RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE, KARNATAKA

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE : NEETHU JOSE AND ADDRESS I YEAR M.Sc NURSING B G S COLLEGE OF NURSING APOLLO B G S HOSPITAL MYSORE

2. NAME OF THE INSTITUTION : B G S COLLEGE OF NURSING MYSORE

3. COURSE OF STUDY AND SUBJECT : I YEAR M.Sc NURSING MEDICAL-SURGICAL NURSING

4. DATE OF ADMISSION OF COURSE : 15-6-2008

5. TITLE OF THE TOPIC :“WORK STRESS AND SPIRITUAL BEHAVIOUR AMONG STAFF NURSES.”

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Our ignorance is God; what we know is science

- Robert Ingersoll

6. Brief resume of the intended work:

Introduction

Stress is derived from the Latin word “stringere”, meaning ‘to draw tight’. In the 17 th century

the word was used to describe affliction. Stress is an experience a person is exposed to, through a

stimulus or stressor. Stress, in essence, is a feeling of doubt about being able to cope, a perception

that the resources available do not match the demands made. When it persists, stress can cause

physical and psychological ill-health and adversely affect social functioning. People experience

stress as a consequence of daily life events and experiences. Stress can provide stimulation and

motivation, as well as cause discomfort and retreat.1

Job or occupational stress is something all face as employees or employers and all handle it

differently. It is a mismatch between the individual capabilities and organizational demands. Also it

is a mismatch between the expectations of both individual and organization. Stress not only affects

the physical, psychological and financial balances of an employee but also the employers as well.

Desired results cannot be expected from employees who are burnt out, exhausted or stressed, as

they loose their energy, accuracy and innovative thinking. By this, employers may loose more

working days there by a decrease in productivity and increase in cost to company. By virtue, some

jobs are highly stressful like Army, Police, and Fire Service etc. Some are relatively moderate viz

service sector and health care industry etc.2

Occupational stress is the interaction of the worker and the conditions of work. Downsizing,

increased workloads, high competition, growing population etc are taking their toll. Occupational

stress has become a common and costly problem, leaving few workers untouched. Not all stress is

bad. Learning how to deal with and manage stress is critical to maximizing job performance,

staying safe on the job, and maintaining physical and mental health. Survey of the literature on

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occupational stress reveals that there are a number of factors related to jobs, which affect the

behaviour of the employees and as a result of it, normal life is disturbed.

Workload, leadership or management style, professional conflict and emotional cost of caring

have been the main sources of distress for nurses for many years, but there is disagreement as to the

magnitude of their impact. Lack of reward and shift working may also now be displacing some of

the other issues in order of ranking. Organizational interventions are targeted at most but not all of

these sources and their effectiveness are likely to be limited, at least in the short to medium term.

Individuals must be supported better, but this is hindered by lack of understanding of how sources

of stress vary between different practice areas, lack of predictive power of assessment tools, and a

lack of understanding of how personal and workplace factors interact.3

Spirituality is derived from the Latin word “spiritus”, meaning, essential part of the person,

‘breath, make alive’, which suggests a broad concept of the essence of life. Nursing is linked to

spirituality when the word “nurse”, comes from a Greek word meaning: “nurturing of the human

spirit”. In ancient Greek there are expressions for human dimensions: soma (body), psyche (soul),

pnevma (spirit). In Greek culture, spirit is opposed to body and material reality. Spirituality is act of

connecting to systems such as God, nature, or other people to find meaning through relationships.

Spirituality is a key element in hope. Spirituality can be the important factor that helps individuals

achieves the balance needed to maintain health and wellbeing and to cope with illness. Spirituality

is a concept that is unique to each individual, depending upon person’s culture, development, life

experiences, beliefs and ideas about life.4

The spiritual life is based on faith, love, moral value, worship and prayer. Sufferings are due

to ignorance of one’s eternal relationship with God. Many experts suggest that stress can be

managed by using spirituality. There are many paths people use to find God. Research shows that

those who have made the spiritual journey find greater relief from stress and enjoy better health and

happier lives. While most people who are religious or spiritual find a religious community that

supports their journey, there are specific ways that can use faith to reduce stress.

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6.1 Need for the study:

Stress is the appraisal or perception of a stressor. Theories on occupational stress focus on a

range of different stressors. One of the most well-known occupational stress theories is the job

Demand Control Support model. It states that three job characteristics (stressors) are crucial in

explaining adverse health: high demands, low control, and low social support.

Job stress in the nursing profession has been a persistent global problem for many years now.

It has been associated with a variety of adverse attitudinal, behavioral, physical and emotional

health consequences. As a result of the occupational burden of health care workers, stress among

nurses is widely studied. The number of studies on stress or strain among nurses has grown

considerably in the last decades. The entries appearing in psychological abstracts after a search on

the keywords “nurses” and “stress” have grown from 21 publications in the period before the 1970s

to 57 in the 70s, 429 in the 80s and 754 in the 90s. From the year 2000, already 585 studies have

appeared on this topic.5

Based on results of a study published in the September 2007 issue of American Journal of

Nursing, the top two priorities for hospitals to address the retention issue are improving nursing

management and taking steps to reduce on-the-job stress. The study surveyed the work experience

of nurses from 35 states who obtained their first license between Aug. 1, 2004, and July 31, 2005,

and had been employed for up to 18 months. Of the 3,226 respondents, 610 had already left their

first job -- 41.8 % to poor management, and 37.2 % because of stressful work conditions. Another

34% changed jobs because they wanted to get experience in a different clinical area.6

The health care industry has grown into a specialized service, nursing, that constitutes the

backbone of this industry, is yet to catch up with the sophistication and advancement. Bad working

conditions, redundant curriculum and limited opportunities are some of the reasons identified as the

causes for holding the nurses back.8 The head of the Manitoba Nurses Union is raising the alarm

about the stresses faced by new nurses in light of a recent Ontario study of burnout in the

profession. A study of 225 junior nurses across Ontario suggests 66 % had symptoms of burnout,

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such as emotional exhaustion and depression, less than two years into their jobs, said researchers at

the University of Western Ontario.(Feb 28 2006)reported by C BC News.7

Stress and ever-increasing work pressure also are a matter of concern. “The patient: nurse

ratio is extremely strained and possibly the worst when compared to developed countries in the

world,” said Arvind Kulkarni, president, Trained Nurses Association of India (TNAI). According to

TNAI, there are only 10 lakh nurses catering to the entire country. “An additional 10 lakh nurses

are needed to balance the dwindling patient: nurse ratio,” said Dileep Kumar, nursing advisor to the

Government of India. Even the Government have started a number of initiatives, like offering new

courses, higher degrees, starting colleges etc and INC proposed increasing the retirement age of

nurses from 60 to 65 years,” he said.8

Many studies on stress in nursing have attempted to measure, or have speculated on, the

effects of such stress on nurses’ health and well-being. There appears to be general agreement that

the experience of work-related stress generally detracts from the quality of nurses’ working lives,

increases minor psychiatric morbidity, and may contribute to some forms of physical illness, with

particular reference to musculoskeletal problems, stress and depression. In India, a study was

conducted by Col S. Biswas in Chandigarh reveals that there is a need to de-stress nurses working

in emergency services. The study says that 20% nurses suffer severe stress while in 65 %

nurses; the level of stress is moderate, according to a study of working conditions of nurses in and

around the city. The participants were in the age group of 26-30.9

Prior researches have suggested that nurses, regardless of workplace or culture, are

confronted with a variety of stressors. As the worldwide nursing shortage increases, the aged

population becomes larger, there is an increase in the incidence of chronic illnesses and technology

continues to advance, nurses continually will be faced with numerous workplace stressors. Thus

nurses need to identify their workplace stressors and to cope effectively with these stressors to

attain and maintain both their physical and mental health.21

Stress is common for all and there is no life without stress. It helps to create a challenge in

the mind to attain the goals. But when stress crosses the limit, it leads to certain physiological and 5

psychological problems. There are various techniques and stress management programs to

overcome occupational stress. The most commonly used technique is spirituality. Whenever a

person thinks of stress management the first preference is to surrender all the worries and

frustrations before the sanctum sanctorum for relief. An optimistic attitude develops in the human

mind that only God can solve the problems.

Indian spiritual culture has been taught that ego struggles and attachments are the roots of

stress. Different studies revealed that spirituality plays a major role in coping with stress or

spirituality reduces the stress to an extent. Spiritual heritage helps for individual growth and

psychological well being. Danah(2002) considers “Spiritual Intelligence” as an essential part of

healing process in life and also setting a direction- “thinking of ourselves as an expression of higher

reality”. It is basically a command over meaning, vision and value as per our thinking and decision.

Awakening of the “spiritual Intelligence”, thus assumes a lot of significance. It develops

confidence, control, clarity and meaning in every action.10

The various studies reviewed, point to the fact that job stress has adverse effects on physical

health, mental health, personal and work behaviour of nurses. It is imperative therefore, that the

government, hospital management boards, or employers of nurses be committed to the reduction or

prevention of high job stress experienced by the nurses. This will enhance their welfare, efficiency

and quality of care given to the patients. Many studies suggested that the spiritual ways of coping

with the stress is more reliable than any other type of stress management programs as human being

is afraid of God and a confidence which is developed within the person that when man is

worshiping God a close attachment is there between man and God and in any of the difficulties God

is there to solve the problems. The same stress management technique can be used in nursing field

also to cope with the stress. Hence, there is need for further research in this direction.

6.2 Review of literature:

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1) Studies related to work stress among nurses

2) Studies related to spiritual behaviour among nurses

3) Studies related to work stress and spiritual behaviour among

Nurses

1) Studies related to work stress among nurses.

Lu J L(may 2008), conducted a cross sectional study on organizational role stress indices

affecting burnout among 246 nurses in the Philippine General Hospital to determine the interaction

between situational, factors, role stressors, hazard exposure and personal factors. Correlation

statistics using the Spearman’s rho showed there is a significant correlation existing between

burnout and self efficacy, hazard exposure and organizational role stress, along with age and illness.

Studies reveled that almost half (49.6%) of the respondents reported being ill due to work in the

past year, and 56.1% missed work because of an illness.11

Siying Wu et al (june2007), conducted a study on relationship between burnout and

occupational stress among 495 nurses in China to study the occupational stress and burnout among

nurses. The data collected through Maslach Burnout Inventory which was used to measure burnout,

and the Occupational Stress Inventory which was used to measure two dimensions of occupational

adjustment (occupational stress and coping resources). Results show that it is important to reduce

occupational stress in nurses and to strengthen their coping resources to prevent burnout. This could

be achieved with job redesign, modification of shift work systems, and by offering occupational

support. Scores for burnout of surgical and medical nurses were statistically significantly higher

than those of other nurses (P < 0·05).The most significant predictors of professional efficacy were

role insufficiency, social support and rational/cognitive coping (P < 0·05).12

Joseph M V et al(2006), conducted a descriptive survey on perceived stress of BSc nursing

students to identify factors influencing stress, to develop a tool for assessing the level of stress

among 100 students who are experiencing hostel life at Jabalpur. Non probability sampling was

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used for collecting the data. Maximum students were found to have moderate level of stress.

Positive correlation was also revealed in self evaluated stress and tool assessed by the

researcher(r=0.02).Findings suggests that by recognition of stress, efforts may be made to reduce

the symptoms of stress and help students to perform better22.

Krishnaswamy L, Gandhi S, Thennasaruk, (2006), conducted a comparative study on

perceived stress among nursing and police personal to identify the level of stress perceived by

nurses and police personal, to correlate socio-demographic variables between both groups, and to

compare the level of stress perceived by nurses and police personal. Data on stress perception was

collected from all nurses (n=28) before the commencement of a workshop on stress management

program for nurses at Mahabodhi mallige Hospital,Bangalore.This was done with their informed

consent. The perceived stress scale was administered along with a socio demographic Performa.

Similarly data collected from all police personal (n=23) prior to participation in a stress

management program at the same venue on a different day. Students test was used to test for

statistically significant difference between two groups based on the perceived stress scores. Test-

retest reliability was 0.85, coefficient alpha reliability was 0.84.There is a significant difference

between nurses and police personal (p<0.05).Nurses perceive more stress (29.96+/-4.99)when

compared to police personal(25.83+/-7.08)which is significant. The findings of the study indicate a

paucity of stress management programs in India for nurses as well as the painful fact that nurses do

perceive high level of stress.13

Sveinsdottir H (2006),conducted a cross sectional survey on occupational stress among 206

Icelandic nurses working within and outside hospitals to understand what factors contribute to nurse

stress in universal in light of the present world wide nurse shortage in which data were collected

randomly by using a mailed questionnaire. Population in this study was composed of working

nurses registered at the Icelandic Nurses Association. The Source Occupational Stress Scale was

used to measure occupational stress(p<0.0017).There was no significant difference in the total score

between the two groups(t=0.748; df=206;p=0.455). The findings suggests preventive measure based

on how to diminish occupational stress among nurses thereby contribute to retaining them in the

workplace. Job satisfaction correlated moderately with occupational stress(r=0.41; p<0.001) 14

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2)Studies related to spiritual behaviour among nurses.

Chung LY,Wong F,Chung MF(2007),conducted a co-relational study on relationship of

nurse’s spirituality to their understanding and practice of spiritual care among 61 nurses at Hong

Kong to examine the relationship of nurses' spirituality to their understanding and practice of

spiritual care. A convenience sample of 61 part time Bachelor of Science degree programme nurses

was selected. A newly developed, 27-item five-point Likert scale questionnaire was used to collect

the data. A positive statistically significant correlation was found between self and following three

variables: dimensions beyond self (r=0.35, p<0.001), understanding of spiritual care

(r=0.57,p<0.001), and practice of spiritual care(r=0.26,p<0.05).The relative contributions of self to

understanding (beta=1.06,t=10.74,p<0.001)and practice of spiritual care

(beta=0.68,t=3.62,p<0.001)were statistically significant. There was no statistically significance

difference between any of the demographic variables and understanding and practice of spiritual

care, except for a negative relationship between religious affiliations and the dimensions beyond

self (p<0.001)15

Yang KP(2006), conducted a cross sectional descriptive study on The spiritual intelligence

of nurses in Taiwan to define the profile of nurses' spiritual intelligence, examine the relationship

between nurses' demographic characteristics and spiritual intelligence; and to explore the mode of

nurses' spiritual intelligence and related factors, among 299 nurses in Taiwan. Wolman's (2001)

Psycho Matrix Spirituality Inventory, a 4-point scaled, self-reported, 49-item questionnaire

covering seven spiritual factors was used to collect data. Results showed that nurses' spiritual

intelligence was centralized in a moderate degree, while trauma and childhood spirituality were

either moderate or high. Age and childhood spirituality were the most significant variables affecting

nurses' spiritual intelligence, accounting for 61.4% of the variance in nurses' spiritual intelligence.16

Yang KP, Mao XY (2005) ,conducted a cross sectional descriptive and inferential designed

study on nurse’s spiritual intelligence in China to explore the profile of spiritual intelligence among

nurses, and to examine the effect of religions on nurses' spiritual intelligence among 130 registered

nurses. Convenience sampling was used to select 130 registered nurses. Wolman's (2001) four-9

point Likert-type Psycho-Matrix Spirituality Inventory (PSI) was used to collect the data. Informed

consent was taken from nursing administrators. The study draws attention to the diverse culture of

the nurse’s concepts of spirituality. The majority of nurses (90%) tended to experience numerous

instances of physical emotional pain and suffering throughout life.17

3)Studies related to work stress and spiritual behaviour among nurses

Desbiens J F , Fillion L (2007) ,conducted a co-relational study on coping strategies,

emotional and spiritual quality of life in 120 palliative care nurses in Quebec to describe the

association between coping strategies ,emotional outcomes and spiritual quality of life by using

revised version of COPE scale, POMS(profile of mood status) and FACIT-sp(Functional

Assessment Of Chronic Illness Therapy) respectively. The findings highlight the importance of

meaning-making strategies in psychological adjustment to bereavement for palliative care nurses.

Positive reinterpretation (beta=.27;p<.01)and turning to religion (beta=.33;p<.001) two strategies

related to meaning –making coping and is engagement (beta=-.19;p<.05) were best predictors,

accounting for 22%of variance of spiritual of life.18

Walker MJ (2006) , conducted an experimental study on the effects of nurses' practicing of

the heart touch technique on perceived stress, spiritual well-being, and hardiness among 98 nurses.

Experimental(n=58) and comparison(n=40)groups received an education session discussing the

effects of thoughts and feelings on stress and health, with the experimental group also learning heart

touch and practicing it for one month. It produced no statistically significant differences between

groups. Effect sizes ranges from 0.14 to0.35, indicating practical significance, suggesting that

nurses who practiced heart touch likely noticed a greater improvement in outcome variables than

nurses who did not practice heart touch. In the experimental group statistically significant within

group differences were seen in two variables. Learning about the power of thoughts and feelings

and using heart touch to change them can reduce stress and increase hardiness and spiritual well-

being.19

Beddoe A.E, Murphy S.O (2004) ,conducted a pilot study on does mindfulness decrease

stress and foster empathy among 16 baccalaureate nursing students to cope with personal and

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professional stress and to foster empathy through intrapersonal knowing. A convenience sample of

16 students who were participated in an 8 week mindful based stress reduction (MBSR) course,

used guided meditation audiotapes at home, and completed journal assignments. Stress and

empathy were measured using paired sample t tests. Participants reported using meditation in daily

life and experiencing greater well-being and improved coping skills as a result of the program.

Participation in the intervention significantly reduced students’ anxiety (p < .05). 20

STATEMENT OF THE PROBLEM:

“A CORRELATIONAL STUDY ON WORK STRESS AND SPIRITUAL BEHAVIOUR

AMONG STAFF NURSES IN SELECTED HOSPITALS AT MYSORE”

6.3 Objectives of the study:

1) To describe the work stress among staff nurses in selected hospitals

at Mysore.

2) To describe spiritual behaviour among staff nurses in selected

hospitals at Mysore.

3) To correlate the work stress and spiritual behaviour among staff

nurses.

4)To find the association between back ground factors, work stress and

Spiritual behaviour among staff nurses in selected hospitals at

Mysore.

Operational Definition:

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Work stress: Refers to the physical and emotional outcomes that occur when there is disparity

between the demands of the job and the amount of control the individual has in meeting those

demands. It is measured in terms of work stress score by the items in the questionnaire.

Spiritual behaviour: Refers to the source of an unlimited number of forms of human experience

may take, like meditation, prayer and treating others with respect, dignity and as equals. It is

measured in terms of spiritual behaviour scores.

Staff nurses: Refers to the registered nurses who are appointed in the first level position.

Back ground factors: Refers to those factors thought to influence the stress among nurses such as

age, gender, education and religion.

7. MATERIAL AND METHODS

7.1 Source of data: Responses from the staff nurses in selected hospitals at Mysore

7.1.1 Research design: Descriptive correlation study

7.1.2 Setting : Selected hospitals in Mysore

7.1.3 Population: Staff nurses in selected hospitals at Mysore

7.2 Method of data collection

7.2.1 Sampling technique: Quota sampling

7.2.2 Sample : Staff nurses from selected hospitals in Mysore

7.2.3 Sample size : 80 samples

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7.2.4 Sampling criteria:

Inclusion criteria:

* The registered nurses working in first level position

* Nurses aged above 20 years and below 50 years

* Both males and females

* Both G N M and B.Sc graduates

Exclusion criteria:

* Nurses who refuse to participate in the study

* Nursing supervisors

7.2.5 Data collection tool : Structured questionnaire, Likert scale

7.2.6 Method of data collection : Self administered (paper pencil)

Method

7.2.7 Duration of data collection: Three weeks

7.2.8 Data analysis plan: Both descriptive and inferential statistics

7.3 Does the study require any investigation or intervention to be

conducted on patients Or other humans or animals ?If so, please

describe briefly.

- No –

7.4 Has ethical clearance been obtained from your institution in case

of 7.3 -Yes-

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8. LIST OF REFERENCES:

1 Potter A P & Perry AG, Fundamentals of nursing,6th edition, Elsevier publication;595

2 R Lakshminarayanan, An overview of strategic planning to combat occupational stress--need

of the hour in the present Indian context; 1-15

3 M C Vicar, Work place stress in nursing – A literature review, Journal of advanced

nursing,44(6);633-642

4 Ljubljana, solvinia, karleskrong Sweden, Spiritual need within nursing, master thesis;1-72

5 Gelsema T, Job stress among nurses, Thesis presentation;1-12

6 Health care news,29 Aug 2007 available at www.new medical net.com

7 Available at www.haworthpress.com

8 Indian nightingales holds candle in the wind, Times of India,Nov2008

9 Need to de-stress nurses, CHANDIGARH Newsline, available at www.cities

expressindia.com

10 Transcendence quarterly news letter, vol X, no 2 ,july-sep2008;1-5

11 Lu J F, Organizational Role Stress Indices Affecting Burnout among Nurses, Journal of

International Women’s Studies Vol. 9 #3 May 2008

12 Siying W.U et al, Relationship between burnout and occupational stress among nurses in

China, Journal of advanced Nursing, volume 59,Pp233-239

13 Krishnaswamy L, Gandhi S, Thennarasu K, perceived stress among nursing and police

personal- a comparative study, Prism’s nursing practice,2006,vol 1,no 2;81-88

14 Sveinsdottir H, “Occupational stress among nurses” Journal of Advanced Nursing page:1-37

15 Chung LY et al, Relationship of nurses' spirituality to their understanding and practice of

spiritual care., Journal of Advanced Nursing. 2007 Apr;58(2):158-70

16 Yang KP , The spiritual intelligence of nurses in Taiwan, Journal of Holistic Nursing, 2006

Sep;24(3):176-7.

17 Yang KP,Mao XY, spiritual intelligence of nurses in China, Journal of nursing research,2005

mar;14(1);24-35

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18 Desbiens JF , et al, Coping strategies, emotional outcomes and spiritual quality of life in

palliative care nurses, International Journal of Palliat Nursing. 2007 Jun;13(6):291-300.

19 Walker M J, The Effects of Nurses’ Practicing of the HeartTouch Technique on Perceived

Stress, Spiritual Well-Being, and Hardiness , Journal of Holistic Nursing, Vol. 24, No. 3,

164-175 (2006)

20 Beddoe A.E, Murphy S.O., Does Mindfulness Decrease Stress and Foster Empathy Among

Nursing Students?, Journal of Nursing Education  Vol. 43   No. 7   July 2004

21 Vickie A Lambert, et al, Nurses' workplace stressors and coping strategies, . Indian Journal

of Palliat Care 2008 Oct 19,:38-44.

22 Joseph M V et al, A study to assess the perceived stress of BSc nursing students, Indian

journal of Holistic nursing, vol 2, no 3, December 2006;28-30

9. Signature of Candidate :

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10. Remarks of the Guide :

11. Name and designation of Guide : Mr. S. Mohan Raju

Principal

11.1 Signature of guide :

11.2 Head of the Department : Mr. S. Mohan Raju

11.3 Signature :

12 Remarks of Principal :

12.1 Signature :

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