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Queensland University of Technology School of Nursing
Centre for Health Research
Identifying Sources of Stress and Level of Job Satisfaction amongst Registered Nurses
within the First Three Years of Work as a Registered Nurse in Brunei Darussalam
Abd Rahim Damit RN, Cert.Ed. B.Ed.
Submitted for the award of Master of Applied Science Research
August 2007.
ABSTRACT
Introduction
The purpose of this study project was to determine the factors contributing to stress in
nurses within the first three years of work as a registered nurse in the speciality units and
general wards in Brunei Darussalam hospitals. It is expected that the findings of this
study would become the point of reference for nurses and Ministry of Health to identify
support strategies and resources that could be used to prepare nurses to cope with stresses
while working in today’s complex clinical environment. Thus the findings are intended to
inform nurse educators, nurse managers and nurse administrators in Brunei Darussalam
regarding the levels and types of stressors among new graduate nurses in different areas.
Background to the study
Many studies have recognized that nursing is, by its nature, a stressful occupation
because of exposure to a wide range of potentially stressful situations and conditions.
Some stressors for nurses’ consistently identified in the literature include work overload,
unpredictability of staffing levels, caring for dying patients, lack of time to give patients
emotional support, tiredness and conflict with doctors and supervisors. Others stressors
may also be associated with safety issues, lack of support and problems which occur
outside of work and conflicts between home and work.
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Method
This study used a descriptive correlational study design to examine new nurses within the
first three years of work as a registered nurses’ perception of stress and level of job
satisfaction in today’s complex clinical nursing working environment. Data was collected
through distribution of self administered questionnaires, which comprised 59 items of
Expanded Nursing Stress Scale (French, Lenton, Walters and Eyles, 1995) and the two
part measurement tool of Index of Work Satisfaction Survey (Stamps, 2001). This
questionnaire was distributed to 120 new registered nurses working in Raja Isteri
Pengiran Anak Saleha Hospital (R.I.P.A.S.), the main referral hospital in Brunei
Darussalam. The sample consisted of both male and female registered nurses (RN) who
had less than three years working experience in nursing.
Results
Responses to the Expanded Nursing Stress Scale (ENSS) identified that the new
registered nurses rated their Uncertainty Concerning Treatment as highly stressful events
that frequently occurred in the workplace. The study findings also revealed that the level
of stress and the common stressors in new registered nurses within the first three years of
work as a registered nurses were similar irrespective of whether they were working in the
speciality units or in general wards. Results for Index Work Satisfaction Survey (IWSS)
Part A and B also suggested that there was no significant difference on the levels of job
satisfaction in both groups of new registered nurses, with the majority of nurse choosing
Professional Status as the most important component.
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Conclusion Results of this study are likely to have important implications for nursing education,
administration, management, organisation, practice, knowledge, and research. The study
findings have the potential to make a significant contribution to determining coping
strategies that might help in reducing the amount of stress experienced by the new
registered nurses in day to day challenging and demanding nursing roles. The study also
has the potential to have wider benefits to nursing practice not just at Brunei Darussalam.
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TABLES OF CONTENTS
Page
ABSTRACTS…………………………………………………………………… i
TABLE OF CONTENTS………………………………………………………. iv
LIST OF TABLES ……………………………………………………………. viii
STATEMENT OF ORIGINAL AUTHORSHIP……………………………….
ACKNOWLEDGMENT……………………………………………………….
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CHAPTER ONE – BACKGROUND AND OVERVIEW
INTRODUCTION……………………………………………………….
BACKGROUND…………………………………………………………
SIGNIFICANCE OF THE STUDY……………………………………..
PURPOSE OF THE STUDY…………………………………………….
THE STUDY AIM………………………………………………………
Aims of the Study …………………………………………………
Objectives………………………………………………………….
Research Questions ……………………………………………….
Hypotheses ………………………………………………………..
Summary ………………………………………………………….
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CHAPTER TWO – THEORETICAL PERSPECTIVE OF STRESS
INTRODUCTION ……………………………………………………….
It Is Stress?........................................................................................
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Work Related Stress and its Effects on Health……………………..
Is Work Related Stress Costly………………………………………
STRESS IN NURSING: A CONCEPTUAL MODEL……………………
Conceptual Model of Stress Amongst New Registered Nurses…….
CHAPTER THREE – LITERATURE REVIEW
INTRODUCTION………………………………………………….........
Stress In Nursing……………………………………………………
Multiple Sources of Stress………………………………………….
Concerns about Clinical Competence………………………………
Role Conflict……………………………..…………………………
Violence and Aggression…………………………………………..
Workload and Resource Constraints……………………………….
The Role of Nurses Providing Care to the Dying Patient....……….
Support From Managers and Colleagues…………………………..
Stressors Associated with the Transition to being a Registered
Nurse…………………………………………..…………………..
Coping and Support Strategies…………………………………….
Summary…………………………………………………………..
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CHAPTER FOUR – METHOD
RESEARCH METHOD………………………………………………….
Research Design……………………………………………………
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Setting………………………………………………………………
Sample………………………………………………………………
Ethical Consideration……………………………………………….
Research Instrument...………………………………………………
Demographic Questions…………………………………………….
Rating of Clinical Practice…..………………………………………
The Expanded Nursing Stress Scale (ENSS)…………………........
The Index of Work Satisfaction (IWS)……………..………………
Pilot Study………………………………………………………….
Data Management and Analysis……………………………………
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CHAPTER FIVE - RESULTS
Introduction…………………………………………………………
Sample Characteristics………………….………………………….
Social Demographic Characteristics of the Sample………………..
Participants’ Confidence about Clinical Practice…………………..
Sources and Level of Stress Scale………………………………….
Comparison of Stress by Practice Setting………………………….
Comparison of Stress by Demographic Variables………………….
Index of Work Satisfaction: Importance of Work Components (Part
A) …………………………………………………..........................
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Index of Work Satisfaction: Rating of Satisfaction (Part B)………..
Computing the Component Sources…………………………………
Strategies That Are Believed to be Helpful in Assisting the New
Nurses’ Transition into the Workplace as a New Registered Nurse…
Summary ……………………………………………………….........
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CHAPTER SIX – DISCUSSION AND CONCLUSIONS
Discussion of The Study Findings...…………………………………
Implications…….…….…………………………………..................
Study Limitations……………………………………………………
Future Research………………………….………………………….
Conclusion ………………………………………………………….
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References …………………………………………………………………….. 141
Appendices …………………………………………………………………….
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LIST OF TABLES Page
Figure 1 Conceptual model of Stress amongst new Registered Nurses……. 23
Figure 2 The Nursing Structure in Brunei Darussalam……………………. 55
Table 1 Practice Setting for Nurses in the Study Sample…………………. 56
Table 2 List of Items for Each Component in the IWS…………………… 64
Table 3 Example of Scoring System for Positively and Negatively Phrased Items in the IWS…………………………………………………..
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Table 4 Demographic Characteristics of the Sample……………………… 69
Table 5 Social Demographic Characteristics of the Sample………………. 70
Table 6 Participants’ Confidence about Clinical Practice………………… 71
Table 7 Ratings of Stress associated with Uncertainty Concerning Treatment………………………………………………………….
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Table 8 Ratings of Stress Associated with Dealing with Patients and their Families……………………………………………………………
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Table 9 Ratings of Stress associated with Workload……………………… 78
Table 10 Rating of Stress Associated with Inadequate Emotional Preparation ……………………………………………………….
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Table 11 Rating of Stress Associated with Conflicts with Doctors……….. 82
Table 12 Rating of Stress Associated with Supervisors…………………… 84
Table 13 Rating of Stress Associated with Death and Dying……………… 86
Table 14 Rating of Stress Associated with Conflicts with Peers………… 88
Table 15 Rating of Stress Associated with Discrimination………………. 90
Table 16 Expanded Nursing Stress Scale Scores by Practice Setting…….. 92
Table 17 Comparison of Stress by Demographic Variables………………. 94
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Table 18 Relationship between Stress and Ratings of Confidence,
Competence and Organisation…………………………………… 96
Table 19 Frequency Matrix for IWS Components by Work Area…………. 98
Table 20 IWS Component Weightings by Work Area……………………. 100
Table 21 Index of Work Satisfaction: Professional Status……………….. 102
Table 22 Index of Work Satisfaction: Interaction………………………… 104
Table 23 Index of Work Satisfaction: Autonomy………………………… 106
Table 24 Index of Work Satisfaction: Task Requirements……………….. 108
Table 25 Index of Work Satisfaction: Organisational Policies……………. 110
Table 26 Index of Work Satisfaction: Pay Component…………………… 112
Table 27 Component Score and the Component Mean Score for IWS Scales
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Table 28 Ranking of Satisfaction with IWSS Work Components……………….. 116
Table 29 IWS Components Weighted Scores………………………………. 118
Table 30 Components T-test………………………………………………… 119
Table 31 Correlations between IWSS and ENSS ………………………….. 120
Table 32 Ratings of Helpfulness of Strategies for Assisting Transition…….. 122
Table 33 Frequency Matrix Appendix 6
Table 34 Matrix of Z-Values - Component Weighting Coefficient Appendix 7
Table 35 Index of Work Satisfaction: Nurse-Nurse Appendix 8
Table 36 Index of Work Satisfaction: Nurse-Physician Appendix 9
Tables 37 - 60
Appendix 10
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STATEMENT OF ORIGINAL AUTHORSHIP
“The work contained in this thesis has not been previously submitted to meet requirement
for an award at this or any other higher education institution. To the best of my
knowledge and belief, the thesis contains no material previously published or written by
another except where due reference is made”
Signature Date: 7th August 2007. Abd Rahim Damit
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ACKNOWLEDGMENT
The undertaking of this thesis was not a solitary effort. I appreciate my supervisor,
colleagues, family and friends who helped me in so many ways; without them this thesis
would not have been completed. I wish to gratefully acknowledge the support and
kindness of the following individuals and organisations:
Firstly, I express my deep and sincere thanks to my supervisor Professor Patsy Yates who
encouraged me through the Masters’ journey. Her continued guidance, support and
critical comments were a source of great encouragement. Thank you so much for being
instrumental in making this happens – I benefited from your vision all along.
I would like to express particular thanks to my spouse, children and mother for their
patience and forbearance during recent months whilst I have been working so hard to
complete my study. It has been a mammoth task and I am very much aware that I have
neglected them in many different ways. I would also like to thank all those who have
contributed ideas and constructive views for my development. A special thanks to
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Government of His Majesty Sultan Haji Hassanal Bolkiah Mu'izzaddin Waddaulah, the
Sultan and Yang Di-Pertuan of Brunei Darussalam for the financial support and to all
academic, administrative and support staff from the Research Department, School of
Nursing, Faculty of Health, Queensland University of Technology, Australia, who
worked so hard to enable me to complete my study.
Special thanks to other contributors, Peter Fell, Dr Diana Batistutta, Boni Macfarlane and
to all of my local and international PhD students/colleagues who have willingly shared
their knowledge and experiences during my study. I have had valuable assistance from
Ms Sheree Smith who worked so hard since she became my principal research supervisor
in April 2005 to August 2006. She spent a lot of time and energy which contributed to the
success of this study and she has kept me well informed of my progress.
I would as well like to thank the participants in the study and the nursing managers,
without their commitment this study would not have been possible. It was a great
pleasure and opportunity to work with them. Thank you to all of you.
My thanks also go to Hajah Thaibah binti PDPD DP Haji Abd Rahim- Principal College
of Nursing Brunei Darussalam, Haji Julaini bin Haji Latip-Deputy Principal College of
Nursing Brunei Darussalam, Haji Daud bin Haji Mahmud-Deputy Permanent Secretary-
Ministry of Education Brunei Darussalam, Pengiran Hajah Azizah binti Pengiran Haji
Tajuddin-Former Director of Nursing Services Brunei Darussalam, Dr. Haji Abdul Hamit
bin Haji Musa-Acting Director of Nursing Services Brunei Darussalam and Dr Awang
Haji Affendy bin Pehin Orang Kaya Saiful Mulok Dato Seri Paduka Haji Abidin-
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Director General Medical Services Brunei Darussalam for their support and permission
for this study to be conducted in RIPAS Hospital Ministry of Health Brunei Darussalam.
I would also like to acknowledge and thank Susan E. French, Rhonda Lenton, Vivienne
Walters and John Eyles from the School of Nursing McMaster University, Canada the
original authors of the Expanded Nursing Stress Scale (ENSS) and Professor Paula L.
Stamps and Market Street Research, Inc from University of Massachusetts, United State
of America the original owner of the Index of Work Satisfaction (IWS), for their
assistance and their permission to use the self-administered questionnaires as the data
collecting tools for this study.
Finally, this thesis is dedicated to my late father Awang Haji Damit Piut who departed
this life on the 11th March 2007 and my late Aunt Hajah Maimunah Piut who passed
away on the 21st of August 2006, whilst I was completing the final stages of my thesis. I
have had a considerable loss of key persons who can never be replaced, and who have
supported my study, living and took care of my children and family whilst I have been in
Australia since April 2005.
Abd Rahim Damit August 2007.
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CHAPTER ONE
1.0. INTRODUCTION
1.1. BACKGROUND.
Nursing is, by its nature, a stressful occupation because of exposure to a wide range of
potentially stressful situations and conditions. Stressors for nurses consistently identified
in the literature include work overload, pressures associated with demands of the
contemporary work environment (World Health Organisation, 2004), unpredictability of
staffing and scheduling, having to complete too many non-nursing tasks, and having to
make decisions under pressure (Fox, 2003; McVicar, 2003). In addition, watching a
patient suffer and feeling helpless in the case of a patient who fails to improve or who
may be dying may cause distress amongst nurses. Lack of time to give patients emotional
support, tiredness, criticism by doctors and conflicts with immediate supervisors (Huang,
2004; Healy and McKay, 1999; Tyler and Cushway, 1995:1992) can also create difficult
situations for nurses. Other factors which have been identified in the literature as
contributing to stress include concern about being isolated and discriminated against
because of race and ethnicity, or being sexually harassed by other nursing colleagues or
other healthcare professionals (Huang, 2004; Uzun, 2003; Sylvia 1996; Guppy and
Gutteridge, 1991).
While there are a considerable number of stressors associated with nursing work, stress is
highly subjective and there is substantial variation in experiences of stress (Santamaria,
1995). New nurses in particular are likely to face some unique stressors that make the
period of transition to the role of registered nurses (RN) an especially difficult time
(McVicar, 2003; Casey, Fink, Krugman and Propst, 2004). In addition to these stressors
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associated with nursing work, new nurses may face additional stressors associated with
job loss and/or relocation (Moore, Kuhrik, Kuhrik, and Barry, 1996), fear of failure while
carrying out nursing tasks/responsibilities, fear of making mistakes or harming patients
while performing procedures that patients experience as painful, and feeling inadequately
prepared to help meet the emotional needs of patients and the patient’s family (Gillespie
and Kermode, 2004; Healy and McKay, 1999). Stress has also been identified with
concerns about job security and stability, work dynamics, safety and self esteem issues
(World Health Organisation, 2004; Rainham, 1994). Poor work organisation, including
poor work design and work systems can also cause work stress (World Health
Organisation, 2004). Other stressors external to the workplace may exist, including
conflicts between home and work especially for those who have young children to care
for (Lu and Shiau, 1997; Rainham, 1994).
Beginning level nurses may lack familiarity with the hospital and have limited experience
in dealing with the new complex working environment, medical emergencies, and the
operation and functioning of specialised equipment (Arnedo, Uranga, and Marin, 2005;
Jackson, 2005; Higgins, 2003; Tyler and Cushway, 1995:1992). Being in charge of
clinical situations with inadequate experience and not knowing what a patient or a
patient’s family ought to be told about the patient’s condition and its treatment may also
present stressors. Work which does not fulfil their needs and work tasks/responsibilities
over which new graduate nurses have little control or which are ambiguous are also found
to be significantly associated with increased levels of emotional exhaustion leading to
occupational stress (Stordeur, Dhoore and Vandenberghe, 2001; Sylvia, 1995; Cox and
Griffiths, 1994).
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According to the World Health Organisation, work related stress occurs in a wide range
of work circumstances. A healthy work environment is one in which the presence and
impact of such stressors are minimised, by ensuring the absence of harmful conditions
and an abundance of health-promoting ones (World Health Organisation, 2007). Some
writers argue that health at work and healthy work environments are among the most
valuable assets of individuals, communities and countries. Occupational health is seen to
be an important moral imperative, not only to ensure the health of workers, but also to
contribute to positive productivity, quality of work, work motivation, job satisfaction and
to overall quality of life of individuals and society (World Health Organisation, 1995).
Importantly, evidence suggests that unhealthy work environments are one important
factor contributing to the worldwide nursing shortage (World Health Organisation, 2004).
Identifying strategies for improving the health and well-being of health workers is thus
crucial at this time. In response to these concerns, the International Council of Nurses in
2007 outlined the characteristics of positive practice environments for nurses. These
characteristics include:
• Innovative policy frameworks focused on recruitment and retention
• Strategies for continuing education and upgrading
• Adequate employee compensation
• Recognition programmes
• Sufficient equipment and supplies
• A safe working environment.
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Other key reports relating to the well-being of health workers similarly argue that the
more control workers have over their work and the way they do it, and the more they
participate in decision making in their job , the less likely they are to experience work
stress (WHO, 2004).
Such international policy documents highlight the importance of understanding the work
place factors that may contribute to adverse work environments, and developing local
approaches in accordance with countries’ priorities to ensure workers’ health and well-
being (World Health Assembly, 2007).
1.2. THE SIGNIFICANCE OF THE STUDY
To date, no research has been conducted to investigate level of stress and work
environments for nurses, and the implications of such stress for nursing services in
Brunei Darussalam. The purpose of this study is thus to examine stressors and work
satisfaction for nurses working in different practice environments within the first three
years of work as a registered nurse in Brunei Darussalam. This study is significant for a
number of reasons. Firstly, nurses comprise the largest group of health personnel
providing support services in primary, secondary and tertiary health care in Brunei
Darussalam. Moreover, with better education and improved living standards, the health
demands of the public have required sophisticated reforms and changes and
improvements to the quality nursing services (Ministry of Health, 2005). Such demands
are likely to cause new registered nurses in Brunei Darussalam to experience even more
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challenging situations as they are required to cope with constant time pressures and the
need to maintain their competence in a rapidly changing field. For example, the impacts
of developments in science and bio-technologies in treatment of many illnesses, and
medical technology advances in nursing have seen an increased pressure for new
registered nurses (Barnard and Gerber, 1999). As a result of this rapidly changing
workplace, new registered nurses may also frequently encounter new ethical dilemmas,
and face an increasing number of situations over which they have limited control
(Rainham, 1994).
Work related stress can result in workers being less productive, may impact on the
quality of services provided by health professionals, and may also place these nurses at
more risk of making errors (International Labour Organisation, 2005). Becky (1994)
describes negative behaviours of stressed employees to include apathy, paranoia, and
distrust. The failure to identify these problems amongst nurses at an early stage is thus
likely to have a major impact on the effectiveness of nursing services and patient care.
Such stressors may also contribute to an increase in psychiatric morbidity such as
depression, as well as an increase in some forms of physical illness, such as
musculoskeletal problems (Higgins, 2003; Cox, Griffiths and Cox, 1996; Santamaria,
1995). Murphy (2004) argues that if nurses feel stressed at work, their practice will
suffer, ultimately affecting the care of the patients. Cartwright and Cooper (1994)
suggest that there is a strong need for a proactive management approach that recognizes
an organisational responsibility to manage and effectively identify and minimise potential
stressors in the workplace.
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1.3. PURPOSE OF THE STUDY Stress in nursing has been well documented in the literature for many years yet it remains
a poorly understood problem. This is in part due to theoretical and methodological
constraints in the investigation of this phenomenon and the multi-factorial nature of
nursing stress (Santamaria, 1994). There is also very limited research on such issues
outside of western countries. This lack of evidence regarding the experiences of nurses in
the first few years of work as a registered nurse presents many challenges, especially for
those who need to prepare future nurses to practice in the contemporary healthcare
setting, in particular social and cultural contexts.
Issues of work related stress and stressors are frequently discussed informally amongst
nurses at all levels in Brunei Darussalam hospitals. However, stress in the nursing
environment especially among registered nurses in Brunei Darussalam hospitals has not
yet been investigated. The primary aim of this study is to determine the sources and level
of stress and levels of work satisfaction among new registered nurses within the first
three years of work as a registered nurse in Brunei Darussalam.
In addition, a secondary aim of this study is to compare the stressors and work
satisfaction experienced by nurses working in general and acute speciality care unit
settings. A speciality care nurse is defined as a licensed professional nurse who is
responsible for ensuring that acutely and critically ill patients (highly vulnerable, unstable
and complex) and their families receive optimal care (American Association of Colleges
of Nursing, 2006). Speciality care units are surrounded by ‘high tech’ medical machinery,
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with many patients requiring specialised devices and equipment (Villaneuva, 1999),
thereby requiring intense and vigilant nursing care. Cooper and Scott (2003) suggest that
specialty care unit nurses’ skills and expertise are different to those of general wards
nurses, as their roles expand to include use of advanced and complex medical
technologies, and more specialised knowledge and skills (Aliso-Viejo, 2002). Due to the
nature of these different environments, this study sought to identify and compare
common stressors, sources and level of stress in these different settings for registered
nurses within the first three years of work as a registered nurse.
In Brunei Darussalam, an 18 month transition program has been developed for new
registered nurses. There is, however, no data available to examine its relevance to the
needs of new graduates today, and ways to improve the program. As such, it is expected
that the findings of this study will become a point of reference for nurses and the Ministry
of Health to understand the levels, types and effect of stress on new nurses within the first
three years of work as a registered nurse, and to identify appropriate support strategies
and resources that could be used to prepare future nurses to cope with these stressors.
Thus the findings from this study will inform nurse educators, nurse managers and
hospital administrators regarding the levels and types of stressors in registered nurses in
different clinical areas of the hospital in their first few years as a registered nurse. The
study will also help to identify areas for further nursing research in Brunei Darussalam.
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1.4. THE STUDY AIM
Aim of the Study
The primary aim of this study was to investigate perceptions of stress and level of job
satisfaction by registered nurses of less than three years experience, in today’s complex
clinical nursing working environment in Brunei Darussalam hospitals.
1.5. Objectives For nurses in Brunei Darussalam, The study objectives are to:-
1. Identify levels and sources of stress experienced by registered nurses with less
than three years experience working in speciality care units and general wards.
2. Compare levels and sources of stress experienced by registered nurses with
less than three years experience working in speciality care units and general
wards.
3. Explore the relationship between the levels of stress and job satisfaction
amongst registered nurses with less than three years experience working in
speciality care units and general wards.
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1.6. Research Questions
The research questions for this study are:
1. What are the stressors for registered nurses with less than three years experience
working in speciality care units and general wards?
2. Do the sources of stress differ for registered nurses with less than three years
experience working in speciality care units and general wards?
3. Do sources and levels of stress differ according to gender, marital status, working
experience in nursing, and perceptions of confidence, and level of competence
with their overall clinical practice?
4. Is there a relationship between level of stress and level of job satisfaction amongst
nurses with less than three years experience working in speciality care units and
general wards?
1.7. Hypotheses
In order to answer the research questions, the study set out to test the following
hypotheses for nurses in Brunei Darussalam:
1. The stressors for registered nurses with less than three years experience are
similar between nurses working in speciality care units and general wards.
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2. The sources of stress for registered nurses with less than three years experience
are similar between nurses working in speciality care units and general wards.
3. The sources and levels of stress for registered nurses with less than three years
experience, irrespective of working environment, are similar according to gender,
marital status, working experience in nursing, perceptions of confidence, and
level of competence with their overall clinical practice.
4. There is a significant relationship between increased level of stress and lower
levels of job satisfaction amongst registered nurses with less than three years
experience.
Summary Chapter one has provided an overview of some of the stressors experienced by nurses in
today’s healthcare environment. The significance of the study to nursing in Brunei
Darussalam has been outlined and the research questions, hypotheses, aim and objectives
of the study have been presented.
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CHAPTER TWO 2.0. THEORETICAL PERSPECTIVES OF STRESS
2.1. INTRODUCTION
There is some evidence in the literature that a notable proportion of nurses report
overwhelming exhaustion, feelings of frustration, anger and cynicism; and a sense of
ineffectiveness and failure (Ootim, 2002; Cole, Slocumb and Mastey, 2001; Black,
Hawks and Keens, 2001; ILO, 2001; Healy and McKay, 1999; Janet, 1995; Sylvia, 1995;
Santamaria, 1994). This chapter begins with an overview of the concept of stress, its
definitions, and its effects on health, the employing organisation and society at large. The
nature of and common sources of stress in the nursing profession are also discussed. The
chapter concludes with a summary of the strategies that might be useful in overcoming
the problems associated with stress amongst nurses, especially in the first few years work
as a registered nurse.
2.2. Is it Stress?
Stress is largely subjective. Nevertheless, it does prompt a series of marked physiological
changes (Kristin, 1998). Hopkinson, Carson, Brown, Fagin, Bartlett and Leary (1998)
describe stress as a subjectively real experience, the meaning of which, although
generally not exact, is understood by a wide variety of people. Specific definitions of
stress vary among stress investigators (Siegall, 1995). Stress has been defined as the
physiological and psychological reaction that occurs when people perceive an imbalance
between the level of demand placed upon them and their ability to meet that demand
11
(Rohleder, 1993). Omdahl and O’Donnell (1999) define stress as an imbalance between
the perceived external demands on a person and his or her abilities to cope through the
employment of cognitive, behavioural and physiological adaptation.
Stress is your body’s instinctive response to situations that are mentally and physically
taxing (Gregory, 1999). Veccio (1995) described stress as the physical and psychological
reactions experienced by an individual when confronted by a threatening situation.
Anger, frustration, guilt and hurt (Santamaria, 1994), anxiety, apathy, and illness (ILO,
2001) are the most universally observed emotional reactions to stress. Stress is
considered to be a process in which environmental events or forces, called stressors,
threatens an organism’s existence and well being (Engel, 2004; Baum, Singer, and Baum,
1981). Becky (1994) stated that stress is a physical, psychological, or spiritual response to
a stressor that may be a reaction to issues such as overwork, decreased support or
appreciation, and limited supervision.
Some of the early theorists in the area of stress emphasised this link between environment
mind and body. Seyle (1976) for example explained that stress results in physiological
responses to the stressors, or a reaction to disturbing or noxious agents or environmental
demands. Lazarus and Folkman (1984) similarly view stress as a dynamic and reciprocal
relationship between the individual and his/her environment. Stress has thus come to be
viewed as a concept that is viewed by some psychologists as a generic term for a broad
area of human responses to any stimuli that produces stress reactions, both physiological
12
and psychological (Monat and Lazarus, 1991). Importantly responses to stress vary,
depending on the perceived situation (Siegall, 1995).
Lazarus and Folkman’s (1984) model is useful for understanding perception of stress, the
factors that may contribute to or ameliorate it, and its effects on the person. The model is
important, as it highlights that stress is a very broad class of problems differentiated from
other problem areas because it deals with any demands which tax the physiological
system, the social system or the psychological system and the response of that system
(Lazarus, 1999).
In this context, stress is seen as multi-factorial and highly subjective (McVicar, 2003).
Although stress has been well investigated in the literature for years, it remains poorly
understood. Stress and threat are concepts used interchangeably in research, however, the
conceptual definitions of each are clearly different (Scholtz, 2000). Stress may be
perceived as an environmental stimulus that evokes a myriad of emotions. It can be either
a positive or a negative stimulus that necessitates adaptation (Lazarus, 1999).
Hiroshi (1994) notes that stress can affect everyone, and although it can serve as a useful
stimulus, excessive stress can lead to physical and mental illness. Stress is strictly a force
which, when applied to a system, modifies its form. Psychological and social forces and
pressure, in the form of events or situations, can be referred to as stressors when they
exert a distorting effect upon a person’s equilibrium. Psychological tension can also be
referred to as stress; in this case the casual agent can be referred to as a stressor.
However, stress is not necessarily bad, since in small doses it can motivate us. A crisis,
13
for example, may provoke positive thinking to regain the upper hand and master the
situation, and very often to succeed. Selye (1976) also used the term eustress to refer to
desirable forms of stress, usually relating to positive events in one’s life.
Janet (1995) similarly argued that stress isn’t all bad as it is a natural reaction to change
or feeling out of control. Stress isn’t just that sinking feeling we get when we have too
much to do in too little time. Janet claimed it can also be that extra “buzz” we need to
achieve higher goals. As such, she argued that it is how stress is handled that makes the
difference. Managing stress effectively therefore requires an understanding not only of
stressors in an environment or situation, but also the meaning of the stressor, and
individual’s ability to respond and manage the stressor and stress response. The
physiological and psychological manifestations of stress thus become apparent when
people are unable to invoke coping mechanisms which assist them to deal with the
stressor in a constructive way.
2.3. Work Related Stress and its Effects on Health.
Stress may have devastating effects on key areas of our lives including: personal/home,
work and finances (Janet, 1995). How people respond to differing stressors varies, and
stress may manifest itself in different ways. Some people know when their bodies are in a
heightened state of excitement: they’re aware of their pulse or they have difficulty in
swallowing. Others may have more subtle responses, such as difficulty in concentrating
or feeling angry or out of control (McConnell, 2000). Black, Hawks and Keens (2001)
explain that behavioural responses to stress include decreased ability to think clearly and
function, increased tobacco and alcohol use, overeating, and disrupted sleep pattern.
14
Black, Hawks and Keens (2001) argue that the physical and emotional demand that stress
places on individuals can have negative effects on health. These authors describe physical
responses to stress as being tight, sore neck and shoulder muscles, increased blood
pressure and heart rate, palpitations, chest discomfort, headaches, gastrointestinal upset
and fatigue. Usually, the effects of stress are short-lived and when this pressure on the
individual recedes there is a quick return to normal behaviour. However, in some cases,
where pressures are on going and intense, stress may lead to long-term psychological and
physical ill health (Harris, 2001). Kristin (1998) argues that prolonged consistent
exposure to stress does prompt a series of marked physiological changes, leading to
certain illnesses including heart disease, hypertension, depression, immune suppression
and diabetes.
Job stress is defined as the harmful physical and emotional responses that occur when the
requirement of the job does not match the capabilities, resources, or needs of the worker.
According to the United Kingdom Health and Safety Commission (1999) the term stress
refers to the reaction people have to excessive pressure or other types of demands placed
on them. Over the past decades, there has been a growing belief that the experience of
stress at work has undesirable effects, both on the health and safety of workers and on the
health and effectiveness of their organisations (International Labour Organisation, [ILO]
1986). A review of the literature on physical ailments that are connected with work stress
have generally concluded that prolonged exposure to certain job demands result in a
variety of pathological outcomes, including mental and physical disorders (Ganster and
Schaubroeck, 1991), to the more serious immune system impairment disorders that lead
to arthritis, cancer or heart disease (O’Cornnor, 2002). Excessive stress can also lead to
15
physical and mental illness (Hiroshi, 1994), insomnia, sexual dysfunction, indigestion,
vomiting, ulcers, diarrhoea, headaches, high blood pressure, heart attacks, and stroke
(Janet, 1995). The ILO (2001) describe that workplace stress may also lead to the
development of musculoskeletal problems, disability and even death. A study of the
effects of stressful job demands for 136 registered nurses employed in a medium-sized
private hospital in the Midwest USA identified several correlations between reports of
stress and physiological outcomes, including elevation in blood pressure both at work and
after work (Fox, Dwyer and Ganster, 1993).
O’Connor (2002) similarly describes emotional and behavioural symptoms that are
related to workplace stress to include complaints of fatigue, heartburn, headache, and
insomnia; irritability, avoidance of co workers, conflicts with supervisors, feelings of
helplessness, loss of self-esteem, and general detachment from the unit or department.
Cole, Slocumb and Mastey (2001), also describes frustration, anger, guilt, resentment,
professional failure, personal loss, powerless, sorrow and burnout as being associated
with workplace stress.
2.4. Is Work Related Stress Costly?
Occupational stress has become a major issue and a problem not just for individuals in
terms of physical and mental disability. Work stress is implicated in 60% to 90% of
medical problems (Information Education Management Resolution, 1999), and as such
has major financial consequences (International Labour Organisation [ILO], 1998; 1993).
A survey in 1998 of 500 randomly selected members of the Institute of Directors in the
US identified that nearly 40% regarded stress as a serious problem for employees in their
16
organisation (Institute of Directors, 1998). In another report from the European Union
cited by the International Council of Nurses (2005), 28% of workers reported stress
related health problems, costing about 41 million Euro (ICN, 2005).
Similarly, Information Education Management Resolution (1999) reported that stress
related to the workplace and its associated problems cost organisations an estimated $200
– $300 billion in the USA each year resulting from worker’s compensation claims of all
kinds (IEMR, 1999). Other studies have reported that the cost of stress-related illness in
the USA is estimated to be around $13,000 per employee each year (Bruhn, Chesney and
Salcido, 1995). As such, work related stress does contribute to economic burden, more
turnover, industrial relations difficulties, and poor quality control (Cooper, Liukkonen
and Cartwright, 1996). The National Mental Health Association in the USA reported that
almost $29 million is wasted each year by the general workforce from symptoms of
reduced productivity related to stress (O’Connor, 2002). The Department of Health, in
the UK estimates it loses seven million working days to stress related illness every year,
at a cost of 5 billion pounds sterling (UKCC, 2001).
The cost of stress and its effect on the Brunei Darussalam economy is not well
documented. Stress is becoming an increasingly global phenomenon that has been
recognised as being very costly to individuals and organisations (Murphy, 2004; Omdahl
and O’Donnell, 1999). The consequences of stress can contribute to organisational
inefficiency, as a result of sickness, decreased quality and quantity of care (Wheeler and
Riding, 1994), decreased job satisfaction (Ernst, Franco, Messmer, and Gonzalez, 2004),
high staff turnover, worker conflict, absenteeism, reduced productivity (Ganster and
17
Schaubroeck, 1991), demoralization and lack of motivation and more (Hiroshi, 1994).
Most organisations have no idea how much stress has cost them each year because they
fail to recognise and address triggers for stress effectively (Harris, 2001). While
contrasting study results have been reported with regard to the relationship between job
stress and job performance (AbuAlRub, 2004), stress has the potential to become an
inhibitive force that can cause diminished individual performance and satisfaction in
work (Healy and McKay, 2000).
A review of the literature suggests that stress can cause burnout, high workforce turnover,
lowered morale and reduced efficiency (Hannigan, Edwards and Burnard, 2004), and can
lead to increased absenteeism, hostility, and aggression (Halvorsen, 2006). It can also
lead to poor time keeping, high turnover of staff, impaired productivity for those at work,
unsafe behaviour and negative health and safety culture in general (Harris, 2001;
Information Education Management Resolution, 1999). Stress is also significantly
associated with an increase in accident rates in the workplace, with one study reporting
that those experiencing high stress are 30% more likely to have accidents than those with
low stress (Lee, 1997). According to the Association of Operating Room Nurses Journal
(2006), situations that produce stress on nurses are more likely to increase the risk of
patients’ injury, and injuries in nurses (Smith, 1999). These injuries can include
contusions, scratches, sprains/strains and cuts/punctures. The authors also concluded that
nurses who experienced more role ambiguity were more likely to incur a reportable
injury at work. Owing to a lack of clarity regarding job responsibilities, nurses may be
performing roles for which they are not properly trained or qualified, thereby placing
18
themselves in unfamiliar situations where the potential for injury is greater. Regardless of
whether the stress is moderate or high, the cost of stress is enormous (Halvorsen, 2006).
2.5. STRESS IN NURSING: A CONCEPTUAL MODEL
Several studies have been undertaken to identify the factors leading to stress in nursing
(Higgins, 2003; Cottrell, 2000; Gray-Toft and Anderson, 1981). Studies conducted in the
1980s by Hingley and Cooper (1986) identified relationships with superiors, role conflict,
home /work conflict, career stress, and stress due to resource management as common
stressors in nursing. Fitter (1987) similarly identified eight factors that may contribute to
stress including responsibility, workload, physically arduous work, shift work, overtime
and covering absent colleagues, interpersonal conflicts, responsibility for training,
uncertainty and unpredictability, and keeping up with change. More recent studies
suggest such stressors continue to exist in nursing, with additional stressors emerging due
to the changing nature of today’s health care system. Schroeder and Carter (2002), for
example, reported nurses found it challenging to meet the demands associated with their
evolving role, such as being a financial manager, resource manager and skilled
commentator. Des (2001) similarly described the difference between historical ideas of
what nursing was and the new image of what nursing has become, with conflicts between
such ideals and realities presenting particular challenges for nurses today.
Several studies have reported that less experienced registered nurses in particular report
work demands as being threatening, as the knowledge and skills provided during training
are sometimes not well matched to the demands of contemporary health care. Such
19
studies report that new nurses often feel their work does not meet the needs of the
patients, that they have very little control over their work, and that they receive very little
support from their supervisors and nurse managers (Casey, Fink, Krugman and Propst,
2004). These studies also suggest that nurses perceive that nursing is emotional work,
involving sharing an intense intimacy with others at their most vulnerable, dealing with
issues of right and wrong in human experiences, and the principles of the right of the
individual versus the common good (Sumner, Townsend-Rocchiccioli, 2003). AbuAlRub
(2004) reports that nurses today also have to cope with the rapid changes and the
complex technological characteristics of the health care system, workload issues and lack
of support (team building and collaborative issues), all of which are major stressors
(Ropis, 2005).
Nursing has also been perceived as less attractive on some important occupational
characteristics such as job independence (Grumbach, 2006). This can be problematic, as
with the increased demands on nurses within a very complex health care system, nurses
may perceive they have accountability with minimal control. Such situations require
nurses to possess exceptional coping skills (Bryant, 1994). Indeed, Duncan-Poitier (2003)
identifies that many nurses new to the profession feel they have too much autonomy, yet
at the same time, may not be in a position to be supported to practice autonomously.
These tensions are reported to be stressful for less experienced nurses. Findings from one
recent survey in the US identified that high levels of autonomy and support by managers
improved the nurses’ identification with the hospital and high levels of autonomy,
support by colleagues, and duties focused on traditional bedside care increased nurses’
identification with the nursing profession (Fox, 2003).
20
Stress theories such as those of Lazarus (1999) emphasise that there are many factors
which may influence a person’s experience of the same stressor, including the meaning of
that stressor, and the strategies that a person may employ to cope with the stressor. For
the present study, the chief investigator will thus also examine what the registered nurses
believe to be helpful in their transition into the real workplace and avoid potential
stressors associated with their work. For example, in this context, strategies which may
be helpful to include stress management training, education, access to hospital resources,
mentoring, team building strategies, balancing priorities, enhancing social and peer
support programs, flexibility in working hours and protocols to deals with violence and
retention.
Figure one presents a conceptual model of stress in nursing that will be used to guide the
present study. The model is based on the core concepts of the Stress-Adaptation theory
originally described by Lazarus and Folkman (1984), and more recently modified by
Folkman (Folkman, Moskoawitz and Tedlie, 2007). Specifically, the model is organised
around two important processes: appraisal and coping. Appraisal refers to the individual's
evaluation of the significance of an event for his or her well-being and the adequacy of
resources for coping (Folkman, Moskoawitz and Tedlie, 2007). Situations that threaten or
harm well-being and that also tax or exceed the individual's coping resources are
appraised as stressful. For registered nurses early in their career, these situations may
include factors such as fear of failure, conflicts with supervisors and other healthcare
professionals, lack of support, lack of organisational skills, or limited experience with the
death and dying. Coping refers to thoughts and behaviours that people use to regulate
their emotions and address underlying problems (Folkman, Moskoawitz and Tedlie,
21
22
2007). For registered nurses early in their career, a range of programs and support
structures, such as mentoring programs, may promote positive coping that will help to
regulate the threat. Importantly, the model also emphasizes that when coping strategies
are inadequate for dealing with a stressor and its meaning to different individuals,
negative outcomes can occur for physical and psychological wellbeing. For stressors
associated with the workplace, these outcomes may include job satisfaction.
While Figure 1 depicts the major concepts that derive from stress-coping theory, this
study seeks to examine selected concepts only. Specifically, this study seeks to examine
stressors and how these are appraised by nurses in the first three years of work as a
registered nurse. The study also seeks to examine the relationship between these
appraisals and work satisfaction, one important outcome in today’s environment of
workforce shortages and increasing demands on the nursing workforce. Some
preliminary investigation of nurses’ perceptions of the types of supports that may assist
their coping is also undertaken. As such, the primary purpose of this study is to provide
an indepth analysis of stressors and how they are appraised by nurses. Further research is
required to examine other key concepts and relationships in this model, such as the
relationships between stress appraisal, coping, and psychological well being.
23
Fig 1: Conceptual model of Stress amongst new Registered Nurses
Harm / Threat/ Challenge Identifies Stressors
- Fear of failure to carry out nursing task - Fear of making mistake - Conflicts with supervisor and other healthcare professionals - Experience of being discriminated - Minimum support from supervisors - Lack of organisational skills - Limited experience dealing with the death and dying
Goals/ Favourable Outcome
- Job Satisfaction
Unfavourable Outcome - Burnout - Job dissatisfaction - Nursing staff turnover (shortages) - Poor patients’ care - Affect physical and psychological
Structure Support and Coping Strategies
- Stress management training - Education - Access to hospital resources - Mentoring - Team building strategies - Balancing priorities - Enhancing social and peer support
programs - Flexibility in work hours - Protocols to deal with violence and
retention - Attraction of nursing staff strategies.
Event
Distress
Positive Emotion
AREA OF STUDY: TRANSITION EXPERIENCE
Emotion Outcome
(Adapted from Lazarus and Folkman, 1984)
Event OutcomeCopingAppraisal
24
CHAPTER 3
3.0. LITERATURE REVIEW
3.1. INTRODUCTION
The increasingly complex world of health care generates the need for nursing staff
members to learn and perform more complicated skills every day. In an era of cost
containment, today’s hospitals are demanding efficient and effective delivery of nursing
services. Rapid changes in the healthcare system and restructuring of some areas of
health care have increased patients’ expectations of what nurses should do and provide
(Sylvia, 1996). Nurse administrators thus expect competent, efficient graduate nurses
upon entry into the organisation (Hamel, 1990). The beginner professional nurse is
required to have the necessary knowledge, skills, attitudes and values which enable them
to render efficient professional service and ensure quality health care delivery (Morolong
and Chabeli, 2005). However, there has been some degree of concern in many countries
across the world over what are perceived to be inadequate levels of skills in graduates
from undergraduate programs (Holloway, 1999). To adequately prepare nurses to
function in today’s health care environment, it is important that educators have a sound
understanding of the stressors and challenges experienced by nurses as they transition
into being a registered nurse. Such information can assist with the development of
education and management support programs to assist nurses to function optimally. This
chapter presents a summary of the empirical literature on stress in nursing.
24
3.2. Stress in Nursing
Nursing is recognized as a stressful occupation (Higgins, 2003; Healy and McKay, 1999;
Laws and Hawkins, 1995; Tyler and Cushway 1995; 1992). There appears to be general
agreement that working in the nursing profession is demanding and often stressful when
compared to other professions, because nurses are more exposed to factors known to
cause stress such as role conflict, role ambiguity, and significant work demands (Sylvia,
1995). Halvorsen (2006) argues that stress affects nurses on a daily basis, and that crises
on the job occur frequently. One qualitative study of the resources and strategies used by
six perioperative nurses to cope with multiple demands upon their role revealed that all
participants expressed that they were experiencing stress (Schroeder and Carter, 2002).
Cox, Griffiths and Cox (1996) suggest that although nursing is acknowledged to be a
stressful profession, there is a need for nurses at all levels to understand the nature of the
stress, its potential sources, and the long and short-term effects on health and safety of an
individual and organisation. There are many factors that may contribute to the demands
placed on nurses. For example, the increasingly higher expectations of patients and
families may be placing greater demands on nurses (Hopkinson, Carson, Brown, Fagin,
Bartlett and Leary, 1998; Sylvia, 1995). Furthermore, the complexity of highly
interactive medical technology (Capka, 1997; Owen and Patton, 2003) means that many
nurses are faced with needing to operate highly specialized equipment with risks to
patient safety.
25
The nursing shortage, and cost containments in the health sector have also meant that
there may be insufficient nursing staff to adequately cover the unit (Baldwin, 1999).
Nurses may have to work through breaks and they may not have enough time to complete
their nursing tasks. These factors may create concerns amongst nurses about their ability
to provide high quality care (Aiken, Clarke, Sloan, Sochalski and Silber, 2002). One
study of 308 nurses in the USA reported that too much work and too little time,
inadequate staffing, inability to meet patients’ needs, and inadequate support
/understanding from senior staff were rated as extremely stressful (Sylvia, 1995).
Nursing is also well-known for its irregular hours and the unsocial nature of its work
(Santamaria, 1995), due to unpredictable staffing and scheduling. The International
Council of Nurses (2007; 1995) has identified that shift work especially evening and
night shifts often introduces additional hardship on nurses providing services in complex
working environments and demanding interpersonal situations.
Moreover, nurses face a wide range of human emotions, for example listening or talking
to a patient about his/her approaching death (Sumner and Townsend-Rocchiccioli, 2003;
Halvorsen, 2006). Working in the nursing profession often involves sharing the traumas
of illness, injury, and death, not only with the patients but with multiple family members
and friends (Gillespie and Kermode, 2004; Cox, Griffiths and Cox, 1996; Sylvia, 1995).
This can cause nurses to harbour emotions such as anxiety, depression, fear and anger
(Halvorsen, 2006). A study of National Health Service Trust staff in the United Kingdom
identified high levels of job-induced stress, depression, anxiety, sickness, absence and
propensity to leave, associated with the presence of greater occupational demands
26
(Quine, 1998). Other Australian studies have also reported that nurses are frequently, and
in some cases, excessively exposed to various traumatic incidents as a part of their daily
work (Gillespie and Kermode, 2004).
The occurrence of stress is common in individuals or groups when their situation is
overly complex, ambiguous, unclear, or highly demanding with regards to competence or
required to deal with the demands (Bass, 1990). Today nurses are expected to have a
wide range of skills from providing basic nursing care, to the ability to use highly
technological equipment, through to bereavement counselling (Ropis, 2005). Nurses must
also deal with complex situations and ethical dilemmas (Rainham, 1994). Support to
continue to develop new knowledge and skills is therefore critical, however, there is often
a lack of time available for activities such as clinical supervision, or for peer support
(Kelly, Simpson, and Brown, 2002).
3.3. Multiple Sources of Stress
The combination of changing work responsibilities (Beynon, Gromshaw, Rubery and
Ward, 2002), work related stressors present in the nursing working environment and
problems occurring outside the nursing working environment (Rainham, 1994) all
contribute to stressful feelings experienced by nurses (Sylvia, 1995). The complexity of
nursing practice especially when workplace and roles of nurses are changing (McVicar,
2003), together with advances in medicines and health technology (Farley, 2004), may
result in variation between nurses in their perception, interpretation of events and
emotions (McConnell, 2000). Johnstone’s (1999) study investigated the causes of
occupational stress and nurses’ perceptions of the effects of modern medical technologies
27
on several aspects of their work life during the preceding three years in Victoria and New
South Wales. She found that there was a strong perception amongst the 433 nurses that
medical technologies had contributed to their increased workloads and higher levels of
stress (Johnstone, 1999). Another study aimed at assessing the different sources of job
stress for nurses in a number of public hospitals in Saudi Arabia identified six possible
sources of job stress for nurses in public hospitals. These included organisational
structure and climate, job itself, managerial role, interpersonal relationships, career and
achievement and homework interface (Al-Aameri, 2003).
The common stressors identified in many nursing studies include family, health,
financial, intellectual, social, spiritual, and professional issues (McConnell, 2000), sexual
harassment, office politics and unclear job roles, role conflicts, and role ambiguity
(Smith, 1999; Information Education Management Resolution, 1999), insufficient
nursing staff (numerically and experientially), lack of equipment, work overload, role
overload, inadequate training opportunities in the use of new advanced technologies, and
aspects of organisational structure (Johnstone 1999). For example a study by Tyler and
Cushway (1992; 1995) noted that workload related to environmental issues which include
inadequate staffing levels and insufficient time to complete the work task was perceived
as the most frequently occurring source of stress in the workplace. Another study of 129
registered nurses in Victorian and regional institutions found that nurses ranked
workload, interpersonal conflict in professional relationships with working colleagues,
uncertainty with treatment, dealing with medical emergencies, sudden and unexpected
deterioration of the patient’s conditions, and lack of support to deal with emergencies
were some of highly rated stressors in the nursing profession (Healy and McKay, 1999).
28
Additionally, Carroll and Adams (1994) noted that the multiple demands of the role were
rated as the most stressful component of all. These included the experience with conflict
resolution, counselling and performance management. In Brunei Darussalam stressors in
nursing have not been investigated.
3.4. Concerns about Clinical Competence
In 1984, Benner defined professional nursing competence as stages of skill achievement
which begins with novice, advance beginner, competent, proficient and expert.
Competence is the ability of a person to fulfil the nursing role effectively and/or expertly;
it can also be considered as made up of a set of separate competencies (Ramritu and
Barnard, 2001). The clinical competence of registered nurses relating to the care of
individual clients is dependent on the nurse’s ability to correlate theoretical knowledge
learned in the classroom with practice and the development of clinical skills. Its
foundation lies in the ability to identify and solve problems that emanate from critical
thinking, analytical reasoning and reflective practice (Moeti, Niekerk and Velden, 2004).
Importantly, Moeti, Niekerk and Velden (2004) found that many new registered nurses
have sufficient theoretical knowledge, but sometimes lack competency in basic nursing
skills and have difficulty correlating theory into practice. Ramritu and Barnard (2001)
further reported that new registered nurses preferred to care for less critically ill patients
and those who required less complex nursing treatment. Over the past few decades, a
number of authors have thus commented on the limited interface between university
schools of nursing and clinical practice agencies preparing registered nurses for the
29
practice setting and in evaluating their competence to perform in this setting (Alex and
MacFarlance, 1992). When considering issues of stress in nursing, it is important
therefore, that the many registered nurses may have concerns about their clinical
competence. This potential source of stress is especially important for new registered
nurses.
3.5. Role Conflict
Conditions of work that are characterised by role conflict and excessive role demands are
particularly stressful (Wallace, 2002). Wallace argues that there is a potential for conflict
between professionals and the organisations when the values, goals and expectations of
the professional are incompatible with those of their employing organisation, especially
when professionals are employed in highly bureaucratic organisations. High levels of
reported role conflict are associated with increased tension, lower work-related
satisfaction, intent to leave, and poorer job performance (Wu, 1994).
Health professionals are often unprepared for organisational professional conflict, and as
such may find such conflicts create stress (WHO, 2004). These conflicts can arise from a
number of factors. For example, for new graduates, a common source of conflict can be
perceived differences between their ideal and the reality of contemporary health care, and
between expectations of managers and those of the graduate themselves (Pines, 1993).
Some writers suggest that a degree of role stress may also be advantageous leading to
better, integrative approaches to tasks (Siegall, 1995). Dawes (1999), for example, argues
that conflicts do not and should not be considered negative or detrimental in all
30
situations. By nature, conflict can be a primary motivator for change. However, such role
conflict often involves negative emotions. As such, conflict may result in low
productivity and can promote mediocre performance, boredom and apathy, thus creating
more stress (Dawes, 1999). Furthermore, for the new registered nurse, inconsistency
between the student role and the staff nurse role can create professional and personal
conflicts that new registered nurses often find devastating.
3.6. Violence and Aggression
Work-related violence is a serious global, multifaceted phenomenon that presents
challenges to nursing management. The International Labour Organisation (1998) reports
that workplace violence, whether it is physical or psychological, has become global,
crossing borders, work setting and occupational groups. This has turned some workplaces
and occupations into high risk arenas where women are especially vulnerable. Reports of
workplace violence against healthcare personnel have thus been increasing and nursing
staff are often the target or most at risk of violence (Uzun, 2003; Hilton, Kottke and
Pfahler, 1994). Mayhew and Chappell (2001a) identified that nurses experienced more
occupational violence compared with allied health providers and GPs, regardless of the
reporting period or whether violence was experienced from patients, patients’ relatives,
or professional colleagues.
The nature of this violence varies substantially. For example, a study of 145 US operating
room nurses identified that the presence of sabotage is common. The most frequent
method of sabotage was being expected to do another’s work followed by being
31
reprimanded in front of others and not being acknowledged for their own work (Dunn,
2003). Cook, Green and Topp (2001) similarly report that the most common form of
aggression is verbal abuse, with an incidence as high as 98.5% (Ergun and Karadakovan,
2005). Verbal abuse is a dysfunctional but common method of dealing with frustration
and anger that has been defined as those kinds of verbal behaviours that humiliate,
degrade, or otherwise indicate a lack of respect for the dignity and worth of another
individual (Cook, Green and Topp, 2001). Hamlin and Hoffman (2002) refer to this as
behaviour that is unwanted or unwelcome by the recipient. It is an illegitimate exercise of
power; neither flattering nor complimentary, and it is not determined by physical
attractiveness. The offender uses his or her authority, dominance, or power to belittle,
humiliate, and refuse to promote, dismiss or demote someone. Cox (1991) explains
verbal abuse is any communication a nurse perceives to be a harsh, condemnatory attack
upon her or himself, professionally or personally. Such abuse may be the form of
devaluing, discouraging, scapegoating, backstabbing, complaining, and other forms of
non therapeutic and destructive communication directed at co workers.
Sofield and Salmond (2003) report that some of the causes of verbal abuse in a hospital
setting are related to the highly stressful situations and the power differentials or unequal
interpersonal relationships that are present. When such abuse is directed at co-workers
who are on the same level within an organisation’s hierarchy, it has been called
horizontal violence (Dunn, 2003). When it is comes from physician colleague to nurse, it
has been called vertical violence. Verbal abuse sometimes also comes from patients and
patient’s families, in some cases this can be extreme (Paul, 2001). A descriptive
correlational study of a randomly selected list of 1000 (33% of total population of nurses
32
in the system) registered nurses from a three-hospital health system in the Northeast of
USA was conducted to examine perceptions of verbal abuse and intent to leave the
organisation. The study identified that physicians were the most common overall source
of verbal abuse experienced in the past six months, followed by patients (56%), families
(48%), peers (28%), supervisors (16%), and subordinates (15%) (Sofield and Salmond,
2003).
Findings from recent research suggests that health care workers, in particular, nurses have
a higher incidence of stress-related illness, depression, fear, and job turnover, as well as
decreased self esteem, when working in stressful, abusive, and authoritative situations
(Cook, Green and Topp, 2001). One survey of around 1500 allied health professionals,
doctors, and nurses working in a rural area in eastern Australia reported that 68% of
nurses, compared to 47% of allied health providers and 48% of GPs, reported
experiencing violence in the workplace. The most frequent form of occupational violence
reported was verbal abuse, followed by threatening behaviour, physical violence and
obscene behaviour (Alexander, 2004).
These high rates of reported occupational violence, especially verbal abuse, are reported
across many countries. In a study of 600 nurses in the Toronto area, one-third had
experienced some form of abuse at work in the five days prior to the study (Whitehorn
and Nowlan, 1997). Another study in Turkey identified that of 72.3 % (141/195) of nurse
respondents had experienced some form of violence. Most of the respondents stated that
they had experienced verbal/emotional abuse (69.5 %), specific threats (53.2 %), and
33
physical action (8.5 %) (Ayranci, 2005). Similarly, a study of 467 nurses in three
hospitals in East Anatolia, Turkey identified that verbal abuse was prevalent in health
care settings, originating from patients’ relatives, patients, and physicians and even from
other nurses. Nurses perceived that it affected their ability to function, and that it
increased the likelihood of staff turnover (Uzun, 2003).
A recent study of more than 400 nurses in Nova Scotia reported that 63% had
experienced verbal abuse at work in the past year, while 35% had experienced attempts
of physical harm and 21% had been the victims of a physical attack (Whitehorn and
Nowlan, 1997). Another study that explored the prevalence of workplace violence
amongst 205 nurses in South Taiwan identified the verbal expressions of violence were
mainly due to misunderstanding and drunkenness on the part of patients and their
families, but also due to personal problems in the nurses’ relationships with doctors and
co-workers (Lin and Liu HE, 2005).
In the USA, a study of the prevalence and consequences of verbal abuse of staff nurses
by physicians amongst 130 staff nurses identified that 90% reported that they experienced
at least one episode of verbal abuse during the past year, with the average number of
reported incidents during the year being between 6 and 12. The most frequent and most
stressful types of verbal abuse came in the forms of abusive anger, ignoring and
condescension (Manderino and Berkey, 1997). In another study in Northwest Ohio of 78
perioperative experiences, 91% reported experiencing at least one episode of physician
verbal abuse during the past year. Of these 32 (45%) reported experiencing verbal abuse
34
several times per year; 16 (22.5%) reported experiencing verbal abuse once a month or
less; 4 (5.6%) reported experiencing verbal abuse once a week; 16 (22.5%) reported
experiencing verbal abuse several times per week and three (4.2%) reported experiencing
verbal abuse every day. Types of verbal abuse that caused the most stress and occurred
most frequently were abusive anger, condemnation, abuse disguised as jokes, ignoring,
accusing, blaming, judging, criticizing, blocking and diverting (Cook, Green, and Topp,
2001). The rate of such abuse in Brunei Darussalam is currently unknown.
Hamlin and Hoffman (2002) argue that historically most nurses are represented by
women. Nurses have been socialised to adopt the traditional female or subordinate role
(caring helper), which is seen as secondary to the role of physician. The authors note that
although men also are victims of sexual harassment, the incidence is much lower. Nurses,
both male and female, have learned patterns of behaviour that include relinquishing
power to the physician and adopting a passive communication style. As a result, an
unequal distribution of power has been perpetuated in the nurse-physician relationship.
Additionally, nurses and physicians experience different economic, political and social
status, which further contributes to an uneven distribution of power (Hamlin and
Hoffman, 2002). These power differentials thus create a relationship in which the use of
violence in many different forms may be more common.
Occupational stress resulting from verbal abuse is thus a major problem for individuals,
organisations and affecting all industries including health care (Hannigan, Edwards, and
Burnard, 2004; Alexander, 2004).It is not surprising that the apparent frequent experience
of occupational violence is one factor contributing to workplace stress (Hamlin and
35
Hoffman, 2002; International Labour Organisation, 1998). One UK study identified that
half of all nurses working in the National Health Services (NHS) trust reported workplace
stress resulting from bullying, harassment and abuse. The study authors estimated that
this cost NHS trusts an average of 450,000 pounds a year from staff feeling unwell
because of stress, with around 3.6 million pounds a year required to cover the resulting
sickness absence (Paton, 2005; Rodham and Bell, 2002). Other writers suggest that if not
dealt with, stress from workplace violence may contribute to an increased incidence of
errors, and low morale (Buback, 2004), or higher turnover (Webb, 2002). Importantly,
many incidents of violence remained unreported (83.5%), with most of the reported cases
not resulting in legal action (Ergun and Karadakovan, 2005).
Despite its potential importance as a stressor for nurses, violence against health care
personnel remains poorly researched or understood (Ferns, 2005). Nurse researchers
have reported that workplace violence such as sexual harassment, physical assault and
verbal abuse experienced by nurses often comes from physicians, resulting in feeling of
insecurity, frustration, attitude problems, stress, situational difficulties, or lack of time
(Sofield and Salmond, 2003; Dunn, 2003; Whitehorn and Nowlan, 1997; Ayranci, 2005;
Ergun and Karadakovan, 2005; Manderino and Berkey, 1997). Verbal abuse directed at
nurses is identified as being widespread and this negatively affects on patient care (Cook,
Green and Topp, 2001). One study reveals that the most severe long-term effects of
verbal abuse were a negative relationship with the offending physician and increasing job
dissatisfaction (Manderino and Berkey, 1997); lack of communication, lack of trust, all of
which negatively affect patient care due to hesitation to call regarding changes in
patient’s condition and hesitation to suggest improvements to care (Cook, Green and
36
Topp, 2001). At least 16 % of nursing turnover was identified as being directly related to
these factors (Cox, 1987). Moreover, studies suggest a large number of staff nurses
report having experienced being verbally abused by registrars and consultants and in
many cases, this abuse has lead to psychological distress, self-doubt and a significant
amount of loss of respect form colleagues and peers (Michael and Jenkins, 2001). Hilton,
Kottke and Pfahler (1994) similarly reported verbal abuse increased stress, produces
negative attitudes and poorer self confidence.
3.7. Workload and Resource Constraints
The inability to meet patient’s needs is a great concern because it goes to the very heart
of what nurses perceive as their role. The importance of the holistic approach to nursing,
providing psychological care and support alongside the physical care, has become widely
accepted over recent decades. However, nurses say that they are frequently unable to do
so because of staff shortages, which reduces the nursing time available to the individual
patient (Sylvia, 1996). One study of 433 Australian nurses, conducted in 1996, found the
main causes of stress were frequently linked with financial constraints. These may
include insufficient staff (numerically and experimentally), lack of equipment, work
overload and role overload, inadequate training opportunities in the use of new medical
technologies and aspects of organisational structure (Johnstone,1999).
The American Association of Colleges of Nursing (AACN) reported that the future of
professional nursing is threatened today by the current and impending shortage of nurses,
while the entire health care industry is affected, it is even more predominant in speciality
areas and if unresolved, the crisis will be even more significant in the future (AACN,
37
2002). The nationwide nursing shortage is expected to balloon from 6% currently to 29%
by 2020, straining hospitals’ finance and inhibiting quality (Health Care Strategic
Management, 2003). The shortages of nurses have resulted in dissatisfaction because of
not enough manpower to carry out the job, and inability to provide high quality patient
care (Aiken et al., 2001). One study found that nurses frequently stated that there are
insufficient staffs to cover illness and, if a nurse is sick they feel guilty because their
colleagues have to carry an even heavier burden (Sylvia, 1996). Dockery (2004)
identified that dissatisfaction with non-pay aspects of the job appears to have a stronger
influence on overall job satisfaction and on intention to leave the profession. Ernst,
Messmer, Franco and Gonzalez (2004) similarly identified that the factors which
influenced work satisfaction in a group of paediatric nurses in the USA included pay,
time to do nursing care, confidence in one’s ability, and task requirements. Importantly, a
relationship between nurses’ job satisfaction and work organisation, job stress, and
recognition was found.
Such results have led some organisations to suggest that financial incentives are one way
of defining the value of nursing services and continue to be a key factor in nurse
retention. Kirsch (2001) stated that salaries and financial benefits continue to be
important themes in combating nurse turnover. A study reported by McDowell (1992)
indicated that nurses voice that their pay as not being commensurate and an important
reason for why they considered leaving nursing. Higher salary opportunities for
experienced nurses versus new registered nurses may lead to decreased turnover rates and
reward clinical expertise (Trossman, 2002). Another study indicated that nurses’ average
level of satisfaction with pay was the lowest of all the job climate satisfaction scale
38
means. About 45% disagreed or strongly disagreed with the statement, “My present
salary is satisfactory”. In contrast, about 20% agreed or strongly agreed with the views
(Duncan-Poitier, 2003). While pay may be an important factor in job satisfaction, the
relationship between concerns about pay, and the level of stress experienced by nurses
has not been investigated in great depth.
What is evident today is that health care settings are increasingly characterised by higher
patient acuity, shortened length of stay, and increased role responsibilities due to the
flattening of the nursing hierarchy. These changes, although very positive in some cases,
have caused a destabilization and disruption to the traditional nursing orientation models
(Higgins, 2004). These high job demands can lead to variety of pathological outcomes,
including mental and physical disorders, absenteeism, and reduced productivity (WHO,
2004). Studies report that nurses are struggling to cope with chronic staff shortages, ever-
increasing workloads, and expectations that they will continue to donate unpaid overtime
(Harulow, 2000). One early study reported that work overload were rated by nursing
respondents as the major contributing factor for nurse’s stress (Hipwell, Tyler and
Wilson, 1989). The Joint Commission on Accreditation of Healthcare Organisations
(JCAHO) describe unrealistic and unsafe nurse-patient ratios and the excessive
paperwork demand by managed care and other insurers, have not enabled nurses to spend
quality time with patients, resulting in job dissatisfaction (2002). Studies report higher
levels of job dissatisfaction and emotional exhaustion among nurses were strongly related
to nurse-patient ratios (Aiken, Clarke, Sloane, Sochalski and Silber, 2002). Ernst, Franco
Messmer and Gonzalez (2004) found similar results, with pay, time to do nursing care,
confidence in one’s ability, and task requirements being identified as factors influencing
39
nurses’ job and organisational work satisfaction. Heavy workloads, a lack of time to
spend with patients and feeling of being unvalued in their work are reported to contribute
to the high turnover of nurses from profession (Davison, 2002). In another study Moore,
Kuhrik, Kuhrik, and Barry (1996) reported that the level of stress perceived by registered
nurses negatively related to their organisational commitment, and that this stress resulted
primarily from work overload, changing assignments and lack of resources.
In a review of the literature on role stress, work overload has been reported as one of the
main reasons for nurses leaving the workforce (Chang, Hancock, Johnson, Daly and
Jackson, 2005). Sylvia (1996) explained that workload which is shared among smaller
numbers of nursing staff leaves less time for the emotional and psychological caring
aspects of nursing. This increases nurses’ stress, often resulting in the failure to maintain
high nursing standards and dissatisfaction with their inability to meet what they perceive
as the patient’s needs. One study identified that eight of every ten nurses report they have
to work very hard in their jobs, close to two thirds reported that they have to work very
fast at their jobs, nearly one third of respondents indicated that they felt under great stress
almost every day, and another fifth reported feeling under great stress several days a
week (Duncan-Poitier, 2003).
3.8. The Role of Nurses Providing Care to Dying Patients.
Most nurses caring for patients will encounter death as part of their work. This
experience often causes anxiety (Brisley and Wood, 2002). Providing care to acutely ill
or dying patients has been identified as one of the more common and important internal
40
sources of stress among nursing staff (Cole, Slocumb and Mastey, 2001; Moszczynski
and Haney, 2002).
Numerous studies have identified caring for dying patients to be an important stressor for
nurses. Edwards (1997) identified that should a normally healthy person die unexpectedly
in the operating theatre during routine surgery or as a result of trauma, this was especially
stressful. The death of patients in the operating room and post anaesthesia care unit is
sometimes an unexpected event that can cause grief, burnout and turnover among the
caregivers who work in the area (Gerber and Workman, 1995). According to Petit de
Mange (1998) death anxiety is a complex multi-factorial phenomenon where individuals
have anxieties related to death issues that can impact upon them psychologically,
physically, socially and spiritually. Death anxiety can be associated with lack of
experience and inadequate death education (Brisley and Wood, 2002). Gillespie and
Kermode (2004) reported that feelings of inadequacy, incompetence and self-blame were
commonly described by nurses in relation to incidents which culminated in patient death.
Studies of the care dying people received in acute hospitals show that nurses experience
difficulties in meeting the patients’ and their families needs (McWhan, 1991). In most
cases new graduate nurses could not recall clearly the details of the education they
received regarding the care for dying patients and their relatives because they all found
that the reality was very different to the theory (Brisley and Wood, 2002). The limitations
of pre nursing registration preparation in care of dying results in difficulties in caring for
dying people (McWhan, 1991). To enable new graduate nurses to provide care for others
and themselves, it is necessary that a safe environment be provided in which to explore
41
death issues. Formal and informal education needs to be made available early in the
under graduate program and continuing through transition programs in the workplace
(Brisley and Wood, 2002).
3.9. Support from Managers and Colleagues
Studies have reported new nurses in particular often feel angry that supervisors and co
worker had done little to increase their self esteem (Chapman, 1993). Dunn (2003)
described feelings of anger and frustration were often pointed towards nursing
administrators, surgeons and other nurses, as nurses viewed their administrators as being
absent from day-to day activities and as providing minimum support and recognition.
Moore, Kuhrik, Kuhrik and Barry (1996) surveyed 336 acute nurses who identified that
job stress was a consequence of non supportive supervisors and co workers, resulting in
dissatisfaction with their position and intention to leave their job.
Issues relating to supportive work environments are especially important for new
registered nurses. Byrne, Cantrell, Fletcher, McRaney and Morris (2004) noted that
concern has been raised by students and new registered nurses who experience being
isolated by experienced nurses who are reluctant to mentor. A qualitative study of new
registered nurses in South Australia identified a culture which was not conducive to new
registered nurses ongoing learning, consolidation of skills and application, to practice. A
rushed environment that was unpredictable, together with lack of support, were recurrent
themes from the nurses’ perspective (De Dellis, Longson, Glover and Hutton, 2001).
Moreover, a study of Swedish nursing students’ about where in the health care system
42
they would like to work as a registered nurse after graduation found that students were
often isolated during working with no apparent support system. This reinforced their own
ambivalence and reluctance towards future work in delivering care (Fagerberg, Winblad
and Ekman, 2000).
Chapman (1993) identified major dissatisfaction with non supportive supervisors and co
workers as being primary reasons nurses leave hospitals. As such, she suggests that by
providing a supportive work group, for example by helping the person or sharing
work/task responsibilities, work stress can be reduced and job satisfaction increased.
Duncan (1997) similarly notes the importance of supportive work environments to new
nurses both before and after accepting the first registered nurse position. Ronsten,
Andersson and Gustafsson (2005) further identified that mentorship enabled novice
nurses to nurse in a more reflective and holistic way and was a crucial ingredient for
maintaining quality standards in nursing.
3.10. Stressors associated with the Transition to being a Registered Nurse
Expectations from the health care environment are that nurses rapidly function as a
competent practitioner (Casey, Fink, Krugman and Propst, 2004). Many nurses do
however experience difficulty in adjustment, with confidence gradually increasing as
they developed organisational and prioritizing skills, find their own style and rhythm and
begin feeling a connection to the unit and institution. One study found that new registered
nurses often do not feel skilled, comfortable, and confident for as long as one year after
being hired, highlighting the need for healthcare organisations to provide extended
43
orientation and support programs for new graduate nurses to facilitate successful entry
into practice (Casey, Fink, Krugman and Propst, 2004). The first year of practice is often
characterised by the feeling of clinical inadequacy, making this a stressful situation for
new graduate nurses because their clinical expertise is often not at the level expected by
nursing administrators, other nursing staff, physicians and hospital administrators
(Ganga, 1998).
Studies indicate that new registered nurses’ clinical competency generally significantly
increases overtime, as did their familiarity with work demands and the hospital
environment. As such a significant increase in their level of job satisfaction is often also
evident (Currie, 1994; Al-Ahmadi 2002). Importantly, the most important determinants
of job satisfaction amongst new nurses were recognition, technical aspects of supervision,
work conditions, utilization of skills, pay and job advancement.
Some authors have described the transition year as providing a mediated entry into the
nursing profession, where the new graduate nurses infuse patterns of adjustment, learning
to cope, and understanding how and when to seek help and support (Clare and Van Loon
2003). When new registered nurses enter the working world they experience a range of
unfamiliar situations for which they may be unprepared due to their limited experience,
shortage of practical and managerial skills, feelings of lack of support and excessive
workloads (Huang, 2004; Maben, 1996). One study on the transition to being a registered
nurse in New Zealand identified five themes relating to the experience. These included:
accepting responsibility, accepting their level of knowledge, becoming a team member,
professional standards and workplace conditions. Graduates’ reported an ability to
44
critique their own practice, but they found it more difficult to challenge their colleagues’
practice and the wider agency culture (Walker, 1998).
Kramer (1974) coined the term ‘reality shock’ to describe the experience of new
registered nurses initial education being in conflict with the work world values. Kramer
(1968, 1974) theorized that the first job in a hospital setting was often marked by
dramatically conflicting value systems, namely, the idealism of pre service education and
the reality of nursing service. New registered nurses have to distinguish the values of
school which is previous work experiences and the current work culture when entering a
new organisation. According to Kramer (1974), nursing students are socialized in school
to a professional model of nursing practice which includes the concept of providing care.
This relies on the individual’s use of her/his judgement, autonomy, knowledge and
decision making skills. This socialization process emphasizes the “should” and “ought”,
or “ideals”, of nursing practice. Upon entering the work world, however, the new
graduate encounters a part-task system of care and a culture which relies on the
bureaucratic characteristics of efficiency, organisation, responsibility, and cooperation.
The hospital socialization process emphasizes the compromises or shortcuts required to
get the job done and how values are put to work in the context of less than “ideal”
situations, such as staff shortages and emergencies (Currie, 1994). Having little warning
or knowledge of the values and expectations of the health care environment, new
registered nurses often experience conflicts and confusion during the initial process of
learning into the new social cultural system (Benner and Benner, 1975).
45
While the concept of reality shock was first described in the 1970s, studies suggest it still
has some relevance today. Godinez, Schweiger, Gruver and Ryan (1999) reported that the
first three months of employment are the most stressful time in nurses’ careers. This is
because the transition from school to the work world is considered as the loss of one’s
familiar social setting which is replaced by a distinctly new culture (Hamel, 1990). The
transitional shift from nursing school to work organizations or from student nurse to
professional nursing is thus a difficult one. During this time the new registered nurse may
attempt to hold onto the school or previous departmental work values and this often
results in a clash between cultures (Higgins 2003). Socialization into a new nursing work
culture involves demonstrating competency and proficiency in delivering patient care
which the new registered nurses may find difficult (Myer, 1992). According to one
survey, half of the new registered nurses sampled felt the orientation period was too
short. Increased technology, complicated medical interventions, inadequate staffing, and
care of patients with complex diagnoses were reported as overwhelming the new
registered nurses (Floyd, 2003).
Hulsmeyer (1994) conducted a qualitative study of 15 new registered nurses to examine
the experiences of new graduates’ during the transition from student to practicing
registered nurse. Major themes that emerged were experiential learning, gendered work
relations, caring and giving care, and the influence of college on moral reasoning and
nursing practice. Experiential learning was vital to participants’ acquisition of technical
skills and self confidence. Their efforts to care and give care were compromised by
gendered work relations. Caring and giving care were dominant concerns throughout the
transition period. They were especially troubled by ethical dilemmas in regards to dying
46
patients. They believed that college taught them to recognise ethical dilemmas and to
think critically. However, different comments by participants at points in time suggest
that they cling to caring values in a sometimes indifferent work environment. Although
some new nurses adjusted their values to adapt to the work reality, others maintained
their ethic of caring and attempted to act on those values (Hulsmeyer, 1994).
Higgins (2004) stated that one of the most important transitions of adult life occurs when
facing the challenges of a new job in a new setting. Making the transition from nursing
student to practicing nurse requires the novice to master a wide range of complex nursing
skills (Hamel, 1990). As a result new graduate nurses experience difficulty in adjusting as
they navigate this challenging moment and found transition from nursing student to
newly graduate staff nurse as stressful (Huang, 2004). Transitions are complex and
multidimensional as a result of changes in life, health, relationships and environment
(Meleis, Sawyer, Im, Messias and Schumacher, 2000). Oerman (1996) explains that
transitions allow new registered nurses to practice in real clinical situations. Such
transitions are essential because of the need to interact with variety of clients and other
health care professionals when providing care. These transitions may include the
opportunities to develop skills, apply scientific principles in providing care and make
clinical judgement in real situations.
Similarly a study on new graduate nurses who had completed their first year of clinical
practice after graduation in a Victorian private hospital, Australia identified three major
themes. The ‘first steps’ described the unexpected shock and feelings of being
unprepared on entry to the work setting along with the reality of the unrealistic
47
expectations of colleagues. ‘Stumbling blocks’ described the multiple role and personal
stressors that challenged the participants. ‘Striding ahead’ described the factors that
facilitated the participants’ adaptation to the registered nurse (RN) role (Goh and Watt,
2003).
Hamel’s (1990) study of the influences of nursing subculture as perceived and understood
by new graduate nurses on entering the nursing profession also revealed some important
factors that may contribute to stress. These factors included fear of failure, fear of total
responsibility, and fear of making mistakes, a subculture which de-emphasized
psychological interactions and placed value on efficiency and task-oriented nursing care,
and a clash between the new graduate nurse’s values and those of the work world. This
made integration into the nursing subculture at times unpleasant. Moreover, preceptors
providing minimal support to the new graduate nurses, largely because they did not
understand the preceptor role were also identified as potential stressors, as they found it
difficult to articulate the values, norms, beliefs, and expectations to new graduate nurses.
New nurses also reported difficulty with task self-esteem because of their lack of
organisational skills (Hamel, 1990).
3.11. Coping and Support Strategies
New registered nurses entering professional practice may have somewhat limited mastery
of or familiarity with various nursing skills and only basic understanding of diseases
processes (Hardy and Conway, 1998). Kelly, Simpson and Brown (2002) therefore
concluded that newly qualified nurses’ required enormous support in further developing
48
their self confidence and professional competence. The transition between school and
work is a time of critical development for the beginning practitioner (Alex and
MacFarlane, 1992). This increasing understanding of the stressors experienced by new
registered nurses during this transition period has thus resulted in increasing interest in
understanding the support and guidance required from their immediate supervisors and
more senior staff in order to effect and achieve a successful transition (Goh and Watt,
2003).
Transition support has been categorized into two categories. Material support for new
graduates may include money, tools, people and a supportive physical environment.
Psychological support is primarily in terms of expert cognitive advice from supervisors,
emotional support from counsellors, or behavioural support (Chapman, 1993). Such
support can positively protect individuals from the deleterious effects of stressors
associated with the work environment, by contributing to feelings of self-esteem and
acceptance (RNAO, 2006). This support may also serve an informational function and
help individuals to interpret, comprehend and cope with potential stressors in functional
ways, and may also simply fulfil needs for social companionship and affiliation that may
contribute to feelings of belongingness. Moreover, this support may serve an instrumental
function by providing individuals with the material resources and services needed to help
combat the source of stress (WHO 2004). One study that examined the relationship
between staff nurses’ perception of collegial support and job stressors within the hospital
revealed that by identifying and reinforcing effective coping mechanisms and developing
supportive relationship, individual perceptions of distress may be reduced and nurses may
be able to provide safe nursing care (Chapman, 1993).
49
Recognition of the particular support needs of new registered nurses has resulted in the
development of a range of transition programs for this group. Duncan (1997) reported
that student clinical and work-related experiences are available at many healthcare
organisations, however, very little is known about how these experiences may contribute
to the employer/nurse work relationship that begins after graduation. Wilson and Startup
(1991) argue that a more unified approach must be adopted to reduce the conflicts which
learner’s experiences. Amos (1993) similarly argue that to minimise the occurrence of
stress during the new graduates’ transition period, employers need to plan an orientation
program at a minimum of six months. During the orientation program the graduate is
introduced to the institutional culture including policies and procedures. Such programs
serve as support mechanism and allows for less stressful transition into nursing practice
(Begat, Severinsson and Berggren, 1997).
Clinical supervision for new registered nurses was also identified as important in
encouraging nurses to think about their skills and professional development needs.
However, it appears that there is often a lack of time available for this in most areas
(Kelly and Simpson, 2002). Huff (2004) argues that mentoring offers a chance for growth
and development within the practice of nursing. Mentoring can offer professional
replenishment to expert nurses, thus contributing to the retention of experienced nurses
and producing future nursing leaders with the skill and passion to make a lifelong
commitment to professional development and nursing growth. Preceptorship approaches
have previously been promoted and have gone some way towards addressing the support
needs of registered nurses (Bain, 1996). One study investigated nurse’s satisfaction with
50
their work environment and moral stress following participation in a systematic clinical
nursing supervision program. Results of the study indicate that there is a significant
relationship between moral sensitivity and systematic nursing clinical supervision,
suggesting that support for nurses to develop personal qualities, integrated knowledge
and self-awareness was important and may be useful for developing the coping strategies
required for dealing with the stressors associated with being a new registered nurse
(Severinsson and Kamaker, 1999).
3.12. Summary
This chapter has presented a review of the literature relating to stressors in nursing. The
literature identifies a range of common stressors in nursing, associated with the nature of
nursing work and today’s health care and the work environment. These sources of stress
include concerns about clinical competence as a new registered nurse, role conflicts,
violence and aggression, workload and resource constraints, care of dying patients, and
inadequate support from managers and colleagues. The particular experiences of new
registered nurses, and the stressors associated with this experience as they transitioned
into a new role were also reviewed. In addition, literature that has described some of the
key strategies that may assist with developing the coping strategies needed to cope with
these stressors has been reviewed. These strategies include both practical and
psychological supports for the new registered nurse, in many instances formalised into
structured transition programs and clinical supervision activities.
51
CHAPTER FOUR
4.0. METHOD
4.1. Research Design
This study used a descriptive correlational design to examine new registered nurses’
(within the first three years of work as a registered nurse) perception of stress and level of
job satisfaction in a complex clinical nursing working environment in Brunei
Darussalam. A self-report survey was used for this study.
4.2. Setting RIPAS hospital was officially opened in 1984. It has 555 beds, operating rooms, a
number of speciality units and surgical wards. These include an Otorhinolaryngology
integrated Head and Neck Surgical Department, Gynaecology and Obstetric Department,
Anaesthetics Department, Urology Department, General Surgical Department,
Orthopaedic Department and Neurology Surgical Department. RIPAS is a Brunei
Darussalam government hospital managed by the Ministry of Health that is a not for
profit hospital, with all services provided being primarily funded through the general
treasury (Ministry of Health, 2007).
RIPAS Hospital is the country’s main referral hospital where the majority of nurses are
employed. It is recognised as a tertiary hospital where the majority of teaching and
learning takes place for nursing and medicine. Currently RIPAS Hospital has been
working collaboratively with the Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah
52
(PAPRSB) College of Nursing of Brunei Darussalam, University Brunei Darussalam and
University of
Queensland Australia. The hospital is selected for this study because it is the largest
referral hospital among the other four main hospitals in the country and most of the
newly registered nurses (target population) are placed in this hospital. The overall total
number of nurses in the country is 1,675 (Ministry of Health, 2006), with the majority of
them located in this hospital.
Formal nursing education programs commenced in Brunei Darussalam in 1946, with
UNICEF/WHO introducing courses to Brunei Darussalam General Hospital. The student
nurses at that time were taught skills of basic bedside nursing, equivalent to Enrolled
Nurse Certification in the United Kingdom (PAPRSB College of Nursing Reports, 1991).
Progress in nursing education continued since that time, with the development of new
programs that emphasized practical skills and good bedside nursing, including anatomy
and physiology taught as a basis of nursing practice. The courses developed at a higher
academic level, and were extended to three year programs. The curriculum was based on
the recommendations of the General Nursing Council for England and Wales, and was
modified to suit local needs. After successful completion of all theoretical and practical
components of the program, the students were awarded the Brunei Trained Nurses
Certificate (PAPRSB College of Nursing Reports, 1996).
In November 1982, the School of Nursing moved to the new Raja Isteri Pengiran Saleha
Hospital and was named the Nurses and Midwives Training Centre. The Centre
continued with the responsibility for the training of Brunei Trained Nurses, Assistant
53
Nurses and Trained Midwives. When the College of Nursing was established in 1986,
intakes for Brunei Trained Nurses were discontinued. The establishment of the Pengiran
Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing under the auspices of the
Ministry of Education was seen as the first step towards the professional education for
nurses in Brunei Darussalam (MOH, 2007). The moved into higher education was
undertaken in response to changing demands in health care needs of the population and
changes in nursing education internationally. In order to ensure academic credibility, an
academic linkage was negotiated by the Ministry of Education with the Department of
Nursing Studies, University of Wales College of Medicine, United Kingdom. The
purpose of the linkage was to ensure academic credibility of the new college acquiring
the assistance of an academic advisor through the development and accreditation of
courses, advice on new developments in the United Kingdom and elsewhere, and access
to an external examination. The medium of instruction in delivering the curriculum is
English Language (PAPRSB College of Nursing, 2006).
On completion of the three year nursing program, students are awarded a Diploma in
Nursing and qualified as a Brunei Darussalam Staff Nurse. The College of Nursing
continues to provide opportunity for the nurses to enrol into a higher speciality nursing
program to enable them to develop knowledge, understanding, practical skills and
professionalism to function safely in the context of speciality nursing. After they have
obtained some experience as a staff nurse in the wards or other departments, nurses may
be promoted to Senior Staff Nurse and from time to time the Senior Staff Nurse
undertaking the duties of the ward Sister (Nursing Officer) in the latter’s absence.
Nursing Officers (Ward Sisters) have to have had considerable experience in nursing and
54
may be in administrative charge of the Unit (such as that described in the Section
“Division” of the Department, or a small Surgical or Medical Nursing Department
depending upon the size and policy of the hospital). A Senior Nursing Officer (Matron) is
a Senior Charge Nurse of very considerable experience whose chief function is to control
and co-ordinate the work and training of the nursing staff within a nursing department
(MOH, 2006). The next level, Principal Nursing Officer, has responsibility is to assist the
Director of Nursing Services. The nursing structure in Brunei is presented in the
following diagram.
Fig. 1 The Nursing Structure in Brunei Darussalam
Nursing Services Ministry of Health
Director of Nursing Services
Principal Nursing Officer (B2-EB3)
Senior Nursing Officer /Matron (M12)
Nursing Officer (M11)
Senior Staff Nurse (M9-EB10)
Staff Nurse
Assistant Nurse
College of Nursing (Education)
Principal
Education Officer/ Senior Nursing Officer (B2-EB 3)
Nursing Officer Teaching B2
Nursing Officer Teaching (M11)
Senior Staff Nurse (M9-EB10)
Staff Nurse (Clinical Instructor)
Student Nurse
4.3. Sample The eligible sample for this study consisted of all male and female registered nurses (RN)
with less than 3 years working experience as a registered nurse and working in acute
speciality care units and general wards, who can speak, write and understand English
language proficiently as a second language. English language is widely spoken and used
55
as the medium of instruction in primary, secondary, tertiary and higher institutions that
include nursing education in Brunei Darussalam. All nurses identified from the duty
roster of these wards who met these criteria were eligible to participate in the study.
The duty rosters were thus used as a sampling frame. A sample of 120 nurses (66.67%)
out of 180 eligible registered nurses on this roster were invited to participate in the study,
with the remaining 60 nurses being unavailable due to leave arrangements associated
with the Brunei Darussalam National Day Celebration procession. Table 1 present the
numbers of registered nurses involved in the survey from the various clinical departments
of the hospital. They consisted of 52 nurses (43.33%) from acute speciality care units and
68 nurses (56.67%) from general medical and surgical wards.
Table 1 Practice Setting for Nurses in the Study Sample
Clinical Departments by Groups No of Nurses Speciality Units
- Operating Theatre Department (OT) - Medical Intensive Care Unit (MICU) - Surgical Intensive Care Unit (SICU) - Otorhinolaryngology, Integrated Head and Neck Surgical
Unit (ORL) - Accident and Emergency Department (A/E) - Special Care Baby Unit (SCBU)
2 nurses 3 nurses 22 nurses 7 nurses 12 nurses 6 nurses
Total 52 nurses Surgical Wards (General Wards)
- Ward 1, Ward 2, Ward 4, Ward 6, Ward 7, Ward 8 Ward 9. Medical (General Wards) - Ward 19, Ward 20, Ward 21 and Ward 22.
41 nurses 27 nurses
Total 68 nurses 120 nurses 4.4. Ethical Considerations As soon as approval to conduct the study was obtained from the Human Research Ethics
Committee at the Queensland University of Technology and the Ministry of Health
56
Brunei Darussalam (Appendix 1 and 2), eligible nurses were invited to participate
voluntarily in the study. To ensure that the rights of research participants were protected
and that they had full understanding of the study, the chief investigator introduced
himself and explained the nature, purpose, objectives and expectations of the study to
each unit/ward nursing officer, managers and staff nurses. Questionnaires together with
information sheets were given to all eligible participants and the chief investigator
assumed implied consent if the nurse returned the completed questionnaires (Polit and
Beck, 2006).
Procedures were implemented for safeguarding the participant’s privacy and to ensure
they received adequate information regarding the study (Polit and Beck, 2006). Nurses
were informed that participation was purely voluntary, and their response would be
completely confidential. To allay any fears arising from the study, volunteers were also
informed that they were free to withdraw from the study at any time and that there are no
right or wrong answers. The instructions were standardised and written in plain English
Language for all participants and each participant was thanked for their participation
(Appendix 5). Questionnaires were distributed to participants by hand and through the
ward/unit nursing officers, managers and nurses in charge. Nurses were asked to
complete the survey in their own time or outside their working hours within two weeks.
Participants were asked to return the completed questionnaires to the chief investigator by
mail using the pre stamped envelope provided or the respondents could leave them at the
nurse’s station in each unit. No identifying information was included with the
questionnaires. After the initial explanation of the study the chief investigator had no
direct contact with the participants during the data collection period.
57
As humans (nurses) were used as the study participants, ethical considerations were
identified and appropriate strategies implemented to ensure participant’s rights were
protected. These meant freedom from any physical, psychological or economic harm. It
also meant freedom from exploitation. In anticipation of potential risks, such as feelings
of discomfort, or worries about responses being known by their supervisor or unit
managers, no personal or identifying information was included in the questionnaire. All
information was kept in strictest confidence, stored and locked securely and only
accessible by the chief investigator. For the purpose of avoiding misunderstandings,
enhancing participation and gaining consent from the participants in the study, a quiet,
polite, unhurried and assertive approach was used when explaining the study. Sufficient
time (three weeks) was given to allow the potential participants to have an adequate
opportunity to ask questions regarding the research questionnaires or details of the
research procedures, aims and objectives. The study participants were informed that the
findings would be shared through nursing seminars, conferences and workshops held at a
future date.
4.5. Research Instrument
4.5.1. Demographic Questions.
58
In this section, respondents were asked to fill in demographic information by simply
shading or ticking the relevant bubbles that matched their responses. The demographic
information obtained was essential to identify personal and social factors outside of work
that may contribute to workplace stress among new graduate nurses in RIPAS Hospital
Brunei Darussalam. The information was thus obtained to examine if particular groups of
nurses experienced more or less stress. Demographic information collected included age,
gender, ethnicity, standard of living, length of working experience, number and ages of
the children they care for and the support they received at home.
4.5.2. Ratings of Clinical Practice
This section was used to assess the overall level of participants’ confidence, competence
and organisational skills while carrying out their day-to-day working tasks or roles as
registered nurses. Respondents were asked to rate on separate five-point likert-type scale
ranging from “1 strongly disagree” to “5 strongly agree” the extent to which they
agreed that they were confident, competent and organised. The higher the score the more
they agreed with the statement.
.
4.5.3. The Expanded Nursing Stress Scale (ENSS)
The ENSS (French, Lenton, Walters and Eyles, 1995) is a self report questionnaire that
takes no longer than thirty minutes to complete. Permission to use the survey was
59
obtained from the original author, Susan E. French, McMaster University, Canada
[Appendix 3].
The Expanded Nursing Stress Scale (ENSS) was developed using a factor analysis of
responses to nurses’ ratings of a list of stressful nursing situations that had been identified
in previous research on nursing stress (Healy and McKay, 1999; Tyler and Cushway,
1995: 1992; Gray Toft and Anderson, 1981). The Expanded Nursing Stress Scale (ENSS)
incorporates 59 items with nine sub-scales. Each item required respondents to rate on a
five-point likert-type ranging from “1 never stressful” to “4 extremely stressful” and “0
does not apply”. The higher the score, the more the respondent agrees that the situation
was stressful. Total and sub-scale score can be derived from this instrument.
The sub-scales include:
(1) Limited experience dealing with the death and dying
(2) Conflicts with others healthcare professionals such as surgeons and physicians
(3) Feeling inadequately prepare to help with the emotional needs of a patient or
patient’s family
(4) Problems relating to peers
(5) Conflicts with supervisor and receiving minimum support by the charge nurse,
immediate supervisor and administrators
(6) Work load due to lack of organisational skills, familiarity with the units,
unpredictable
staffing and scheduling within the new complex working environment
(7) Uncertainty concerning treatment and inadequate information from physicians
regarding the medical condition of a patient
60
(8) The fear of failure to carry out the nursing tasks/responsibilities because patients and
their families make unreasonable demands
(9) Experience of being discriminated and isolated by other nursing colleagues and other
healthcare professionals
(French, Lenton, Walters and Eyles, 2000: 1995; Higgins, 2003; Gray-Toft and Anderson
1981).
The total stress score that provides the overall levels of stress among new graduate nurses
was obtained by adding all the scores on 59 items together. French, Lenton, Walters and
Eyles (2000) explained that there are two items (number 6 and 14) that did not appear to
be related to any of the nine subscales that emerged in the original study of Ontario
nurses, but they recommended retaining the two items.
The Expanded Nursing Stress Scale (ENSS) was designed in a simple and understandable
English language form and there was no need to translate the original questionnaires into
the respondents’ mother tongue (Malay). The Expanded Nursing Stress Scale (ENSS) is
well validated with good test retest reliability. The reliability a coefficient for ENSS and
its subscales has been calculated by using Cronbach’s alpha, with good internal
consistency scores demonstrated. One study conducted with 129 nurses recruited from
Victorian metropolitan and regional institutions in Australia reported a reliability
coefficient of 0.89 for the total scale, and coefficients ranging from 0.64 to 0.77 for the
subscales (Healy and McKay, 1999).
4.5.4. The Index of Work Satisfaction (IWS)
The self-report scale, Index of Work Satisfaction (IWS) developed by Stamps (2001), is
designed to assess nurses’ level of satisfaction with their work. This self report survey
61
questionnaire takes no longer than thirty minutes to complete. Permission to use this
Index of Work Satisfaction Survey (IWS) was obtained when purchasing the IWS from
the cooperative owner, Professor Paula Stamps, University of Massachusetts, United
States of America and Doreen Masi, Market Street Research Inc, Pleasant Street
Northampton, Massachusetts, United State of America [Appendix 4].
The Index of Work Satisfaction (IWS) was designed in a simple and understandable
English language form. Similar to the Expanded Nursing Stress Scale (ENSS), the IWS
did not require translation of its original questions statements into the respondents’
mother tongue (Malay). This minimised the risk of misinterpretation of some of the
words or questions asked. The Index of Work Satisfaction (IWS), is a two-part
measurement tool (Part A and B), that make up the self-administered instrument
measuring six components of job satisfaction. These six components are:
(1) Pay (dollar remuneration and fringe benefits received for work done)
(2) Autonomy (amount of job related independence, initiative, and freedom, either
permitted
or require in daily work activities)
(3) Task requirements (tasks or activities that must be done as a regular part of the job)
(4) Organizational policies (management policies and procedures put forward by the
hospital
and nursing administration of the hospital)
(5) Professional status (overall importance or significance of their job, both in their
view and in the view of others)
62
(6) Interaction and formal social and professional contacts during work hours
opportunities
presented for both formal and informal social and professional contact during
working
hours
(Stamps,
2001).
Part A of the Index of Work Satisfaction (IWS) was designed to rank how the
participants feel about their work situation. Here, the investigator was interested in
determining which of these six job satisfaction components were perceived by
participants as being of most importance to them. A total of 15 pairs were presented and
no pair was repeated or reversed.
Part B of the Index of Work Satisfaction (IWS), incorporates 44 randomly ordered,
positively and negatively worded statements. A positively worded statement was one
which the respondent marked Strongly Agreed when they were very satisfied. A
negatively worded statement was one which the respondent marked Strongly Disagreed
when they were very dissatisfied (Table 2). The response which indicated the most
satisfied respondents was given the most points. An example of this is presented in Table
3. Part B thus measures the current level of satisfaction for each of six components, as
well as overall satisfaction.
63
Table 2 List of Items for Each Component in the IWS
. Component
Number of Items
Range of Component Scores
Negatively Worded Items: Strongly Agree=1
Strongly Disagree= 7
Positively Worded Items: Strongly Agree = 7
Strongly Disagree= 1
Pay
6 6 to 42 8, 21, 44 1, 14, 32
Professional Status
7 7 to 49 2, 27, 41 9, 11, 34, 38
Autonomy
8 8 to 56 7, 17, 20, 30, 31 13, 26, 43
Organisational Policies
7 7 to 49 12 ,18, 33 5, 25, 40, 42
Task Requirement
6 6 to 42 4, 15, 36 22, 24, 29
Interaction
10 10 to 70 10, 23, 28, 35, 39 3, 6, 16, 19, 37
Nurse-Nurse
5 5 to 35 10, 23, 28 3, 16
Nurse-Physician
5 5 to 35 35, 39 6, 19, 37
Table 3 Example of Scoring System for Positively and
Negatively Phrased Items in the IWS
Phrasing Pay S/ Agree N S/ Disagree POSITIVE
My present salary is satisfactory. 7 6 5 4 3 2 1
NEGATIVE
It is my impression that a lot of nursing personnel at this hospital are dissatisfied with their pay.
1 2 3 4 5 6 7
Convergent validity, discriminant validity, and face validity were assessed during the
development of the tool and through further comparative analysis of 21 studies with
nursing staff. The reliability and validity of the instrument were supported. The
instrument was first tested by Stamps and Piedmonte (1986) with a sample of 246 nurses.
64
The Cronbach’s alpha Coefficient for the six sub-scales was acceptable, and ranged from
.52 to .81, with the reliability for the total score of being .81. More recently another
study conducted by Woods (2003) with 45 Academic Nurse Residency Participants in a
major academic 500-bed teaching hospital in the US, similarly reported the Cronbach’s
alpha scores for the six subscales ranged from a low of .55 for the subscale task
requirements to a high of .89 for interactions. The Cronbach’s alpha for the total scale
score was .78.
4.6. Pilot Study
Pre-testing of the data collection instrument was undertaken to trial run the study. A pilot
study involving a sample with similar characteristics to the sample used for actual study
was undertaken. This involved 15 Post Basic speciality nursing students who are
currently enrolled in Operating Theatre Nursing and Otorhinolaryngology Nursing
Program at the Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing
Brunei Darussalam. Nurses involved in the pilot sample did not take part in the main
study. The pilot study was used to: determine the feasibility of the major study; identify
problems in the research design; refine the data collection and analysis plan; test the
instrument to be used in the major study; and give the investigator some experience with
the subjects, research method and instruments (Roberts and Taylor, 2002). The pilot
study also enabled the investigator to ascertain the clarity of items and participants’
understanding of the instruments (Nieswiadomy, 1993), and the time required by
respondents to fill in the questionnaires. The pilot sample was invited to give their
comments, ideas and views for the improvement of the instrument based on a Brunei
65
Darussalam perspective. Issues raised by the pilot sample were that there were too many
questions in each section and that the time required to respond to the questionnaires was
more than 30 minutes. No participants raised any issue about lack of clarity or ambiguity
of questions in the questionnaire. While the feedback about the length of the
questionnaire was considered, participants in the pilot sample indicated that this was not
likely to prevent them from participating in the study.
4.7. Data Management and Analysis
Data collected from the self- report questionnaires, the Expanded Nursing Stress Scale
(ENSS) and Index Work Satisfaction (IWS), were analysed to describe stressors and job
satisfaction perceived by nurses within the first three years of works as a registered nurse
working in speciality care units and general wards in RIPAS Hospital, Brunei
Darussalam.
All returned questionnaires were checked for consistency and omissions to minimise
missing values. Completed questionnaires with missing values were examined carefully
to assess for any misinterpretation or inconsistency in responses. For example in the
demographic section the respondents were asked to state their ethnic group as “Malay”,
“Chinese”, “Indian”, “Indigenous” and “Others”. Two of the respondents answered
“Others”. These were later categorised as “Indigenous”, because participants stated their
ethnic origin as Iban and Dusun. Two responses who ticked “Single” for their marital
status were corrected to “Married” because both claimed they received “Good Support
from Their Husband” to care for their children. Confusion was also noted in Question 8,
66
where the participants were asked to declare whether they have children to care for. Many
of the single new graduate nurses indicated “No” when this should have been “Not
Applicable”. Once errors had been rectified further inspection was conducted to confirm
the entire N=94 (78.3%) responses out of 120 distributed questionnaires were valid and
usable. The survey data has been kept safely in the investigator’s personal computer and
locked cabinet.
The data collected from the study sample was coded and entered into the database of
Statistical Package Social Science Software (SPSS) Graduate Pack version 14. The data
were checked for errors including outliers and wild codes. The procedures carried out
included inspecting the frequency distribution values, for example, gender was coded as
1=female and 2=male. If other codes appeared, a data entry error would have been made.
The second strategy was to compare the entered data with the hard copy record available.
This procedure was undertaken with all surveys.
Descriptive analyses were employed to summarise frequencies, means and standard
deviations for each variables. Bivariate (two-variable) analyses were then undertaken to
describe the relationships between variable in each group. Contingency tables were used
for categorical variables in which the frequencies of the two variables were cross-
tabulated.
67
CHAPTER FIVE 5.0. RESULTS
5.1 Introduction
This chapter presents the findings of the study. Firstly, a description of the characteristics
of the study sample is presented. Data relating to each of the key research questions is
then presented.
5.2. Sample Characteristics
The demographic profile of the sample is presented in Table 4. For this study the total
number of respondents who returned the questionnaire were 94 (78.3%), out of 120 the
distributed questionnaires. Response rates for nurses from speciality units were similar to
those responses from general surgical and medical wards (78.8 % and 77.9 %
respectively). The sample was primarily female (80.9%). Participants’ ages ranged from
20 years to 30 years old.
There were only ten (10.6%) participants with an extra nursing qualification - Registered
Nurse + Post Basic Nursing Diploma (Nursing Specialist). Nine out of ten new graduate
nurses with this additional diploma qualification were from the intensive care units. Even
though more than half of the participants have a minimum of one year working
experience in nursing, a large number in both groups (64% general and 22% ICU) have
less than a year working experience in the current units. The majority of participants were
Malays (N=83; 88.3%) This is consistent with the population in Brunei, where Malays
constitutes the major ethnic group of population in the country, numbering 237, 100 of
357, 800 persons (Brunei Government, 2007).
68
Table 4 Demographic Characteristics of the Sample
General n=53 SPU n=41 Total n=94
Dichotomous / Categorical n (%) n (%) n (%) Gender
Female Male
44 9
(83.0) (17.0)
32 9
(78.0) (22.0)
76 18
(80.9) (19.1)
Educational Background Registered Nurse (Diploma in Nursing) Registered Nurse + Post Basic Diploma (Nursing Specialist)
52 1
(98.1) (1.9)
32 9
(78.0) (22.0)
84 10
(89.4) (10.6)
Working Experience in Nursing 0 -Less Than 1 Year 1 Year - Less Than 2 Years 2 Years - Less Than 3 years
34 8 11
(64.2) (15.1) (20.8)
9 19 13
(22.0) (46.3) (31.7)
43 27 24
(45.7) (28.7) (25.5)
Working Experience in the Units 0 -Less Than 1 Year 1 Year - Less Than 2 Years 2 Years - Less Than 3 years
37 7 9
(69.8) (13.2) (17.0)
23 9 9
(56.1) (22.0) (22.0)
60 16 18
(63.8) (17.0) (19.1)
Marital Status Single Married
47 6
(88.7) (11.3)
28 13
(68.3) (31.7)
75 19
(79.8) (20.2)
Ethnic Group Malay Others (Chinese, Indian, Indigenous)
47 6
(88.7) (11.4)
36 5
(87.8) (12.2)
83 11
(88.3) (11.7)
5.3. Social Demographic Characteristics of the Sample
The social demographic characteristics of the sample are presented in Table 5. The
majority of the respondents were single (N=75; 79.8%). Twelve (12.8% of the total
sample) of the married study respondents had pre school age children, and almost all of
these reported that they received very good support from their spouses (husband/wife),
housemaid, their parents or in-law and from their sister/brother in-laws to care for their
children. From the total study respondents, 75 (79.8%) were still living in their parent’s
dwelling.
69
Table. 5. Social Demographic Characteristics of the Sample
General n=53 SPU n=41 Total n=94
Categorical/ Ordinal n (%) n (%) n (%) Support From Husband or Wife to Care for Their Children
Not Applicable Very Good support Good Support Average
48 3 2 0
(90.6) (5.7) (3.8) (0.0)
34 3 3 1
(82.9) (7.3) (7.3) (2.4)
82 6 5 1
(87.2) (6.4) (5.3) (1.1)
Support from House Maid to Care for Their Children
Not Applicable Very Good support Good Support Poor Support No Support
50 1 2 0 0
(94.3) (1.9) (3.8) (0.0) (0.0)
35 0 4 0 2
(85.4) (0.0) (9.8) (0.0) (4.9)
85 1 6 0 2
(90.4) (1.1) (6.4) (0.0) (2.1)
Support From Their Parents or in-Law to Care for Their Children
Not Applicable Very Good support Good Support Average
48 1 2 2
(90.6) (1.9) (3.8) (3.8)
34 1 2 4
(82.9) (2.4) (4.9) (9.8)
82 2 4 6
(87.2) (2.1) (4.3) (6.4)
Support from Their Sister/Brother in-laws to Care for Their Children
Not Appropriate Very Good support Good Support Average Poor Support
48 1 1 2 1
(90.6) (1.9) (1.9) (3.8) (1.9)
34 1 1 4 1
(82.9) (2.4) (2.4) (9.8) (2.4)
82 2 2 6 2
(87.2) (2.1) (2.1) (6.4) (2.1)
Home Ownership Owned Outright Renting Living in Parents Dwelling Government Residence (Flat/House)
0 0
46 7
(0.0) (0.0) (86.8) (13.2)
2 2
29 8
(4.9) (4.9) (70.7) (19.5)
2 2
7515
(2.1) (2.1) (79.8) (16.0)
Having Children Yes No Not Applicable
51
47
(9.4) (1.9) (88.7)
7 6
28
(17.1) (14.6) (68.3)
12 7
75
(12.8) (7.4) (79.8)
No of Children One Two Not Applicable
50
48
(9.4) (0.0) (90.6)
6 1
34
(14.6) (2.4) (82.9)
11 1
82
(11.7) (1.1) (87.2)
Ages of Their Children Pre School Age (0 - Less than 5 years) Not Applicable
548
(9.4) (90.6)
7 34
(17.1) (82.9)
12 82
(12.8) (87.2)
70
5.4. Participants’ Confidence about Clinical Practice
Respondents were requested to rate how they felt about their overall clinical practice in
terms of feeling confident, competent and organised with their responsibilities and roles
as a RN. They were asked to rate a five-point likert-type ranging from “1 strongly
disagree” to “5 strongly agree”. The higher the score the more they agreed with the
statement. Nearly all respondents (86.1%) agreed that they felt confident about their
overall clinical practice. Most (74.4%) also agreed that they felt competent and that they
were well organised in their overall clinical practice (62.8%). The results are presented in
Table 6.
Table 6. Participants’ Confidence about Clinical Practice
General n=53 SPU n=41 Total n=94
Categorical/Ordinal n (%) n (%) n (%) Feeling Confident About Their Overall Clinical Practice
Strongly Disagree Disagree Uncertain Agree Strongly Agree
1 0 7
40 5
(1.9) (0.0) (13.2) (75.5) (9.4)
0 1 4
31 5
(0.0) (2.4) (9.8) (75.6) (12.2)
1 1
11 71 10
(1.1) (1.1) (11.7) (75.5) (10.6)
Feeling Competent About Their Overall Clinical Practice
Strongly Disagree Disagree Uncertain Agree Strongly Agree
02
14 32 5
(0.0) (3.8) (26.4) (60.4) (9.4)
02 6
31 2
(0.0) (4.9) (14.6) (75.6) (4.9)
04
20 63 7
(0.0) (4.3) (21.3) (67.0) (7.4)
Feeling Organized About Their Overall Clinical Practice
Strongly Disagree Disagree Uncertain Agree Strongly Agree
0 3 19 26 5
(0.0) (5.7) (35.8) (49.1) (9.4)
0 1 12 27 1
(0.0) (2.4) (29.3) (65.9) (2.4)
0 4 31 53 5
(0.0) (4.3) (33.0) (56.4) (6.4)
71
5.5. Sources and Level of Stress Scale
The 59 item Expanded Nursing Stress Scale (ENSS) study instrument was used to assess stressful
situations and experiences. Each item required respondents to rate a five-point likert-type scale by
shading or ticking the relevant bubbles on a scale ranging from to “1 never stressful” to “4
extremely stressful”, with “0 does not apply”. The higher the score, the more the respondent
agrees that the situation was stressful. Total and sub-scale score can be derived from this
instrument.
In order to compute the total stress score, all 59 items were added together. Scores for each nine
ENSS subscales were also calculated by adding scores for the items comprising the subscale. For
example, Uncertainty Concerning Treatment Component is the sum of the average scores for items
7, 16, 20, 26, 31, 35, 38, 41, and 45. In all cases, the category “Not Applicable” was scored as “0”.
Reliability coefficients were calculated using Cronbach’s alpha for the total ENSS and each of the
nine subscales components. For this study, the total ENSS 59 item scale had a reliability
coefficient of r = 0.96, with reliability coefficients for the subscales ranging from r = 0.58 to 0.83.
On average, responses to items in the Uncertainty Concerning Patient Treatment were rated by the
study sample as the most frequent stressful events. Table 7 presents responses to items in this
subscale. Responses indicate the majority of items in the scale were often stressful to registered
nurses within the first three years of workings as a registered nurse in this sample. In particular,
fear of making a mistake in treating a patient was rated as the most frequently occurring stressful
72
73
event. Being in charge with inadequate experience, and physician not being present in a medical
emergency were also rated as frequently resulting in stress. The least stressful events rated by the
registered nurses within the first three years of working as a registered nurse were uncertainty
regarding the operation and functioning of specialised equipment and a physician ordering
inappropriate treatment, although these still had high mean scores (2.57 and 2.59 respectively on
the scale ranging from 0 - 4).
74
Table 7 Ratings of Stress associated with Uncertainty Concerning Treatment
UNCERTAINTY CONCERNING TREATMENT α = 0.81 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
7 Inadequate information from a physician regarding the medical condition of a patient
7.3 (3)
31.7 (13)
29.3 (12)
26.8 (11)
4.9 (2)
2.66 1.11 5.7 (3)
15.1 (8)
39.6 (21)
32.1 (17)
7.5 (4)
2.83 1,17 6.4 (6)
22.3 (21)
35.1 (33)
29.8 (28)
6.4 (6)
2.76 1.14
16 A physician ordering what appears to be inappropriate treatment for a patient
7.3 (3)
31.7 (13)
36.6 (15)
17.1 (7)
7.3 (3)
2.49 1.10 3.8 (2)
26.4 (14)
24.5 (13)
34 (18)
11.3 (6)
2.66 1.30 5.3 (5)
28.7 (27)
29.8 (28)
26.6 (25)
9.6 (9)
2.59 1.21
20 Fear of making a mistake in treating a patient
0 (0)
46.3 (19)
26.8 (11)
22 (9)
4.9 (2)
2.61 1.0 5.7 (3)
15.1 (8)
22.6 (12)
54.7 (29)
1.9 (1)
3.23 1.03 3.2 (3)
28.7 (27)
24.5(23)
40.4 (38)
3.2 (3)
2.96 1.06
26 A physician not being present in a medical emergency
2.4 (1)
17.1 (7)
12.2 (5)
53.7 (22)
14.6 (6)
2.88 1.47 5.7 (3)
7.5 (4)
26.4 (14)
47.2 (25)
(13.2)
(7)
2.89 1.41 4.3 (4)
11.7 (11)
20.2 (19)
50.0 (47)
13.8 (13)
2.88 1.43
31 Feeling inadequately trained for what I have to do
9.8 (4)
41.5 (17)
17.1 (7)
29.3 (12)
2.4 (1)
2.61 1.09 3.8 (2)
20.8 (11)
30.2 (16)
41.5 (22)
3.8 (2)
3.02 1.07 6.4 (6)
29.8 (28)
24.5 (23)
36.2 (34)
3.3 (3)
2.84 1.09
35 Not knowing what a patient or a patient's family ought to be told about the patient's condition and its treatment
12.2 (5)
39 (16)
24.4 (10)
22 (9)
2.4 (1)
2.51 1.05 9.4 (5)
24.5 (13)
30.2 (16)
30.2 (16)
5.7 (3)
2.70 1.17 10.6 (10)
30.9 (29)
27.7 (26)
26.6 (25)
4.3 (4)
2.62 1.12
38 Being exposed to health and safety hazards
9.8 (4)
26.8 (11)
34.1 (14)
26.8 (11)
2.4 (1)
2.73 1.05 9.4 (5)
18.9 (10)
34 (18)
34 (18)
3.8 (2)
2.85 1.11 9.6 (9)
22.3 (21)
34.0 (32)
30.9 (29)
3.2 (3)
2.80 1.08
41 Being in charge with inadequate experience
7.3 (3)
14.6 (6)
19.5 (8)
43.9 (18)
14.6 (6)
2.71 1.47 7.5 (4)
15.1 (8)
13.2 (7)
56.6 (30)
7.5 (4)
3.04 1.32 7.4 (7)
14.9 (14)
16.0 (15)
51.1 (48)
10.6 (10)
2.89 1.39
45 Uncertainty regarding the operation and functioning of specialized equipment
7.3 (3)
34.1 (14)
17.1 (7 )
29.3 (12)
12.2 (5)
2.44 1.32 1.9 (1)
24.5 (13)
32.1 (17)
30.2 (16)
11.3 (6)
2.68 1.25 4.3 (4)
28.7 (27)
25.5 (24)
29.8 (28)
11.7 (11)
2.57 1.28
Total Mean Score = 2.63 Total Mean Score = 2.88 Total Mean Score = 2.77
75
On average, responses indicate items in the Dealing with Patients and Their Families
were rated as the second most frequently stressful events. Table 8 presents responses to
items assessing dealing with this subscale. Responses indicate patients’ family making
unreasonable demands was rated as the most frequently occurring stressful events. Being
blamed for anything that goes wrong was ranked as next most stressful, followed by
patient making unreasonable demands. Respondents also reported having to deal with
abusive patients and abusive patients’ families were the least frequently resulting in
stress, although these still had a high mean score (2.07 and 2.09 respectively).
76
Table 8 Ratings of Stress Associated with Dealing with Patients and their Families
DEALING WITH PATIENTS AND THEIR FAMILIES α = 0.81
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94 Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
8 Patients making unreasonable demands
2.4 (1)
26.8 (11)
22 (9)
43.9 (18)
4.9 (2)
2.98 1.13 7.5 (4)
15.1 (8)
34 (18)
39.6 (21)
3.8 (2)
2.98 1.10 5.3 (5)
20.2 (19)
28.7 (27)
41.5 (39)
4.3 (4)
2.98 1.11
17 Patients' families making unreasonable demands
2.4 (1 )
9.8 (4)
36.6 (15)
48.8 (20)
2.4 (1)
3.27 .92 11.3
(6)
5.7 (3)
37.7 (20)
43.3 (23)
1.9 (1)
3.09 1.06 7.4 (7)
7.4 (7)
37.2 (35)
45.7 (43)
2.1 (2)
3.17 1.0
27 Being blamed for anything that goes wrong
0 (0)
14.6 (6)
9.8 (4)
61 (25)
14.6 (6)
3.02 1.46 1.9 (1)
15.1 (8)
15.1 (8)
56.6 (30)
11.3 (6)
3.04 1.36 1.1 (1)
14.9 (14)
12.8 (12)
58.5 (55)
12.8 (12)
3.03 1.4
36 Being the one that has to deal with patients' families
14.6 (6)
14.6 (6)
29.3 (12)
31.7 (13)
9.8 (4)
2.59 1.34 5.7 (3)
11.3 (6)
35.8 (19)
39.6 (21)
7.5 (4)
2.94 1.20 9.6 (9)
12.8 (12)
33.0 (31)
36.2 (34)
8.5 (8)
2.79 1.27
37 Having to deal with violent patients
0 (0)
24.4 (10)
26.8 (11)
29.3 (12)
19.5 (8)
2.46 1.43 3.8 (2)
13.2 (7)
24.5 (13)
41.5 (22)
17 (9)
2.70 1.48 2.1 (2)
18.1 (17)
25.5 (24)
36.2 (34)
18.1 (17)
2.60 1.45
46 Having to deal with abusive patients
12.2 (5)
31.7 (13)
19.5 (8)
17.1 (7)
19.5 (8)
2.02 1.35 5.7 (3)
17 (9)
32.1 (17)
18.9 (10)
26.4 (14)
2.11 1.49 8.5 (8)
23.4 (22)
26.6 (25)
18.1 (17)
23.4 (22)
2.07 1.42
54 Having to deal with abuse from patients' families
7.3 (3)
14.6 (6)
17.1 (7)
22 (9)
39) (16)
1.76 1.64 3.8 (2)
15.1 (8)
18.9 (10)
35.8 (19)
26.4 (14)
2.34 1.63 5.3 (5)
14.9 (14)
18.1 (17)
29.8 (28)
31.9 (30)
2.09 1.65
58 Not knowing whether patients' families will report you for inadequate care
2.4 (1)
22 (9)
17.1 (7)
31.7 (13)
26.8 (11)
2.24 1.59 7.5 (4)
15.1 (8)
26.4 (14)
45.3 (24)
5.7 (3)
2.98 1.201 5.3 (5)
18.1 (17)
22.3 (21)
39.4 (37)
14.9 (14)
2.66 1.43
Total Mean Score = 2.54 Total Mean Score = 2.77 Total Mean Score = 2.67
77
Table 9 presents responses to item assessing stress associated with Workload subscale.
Responses indicate situations of work overload were rated on average as third most often
stressful events for registered nurses within the first three years of works as a registered
nurse. In particular not having enough staff to adequately cover the unit was rated as the
most stressful event. In this subscale unpredictable staffing and scheduling and not
having enough time to complete all the nursing tasks were also rated stressful. The least
stressful events in this area were demands of patient classification system.
Workload α = 0.78 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4 N
ever
Str
essf
ul
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
15 Unpredictable staffing and scheduling
0 (0)
29.3 (12)
24.4 (10)
41.5 (17)
4.9 (2)
2.98 1.08 3.8 (2)
17 (9)
35.8 (19)
37.7 (20)
5.7 (3)
2.96 1.11 2.1 (2)
22.3 (21)
30.9 (29)
39.4 (37)
5.3 (5)
2.97 1.09
25 Not enough time to provide emotional support to the
patient
14.6 (6)
41.5 (17)
17.1 (7)
22 (9)
4.9 (2)
2.37 1.14 7.5 (4)
34 (18)
30.2 (16)
22.6 (12)
5.7 (3)
2.57 1.10 10.6 (10)
37.2 (35)
24.5 (23)
22.3 (21)
5.3 (5)
2.48 1.11
34 Not enough time to complete all of my nursing tasks
2.4 (1)
29.3 (12)
19.5 (8)
39 (16)
9.8 (4)
2.76 1.28 5.7 (3)
20.8 (11)
22.6 (12)
43.3 (23)
7.5 (4)
2.89 1.25 4.3 (4)
24.5 (23)
21.3 (20)
41.5 (39)
8.5 (8)
2.83 1.26
43 Too many non-nursing tasks required, such as clerical
work
0 (0)
22 (9)
29.3 (12)
34.1 (14)
14.6 (6)
2.68 1.35 3.8 (2)
24.5 (13)
32.1 (17)
26.4 (14)
13.2 (7)
2.55 1.29 2.1 (2)
23.4 (22)
30.9 (29)
29.8 (28)
13.8 (13)
2.61 1.31
44 Not enough staff to adequately cover the unit
0 (0)
14.6 (6)
22 (9)
61 (25)
2.4 (1)
3.39 .92 0 (0)
22.6 (12)
22.6 (12)
50.9 (27)
3.8 (2)
3.17 1.03 0 (0)
19.1 (18)
22.3 (21)
55.3 (52)
3.2 (3)
3.27 .99
47 Not enough time to respond to the needs of patients' families
9.8 (4)
36.6 (15)
29.3 (12)
7.3 (3)
17.1 (7)
2.00 1.18 11.3
(6)
26.4 (14)
39.6 (21)
17 (9)
5.7 (3)
2.51 1.09 10.6 (10)
30.9 (29)
35.1 (33)
12.8 (12)
10.6 (10)
2.29 1.15
53 Demands of patient classification system
26.8 (11)
24.4 (10)
12.2 (5)
14.6 (6)
22 (9)
1.71 1.35 7.5 (4)
26.4 (14)
32.1 (17)
13.2 (7)
20.8 (11)
2.09 1.33 16.0 (15)
25.5 (24)
23.4 (22)
13.8 (13)
21.3 (20)
1.93 1.35
57 Having to work through breaks
12.2 (5)
22 (9)
22 (9)
36.6 (15)
7.3 (3)
2.68 1.29 11.3
(6)
20.8 (11)
30.2 (16)
32.1 (17)
5.7 (3)
2.72 1.2 11.7 (11)
21.3 (20)
26.6 (25)
34.0 (32)
6.4 (6)
2.70 1.23
59 Having to make decisions under pressure
2.4 (1)
24.4 (10)
26.8 (11)
26.8 (11)
19.5 (8)
2.39 1.43 5.7 (3)
18.9) (10)
18.9 (10)
47.2 (25)
9.4 (5)
2.89 1.33 4.3 (4)
21.3 (20)
22.3 (21)
38.3 (36)
13.8 (13)
2.67 1.39
Total Mean Score = 2.55 Total Mean Score = 2.70 Total Mean Score = 2.64
78
Table 9 Ratings of Stress associated with Workload
79
On average, responses to items in the Inadequate Emotional Preparation were rated as
the fourth most frequently occurring stressful events. Table 10 presents responses to item
assessing stress associated with Inadequate Emotional Preparation Subscale. In
particular being asked a question by a patient for which the nurses do not have a
satisfactory answer was rated as the most frequently occurring stressful event in this
subscale. Feeling inadequately prepared to help with the emotional needs of a patient was
also rated frequently stressful. Least stressful events in this area were feeling
inadequately prepared to help with the emotional needs of a patient’s family, although the
mean score was still at a high level with a mean of 2.47.
80
Table 10 Rating of Stress Associated with Inadequate Emotional Preparation
Inadequate Emotional Preparation α = 0.58 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
3 Feeling inadequately prepared to help with the
emotional needs of a patient's family
9.8) (4)
39) (16)
31.7) (13)
14.6) (6)
4.9) (2)
2.41 1.04 5.7 (3)
47.2 (25)
30.2 (16)
15.1 (8)
1.9 (1)
2.51 .89 7.4 (7)
43.6 (41)
30.9 (29)
14.9 (14)
3.2 (3)
2.47 .95
12 Being asked a question by a patient for which I do not have a satisfactory answer
4.9 (2)
36.6 (15)
29.3 (12)
26.8 (11)
2.4 (1)
2.73 1.0 5.7 (3)
20.8 (11)
34 (18)
34 (18)
5.7 (3)
2.85 1.13 5.3 (5)
27.7 (26)
31.9 (30)
30.9 (29)
4.3 (4)
2.80 1.07
21 Feeling inadequately prepared to help with the
emotional needs of a patient
7.3 (3)
41.5 (17)
34.1 (14)
12.2 (5)
4.9 (2)
2.41 .97 11.3
(6)
22.6 (12)
35.8 (19)
26.4 (14)
3.8 (2)
2.70 1.10 9.6 (9)
30.9 (29)
35.1 (33)
20.2(19)
4.3 (4)
2.57 1.05
Total Mean Score = 2.52 Total Mean Score = 2.69 Total Mean Score = 2.61
81
Table 11 presents responses to item assessing stress associated with Conflicts with
Doctors (Physicians) subscale. Mean scores for this area was ranked as the fifth most
often stressful for registered nurses within the first three years works as a registered
nurse. In particular criticism by a physician was the most frequently occurring stressful
event in this subscale. This is followed by making a decision concerning a patient when
the physician is unavailable in second place and conflict with a physician in third. The
least stressful occurring events rated by new registered nurses were disagreement with the
treatment of a patient and having to organise doctors’ work.
Conflicts With Doctors (Physicians) α = 0.69 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
2 Criticism by a physician 2.4 (1)
29.3 (12)
51.2 (21)
9.8 (4)
7.3 (3)
2.54
.98 3.8 (2)
24.5 (13)
22.6 (12)
41.5 (22)
7.5 (4)
2.87 1.23 3.2 (3)
26.6 (25)
35.1 (33)
27.7 (26)
7.4 (7)
2.72 1.13
11 Conflict with a physician 2.4 (1)
31.7 (13)
29.3 (12)
14.6 (6)
22 (9)
2.12 1.35 0 (0)
28.3 (15)
26.4 (14)
32.1 (17)
13.2 (7)
2.64 1.3 1.1 (1)
29.8 (28)
27.7 (26)
24.5 (23)
17.0 (16)
2.41 1.34
30 Disagreement concerning the treatment of a patient
12.2 (5)
43.9 (18)
26.8 (11)
9.8 (4)
7.3 (3)
2.20 1.03 5.7 (3)
17 (9)
37.7 (20)
17 (9)
22.6 (12)
2.21 1.42 8.5 (8)
28.7 (27)
33.0 (31)
13.8 (13)
16.0 (15)
2.20 1.26
40 Making a decision concerning a patient when the physician
is unavailable
9.8 (4)
17.1 (7)
17.1 (7)
39 (16)
17.1 (7)
2.51 1.52 1.9 (1)
15.1 (8)
22.6 (12)
41.5 (22)
18.9 (10)
2.66 1.51 5.3 (5)
16.0 (15)
20.2 (19)
40.4 (38)
18.1 (17)
2.60 1.51
50 Having to organize doctors' work
0 (0)
14.6 (6)
19.5 (8)
34.1 (14)
31.7 (13)
2.24 1.69 7.5 (4)
13.2 (7)
18.9 (10)
32.1 (17)
28.3 (15)
2.19 1.64 4.3 (4)
13.8 (13)
19.1 (18)
33.0 (31)
29.8 (28)
2.21 1.65
Total Mean Score = 2.32 Total Mean Score = 2.51 Total Mean Score = 2.43
82
Table 11 Rating of Stress Associated with Conflicts with Doctors
83
Table 12 presents responses to item assessing Problems Relating to Supervisors.
Responses indicate situations of Problems Relating to Supervisors were ranked as the
sixth most often stressful for registered nurses within the first three years of work as a
registered nurse. In particular, lack of support by nursing administration was rated as the
most frequently occurring stressful event in today’s complex clinical nursing working
environment. This is followed by lack of support from other health care administration in
the second place and criticism by nursing administration rated in third position. The least
stressful events rated by new registered nurses were conflict with a supervisor, although
this item still had a high mean score at 2.05.
Problems Relating to Supervisors α = 0.83 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
5 Conflict with a supervisor 4.9 (2)
29.3 (12)
14.6 (6)
22) (9)
29.3 (12)
1.95 1.52 11.3
(6)
35.8 (19)
13.2 (7)
22.6 (12)
17 (9)
2.13 1.36 8.5 (8)
33.0 (31)
13.8 (13)
22.3 (21)
22.3 (21)
2.05 1.43
32 Lack of support from my immediate supervisor
2.4 (1)
29.3 (12)
29.3 (12)
17.1 (7)
22 (9)
2.17 1.38 13.2
(7)
11.3 (6)
32.1 (17)
30.2 (16)
13.2 (7)
2.53 1.4 8.5 (8)
19.1 (18)
30.9 (29)
24.5 (23)
17.0 (16)
2.37 1.39
33 Criticism by a supervisor 4.9 (2)
36.6 (15)
24.4 (10)
17.1 (7)
17.1 (7)
2.20 1.29 17 (9)
22.6 (12)
22.6 (12)
28.3 (15)
9.4 (5)
2.43 1.32 11.7 (11)
28.7 (27)
23.4 (22)
23.4 (22)
12.8 (12)
2.33 1.31
42 Lack of support by nursing administrators
4.9 (2)
17.1 (7)
26.8 (11)
34.1 (14)
17.1 (7)
2.56 1.45 5.7 (3)
17 (9)
22.6 (12)
39.6 (21)
15.1 (8)
2.66 1.44 5.3 (5)
17.0 (16)
24.5 (23)
37.2 (35)
16.0 (15)
2.62 1.44
48 Being held accountable for things over which I have no
control
4.9 (2)
19.5 (8)
24.4 (10)
24.4 (10)
26.8 (11)
2.5 1.54 9.4 (5)
20.8 (11)
20.8 (11)
32.1 (17)
17 (9)
2.42 1.46 7.4 (7)
20.2 (19)
22.3 (21)
28.7 (27)
21.3 (20)
2.30 1.49
51 Lack of support from other health care administrators
4.9 (2)
14.6 (6)
19.5 (8)
36.6 (15)
24.4 (10)
2.39 1.61 1.9 (1)
20.8 (11)
24.5 (13)
35.8 (19)
17 (9)
2.60 1.43 3.2 (3)
18.1 (17)
22.3 (21)
36.2 (34)
20.2 (19)
2.51 1.51
56 Criticism by nursing administration
12.2 (5)
26.8 (11)
14.6 (6)
26.8 (11)
19.5 (8)
2.17 1.47 7.5 (4)
15.1 (8)
30.2 (16)
34 (18)
13.2 (7)
2.64 1.37 9.6 (9)
20.2 (19)
23.4 (22)
30.9 (29)
16.0 (15)
2.44 1.43
Total Mean Score = 2.23 Total Mean Score = 2.49 Total Mean Score = 2.37
84
Table 12 Rating of Stress Associated with Supervisors
85
Table 13 presents responses to item assessing stress associated with Death and Dying
subscale. Responses indicate situations of caring for Dying patients whilst on duty were
ranked as the seventh most often stressful for registered nurses within the first three years
of works as a registered nurse. In particular watching a patient suffer was the most
frequently occurring stressful event in this area. This was followed by feeling helpless in
the case of a patient who fails to improve and the death of a patient with whom they have
developed a close relationship. The least stressful occurring events in this area were
listening or talking to a patient about his/her approaching death.
Death and Dying α = 0.78 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
1 Performing procedures that patients experience as painful
(9.8 4)
(43.9 18)
(26.8 11)
(17.1 7)
(2.4 1)
2.46 .98 11.3
(6)
47.2 (25)
32.1 (17)
3.8 (2)
5.7 (3)
2.17 .89 10.6 (10)
45.7 (43)
29.8 (28)
9.6 (9)
4.3 (4)
2.30 .94
10 Feeling helpless in the case of a patient who fails to improve
(7.3 3)
(34.1 14)
(29.3 12)
(17.1 7)
(12.2 5)
2.32 1.21 7.5 (4)
30.2 (16)
26.4 (14)
24.5 (13)
11.3 (6)
2.45 1.26 7.4 (7)
31.9 (30)
27.7 (26)
21.3 (20)
11.7 (11)
2.39 1.24
19 Listening or talking to a patient about his/her approaching death
(14.6 6)
(29.3 12)
(14.6 6)
(7.3 3)
(34.1 14)
1.46 1.31 18.9
(10)
28.3 (15)
22.6 (12)
17 (9)
13.2 (7)
2.11 1.28 17.0 (16)
28.7 (27)
19.1 (18)
12.8 (12)
22.3 (21)
1.83 1.33
29 The death of a patient (26.8 11)
(26.8 11)
(22 9)
(17.1 7)
(7.3 3)
2.15 1.22 18.9
(10)
22.6 (12)
24.5 (13)
20.8 (11)
13.2 (7)
2.21 1.34 22.3 (21)
24.5 (23)
23.4 (22)
19.1 (18)
10.6 (10)
2.18 1.28
39 The death of a patient with whom you developed a close
relationship
(7.3 3)
(19.5 8)
(19.5 8)
(26.8 11)
(26.8 11)
2.12 1.57 11.3
(6)
9.4 (5)
24.5 (13)
37.7 (20)
17 (9)
2.55 1.51 9.6 (9)
13.8 (13)
22.3 (21)
33.0 (31)
21.3 (20)
2.36 1.54
49 Physician(s) not being present when a patient dies
(2.4 1)
(22 9)
(14.6 6)
(29.3 12)
(31.7 13)
2.07 1.63 9.4 (5)
1.9 (1)
22.6 (12)
37.7 (20)
28.3 (15)
2.32 1.71 6.4 (6)
10.6 (10)
19.1 (18)
34.0 (32)
29.8 (28)
2.21 1.67
55 Watching a patient suffer (9.8 4)
(39 16)
(34.1 14)
(9.8 4)
(7.3 3)
2.29 1.03 5.7 (3)
13.2 (7)
30.2 (16)
37.7 (20)
13.2 (7)
2.74 1.38 7.4 (7)
24.5 (23)
31.9 (30)
25.5 (24)
10.6 (10)
2.54 1.25
Total Mean Score = 2.13 Total Mean Score = 2.36 Total Mean Score = 2.26
86
Table 13 Rating of Stress Associated with Death and Dying
87
Table 14 presents responses to item assessing stress associated with conflict relating to
peers. Responses indicate situations of conflict relating to peers were ranked as the
eighth most often stressful for registered nurses within the first three years of work as a
registered nurse. In particular difficulty in working with a particular nurse (or nurses)
inside their immediate work setting were rated as the most frequently occurring stressful
event in the work place. This was followed by lack of opportunity to talk openly with
other personnel about problems in the work setting and difficulty in working with a
particular nurse (or nurses) outside their immediate work setting. The least stressful
events in this area were difficulty in working with nurses of the opposite sex, receiving a
mean score of 1.19 only.
Conflicts Relating to Peers α = 0.71 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
4 Lack of opportunity to talk openly with other personnel about problems in the work
setting
7.3 (3)
41.5 (17)
26.8 (11)
14.6 (6)
9.8 (4)
2.29 1.12 11.3
(6)
22.6 (12)
28.3 (15)
32.1 (17)
5.7 (3)
2.70 1.20 9.6 (9)
30.9 (29)
27.7 (26)
24.5 (23)
7.4 (7)
2.52 1.18
13 Lack of opportunity to share experiences and feelings with other personnel in the work
setting
14.6 (6)
46.3 (19)
9.8 (4)
12.2 (5)
17.1 (7)
1.85 1.2 7.5 (4)
34 (18)
26.4 (14)
24.5 (13)
7.5 (4)
2.53 1.17 10.6 (10)
39.4 (37)
19.1 (18)
19.1 (18)
11.7 (11)
2.23 1.22
22 Lack of an opportunity to express to other personnel on the unit my negative feelings
towards patients
14.6 (6)
34.1 (14)
19.5 (8)
4.9 (2)
26.8 (11)
1.61 1.22 13.2
(7)
35.8 (19)
17 (9)
11.3 (6)
22.6 (12)
1.81 1.29 13. (13)
8 (33)
35.1 (17)
18.1 (8)
24.5 (23)
1.72 1.26
23 Difficulty in working with a particular nurse (or nurses) inside my immediate work
setting
9.8 (4)
39 (16)
9.8 (4)
34.1 (14)
7.3 (3)
2.54 1.27 9.4 (5)
20.8 (11)
18.9 (10)
43.3 (23)
7.5 (4)
2.81 1.30 9.6 (9)
28. 7 (27)
14.9 (14)
39.4 (37)
7.4 (7)
2.69 1.29
24 Difficulty in working with a particular nurse (or nurses) outside my immediate work
setting
19.5 (8)
31.7 (13)
14.6 (6)
24.4 (10)
9.8 (4)
2.24 1.30 5.7 (3)
26.4 (14)
20.8 (11)
30.2 (16)
17 (9)
2.42 1.42 11.7 (11)
28.7 (27)
18.1 (17)
27.7 (26)
13.8 (13)
2.34 1.36
52 Difficulty in working with nurses of the opposite sex
58.5 (24)
19.5 (8)
0 (0)
0 (0)
22 (9)
.98 .65 34 (18)
24.5 (13)
15.1 (8)
1.9 (1)
24.5 (13)
1.36 1.08 44.7 (42)
22.3 (21)
8.5 (8)
1.1 (1)
23.4 (22)
1.19 .93
Total Mean Score = 1.92 Total Mean Score = 2.27 Total Mean Score = 2.12
88
Table 14 Rating of Stress Associated with Conflicts with Peers
89
Table 15 presents responses to item assessing stress associated with Discrimination.
Responses indicate situations of being discriminated were ranked as the ninth most often
stressful for registered nurses within the first three years of work as a registered nurse. In
particular experiencing discrimination because of race or ethnicity were the most
frequently occurring stressful events in the workplace. This is followed by experiencing
discrimination because of the basis of sex in second place. The least stressful occurring
events rated by registered nurses were being sexually harassed, with a mean score of
1.18. Importantly, while almost 60% of the sample indicated this later item did apply,
around 40% of the sample responded that this experience had resulted in stress. Of those
who responded to this item as if it did apply (38 respondents) almost 66% indicated this
was frequently an extremely stressful event.
Discrimination α = 0.60 Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Does Not Apply = 0 Never Stressful = 1 Occasional Stressful = 2 Frequently Stressful = 3 Extremely Stressful = 4
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
Nev
er S
tres
sful
Occ
asio
nal S
tres
sful
Freq
uent
ly S
tres
sful
Extr
emel
y St
ress
ful
Doe
s Not
App
ly
Mea
n
SD
No Items % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
9 Being sexually harassed 4.9 (2)
4.9 (2)
14.6 (6)
9.8 (4)
65.9 (27)
.98 1.49 7.5 (4)
9.4 (5)
5.7 (3)
22.6 (12)
54.7 (29)
1.34 1.69 6.4 (6)
7.4 (7)
9.6 (9)
17.0 (16)
59.6 (56)
1.18 1.61
18 Experiencing discrimination because of race or ethnicity
14.6 (6)
26.8 (11)
14.6 (6)
2.4 (1)
41.5 (17)
1.22 1.22 15.1
(8)
28.3 (15)
15.1 (8)
9.4 (5)
32.1 (17)
1.55 1.34 14.9 (14)
27.7 (26)
14.9 (14)
6.4 (6)
36.2 (34)
1.40 1.29
28 Experiencing discrimination on the basis of sex
9.8 (4)
14.6 (6)
14.6 (6)
9.8 (4)
51.2 (21)
1.22 1.46 9.4 (5)
13.2 (7)
17 (9)
13.2 (7)
47.2 (25)
1.40 1.54 9.6 (9)
13.8 (13)
16.0 (15)
11.7 (11)
48.9 (46)
1.32 1.50
Total Mean Score = 1.14 Total Mean Score = 1.43 Total Mean Score = 1.30
90
Table 15 Rating of Stress Associated with Discrimination
5.6. Comparison of Stress by Practice Setting
Table 16 presents a comparison of the mean subscale scores for each of the nine
subscales for nurses in the different practice settings. Results indicate that the common
stressors and sources of stress for registered nurses within the first three years of work as
a registered nurse were similar irrespective whether they were working in the speciality
units or in the general medical and surgical wards. Both groups of new graduate nurses
ranked the component subscale Uncertainty Concerning Patient Treatment as most
frequent stressor, followed by Dealing with Patients and Their Families, then Work
Overload. Discrimination was also rated by both groups as the least frequently occurring
stressor. The only statistically significant difference between groups was for problems
relating to peers, where general nurses reported higher mean scores than those reported
by nurses in speciality units.
91
Table 16 Expanded Nursing Stress Scale Scores by Practice Setting
Speciality Unit Nurses
N=41
General Nurses N =
53
Total Sample N=94
Expanded Nursing Stress Scale Total (1-59)
Mean Range (1-4) Mean SD Mean SD Mean SD
t
Uncertainty Concerning Treatment 2.63 .74 2.88 .77 2.77 .77 t(92)= -1.59, p .116
Patient And Their Families 2.54 .90 2.77 .87 2.67 .88 t(92)= -1.26, p .211
Workload 2.55 .70 2.70 .75 2.64 .73
t(92)= -1.02, p .312
Inadequate Emotional Preparation 2.52 .78 2.69 .74 2.61 .76 t(92)= -1.05, p .296
Conflict With Physician 2.32 .79 2.51 1.02 2.43 .93
t(92)= -.99, p .324
Problem Relating To Supervisor 2.23 .98 2.49 1.02 2.37 1.01
t(92)= -1.25, p .214
Death And Dying 2.13 .75 2.36 .97 2.26 .88
t(92)= -1.30, p .196
Problem Relating To Peers 1.92 .67 2.27 .82 2.12 .77
t(92)= -2.23, p .028*
Discrimination
1.14 .98 1.43 1.17 1.30 1.09 t(92)= -1.28, p .205
ENSS (Total Scale) 2.31 .63 2.55 .73 2.44 .70 t(92)= -1.63, p .106
*p<.05
92
5.7. Comparison of Stress by Demographic Variables
Due to small numbers in various demographic groups, including age, gender, educational
background, working experience in the current units, ethnic group, number and ages of
their children, support they received to care for their children, and home ownership
status, the relationship between these variables and ENSS scores were not assessed in
these study. The only bivariate analysis that was conducted was working experience in
nursing. Since the values of the variables were normally distributed, ANOVA was used
for this categorical independent variable.
Table 17 presents the findings of the bivariate analysis using ANOVA between Expanded
Nursing Stress Scale and its nine components subscales with the independent variable of
working experience in nursing. These results indicate that nurses with less than 1 year
experience reported higher mean stress scores for the Uncertainty Concerning Treatment,
Inadequate Emotional Preparation and Problem Relating to Peers subscales.
93
Table 17.
Comparison of Stress by Demographic Variables Total Sample (94) 0 – less 1 yr 1- less 2 yrs 2 – less 3 yrs F
N 43 24 27 Mean 3.03 2.60 2.49 SD .69 .78 .75 Min 2 1 1
Uncertainty
Max 4 4 4
F91= 5.42, p .006
Mean 2.80 2.61 2.53 SD .88 .99 .80 Min 1 0 1
Patient And Their Families
Max 4 4 4
F91=.83, p .438
Mean 2.79 2.52 2.51 SD .73 .86 .57 Min 1 1 1
Workload
Max 4 4 4
F91= 1.66, p .196
Mean 2.81 2.28 2.60 SD .80 .79 .56 Min 1 1 1
Inadequate Emotional Preparation
Max 4 4 4
F91=4.01, p .021
Mean 2.62 2.35 2.19 SD 1.00 .92 .77 Min 0 0 0
Conflict With Physician
Max 4 4 4
F91= 1.95, p .148
N 43 24 27 Mean 2.64 2.18 2.12 SD 1.06 .92 .92 Min 0 0 0
Problem Relating To
Supervisors
Max 4 4 4
F91=2.86, p .063
Mean 2.37 2.16 2.18 SD .94 .90 .78 Min 0 1 0
Death and Dying
Max 4 4 3
F91=.56, p .571
Mean 2.39 1.88 1.90 SD .78 .70 .72 Min 1 1 1
Problem Relating To Peers
Max 4 4 4
F91=5.29, p .007
Mean 1.43 1.26 1.12 SD 1.24 .98 .93 Min 0 0 0
Discrimination
Max 4 3 3
F91= .68, p .507
Mean 2.63 2.31 2.27 SD .69 .73 .62 Min 1 1 1
ENSS
Max 4 4 4
F91=3.04, p .053
94
Table 18 presents comparison of stress by feeling confident, competent and organised
about their overall clinical practice variables. Results indicate were significant negative
correlations for feeling organised about their clinical practice uncertainty concerning
patient treatment, dealing with patients and their families, work overload, conflict with
doctors, problems relating to supervisors and discrimination. There was also a significant
negative correlation between feeling organised and the total ENSS scale scores. There
were no significant relations between feeling confident and competent and stress scores,
except for a significant negative correlation between the feeling of confidence about their
overall clinical practice and problems relating to supervisors.
95
Table 18 Relationship between Stress and Ratings of Confidence,
Competence and Organisation
Total Sample N=94
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).
Fee
ling
Con
fiden
t Abo
ut
Thei
r Ove
rall
Clin
ical
Pr
actic
e
Fee
ling
Com
pete
nt A
bout
Th
eir O
vera
ll C
linic
al
Prac
tice
Fee
ling
Org
aniz
ed A
bout
Th
eir O
vera
ll C
linic
al
Prac
tice
N
Mea
n
SD
Pearson Correlation -.170 -.066 -.253(*) Uncertainty
Concerning Treatment
Sig. (2-tailed) .101 .529 .014 94
2.77
.77
Pearson Correlation -.095 -.054 -.208(*)
Patient And Their Families
Sig. (2-tailed) .361 .603 .044 94 2.67 .88
Pearson Correlation -.187 -.160 -.218(*)
Workload Sig. (2-tailed)
.072 .125 .035 94 2.64 .73
Pearson Correlation -.015 .020 -.116
Inadequate Emotional
Preparation Sig. (2-tailed) .883 .852 .267 94 2.61 .76
Pearson Correlation -.043 -.104 -.327(**)
Conflict With Doctors
(Physicians) Sig. (2-tailed) .682 .317 .001 94 2.43 .93
Pearson Correlation -.242(*) -.121 -.326(**)
Problems Relating To Supervisors
Sig. (2-tailed) .019 .244 .001 94 2.37 1.01
Pearson Correlation .011 .022 -.190
Death And Dying Sig. (2-tailed) .914 .832 .066
94 2.26 .88
Pearson Correlation -.169 -.069 -.110
Conflict Relating To Peers Sig. (2-tailed)
.104 .506 .290 94 2.12 .77
Pearson Correlation -.063 -.061 -.212(*)
Discrimination Sig. (2-tailed) .546 .557 .040
94 1.30 1.09
ENSS
Pearson Correlation -.156 -.096 -.283(**) 94 2.44 .70
Sig. (2-tailed) .133 .360 .006
96
5.8. Index of Work Satisfaction: Importance of Work Components (Part A)
This section identifies how important each of the six components of work satisfactions
were to the registered nurses in this study. The importance rankings developed in this
stage are used to develop weights for each of the satisfaction components (Component
Weighting Coefficients). To determine these importance ratings, each of the six
components of satisfaction were arranged in pairs with one other component and the
nurses were asked to select which one of each pair was more important to them. Tables
were formed and the results obtained were tabulated according to the number of times
each component was chosen. Results of these calculations are presented in Table 19. The
raw count was transformed to a percentage of the whole study sample. The percentages
were then converted into standard deviations based on a normal distribution of responses,
using a standard Z-table provided with the package. This was an important part of the
theoretical basis of scoring, since it enables weighting to be given to those components
which were strongly preferred by the study sample. The Z-table thus generated a single
number for each component, called the Component Weighting Coefficient.
As shown in Table 19, results for IWS Part A demonstrate that for speciality unit nurses,
the component Autonomy (70.7%) was most important, followed by Professional Status
(65.9%) and Organisational Policies (61%). Task Requirement and Interaction were
ranked in the fourth and fifth places respectively by specialty unit nurses. The least
important of all six components by speciality units’ nurses was Pay.
97
Table 19. Frequency Matrix for IWS Components by Work Area
Most Important
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total (N=94)
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
% (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) Pay
70.7 (29)
56.1 (23)
61.0 (25)
51.2 (21)
46.3 (19)
62.3 (33)
49.1 (26)
54.7 (29)
64.2 (34)
47.2 (25)
66.0 (62)
52.1 (49)
57.4 (54)
58.5 (55)
46.8 (44)
Autonomy
29.3 (12)
48.8 (20)
61.0 (25)
43.9 (18)
51.2 (21)
37.8 (20)
52.8 (28)
54.7 (29)
43.4 (23)
56.6 (30)
34.0 (32)
51.1 (48)
57.4 (54)
43.6 (41)
54.3 (51)
Task Requirement
43.9 (18)
51.2 (21)
51.2 (21)
65.9 (27)
43.9 (18)
50.9 (27)
47.2 (25)
37.7 (20)
64.2 (34)
50.9 (27)
47.9 (45)
48.9 (46)
43.6 (41)
64.9 (61)
47.9 (45)
Organisational Policies
39.0 (16)
39.0 (16)
48.8 (20)
61.0 (25)
56.1 (23)
45.3 (24)
45.3 (24)
62.3 (33)
64.2 (34)
69.8 (37)
42.6 (40)
42.6 (40)
56.4 (53)
62.8 (59)
63.8 (60)
Professional Status
48.8 (20)
56.1 (23)
34.1 (14)
39.0 (16)
51.2 (21)
35.8 (19)
56.6 (30)
35.8 (19)
35.8 (19)
47.2 (25)
41.5 (39)
56.4 (53)
35.1 (33)
37.2 (35)
48.9 (46)
Leas
t Im
port
ant
Interaction
53.7 (22)
48.8 (20)
56.1 (23)
43.9 (18)
48.8 (20)
52.8 (28)
43.4 (23)
49.1 (26)
30.2 (16)
52.8 (28)
53.2 (50)
45.7 (43)
52.1 (49)
36.2 (34)
51.1 (48)
98
For new registered respondent nurses from the general wards however, Interaction
(69.8%) was the most important component. General ward nurses ranked Professional
Status, followed by Autonomy and Task Requirement in second, third and fourth place
respectively. Organisational Policies and Pay were ranked in fifth and sixth place.
The next step of analysis involved placing the weights for each of the six components on
a normal distribution by using the table of Z values. All percentages in Table 19 were
converted into 3 decimal places (Table 33, Appendix 6) then to Z-matrix values from the
Z table available (Table 34, Appendix 7). The Z-matrix values for each pair are the same
values, but with opposite signs. An example of this is the intensive care units nurses’
ranking of Pay versus Autonomy are scored -0.545 for Pay and +0.545 for Autonomy. To
calculate for the Component Weighting Coefficient, the Z values in each column in
(Table 34, Appendix 7) were added and the mean value (average) for each column was
divided by five (that is, the number of comparisons made). In order to eliminate the
negative values a constant was added. Since the largest possible negative Z value was -
3.090, the constant used was +3.100 added. This was added to each of the mean values to
give the Component Weighting Coefficient. Table 20 presents the Component Weighting
Coefficients for nurses in this study. Results indicate that the Component Weighting
Coefficient for Professional Status and Interaction were highest, indicating these
components are ranked as the most important by respondents. Autonomy, Task
Requirement and Organisational Policies were ranked in third, fourth and fifth order of
importance. The least most important component rated by respondents was Pay.
99
Table 20 IWS Component Weightings by Work Area
Component Weighting Coefficient According to Ranking
Speciality Units Nurses (N= 41) General Wards Nurses (N= 53) Total Sample of Nurses (N= 94)
1 Professional Status
3.20 1 Professional Status
3.30 1 Professional Status
3.26
2 Autonomy
3.18 2 Interaction
3.21 2 Interaction
3.16
3 Organisational Policies 3.13 3 Autonomy
3.13 3 Autonomy
3.15
4 Interaction
3.10 4 Task Requirement
3.10 4 Task Requirement
3.08
5 Task Requirement
3.07 5 Pay
2.96 5 Organisational Policies
3.001
6 Pay
2.92
6 Organisational Policies 2.91
6 Pay
2.94
100
5.9. Index of Work Satisfaction: Rating of Satisfaction (Part B)
Part B of the Index of Work Satisfaction (IWS) measures the satisfaction of the nurse
respondents using a series of attitude statements about each component. Each statement
uses a 7-point scale that ranges from “1- Strongly Agree” “2– Moderately Agree” “3-
Agree” “4- Neutral” “5- Disagree” “6- Moderately Disagree” and “7- Strongly
Disagree”. This scale was designed that half of the items on the scale were phrased
positively and half were phrased negatively to minimise a response bias.
Responses to item in the component Professional Status is presented in Table 21. More
than half of the 94 study respondents nurses 60 (63.8%) believed that most people
appreciate the importance of nursing care to hospital patients, and 53 (56.4%) agreed that
they are proud to talk to other people about what they do as nurses. The majority (75.6%)
agreed that there is no doubt whatever in their mind that what they do on their job was
really important. Most nurses (74.2%) agreed that nursing really required much skill or
“know-how”, and (38%) disagreed that their job does not add up to anything really
significant. Over half, the sample (51.1%) would still go into nursing, if they had the
decision to make all over again. On the other hand n=56 (60.4%) also believe that
nursing is not widely recognised as being an important profession.
101
Table 21 Index of Work Satisfaction: Professional Status
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94) Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
7 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
9. Most people appreciate the importance of nursing care to hospital patients.
17.1 (7)
22.0 (9)
19.5 (8)
24.4 (10)
4.9 (2)
4.9 (2)
7.3 (3)
13.2 (7)
22.6 (12)
32.1 (17)
11.3 (6)
11.3 (6)
3.8 (2)
5.7 (3)
14.9 (14)
22.3 (21)
26.6 (25)
17.0 (16)
8.5 (8)
4.3 (4)
6.4 (6)
11. There is no doubt whatever in my mind that what I do on my job is really important.
29.3 (12)
19.5 (8)
22.0 (9)
24.4 (10)
2.4 (1)
0 (0)
2.4 (1)
28.3 (15)
13.2 (7)
37.7 (20)
13.2 (7)
1.9 (1)
1.9 (1)
3.8 (2)
28.7 (27)
16.0 (15)
30.9 (29)
18.9 (17)
2.1 (2)
1.1 (1)
3.2 (3)
34. It makes me proud to talk to other people about what I do on my job.
14.6 (6)
7.3 (3)
36.6 (15)
24.4 (10)
4.9 (2)
7.3 (3)
4.9 (2)
15.1 (8)
13.2 (7)
26.4 (14)
22.6 (12)
11.3 (6)
3.8 (2)
7.6 (4)
14.9 (14)
10.6 (10)
30.9 (29)
23.4 (22)
8.5 (8)
5.3 (5)
6.4 (6)
38. If I had the decision to make all over again, I would still go into nursing.
14.6 (6)
14.6 (6)
26.8 (11)
21.9 (9)
9.8 (4)
2.4 (1)
9.8 (4)
11.3 (6)
11.3 (6)
24.5 (13)
18.9 (10)
15.1 (8)
3.8 (2)
15.1 (8)
12.8 (12)
12.8 (12)
25.5 (24)
20.2 (19)
12.8 (12)
3.2 (3)
12.8 (12)
** 2. Nursing is not widely recognized as being an important profession
17.1 (7)
24.4 (10)
14.6 (6)
4.9 (2)
17.1 (7)
7.3 (3)
14.6 (6)
24.5 (13)
17.0 (9)
20.8 (11)
5.7 (3)
15.1 (8)
3.8 (2)
13.2 (7)
21.3 (20)
20.2 (19)
18.9 (17)
5.3 (5)
16.0 (15)
5.3 (5)
13.8 (13)
** 27. What I do on my job does not add up to anything really significant.
4.9 (2)
4.9 (2)
9.8 (4)
31.7 (13)
34.1 (14)
4.9 (2)
9.8 (4)
3.8 (2)
13.2 (7)
16.9 (9)
32.1 (17)
18.9 (10)
13.2 (7)
1.9 (1)
4.3 (4)
9.6 (9)
13.8 (13)
31.9 (30)
25.5 (24)
9.6 (9)
5.3 (5)
** 41. My particular job really doesn’t require much skill or “know-how”.
2.4 (1)
2.4 (1)
4.9 (2)
17.1 (7)
9.8 (4)
31.7 (13)
31.7 (13)
3.8 (2)
3.8 (2)
9.4 (5)
9.4 (5)
24.5 (13)
11.3 (6)
37.7 (20)
3.2 (3)
3.2 (3)
7.4 (7)
12.8 (12)
18.9 (17)
20.2 (19)
35.1 (33)
** Reverse Scored Statement.
102
Responses to items in the component Interaction are presented in Table 22. Results
indicate that the majority of respondents (71.2%) agreed that the nursing personnel in
their wards/units always help one another out when things get in a rush. More than half,
(60.7%) agreed that there is a good deal of teamwork and cooperation between various
levels of nursing personnel in their wards/units. However, quite a number of nurses
(71%) expressed that it is hard for new nurses to feel ‘at home’ in the wards/unit. This
was because of concerns such as a lot of “rank consciousness” where nurses seldom
mingle with those with less experience or different types of educational background.
Around 40% agreed that the nursing personnel where they work are not as friendly and
outgoing as they thought.
Additionally, nearly all (87.2%) agreed the physicians in their ward/units should show
more respect for the skill and knowledge of the nursing staff, although around (41.5%)
agreed that physicians at this hospital generally understand and appreciate what nursing
staff do. Over half, (63.3%) agreed that the physicians at this hospital look down too
much on the nursing staff, although (63.7%) of the respondents agreed there is a lot of
teamwork between nurses and doctors on their own wards/unit, and (59.6%) agreed that
physicians in general cooperate with nursing staff on their unit.
103
Table 22 Index of Work Satisfaction: Interaction
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94) Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
10 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
3. The nursing personnel on my service pitch in and help one another out when things get in a rush.
22.0 (9)
31.7 (13)
19.5 (8)
22.0 (9)
4.9 (2)
0 (0)
0 (0)
18.9 (10)
20.8 (11)
30.2 (16)
18.9 (10)
7.5 (4)
3.8 (2)
0 (0)
20.2 (19)
25.5 (24)
25.5 (24)
20.2 (19)
6.4 (6)
2.1 (2)
0 (0)
6. Physicians in general cooperate with nursing staff on my unit
9.8 (4)
26.8 (11)
24.4 (10)
29.3 (12)
4.9 (2)
4.9 (2)
0 (0)
9.4 (5)
9.4 (5)
39.6 (21)
22.6 (12)
7.5 (4)
7.5 (4)
3.8 (2)
9.6 (9)
17.0 (16)
33.0 (31)
25.5 (24)
6.4 (6)
6.4 (6)
2.1 (2)
16. There is a good deal of teamwork and cooperation between various levels of nursing personnel on my service.
17.1 (7)
26.8 (11)
31.7 (13)
17.1 (7)
4.9 (2)
0 (0)
2.4 (1)
17.0 (9)
28.3 (15)
13.2 (7)
7.5 (4)
17.0 (9)
7.5 (4)
9.4 (5)
17.0 (16)
27.7 (26)
21.3 (20)
11.7 (11)
11.7 (11)
4.3 (4)
6.4 (6)
19. There is a lot of teamwork between nurses and doctors on my own unit.
17.1 (7)
26.8 (11)
19.5 (8)
14.6 (6)
14.6 (6)
4.9 (2)
2.4 (1)
13.2 (7)
32.1 (17)
18.9 (10)
11.3 (6)
18.9 (10)
3.8 (2)
1.9 (1)
14.9 (14)
29.7 (28)
19.1 (18)
12.8 (12)
17.0 (16)
4.3 (4)
2.1 (2)
37. Physicians at this hospital generally understand and appreciate what the nursing staffs does.
7.3 (3)
12.2 (5)
22.0 (9)
24.4 (10)
17.1 (7)
12.2 (5)
4.9 (2)
5.7 (3)
9.4 (5)
26.4 (14)
18.9 (10)
22.6 (12)
11.3 (6)
5.7 (3)
6.4 (6)
10.6 (10)
24.5 (23)
21.3 (20)
20.2 (19)
11.7 (11)
5.3 (5)
** 10. It is hard for new nurses to feel ‘at home’ in my unit.
19.5 (8)
17.1 (7)
29.3 (12)
14.6 (6)
7.3 (3)
4.9 (2)
7.3 (3)
24.5 (13)
34.0 (18)
17.0 (9)
13.2 (7)
5.7 (3)
1.9 (1)
3.8 (2)
22.3 (21)
26.6 (25)
22.3 (21)
13.8 (13)
6.4 (6)
3.2 (3)
5.3 (5)
** 23. The nursing personnel on my service are not as friendly and outgoing as I would like.
2.4 (1)
4.9 (2)
14.6 (6)
36.6 (15)
14.6 (6)
17.1 (7)
9.8 (4)
15.1 (8)
13.2 (7)
11.3 (6)
20.8 (11)
18.9 (10)
13.2 (7)
7.5 (4)
9.6 (9)
9.6 (9)
12.8 (12)
27.7 (26)
17.0 (16)
14.9 (14)
8.5 (8)
** 28. There is a lot of “rank consciousness” on my unit: nurses seldom mingle with those with less experience or different types of educational preparation.
7.3 (3)
12.2 (5)
12.2 (5)
39.2 (16)
14.6 (6)
4.9 (2)
9.8 (4)
18.9 (10)
11.3 (6)
16.9 (9)
13.2 (7)
24.5 (13)
9.4 (5)
5.7 (3)
13.8 (13)
11.7 (11)
14.9 (14)
24.5 (23)
20.2 (19)
7.4 (7)
7.4 (7)
** 35. I wish the physicians here would show more respect for the skill and knowledge of the nursing staff.
43.9 (18)
29.3 (12)
9.8 (4)
14.6 (6)
0 (0)
0 (0)
2.4 (1)
47.2 (25)
15.1 (8)
28.3 (15)
5.7 (3)
0 (0)
1.9 (1)
1.9 (1)
45.7 (43)
21.3 (20)
20.2 (19)
9.6 (9)
0 (0)
1.1 (1)
2.1 (2)
** 39. The physicians at this hospital look down too much on the nursing staff.
17.1 (7)
19.5 (8)
24.4 (10)
24.4 (10)
7.3 (3)
7.3 (3)
0 (0)
18.9 (10)
17.0 (9)
26.4 (14)
13.2 (7)
15.1 (8)
3.8 (2)
5.7 (3)
18.9 (17)
18.9 (17)
25.5 (24)
18.9 (17)
11.7 (11)
5.3 (5)
3.2 (3)
** Reverse Scored Statement.
104
Responses to items in the component Autonomy are presented in Table 23. These results
indicate that 44 out of 94 respondents (46.7%) agreed that they have sufficient input into
the program of care for each of their patients, with only 28 respondents agreeing that
there was unnecessary close supervision (29.7%). Less than half (44%) of respondents
agreed that they have freedom in their work to make decisions as they see fit, and can
count on their supervisor for back up. However, 41.5% agreed that all activities seem to
be programmed for them. More than half of the respondents (62.7%) experienced too
much responsibility but were not given enough authority, with a further (25.5%) being
undecided. More than half the sample agreed they sometimes were required to do things
that are against their professional nursing judgement.
105
Table 23 Index of Work Satisfaction: Autonomy
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94) Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
8 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
13. I feel I have sufficient input into the program of care for each of my patients.
4.9 (2)
4.9 (2)
39.0 (16)
29.3 (12)
19.5 (8)
2.4 (1)
0 (0)
11.3 (6)
11.3 (6)
22.6 (12)
28.3 (15)
13.2 (7)
5.7 (3)
7.5 (4)
8.5 (8)
8.5 (8)
29.7 (28)
28.7 (27)
16.0 (15)
4.3 (4)
4.3 (4)
26. A great deal of independence is permitted, if not required, of me.
4.9 (2)
4.9 (2)
17.1 (7)
65.9 (27)
7.3 (3)
0 (0)
0 (0)
3.8 (2)
7.5 (4)
26.4 (14)
39.6 (21)
15.1 (8)
3.8 (2)
3.8 (2)
4.3 (4)
6.4 (6)
22.3 (21)
51.1 (48)
11.7 (11)
2.1 (2)
2.1 (2)
43. I have the freedom in my work to make important decisions as I see fit, and can count on my supervisors to back me up.
7.3 (3)
4.9 (2)
34.1 (14)
31.7 (13)
7.3 (3)
9.8 (4)
4.9 (2)
7.6 (4)
13.2 (7)
26.4 (14)
18.9 (10)
15.1 (8)
11.3 (6)
7.5 (4)
7.4 (7)
9.6 (9)
29.7 (28)
24.5 (23)
11.7 (11)
10.6 (10)
6.4 (6)
** 7. I feel that I am supervised more closely than is necessary.
2.4 (1)
4.9 (2)
14.6 (6)
63.4 (26)
7.3 (3)
0 (0)
7.3 (3)
7.6 (4)
9.4 (5)
18.9 (10)
17.0 (9)
20.8 (11)
15.1 (8)
11.3 (6)
5.3 (5)
7.4 (7)
17.0 (16)
37.2 (35)
14.9 (14)
8.5 (8)
9.6 (9)
** 17. I have too much responsibility and not enough authority.
22.0 (9)
17.1 (7)
26.8 (11)
31.7 (13)
2.4 (1)
0 (0)
0 (0)
16.9 (9)
24.5 (13)
18.9 (10)
20.8 (11)
7.6 (4)
1.9 (1)
9.4 (5)
19.1 (18)
21.3 (20)
22.3 (21)
25.5 (24)
5.3 (5)
1.1 (1)
5.3 (5)
** 20. On my service, my supervisors make all the decisions. I have little direct control over my own work.
7.3 (3)
2.4 (1)
19.5 (8)
39.2 (16)
19.5 (8)
12.2 (5)
0 (0)
7.5 (4)
15.1 (8)
22.6 (12)
15.1 (8)
30.2 (16)
9.4 (5)
0 (0)
7.4 (7)
9.6 (9)
21.3 (20)
25.5 (24)
25.5 (24)
10.6 (10)
0 (0)
** 30. I am sometimes frustrated because all of my activities seem programmed for me.
0 (0)
12.2 (5)
24.4 (10)
36.6 (15)
7.3 (3)
9.8 (4)
9.8 (4)
9.4 (5)
7.6 (4)
28.3 (15)
13.2 (7)
26.4 (14)
5.7 (3)
9.4 (5)
5.3 (5)
9.6 (9)
26.6 (25)
23.4 (22)
18.9 (17)
7.4 (7)
9.6 (9)
** 31. I am sometimes required to do things on my job that are against my better professional nursing judgment.
4.9 (2)
9.8 (4)
39.2 (16)
22.0 (9)
14.6 (6)
7.3 (3)
2.4 (1)
11.3 (6)
15.1 (8)
26.4 (14)
20.8 (11)
13.2 (7)
9.4 (5)
3.8 (2)
8.5 (8)
12.8 (12)
31.9 (30)
21.3 (20)
13.8 (13)
8.5 (8)
3.2 (3)
** Reverse Scored Statement.
106
Responses to item in the component Task Requirements are presented in Table 24.
Results indicate that around two-third of nurses were satisfied with their job activities
(63.8%), however, 60.4% expressed that there was too much clerical and paperwork
required of nursing personnel in the hospital. Almost half of the 94 respondents (45.7%)
agreed that they do not have sufficient time for direct patient care and 55.3% agreed that
they do not have plenty of time and opportunity to discuss patient care problems with
other nursing personnel. Nearly all of the sample (88.3%) agreed that they could deliver
much better care if they had more time with each patient.
107
Table 24 Index of Work Satisfaction: Task Requirements
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94) Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
6 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
22. I am satisfied with the types of activities that I do on my job.
14.6 (6)
22.0 (9)
39.0 (16)
12.2 (5)
12.2 (5)
0 (0)
0 (0)
9.4 (5)
18.9 (10)
26.4 (14)
26.4 (14)
9.4 (5)
5.7 (3)
3.8 (2)
11.7 (11)
20.2 (19)
31.9 (30)
20.2 (19)
10.6 (10)
3.2 (3)
2.1 (2)
24. I have plenty of time and opportunity to discuss patient care problems with other nursing service personnel.
0 (0)
4.9 (2)
19.5 (8)
26.8 (11)
36.6 (15)
4.9 (2)
7.3 (3)
3.8 (2)
7.5 (4)
15.1 (8)
13.2 (7)
35.9 (19)
11.3 (6)
13.2 (7)
2.1 (2)
6.4 (6)
17.0 (16)
19.1 (18)
36.2 (34)
8.5 (8)
10.6 (10)
29. I have sufficient time for direct patient care.
4.9 (2)
7.3 (3)
19.5 (8)
24.4 (10)
29.3 (12)
7.3 (3)
7.3 (3)
3.8 (2)
13.2 (7)
22.6 (12)
13.2 (7)
34.0 (18)
7.5 (4)
5.7 (3)
4.3 (4)
10.6 (10)
21.3 (20)
18.9 (17)
31.9 (30)
7.4 (7)
6.4 (6)
** 4. There is too much clerical and “paperwork” required of nursing personnel in this hospital.
17.1 (7)
12.2 (5)
22.0 (9)
29.3 (12)
12.2 (5)
4.9 (2)
2.4 (1)
18.9 (10)
18.9 (10)
28.3 (15)
18.9 (10)
9.4 (5)
1.9 (1)
3.8 (2)
18.9 (17)
16.0 (15)
25.5 (24)
23.4 (22)
10.6 (10)
3.2 (3)
3.2 (3)
** 15. I think I could do a better job if I did not have so much to do all the time.
29.3 (12)
17.1 (7)
22.0 (9)
17.1 (7)
4.9 (2)
4.9 (2)
4.9 (2)
22.6 (12)
30.2 (16)
11.3 (6)
15.1 (8)
11.3 (6)
3.8 (2)
5.7 (3)
25.5 (24)
24.5 (23)
16.0 (15)
16.0 (15)
8.5 (8)
4.3 (4)
5.3 (5)
** 36. I could deliver much better care if I had more time with each patient.
34.1 (14)
36.6 (15)
17.1 (7)
4.9 (2)
4.9 (2)
0 (0)
2.4 (1)
41.5 (22)
18.9 (10)
28.3 (15)
7.5 (4)
1.9 (1)
0 (0)
1.9 (1)
38.3 (36)
26.6 (25)
23.4 (22)
6.4 (6)
3.2 (3)
0 (0)
2.1 (2)
** Reverse Scored Statement.
108
Responses to the items on the component Organisational Policies are presented in Table
25. Results indicate that around half of the respondents (49.9%) agreed that nursing staff
had sufficient control over scheduling their own shifts in the hospital. However, 38
(40.3%) raised concerns that nursing administrators did not generally consult with staff
on daily problems and procedures. Around one-third (39.4%) agreed that their voice in
planning policies and procedures for the hospital and the unit where they work was not
regarded as what they want. Around (65.9%) agreed that there is a great gap between the
administration of this hospital and the daily problems of the nursing service, and around
half believed that the administrative decisions at the hospital interfere too much with
daily patient care (45.8%). The majority of respondents (63.8%) agreed there are not
enough opportunities for advancement of nursing personnel at this hospital.
109
Table 25 Index of Work Satisfaction: Organisational Policies
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94) Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
7 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
5. The nursing staff has sufficient control over scheduling their own shifts in my hospital.
4.9 (2)
19.5 (8)
22.0 (9)
26.8 (11)
14.6 (6)
4.9 (2)
7.3 (3)
5.7 (3)
18.9 (10)
28.3 (15)
9.4 (5)
15.1 (8)
13.2 (7)
9.4 (5)
5.3 (5)
19.1 (18)
25.5 (24)
17.0 (16)
14.9 (14)
9.6 (9)
8.5 (8)
25. There is ample opportunity for nursing staff to participate in the administrative decision-making process.
4.9 (2)
7.3 (3)
17.1 (7)
51.2 (21)
12.2 (5)
4.9 (2)
2.4 (1)
0 (0)
11.3 (6)
24.5 (13)
32.1 (17)
17.0 (9)
7.5 (4)
7.5 (4)
2.1 (2)
9.6 (9)
21.3 (20)
40.4 (38)
14.9 (14)
6.4 (6)
5.3 (5)
40. I have all the voice in planning policies and procedures for this hospital and my unit that I want
2.4 (1)
9.8 (4)
14.6 (6)
43.9 (18)
9.8 (4)
12.2 (5)
7.3 (3)
3.8 (2)
1.9 (1)
9.4 (5)
37.7 (20)
18.9 (10)
11.3 (6)
17.0 (9)
3.2 (3)
5.3 (5)
11.7 (11)
40.4 (38)
14.9 (14)
11.7 (11)
12.8 (12)
42. The nursing administrators generally consult with the staff on daily problems and procedures.
2.4 (1)
7.3 (3)
17.1 (7)
31.7 (13)
14.6 (6)
14.6 (6)
12.2 (5)
13.2 (7)
3.8 (2)
22.6 (12)
20.8 (11)
22.6 (12)
7.5 (4)
9.4 (5)
8.5 (8)
5.3 (5)
20.2 (19)
25.5 (24)
19.1 (18)
10.6 (10)
10.6 (10)
** 12. There is a great gap between the administration of this hospital and the daily problems of the nursing service.
19.5 (8)
22.0 (9)
24.4 (10)
19.5 (8)
9.8 (4)
4.9 (2)
0 (0)
30.2 (16)
18.9 (10)
17.0 (9)
22.6 (12)
1.9 (1)
5.7 (3)
3.8 (2)
25.5 (24)
20.2 (19)
20.2 (19)
21.3 (20)
5.3 (5)
5.3 (5)
2.1 (2)
** 18. There are not enough opportunities for advancement of nursing personnel at this hospital.
9.8 (4)
17.1 (7)
34.1 (14)
19.5 (8)
17.1 (7)
0 (0)
2.4 (1)
18.9 (10)
17.0 (9)
30.2 (16)
18.9 (10)
13.2 (7)
1.9 (1)
0 (0)
14.9 (14)
17.0 (16)
31.9 (30)
19.1 (18)
14.9 (14)
1.1 (1)
1.1 (1)
** 33. Administrative decisions at this hospital interfere too much with patient care.
14.6 (6)
4.9 (2)
21.9 (9)
46.3 (19)
4.9 (2)
4.9 (2)
2.4 (1)
9.4 (5)
13.2 (7)
26.4 (14)
32.1 (17)
11.3 (6)
5.7 (3)
1.9 (1)
11.7 (11)
9.6 (9)
24.5 (23)
38.3 (36)
8.5 (8)
5.3 (5)
2.1 (2)
** Reverse Scored Statement.
110
Responses to items for the component Pay are shown in Table 26. Results indicate that
only 28 out of 94 nurses were satisfied with their present salary (29.7%), and 64.9% did
not agree with the present rate of increase in pay for nursing service personnel. Nearly all
respondents (85.2%) believed that an upgrading of the pay schedule for nursing personnel
is needed. Around half the sample (53.1%) disagreed that the pay they received is
reasonable given what is expected of nursing personnel.
111
112
** Reverse Scored Statement.
Table 26 Index of Work Satisfaction: Pay Component
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94) Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
6 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
1. My present salary is satisfactory.
2.4 (1)
9.8 (4)
12.2 (5)
19.5 (8)
19.5 (8)
4.9 (2)
31.7 (13)
7.5 (4)
17.0 (9)
9.4 (5)
17.0 (9)
24.5 (13)
7.6 (4)
16.9 (9)
5.3 (5)
13.8 (13)
10.6 (10)
18.9 (17)
22.3 (21)
6.4 (6)
23.4 (22)
14. Considering what is expected of nursing service personnel at this hospital, the pay we get is reasonable.
2.4 (1)
7.3 (3)
7.3 (3)
29.3 (12)
22.0 (9)
14.6 (6)
17.1 (7)
5.7 (3)
11.3 (6)
9.4 (5)
22.6 (12)
18.9 (10)
20.8 (11)
11.3 (6)
4.3 (4)
9.6 (9)
8.5 (8)
25.5 (24)
20.2 (19)
18.9 (17)
13.8 (13)
32. From what I hear about nursing service personnel at other hospitals, we at this hospital are being fairly paid.
2.4 (1)
9.8 (4)
9.8 (4)
31.7 (13)
19.5 (8)
12.2 (5)
14.6 (6)
9.4 (5)
9.4 (5)
9.4 (5)
32.1 (17)
26.4 (14)
5.7 (3)
7.6 (4)
6.4 (6)
9.6 (9)
9.6 (9)
31.9 (30)
23.4 (22)
8.5 (8)
10.6 (10)
** 8. It is my impression that a lot of nursing personnel at this hospital are dissatisfied with their pay.
17.1 (7)
19.5 (8)
26.8 (11)
19.5 (8)
7.3 (3)
4.9 (2)
4.9 (2)
22.6 (12)
20.8 (11)
15.1 (8)
22.6 (12)
9.4 (5)
1.9 (1)
7.5 (4)
20.2 (19)
20.2 (19)
20.2 (19)
21.3 (20)
8.5 (8)
3.2 (3)
6.4 (6)
** 21. The present rate of increase in pay for nursing service personnel at this hospital is not satisfactory.
24.4 (10)
7.3 (3)
34.1 (14)
29.3 (12)
4.9 (2)
0 (0)
0 (0)
16.9 (9)
22.6 (12)
24.5 (13)
18.9 (10)
7.5 (4)
5.7 (3)
3.8 (2)
20.2 (19)
16.0 (15)
28.7 (27)
23.4 (22)
6.4 (6)
3.2 (3)
2.1 (2)
** 44. An upgrading of pay schedules for nursing personnel is needed at this hospital.
39.0 (16)
24.4 (10)
19.5 3.2 1.1 (1)
3.8 (2)
0 (0)
3.8 (2)
39.4 (37)
21.3 (20)
24.5 (23)
8.5 (8)
2.1 (2)
5.7 (3)
0 (0)
2.4 (1)
2.4 (1)
39.6 (21)
18.9 (10)
28.3 (15)
12.2 (5) (8) (3)
5.10. Computing the Component Scores.
To calculate the Component Scores, a table was created for each component, using the
formula described by the authors of the IWSS. The scoring system can be found in
Appendix 10. Positively worded statement were given the maximum number of points (7)
for a strongly agree and points of (1) for strongly disagree response. For every negatively
worded statement, the maximum number of points (7) was given for a response of
strongly disagree and (1) points for strongly agree.
In order to get the Component Score, the obtained Average Scores for all items in the
component subscale were added, and the mean component subscale score calculated by
dividing this number by the number of items measuring the component. Table 27 presents
the Component Score and the Component Mean Score for each of the six components of
the IWSS.
113
Table 27 Component Score and the Component Mean Score for IWS Scales
PAY PROFESSIONAL STATUS
AUTONOMY
Item ICU GW Total Item ICU GW Total Item ICU GW Total 1 3.15 3.75 3.49 2 3.61 3.34 3.46 7 3.98 4.25 4.13 8 3.15 3.11 3.02 9 4.78 4.81 4.8 13 4.39 4.32 4.35 14 3.27 3.55 3.43 11 5.39 5..32 5.35 17 2.76 3.20 3.01 21 2.83 3.09 2.98 27 4.39 3.96 3.62 20 3.98 3.74 3.84 32 3.49 3.96 3.76 34 4.61 4.57 4.59 26 4.34 4.19 4.26 44 2.39 2.30 2.29 38 4.56 4.13 4.32 30 4.07 3.94 4 41 5.54 5..32 5.4 31 3.63 3.53 3.57
43 4.24 4.15 4.19 Component Score
18.27 19.76 18.97 32.88 31.45 31.54 31.38 31.32 31.35
Mean Score
3.05 3.29 3.16
4.697 4.49 4.51
3.92 3.92 3.92
ORGANIZATIONAL POLICIES
TASK REQUIREMENT
INTERACTION
Item ICU GW Total Item ICU GW Total Item ICU GW Total 5 4.29 4.13 4.2 4 3.32 3.02 3.15 3 5.44 5.13 5.27 12 2.93 2.79 2.85 15 2.85 2.96 2.89 10 3.17 2.62 2.86 18 3.27 2.96 3.1 22 5.15 4.60 4.84 16 5.24 4.60 4.88 25 4.17 3.92 4.03 24 3.61 3.43 3.51 23 4.46 3.85 4.12 33 3.46 3.47 3.47 29 3.83 3.94 3.89 28 3.95 3.64 3.78 40 3.85 3.32 3.55 36 2.20 2.17 2.18 6 5.07 4.53 4.7 42 3.59 4.04 3.8 19 4.93 4.91 4.91 35 2.07 2.09 2.09 37 4.12 4 4.05
39 3.07 3.23 3.16 Component Score
25.56 24.52 25 20.95 20.12 20.46 41.54 38.6 39.82
Mean Score
3.65 3.50 3.57
3.49 3.35 3.41
4.15 3.86 3.98
114
Table 28 provides responses for each of the six components scores. Results indicate that
Component Score for Professional Status, received the highest satisfaction scores
followed by Interaction, then Autonomy in third place. Organisational Policies and Task
Requirement components were rated fourth and fifth, while the component Pay scored
the lowest of all satisfaction ratings.
115
116
Table 28 Ranking of Satisfaction with IWSS Work Components
Speciality Units Nurses (N= 41)
General Wards Nurses (N=53)
Total Sample (N=94)
Component Component Scale Score
Component Mean Score
Component Scale Score
Component Mean Score
Component Scale Score
Component Mean Score
Professional Status
32.88 4.70 31.45 4.49 31.54 4.51
Interaction 41.54 4.15 38.62 3.86 39.82 3.98 Autonomy 31.38 3.92 31.32 3.92 31.35 3.92 Organisational Policies
25.56 3.65 24.52 3.50 25 3.57
Task Requirement 20.95 3.49 20.12 3.35 20.46 3.41 Pay 18.27 3.05 19.76 3.29 18.97 3.16 Nurse-Nurse 22.27 4.45 19.84 3.97 20.91 4.18 Nurse-Physician 19.27 3.85 18.76 3.75 18.91 3.78 Total Scale
Score Mean Scale
Score Total Scale
Score Mean
Scale Score Total Scale
Score Mean Scale
Score 170.6 3.9 165.8 3.8 167.1 3.8
Finally using weightings derived from the ranking of importance derived in part A of the
questionnaire, satisfaction scores are adjusted to reflect the relative importance of these
various components to this study sample. This is achieved by multiplying the Component
Weighting Coefficient for each component from (Part A) by the Mean Satisfaction Score
for each component from (Part B). The results represent the weights of satisfaction
Component Adjusted Score, for the six components based on the level of importance
placed on each component by the study respondents (see Table 29). According to the
authors of the scale, scores on this scale range from 0.9 to 37.1, with most scores falling
somewhere around 12.
As illustrated in Table 29, there were no changes in the rank of satisfaction following
adjustment for importance, with Professional Status continuing to be the highest area of
satisfaction and Pay the lowest.
117
Table 29 IWS Components Weighted Scores
Speciality Units Nurses (N= 41) General Wards Nurses (N=53) Total Sample (N=94)
Component 1
C
ompo
nent
w
eigh
ting
Coe
ffici
ent
(Par
t A)
11
(PA
RT
B)
Com
pone
nt S
cale
Sc
ore
(Ave
rage
)
111
(
PAR
T B
) C
ompo
nent
Mea
n Sc
ale
Scor
e
1V
Com
pone
nt A
djus
ted
Scor
es
1
Com
pone
nt
wei
ghtin
g C
oeffi
cien
t (P
art A
)
11
(PA
RT
B)
Com
pone
nt S
cale
Sc
ore
(Ave
rage
)
111
(
PAR
T B
) C
ompo
nent
Mea
n Sc
ale
Scor
e
1V
Com
pone
nt A
djus
ted
Scor
es
1
Com
pone
nt
wei
ghtin
g C
oeffi
cien
t (P
art A
)
11
(PA
RT
B)
Com
pone
nt S
cale
Sc
ore
(Ave
rage
)
111
(
PAR
T B
) C
ompo
nent
Mea
n Sc
ale
Scor
e
1V
Com
pone
nt A
djus
ted
Scor
es
Pay 2.92 18.27 3.05 8.91 2.96 19.76 3.29 9.74 2.94 18.97 3.16 9.31 Autonomy 3.18 31.38 3.92 12.47 3.13 31.32 3.92 12.27 3.15 31.35 3.92 12.35 Task Requirement
3.07 20.95 3.49 10.71 3.1 20.12 3.35 10.39 3.08 20.46 3.41 10.51
Organisational Policies
3.13 25.56 3.65 11.42 2.91 24.52 3.50 10.19 3.00 25 3.57 10.71
Professional Status
3.21 32.88 4.70 15.09 3.30 31.45 4.49 14.82 3.26 31.54 4.51 14.7
Interaction 3.1 41.54 4.15 12.87 3.21 38.62 3.86 12.4 3.16 39.82 3.98 12.58 Total Scale Score
Mean Scale Score 3.9 (170.6 / 44)
Index of Work Satisfaction: 11.91 [71.47/6]
Mean Scale Score 3.8 (165.8 /44)
Index of Work Satisfaction: 11.64
[69.81/6]
Mean Scale Score 3.79 (167.1/44)
Index of Work Satisfaction: 11.69 [70.16 / 6]
118
Table 30 present t-tests for all the six IWS components to compare levels of satisfaction
between nurses in general and speciality settings. Since the values of the variables were
normally distributed, Independent sample t-test was used. This analysis revealed no
statistically significant differences between groups in any component.
Table 30 Components T-test
SPU General Mean SD Mean SD T test
1 Professional Status
26.2 4.05 25.8 4.26 T92=.436, p.664
2 Interaction
32.1 5.56 32.3 6.23 T92=.154, p .878
3 Autonomy
29.4 3.63 30.0 5.27 T92= -.610, p .543
4 Organisational Policies
25.8 3.97 25.8 4.49 T92= -.062, p .951
5 Task Requirement
19.8 3.73 20.2 3.97 T92= -.484, p .629
6 Pay
22.3 4.22 21.3 3.65 T92= 1.350, p .180
7 IWS
155.6 16.59 155.3 15.60 T92=.083, p .934
Table 31 presents Pearson Correlation statistics calculated to assess the relationship
between the total Expanded Nursing Stress Scale score and its nine subscales, and the
IWSS and its six components. Findings indicate that the Component Autonomy was
significantly correlated with the total ENSS score, and ENSS subscales Patient and Their
Families, Problem Relating to Supervisors and Workload. No other significant
associations were identified between stress and work satisfaction.
119
Table 31 Correlations between IWSS and ENSS (n=94)
Aut
onom
y
Inte
ract
ion
Org
aniz
atio
nal
polic
ies
Task
R
equi
rem
ent
Pay
Prof
essi
onal
st
atus
IWS
Pearson Correlation -.204(*) -.080 -.159 -.056 -.017 -.071 -.168ENSS
Sig. (2-tailed) .049 .441 .125 .593 .870 .494 .107
Pearson Correlation -.179 -.059 -.136 -.035 -.048 -.067 -.148Conflict with Physician
Sig. (2-tailed) .084 .572 .191 .738 .646 .523 .156
Pearson Correlation -.143 -.038 -.189 -.157 -.006 .021 -.140Death and Dying
Sig. (2-tailed) .169 .713 .068 .130 .957 .844 .179
Pearson Correlation -.100 -.060 -.014 .101 -.023 -.132 -.070Discrimination
Sig. (2-tailed) .336 .569 .895 .331 .826 .204 .500
Pearson Correlation .018 .013 -.093 .106 -.024 -.026 -.002Inadequate Emotional Preparation Sig. (2-tailed) .865 .898 .374 .310 .816 .805 .987
Pearson Correlation -.238(*) -.091 -.145 -.090 -.005 -.136 -.200Patient and Their Families
Sig. (2-tailed) .021 .381 .164 .386 .961 .191 .053
Pearson Correlation -.084 -.003 -.065 .022 .003 -.075 -.056Problem Relating to Peers
Sig. (2-tailed) .423 .976 .532 .831 .976 .474 .591
Pearson Correlation -.224(*) -.072 -.151 .032 -.073 .011 -.139Problem Relating to Supervisor Sig. (2-tailed) .030 .489 .146 .756 .484 .918 .181
Pearson Correlation -.182 -.056 -.167 -.112 .001 -.052 -.158Uncertainty
Sig. (2-tailed) .079 .591 .109 .282 .992 .618 .128
Pearson Correlation -.210(*) -.096 -.091 -.078 .008 -.083 -.159Workload
Sig. (2-tailed) .043 .357 .385 .456 .942 .428 .126
*p<.05
120
5.11. Strategies that are believed to be helpful in assisting the new nurses’ transition
into
the workplace as a new Registered nurse.
In this section the respondents were requested to rate how helpful they believe each of a
series of items would be in assisting their transition with the new responsibilities in the
workplace as a newly graduated staff nurse (RN) working in today’s complex clinical
nursing working environment. They were asked to rate a seven-point likert-type scale by
shading or ticking the relevant bubbles on a scale ranging from “1 to 3 (not helpful at
all)”; “4 (uncertain)”; “5 to 7
(extremely helpful)”. The higher the score the more they agreed with the statement.
Responses to strategies that are believed to be helpful in assisting the new graduates’
transition into the workplace as a new graduate nurse are presented in Table 32. Results
indicate that most of the respondents (86.2%) chose Education as the most helpful
strategies in assisting their transition with the new responsibilities in the workplace.
81.9% of the study respondents favoured Team Building Strategies in the second place
and third most common choice was Access to hospital resources with 73 (77.7%). Proper
Mentoring for new graduates by more experienced senior nurses, Flexibility in working
hours, Balancing priorities were also rated highly be more than 75% of the sample. More
than half (65.9%) agreed that Stress management training, and enhancing social and peer
support programs would also benefit strategies. The least most favoured was Protocols to
deals with violence and retention. As illustrated in Table 32, responses from nurses in
general and speciality areas were similar.
121
Table 32: Ratings of Helpfulness of Strategies for Assisting Transition
Please rate how helpful you believe each of the following items would be in assisting your transition into the workplace as a new graduate nurse
Not at all helpful Extremely helpful Not at all helpful Extremely helpful Not at all helpful Extremely helpful
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 No Items %
(n) % (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
1 Education 0 (0)
0 (0)
0 (0)
7.3 (3)
14.6 (6)
19.5 (8)
58.5 (24)
0 (0)
7.5 (4)
0 (0)
11.3 (6)
26.4 (14)
13.2 (7)
41.5 (22)
0 (0)
4.3 (4)
0 (0)
9.6 (9)
21.3 (20)
16.0 (15)
48.9 (46)
2 Team building strategies 0
(0) 0
(0) 0
(0) 14.6 (6)
19.5 (8)
19.5 (8)
46.3 (19)
5.7 (3)
1.9 (1)
1.9 (1)
11.3 (6)
17.0 (9)
17.0 (9)
45.3 (24)
3.2 (3)
1.1 (1)
1.1 (1)
12.8 (12)
18.1 (17)
18.1 (17)
45.7 (43)
3 Access to hospital resources 2.4
(1) 2.4 (1)
2.4 (1)
14.6 (6)
24.4 (10)
24.4 (10)
29.3 (12)
0 (0)
3.8 (2)
7.5 (4)
11.3 (6)
28.3 (15)
17.0 (9)
32.1 (17)
1.1 (1)
3.2 (3)
5.3 (5)
12.8 (12)
26.6 (25)
20.2 (19)
30.9 (29)
4 Mentoring 2.4 (1)
0 (0)
0 (0)
17.1 (7)
26.8 (11)
29.3 (12)
24.4 (10)
3.8 (2)
0 (0)
5.7 (3)
7.5 (4)
26.4 (14)
34.0 (18)
3.2 (3)
0 (0) 22.6
(12) 3.2 (3)
11.7 (11)
24.5 (23)
27.7 (26)
29.8 (28)
5 Flexibility in working hours 0
(0) 4.9 (2)
4.9 (2)
19.5 (8)
22.0 (9)
22.0 (9)
26.8 (11)
1.9 (1)
1.9 (1)
3.8 (2)
15.1 (8)
18.9 (10)
28.3 (15)
30.2 (16)
1.1 (1)
3.2 (3)
4.3 (4)
17.0 (16)
20.2 (19)
25.5 (24)
28.7 (27)
6 Balancing priorities 0 (0)
0 (0)
2.4 (1)
22.0 (9)
31.7 (13)
29.3 (12)
14.6 (6)
1.9 (1)
3.8 (2)
1.9 (1)
13.2 (7)
22.6 (12)
22.6 (12)
34.0 (18)
1.1 (1)
2.1 (2)
2.1 (2)
17.0 (16)
26.6 (25)
25.5 (24)
25.5 (24)
7 Stress management training 12.2
(5) 2.4 (1)
2.4 (1)
14.6 (6)
24.4 (10)
22.0 (9)
22.0 (9)
3.8 (2)
5.7 (3)
3.8 (2)
22.6 (12)
20.8 (11)
15.1 (8)
28.3 (15)
7.4 (7)
4.3 (4)
3.2 (3)
19.1 (18)
22.3 (21)
18.1 (17)
25.5 (24)
8 Enhancing social and peer support programs
2.4 (1)
0 (0)
0 (0)
22.0 (9)
26.8 (11)
31.7 (13)
17.1 (7)
0 (0)
3.8 (2)
1.9 (1)
20.8 (11)
18.9 (10)
34.0 (18)
20.8 (11)
1.1 (1)
2.1 (2)
1.1 (1)
21.3 (20)
22.3 (21)
33.0 (31)
19.1 (18)
9 Protocols to deals with violence and retention
4.9 (2)
0 (0)
0 (0)
31.7 (13)
22.0 (9)
22.0 (9)
19.5 (8)
3.8 (2)
5.7 (3)
5.7 (3)
13.2 (7)
28.3 (15)
24.5 (13)
18.9 (10)
4.3 (4)
3.2 (3)
3.2 (3)
21.3 (20)
25.5 (24)
23.4 (22)
19.1 (18)
122
5.12 Summary
Despite several studies having addressed stress in nursing, this issue continues to be a
popular topic amongst researchers because of its consequences to individual health and
the organization. For this study, registered nurses with less than three years experience
were surveyed to determine the factors contributing to stress that are frequently occurring
in the workplace. The study also investigated job satisfaction among registered nurses
with less than three years experience working in specialty units and general wards in
Brunei Darussalam.
Responses to the ENSS indicate new registered nurses experience a range of stressful
events while at work. The most common stressful events were uncertainty concerning
patient treatment, and dealing with the patient and their families. The new registered
nurses also rated the stress associated with workload highly. Responses indicated that
problems relating to peers and the experience of being discriminated against in the
workplace were the least stressful events. No significant differences were observed
between the level and sources of stress experienced by registered nurses with less than
three years experience according to practice setting.
Responses to Index Work Satisfaction Scale (IWS) indicated that new nurses rated the
component professional status as being the most important aspect of work, followed by
the component interaction. The least important of all six components was pay.
123
Study participants agreed that education (48.9%), team building (45.7%), access to
hospital resources (30.9%), mentoring (29.8%), flexibility in working hours (28.7%),
balancing priorities (25.5%), stress management training (25.5%), enhancing social and
peer support programs (19.1%) and protocols to deals with violence and retention
(19.1%) would be extremely helpful in assisting their transition into the workplace as a
graduate nurse.
124
CHAPTER SIX 6.0. Discussion
The primary aim of this descriptive correlational study was to investigate perceptions of
stress and levels of job satisfaction of registered nurses within the first three years of
employment in Brunei Darussalam hospitals. This enquiry examined the common
stressors, sources and levels of stress and level of job satisfaction.
Findings of the study suggest that registered nurses during their early years as a nurse
have been frequently, and in some case, excessively exposed to stressful situations as part
of their daily work. The major stressors they experienced according to most stressful to
the least stressful events as perceived by respondents were assessed by the Expanded
Nurses Stress Scale. Specifically, common sources of stress were uncertainty concerning
patient treatment, dealing with patients and their families, work overload, inadequate
emotional preparation, conflicts with doctors, problems relating to supervisors, death and
dying, conflict relating to peers, and discrimination. These findings are consistent with
those from numerous other studies that suggest that stress in nursing can be derived from
numerous areas, including job content, resources issues, professional concerns,
professional working relationships and extrinsic factors (Murphy, 1994).
The findings of this study are similar to those of others which have used the Nursing
Stress Scale (e.g., Healy and McKay 1999; Tyler and Cushway 1995; 1992). More
specifically, the most common stressful events that arose for nurses in this study resulted
from factors including Uncertainty Concerning Patient Treatment, in particular the fear
125
of making a mistake in treating a patient, being in charge with inadequate experience, and
fear that the physician would not being present in a medical emergency. Murphy (2004)
similarly identified that newly registered nurses often felt under pressure to take charge
when they were not ready. At these times, their lack of knowledge and experience
frustrated them, as they felt they were not able to give patients correct information.
Murphy also reported that new graduates rated feeling inadequately trained for what they
have to do and being exposed to health and safety hazards as highly stressful events that
are frequently occurring in the nursing working environment. Providing less experienced
nurses with the support needed to develop their knowledge and apply this to their practice
may be helpful.
Issues of Dealing with Patients and Their Families, also commonly provided a source of
stress for nurses. In particular, when the patients’ family made unreasonable demands,
when nurses were blamed for anything that goes wrong, and when they did not know
whether the patients’ family will report them for inadequate care placed the nurses in
especially difficult situations. Of much concern to many new registered nurses is the
stress experienced when dealing with abusive patients and abusive patients’ families. It
is likely that impact of such experience will lead to psychological distress, self doubt and
a significant amount of loss of respect (Michael and Jenkins, 2001). A study by Lin and
Liu (2005) reported that violence occurring in hospitals was mainly due to
misunderstandings, drunkenness, and personal problems, or from patients who were
mentally unstable. Tabone (2001) suggests the solution for these problems is to identify
the sources of this violence, and advocate on behalf of nurses to ensure the quality of the
126
work environment and patient care. Having clear written policies as a guideline for
dealing with abusive patients and patients (Johnson, Moss, Clarke, and Armistead, 1996)
is highlighted by the findings of this study.
Nurses in this study also reported that Work Overload was common, in particular not
having enough staff to adequately cover the unit as a result of unpredictable staffing and
scheduling. Shift work often introduces additional hardship on nurses providing services
in complex environments and demanding interpersonal situations. New registered nurses
who were burdened with extra responsibilities such as having too many non nursing
tasks, having to work through breaks, and in some case having to make decisions under
pressure are important concerns that require attention. Many nurses in this study reported
that there was not enough staff to get the work done, and that this resulted in them not
having enough time to provide emotional support to the patient and to respond to patient
needs.
Work satisfaction levels for nurses in this study were at a moderate to high level for most
components. Specifically, the component Professional Status was chosen as the most
important component of work satisfaction. Despite its importance, many nurses in this
study reported that they believed that nursing is not widely recognised as being an
important profession (Ma, Samuels, and Alexander, 2004).
Nursing roles are rapidly expanding in areas including performing minor surgery,
prescribing medicines and treatments, making and receiving direct referrals, admitting
127
and discharging patients for specified conditions, managing patient caseloads, running
clinics and taking a lead in the way local health services are organised (Hilpern, 2002).
While presenting significant challenges, responses of nurses in this study indicate that
many nurses did not hold the view that their job does not add up to anything really
significant. This high level of satisfaction with the nursing role may reflect the increasing
value being placed on some aspects of nursing, due to the growing demand for nursing
services associated with the ageing population growth and increased opportunities for
expanded scope of practice (ICN, 2007; American Association of Colleges of Nursing,
2006; Mee and Robinson, 2003; Spratley et. al 2002). When nurses are satisfied in their
jobs, they are more likely to remain in nursing (Roberts, Jones and Lynn, 2004). The
importance of nursing work to health care thus needs to continue to be supported and
promoted.
Respondents also reported that the component Interaction was important to job
satisfaction. New registered nurses agreed that the nursing personnel in their wards/units
always help one another out when things get in a rush and they also agreed that there is a
good deal of teamwork and cooperation between various levels of nursing personnel in
their wards/units. Good communication regardless of age, experience, and length of
tenure in an organization is one process that has been recognized to promote job
satisfaction (Manojlovich and Laschinger, 2002). Regardless of their types of practice,
work setting or country, it is very important for nurses to share and be committed to a
holistic philosophy of care. This perhaps more than anything else that shapes their
expectation and fit within today’s challenging workplace (ICN, 2007).
128
Not surprisingly, new registered nurses expressed that it was hard for them to feel ‘at
home’ in the wards/unit because of concerns such as a lot of “rank consciousness” or
limited interaction with experienced nurses and staff. Jackson (2005) identified that new
registered nurses were striving to develop a level of care and competency and unlike
expert nurses, they did not have vast experience and knowledge to work effectively as
part of the team. Numerous writers have suggested that manager behaviours can have a
significant impact on health outcomes of subordinates (WHO, 2007). The manager-
subordinate relationship is the most commonly reported cause of stress within a work
team, and this appears to be associated with a reduction in performance (De Dreu and
Weingart, 2003). Attention to these issues is therefore important in any transition support
program for new registered nurses.
Many respondents agreed with statements that the physicians in their ward/units should
show more respect for the skill and knowledge of the nursing staff. Because studies have
found that role conflict and ambiguity are positively correlated with job dissatisfaction,
and can generate low organizational commitment and increased psychological and
physiological stress, it is important that attention be given to improving nurse-physician
relationships (Sherman, 1998). While most nurses reported that physicians at this hospital
generally understood and appreciated what nursing staff do, and would cooperate and
work as part of a team, many still perceived physicians as looking down too much on the
nursing staff (Tabone, 2001).
129
The findings of this study also indicate nurses rated the component Autonomy as an
important component of their job satisfaction. Nearly half agreed that they have sufficient
input into the program of care for each of their patients, and that they don’t require close
supervision. Registered nurses in this study agreed that they have freedom in their work
to make decisions as they see fit, and can count on their supervisor for back up.
Transition programs specifically designed to bridge the gap between the academic and
service setting and to prepare novice nurses to utilize critical thinking skills in the
management of acutely ill patients are therefore likely to be important to ensure nurses
are confident to deal with the degree of autonomy they are required to demonstrate as a
registered nurse (Halfer, 2007). Indeed, some authors argue that such programs are
especially helpful for developing effective decision making power and improving a new
graduates’ level of work performance (Bond and Bunce, 2001).
Moreover, satisfaction with autonomy in the workplace has been identified in this study
as being especially important, since it is moderately correlated with the overall stress
score, and with ENSS subscales of patients and families, problems with supervisors and
workload. Specifically, higher levels of satisfaction with autonomy were associated with
lower levels of stress in all these domains. Similarly, nurses perceptions of their level of
organization was associated with several ENSS subscales, including stress associated
with treatment uncertainty, patients and families, workload, conflict with doctors,
problems relating to supervisors and discrimination. These findings underscore the
importance of developing nurses’ skills and confidence in their ability to function as a
registered nurse.
130
Task Requirements were also rated by nurses in this study as an important component of
job satisfaction. The majority of respondents were satisfied with their job activities
however, a notable proportion expressed concern that there was too much clerical and
paperwork required of nursing personnel in the hospital. The International Council of
Nurses (2007) reports argue that nurses today are often stressed because of heavy
workloads. Such work related stressors are reported to be correlated with increases in job
dissatisfaction, health complaints and absenteeism of nurses (Landeweerd and Boumans,
1994).
Of particular note, almost half the nurses in this study believed that they did not have
sufficient time for direct patient care and they did not have plenty of time and opportunity
to discuss patient care problems with other nursing personnel. Many also believed that
they could deliver much better care if they had more time with each patient. Studies
suggest that perceptions of the quality of one’s work are related to job satisfaction
(Murphy, 2004), and that higher job satisfaction is associated with increased attention to
patient psychological and educational needs (Perumal and Sehgal, 2003). Moreover, high
patient-to-nurse ratios have been linked to higher patient mortality and lower nurse job
satisfaction (Aiken, Clarke, Sloane, Sochalski and Silber, 2002). The current shortages of
nurses will thus continue to challenge the ability of nurses to meet the needs of their
patients (ICN, 2007), thereby potentially providing a situation where levels of work
related stress increase and work satisfaction decreases.
131
With respect to the Organizational Policies component of job satisfaction, most of the
respondents reported having sufficient control over scheduling their own shifts in the
hospital. However, many raised concerns that nursing administrators did not generally
consult with the staff on daily problems and procedures and that their voice in planning
policies and procedures for the hospital and the unit where they work was not regarded as
what they want. Many nurses in this study also agreed that there is a gap between the
administration of the hospital and the daily problems of the nursing service. Such factors
may contribute to decreased job satisfaction and an employee’s disengagement from the
organization (Lopopopo, 2002). Hence, developing organizational policies that are
conducive to a supportive and flexible work environment are important considerations for
administrators and policy makers if work satisfaction levels are to be high (Kovner,
Brewer, Yow-Wu, Ying, Miho, 2006).
The International Council of Nurses (2007) has also outlined the characteristics of
positive practice environments that are needed to deal with these situations. These
characteristics innovative policy frameworks focused on recruitment and retention,
strategies for continuing education and upgrading, adequate employee compensation,
recognition programmes, sufficient equipment and supplies, and a safe working
environment.
Findings also indicate that t Pay was important, although it was the area with which
nurses were least satisfied. Although nurses were satisfied with their present salary, the
majority of them did not agree with the present rate of pay increases for nursing service
132
personnel. Many agreed that an upgrading of pay schedule for nursing personnel is
needed at the hospital, and most disagreed that the pay they received is reasonable given
what is expected of nursing personnel. The International Council of Nurses (2007)
reported that job dissatisfaction among nurses were worsened by migration of nurses in
search for better working conditions, quality of life and higher paying jobs in richer
countries. In Ghana, for instance the migration of nurses was double than the number of
nursing graduates in the year of 2000, resulting in a major nursing workforce crisis
(ICN). The impact of nurse migration on nursing in Brunei is not well described.
A key finding of this study was that no significant differences were noted in levels of
stress or work satisfaction for nurses working in specialty areas of practice compared to
those in general medical/surgical units. While the sample size for this study was small,
such findings emphasise that the experience of stress for registered nurses in the first few
years following graduation has some common elements, no matter what the work
environment. Such stressors seemed to be common across nurses with different years of
experience, although analysis of sources of stress by years of experience identified that ,
nurses with less than 1 year experience reported higher mean stress scores for the
Uncertainty Concerning Treatment, Inadequate Emotional Preparation and Problem
Relating to Peers subscales. Nurses with less experience also reported higher total stress
scores than nurses with more than 1 year experience. These results emphasise that
particular attention needs to be given to supporting nurses in the early years as a
registered nurse.
133
As mentioned in the earlier chapters, nursing manpower comprises the largest component
of the health care workforce in Brunei Darussalam hospitals (MOH, 2007). Nurses’
vigilance is crucial to keeping patients and the community safe and healthy. The stability
and quality of Brunei Darussalam health care system relies on a sufficient supply of well-
educated and skilled nurses. Increasing job stress and low job satisfaction among nurses
in hospitals in Brunei Darussalam may therefore place the system at risk of lower quality
unsafe practices. Brunei is experiencing rapid population growth in several districts, and
an increasingly diverse population requiring better health care services (MOH, 2008).
The shortage of nursing manpower is occurring when the majority of experienced nurses
are retiring and their place is being taken up by inexperience nurses. This study has
identified areas of job stresses and job satisfaction experienced by nurses in hospitals and
clinics in Brunei Darussalam that may have important implications for managers and
educators.
6.1. Implications
In this current study, the findings have several important implications for nursing practice
and education. There is also a need for more research to be carried out. Perhaps the most
important implication is the need for collaboration between education and service sectors
in the development of programs which address the types of stressors and concerns
reported by nurses in this study. The findings of this study allow educators to redesign
educational approaches to support the role transition of new graduate nurse. At the same
time, the nursing service personnel need to consider a redesign of their internship
134
program to assist nurses to overcome challenges associated with stressors such as
uncertainty of treatments, and relationships with other health professionals. For example,
additional mentoring strategies may assist to promote critical thinking, foster peer
networking and discussion, and support professional role transition throughout the few
years of employment (Graf, 2006).
The United Kingdom Central Council has highlighted the importance of continuing
nursing education together with close clinical supervision by mentors for new registered
nurses to enable them to adjust to the demands of nursing profession during the critical
12 to 18 months taking up their career (UKCC, 1996). The findings of this study will
assist hospital administrators, educators and others nursing leaders in formulating the
direction of appropriate support and organisational structures for the development of
future professional nurses (RN). More specifically, nurses in this study have highlighted
particular areas that may be of assistance to their transition to being a competent
registered nurse. These include education, team building, access to hospital resources to
support professional development, mentoring, and stress management training. Many
nurses also identified that organisational policies that are flexible and which assist with
balancing priorities may be useful.
The International Council of Nurses (2007) outline three important characteristics of
positive practice environments: (1) a climate of safety for nurses and patients
(organizational commitment, management involvement, employee empowerment, reward
system and reporting system); (2) a climate of organisational support for life long
135
learning (encourage life long learning by supporting professional development and the
mutual sharing of knowledge, they become learning organisation); and (3) a climate of
leadership (when the organisational climate enhances the empowerment of individual
employees, nurses express greater job satisfaction and patients achieve better outcomes).
Programs of support for registered nurses need to include educational, team based,
organisational, and professional activities that will create this type of climate.
6.2. Study Limitations This study has several limitations. Most importantly, the study has addressed only
selected concepts important to our understanding of stress. The scope of this study
included an examination of perceived sources of stress and its links with work
satisfaction only. It was beyond the scope of this study to undertaken a comprehensive
analysis of other key concepts on stress theory, such as appraisal and coping. It was also
beyond the scope of this study to examine the implications of stress and coping for the
health and well being of nurses in this study, and the impact on the quality of care
provided. Such research is urgently needed to better understand the types of intervention
strategies that are needed at the system, organizational and individual level to minimise
the deleterious effects of stress.
There are also a number of methodological limitations of this study. The study includes
non-probability random sampling of new registered nurses who have experienced the
recent transition from student to practicing professional nurse working in today’s
136
complex clinical nursing working environment in one hospital setting. Though the sample
involved all new graduate nurses (N=120) working in the general surgical and medical
and specialty units at the time of survey, and a high response rate was achieved, it is
relatively small in number as participation was voluntary. Moreover, the sample excluded
nurses who were on leave at the time of data collection. While it is unlikely that this
created a systematic bias, the limits of the sample need to be acknowledged.
Nearly all of the samples were past students of the investigator, as they had recently
completed their nursing education in Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah
(PAPRSB) College of Nursing, Brunei Darussalam. There was a possibility of bias
resulting from the previous ex-students-teacher relationship, as the respondents may wish
to respond in socially desirable ways. In order to avoid this, the investigator assured all
participants of privacy and anonymity throughout the study. All nurses who were selected
as the study sample were aware that participation was voluntary. The participant’s
confidentiality and dignity was maintained and respected, by ensuring no identifying
information was included on the questionnaire. All respondents were given an
opportunity to receive an explanation of the nature and purpose of the study in a small
group presentation in units and wards three days prior to conducting the study, and
written information was provided in an information letter attached to the survey.
Participants were given sufficient time to complete the survey questionnaires at their own
pace or outside their working hours within three weeks and return the completed
questionnaires to the investigator either by mail using the pre stamped envelopes
137
provided or by placing them in sealed boxes at the nurse’s station in each unit. During the
data collection period, the investigator had no direct contact with the study participants.
The advantages of using self administered questionnaires as data collecting tool for this
study was that they were relatively less costly, offered complete anonymity for
respondents and resulted in no interaction bias. However, it is acknowledged that
collecting self reported data on stress and coping assumes that the study respondents have
clearly understood the questions and that they are able to define their stressors
(Wegmann, 1992), even if they understand and are able to speak English as their second
language. Moreover, information obtained from self-administered questionnaires can be
more superficial largely because they typically contain mostly a fixed number of closed-
ended items. Much of the richness and complexity of respondents’ experiences are lost or
unanswered. In reality, some stressors are taboo, and recall of others may cause
discomfort and therefore are not readily recalled (Gillespie and Kermode, 2004).
6.3. Future Research
The study findings reported here reflect the experiences of registered nurses with less
than three years experience from the specialty units and general surgical and medical
wards RIPAS Hospital, Brunei Darussalam. These findings provide nurse managers,
educators and hospital administrators in the country with findings that will assist with
developing appropriate professional support programs. Importantly, this study opens up
several areas that require future research. These may include another replication study
138
carried out at multiple sites with different sample of nurses, and more in-depth enquires
into each major stress source that has been identified in this study. In addition, further
research that is more closely guided by contemporary theoretical understandings of stress,
are needed to better understand concepts such as the influence of stress appraisal, and the
relationships between various coping strategies and positive outcomes for nurses.
6.4. Conclusion
It appears from previous studies that the nursing workplace is often stressful and that this
issue should not be ignored. Ganga (1998) argues it is obvious that nurses experience
stress in the clinical setting, and that there are no easy solutions to the problems of stress
in nursing education and practice. It is the role of the nurse educators, managers, and
administrators to find ways to make the nursing workplace more harmonious, pleasant
and less stressful, especially to new graduate nurses. The findings of this limited study
will assist nursing educators, directors and human resources managers to determine
coping strategies that might help in reducing amounts of stress experienced by new
graduate nurses in their day to day challenging and demanding nursing roles.
Stress is an unavoidable part of human life. Some stress may be normal and necessary,
but too much of it may affect the quality of life and health (WHO, 2004). The effects of
stress can be reduced by early identification of its problems, understanding its potential
contributing factors and finding effective coping strategies In this study, registered nurses
with less than three years experience were asked to nominate what they believed to be the
139
most effective ways to relieve the workplace stress and what would be extremely helpful
in assisting the new registered nurses’ transition as a practicing professional nurse. Ways
to reduce and avoid unnecessary stress that were suggested by participants in this present
study, indicating education; team building strategies; access to hospital resources;
mentoring; flexibility in working hours; stress management training; balancing priorities;
enhancing social and peer support programs and, finally, protocols to deal with violence
and retention. Such recommendations are worthy of attention by educators and
administrators to ensure positive practice environments for nurses, and the best outcomes
for those who require nursing services.
140
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157
Appendix 1
Telephone: 3820 18 381640 ext 7727 Fax 380687
Rujukan Kami : Our Reference :
PPK/lNT/39/2000
PERKHIDMATAN KEJURURAWATAN PEJABAT PENGARAH PERKHIDMATAN KEJURURAWATAN
JALAN MENTERI BESAR BANDAR SERI BEGAWAN BB3910 NEGARA BRUNEI DARUSSALAM
NURSING SERVICES DIRECTOR OF NURSING SERVICES OFFICE
JALAN MENTERI BESAR BANDAR SERI BEGAWAN BB3910
BRUNEI DARUSSALAM
1 4 September 2005
Mr Rahim Damit Room N-602 (level 6)QUT School of Nursing Victoria Park, Kelvin Grove Queensland 4059 Australia
Dear Mr. R. Damit
Re: PROPOSED STUDY ON "THE NEW GRADUATE NURSE'S PERCEPTIONS OF STRESS IN THE NEW COMPLEX CLINICAL WORKING ENVIRONMENT"
I am referring to your letter addressed to the Director General of Medical Services, Department of Medical Services, Ministry of Health dated 16 th August 2005 which is being referred to the Department of Nursing for comment and action.
Following the review of the information stated in the letter with regards to the proposed topic, the objectives, target sample and sample size, the setting and site, the department considered them as sufficient and appropriate. The Department also foresees the potential benefit of the proposed study towards enhancement of working environment in the context of practice delivery. I wish you could share the finding with us after you complete the study later.
I would like to state that there is no Ethics Committee as yet within the Ministry, However, the Director General of Medical Services has no objection to your proposal and permission is being granted for you to undertake the proposed study with conditions that you adhere to the ethical aspects and other related issues that need to be observed in conducting the research.
I wish you success with your undertaking. Kind regards.
Acting Director of Nursing
c.c. Director General of Medical Services: Ministry of Health
Appendix 1
Tel. : 2382031Fax : 2380687 E-mail : [email protected] General Office : 2381640
Our Ref. : JKPPP/8/2000/K
Your Ref. :
MEDICAL HEADQUARTERSMINISTRY OF HEALTH
BANDAR SERI BEGAWAN BB3510BRUNEI DARUSSALAM
March 2006
Date : ...........................................20 ......
Mr. Rahim DamitRoom N - 602 (level 6) School of Nursing Queensland University of Technology (QUT) Brisbane, Australia
Dear M r Damit,
Re: REQUEST FOR NEW DATE / TIME LINE FOR CONDUCTING RESEARCH PROJECT
Referring to your letter dated 27th February 2006 regarding the above to conduct the research project at Raja Isteri Pengiran Anak Saleha Hospital, Ministry of Health.
In relation to that, I have no objection to your proposed change of date (6th ~ 30th March 2006) and duration in order to enable you to conduct and complete the project, andinvolving the specified number of nurses within the Hospital setting.
I look forward for you to share the finding of your research later as it is important for the improvement of the service delivery at the Raja Isteri Pengiran Anak Saleha Hospital.
Sincerely
(Dr. Haji Affendy bin POKSM DSP Haji Abidin) Director General Medical Services Department Ministry of Health.
C.C.
Director of Hospital Services Director of Nursing Services Chief Executive Officer, RIPAS Hospital
Appendix 1
To: Director General Medical Services Department Ministry of Health Brunei Darussalam 16th August 2005. Dear Dr Haji/Sir,
I am a student, currently undertaking HL84 Master of Applied Science (Research) at the Queensland University of Technology (QUT), Brisbane Queensland Australia. I am working on my major study for this degree under the supervision of academic staff from the School of Nursing QUT’s Faculty of Health. I am very grateful of the support from ministry to be able to undertake this important project so that the health care system can benefit from this new knowledge.
The primary aim of this study is to investigate new graduate nurses’ perceptions of stress in today’s complex clinical working environment. The study objectives are to:
1. Identify and describe levels and sources of stress experienced by new graduate nurses
2. Compare levels of stress experienced by new graduate nurses working in operating theatre and surgical units and intensive care units.
3. Explore the relationship between workload, new complex working environment and levels of stress among new graduate nurses in operating theatre and surgical units and intensive care units.
I am, therefore requesting a permission to carry out a research project in Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital. The project will be commencing on the 1st December 2005 and expected to be complete by 27th February 2006. Some of 200 new graduate nurses with less than 2 years working experience as staff nurse in the new complex clinical working environment will be involved in the project. These may include nurses working in the speciality areas such as Operating Theatre, Surgical, Medical Units/Wards, Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU), Surgical Intensive Care Unit (SICU), Paediatric Intensive Care Unit (PICU), Special Care Baby Unit (SCBU), Otorhinolaryngology and integrated Head and Neck Department, and Accident and Emergency Department (A&E). The research findings will be used to plan for the future needs for the improvement of our Nursing Education; Clinical Nursing Practice, Generating New Knowledge as well as to plan in creating good nursing working environment in Brunei Darussalam.
Appendix 1 If you have any concerns or require further information about the project and have
any questions, please contact;
Chief Investigator: Mr Abd Rahim Damit Room N-602 (level 6) QUT School of Nursing Phone : +614 2495 4660 : +617 3357 4741 : +617 3357 4741 Fax email : [email protected] Principal Supervisor Sheree Smith Room N-537 (Level 5) QUT School of Nursing Phone : +617 3864 3905 email : [email protected]
Associate Supervisor Professor Patsy Yates Room N-334 QUT School of Nursing Phone : +617 3864 3835 email : [email protected]
Queensland Research Ethics Officer University Phone : +617 3864 2340 of Technology email : [email protected]
Your permission and consideration for me to carry out this project is highly appreciated. Your response to this letter can be address to:
Mr Haji Abd Rahim bin Haji Damit 2/ 80 Thistle Street Gordon Park Brisbane Queensland 4031 Australia Fax: +617 3357 4741 Tel: +614 2495 4660
I would like to take the opportunity in advance to say thank you for your consideration and any information that you can give me.
Yours sincerely
Mr Rahim Damit
Appendix 1 cc.
Director of Nursing Services, Nursing Services Department, Brunei Darussalam. Ministry of Health. Director of Medical Services. Medical Services. Ministry of Health. Director of Technical Education, Technical and Vocational Department. Ministry of Education. Principal, Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah College of Nursing. Chief Executive Officer, RIPAS Hospital. Ministry of Health. Principal Nursing Officer, RIPAS Hospital. Ministry of Health. Senior Nursing Officers, OT; MICU; CCU; ORL; PICU; SICU; SCBU; A & E; Surgical Wards/Units. RIPAS Hospital. Ministry of Health.
Appendix 1
Faculty of Health School of Nursing
Queensland University of Technology
To: Director General Medical Services Department Ministry of Health Brunei Darussalam 27th February 2006. Dear Dr Haji/Sir,
With reference to Dr Haji letter of permission PPK/INT/39/2000 dated on the 14th September 2005, I am therefore requesting permission for a new date timeline for conducting a research project in RIPAS Hospital as I am still waiting for an approval letter from the Queensland University of Technology (QUT), Research Ethic Committee.
The new proposed date for the project to be commencing is on the 6th March 2006 and expected to be complete by 30th March 2006. Some of 200 new graduate nurses with less than 3 years working experience as staff nurse in the new complex clinical working environment will be involved in the project. These may include nurses working in the speciality areas such as Operating Theatre, Surgical, Medical Units/Wards, Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU), Surgical Intensive Care Unit (SICU), Paediatric Intensive Care Unit (PICU), Special Care Baby Unit (SCBU), Otorhinolaryngology and integrated Head and Neck Department, and Accident and Emergency Department (A&E). The research findings will be used to plan for the future needs for the improvement of our Nursing Education; Clinical Nursing Practice, Generating New Knowledge as well as to plan in creating good nursing working environment in Brunei Darussalam.
I am very grateful of the support from Dr Haji and the Ministry of Health Brunei Darussalam to be able to undertake this important project so that the health care system can benefit from this new knowledge.
I would like to take the opportunity in advance to say thank you for your consideration.
Yours sincerely
Mr Rahim Damit Room N-602 (level 6) School of Nursing Queensland University of Technology (QUT), Brisbane Australia. Phone : 8891226 Home : 2447512 Fax : 2447512
Appendix 2 Date: Wed 7 Mar 13:39:28 EST 2007 From: "Janette Lamb" <[email protected]> Add To Address Book | This is Spam Subject: re ethics clearance -- 0600000023 To: <[email protected]>
Dear Abd
Thank you for providing the Progress Report in relation to ethical clearance for your project, QUT Ref 0600000023 – Stress in new graduate nurses: a comparative analysis between intensive care units and general wards.
I have noted on the ethics database:
The project has been completed; The project was carried out in accordance with the original application and the
National Statement on Ethical Conduct in Research Involving Humans; No unforeseen risks were identified; and No other ethical concerns have emerged from the study.
Information regarding the completion of this project will be provided to the University Human Research Ethics Committee at its next meeting. I will only contact you again in relation to this matter if the Committee raises any additional questions or concerns.
Please do not hesitate to contact me if you have any further queries in relation to this matter.
Yours sincerely
Janette Lamb
Research Ethics Support | Office of Research
Queensland University of Technology
Level 3 O Block Podium | Gardens Point
GPO Box 2434 | BRISBANE QLD 4001
Appendix 2 Date: Wed 1 Feb 10:21:40 EST 2006 From: "Research Ethics" <[email protected]> Add To Address Book | This is Spam Subject: Ethics Application Received Stress in new graduate nurses: a comparative analysis between intensive care units and general wards To: "Mr Haji Abd Rahim Haji Damit" <[email protected]> Cc: "Research Ethics" <[email protected]>
Dear Mr Haji Haji Damit , Re: Stress in new graduate nurses: a comparative analysis between intensive care units and general wards This email is to advise that your application has been received by the Research Ethics Office. Dependant on the type of application the following general process will occur: - Human Level 1 (Low Risk) - applications in this category are forwarded to the Chairperson of the UHREC for consideration. You should expect to receive details of outcome within 7-14 days; - Human Level 2 (Expedited) - applications in this category are forwarded to a representative panel of the UHREC for consideration. You should expect to receive details of outcome within 14-21 days; - Human Level 3 (Full Application) - applications in this category are forwarded to the UHREC Committee for consideration at a meeting. Details of meeting dates can be found on the Research Ethics website at http://www.research.qut.edu.au/oresearch/ethics/meet.jsp. You should expect to receive details of outcome within 7-14 days; - Animal Ethics Application - applications in this category are forwarded to the UAEC Committee for consideration at a meeting. Details of meeting dates can be found on the Research Ethics website at http://www.research.qut.edu.au/oresearch/ethics/meet.jsp. You should expect to receive details of outcome within 7-14 days; - Biosafety/GMO Application - applications in this category are forwarded to the IBC Committee for consideration at a meeting. Details of meeting dates can be found on the Research Ethics website at http://www.research.qut.edu.au/oresearch/ethics/meet.jsp. You should expect to receive details of outcome within 7-14 days; If you have any queries regarding this email please call or email, however, it would be appreciated if communication regarding the status of your
Appendix 2 application could be held over until the outcome period has passed, unless approval is required urgently. Please quote application number 0600000023 in any communication with the office. Kind regards David Wiseman Research Ethics Officer
Appendix 2 Date: Tue 24 Oct 11:21:00 EST 2006 From: "Lisa Reyes" <[email protected]> Add To Address Book | This is Spam Subject: RDC Reply: OS Fieldwork - Abd Rahim DAMIT (#5142555/HL84) To: <[email protected]> Cc: "Kristy Bensley" <[email protected]>, "Team E QUT International" <[email protected]>, "MS Sheree Smith" <[email protected]>
Hi Abd Rahim
OVERSEAS FIELDWORK The Research Degrees Committee and the International Students Business Services have approved your request for Overseas Fieldwork from 13August 2006 to 30 March 2007.
This leave does not affect your Candidature Milestone Dates. You can access your milestones on the student portal “Portia”. Portia can be accessed via QUT Virtual and you will need your QUT Access username and password - log in as Student and use the first 10 digits of your current QUT student password.
Please contact your Faculty Research Administration Officer or the Research Student Centre if you have any queries relating to your candidature.
Regards
Lisa
Appendix 3
Date: Mon 18 Jul 09:10:53 EST 2005 From: Sheree Smith <[email protected]> Add To Address Book | This is Spam Subject: Fwd: ENSS To: [email protected]
From: "Susan French" <[email protected]> To: <[email protected]> Subject: ENSS Date: Fri, 10 Jun 2005 18:04:07 -0400 X-Mailer: Microsoft Outlook Express 6.00.2900.2180 X-Junkmail-Status: score=20/50, host=mail-router02.qut.edu.au Dear Sheree I am sending you a copy of the ENSS, directions for usage and information on the grouping og the items. If you wish to use the instrument you have our permission to do so. Susan
Sheree M S Smith Lecturer, Queensland University of Technology, Kelvin Grove Campus, Kelvin Grove, AUSTRALIA 4059 email: [email protected] telephone 61+ 7 + 38643905
Appendix 3
Expanded Nursing Stress Scale (Final Version)
by
Susan E. French, RN, PhD1
Rhonda Lenton, PhD2
Vivienne Walters, PhD2
John Eyles, PhD3
1995
1School of Nursing, McMaster University 2Department of Sociology, McMaster University 3Department of Geography, McMaster University
Appendix 3 Expanded Nursing Stress Scale
Below is a list of situations that commonly occur in a work setting. For each situation you have encountered in your PRESENT WORK SETTING, would you indicate HOW STRESSFUL it has been for you: (Enter the number in the right hand column that best applies to you. If you have not encountered the situation, write ’0'.)
Never Stressful
1
Occasionally Stressful
2
Frequently Stressful
3
Extremely Stressful
4
Does Not Apply
5
1. Performing procedures that patients experience as painful………………... ___ 2. Criticism by a physician…………………………………………………… ___ 3. Feeling inadequately prepared to help with the emotional needs of a patient’s family………………………………………………… ___ 4. Lack of opportunity to talk openly with other personnel about problems in the work setting………………………………………………………… ___ 5. Conflict with a supervisor………………………………………………….. ___ 6. Inadequate information from a physician regarding the medical condition of a patient………………………………………….. ___ 7. Patients making unreasonable demands…………………………………….___ 8. Being sexually harassed……………………………………………………. ___ 9. Feeling helpless in the case of a patient who fails to improve…………….. ___ 10. Conflict with a physician…………………………………………………... ___ 11. Being asked a question by a patient for which I do not have a satisfactory answer…………………………………………………………. ___ 12. Lack of opportunity to share experiences and feelings with other personnel in the work setting………………………………………………. ___ 13. Unpredictable staffing and scheduling…………………………………….. ___ 14. A physician ordering what appears to be inappropriate treatment for a patient……………………………………………………… ___ 15. Patients’ families making unreasonable demands…………………………. ___ 16. Experiencing discrimination because of race or ethnicity…………………. ___ 17. Listening or talking to a patient about his/her approaching death…………. ___ 18. Fear of making a mistake in treating a patient……………………………... ___
Appendix 3
Never Stressful
1
Occasionally Stressful
2
Frequently Stressful
3
Extremely Stressful
4
Does Not Apply
5 19. Feeling inadequately prepared to help with the emotional needs of a patient…………………………………………………………………. ___ 20. Lack of an opportunity to express to other personnel on the unit my negative feelings towards patients…………………………. ___ 21. Difficulty in working with a particular nurse (or nurses) in my immediate work setting…………………………………………….. ___ 22. Difficulty in working with a particular nurse (or nurses) outside my immediate work setting………………………………………... ___ 23. Not enough time to provide emotional support to the patient……………... ___ 24. A physician not being present in a medical emergency……………………. ___ 25. Being blamed for anything that goes wrong……………………………….. ___ 26. Experiencing discrimination on the basis of sex…………………………… ___ 27. The death of a patient……………………………………………………… ___ 28. Disagreement concerning the treatment of a patient………………………. ___ 29. Feeling inadequately trained for what I have to do………………………… ___ 30. Lack of support of my immediate supervisor ……………………………... ___ 31. Criticism by a supervisor…………………………………………………... ___ 32. Not enough time to complete all of my nursing tasks……………………... ___ 33. Not knowing what a patient or a patient’s family ought to be told about the patient’s condition and its treatment………………….. ___ 34. Being the one that has to deal with the patients’ families…………………. ___ 35. Having to deal with violent patients……………………………………….. ___ 36. Being exposed to health and safety hazards……………………………….. ___ 37. The death of a patient with whom you developed a close relationship……. ___ 38. Making a decision concerning a patient when the physician is unavailable……………………………………………………. ___ 39. Being in charge with inadequate experience………………………………. ___ 40. Lack of support by nursing administration………………………………… ___ 41. Too many non-nursing tasks required, such as clerical work ……………... ___ 42. Not enough staff to adequately cover the unit…………………………….. ___ 43. Uncertainty regarding the operation and functioning of specialised equipment………………………………………………….. ___ 44. Having to deal with abusive patients……………………………………… ___
Appendix 3 Never
Stressful 1
Occasionally Stressful
2
Frequently Stressful
3
Extremely Stressful
4
Does Not Apply
5 45. Not enough time to respond to the needs of patients’ families…………….. ___ 46. Being held accountable for things over which I have no control………….. ___ 47. Physician(s) not being present when a patient dies………………………... ___ 48. Having to organise doctors’ work…………………………………………. ___
49. Lack of support from other health care administrators…………………….. ___ 50. Difficulty in working with nurses of the opposite sex……………………... ___ 51. Demands of patient classification system………………………………….. ___ 52. Having to deal with abuse from patients’ families………………………… ___ 53. Watching a patient suffer…………………………………………………... ___ 54. Criticism from nursing administration……………………………………... ___ 55. Having to work through breaks……………………………………………..___ 56. Not knowing whether patients’ families will report you for inadequate care…………………………………………………………….. ___ 57. Having to make decisions under pressure…………………………………. ___
Appendix 3 Instructions for the Scoring of the ENSS There are a total of 59 items in the Expanded Nursing Stress Scale. Two items (#6 and #14) did not appear to be related to any of the nine subscales that emerged in the original study of Ontario nurses (Susan French, Rhonda Lenton, John Eyles and Vivienne Walters. "An Empirical Evaluation of an Expanded Nursing Stress Scale". Journal of Nursing Measurement, Vol. 8, No. 2, 2000), but we suggest retaining those items for now. Subsequent applications would be able to assess whether these two items load on the subscales in any situations or among different populations of nurses. The nine subscales that have emerged, and the items in each subscale are as follows: a) Death and Dying - items 1, 10, 19, 29, 39, 49 and 55 b) Conflict with physicians - items 2, 11, 30, 40, and 50 c) Inadequate preparation - items 3, 12, and 21 d) Problems with peers - items 4, 13, 22, 23, 24, 52 e) Problems with supervisors - items 33, 42, 48, 51, and 56 f) Workload - items 15, 25, 34, 43, 44, 47, 53, 57, and 59 g) Uncertainty concerning treatment - items 7, 16, 26, 31, 35, 38, 41 and 45 h) Patients and their families - items 8, 17, 27, 36, 37, 46, 54, and 58 i) Discrimination - items 9, 18, and 28 In order to compute total stress score, we added together the scores on all 59 items. In order to measure scores on specific subscales, the appropriate items should be added together. In all cases, the category “not applicable” was scored as 0. Addressing missing data depends on the extent of the problem. While several options are available (some more complicated, such as using a regression method to estimate missed scores), we substituted missing values with mean scores for individual items, and proceeded to calculate the subscale score for any individual who had answered the majority of items in any subscale. In the case of the “Death and Dying” subscale, for example, an individual would have to have answered at least 4 of the 7 items that comprise the subscale. Otherwise, the subscale was not constructed, and the individual received was scored “missing” for that specific subscale. Items were scored so that the higher the score, the greater the stress on any subscale. It would be appreciated if you would forward a copy of your analysis of the ENSS to Dr. Lenton, at York University, and to Dr. Susan French at McGill University, so that we are able to monitor the assessment of the ENSS. Rhonda Lenton, PhD (Sociology) Susan E. French, R.N., PhD e-mail address: [email protected]
Appendix 3 Grouping of Items Within Factors in the Expanded Nursing Stress Scale
Factor 1: Death and Dying
• Performing procedures that patients experience as painful. • Feeling helpless in the case of a patient who fails to improve. • Listening or talking to a patient about his/her approaching death. • The death of a patient. • The death of a patient with whom you have developed a close relationship. • Physician not being present when a patient dies. • Watching a patient suffer.
Factor 2: Conflict with Physicians
• Criticism by a physician. • Conflict with a physician. • Disagreement concerning the treatment of a patient. • Making a decision concerning a patient when the physician is unavailable. • Having to organize physicians’ work.
Factor 3: Inadequate Emotional Preparation
• Feeling inadequately prepared to help with the emotional needs of a patient’s family. • Being asked a question by a patient for which I do not have a satisfactory answer. • Feeling inadequately prepared to help with the emotional needs of a patient.
Factor 4: Problems Relating to Peers
• Lack of an opportunity to talk openly with other unit personnel about problems in the work setting. • Lack of an opportunity to share experiences and feelings with other personnel in the work setting. • Lack of an opportunity to express to other personnel on the unit my negative feelings toward patients. • Difficulty in working with a particular nurse (or nurses) outside my immediate work setting. • Difficulty in working with a particular nurse (or nurses) inside my immediate work setting. • Difficulty in working with nurses of the opposite sex.
Factor 5: Problems Relating to Supervisors
• Conflict with a supervisor. • Lack of support from my immediate supervisor. • Lack of support by nursing administrators. • Lack of support by other health care administrators. • Criticism by a supervisor. • Being held accountable for things over which I have no control. • Criticism by nursing administration.
Factor 6: Work Load • Unpredictable staffing and scheduling. • Too many non-nursing tasks required such as clerical work. • Not enough time to provide emotional support to a patient. • Not enough time to complete all of my nursing tasks. • Not enough staff to adequately cover the unit. • Not having enough time to respond to the needs of the patients’ families. • Demands of patient classification system. • Having to work through breaks.
Appendix 3 • Having to make decisions under pressure.
Factor 7: Uncertainty Concerning Treatment
• Inadequate information from a physician regarding the medical condition of a patient. • A physician ordering what appears to be inappropriate treatment for a patient. • Fear of making a mistake in treating a patient. • A physician not being present in a medical emergency. • Not knowing what a patient or a patient’s family ought to be told about the patient’s condition and its
treatment. • Being exposed to health and safety hazards. • Uncertainty regarding the operation and functioning of specialized equipment. • Feeling in adequately trained for what I have to do. • Being in charge with inadequate experience
Factor 8: Patients and their Families
• Patients making unreasonable demands. • Patients’ families making unreasonable demands. • Being blamed for anything that goes wrong. • Being the one who has to deal with patients’ families. • Having to deal with violent patients. • Having to deal with abusive patients. • Having to deal with abuse from patients’ families. • Not knowing whether patients’ families will report you for inadequate care.
Factor 9: Discrimination • Being sexually harassed. • Experiencing discrimination because of race or ethnicity. • Experiencing discrimination on the basis of sex.
MASS.
Appendix 4
Haji Abd Rahim Haji Damit School of NursingQueensland University of Technology Victoria Park Road Kelvin Grove 4059 AUSTRALIA
School of Public Healthand Health Sc iences
I appreciate receiving your request for permission to use the Index of Work Satisfaction (IWS) in the very interesting research project described in your recent letter. The second edition of my book Nurses and Work Satisfaction: An Index of Measurement, 2nd Edition (1997) gives the most recent version of the IWS, along with the statistical description of the scale itself. Also included in this volume are results from over 80 studies that have used the IWS. Several investigators write about their experiences using this measurement tool. The book may be ordered by you or your school's library from Health Administration Press (US $43.00) by mail, telephone or fax:
Health Administration Press P.O. Box 401 Annapolis Junction, MD 20701-0401
Phone orders: 301-362-6905 FAX # 301 -206-9789 ISBN #1 -56793-061-1
The IWS questionnaire is a copyrighted measurement tool, with the copyright held by myself and Market Street Research, Inc., a full-service marketing research and evaluationfirm located in Northampton, Massachusetts. If you wish to use the IWS questionnaire, afee of $30.00 payable to Market Street Research covers permission to use the questionnaire, a print-ready hard copy formatted for use in your study, and an IBM-compatible floppy diskette which you can use in the event you wish to add questions of
@Printed on Recycled Paper
Department of Community Health Studies
voice: 413.545.1312 fax: 413.545.6536
October 10, 2005
Dear Mr. Damit:
Appendix 4
interest to your particular area of research. Other services available from Market StreetResearch include:
A step-by step instruction manual so you can score the IWS yourself Data entry services; scoring assistance and basic data analysis Technical assistance in modifying or expanding the questionnaire
I have enclosed a complete description of these services as well as a price list. Please send any checks directly to Market Street Research, using the order form I have included. If you do decide to use the IWS in your study, you will need the scoring manual unless you would like for Market Street Research to do the scaring for you. This scoring service comes with a basic analysis and results are available quickly. If you have any questions about the IWS or any of the support services available for users of the IWS, please call either myself or Market Street Research. Market Street Research does not need a separate letter from you.
I would very much appreciate hearing about your results, as I am keeping a file of thetypes of research for which people are using the IWS. Good luck with your study and feel free to contact me for any additional information.
Sincerely,
Paula Stamps, Ph.D. University of Massachusetts Phone: (413) 545-6880 Fax: (413) 545-6536 Email: [email protected]
Appendix 4
INDEX OF WORK SATISFACTION DESCRIPTION OF SERVICES
Market Street Research, Inc. is a full-service, independent marketing research firm based in Northampton, Massachusetts, with over 20 years of experience in providing state-of- the-art, custom-designed marketing and evaluation research services to clients within a wide range of health care settings, Far the past three years, Market Street Research has worked closely with Paula Stamps, Ph.D., to develop services which will support users of the Index of Work Satisfaction (IWS). The following services are available from Market Street Research and/or Paula Stamps:
1. Questionnaires: The copyrighted version of the IWS questionnaire is available as a print- ready paper copy and on an IBM-compatible floppy diskette for $30.00. Users may customize the questionnaires by adding items or with minor changes in wording to reflect local institutional characteristics. Market Street Research or Paula Stamps can also provide technical assistance in questionnaire design or data collection methods at a consulting rate oof $150.00 per hour.
2. Scoring instructions. A packet that gives step-by-step instructions for scoring the IWS is available for $60.00. The packet describes the method for scoring both parts of the questionnaire. The instructions for each part are given separately for those who are using only one part of the scale. These instructions may be used by researchers to create their own computerized scoring programs, if desired.
3. Scoring service with data entry. For those who do not wish to score their own questionnaires, completed questionnaires can be scored by Market Street Research. The fee will vary depending on the number of questionnaires to be entered and analyzed, the degree to which researchers added to or otherwise modified the IWS, and the level of analysis. If the copyrighted IWS questionnaire is used as is, the baseline fee for a sample size of 50 nurses is $975.00 plus $2.30 per additional questionnaire. This fee includes data entry and scoring, with users receiving a summary of the scores and a data file on diskette.
4. Scaring service without data entry. Some organizations have the ability to do their own data entry of completed questionnaires, but would like assistance in scoring the IWS. Market Street Research will provide these researchers with instructions an formatting the data appropriately. The fee far simple scoring of the IWS is $775.00 per data set.
5. Technical assistance in design. Although many studies using the IWS are straightforward, some involve more complicated designs. Some studies using the IWS involve management or job redesign initiatives and are primarily concerned with evaluation. Assistance is available in designing these studies and interpreting the results. Management consulting, the creation of altemative managerial systems, and evaluation and marketing research services are also available. Prices for this are determined based on individual requirements.
Users must receive permission to use the copyrighted version of the IWS in order to access the support services provided by Market Street Research, In addition, researchers who request IWS scoring services will be asked to submit summary information for their research projects to Market Street Rasearch, which will be incorporated in a national data base that we are developing. Your results will be held strictly confidential, and will be combined with those of other research projects in order to build a better understanding of the variations in IWS results among diverse institutions. For questions relating to use of the national data base, please contact Paula Stamps.
Appendix 4
FOR MORE INFORMATION, CONTACT:
Attn: IWS SupportMarket Street Research, Inc. 2 Maple Ave. , Suite 52 Northampton, MA 01060Phone: (413) 584-0465Fax: (413) 582-1206Ernaii: [email protected]
Appendix 4
IWS ORDER FORM FOR PRODUCTS AND SERVICES (valid through May 2003)
* Not available without initial purchase of copyrighted IWS questionnaire. ** Make checks payable to: Market Street Research, Inc.
Name:
Organization:
Address:
City: State: Zip:
Phone: Fax:
TYPE OF ORGANIZATION:
hospital
hospital/health system
visiting nurse association
other home health care organization
managed care organization
graduate student
college or university faculty
other:
MAIL ORDERS TO: Attn: IWS OrdersMarket Street Research, Inc.2 Maple Avenue, Suite 52 Northampton, MA 01060
Appendix 4
November 22, 2005 Abd Rahim Damit No 23 “A” Simpang 97, 97-23 Jalan Kiarong Kampong Kiulap BE 1518 Negara Brunei Darussalam To Whom It May Concern: This letter gives Abd Rahim Damit permission to use the copyrighted Index of Work Satisfaction. It maybe re-published in its original form or a modified form. Sincerely,
Doreen Masi Market Street Research
Appendix 4 Date: Tue 22 Nov 03:20:17 EST 2005 From: Doreen Masi <[email protected]> Add To Address Book | This is Spam Subject: Your Index of Work Satisfaction Order To: [email protected]
Hello Abd, My name is Doreen Masi, I work at Market Street Research. I received your order for IWS questionnaire and Scoring Manual in Friday's mail. To make things easier, I could send you both items via email to this email address. I wanted to check in with you before doing so. If you could reply to this email and let me know if I can send off the items via email, that would be great. The questionnaire would be in Word 6.0 and the scoring manual would be a pdf file. Please let me know how to proceed. I look forward to hearing back from you, Doreen -- Doreen Masi Office Manager Market Street Research 2 Maple Avenue, Suite 52 Northampton, MA 01060 413-584-0465 fax: 413-582-1206 [email protected]
Appendix 4 Date: Wed 23 Nov 05:01:21 EST 2005 From: Doreen Masi <[email protected]> Add To Address Book | This is Spam Subject: Re: Your Index of Work Satisfaction Order To: [email protected]
Hi Rahim, I'm very glad you liked my idea and hopefully this will speed things along for you. Attached you will find the questionnaire and the scoring manual. I have also included a letter of permission to use the survey, just in case you need to submit a document such as this with your study. If I can be of further assistance, do not hesitate to contact me. I wish you luck! Doreen [email protected] wrote: Dear Doreen Masi, Thanks a lot. That would be great. Yes you could send those items to this email address. I appreciate you brilliant idea. Kindly regards, Rahim Damit [email protected] +614 2495 4660 +617 3252 0250 H67 Cathedral Place 41 Gotha Street FORTITUDE VALLEY QLD 4006 Brisbane Queensland Australia Doreen Masi Office Manager Market Street Research 2 Maple Avenue, Suite 52 Northampton, MA 01060 413-584-0465 fax: 413-582-1206 [email protected]
Attachment: IWS-quest-ver6-0.doc (206k bytes) Open
Attachment: IWS Score Manual.pdf (236k bytes) Open
Attachment: Permission_letter.doc (63k bytes) Open
Appendix 4
The Index of Work Satisfaction Questionnaire © Part A (Paired Comparisons) Listed and briefly defined below are six terms or factors that are involved in how people feel about their work situation. Each factor has something to do with “work satisfaction”. We are interested in determining which of these is most important to you in relation to the others. Please carefully read the definitions for each factor as given below:
Pay -- dollar remuneration and fringe benefits received for work done
Autonomy -- amount of job related independence, initiative, and freedom, either permitted or required in daily work activities.
Task Requirements -- tasks or activities that must be done as a regular part of the job
Organizational Policies -- management policies and procedures put forward by the hospital and nursing administration of this hospital
Interaction -- opportunities presented for both formal and informal social and professional contact during working hours
Professional Status -- overall importance or significance felt about your job, both in your view and in the view of others
Instructions: These factors are presented in pairs on the next page. A total of 15 pairs are presented: this is every set of combinations. No pair is repeated or reversed. For each pair of terms, decide which one is more important for your job satisfaction or morale, and check the appropriate box. For example, if you feel that Pay (as defined above) is more important than Autonomy (as defined above), check the box for Pay.
It will be difficult for you to make choices in some cases. However, please do try to select the factor which is more important to you. Please make an effort to answer every item; do not go back to change any of your answers.
© The IWS Questionnaire is used by permission of Paula L. Stamps, Ph.D., and Market Street Research, Inc., Northampton, Massachusetts.
Appendix 4 Part A (Paired Comparisons, Continued) Please choose the one member of the pair which is most important to you. 1. Professional Status or Organizational Policies
2. Pay Requirements or Task Requirements
3. Organizational Policies or Interaction
4. Task Requirements or Organizational Policies
5. Professional Status or Task Requirements
6. Pay or Autonomy
7. Professional Status or Interaction
8. Professional Status or Autonomy
9. Interaction or Task Requirements
10. Interaction or Pay
11. Autonomy or Task Requirements
12. Organizational Policies or Autonomy
13. Pay or Professional Status
14. Interaction or Autonomy
15. Organizational Policies or Pay Part B (Attitude Questionnaire) The following items represent statements about how satisfied you are with your current nursing job. Please respond to each item. It may be very difficult to fit your responses into the seven categories; in that case, select the category that comes closest to your response to the statement. It is very important that you give your honest opinion. Please do not go back and change any of your answers. Instructions: Please circle the number that most closely indicates how you feel about each statement. The left set of numbers indicates degrees of agreement. The right set of numbers indicates degrees of disagreement. For example, if you strongly agree with the first item, circle 1; if you agree with this item, circle 2; if you moderately agree with the first statement, circle 3. The middle response (4) is reserved for feeling neutral or undecided. Please use it as little as possible. If you moderately disagree with this first item, you should circle 5; to disagree, circle 6; and to strongly disagree, circle 7.
© IWS Questionnaire 2
Appendix 4 Part B (Attitude Questionnaire, Continued) Remember: The more strongly you feel about the statement, the further from the center you should circle, with agreement to the left and disagreement to the right. Use 4 for neutral or undecided if needed, but please try to use this number as little as possible.
Agree Disagree 1. My present salary is satisfactory. 1 2 3 4 5 6 7 2. Nursing is not widely recognized as being an
important profession. 1 2 3 4 5 6 7 3. The nursing personnel on my service pitch in and
help one another out when things get in a rush. 1 2 3 4 5 6 7 4. There is too much clerical and “paperwork” required
of nursing personnel in this hospital. 1 2 3 4 5 6 7 5. The nursing staff has sufficient control over
scheduling their own shifts in my hospital. 1 2 3 4 5 6 7 6. Physicians in general cooperate with nursing staff
on my unit. 1 2 3 4 5 6 7 7. I feel that I am supervised more closely than is
necessary. 1 2 3 4 5 6 7 8. It is my impression that a lot of nursing personnel at
this hospital are dissatisfied with their pay. 1 2 3 4 5 6 7 9. Most people appreciate the importance of nursing
care to hospital patients. 1 2 3 4 5 6 7 10. It is hard for new nurses to feel ‘at home’ in my unit. 1 2 3 4 5 6 7 11. There is no doubt whatever in my mind that what I
do on my job is really important. 1 2 3 4 5 6 7 12. There is a great gap between the administration of
this hospital and the daily problems of the nursing service.
1 2 3 4 5 6 7
13. I feel I have sufficient input into the program of care for each of my patients. 1 2 3 4 5 6 7
14. Considering what is expected of nursing service personnel at this hospital, the pay we get is reasonable.
1 2 3 4 5 6 7
15. I think I could do a better job if I did not have so much to do all the time. 1 2 3 4 5 6 7
16. There is a good deal of teamwork and cooperation between various levels of nursing personnel on my service.
1 2 3 4 5 6 7
© IWS Questionnaire 3
Appendix 4 Part B (Attitude Questionnaire, Continued) Remember: The more strongly you feel about the statement, the further from the center you should circle, with agreement to the left and disagreement to the right. Use 4 for neutral or undecided if needed, but please try to use this number as little as possible.
Agree Disagree 17. I have too much responsibility and not enough
authority. 1 2 3 4 5 6 7 18. There are not enough opportunities for
advancement of nursing personnel at this hospital. 1 2 3 4 5 6 7 19. There is a lot of teamwork between nurses and
doctors on my own unit. 1 2 3 4 5 6 7 20. On my service, my supervisors make all the
decisions. I have little direct control over my own work.
1 2 3 4 5 6 7
21. The present rate of increase in pay for nursing service personnel at this hospital is not satisfactory. 1 2 3 4 5 6 7
22. I am satisfied with the types of activities that I do on my job. 1 2 3 4 5 6 7
23. The nursing personnel on my service are not as friendly and outgoing as I would like. 1 2 3 4 5 6 7
24. I have plenty of time and opportunity to discuss patient care problems with other nursing service personnel.
1 2 3 4 5 6 7
25. There is ample opportunity for nursing staff to participate in the administrative decision-making process.
1 2 3 4 5 6 7
26. A great deal of independence is permitted, if not required, of me. 1 2 3 4 5 6 7
27. What I do on my job does not add up to anything really significant. 1 2 3 4 5 6 7
28. There is a lot of “rank consciousness” on my unit: nurses seldom mingle with those with less experience or different types of educational preparation.
1 2 3 4 5 6 7
29. I have sufficient time for direct patient care. 1 2 3 4 5 6 7 30. I am sometimes frustrated because all of my
activities seem programmed for me. 1 2 3 4 5 6 7 31. I am sometimes required to do things on my job
that are against my better professional nursing judgment.
1 2 3 4 5 6 7
© IWS Questionnaire 4
Appendix 4 Part B (Attitude Questionnaire, Continued) Remember: The more strongly you feel about the statement, the further from the center you should circle, with agreement to the left and disagreement to the right. Use 4 for neutral or undecided if needed, but please try to use this number as little as possible.
Agree Disagree 32. From what I hear about nursing service personnel
at other hospitals, we at this hospital are being fairly paid.
1 2 3 4 5 6 7
33. Administrative decisions at this hospital interfere too much with patient care. 1 2 3 4 5 6 7
34. It makes me proud to talk to other people about what I do on my job. 1 2 3 4 5 6 7
35. I wish the physicians here would show more respect for the skill and knowledge of the nursing staff.
1 2 3 4 5 6 7
36. I could deliver much better care if I had more time with each patient. 1 2 3 4 5 6 7
37. Physicians at this hospital generally understand and appreciate what the nursing staff does. 1 2 3 4 5 6 7
38. If I had the decision to make all over again, I would still go into nursing. 1 2 3 4 5 6 7
39. The physicians at this hospital look down too much on the nursing staff. 1 2 3 4 5 6 7
40. I have all the voice in planning policies and procedures for this hospital and my unit that I want 1 2 3 4 5 6 7
41. My particular job really doesn’t require much skill or “know-how”. 1 2 3 4 5 6 7
42. The nursing administrators generally consult with the staff on daily problems and procedures. 1 2 3 4 5 6 7
43. I have the freedom in my work to make important decisions as I see fit, and can count on my supervisors to back me up.
1 2 3 4 5 6 7
44. An upgrading of pay schedules for nursing personnel is needed at this hospital. 1 2 3 4 5 6 7
© IWS Questionnaire 5
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
Faculty of Health School of Nursing Queensland University of Technology
SUBJECT INFORMATION SHEET
JOB STRESS PROJECT
Chief Investigator: Mr Abd Rahim Damit Room N-602 (level 6) QUT School of Nursing Phone : +614 2495 4660 : +673 8891226 : +617 3252 0250 Fax : [email protected]
Principal Supervisor Sheree Smith Room N-537 (Level 5) QUT School of Nursing Phone : +617 3864 3905 : [email protected]
Associate Supervisor Professor Patsy Yates Room N-334 QUT School of Nursing Phone : +617 3864 3835 : [email protected]
Dear Colleagues,
I am a student, currently undertaking HL84 Master of Applied Science (Research) at the Queensland University of Technology (QUT), Brisbane Queensland Australia. As part of this degree I am working on my major study supported by academic staff from the School of Nursing, at QUT’s Faculty of Health.
The primary aim of this study is to investigate new graduate nurses’ perceptions of stress in today’s complex clinical working environment. The study objectives are to:
1. Identify levels and sources of stress experienced by new graduate nurses 2. Compare levels and sources of stress experienced by new graduate nurses working in operating
theatre, surgical, medical and intensive care units. 3. Explore the relationship between the levels of stress among new graduate nurses in operating
theatre, surgical, medical and intensive care units and o fear of failure to carry out nursing tasks, o fear of making mistakes, o conflicts with supervisor and other healthcare professionals, o experience of being discriminated, o perceived support from supervisors, o perceived organisational skills, o experience dealing with the death and dying and new complex working environment.
1
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
I am writing to you because you are a new graduate working in the clinical departments of interest to this study. I hope that you will be able to help me with this project. I am, therefore requesting you to take a few minutes of your time to complete the attached questionnaire and return it to me no later than Friday, 17th March 2006. Your feedback will be used to plan for future improvements to our nursing education programs and to assist with creating a good working environment for new graduates.
Your participation in this project is voluntary and if you do feel any discomfort regarding questions in this survey, you are free to withdraw from the study at any time. There are no right or wrong answers and the information that you are going to provide will be confidential, no identifying information is required. If you require further information about the project or have any questions, please contact me on +673 8891226 (mp) Brunei Darussalam or +61732520250(hp/Fax); +61424954660 (hp) email: [email protected] Australia Haji Abd Rahim bin Haji Damit as the chief investigator.
I would like to take the opportunity in advance to say thank you for your consideration and any information that you can give me. I enclose a stamped addressed envelope for returning of the survey. Alternatively, you may drop them into the box provided in each unit.
Yours sincerely
(Mr Rahim Damit)
----------------------------------------------------------------------------------------------------
I confirm that (Mr Rahim Damit) is currently enrolled in the HL84 Master of Applied Science (Research) Degree in the Faculty of Health, School of Nursing at the Queensland University of Technology, Brisbane Queensland Australia and any assistance given by you would be very much appreciated.
Signed.............................. Ms Sheree Smith. Project principal investigator’s supervisor email: [email protected]
Date: …………………….
2
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
INFORMATION FOR JOB STRESS PROJECT PARTICIPANTS
Thank you for agreeing to participate in this study. Work situations typically experienced and
encountered by nurses in day to day practice may be stressful. The valuable information you provide will assist
me as the project chief investigator to investigate new graduate nurses’ perceptions of stress in the new complex
clinical working environment.
Please read the subject information sheet carefully. If you are a staff nurse who currently works in Raja
Isteri Pengiran Anak Saleha (RIPAS) Hospital and you have less than 36 months (3 years), experience working
as a hospital staff nurse then you are invited to participate.
Be assured that all your responses are confidential and no information about the project will be
published in any form that would allow any individual to be recognised. All information is coded so that you will
remain anonymous. Your participation is voluntary. Completion of the questionnaire should take no longer than
thirty minutes.
If you wish to discuss any aspect of this study feel free to contact Abd Rahim Damit on +673 8891226
or +614 2495 4660. You may also contact the project chief investigator’s supervisor Sheree Smith on +617 3864
3905 or Queensland University of Technology, Research Ethics Officer on +617 3864 2340 or Director General,
Medical Services Department, Ministry of Health, Brunei Darussalam on +673 2381887 Fax.
Thank you again for your cooperation.
Participant information sheet read
SURVEY NUMBER
For your convenience, you may return the complete questionnaire to me by post using the enclosed pre-paid envelop. Alternatively, you may drop them into the box provided in each unit. Date Received: CONFIDENTIAL 3
OT, MICU.SICU,CCU, A&E, PICU,ORL,WARDS 1,2,3,4,6,7,8,9,10,11,19,20,21,22
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
This part of the questionnaire is about your DEMOGRAPHIC INFORMATION. For each of the following items, please tick ( / ) or darken the bubble on your choice that matches your response in relationship to your staff nurse position.
1. In what year were you born? 19
2. What is your sex?
Male Female
3. What is the highest level of nursing education that you have?
Registered Nurse (Diploma in Nursing)
Registered Nurse + Post Basic Diploma (Nursing Speciality)
Registered Nurse + Bachelor Degree in Nursing/ Honours
Registered Nurse + Postgraduate Certificate (Nursing Speciality)
Registered Nurse + Postgraduate Diploma (Nursing Speciality)
4. How long have you been working as a Registered Nurse?
0 – less than 1 year
1 Year – less than 2 years
2 Years – less than 3 years
5. How long have you been working in this unit as a Registered Nurse?
0 – less than 1 year
1 Year – less than 2 years
2 Years – less than 3 years
6. Marital Status
Single (never married)
Married
Divorced
Widowed
4
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
7. Which ethnic group you belong to
Malay
Chinese
Indian
Indigenous
Others, please state…………
8. Do you have children?
Yes
No
Not Applicable
9. How many children do you have?
One
Two
Three
More than four
Not Applicable
10. How old are your children?
Pre School Age (0 – less than 5 years) number of children in this range
School Age (5 – less than 10 years) number of children in this range
Teenager (10 – less than 20 years) number of children in this range
Adult (20 or above) number of children in this range
Not Applicable
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE 5
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
11. If you have children, how much support do you have at home to care for them?
Not Applicable
VERY GOOD
SUPPORT
GOOD SUPPORT AVERAGE
POOR
SUPPORT
NO
SUPPORT
1 2 3 4 5 1 HUSBAND 2 HOUSE MAID 3 PARENTS / IN LAW
4 SISTER/ BROTHER/ IN LAW
12. Home ownership status
Owned Outright
Renting
Living in Parents Dwelling
Government Residence (Flat/House)
SECTION: 2
This part of the questionnaire relates to HOW YOU FEEL ABOUT YOUR OVERALL CLINICAL PRACTICE as a new graduate staff nurse. Please tick ( / ) or darken the bubble underneath the numbers in the right hand column on your choice to indicate on the following scale that includes "(1) Strongly Disagree", "(2) Disagree", "(3) Uncertain" "(4) Agree" and “ (5) Strongly Agree”.
STRONGLY DISAGREE DISAGREE UNCERTAIN
AGREE
STRONGLY
AGREE 1 2 3 4 5 1 CONFIDENT
2 COMPETENT
3 ORGANISED
4
PLEASE ADD ANY COMMENTS HERE TO ELABORATE ON YOUR ANSWERS
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE 6
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
SECTION: 3
Below is a list of situations that commonly occur in a work setting. For each situation you have encountered in your PRESENT WORK SETTING, would you indicate HOW STRESSFUL it has been for you: Tick ( / ) or darken the bubble underneath the numbers in the right hand column that best applies to you. If you have not encountered the situation, Tick ( / ) or darken the bubble underneath '0'.
Nev
er S
tres
sful
Occ
asio
nally
Str
essf
ul
Fre
quen
tly S
tres
sful
Ext
rem
ely
Stre
ssfu
l
Doe
s Not
App
ly
No Items 1 2 3 4 0 1 Performing procedures that patients experience as painful
2 Criticism by a physician
3 Feeling inadequately prepared to help with the emotional needs of a patient's family
4 Lack of opportunity to talk openly with other personnel about problems in the work setting
5 Conflict with a supervisor
6 Breakdown of computer
7 Inadequate information from a physician regarding the medical condition of a patient
8 Patients making unreasonable demands
9 Being sexually harassed
10 Feeling helpless in the case of a patient who fails to improve
11 Conflict with a physician
12 Being asked a question by a patient for which I do not have a satisfactory answer
13 Lack of opportunity to share experiences and feelings with other personnel in the work setting
14 Floating to other units/services that are short-staffed
15 Unpredictable staffing and scheduling
16 A physician ordering what appears to be inappropriate treatment for a patient
17 Patients' families making unreasonable demands
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE
7
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
Nev
er S
tres
sful
Occ
asio
nally
Str
essf
ul
Fre
quen
tly S
tres
sful
Ext
rem
ely
Stre
ssfu
l
Doe
s Not
App
ly
Below is a list of situations that commonly occur in a work setting. For each situation you have encountered in your PRESENT WORK SETTING, would you indicate HOW STRESSFUL it has been for you: Tick ( / ) or darken the bubble underneath the numbers in the right hand column that best applies to you. If you have not encountered the situation, Tick ( / ) or darken the bubble underneath '0'.
1 2 3 4 0 18 Experiencing discrimination because of race or ethnicity
19 Listening or talking to a patient about his/her approaching death
20 Fear of making a mistake in treating a patient
21 Feeling inadequately prepared to help with the emotional needs of a patient
22 Lack of an opportunity to express to other personnel on the unit my negative feelings towards patients
23 Difficulty in working with a particular nurse (or nurses) inside my immediate work setting
24 Difficulty in working with a particular nurse (or nurses) outside my immediate work setting
25 Not enough time to provide emotional support to the patient
26 A physician not being present in a medical emergency
27 Being blamed for anything that goes wrong
28 Experiencing discrimination on the basis of sex
29 The death of a patient
30 Disagreement concerning the treatment of a patient
31 Feeling inadequately trained for what I have to do
32 Lack of support from my immediate supervisor
33 Criticism by a supervisor
34 Not enough time to complete all of my nursing tasks
35 Not knowing what a patient or a patient's family ought to be told about the patient's condition and its treatment
36 Being the one that has to deal with patients' families
37 Having to deal with violent patients
38 Being exposed to health and safety hazards
39 The death of a patient with whom you developed a close relationship
40 Making a decision concerning a patient when the physician is unavailable
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE 8
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
Nev
er S
tres
sful
Occ
asio
nally
Str
essf
ul
Fre
quen
tly S
tres
sful
Ext
rem
ely
Stre
ssfu
l
Doe
s Not
App
ly
Below is a list of situations that commonly occur in a work setting. For each situation you have encountered in your PRESENT WORK SETTING, would you indicate HOW STRESSFUL it has been for you: Tick ( / ) or darken the bubble underneath the numbers in the right hand column that best applies to you. If you have not encountered the situation, Tick ( / ) or darken the bubble underneath '0'.
1 2 3 4 0 41 Being in charge with inadequate experience
42 Lack of support by nursing administrators
43 Too many non-nursing tasks required, such as clerical work
44 Not enough staff to adequately cover the unit
45 Uncertainty regarding the operation and functioning of specialized equipment
46 Having to deal with abusive patients
47 Not enough time to respond to the needs of patients' families
48 Being held accountable for things over which I have no control
49 Physician(s) not being present when a patient dies
50 Having to organize doctors' work
51 Lack of support from other health care administrators
52 Difficulty in working with nurses of the opposite sex
53 Demands of patient classification system
54 Having to deal with abuse from patients' families
55 Watching a patient suffer
56 Criticism by nursing administration
57 Having to work through breaks
58 Not knowing whether patients' families will report you for inadequate care
59 Having to make decisions under pressure
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE
9
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
SECTION: 4
The Index of Work Satisfaction Questionnaire © Part A (Paired Comparisons) Listed and briefly defined below are six terms or factors that are involved in how people feel about their work situation. Each factor has something to do with “work satisfaction”. We are interested in determining which of these is most important to you in relation to the others. Please carefully read the definitions for each factor as given below:
Pay -- dollar remuneration and fringe benefits received for work done
Autonomy -- amount of job related independence, initiative, and freedom, either permitted or required in daily work activities.
Task Requirements -- tasks or activities that must be done as a regular part of the job
Organizational Policies -- management policies and procedures put forward by the hospital and nursing administration of this hospital
Interaction -- opportunities presented for both formal and informal social and professional contact during working hours
Professional Status -- overall importance or significance felt about your job, both in your view and in the view of others
Instructions: These factors are presented in pairs on the next page. A total of 15 pairs are presented: this is every set of combinations. No pair is repeated or reversed. For each pair of terms, decide which one is more important for your job satisfaction or morale, and check the appropriate box. For example, if you feel that Pay (as defined above) is more important than Autonomy (as defined above), check the box for Pay.
It will be difficult for you to make choices in some cases. However, please do try to select the factor which is more important to you. Please make an effort to answer every item; do not go back to change any of your answers.
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE
10
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
SECTION: 4.1
Part A (Paired Comparisons) Please choose the one member of the pair which is MOST IMPORTANT to you. 1. Professional Status or Organizational Policies
2. Pay Requirements or Task Requirements
3. Organizational Policies
or Interaction
4. Task Requirements
or Organizational Policies
5. Professional Status
or Task Requirements
6. Pay
or Autonomy
7. Professional Status
or Interaction
8. Professional Status
or Autonomy
9. Interaction
or Task Requirements
10. Interaction
or Pay
11. Autonomy
or Task Requirements
12. Organizational Policies
or Autonomy
13. Pay
or Professional Status
14. Interaction
or Autonomy
15. Organizational Policies
or Pay
PLEASE ANSWER QUESTIONS ON THE NEXT PAGE
11
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
SECTION: 4.2 Part B (Attitude Questionnaire) The following items represent statements about how satisfied you are with your current nursing job. Please respond to each item. It may be very difficult to fit your responses into the seven categories; in that case, select the category that comes closest to your response to the statement. It is very important that you give your honest opinion. Please do not go back and change any of your answers. Instructions: Please tick ( / )or darken the number that most closely indicates how you feel about each statement. The LEFT set of numbers indicates degrees of AGREEMENT. The RIGHT set of numbers indicates degrees of DISAGREEMENT. For example, if you strongly agree with the first item, tick ( / ) or darken no 1; if you agree with this item, tick ( / ) or darken no 2; if you moderately agree with the first statement, tick ( / ) or darken no 3. The middle response (4) is reserved for feeling neutral or undecided. Please use it as little as possible. If you moderately disagree with this first item, you should tick ( / ) or darken no 5; to disagree, tick ( / ) or darken no 6; and to strongly disagree, tick ( / ) or darken no 7. Remember: The more strongly you feel about the statement, the further from the center you should darken or tick ( / ), with agreement to the left and disagreement to the right. Use 4 for neutral or undecided if needed, but please try to use this number as little as possible.
Strongly Agree N Strongly
Disagree 1 2 3 4 5 6 7 1. My present salary is satisfactory.
2. Nursing is not widely recognized as being an important profession.
3. The nursing personnel on my service pitch in and help one another out when things get in a rush.
4. There is too much clerical and “paperwork” required of nursing personnel in this hospital.
5. The nursing staff has sufficient control over scheduling their own shifts in my hospital.
6. Physicians in general cooperate with nursing staff on my unit.
7. I feel that I am supervised more closely than is necessary.
8. It is my impression that a lot of nursing personnel at this hospital are dissatisfied with their pay.
9. Most people appreciate the importance of nursing care to hospital patients.
10. It is hard for new nurses to feel ‘at home’ in my unit.
11. There is no doubt whatever in my mind that what I do on my job is really important.
12. There is a great gap between the administration of this hospital and the daily problems of the nursing service.
13. I feel I have sufficient input into the program of care for each of my patients.
14. Considering what is expected of nursing service personnel at this hospital, the pay we get is reasonable.
15 I think I could do a better job if I did not have so much to do all the time.
16. There is a good deal of teamwork and cooperation between various levels of nursing personnel on my service.
17. I have too much responsibility and not enough authority.
12
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
Strongly Agree N Strongly
Disagree
1 2 3 4 5 6 7 18. There are not enough opportunities for advancement of
nursing personnel at this hospital.
19. There is a lot of teamwork between nurses and doctors on my own unit.
20. On my service, my supervisors make all the decisions. I have little direct control over my own work.
21. The present rate of increase in pay for nursing service personnel at this hospital is not satisfactory.
22. I am satisfied with the types of activities that I do on my job.
23. The nursing personnel on my service are not as friendly and outgoing as I would like.
24. I have plenty of time and opportunity to discuss patient care problems with other nursing service personnel.
25. There is ample opportunity for nursing staff to participate in the administrative decision-making process.
26. A great deal of independence is permitted, if not required, of me.
27. What I do on my job does not add up to anything really significant.
28. There is a lot of “rank consciousness” on my unit: nurses seldom mingle with those with less experience or different types of educational preparation.
29. I have sufficient time for direct patient care.
30. I am sometimes frustrated because all of my activities seem programmed for me.
31. I am sometimes required to do things on my job that are against my better professional nursing judgment.
32. From what I hear about nursing service personnel at other hospitals, we at this hospital are being fairly paid.
33. Administrative decisions at this hospital interfere too much with patient care.
34. It makes me proud to talk to other people about what I do on my job.
35. I wish the physicians here would show more respect for the skill and knowledge of the nursing staff.
36. I could deliver much better care if I had more time with each patient.
37. Physicians at this hospital generally understand and appreciate what the nursing staff does.
38. If I had the decision to make all over again, I would still go into nursing.
39. The physicians at this hospital look down too much on the nursing staff.
40. I have all the voice in planning policies and procedures for this hospital and my unit that I want
41. My particular job really doesn’t require much skill or “know-how”.
42. The nursing administrators generally consult with the staff on daily problems and procedures.
43. I have the freedom in my work to make important decisions as I see fit, and can count on my supervisors to back me up.
44. An upgrading of pay schedules for nursing personnel is needed at this hospital.
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
Section 5.
Please rate how helpful you believe each of the following items would be in assisting your transition into the workplace as a new
graduate nurse
Not at all helpful
Extremely helpful
No Items 1 2 3 4 5 6 7
1 Stress management training
2 Education
3 Access to hospital resources
4 Mentoring
5 Team building strategies
6 Balancing priorities
7 Enhancing social and peer support programs
8 Flexibility in working hours
9 Protocols to deals with violence and retention
10 Other (Please specify)
14
Appendix 5
hard, 2005 -2006. Master of Applied Science Research Student, QUT, Brisbane, Australia.
Please make sure you have ANSWERED ALL QUESTIONS.
No Section Items 1 1 12 2 2 4 3 3 59 4 4.1 15 5 4.2 44 6 5 10
Total 144
Thank you very much for your participation in this study.
Be assured that all your RESPONSES ARE COMPLETELY CONFIDENTIAL.
NOTE: © The IWS Questionnaire ÿÿ used by permiÿÿion of Paula L. Stamps, Ph.D., Market Street Research, Inc.,
Northampton, Massachusetts. @ ÿÿe ENSS Expanded Nursing Stress Scaleÿÿs used by permission of Susan E. French, Rhonda Lenton,
Vivienne Walters and John Eyles, School of Nursing Department of Sociology and Department of Geography. McMaster University Canada.
15
SECTION: 1
Appendix 6
Table 33
Frequency Matrix
Most Important Intensive Care Units a Sample of 41 General Wards Nurses Sample of 53 The Whole Nurses
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
.707
.561
.610
.512
.463
.623
.491
.547
.642
.472
.660
.521
.574
.585
.468
Autonomy
.293
.488
.610
.439
.512
.378
.528
.547
.434
.566
.340
.511
.574
.436
.543
Task Requirement
.439
.512
.512
.659
.439
.509
.472
.377
.642
.509
.479
.489
.436
.649
.479
Organisational Policies
.390
.390
.488
.610
.561
.453
.453
.623
.642
.698
.426
.426
.564
.628
.638
Professional Status
.488
.561
.341
.390
.512
.358
.566
.358
.358
.472
.415
.564
.351
.372
.489
LEA
ST IM
POR
TAN
T
Interaction
.537
.488
.561
.439
.488
.528
.434
.491
.302
.528
.532
.457
.521
.362
.511
Appendix 7
Table 34 Matrix of Z-Values - Component Weighting Coefficient
Most Important Intensive Care Units a Sample of 41 General Wards Nurses Sample of 53 The Whole Nurses
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
Auto
nom
y
Task
Re
quir
emen
t
Org
anis
atio
nal
Pol
icie
s
Prof
essi
onal
St
atus
Inte
ract
ion
Pay
0.545 0.154 0.279 0.030 - 0.093 0.313 -0.023 0.118 0.364 -0.070 .412 .053 .187 .215 -.080
Autonomy
-0.545 -0.030 0.279 -0.154 0.030 -0.313 0.070 0.118 -0.166 0.166 -.412 .028 .187 -.161 .108
Task Requirement
-0.154 0.030 0.030 0.410 -0.154 0.023 -0.070 -0.313 0.364 0.023 -.053 -.028 -.161 .383 -.053
Organisational Policies
-0.279 -0.279 -0.030 0.279 0.154 -0.118 -0.118 0.313 0.364 0.519 -.187 -.187 .161 .327 .353
Professional Status
-0.030 0.154 -0.410 -0.279 0.030 -0.364 0.166 -0.364 -0.364 -0.07 -.215 .161 -.383 -.327 -.028
Interaction
0.093 -0.030 0.154 -0.154 -0.030
0.070 -0.166 -0.023 -0.519 0.070
.080 -.108 .053 -.353 .028
Sum -0.915 0.42 -0.162 0.155 0.535 -0.033 -0.702 0.125 -0.027 -0.96 0.996 0.568 -0.79 0.25 -0.09 - 0.47 0.792 0.3
LEA
ST IM
POR
TAN
T
Mean -0.183 0.084 -0.032 0.031 0.107 -0.006 -0.140 0.025 -0.005 -0.192 0.1992 0.114 -0.16 0.05 -0.02 0.093 0.158 0.06
Component Weighting Coefficient
2.917 3.184 3.067 3.131 3.207 3.1 2.96 3.125 3.095 2.908 3.299 3.214 2.94 3.15 3.08 3.001 3.258 3.16
Appendix 8
Table 35 Index of Work Satisfaction: Nurse-Nurse
Intensive Care Units Nurses (N= 41) General Wards Nurses (N= 53) Whole Sample 94 Nurses Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
5 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
3. The nursing personnel on my service pitch in and help one another out when things get in a rush.
22.0 (9)
31.7 (13)
19.5 (8)
22.0 (9)
4.9 (2)
0 (0)
0 (0)
18.9 (10)
20.8 (11)
30.2 (16)
18.9 (10)
7.5 (4)
3.8 (2)
0 (0)
20.2 (19)
25.5 (24)
25.5 (24)
20.2 (19)
6.4 (6)
2.1 (2)
0 (0)
16. There is a good deal of teamwork and cooperation between various levels of nursing personnel on my service.
17.1 (7)
26.8 (11)
31.7 (13)
17.1 (7)
4.9 (2)
0 (0)
2.4 (1)
17.0 (9)
28.3 (15)
13.2 (7)
7.5 (4)
17.0 (9)
7.5 (4)
9.4 (5)
17.0 (16)
27.7 (26)
21.3 (20)
11.7 (11)
11.7 (11)
4.3 (4)
6.4 (6)
** 10. It is hard for new nurses to feel ‘at home’ in my unit.
19.5 (8)
17.1 (7)
29.3 (12)
14.6 (6)
7.3 (3)
4.9 (2)
7.3 (3)
24.5 (13)
34.0 (18)
17.0 (9)
13.2 (7)
5.7 (3)
1.9 (1)
3.8 (2)
22.3 (21)
26.6 (25)
22.3 (21)
13.8 (13)
6.4 (6)
3.2 (3)
5.3 (5)
** 23. The nursing personnel on my service are not as friendly and outgoing as I would like.
2.4 (1)
4.9 (2)
14.6 (6)
36.6 (15)
14.6 (6)
17.1 (7)
9.8 (4)
15.1 (8)
13.2 (7)
11.3 (6)
20.8 (11)
18.9 (10)
13.2 (7)
7.5 (4)
9.6 (9)
9.6 (9)
12.8 (12)
27.7 (26)
17.0 (16)
14.9 (14)
8.5 (8)
** 28. There is a lot of “rank consciousness” on my unit: nurses seldom mingle with those with less experience or different types of educational preparation.
7.3 (3)
12.2 (5)
12.2 (5)
39.2 (16)
14.6 (6)
4.9 (2)
9.8 (4)
18.9 (10)
11.3 (6)
16.9 (9)
13.2 (7)
24.5 (13)
9.4 (5)
5.7 (3)
13.8 (13)
11.7 (11)
14.9 (14)
24.5 (23)
20.2 (19)
7.4 (7)
7.4 (7)
** Reverse Worded Statement.
Appendix 9
Table 36 Index of Work Satisfaction: Nurse-Physician
Intensive Care Units Nurses (N= 41) General Wards Nurses (N= 53) Whole Sample 94 Nurses Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
5 items
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
6. Physicians in general cooperate with nursing staff on my unit
9.8 (4)
26.8 (11)
24.4 (10)
29.3 (12)
4.9 (2)
4.9 (2)
0 (0)
9.4 (5)
9.4 (5)
39.6 (21)
22.6 (12)
7.5 (4)
7.5 (4)
3.8 (2)
9.6 (9)
17.0 (16)
33.0 (31)
25.5 (24)
6.4 (6)
6.4 (6)
2.1 (2)
19. There is a lot of teamwork between nurses and doctors on my own unit.
17.1 (7)
26.8 (11)
19.5 (8)
14.6 (6)
14.6 (6)
4.9 (2)
2.4 (1)
13.2 (7)
32.1 (17)
18.9 (10)
11.3 (6)
18.9 (10)
3.8 (2)
1.9 (1)
14.9 (14)
29.7 (28)
19.1 (18)
12.8 (12)
17.0 (16)
4.3 (4)
2.1 (2)
37. Physicians at this hospital generally understand and appreciate what the nursing staffs does.
7.3 (3)
12.2 (5)
22.0 (9)
24.4 (10)
17.1 (7)
12.2 (5)
4.9 (2)
5.7 (3)
9.4 (5)
26.4 (14)
18.9 (10)
22.6 (12)
11.3 (6)
5.7 (3)
6.4 (6)
10.6 (10)
24.5 (23)
21.3 (20)
20.2 (19)
11.7 (11)
5.3 (5)
** 35. I wish the physicians here would show more respect for the skill and knowledge of the nursing staff.
43.9 (18)
29.3 (12)
9.8 (4)
14.6 (6)
0 (0)
0 (0)
2.4 (1)
47.2 (25)
15.1 (8)
28.3 (15)
5.7 (3)
0 (0)
1.9 (1)
1.9 (1)
45.7 (43)
21.3 (20)
20.2 (19)
9.6 (9)
0 (0)
1.1 (1)
2.1 (2)
** 39. The physicians at this hospital look down too much on the nursing staff.
17.1 (7)
19.5 (8)
24.4 (10)
24.4 (10)
7.3 (3)
7.3 (3)
0 (0)
18.9 (10)
17.0 (9)
26.4 (14)
13.2 (7)
15.1 (8)
3.8 (2)
5.7 (3)
18.9 (17)
18.9 (17)
25.5 (24)
18.9 (17)
11.7 (11)
5.3 (5)
3.2 (3)
** Reverse Worded Statement.
Appendix 10
Table 37
PAY
Item # 1 Item# 8 Item # 14 Item # 21 Item # 32 Item # 44
Score 7 1 7 1 7 1
# of resp
1 7 1 10 1 16
Stro
ngly
A
gree
subtotal
7
7
7
10
7
16
Score
6 2 6 2 6 2
# of resp
4 8 3 3 4 10
Agr
ee
Subtotal
24
16
18
6
24
20
Score
5 3 5 3 5 3
# of resp
5 11 3 14 4 8
Mod
erat
ely
Agr
ee
subtotal
25
33
15
42
20
24
Score
4 4 4 4 4 4
# of resp
8 8 12 12 13 5
Und
ecid
ed
subtotal
32
32
48
48
52
20
Score
3 5 3 5 3 5
# of resp
8 3 9 2 8 0
Mod
erat
ely
Dis
agre
e
subtotal
24
15
27
10
24
5
Score
2 6 2 6 2 6
# of resp
2 2 6 0 5 1
Dis
agre
e
subtotal
4
12
12
0
10
6
Score
1 7 1 7 1 7
# of resp
13 2 7 0 6 1
Stro
ngly
D
isag
ree
subtotal
13
14
7
0
6
7
Total of Item
129 129 134 116 143 98
Total # of Resp.
41 41 41 41 41 41
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.146 3.146 3.268 2.829 3.488 2.390 18.27
3.045
Appendix 10
Table 38
PROFESS-IONAL
STATUS
Item # 2 Item# 9 Item # 11 Item# 27 Item# 34 Item# 38 Item# 41
Score 1 7 7 1 7 7 1
# of resp
7 7 12 2 6 6 1
Stro
ngly
A
gree
subtotal
7
49
84
2
42
42
1
Score
2 6 6 2 6 6 2
# of resp
10 9 8 2 3 6 1
Agr
ee
Subtotal
20
54
48
4
18
36
2 Score
3 5 5 3 5 5 3
# of resp
6 8 9 4 15 11 1
Mod
erat
ely
Agr
ee
subtotal
18
40
45
12
75
55
3 Score
4 4 4 4 4 4 4
# of resp
2 10 10 13 10 9 8
Und
ecid
ed
subtotal
8
40
40
52
40
36
32 Score
5 3 3 5 3 3 5
# of resp
7 2 1 14 2 4 4
Mod
erat
ely
Dis
agre
e
subtotal
35
6
3
70
6
12
20
Score
6 2 2 6 2 2 6
# of resp
3 2 0 2 3 1 13
Dis
agre
e
subtotal
18
4
0
12
6
2
78
Score
7 1 1 7 1 1 7
# of resp
6 3 1 4 2 4 13
Stro
ngly
D
isag
ree
subtotal
42
3
1
28
2
4
91
Total of Item
148 196 221 180 189 187 227
Total # of Resp.
41 41 41 41 41 41 41 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.61 4.780 5.390 4.39 4.61 4.56 5.54 32.88
4.697
Appendix 10
Table 39
AUTONOMY
Item # 7 Item# 13 Item # 17 Item# 20 Item# 26 Item# 30 Item # 31 Item # 43
Score 1 7 1 1 7 1 1 7
# of resp
1 2 9 3 2 0 2 3
Stro
ngly
A
gree
subtotal
1
14
9
3
14
0
2
21
Score
2 6 2 2 6 2 2 6
# of resp
2 2 7 1 2 5 4 2
Agr
ee
Subtotal
4
12
14
2
12
10
8
12
Score
3 5 3 3 5 3 3 5
# of resp
6 16 11 8 7 10 16 14
Mod
erat
ely
Agr
ee
subtotal
18
80
33
24
35
30
48
70
Score
4 4 4 4 4 4 4 4
# of resp
26 12 13 16 27 15 9 13
Und
ecid
ed
subtotal
104
48
52
64
108
60
36
52
Score
5 3 5 5 3 5 5 3
# of resp
3 8 1 8 3 3 6 3
Mod
erat
ely
Dis
agre
e
subtotal
15
24
5
40
9
15
30
9
Score
6 2 6 6 2 6 6 2
# of resp
0 1 0 5 0 4 3 4
Dis
agre
e
subtotal
0
2
0
30
0
24
18
8
Score
7 1 7 7 1 7 7 1
# of resp
3 0 0 0 0 4 1 2
Stro
ngly
D
isag
ree
subtotal
21
0
0
0
0
28
7
2
Total of Item
163 180 113 163 178 167 149 174
Total # of Resp.
41 41 41 41 41 41 41 41 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.976 4.39 2.756 3.976 4.341 4.073 3.63 4.24 31.38
3.923
Appendix 10
Table 40
ORGANIZA-TIONAL
POLICIES
Item # 5 Item# 12 Item # 18 Item# 25 Item# 33 Item# 40 Item# 42
Score 7 1 1 7 1 7 7
# of resp
2 8 4 2 6 1 1
Stro
ngly
A
gree
subtotal
14
8
4
14
6
7
7
Score
6 2 2 6 2 6 6
# of resp
8 9 7 3 2 4 3
Agr
ee
Subtotal
48
18
14
18
4
24
18
Score
5 3 3 5 3 5 5
# of resp
9 10 14 7 9 6 7
Mod
erat
ely
Agr
ee
subtotal
45
30
42
35
27
30
35
Score
4 4 4 4 4 4 4
# of resp
11 8 8 21 19 18 13
Und
ecid
ed
subtotal
44
32
32
84
76
72
52
Score
3 5 5 3 5 3 3
# of resp
6 4 7 5 2 4 6
Mod
erat
ely
Dis
agre
e
subtotal
18
20
35
15
10
12
18
Score
2 6 6 2 6 2 2
# of resp
2 2 0 2 2 5 6
Dis
agre
e
subtotal
4
12
0
4
12
10
12
Score
1 7 7 1 7 1 1
# of resp
3 0 1 1 1 3 5
Stro
ngly
D
isag
ree
subtotal
3
0
7
1
7
3
5
Total of Item
176 120 134 171 142 158 147
Total # of Resp.
41 41 41 41 41 41 41 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.29 2.927 3.27 4.171 3.463 3.85 3.59 25.56
3.65
Appendix 10
Table 41
TASK REQUIRE-
MENT
Item # 4 Item# 15 Item # 22 Item# 24 Item# 29 Item# 36
Score 1 1 7 7 7 1
# of resp
7 12 6 0 2 14
Stro
ngly
A
gree
subtotal
7
12
42
0
14
14
Score
2 2 6 6 6 2
# of resp
5 7 9 2 3 15
Agr
ee
Subtotal
10
14
54
12
18
30
Score
3 3 5 5 5 3
# of resp
9 9 16 8 8 7
Mod
erat
ely
Agr
ee
subtotal
27
27
80
40
40
21
Score
4 4 4 4 4 4
# of resp
12 7 5 11 10 2
Und
ecid
ed
subtotal
48
28
20
44
40
8
Score
5 5 3 3 3 5
# of resp
5 2 5 15 12 2
Mod
erat
ely
Dis
agre
e
subtotal
25
10
15
45
36
10
Score
6 6 2 2 2 6
# of resp
2 2 0 2 3 0
Dis
agre
e
subtotal
12
12
0
4
6
0
Score
7 7 1 1 1 7
# of resp
1 2 0 3 3 1
Stro
ngly
D
isag
ree
subtotal
7
14
0
3
3
7
Total of Item
136 117 211 148 157 90
Total # of Resp.
41 41 41 41 41 41 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.317 2.854 5.146 3.61 3.829 2.195 20.95 3.492
Appendix 10
Table 42
Interaction
Item # 3
Item# 10
Item # 16
Item# 23
Item# 28
Item# 6 Item # 19
Item# 35
Item# 37
Item# 39
Score 7 1 7 1 1 7 7 1 7 1
# of resp
9 8 7 1 3 4 7 18 3 7
Stro
ngly
Agr
ee
subtotal
63
8
49
1
3
28
49
18
21
7
Score
6 2 6 2 2 6 6 2 6 2
# of resp
13 7 11 2 5 12 11 12 5 8
Agr
ee
Subtotal
78
14
66
4
10
72
66
24
30
16
Score
5 3 5 3 3 5 5 3 5 3
# of resp
8 12 13 6 5 10 8 4 9 10
Mod
erat
ely
Agr
ee
subtotal
40
36
65
18
15
50
40
12
45
30
Score
4 4 4 4 4 4 4 4 4 4
# of resp
9 6 7 15 16 12 6 6 10 10
Und
ecid
ed
subtotal
36
24
28
60
64
48
24
24
40
40
Score
3 5 3 5 5 3 3 5 3 5
# of resp
2 3 2 6 6 2 6 0 7 3
Mod
erat
ely
Dis
agre
e
subtotal
6
15
6
30
30
6
18
0
21
15
Score
2 6 2 6 6 2 2 6 2 6
# of resp
0 2 0 7 2 2 2 0 5 3
Dis
agre
e
subtotal
0
12
0
42
12
4
4
0
10
18
Score
1 7 1 7 7 1 1 7 1 7
# of resp
0 3 1 4 4 0 1 1 2 0
Stro
ngly
D
isag
ree
subtotal
0
21
1
28
28
0
1
7
2
0
Total of Item
223 130 215 183 162 208 202 85 169 126
Total # of Resp.
41 41 41 41 41 41 41 41 41 41
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.439 3.171 5.244 4.463 3.95 5.073 4.927 2.073 4.122 3.073 41.54 4.154
Appendix 10
Table 43
Nurse-Nurse
Item # 3 Item# 10 Item # 16 Item# 23 Item# 28
Score 7 1 7 1 1
# of resp
9 8 7 1 3 St
rong
ly
Agr
ee
subtotal
63
8
49
1
3
Score
6 2 6 2 2
# of resp
13 7 11 2 5
Agr
ee
Subtotal
78
14
66
4
10
Score
5 3 5 3 3
# of resp
8 12 13 6 5
Mod
erat
ely
Agr
ee
subtotal
40
36
65
18
15
Score
4 4 4 4 4
# of resp
9 6 7 15 16
Und
ecid
ed
subtotal
36
24
28
60
64
Score
3 5 3 5 5
# of resp
2 3 2 6 6
Mod
erat
ely
Dis
agre
e
subtotal
6
15
6
30
30
Score
2 6 2 6 6
# of resp
0 2 0 7 2
Dis
agre
e
subtotal
0
12
0
42
12
Score
1 7 1 7 7
# of resp
0 3 1 4 4
Stro
ngly
D
isag
ree
subtotal
0
21
1
28
28
Total of Item
223 130 215 183 162
Total # of Resp.
41 41 41 41 41 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.439 3.171 5.244 4.463 3.95 22.27
4.45
Appendix 10
Table 44
Nurse-Physician
Item # 6 Item# 19 Item # 35 Item# 37 Item# 39
Score 7 7 1 7 1
# of resp
4 7 18 3 7
Stro
ngly
A
gree
subtotal
28
49
18
21
7
Score
6 6 2 6 2
# of resp
12 11 12 5 8
Agr
ee
Subtotal
72
66
24
30
16
Score
5 5 3 5 3
# of resp
10 8 4 9 10
Mod
erat
ely
Agr
ee
subtotal
50
40
12
45
30
Score
4 4 4 4 4
# of resp
12 6 6 10 10
Und
ecid
ed
subtotal
48
24
24
40
40
Score
3 3 5 3 5
# of resp
2 6 0 7 3
Mod
erat
ely
Dis
agre
e
subtotal
6
18
0
21
15
Score
2 2 6 2 6
# of resp
2 2 0 5 3
Dis
agre
e
subtotal
4
4
0
10
18
Score
1 1 7 1 7
# of resp
0 1 1 2 0
Stro
ngly
D
isag
ree
subtotal
0
1
7
2
0
Total of Item
208 202 85 169 126
Total # of Resp.
41 41 41 41 41 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.073 4.927 2.073 4.122 3..073 19.27
3.85
Appendix 10
Table 45
PAY
Item # 1 Item# 8 Item # 14 Item # 21 Item # 32 Item # 44
Score 7 1 7 1 7 1
# of resp
4 12 3 9 5 21
Stro
ngly
A
gree
subtotal
28
12
21
9
35
21
Score
6 2 6 2 6 2
# of resp
9 11 6 12 5 10
Agr
ee
Subtotal
54
22
36
24
30
20 Score
5 3 5 3 5 3
# of resp
5 8 5 13 5 15
Mod
erat
ely
Agr
ee
subtotal
25
24
25
39
25
45
Score
4 4 4 4 4 4
# of resp
9 12 12 10 17 3
Und
ecid
ed
subtotal
36
48
48
40
68
12 Score
3 5 3 5 3 5
# of resp
13 5 10 4 14 2
Mod
erat
ely
Dis
agre
e
subtotal
39
25
30
20
42
10 Score
2 6 2 6 2 6
# of resp
4 1 11 3 3 0
Dis
agre
e
subtotal
8
6
22
18
6
0 Score
1 7 1 7 1 7
# of resp
9 4 6 2 4 2
Stro
ngly
D
isag
ree
subtotal
9
28
6
14
4
14 Total of Item
199 165 188 164 210 122
Total # of Resp.
53 53 53 53 53 53
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.75 3.11 3.55 3.09 3.96 2.30 19.76
3.29
Appendix 10
Table 46
PROFESS-IONAL
STATUS
Item # 2 Item# 9 Item # 11 Item# 27 Item# 34 Item# 38 Item# 41
Score 1 7 7 1 7 7 1
# of resp
13 7 15 2 8 6 2
Stro
ngly
A
gree
subtotal
13
49
105
2
56
42
2
Score
2 6 6 2 6 6 2
# of resp
9 12 7 7 7 6 2
Agr
ee
Subtotal
18
72
42
14
42
36
4 Score
3 5 5 3 5 5 3
# of resp
11 17 20 9 14 13 5
Mod
erat
ely
Agr
ee
subtotal
33
85
100
27
70
65
15 Score
4 4 4 4 4 4 4
# of resp
3 6 7 17 12 10 5
Und
ecid
ed
subtotal
12
24
28
68
48
40
20 Score
5 3 3 5 3 3 5
# of resp
8 6 1 10 6 8 13
Mod
erat
ely
Dis
agre
e
subtotal
40
18
3
50
18
24
65
Score
6 2 2 6 2 2 6
# of resp
2 2 1 7 2 2 6
Dis
agre
e
subtotal
12
4
2
42
4
4
36
Score
7 1 1 7 1 1 7
# of resp
7 3 2 1 4 8 20
Stro
ngly
D
isag
ree
subtotal
49
3
2
7
4
8
140
Total of Item
177 255 282 210 242 219 282
Total # of Resp.
53 53 53 53 53 53 53 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.34 4.81 5..32 3.96 4.57 4.13 5..32 31.45
4.49
Appendix 10
Table 47
AUTONOMY
Item # 7 Item# 13 Item # 17
Item# 20 Item# 26
Item# 30
Item # 31
Item # 43
Score 1 7 1 1 7 1 1 7
# of resp
4 6 9 4 2 5 6 4
Stro
ngly
Agr
ee
subtotal
4
42
9
4
14
5
6
28
Score
2 6 2 2 6 2 2 6
# of resp
5 6 13 8 4 4 8 7
Agr
ee
Subtotal
10
36
26
16
24
8
16
42
Score
3 5 3 3 5 3 3 5
# of resp
10 12 10 12 14 15 14 14
Mod
erat
ely
Agr
ee
subtotal
30
60
30
36
70
45
42
70
Score
4 4 4 4 4 4 4 4
# of resp
9 15 11 8 21 7 11 10
Und
ecid
ed
subtotal
36
60
44
32
84
28
44
40
Score
5 3 5 5 3 5 5 3
# of resp
11 7 4 16 8 14 7 8
Mod
erat
ely
Dis
agre
e
subtotal
55
21
20
80
24
70
35
24
Score
6 2 6 6 2 6 6 2
# of resp
8 3 1 5 2 3 5 6
Dis
agre
e
subtotal
48
6
6
30
4
18
30
12
Score
7 1 7 7 1 7 7 1
# of resp
6 4 5 0 2 5 2 4
Stro
ngly
D
isag
ree
subtotal
42
4
35
0
2
35
14
4
Total of Item
225 229 170 198 222 209 187 220
Total # of Resp.
53 53 53 53 53 53 53 53
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.25 4.32 3.20 3.74 4.19 3.94 3.53 4.15 31.32 3.92
Appendix 10
Table 48
ORGANIZA-TIONAL
POLICIES
Item # 5 Item# 12 Item # 18 Item# 25 Item# 33 Item# 40 Item# 42
Score 7 1 1 7 1 7 7
# of resp
3 16 10 0 5 2 7
Stro
ngly
A
gree
subtotal
21
16
10
0
5
14
49
Score
6 2 2 6 2 6 6
# of resp
10 10 9 6 7 1 2
Agr
ee
Subtotal
60
20
18
36
14
6
12
Score
5 3 3 5 3 5 5
# of resp
15 9 16 13 14 5 12
Mod
erat
ely
Agr
ee
subtotal
75
27
48
65
42
25
60
Score
4 4 4 4 4 4 4
# of resp
5 12 10 17 17 20 11
Und
ecid
ed
subtotal
20
48
40
68
68
80
44
Score
3 5 5 3 5 3 3
# of resp
8 1 7 9 6 10 12
Mod
erat
ely
Dis
agre
e
subtotal
24
5
35
27
30
30
36
Score
2 6 6 2 6 2 2
# of resp
7 3 1 4 3 6 4
Dis
agre
e
subtotal
14
18
6
8
18
12
8
Score
1 7 7 1 7 1 1
# of resp
5 2 0 4 1 9 5
Stro
ngly
D
isag
ree
subtotal
5
14
0
4
7
9
5
Total of Item
219 148 157 208 184 176 214
Total # of Resp.
53 53 53 53 53 53 53 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.13 2.79 2.96 3.92 3.47 3.32 4.038 24.52
3.502
Appendix 10
Table 49
TASK REQUIRE-
MENT
Item # 4 Item# 15 Item # 22 Item# 24 Item# 29 Item# 36
Score 1 1 7 7 7 1
# of resp
10 12 5 2 2 22
Stro
ngly
A
gree
subtotal
10
12
35
14
14
22
Score
2 2 6 6 6 2
# of resp
10 16 10 4 7 10
Agr
ee
Subtotal
20
32
60
24
42
20
Score
3 3 5 5 5 3
# of resp
15 6 14 8 12 15
Mod
erat
ely
Agr
ee
subtotal
45
18
70
40
60
45
Score
4 4 4 4 4 4
# of resp
10 8 14 7 7 4
Und
ecid
ed
subtotal
40
32
56
28
28
16
Score
5 5 3 3 3 5
# of resp
5 6 5 19 18 1
Mod
erat
ely
Dis
agre
e
subtotal
25
30
15
57
54
5
Score
6 6 2 2 2 6
# of resp
1 2 3 6 4 0
Dis
agre
e
subtotal
6
12
6
12
8
0
Score
7 7 1 1 1 7
# of resp
2 3 2 7 3 1
Stro
ngly
D
isag
ree
subtotal
14
21
2
7
3
7
Total of Item
160 157 244 182 209 115
Total # of Resp.
53 53 53 53 53 53 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.02 2.96 4.60 3.43 3.94 2.17 20.12 3.35
Appendix 10
Table 50
Interaction
Item # 3
Item# 10
Item # 16
Item# 23
Item# 28
Item# 6 Item # 19
Item# 35
Item# 37
Item# 39
Score 7 1 7 1 1 7 7 1 7 1
# of resp
10 13 9 8 10 5 7 25 3 10
Stro
ngly
Agr
ee
subtotal
70
13
63
8
10
35
49
25
21
10
Score
6 2 6 2 2 6 6 2 6 2
# of resp
11 18 15 7 6 5 17 8 5 9
Agr
ee
Subtotal
66
36
90
14
12
30
102
16
30
18
Score
5 3 5 3 3 5 5 3 5 3
# of resp
16 9 7 6 9 21 10 15 14 14
Mod
erat
ely
Agr
ee
subtotal
80
27
35
18
27
105
50
45
70
42
Score
4 4 4 4 4 4 4 4 4 4
# of resp
10 7 4 11 7 12 6 3 10 7
Und
ecid
ed
subtotal
40
28
16
44
28
48
24
12
40
28
Score
3 5 3 5 5 3 3 5 3 5
# of resp
4 3 9 10 13 4 10 0 12 8
Mod
erat
ely
Dis
agre
e
subtotal
12
15
27
50
65
12
30
0
36
40
Score
2 6 2 6 6 2 2 6 2 6
# of resp
2 1 4 7 5 4 2 1 6 2
Dis
agre
e
subtotal
4
6
8
42
30
8
4
6
12
12
Score
1 7 1 7 7 1 1 7 1 7
# of resp
0 2 5 4 3 2 1 1 3 3
Stro
ngly
D
isag
ree
subtotal
0
14
5
28
21
2
1
7
3
21
Total of Item
272 139 244 204 193 240 260 111 212 171
Total # of Resp.
53 53 53 53 53 53 53 53 53 53
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.13 2.62 4.60 3.85 3.64 4.53 4.91 2.09 4 3.23 38.6 3.86
Appendix 10
Table 51
Nurse-Nurse
Item # 3 Item# 10 Item # 16 Item# 23 Item# 28
Score 7 1 7 1 1
# of resp
10 13 9 8 10
Stro
ngly
A
gree
subtotal
70
13
63
8
10
Score
6 2 6 2 2
# of resp
11 18 15 7 6
Agr
ee
Subtotal
66
36
90
14
12
Score
5 3 5 3 3
# of resp
16 9 7 6 9
Mod
erat
ely
Agr
ee
subtotal
80
27
35
18
27
Score
4 4 4 4 4
# of resp
10 7 4 11 7
Und
ecid
ed
subtotal
40
28
16
44
28
Score
3 5 3 5 5
# of resp
4 3 9 10 13
Mod
erat
ely
Dis
agre
e
subtotal
12
15
27
50
65
Score
2 6 2 6 6
# of resp
2 1 4 7 5
Dis
agre
e
subtotal
4
6
8
42
30
Score
1 7 1 7 7
# of resp
0 2 5 4 3
Stro
ngly
D
isag
ree
subtotal
0
14
5
28
21
Total of Item
272 139 244 204 193
Total # of Resp.
53 53 53 53 53 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.13 2.62 4.60 3.85 3.64 19.84
3.97
Appendix 10
Table 52
Nurse-Physician
Item # 6 Item# 19 Item # 35 Item# 37 Item# 39
Score 7 7 1 7 1
# of resp
5 7 25 3 10
Stro
ngly
A
gree
subtotal
35
49
25
21
10
Score
6 6 2 6 2
# of resp
5 17 8 5 9
Agr
ee
Subtotal
30
102
16
30
18
Score
5 5 3 5 3
# of resp
21 10 15 14 14
Mod
erat
ely
Agr
ee
subtotal
105
50
45
70
42
Score
4 4 4 4 4
# of resp
12 6 3 10 7
Und
ecid
ed
subtotal
48
24
12
40
28
Score
3 3 5 3 5
# of resp
4 10 0 12 8
Mod
erat
ely
Dis
agre
e
subtotal
12
30
0
36
40
Score
2 2 6 2 6
# of resp
4 2 1 6 2
Dis
agre
e
subtotal
8
4
6
12
12
Score
1 1 7 1 7
# of resp
2 1 1 3 3
Stro
ngly
D
isag
ree
subtotal
2
1
7
3
21
Total of Item
240 260 111 212 171
Total # of Resp.
53 53 53 53 53 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.53 4.91 2.09 4 3.23 18.76
3.75
Appendix 10
Table 53
PAY
Item # 1 Item# 8 Item # 14 Item # 21 Item # 32 Item # 44
Score 7 1 7 1 7 1
# of resp
5 19 4 19 6 37
Stro
ngly
A
gree
subtotal
35
9
28
19
42
37
Score
6 2 6 2 6 2
# of resp
13 19 9 15 9 20
Agr
ee
Subtotal
78
38
54
30
54
40 Score
5 3 5 3 5 3
# of resp
10 19 8 27 9 23
Mod
erat
ely
Agr
ee
subtotal
50
57
40
81
45
69
Score
4 4 4 4 4 4
# of resp
17 20 24 22 30 8
Und
ecid
ed
subtotal
68
80
96
88
120
32 Score
3 5 3 5 3 5
# of resp
21 8 19 6 22 2
Mod
erat
ely
Dis
agre
e
subtotal
63
40
57
30
66
10 Score
2 6 2 6 2 6
# of resp
6 3 17 3 8 1
Dis
agre
e
subtotal
12
18
34
18
16
6 Score
1 7 1 7 1 7
# of resp
22 6 13 2 10 3
Stro
ngly
D
isag
ree
subtotal
22
42
13
14
10
21 Total of Item
328 284 322 280 353 215
Total # of Resp.
94 94 94 94 94 94
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.49 3.02 3.43 2.98 3.76 2.29 18.97
3.162
Appendix 10
Table 54
PROFESS-IONAL
STATUS
Item # 2 Item# 9 Item # 11 Item# 27 Item# 34 Item# 38 Item# 41
Score 1 7 7 1 7 7 1
# of resp
20 14 27 4 14 12 3
Stro
ngly
A
gree
subtotal
20
98
189
4
98
84
3
Score
2 6 6 2 6 6 2
# of resp
19 21 15 9 10 12 3
Agr
ee
Subtotal
38
126
90
18
60
72
6 Score
3 5 5 3 5 5 3
# of resp
17 25 29 13 29 24 7
Mod
erat
ely
Agr
ee
subtotal
51
125
145
39
145
120
21 Score
4 4 4 4 4 4 4
# of resp
5 16 17 30 22 19 12
Und
ecid
ed
subtotal
20
64
68
120
88
76
48 Score
5 3 3 5 3 3 5
# of resp
15 8 2 24 8 12 17
Mod
erat
ely
Dis
agre
e
subtotal
75
24
6
70
24
36
85
Score
6 2 2 6 2 2 6
# of resp
5 4 1 9 5 3 19
Dis
agre
e
subtotal
30
8
2
54
10
6
114
Score
7 1 1 7 1 1 7
# of resp
13 6 3 5 6 12 33
Stro
ngly
D
isag
ree
subtotal
91
6
3
35
6
12
231
Total of Item
325 451 503 340 431 406 508
Total # of Resp.
94 94 94 94 94 94 94 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.46 4.8 5.35 3.62 4.59 4.32 5.4 31.54
4.51
Appendix 10
Table 55
AUTONOMY
Item # 7 Item# 13 Item # 17
Item# 20 Item# 26 Item# 30
Item # 31
Item # 43
Score 1 7 1 1 7 1 1 7
# of resp
5 8 18 7 4 5 8 7
Stro
ngly
Agr
ee
subtotal
5
56
18
7
28
5
8
49
Score
2 6 2 2 6 2 2 6
# of resp
7 8 20 9 6 9 12 9
Agr
ee
Subtotal
14
48
40
18
36
18
24
54
Score
3 5 3 3 5 3 3 5
# of resp
16 28 21 20 21 25 30 28
Mod
erat
ely
Agr
ee
subtotal
48
140
63
60
105
75
90
140
Score
4 4 4 4 4 4 4 4
# of resp
35 27 24 24 48 22 20 23
Und
ecid
ed
subtotal
140
108
96
96
192
88
80
92
Score
5 3 5 5 3 5 5 3
# of resp
14 15 5 24 11 17 13 11
Mod
erat
ely
Dis
agre
e
subtotal
70
45
25
120
33
85
65
33
Score
6 2 6 6 2 6 6 2
# of resp
8 4 1 10 2 7 8 10
Dis
agre
e
subtotal
48
8
6
60
4
42
48
20
Score
7 1 7 7 1 7 7 1
# of resp
9 4 5 0 2 9 3 6
Stro
ngly
D
isag
ree
subtotal
63
4
35
0
2
63
21
6
Total of Item
388 409 283 361 400 376 336 394
Total # of Resp.
94 94 94 94 94 94 94 94
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.13 4.35 3.01 3.84 4.26 4 3.57 4.19 31.35 3.92
Appendix 10
Table 56
ORGANIZA-TIONAL
POLICIES
Item # 5 Item# 12 Item # 18 Item# 25 Item# 33 Item# 40 Item# 42
Score 7 1 1 7 1 7 7
# of resp
5 24 14 2 11 3 8
Stro
ngly
A
gree
subtotal
35
24
14
14
11
21
56
Score
6 2 2 6 2 6 6
# of resp
18 19 16 9 9 5 5
Agr
ee
Subtotal
108
38
32
54
18
30
30
Score
5 3 3 5 3 5 5
# of resp
24 19 30 20 23 11 19
Mod
erat
ely
Agr
ee
subtotal
120
57
90
100
69
55
95
Score
4 4 4 4 4 4 4
# of resp
16 20 18 38 36 38 24
Und
ecid
ed
subtotal
64
80
72
152
144
152
96
Score
3 5 5 3 5 3 3
# of resp
14 5 14 14 8 14 18
Mod
erat
ely
Dis
agre
e
subtotal
42
25
70
42
40
42
54
Score
2 6 6 2 6 2 2
# of resp
9 5 1 6 5 11 10
Dis
agre
e
subtotal
18
30
6
12
30
22
20
Score
1 7 7 1 7 1 1
# of resp
8 2 1 5 2 12 10
Stro
ngly
D
isag
ree
subtotal
8
14
7
5
14
12
10
Total of Item
395 268 291 379 326 334 361
Total # of Resp.
94 94 94 94 94 94 94 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.2 2.85 3.1 4.03 3.47 3.55 3.8 25 3.57
Appendix 10
Table 57
TASK REQUIRE-
MENT
Item # 4 Item# 15 Item # 22 Item# 24 Item# 29 Item# 36
Score 1 1 7 7 7 1
# of resp
17 24 11 2 4 36
Stro
ngly
A
gree
subtotal
17
22
77
14
28
36
Score
2 2 6 6 6 2
# of resp
15 23 19 6 10 25
Agr
ee
Subtotal
30
46
114
36
60
50
Score
3 3 5 5 5 3
# of resp
24 15 30 16 20 22
Mod
erat
ely
Agr
ee
subtotal
72
45
150
80
100
66
Score
4 4 4 4 4 4
# of resp
22 15 19 18 17 6
Und
ecid
ed
subtotal
88
60
76
72
68
24
Score
5 5 3 3 3 5
# of resp
10 8 10 34 30 3
Mod
erat
ely
Dis
agre
e
subtotal
50
40
30
102
90
15
Score
6 6 2 2 2 6
# of resp
3 4 3 8 7 0
Dis
agre
e
subtotal
18
24
6
16
14
0
Score
7 7 1 1 1 7
# of resp
3 5 2 10 6 2
Stro
ngly
D
isag
ree
subtotal
21
35
2
10
6
14
Total of Item
296 272 455 330 366 205
Total # of Resp.
94 94 94 94 94 94 Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
3.15 2.89 4.84 3.51 3.89 2.18 20.46 3.41
Appendix 10
Table 58
Interaction
Item # 3 Item# 10
Item # 16
Item# 23 Item# 28
Item# 6 Item # 19
Item# 35
Item# 37 Item# 39
Score 7 1 7 1 1 7 7 1 7 1
# of resp
19 21 16 9 13 9 14 43 6 17
Stro
ngly
Agr
ee
subtotal
133
21
112
9
13
63
98
43
42
17
Score
6 2 6 2 2 6 6 2 6 2
# of resp
24 25 26 9 11 16 28 20 10 17
Agr
ee
Subtotal
144
50
156
18
22
96
168
40
60
34
Score
5 3 5 3 3 5 5 3 5 3
# of resp
24 21 20 12 14 31 18 19 23 24
Mod
erat
ely
Agr
ee
subtotal
120
63
100
36
42
155
90
57
115
72
Score
4 4 4 4 4 4 4 4 4 4
# of resp
19 13 11 26 23 24 12 9 20 17
Und
ecid
ed
subtotal
76
52
44
104
92
96
48
36
80
68
Score
3 5 3 5 5 3 3 5 3 5
# of resp
6 6 11 16 19 6 16 0 19 11
Mod
erat
ely
Dis
agre
e
subtotal
18
30
33
80
95
18
48
0
57
55
Score
2 6 2 6 6 2 2 6 2 6
# of resp
2 3 4 14 7 6 4 1 11 5
Dis
agre
e
subtotal
4
18
8
84
42
12
8
6
22
30
Score
1 7 1 7 7 1 1 7 1 7
# of resp
0 5 6 8 7 2 2 2 5 3
Stro
ngly
D
isag
ree
subtotal
0
35
6
56
49
2
2
14
5
21
Total of Item
495 269 459 387 355 442 462 196 381 297
Total # of Resp.
94 94 94 94 94 94 94 94 94 94
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.27 2.86 4.88 4.12 3.78 4.7 4.91 2.09 4.05 3.16 39.82 3.98
Appendix 10
Table 59
Nurse-Nurse
Item # 3 Item# 10 Item # 16 Item# 23 Item# 28
Score 7 1 7 1 1
# of resp
19 21 16 9 13
Stro
ngly
A
gree
subtotal
133
21
112
9
13
Score
6 2 6 2 2
# of resp
24 25 26 9 11
Agr
ee
Subtotal
144
50
156
18
22
Score
5 3 5 3 3
# of resp
24 21 20 12 14
Mod
erat
ely
Agr
ee
subtotal
120
63
100
36
42
Score
4 4 4 4 4
# of resp
19 13 11 26 23
Und
ecid
ed
subtotal
76
52
44
104
92
Score
3 5 3 5 5
# of resp
6 6 11 16 19
Mod
erat
ely
Dis
agre
e
subtotal
18
30
33
80
95
Score
2 6 2 6 6
# of resp
2 3 4 14 7
Dis
agre
e
subtotal
4
18
8
84
42
Score
1 7 1 7 7
# of resp
0 5 6 8 7
Stro
ngly
D
isag
ree
subtotal
0
35
6
56
49
Total of Item
495 269 459 387 355
Total # of Resp.
94 94 94 94 94
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
5.27 2.86 4.88 4.12 3.78 20.91 4.18
Appendix 10
Table 60
Nurse-Physician
Item# 6 Item # 19 Item# 35 Item# 37 Item# 39
Score 7 7 1 7 1
# of resp
9 14 43 6 17
Stro
ngly
A
gree
subtotal
63
98
43
42
17
Score
6 6 2 6 2
# of resp
16 28 20 10 17
Agr
ee
Subtotal
96
168
40
60
34
Score
5 5 3 5 3
# of resp
31 18 19 23 24
Mod
erat
ely
Agr
ee
subtotal
155
90
57
115
72
Score
4 4 4 4 4
# of resp
24 12 9 20 17
Und
ecid
ed
subtotal
96
48
36
80
68
Score
3 3 5 3 5
# of resp
6 16 0 19 11
Mod
erat
ely
Dis
agre
e
subtotal
18
48
0
57
55
Score
2 2 6 2 6
# of resp
6 4 1 11 5
Dis
agre
e
subtotal
12
8
6
22
30
Score
1 1 7 1 7
# of resp
2 2 2 5 3
Stro
ngly
D
isag
ree
subtotal
2
2
14
5
21
Total of Item
442 462 196 381 297
Total # of Resp.
94 94 94 94 94
Com
pone
nt S
core
(Sum
of a
vera
ge sc
ore)
Com
pone
nt M
ean
Scor
e (c
ompo
nent
scor
e / n
umbe
r of i
tem
s)
Average Score
4.7 4.91 2.09 4.05 3.16 18.91 3.78