslach & Jackson, 1981a,b) was also employed. The

assumption that: greater the burnout the more it will predict turnover. PANAS, the

positive and negative affect scale (Watson, Clark, & Tellegen, 1988; Watson,

Permebaker, & Folger, 1987) was used to assess affective state “during the past few

weeks”. In the results, age and professional tenure were strongly related (r = .73, p <

.00l). Regardless of how career stage was operationalized, continuance and normative

commitment significantly increased with career stage while career commitment remained

stable. The career stage analysis also suggests that nurses’ self-reported commitment to

the nursing profession is high and consistent, regardless of career stage. When career

stage was defined by professional tenure, career and affective-organizational commitment

remained stable and continuance and normative commitment increased. When career

stage was defined by age, career commitment was again stable, but affective-

organizational, continuance and normative commitment increased. Continuance

commitment was independent of both career and affective-organizational commitment

but was weakly related to normative commitment. Nurses in the last career stage reported

that their continuance commitment was significantly stronger than that of nurses in the

first career stage, regardless of career stage definition. Affect measures were most

strongly associated with career and affective-organizational commitment.

O’Reilly and Chatman (1986) report that the desire to affiliate with an

organization (i.e., affective-organizational commitment) and the congruence between

individual and organizational values (i.e., normative commitment) are positively

correlated with voluntary work-related behaviors and negatively associated with turnover.

Meyer, Paunonen, Gellatly, Goffin, and Jackson (1989) also provide data that suggest

that the affective component of organizational commitment correlates positively with

performance.

23

Few studies conducted brought to fore-front high attrition among the nursing

workforce (Murrells and Robinson, 1999; Turner and Ogle, 1999; Buerhaus et al., 2000).

An exploratory study conducted by Duffield and Franks(2002) study undertaken in New

South Wales, Australia which sought to identify the positions nurses go on to when they

leave nursing and the skills and experience they gained from nursing which they believe

enabled them to obtain employment outside the profession. In addition, the reasons why

they left nursing were also ascertained. A network sampling technique was used to recruit

17 participants. Of the 17 participants 15 were female and two male. Participants had a

mean of 10.98 years as a clinical nurse and 3.3 years in the non nursing workforce/study

environment. A tape-recorded semi-structured interview of approximately one hour was

conducted with each participant. Interviews were conducted until no new information

emerged and the remaining three interviews were used for validation. While many

participants were employed in health-related fields, others were in diverse areas such as

business, landscape coordination and market research, to name a few. The results

indicated that all participants reported positively on the range of skills, like effective

communication skills, knowledge of medical terminology, their ability to be professional,

that they were able to demonstrate an ability to learn quickly, organize and prioritize as

well as assess situations and work as a team they had acquired as a nurse and years of

experience in nursing profession. Reasons provided for leaving the nursing workforce

included reaching a ceiling in nursing or wishing to develop themselves in another

direction and attaining positions outside the nursing workforce like communication,

management, expert advisor, professional, intellectual and utility. Respondents had also

undertaken a wide range of additional qualifications. Similar findings were made by

Jones (1996) in the US who suggested that turnover is likely to be higher amongst better

educated nurses simply because of the additional opportunities incidental from on the job

trainings and education. Nursing students are using their training as a foundation course

for other careers (Williams, 1997), although Kipping and Hickey’s (1996) study found

some nurses who wanted a change in direction did so through obtaining another nursing

qualification, in their case in psychiatric nursing. Another study reported that registered

24

nurses saw their work or their position as a ‘stepping stone’ to other careers either within

or outside of nursing. In common with others outside the nursing workforce, they

recognized the need to be multi-skilled and saw their specialization as a way of achieving

this (Turner and Ogle, 1999).

Nursing shortage and turnover has been reported in Australia, USA and Canada

(Jones, 1996; O’Brien-Pallas et al., 2001). There are several reasons for mobility in

nursing workforce, one is that nursing is predominantly female profession traditionally

constructed around the careers of single women (Robinson, 1993). Several studies have

pointed to the differences in career paths of men and women working in health oriented

professions (Lambert et al., 1996; Marsland et al., 1996; Davidson et al., 1998). Women

for example, tend to interrupt their careers to have children and on their return to the

workforce, are likely to take on lower grade and/or part time jobs, achieving less in terms

of career attainment (Robinson, 1993; Marsland et al., 1996). Other reasons for increased

mobility in nurses could be that they are influenced by the general workforce such as the

increased geographical mobility of employees, organizational change and restructuring,

job insecurity and the trend towards temporary and part time employment.

The research literature indicates that nurses leave nursing positions for many

reasons which can be grouped into three distinct areas (Duffield et al., 1999) Family

commitments and or personal circumstances (Battersby et al., 1990; Bell et al., 1997)

professional reasons and organisational factors (Duffield. C, Franks. H., 2001). The

decision to leave nursing may not necessarily occur because of dissatisfaction but instead,

as a consequence of positive forces such as being actively recruited by another employer,

wishing to avail oneself of a range of opportunities, changed personal circumstances, or

to facilitate professional development. Studies also report that nurses retain their nursing

registration despite no longer working in nursing (NSW Health,2000). Some nurses

indicated that they retained their registration in case they needed to return to nursing

work at some point in the future. Reasons nurses gave for entering into this profession fell

25

into four main themes: vocational, professional, academic and personal (Tang et al.,

1999).

The vocational decisions of nursing students have always been a concern for

nursing educators and administrators. Study done by Lai, Peng and Chang(2005) was

designed to investigate the factors associated with career choices in Taiwan’s nursing

students. The convenience sample included all fourth-year nursing students of a college

in eastern Taiwan. A validated and reliable self-administered questionnaire developed by

the investigators was used in the study. The sample population consisted of 231 fourth-

year nursing students. Notably, 65.4% reported that they would not choose nursing as a

career after graduation. Significant variables associated with this career decision were

clinical ability, degree of stress during clinical practice and perceived support from staff

nurses. Students with greater clinical ability tended to have a stronger intention to

become nurses. Clinical practice is inherently stressful for students due to the greater

responsibility and the steep learning required. A curvilinear relationship is determined

between stress and learning, therefore, the high stress levels characteristic of initial

exposure to clinical practice may negatively influence student learning and achievement.

Factors that may have influenced the results of this study are the non-probability sample

and its cross-sectional design. Researchers studying the perceptions and sources of stress

among Baccalaureate nursing students found high levels of anxiety were experienced by

nursing students (Deary et al., 2003). Similar results have been reported by Shelton

(2003), who also confirms that student anxiety is exacerbated in the clinical setting by the

perception that fellow staff members are not supportive. These results suggest that both

educators and administrators need to reconsider the way nursing students are educated,

and indicate that strategies must be developed to enhance students’ motivation to select

nursing as a career.

Receiving high pay and promotions also do not necessarily make people feel

proud or successful (Schein, 1978). In fact, they can cause work and personal alienation

26

(Burke, 1999), as well as depressive reactions. Bandura (1997) described how newly

appointed managers who do not delegate adequately can soon become overwhelmed and

depressed, potentially leading to both subjective and objective career failure. Such

evidence that subjective success is not necessarily a function of objective attainment.

Job satisfaction is the most salient aspect of subjective career success (Boudreau,

Boswell, & Judge, 2001). On the other hand, Wilensky (1960) described how graduate

students defer gratification by working long hours for little direct compensation, in the

hope of being well-rewarded following graduation. Finally, high job satisfaction does not

necessarily lead to subjective career success when it exacts a high toll in terms of health,

family relationships, or other salient personal values. Subjective career success thus

includes sense of identity (Law, Meijers, & Wijers, 2002), purpose (Cochran, 1990), and

work-life balance (Finegold & Mohrman, 2001). Career satisfaction is most often

assessed using the widely career satisfaction scale developed by Greenhaus et al. (1990).

Job satisfaction in staff nurses should be of great concern to any organization. Job

satisfaction is an important component of nurses' lives that can influence patient safety,

productivity and performance, quality of care, retention and turnover, commitment to the

organization and the profession. Al-Doski and Aziz(2010) conducted a study to find out

the extent to which nurses are satisfied with their jobs in public hospitals in Erbil- Iraq.

Job dissatisfaction over time can result in burnout and eventually turnover (Blegen 1993).

Job dissatisfaction resulting in burnout and turnover would exacerbate the current

shortages and result in serious understaffing of health care facilities. This understaffing

has the potential to have a negative impact on the delivery of patient care. A purposive

sample of (200), nurse were selected, out of which included male staff(75) and female

nurse(125), those who were in the position for at least 6 months. Interviews technique

was used as method to gather data about and factors influencing productivity from

different nursing units. Recruitment of nurses was done from four general Hospitals. Job

satisfaction was evaluated on several points: Profits, Job performance, intrinsic work

27

values, relationship, responsibility and communication. The result showed no significant

difference in: job satisfaction of male and female nurses, difference in job satisfaction

according to age, difference in job satisfaction according to social status. However there

were significant differences in job satisfaction according to level of education, difference

in job satisfaction according to years working.

A five-year follow-up study of stress among nurses in public and private hospitals

was conducted in Thailand. Results revealed that intrinsic job satisfaction was higher

than extrinsic satisfaction and nurses in private hospitals were more satisfied than nurses

in public hospitals. When job satisfaction was examined in terms of intrinsic factors, it

was found that nurses in both public and private hospitals became increasingly satisfied

with their social status and ability utilization after 5 years. Although nurses working in

public hospitals generally reported more stress than private hospitals, surprisingly nurses’

satisfaction with their job increased particularly in public hospitals, which may be

attributable to age, improvements in monetary compensation, and organizational support

(Tyson and Pongruengphant, 2004). Cavanagh and Coffin (1992) also reported that, out

of the sample collected from 221 nurses; a response rate of 80.5% in a public hospital

and 19.5% in a private hospital nurses; nurses reported factors related to intention to stay

were job satisfaction, kinship responsibilities, pay and opportunity. Lu, While and

Barriball, (2005) report that job satisfaction was a key determinant in the turnover

process. Yin and Yang (2002) report in their study, a meta-analysis found that salary and

fringe benefits were the strongest factors related to nursing turnover and job satisfaction.

In Taiwan, the health department implemented a series of measures that reduced turnover

rates from 27% to 13% in private hospitals and 17% to 8% in public hospitals. These

measures included more opportunities for advancement by in-service programs, better

monetary compensation and benefits, and organizational support (Tzeng, 2002).

Years of experience, higher professional titles, are also known to be predictors of

job satisfaction among nurses. Research evidence shows that nurses with more years of

28

experience, higher professional titles, and more opportunities to attend continuing

education programs were more likely to have a high level of job satisfaction than nurses

with fewer years of experience (Clark, 1997). In respect to marital status (54%) of them

were married, Results of staff nurses and unmarried nurses showed trends of more

dissatisfaction than the married and nurses of higher positions (Fletcher, 2001). Items

related to level of job satisfaction for staff nurses were low, the findings indicated that,

overall, nurses were dissatisfied with work, pay, and promotions. Nurses were most

dissatisfied with salary and lack of prospects for promotion. A study has shown that

females possess higher levels of job satisfaction compared to males (Clark, 1997;

Toscano & Ponterdolph, 1998). While another study, found that no conclusive evidence

with regard to the levels of satisfaction among men and women has been reported (Al-

Ajmi, 2006). This is may due to male and females having lower expectations at work due

to “the poorer position in the labor market that other professional have held. It shows

there are no relationship between job satisfaction according to social status. The findings

suggest that personal characteristics have important influences on nurses' job perceptions.

The findings show that job satisfaction has a significant direct negative effect on

emotional exhaustion, whereas emotional exhaustion has a direct positive effect on

depersonalization (Kanter, 1993). Significant differences between nurses satisfaction

concerning the level of education, this may due that educated nurses provide good

environment for her works.

Aiken et al. (2001) found job dissatisfaction among nurses was highest in the

United States (41%) followed by Scotland (38%), England (36%), Canada (33%) and

Germany (17%). Adams and Bond (2000) found that most nurses positively rated aspects

of ward services, facilities and layout. The highest correlations were found between job

satisfaction and cohesion of the ward nursing team, staff organization, the level of

professional practice achieved within the ward and collaboration with medical staff. Price

(2002) explored key areas of job satisfaction using the Mueller and McCloskey’s (1990)

Satisfaction Scale. It is a 5-point Likert scale (5=very satisfied, 1=very dissatisfied)

29

comprising 31 items on eight dimensions: extrinsic rewards, scheduling, balance of

family and work, co-workers, interaction opportunities, professional opportunities, praise

and recognition, control and responsibility. The results demonstrated that over half of the

respondents (58%) were generally satisfied with their job. They identified that highest

satisfaction was related to co-workers and extrinsic rewards (mean=3.8 and 3.5,

respectively) and that most dissatisfaction was with the amount of control and

responsibility they had and with professional opportunities. Nurses were most satisfied

with their nursing peers, the opportunity to work part-time, the hours they worked, the

opportunity to work day shifts, and the weekends off each month. Nurses were most

dissatisfied with their level of participation in organizational decision-making, pay,

control over work conditions and child care facilities.

The impact of job satisfaction upon nursing absenteeism, burnout and nurses’

intention to quit and turnover has been explored in a number of research studies. Lee et

al.’s (2003) South Korean study showed that the most frequently mentioned reasons for

nurses’ intending to leave their jobs were work overload, rotating shifts and conflict in

interpersonal relationships. A total of 24%, 15% and 35% of variance regarding

depersonalization, emotional exhaustion and personal accomplishment, respectively, was

explained by the individual characteristics, job stress and personal resources. It was

particularly noteworthy that nurses who experienced higher job stress showed lower

cognitive empathy and empowerment, and worked on night shifts at tertiary hospitals

were more likely to experience burnout. Gauci Borda and Norman (1997a) found a

significant positive relationship between job satisfaction and intent to stay and negative

relationships between job satisfaction and frequency of 1 day absence and short-term

absence (lasting 3 days or less) among Maltese nurses.

Gender differences have also been observed in the level of job satisfaction

experienced among nurses. a study have shown that female nurses possess higher levels

of job satisfaction compared to male nurses (Clark, 1997; Fletcher,2001). Most evidence

30

necessarily conflates the role of segregation per se and its role as a proxy for job

characteristics in relation to job satisfaction. Tsui et al. (1992) find that the job

satisfaction of male workers decreases with the proportion of females in their work

group, and Sloane and Williams (2000) found that the job satisfaction of UK women is

significantly lower in ‘male dominated workplaces’. Clark (1997) presents very similar

evidence also for the UK, finding that the gender satisfaction gap increases with the

extent of females in the workplace, a result that flows from the greater satisfaction of

women in more female dominated workplaces. Donohue and Heywood (2004) report for

the US, indicate that higher earnings add more to the job satisfaction of men than to that

of women. In addition, higher comparison earnings, the average earnings of otherwise

equal workers, reduce male job satisfaction more than female job satisfaction. Finally,

increased usual hours of work are often associated with lower job satisfaction of women

but not of men. Studies also conclude that men consider earnings and responsibility to be

more important then do women. On the other hand, they conclude that women consider

good co-workers, a good supervisor, and the significance of the task to be more important

than men do. (Konrad et. al., 2000)

While another study, found that no conclusive evidence with regard to the levels

of satisfaction among men and women has been reported an article analyses gender

differences in job satisfaction among full-time workers. The findings report that women

experience equal or greater job satisfaction than men in spite of objectively inferior jobs.

This is mainly due to few differences between men and women in the determinants of job

satisfaction when considering job characteristics, family responsibilities, and personal

expectations. (Hodson,1989).

Differences in the level of interpersonal abuse experienced, have also been

noticed among the male and female nurses and as well as in private and government

sector. A study reported by Clark (1997) reports that women in male dominated jobs have

higher expectations for satisfaction from work and so their expectations are not as easy

31

fulfilled. The result is that women in male dominated jobs are less satisfied than women

not in male dominated jobs. Also, other reasons may be as nurses working in private

sector start their work with lesser experience and qualifications, so being young they

often have to face criticism by staff and authority members regarding their work. They

are often bullied as well. There are studies that report interpersonal abuse among nurses

in government (that is public) hospitals as well. A research study reports out of sample of

234 nurses working in public hospitals, 45 nurses report lack of respect and recognition

from doctors and 25 nurses report lack of support. Nurses report that they frequently face

lack of recognition and support from higher authorities and doctors. Nurses complained

of being undervalued and being made to feel inferior as doctors issued orders and

appeared to question their abilities (Lane,2004). Another study reported by

Nabirye(2011) examined interpersonal abuse as part of occupational stress. The

occupational stress has been reported to affect job satisfaction and job performance

among nurses, thus compromising nursing care and placing patients' lives at risk. Study

findings demonstrated that there were significant differences in levels of occupational

stress, job satisfaction and job performance between the public and private not-for-profit

hospitals. Nurses in the public hospital reported higher levels of occupational stress and

lower levels of job satisfaction and performance. There were significant negative

relationships between occupational stress and job performance and between occupational

stress and job satisfaction. Nursing experience, type of hospital, and number of children

had a statistically significant relationship with occupational stress, job satisfaction and

job performance.

Lumby(1996) also found in her study of Australian nurses that doctors did not

provide support to nurses and that verbal abuse by some doctors was increasing. In a

study conducted on work place violence in health sector in south Africa done by

Steinman(2003), which reports that nursing sector, is at great risk of workplace violence.

The number of cases in the private health care sector amounted to 1578 and the public

health care sector amounted to 23; 1601 in total. Poor interpersonal relationships with

32

doctors and other superiors - 61,6%. Low "team-spirit" between nurses, superiors and

medical staff 56,6%. Unreasonable behaviour of superiors (e.g. being rude, favouritism)

36,6%. There is a significant higher incidence of verbal abuse, bullying/mobbing, and

racial harassment in the public health care settings than in the private health care settings.

Thus there are mixed views on the levels of interpersonal abuse experienced by nurses in

private and government hospitals.

Research articles have also provided studies with differences in the experience by

male and female nurses, in geographical barriers; differences in experience of

geographical location as a barrier were observed among nurses working in both private

and government sector. A study conducted in selected public and private hospitals at

Ludhiana to find out the attrition of nurses, their expected destination and reasons for

leaving their own country. It was found that attrition was higher in private hospitals (

10.9 mean percent nurses/year) as compared to government hospitals (2.8 percent nurses

per year). In addition it was found that in private hospitals 47.5% nurses were intent to

leave for developing countries, while in government hospitals there were only 12.5%.

Majority of them were willing to leave because of better lucrative job opportunities, high

salaries, better quality of life and recognition of nursing profession (Sharma and Kamra,

2009).

Another study done by Courtney et al. (2007) conducted a research on profile of

nurse executives’ roles, career opportunities and professional development needs across

metropolitan, provincial, rural and remote settings in Queensland. A cross-sectional

survey was posted to all Directors / Assistant Directors of Nursing in the Queensland

Public Health with a response rate of 52.3% (n=147). Nurse executives in remote areas

were less satisfied with the quality of supervision and mentorship they received, and least

likely to participate in career enhancing activities. Metropolitan nursing executives

utilised more of the career enhancing opportunities provided by the Queensland Public

Sector than provincial, rural or remote nursing executives. Professional development

33

needs, although generally common to all groups, were more practice specific for those in

rural and remote areas. Many nurse executives begin their careers in rural or remote areas

where limited opportunities for career development may be detrimental to their future

development.

Gender differences in nursing profession

In terms of traditional gender stereotypes, male and female behaviors are often

rigidly codified and choices of male or female professional development are by no means

exempt from such expectations. In Europe, although men have been prominent in the

nursing profession during the middle ages and renaissance, the modern image of an ‘ideal

nurse’ is feminized. This is primarily because of the Nightingale system for training

nurses, as well as to wartime and economic factors (Halloran & Welton 1994). In other

words, since the time of Florence Nightingale, nursing has been stereotyped as a female-

dominated profession throughout the world (Thomas,1998). In the United States of

America (USA), the proportion of men who were Registered Nurses (RNs) decreased

from 5.5% in 1990 to 4.0% in 1996 (Williams 1995a, 1995b, Thomas 1998). A review of

the international literature suggests that male nurses’ experiences of studying in nursing

schools and their continued career development differ from those of female nurses; this

stems from implicit or explicit influences of gender roles. In some instances, inequalities

appear in specialty fields (e.g. obstetrics and gynaecology) and in society generally, and

these can create substantial pressures on professional male nurses (Williams 1995a,

Tseng 1997), to the point that their sexuality is questioned and they are categorized as

homosexual (Kelly et al. 1996). As a result, men throughout the world generally enter

‘suitable’ professional specializations such as emergency care, psychiatry, or surgery

(Okrainec 1994, Williams 1995a, 1995b, Kin et al. 1996). Despite the continued

existence of some gender stereotyping, increasing numbers of nursing leaders are

acknowledging male nurses’ contributions, because of their clinical competency and day-

34

to-day nursing shortages, particularly in Western societies (Halloran & Welton 1994,

Mackintosh 1997, Tseng 1997).

Yang et.al (2004) conducted a study on Professional career development of male

nurses. The aim of this paper is to report a study to: (a) explore Taiwanese male nurses’

motivations for becoming a nurse; (b) reveal their professional developmental

process in nursing; (c) understand the difficulties hindering their professional

development from both professional and gender aspects; and (d) identify the strategies

they use to cope with these difficulties. A a convenience sample of 15 male nurses (mean

age 30.8 years) with a Bachelor’s degree in Nursing Science was collected. Taiwanese

male nurses’ entrance into the nursing profession involved three phases: pre-study, study

and employment. Several factors were reported to have hindered Taiwanese male nurses

in developing their nursing careers after they became full-time RNs (a) excessive

curiosity about gender differences in professional roles by the public; (b) lack of

confidence in being a competent male nurse; and (c) lack of adequate support from

important people in their lives who had power to help in their career development. All

participants reported that, while in school or on the job as a male nurse, they felt bored by

the curiosity exhibited by others about their becoming a nurse. Some felt challenged by

patients and family members, and this led to frustration. They also lacked social support

where ten participants reported that they did not receive adequate support from

significant others, including their family members, friends and people who have power to

influence their career planning. Patients openly questioned their skill as a nurse, and even

requested that their care be entrusted to a female nurse. Colleagues questioned the

legitimacy and quality of their nursing care when performing urinary catheterization on a

woman or providing teachings about breast care or breastfeeding. As a result, participants

sometimes felt frustrated and worried that they might be judged inferior to their female

colleagues. Some began to question their decision to become a nurse. Participants

developed several strategies to manage the factors hindering their professional nursing

development: appreciating their value as a male nurse and learning from teachers and

35

nursing supervisors; changing their own mindset to appreciate others’ curiosity; taking

time to clarify others’ concerns about their professional roles; and winning support from

the people important to their personal and professional life, improving their professional

knowledge and skills to obtain higher levels of satisfaction and better opportunities for

promotion, thinking aggressively about job promotion.

Grossman and Northop (1993) in their study of 503 senior high school pupils

perceptions of nursing as a career reported that only 7% of pupils listed nursing as their

desired career, where as, a majority (74%) perceived nursing as a career that provided

opportunities to care for individuals, families and communities in time of need and help

them live healthy lives. Grossman and Northop also found high school pupils views were

influenced by gender, the students’ desired occupation, and opinion of parents, friends,

and guidance teachers. Stevens and Walker, (1993) used a descriptive design with 641

high school students and attempted to determine why nursing was not selected more

frequently as a career. The results showed that willingness to work with sick people,

desire to help people, to do important work, and to work with a variety of people were the

highest ratings for choosing nursing as a career. Dislike of dealing with death and nurses’

salaries were reported as the main reasons for choosing another career.

Factors that influence a person’s organizational commitment have also been

identified by researches. In particular, as Schein (1978) argues, one of the major

weaknesses of traditional employee and management development programs is the

assumption that people leave 'family and self' at home when they come to work, and that

home family/self issues are of no interest to or, indeed, any business of the organization.

The problems human beings face are divided in three basic categories: those that derive

from biological and social ageing processes, those that derive from family processes, and

those that derive from work. These factors influence a person’s organizational

commitment.

36

Career-family priorities vary because of family pressures, including the need for

geographic stability when children reach high school age. There are changes in

commitment towards the family have a negative influence on organizational commitment

(Hall, 1971, 1976). Surveys of service personnel often identify family stability factors or

similar issues as significant reasons for wanting to leave the service (Hall, 1981). The

family represents one of the potentially most important life roles: for many, it is the most

important. For example, a study of nursing school entrants (Davis, Olesen and Wittaker,

1966, cited in Morrow, 1983, p.495) found that 'nearly all' subjects valued home and

family as their first life priority, and that this tendency was still present at graduation

from the nursing school. Research on male life cycles (Levinson, Darrow, Klein,

Levinson and McKee, 1978) indicates that, married or not, men in their 20s will often

devote themselves to their career, broadening their commitments into family and perhaps

other roles in their 30s. Perhaps family involvement is a function of the nature of the

family situation (Mihal, Sorce and Comte, 1984) e.g. whether or not the spouse is

working full-time in what he or she sees as a 'career', or whether there are children and, if

so, their schooling stage. Thus the more a person gives work/ career priority over family,

the higher will be his or her organizational commitment. The implications of these results

for the services include the need to facilitate organizational commitment in the apparently

difficult career years just prior to qualifying for pension entitlements. Reducing the

frequency of job rotation, or at least the frequency of geographic relocation, would

reduce such work family conflict (but it would be a radical departure from current

practice). For younger officers, job redesign to stimulate job involvement would have a

pay-off in terms of higher organizational commitment.

Stress experienced in nursing profession

Stress is part of everyday life for health professionals such as nurses, physicians,

and hospital administrators since their main responsibility focuses upon providing help to

patients who are usually encountering life crises. Selye proposed a physiological

37

assessment that supports considering the association between stress and illness.

Conversely, Lazarus advocated a psychological view in which stress is “a particular

relationship between the person and the environment that is appraised by the person as

taxing or exceeding his or her resources and endangering his or her well-being.”

Personality traits also influence the stress equation because what may be overtaxing to

one person may be exhilarating to another (French,1972).

Stress has been regarded as an occupational hazard since the mid-1950s. In fact,

occupational stress has been cited as a significant health problem (Caplan and Pelletier,

1980, 1984). Work stress in nursing was first assessed in 1960 when Menzies, (1960)

identified four sources of anxiety among nurses: patient care, decision-making, taking

responsibility, and change. The nurse’s role has long been regarded as stress-filled based

upon the physical labour, human suffering, work hours, staffing, and interpersonal

relationships that are central to the work nurses do. Since the mid-1980s, however,

nurses’ work stress may be escalating due to the increasing use of technology, continuing

rises in health care costs and turbulence within the work environment (Jennings,2007).

In 1974, Freudenberger coined the term “burnout” to describe workers’ reactions

to the chronic stress common in occupations involving numerous direct interactions with

people. Burnout is typically conceptualized as a syndrome characterized by emotional

exhaustion, depersonalization, and reduced personal accomplishment (Masclach, 1982).

Simoni and Paterson (1997) reported that nurses who engaged in avoidance coping (e.g

ignoring the stressor, avoiding the stressor, leaving the stressor) manifested more signs of

burnout. The results reported by Tyler and Cushway (1992) on general hospital nurses in

England were also consistent with the present findings. They also found that avoidance

coping increased the severity of psychological distress whereas approach behavioral

coping was associated with less depressive symptoms as measured by GHQ-28.

38

Research evidence suggests stress experienced by male and female nurses

working in private and government hospitals. Stress due to conflict with physician is

experiences by nurses from both sectors. A study on nurse physician relations in private

hospital in turkey, by Demir and Kasapoglu (2008), who found that there were gender-

based conflicts among physicians and nurses, also there were conflicts due to the

personal, professional, economic and gender-based inequalities of society. French et al.

(2000) identified the following workplace stressors among nurses were conflict with

physicians, inadequate preparation, problems with peers, problems with supervisor,

discrimination, workload, uncertainty concerning treatment, dealing with death and dying

patients, and patients and their families. Findings have suggested that registered nurses

working in public hospitals have been exposed to stressful situations in their daily work.

The major stressors they experienced from most stressful to least stressful were patient

treatment, dealing with patients and their families, work overload, inadequate emotional

preparation, conflict with doctors, problems relating to supervisors, death and dying,

conflicts relating to peers, and discrimination (Damit, 2007).

Tyson and Pongruengphant (2003) did a five-year follow-up study of stress

among nurses in public and private hospitals in Thailand. A longitudinal perspective on

14 hospitals in Thailand examined sources of occupational stress, coping strategies, and

job satisfaction. A sample of 200 female professional nurses was compared to 147 nurses

sampled from the same hospital wards after 5 years. The data was collected from three

public hospitals and four private hospitals. The results indicated that that nurses working

in public hospitals reported more stress than nurses in private hospitals, but after 5 years

there were improvements in public hospitals. A major source of stress among nurses

working in public hospitals was management’s misunderstanding of the needs of the

hospital ward, lack of support from senior staff. Fluctuations in workload also improved

among nurses working in public hospitals but became considerably more stressful in

private hospitals moving after 5 years. Stress associated with deciding priorities increased

in public hospitals and substantially in private hospitals. In public hospitals, stress due to

39

involvement with life and death situations increased and in private hospitals increased

afterwards. Finally, a major change in stress after 5 years was from supervisors requiring

nurses to perform doctor’s functions that increased from 1.66 to 2.77 in public hospitals

and from 1.77 to 2.46 in private hospitals (p<0:001). Although levels of stress were

generally higher, surprisingly, job satisfaction among nurses increased significantly after

5 year. Nurses’ satisfaction increased from 0.45 to 0.63 in public hospitals and in private

hospitals from 0.59 to 0.79 afterwards (p<0:001). Nurses in private hospitals were more

satisfied than nurses in public hospitals. Although nurses working in public hospitals

generally reported more stress than private hospitals, surprisingly nurses’ satisfaction

with their job increased particularly in public hospitals, which may be attributable to age,

improvements in monetary compensation, and organizational support.

Lack of support is another source of stress experienced by nurses. A study by

Alnems. RN (2005) examined the main job related stressors affect the staff nurses and to

examine the relationship between job related stress and job satisfaction. Of the 73 nurses

who responded, 42 nurses (57.5%) were male and 31 nurses (42.5 %) were female nurses.

The nursing sample included youthful nurses (the majority is younger than 25 years old)

who were from three private hospitals in Amman Private Hospitals. Instruments used in

the study were expanded nursing stress scale and Job Satisfaction Survey. Results

showed that the lack of enough staff to adequately cover the unit is the most stressful

event perceived by the staff nurses as indicated by the Mean (N= 73, Mean= 3.03). The

experiencing of discrimination on the basis of sex and break down of the computer is the

least stressful events perceived by the staff nurses as indicated in the Mean (N= 73,

Mean= 1.60). Lack of staff support perceived by the staff nurses is among the less

stressful subscales as indicated by the Mean 2.2603, standard deviation of .6787. The

total job satisfaction for the staff nurses was (N= 73, Mean= 1.85); and this was an

indication of dissatisfaction according to the study. There is a significant negative

relationship between the perceived job related stress and the job satisfaction of the staff

nurses in private hospital in Amman. The lack of supportive relationship or poor

40

relationship with peers, colleagues and the superiors are also potential sources of stress,

leading to low trust and low interest in problem solving (Kahn and Byosiere, 1995; Baron

and Greenberg, 1990: Schultz and Schultz, 1994).

Another source of stress among nurses is conflict with other nurses and

supervisors. Healy and McKay (1999), who conducted research on registered nurses in

Victorian and regional institutions, and found that nurses ranked workload, interpersonal

conflict with other nurses, uncertainty with treatment, dealing with medical emergencies,

lack of support were some of the highly rated stressors in nursing profession. Another

research done on conflicts among Iranian hospital nurses by Nayeri and Negarandeh

(2009), reports that participants confirmed psychological stress among nurses and

supervisors, arising from misunderstanding and emphasized the importance of mutual

understanding between nurses and other staff. This functional conflict can turn into

emotional conflict if not managed properly, which in turn disrupts collaborative efforts;

leads to unprofessional behaviours; results in under commitment to the organization;

increases psychological stress (O'Driscoll, Beehr, 2000) and emotional exhaustion;

results in mistreatment of patients; elevates anxiety and work resignation; and decreases

altruistic behaviours. Conflict with supervisors has been reported, which usually arose

from sources such as doctors' influence on decision making, unwarranted interference of

doctors and their inappropriate treatment of nurses. Relationships between staff nurses

and nurse managers are particularly important when examining stress and burnout

(Decker et.al. 1997; Fletcher et.al., 2001; Laschinger et.al.1999). Numeric ratings from a

survey of 1,780 RNs indicated that supervisor support and quality of supervision were

lowest for nurse managers(Fletcher, 2001). One study was conducted in the United

States(Lee,1996) and the other study in Canada Investigators for the Canadian study

examined burnout in a random sample of nurses in first-line (n = 202) and middle-

management (n = 84) positions (Lachinger, 2004). Nurses in both groups reported high

levels of emotional exhaustion and average job satisfaction. In the U.S. study, the

investigators explored burnout among nurses (N = 78) from rural and urban hospitals in a

41

south-eastern State who held positions in middle-management and higher (Lee,1996).

Almost half the respondents (49%) reported high levels of emotional exhaustion.

In Thailand, a lack of organizational support was the greatest source of stress

among public sector nurses particularly due to lack of involvement in planning and

decision making (Pongruengphant and Tyson, 1997). Nurses in Thai private hospitals

received higher salaries, more stable workloads, and organizational support than nurses

working in public hospitals. Moreover, dissatisfaction with extrinsic factors like

management decisions and monetary compensation were found to be strongly related to

nurses’ organizational stress (Tyson et al.,2002) and predicted depression, health risks,

and intention to quit (Tyler and Cushway, 1992; Tzeng,2002). Nurses working in the

public heath sector in Singapore were generally dissatisfied with their working conditions

and half of them had been thinking of quitting the profession (Boey, 1998). In Thailand,

public sector nurses working in hospitals were significantly more dissatisfied with

extrinsic factors such as salary and promotion than private hospital nurses

(Pongruengphant and Tyson, 1997). Thai nurses in private hospitals were found to be

more intrinsically satisfied with factors such as accomplishments, professionalism, and

opportunity to utilize their abilities, than nurses in public hospitals.

Workload is another very prominent source of stress reported by nurses. There

are many studies reported in relevance to stress experienced by nurses in nursing

profession. A study by Parahoo and Barr (1994) showed that heavy caseload, too much

administrative work, lack of resources, lack of support from staff were stressors, which

contributed to nurses and low job satisfaction. Another study conducted on community

health nurses (Stewart, 1993) found that stress associated with time pressure, dealing with

difficult or problem clients, uncertainty in the nursing role would lead to low job

satisfaction. Low job satisfaction is likely to lead to absenteeism (Rees and Cooper, 1992;

Petterson, 1994) and a high turnover rate (Somers,1995) which would further aggravate

the stress from staff shortages and work overload. The nurses and midwives association

42

(Nurses and Midwives Associaion, 2008) surveyed private hospital members to find out

their priorities for a new agreement. Pay parity with public hospital colleagues and high

workloads are the top issues for private hospital members. One third of nurses say their

workplace is understaffed most days. Sixty-one percent of nurses worked unpaid

overtime, with 25% doing between two and five hours per week and 4% more than six

hours. Another study by Khowaja, et. al. (2005) cite Thomas’(1997) report that work

stress in National health services (UK) had been aggravated by increased workloads,

nursing shortages, job insecurities and organizational changes. According to Khwaja

(2005), workload was one of the main causes of job dissatisfaction among nurses in

Pakistan. Several studies done abroad also report similar findings. Billingsley’s (1999)

cited in Lephalala.R.P. (2006) report about the UK, Canada and USA where there is

nursing shortages, where nursing vacancies are estimated to be about 20%. Reasons

mentioned for nursing shortage is poor working conditions and inadequate remuneration.

Nurses from both public and private hospitals report a similar pattern of stressful

experiences (Dewe, 1987; Hingley and Cooper, 1986). Nurses rated high workloads and

dealing with ‘death and dying’ as their major stressful events (Hipwell et al., 1989). In

Great Britain, nurses in public hospitals reported significantly higher levels of workload,

whereas in private hospitals conflicts with doctors and role ambiguity were more

frequently reported as sources of stress (Tyler and Cushway, 1992).

Gender differences have also been mentioned in research literature with regard to

level of stress experienced by male and female nurses. Male nurses often ascend the

hierarchy more quickly than female counterparts (Bradley, 1993). Men therefore tend to

monopolise positions of power and are rewarded for their difference from women in

terms of higher pay and other benefits (Williams, 1993). On the other hand, emotional

labour such as teaching, nursing and social work may call for special abilities that only

women are deemed to possess (Hochschild, 1983). The motivations and aspirations of

men in non-traditional occupations was the desire to work in a caring profession, which

was paramount. Male nurses were preferably given higher promotions easily than female

43

nurse. Thus male nurses became specialized nurses, thereby enjoyed positive relationship

with doctors than other female general nurses. General nursing (largely female) was

therefore seen to have a lower standing. Men had “masculine” characteristics that females

did not possess such as special skills requirements that were seen as essentially male (e.g.

coping under stress) and the nature of the job that was seen to embody ‘masculine’

qualities (e.g. excitement, challenge). Heikes (1992) study of nurses, explains some men

were expected to conform to a ‘muscle-man’ role and to take on physically demanding

jobs even when this lay outside their specific remit. This suggests that expectations by

women may precipitate men into more ‘masculine’ roles.

The complexity of work stress is further illustrated in studies that considered

gender effects. The prevalence of burnout was studied in a convenience sample of

hospital-based neonatologists (n = 86) and office-based pediatricians (n = 97) (Marshall

1998). Burnout was found more frequently in female physicians (79 percent) than male

physicians (62 percent). The study may have particular relevance for nursing because the

profession is predominately female. Work life, however, is not independent from family

life; these domains may even be in conflict (Near,1980; Perlin,1983). Stress may result

from the combined responsibilities of work, marriage, and children (Haw1982,

Woods1985). And yet, non-work stress may be particularly salient to nursing, a

predominantly female profession. Women continue to juggle multiple roles, including

those roles related to the home and family, for which the women may have sole or major

responsibility. Nevertheless, work stress and burnout remain significant concerns in

nursing, affecting both individuals and organizations. For the individual nurse, regardless

of whether stress is perceived positively or negatively, the neuro-endocrine response

yields physiological reactions that may ultimately contribute to illness. In the health care

organization, work stress may contribute to absenteeism and turnover, both of which

detract from the quality of care (Jennings, 1994).

Findings from studies that explored family-work conflict in relation to stress,

burnout, and well-being indicated the importance of considering both work and family

44

spheres (Jennings,1994; Blau et.al. 2003; Carr, et.al.2003; Weinberg,2000). An

investigation conducted using a diverse sample of 342 non-professional employees (17

percent worked in health care; 70 percent were women) found family-work conflict was a

predictor of well-being. A study of a diverse group of health care personnel compared 64

cases with 64 controls. Although the subjects in the case group were more likely to

experience more objective stressful situations in and out of work, for both the case group

and the control group, both work and non-work stress contributed to anxiety and

depressive disorders.

Stress due to death and dying of patients is also experience among male and

female nurses among private and government hospitals. A study conducted by

Foxall.et.al. (1990), compared the frequency and sources of nursing job stress perceived

by 35 intensive care (ICU), 30 hospice and 73 medical-surgical nurses. Post-hoc Tukey

tests demonstrated a significant difference in three stress subscales among the three

groups. The ICU and hospice nurses perceived significantly more stress than medical-

surgical nurses related to death and dying, ICU and medical-surgical nurses perceived

significantly more stress than hospice nurses related to floating, and medical-surgical

nurses perceived significantly more stress than ICU and hospice nurses related to work-

overload/staffing. Death and dying situations were the most stressful to ICU and hospice

nurses, while work-overload/staffing situations were the most stressful to medical-

surgical nurses. Cole et al (2001) reported that intensive care units are recognized as most

stressful areas both for patients and nursing staff. While this author is saying death and

dying are recognized as one source of stress for intensive care nurses. With regard to

Intensive Care Unit, the greatest perceived source of stress is emotional issues related to

death and dying (mean=1.83, n=11) followed by conflict with Physician, Nurses and

Supervisors (mean=1.37, n=13). Studies therefore also point to critical care unit nurses

experiencing stressors associated with death and dying (Hipwell et al 1989, Ogus 1992,

Mallet et al 1991).

45

Inadequacy in dealing with emotional needs of patients and their families is

also another source of stress reported by both male and female nurses working in private

hospitals and government hospitals. A study done by McCreight (2004), explored the

experiences of nurses in Gaynae wards, and how they dealt with patient’s perinatal grief

and emotional labour. The findings reported that the general view of the nurses was that

their training had been focused on disciplinary knowledge which was not always helpful

in enabling them to cope with the emotional demands of their work that is, they were

unable to deal with the emotional needs of patients and their families. Another study by

Olesen and Bone (1998) suggest that there is the potential for role conflict among nurses

who attempt to deal with the needs of patients while satisfying institutional demands and

attending to their own emotional requirements. Furthermore, because of the potentially

high degree of emotional expression in the medical relationship, health professionals

often employ precautionary, or self-protective strategies, to limit investment of the self

for example, by systematically limiting their involvement in the emotional aspects of

their work. Emotional involvement of nurses with patients is difficult to avoid, and

attempts by nurses to do so, in order to maintain professional distance, may result in

problems for both nurses and patients (Gow,1982). The intimate nature of the caring role

means that nurses often develop a personal relationship with parents who have

experienced a pregnancy loss, if for example, the woman has been in hospital for a

significant length of time prior to the loss.

Research shows lot of studies on burnout experienced among both male and

female nurses, and differences observed in the experience of burnout across private and

government sector nurses. A study by Maslach and Jackson (1985) cited in article by

Schaufeli and Grennglass (2001); examined sex differences in a wide range of human

service occupations. Women were higher on emotional exhaustion and lower on personal

accomplishment than men. In others words, women were more likely to feel emotionally

drained by their work than men. But, in this study gender was confounded with type of

occupation. Police officers and psychiatrists were usually men and nurses, social workers

46

and counsellors were typically women. Therefore, the sex differences reported may in

fact reflect differences in occupations (Schaufeli and Greenglass, 2001). However, in

contrast there are studies that report that gender has no significant impact on nurse’s

perception of work stress, with male and female reporting levels of work stress. Work

stress is predominantly related to an excessive workload and insufficient staffing

resources to cope with organizational demands (Lane, 2004). The prevalence of burnout

was studied in a convenience sample of hospital-based neonatologists (n = 86) and office-

based pediatricians (n = 97). Burnout was found more frequently in female physicians (79

percent) than male physicians (62 percent). Burnout was lower if female physicians

worked the number of hours they preferred (r = -0.22, P = 0.03). These studies may have

particular relevance for nursing because the profession is predominately female (Jenning,

2008). Some studies report similar stress levels in private and government sector. In a

study by Shimizu, et. al (2005) was done to explore relationship between turnover and

burnout among Japenese private hospitals nurses. Results showed that nurses experienced

exhaustion and their turnover was related to burnout, especially exhaustion. However

results also show that, the stress level of female nurse who were working in government

& private hospitals, had no significance differences across the two groups.

(Lakshmi.et.al., 2012).

Research articles also report depersonalisation in nurses working in public

hospitals. Spooner-Lan and Patton (2007) conducted a study on the main determinants of

burnout among nurses working in public hospitals and investigates the impact of work

support on the stress- burnout relationship. Results showed that the influence of work

stressors (ie. job-specific stressors and role stressors) and work support (ie. supervisor

and co-worker support) on burnout amongst public hospital nurses. Nurses reporting

higher levels of role boundary and professional uncertainty had higher levels of

depersonalisation. Only supervisor support was a significant predictor of

depersonalisation. Differences on depersonalisation have not been much reported,

however, one of the study reports that men experience higher scores on depersonalisation

47

than women (Greenglass et al., 1988; Ogus et al., 1990; Greenglass et al., 1990;

Anderson and Iwanicki, 1984).

Studies report similar findings where nurses in public hospitals do have high

levels of personal accomplishment. Spooner-Lane(2007) reports supervisor support as the

main determinant of Personal Accomplishment. In alignment with the results of the

present study, a study conducted by Sahraian et. al. (2008) conducted a study, that

compared the levels of burnout among nurses in different nursing specialties, a

comparison of internal, surgery, psychiatry and burns wards. The sample of the study

consisted of all the nurses both male and female working in all public hospitals in Shiraz,

Iran. Study results indicated that nurses of psychiatry wards showed significantly higher

levels of emotional exhaustion and depersonalisation in comparison with nurses working

in other wards, and burn wards nurses showed significantly higher levels of personal

accomplishment. Older nurses in psychiatry wards and those who were married had more

personal accomplishment. Nurses who are focused on the duties and are under intensive

control from the administrator have a strong feeling of personal accomplishment. Ogus

(1992) found that the medical and surgical nurses reported high levels of emotional

exhaustion and depersonalisation but still reported high levels of personal

accomplishment.

Thus it can be said that stress and burnout is prevalent among many nurses in

India and nurses in other countries. Hence the current study also tries a step ahead to

know the differences in levels of stress experiences across gender and sector. Some of

research review reports prevalence of stress in other countries. A Human Science

Research Council (HSRC) study, published by Hall (2004) cited in article by Makie, V.

V. (2006), used the Department of Labour statistics, which indicate that there are 155,000

nurses employed in the country. Only 43% of nurses who are registered with the South

Africa Nursing Council are working in the public sector. According to the PERSAL

system, there are approximately 42 000 vacant nursing positions in the public service.

48

Some of the reasons for leaving the public sector, as stated in the Nursing Update are

poor working conditions, including high workload, poorly resourced environments;

workplace violence and uncompetitive salaries. Private health care sector employers also

reported registered nurse vacancy rates of between 15 to 20 percent. Reports indicate that

both public and private sectors are finding it difficult to fill positions, especially where

specialized skills are required (Nursing Updated May 2005). 84% South African

registered nurses reported increase in their workload, 72% of the respondents stated that

the quality of nursing has declined in the past two years. It was found that job stress

impacts not only on nurses’ health but also their abilities to cope with job demands. This

will seriously impair the provision of quality care and the efficacy of health service

delivery (Lee 2003).

Thomas (1997), who concluded that mental health problems were significantly

correlated with increasing workload, under-staffing, job insecurity and perpetual

organizational change. So serious have nursing absence and sickness rates become that

they were estimated in 1998 to be costing the NHS about £700 million annually

(Williams et al, 1998). Identifying the predisposing factors of mental health problems in

nurses is of considerable interest worldwide. A Canadian study (Decker, 1997) found that

job satisfaction and psychological distress of nurses in an urban university teaching

hospital were significantly correlated with job security and the quality of relationships

with seniors, colleagues, physicians and personnel from other units and departments.

Vishwanath et al (1999) found that role conflict, work overload and lack of social support

were predictors of stress, that burnout was the sole predictor of depression and that this in

turn predicted both absenteeism and intention to leave the profession.

Work and family conflict in nursing profession.

Work family conflict is “a form of inter-role conflict in which the role pressures

from the work and family domains are mutually incompatible in some respect (Greenhaus

49

and Beutell, 1985). That is participation in the work (family) role is made more difficult

by virtue of participation in the family (work) role”. Conflict between work and family is

important for organizations and individuals because it is linked to negative consequences.

For example, conflict between work and family is associated with increased absenteeism,

increased turnover, decreased performance and poorer physical and mental health (for.

eg. Kinnunen, Feldt, Geurts & Pulkkinen, 2006). Conceptually conflict between work and

family is bi-directional. Work-to-family conflict occurs when experiences at work

interfere with family life, like extensive, irregular, or inflexible work hours, work

overload and other forms of job stress, interpersonal conflict at work, extensive travel,

career transitions, unsupportive supervisor or organization. (Frone et.al 1992). For

example, an unexpected meeting late in the day may prevent a parent from picking up his

or her child from school. This type conflict is associated with health problems such as

psychological strain, depression, anxiety (Lapierre & Allen, 2006), lowest sleep quality

(Williams, Franche, Ibrahim, Mustard & Layton, 2006).

Burke and Greenglass (2007) conducted a study to examine the relationships

between hospital restructuring and downsizing stressors, work–family and family–work

conflict, job and family satisfaction and psychological well-being. Data were collected

from 686 hospital-based nurses, the vast majority women, using anonymous

questionnaires. Respondents were mainly women (97%), about one-half worked full

time, about half had some type of supervisory duties, over 80% had an RN degree, either

college or hospital based, 82% were married or living with a partner and about three-

quarters had children. The respondents worked in a variety of nursing units, with two-

thirds in medical/surgical, intensive care/coronary, emergency and obstetrics. Work–

family conflict was measured by a four-item scale developed by Kopelman, Greenhaus

and Connolly (1983). Job satisfaction scale developed by Quinn and Shepard (1974).

Psychosomatic symptoms were also measured. Three components of psychological

burnout were also assessed including emotional exhaustion, professional efficacy and

cynicism. The results showed that work family conflict and family work conflict were

50

moderately but significantly correlated (r = .26, p < .001). Organizational restructuring

and downsizing stressors had stronger and more consistent relationships with work

family conflict and family work conflict. Nursing staff working full-time, reporting

greater increases in workload and indicating more negative effects of staff bumping also

reported more work family conflict. Nursing staff who were younger, had children and

reported greater use of generic workers also reported greater family work conflict. Full

time nursing staff reported higher levels of emotional exhaustion and higher levels of

Professional Efficacy. Nursing staff reporting greater increases in workload also reported

more Emotional Exhaustion and Cynicism. Nursing staff reporting greater work family

conflict also reported higher levels of emotional exhaustion and cynicism, nursing staff

reporting greater family work conflict reported lower levels of professional efficacy. The

limitation of the mentioned study is that, the sample in the present study was almost

exclusively comprised of women (97%). It is necessary to validate the present findings

with a male sample drawn from the same occupation.

Research reports high levels of work family conflict have been reported by nurses

working in private hospitals. (Burke and Greenglass, 2001). Also it has been reported that

women, more than men, shoulder greater responsibility for family responsibilities and

experience greater work-family and family-work concerns as a result (Burke and

Greenglass, 1987; Hochschild, 1989; cited in article Burke, Greenglass, 1999). Whereas,

some literature supports that there is no significant difference between the stress levels

due to managing work life balance by female nurses working in government and private

hospitals. A research conducted to analyse the work life balance of female nurses in

hospitals also, compare nurses working in both Government and Private Hospital in

Chennai, Tamil Nadu., India. Results found were, among the independent samples to

ascertain differences between the stress level due to managing work life balance of

female nurse who were working in both government & private hospitals, the result on the

basis of T-test (0.853) indicates that there is no significance difference among nurses

from both sectors (Lakshmi, Ramachandran and Boohene, 2012). Not much literature has

51

been found comparing nurses based on gender and sector on work family conflict

experienced among nurses to the best of our knowledge, but individually nurses from

both sectors experience high level of work family conflict. Studies of nurses working in

public hospital report high level of work family conflict experienced by private hospital

nurses as well. (Namayandeh et.al., 2011).

Boey (1998) examined the role of coping strategies and family relationships in

mitigating the negative effect of work stress on nurses. A sample of 1043 of nurses

working in three main public hospitals in Singapore. This sample consisted of 371

assistant nurses,532 staff nurses, 121 nursing officers. The mean age of the nurses was

33.8 years. The average length of service was 15.8 years. A great majority of these nurses

were females 6% were males. Job satisfaction scale, Coping strategy scale, Family

relationship scale, nursing stress scale was used. The results showed that the level of job

satisfaction of the nurses was generally low. Only one third of the nurses felt satisfied

with their job situation. About two third of the nurses had thought of quitting the

profession altogether. The percentage of nurses who indicated they were often or always

satisfied with various aspects of their family relationships were consistently higher than

the proportion that never or rarely felt so. In order to examine the effect of coping

strategies and family support two groups of subjects were selected for comparison. The

nurses who experienced considerable or extreme stress in the course of their work were

identified as the high stress group (N=338). Nurses who experienced high levels of work

stress and had low levels of job satisfaction formed the distressed group (N=2000). The

stress resistant group (N=138) was formed by nurses who had high levels of work stress

but nonetheless experienced high job satisfaction. Compared with the distressed group

the stress resistant group was distinguished by greater orientation towards problem

solving and ability enhancement and were able to cope with work stress and received

better family support.

52

Work interfering with family had a direct relationship with work exhaustion in a

four year study of medical technologists, 80 percent of whom were female (Blau,

et.al.2003). A study of 101 female nurses found that work interfered with family more

than family interfered with work (Gottlieb, 1996). The investigators noted, however, that

most of the nurses, who were in their mid-40s, were between the demands of child care

and elder care. This finding is consistent with findings from a study of 170 Australian

nurses: the principal determinant of stress was workload; nurses were unlikely to bring

personal stress to work (Bryant,2000). Conversely, there was no difference between

female physicians working full-time or reduced hours in regard to work interfering with

family or family interfering with work (Carr, et.al.2003). A previous study on nurses in

Singapore indicated that stress associated with meeting family demands was detrimental

to nurse’s emotional stability and sense of adequacy (Boey et al., 1999). As women they

are still the primary persons to attend to household and children’s needs. Without family

support stress encountered in nursing would be more difficult to withstand. As a

consequence they may derive less satisfaction from their job.

Literature suggests that work demands such as number of hours worked,

workload, shift work are positively associated with work–family conflict, which, in turn

is related to poor mental health and negative organizational attitudes. The role of social

support has been an issue of debate in the literature. This study examined the extent to

which work demands (i.e., work overload, irregular work schedules, long hours of work,

and overtime work) were related to work-to-family conflict as well as life and job

satisfaction of nurses in Turkey. The role of supervisory support in the relationship

among work demands, work-to-family conflict, and satisfaction with job and life was also

investigated. The sample was comprised of 243 participants: 106 academic nurses

(43.6%) and 137 clinical nurses (56.4%). All of the respondents were female. The

research instrument was a questionnaire comprising nine parts. The variables were

measured under four categories: work demands, work support (i.e., supervisory support),

work-to family conflict and its outcomes (i.e., life and job satisfaction). The result

53

showed that the structural equation modeling results showed that work overload and

irregular work schedules were the significant predictors of work-to-family conflict and

that work-to-family conflict was associated with lower job and life satisfaction.

Moderated multiple regression analysis showed that social support from the supervisor

did not moderate the relationships among work demands, work-to-family conflict, and

satisfaction with job and life. Exploratory analyses suggested that social support could be

best conceptualized as the main effect directly influencing work-to family conflict and

job satisfaction. This confirmed the results of previous research on nursing, which also

showed that work overload and irregular work schedules had a strong positive

relationship with WFC (Burke and Greenglass, 2001; Simon et al., 2004).

Another study investigated the prevalence of Work Interference with Family in

the nursing profession, as well as the nature of it (Grzywacz et al., 2006). The study

included over 1,200 female nurses from across the U.S. currently practising in the

profession, including close to 63% of the nurses working in a hospital setting. Work

interference with family was identified in almost all nurses (92%) over the previous 6-

month period, with over 50% reporting chronic exposure (defined as 1 day a week or

more), and over 41% indicating episodic exposure (defined as less than monthly or 1 to 3

days per month). Parental status, age of youngest child, and number of children were the

possible variables associated with work interference with family in the study. Nurses

who had a child living at home reported higher work interference with family; whereas

the older nurses reported less work interference with family. Additionally, nurses

working more hours per week had an increased work interference with family. Job tenure

was not a predictor of work interference with family. Work-family conflict has been

found to be significantly related to professional turnover intent with registered nurses (N

= 27,603) from eight European countries (Simon et al., 2004). Simon et al. (2004) found

the work-family conflict was prevalent among nurses in every country. This study

included several Eastern European countries. Nurses who were younger reported higher

incidences of work-family conflict in two of the countries in the study.

54

Another study involving nurses in Turkey examined work demands and their

influence on work-family conflict (Yilidirim & Aycan, 2008). The sample consisted of

243 nurses working in Turkey; however, only 137 of nurses worked in the clinical

setting. Work overload (p < .001) and irregular work schedules (p < .001) emerged as

significant role characteristics related to work interference with family, whereas overtime

and work hours were not related to work interference with family. Greenhaus &

Buetell(1985), suggests in their study that the individuals who are married would have

more work interference with family. Yet supportive spouses or significant others may

also lessen the effect of work-family conflict. Another study conducted by Grzywacz and

Marks (2000) found that being unmarried, regardless of gender, was related to less work

interference with family. Their sample consisted of 1,986 people who participated in the

National Survey of Midlife Development, which was conducted through telephone calls.

Burke and Greenglass (2001) investigated nurses in Canada undergoing restructuring.

The study sample consisted primarily of women (97%). There were no differences for

work interference with family among those nurses with children and those without.

Whereas, in a study conducted by Grzywacz et al. (2006) found that nurses who had

children at home experienced more work interference with family than those nurses

without children. Research has produced mixed results on whether having children at

home influences work interference with family among women.

Carlson et al. (2000) examined gender differences using their six-dimension

instrument of work-family conflict. In four of the six dimensions significant differences

were found. In all three measures of family interference with work (time, strain, and

behavior) females had more conflict than the males in the sample. With work interference

with family females had significantly more conflict with strain-based work interference

with family than males. A recent study involving 4,371 men and women working in

Switzerland showed some gender differences in work-family conflict (Hammig,

Gutzwiller, & Bauer, 2009). Overall, men had higher work-family conflict compared to

women; however, whenever adjustments were made for similar positions, women

55

reported higher work-family conflict compared to men in similar positions and jobs. The

number of hours and workload were the highest explanatory variables for women

compared to variable work schedules, work overtime, and being in management, which

were the explanatory variables for men.

Namayandeh, Juhari and Yaacob(2011) examined the effect of job satisfaction

and family satisfaction on work family conflict and family work conflict among married

female nurses in Shiraz Iran. The population of the study consists of N =647 married

female nurses in13 public hospitals in Shiraz. The method of data collection used was

self-administered questionnaire. Work- family conflict (W-FC) and Family-work conflict

(F-WC) Scale developed by Netemeyer et al. (1996). Job satisfaction and family

satisfaction was also assessed. The current research established that the respondents with

higher level of job satisfaction experienced lower level of work family conflict. The

findings are in consistency with finding of past studies by_Namasivayam and Mount

(2004), Ngah et al. (2009) and Cohen and Liani (2009) which have successfully

recognized that when work roles interfere with family roles, the individual’s job

satisfaction is lower. Results indicate that higher level of family satisfaction is associated

with lower level of work family conflict. The finding indicates that there was no

significant relationship between the respondents’ job satisfaction and family work

conflict.

Burke and Greenglass (2001) examined work-family conflict, family-work

conflict and psychological burnout among nursing staff during a time of hospital

restructuring and downsizing. Data were collected from 686 hospital-based nurses, the

vast majority women. On average, respondents had been employed in their current units

about 9 years and in their current hospital about 15 years. The average age of respondents

was 42. Respondents lived and worked in communities and hospitals of various sizes.

Work-family conflict and family work conflict was measured by a four item scale (a=.73)

developed by Parasuraman et al. (1996). Restructuring and downsizing stressors included

56

measures of three work stressors, specific to the restructuring and downsizing process,

were included: Increased workload, Staff bumping and use of generic workers.

Psychological burnout was also assessed. The results showed that the personal

demographics but not downsizing and restructuring stressors predicted family-work

conflict; downsizing and restructuring stressors but not personal demographics predicted

work-family conflict. Restructuring stressors and both work-family conflict and family-

work conflict were associated with higher levels of psychological burnout.

Thus it can be explained that work–family conflict is a type of inter-role conflict

that occurs as a result of incompatible role pressures from the work and family domains.

Work role characteristics that are associated with work demands refer to pressures arising

from excessive workload and time pressures. Literature suggests that work demands such

as number of hours worked, workload, shift work are positively associated with work–

family conflict, which, in turn is related to poor mental health and negative organizational

attitudes. A study conducted by Yildirim (2008) and Aycan (2005) examined the extent

to which work demands (i.e., work overload, irregular work schedules, long hours of

work, and overtime work) were related to work-to-family conflict as well as life and job

satisfaction of nurses in Turkey. The role of supervisory support in the relationship

among work demands, work-to-family conflict, and satisfaction with job and life was also

investigated. The sample was comprised of 243 participants: 106 academic nurses

(43.6%) and 137 clinical nurses (56.4%). All of the respondents were female.

Approximately two thirds of the nurses (71%) were married, and 75% of married

respondents had at least one child. The variables were measured under four categories:

work demands, work support (i.e., supervisory support), work-to family conflict and its

outcomes (i.e., life and job satisfaction). Time demands of job and inflexibility was

assessed by an 11-item scale developed by Duxbury and Higgins (1994) and adapted to

Turkish by Aycan and Eskin (2005). The scale assessed the extent to which participants

experienced overload, inflexibility, and lack of control in their jobs. The total number of

hours worked per week was assessed. Work schedule and overtime work was measured

57

using questions with multiple choice. Supervisory support was also measured, where the

items assessed the extent to which managers provided emotional and instrumental

support to employees on balancing work and family responsibilities. A measure of job

satisfaction and life Satisfaction scale was used in the present study. The results reported

that the suggested that irregular work schedules and work overload had the strongest

relationship with nurses’ work-to-family conflict. This confirmed the results of previous

research on nursing, which also showed that work overload and irregular work schedules

had a strong positive relationship with WFC (Burke and Greenglass, 2001; Simon et al.,

2004). However, contrary to expectations, working hours and overtime work were not

associated with work-to-family conflict. Also, work-to-family conflict was associated

with lower life and job satisfaction. Exploratory analyses suggested that social support

could be best conceptualized as the main effect directly influencing work-to family

conflict and job satisfaction. As argued by Frone et al. (1992) work stressors lead to

higher interference of work with family, and result in increased family distress or

dissatisfaction.

58

Chapter Summary

On the basis of the introduction and the review, the present researcher has formulated the

following hypotheses.

Hypothesis 1: There will be significant differences among the groups based on sex and

sector on the dimensions of career development, self reported inappropriate negotiation

strategy, stress, burnout, work family conflict.

Hypothesis 2: There will be a significant relation between variables of career

development and stress in male and female nursing professionals of private and

government sectors.

Hypothesis 3: There will be significant relation between variables of career development

and burnout in male and female nursing professionals of private and government sectors.

Hypothesis 4: There will be significant relation between variables of career development

and self reported inappropriate negotiation strategy in male and female nursing

professionals of private and government sectors.

Hypothesis 5: There will be significant relation between variables of career development

and work family conflict in male and female nursing professionals of private and

government sectors.

Hypothesis 6: There will be significant relation between variables of work family

conflict and stress in male and female nursing professionals of private and government

sectors.

Hypothesis 7: There will be significant relation between variables of work family conflict

and burnout in male and female nursing professionals of private and government sectors.

59

Hypothesis 8: There will be significant relation between variables of work family conflict

and self reported inappropriate negotiation strategy in male and female nursing

professionals of private and government sectors.

Hypothesis 9: There will be significant relation between variables of stress and burnout in

male and female nursing professionals of private and government sectors.

Hypothesis 10: There will be significant relation between variables of stress and self

reported inappropriate negotiation strategy in male and female nursing professionals of

private and government sectors.

Hypothesis 11: There will be significant relation between the variables of burnout and

self reported inappropriate negotiation strategy in male and female nursing professionals

of private and government sectors.