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Health Policy 108 (2012) 149– 157

Contents lists available at SciVerse ScienceDirect

Health Policy

j ourna l ho me pag e: ww w.elsev ier .com/ locate /hea l thpol

tress, depression, and intention to leave among nurses in differentedical units: Implications for healthcare management/nursing

ractice

u-Mei Chianga,b,∗, Yuhsuan Changa

College of Management, Yuan Ze University, 135 Yuan-Tung Road, Chungli, Taoyuan, TaiwanHsing Wu University. No. 101, Sec.1, Fenliao Rd., LinKou District, New Taipei City, Taiwan

r t i c l e i n f o

rticle history:eceived 8 September 2011eceived in revised form 31 August 2012ccepted 31 August 2012

eywords:epression

ntention to leaveational Health Insurance Systemtress

a b s t r a c t

Aims: The aim of the present study was to compare the levels of stress, depression, andintention to leave among clinical nurses employed in different medical units in relationto their demographic characteristics under the National Health Insurance (NHI) System inTaiwan.Methods: Cross-sectional Spearman’s correlation, one-way ANOVA with Scheffe post hocanalysis tests, and multiple regression analyses were conducted. Several self-report ques-tionnaires, such as the Center for Epidemiological Studies Depression Scale, the PerceivedStress Scale and Intention to Leave Scale, were administered. A total of 314 research par-ticipants were surveyed, all of whom came from regional hospitals in Northern Taiwan.Results: Marital status and working tenure were significant predictors to the levels of stress,depression, and intention to leave among nurses before taking the medical units into con-sideration. However, with adding medical units as predictors, the effect of marital statusand working tenure were insignificant except for the stress model, indicating medical unitswere showing dominant effect over other variables. In particular, internal medical ward(IMW) nurses experienced a higher prevalence of depression than emergency room (ER)nurses and professional nursing practitioners. External medical ward (EMW) nurses alsoexperienced greater depression than emergency room (ER) nurses. Both IMW and EMWnurses perceived significantly greater stress than ER and dialysis center. Moreover, IMWnurses also perceived greater stress than operating room (OR) nurses and showed strongerintention to leave than their counterparts in the outpatient service departments.

Conclusions: The results indicated that significant differences existed among various medi-cal units with regards to nurses’ stress, depression, and intention to leave. Nurses workingin internal and external medical wards, especially the inexperienced and married ones,experienced greater depression and stress, thereby developing stronger intention to leavetheir job.

© 2012 Elsevier Ireland Ltd. All rights reserved.

∗ Corresponding author at: College of Management, Yuan Ze University,35 Yuan-Tung Road, Chungli, Taoyuan, Taiwan.el.: +886 2 26015310x1335; fax: +886 2 26014501.

E-mail address: s969408@mail.yzu.edu.tw (Y.-M. Chiang).

168-8510/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.healthpol.2012.08.027

1. Introduction

In a competitive healthcare industry, improving thequality of healthcare services is a continuing challenge tonursing leaders and hospital administrators. In any health-care organization, nurses are the frontline professional

ealth Policy 108 (2012) 149– 157

Table 1The ratio of nurse to patient comparisons among Taiwan, Australia, USA,and Japan.

Taiwan Australia and USA Japan

Day shift 5–13 4–5 7Swing shift 6–18 4–6 7

150 Y.-M. Chiang, Y. Chang / H

staffs in a healthcare organization, playing an importantand direct role in the delivery of high-quality healthcareservices. However, the turnover of highly skilled nurseshas been an international concern, particularly in Taiwan.According to the Department of Health (DoH) in Taiwan,compared with a rate of 21.3% in the USA in 2000 [1],there were turnover rates of approximately 17% of 8772registered nurses (RNs) [2] and 22.1% of 4602 new nurseswith work tenure under 3 months in medical centers [3]in 2009. Moreover, the Taiwanese healthcare industry hasbeen having difficulties in recruiting new RNs and nurs-ing students. According to the data from DoH in Taiwan,a substantial number of vacant positions (approximately5500) are waiting to be filled [3]. Generally speaking, thewillingness to become a nurse is relatively low after gradu-ation from nursing schools or even after obtaining nursinglicensure. For example, only 59.3% nurses with licensureare willing to work as a nurse compared to 83% of nursesin the US [4].

Meanwhile, Taiwan’s healthcare industry has become acostly environment after the government implemented theNational Health Insurance (NHI) System in 1995. Althoughthe NHI system improved the quality of healthcare andexpanded insurance coverage, it also significantly andrapidly increased the volume of medical services. As aresult, nurses have assumed higher level of workloadsand responsibilities with limited amount of nursing staffs,which can lead to a variety of negative outcomes includ-ing higher levels of stress and depression, burnout, lowerpatient satisfaction, intention to leave [5]. A growing bodyof evidence from several studies highlights the intention ofnurses to leave significantly predicting their actual decisionto resign from the profession [6–10], and its associationwith stress and depression. The levels of nurses’ stress,depression, and intention to leave may differ among vari-ous medical departments in a healthcare system, especiallyunder the NHI policy. Thus, gaining further understand-ing of these issues is an important step in providingpolicymakers and hospital administrators’ guidelines todevelop appropriate strategies that can mitigate turnoverand retain skilled nursing staff.

2. Background: the NHI system in Taiwan andinadequate numbers of nursing staff

The implementation of the NHI system in Taiwan aimedto achieve three essential objectives [11]: (1) expandhealthcare coverage to the entire population; (2) improvethe quality of medical care through competition; and (3)control healthcare expenditures. From 1996 to 2010, thehealthcare coverage of the total population increased from94.2% to 99.9% [12], in which individuals without insur-ance were mostly children under 14 years old and theelderly who were 65 years old and over [13]. Unfortu-nately, with the implementation of the Scheme, medicalexpenditures increased by 35.4% for the elderly with insur-ance, who used more hospital services, as well as services

for the treatment of complicated types of medical cases,thereby damaging the financial balance of the Bureau ofNHI since 1996 [13]. Furthermore, the fee-for-service (FFS)payment method has encouraged more people to avail of

Night shift 7–20 8–10 7

Note. The number indicates numbers of patients/per nurse.

clinical check-up and rehabilitation services. The patients’option of having a wider range of hospitals to go to has alsoled to the establishment of higher quality facilities, whichemploy new technologies and offer treatments encour-aging longer periods of confinement. According to thestudy reported by DoH [12], as Taiwan’s population grewby 3.4% between 2000 and 2010, the volume of servicesdelivered significantly increased as well. Between 2000and 2010, the total hospital outpatient visits increased by43.6%, emergency room visits by 69.3%, outpatient surgeryby 46.6%, in-patient surgery by 53%, and kidney dialysisby 127.4%. Within the same period, the number of hos-pital beds increased by 25.7%, while the average lengthof stay (LOS) extended from an average of 8.5–11.6 days.Meanwhile, although the number of nursing staff increasedby 56.4%, from 71,092 to 111,214, the staffing intensity(i.e., the ratio of nurses to patients) and the length ofwork duration reached average rates of 5–20 patientsand 3.06–17.5 hours, respectively, depending on the shiftsystem of each medical institution and its units [13]. Specif-ically, as shown in Table 1 [14], the ratio of nurses topatients in Taiwan seemed to be extremely inadequate,comparing with some western countries. Accordingly, theNHI system resulted in a statistically significant increasein the amount of outpatient visits, hospital admissions,and emergency department referrals; payment rates alsoseemed to favor certain specializations [15]. These changesnot only created a high degree of stress in the health-care environment, but also resulted in the high turnoverrate and severe shortage of nurses due to heavier work-loads, long working times, inadequate number of staff,and increasing responsibilities in the post-NHI period [4,5].High absenteeism and turnover rates potentially causedelays in the treatment of patients, increase spending ofmedical expenditures, and decrease the quality of health-care services [16–18], resulting in rising concerns amongpolicymakers and nurse executives. Recently, with respectto the severe shortage of nurses, the DoH in Taiwan hasfocused on creating policies designed to reduce the flowof nurses out of the workforce as well as improve thehealthcare workplace. Numerous studies have reportedthat the turnover rate is significantly related to nurses’work stress, depression, and intention to leave [19,20].With possible variations among medical units on the per-ception of stress, risk of depression prevalence and theintention of nurses to leave, a further exploration of thisphenomenon is important to guide policymakers and hos-pital administrators in formulating retention strategies for

human resource management and to reduce nurses’ levelof stress and depression to ensure better medical servicesatisfaction.

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. Literature review

.1. Intention to leave and stress

A nurse’s intention to leave has been regarded as aithdrawal process from her/his workforce [21]. A grow-

ng body of research suggests that intention to leave cane associated with an array of factors, including workverload, lack of social support [22–24], burnout [25], feel-ngs of work–family conflict [26] or stress [25,27], low jobatisfaction [25,28–34], supervisory support [35], organi-ational commitment [36,37], organizational climate [38],he quality of care [34], dissatisfaction with salary or loway [25,39], and few possibilities for development [40]. Evi-ence from several present studies highlighted that stressesults in high absenteeism and turnover, and low reten-ion of nurses, which consequently affect the quality of carerovided [19,20]. According to Lazarus and Folkman [41,. 19], stress is “any situation in which internal demands,xternal demands, or both, are appraised as taxing orxceeding the adaptive or coping resources of an individualr group.” Stress does not only have a negative effect on theealth and well-being of nurses, but also on the functional-

ty of the nursing profession [42]. The intensity of stress canary among different medical units. For example, severaltudies indicated that intensive care unit (ICU) nurses expe-ience more stress than medical-surgical nurses [43–45].elly and Cross [46] found that ward nurses in two Aus-

ralian hospitals were more highly stressed by inadequatetaffing and used less problem-solving strategies than ICUurses. Dewe [47] argued that medical wards experienceore frequent stress in comparison to critical intensive

nits. Gray-Toft and Anderson [48] suggested that hos-ice nurses experience lower levels of stress than othersmedical-surgical, cardiovascular, surgical, oncology). Colet al. [49] pointed out that ICUs register as the most stress-ul areas for both patients and nursing staff. Thus, nurses

ay experience a significant difference in stress among dif-erent medical units which may affect the quality of patientare [45].

.2. Stress and depression

Stress has been studied with an array of variablesncluding workload [50–52], self-esteem [53], social sup-ort [54], copy [42,46,55,56], burnout [57–61], andepression [56,62]. However, studies on stress in rela-ion to depression in the nursing profession have beenignificantly lacking [63]. Depression among nurses maye linked to the high level of stress they experience on

daily basis in a hospital without proper interventions.urses can be a high-risk occupational population for expe-

iencing depressive symptoms due to high job demands,ob characteristics, and complex environmental condi-ions [64]. The effect of depression on clinical nurses haseen historically neglected. Depression among the gen-ral public and hospital patients has generated numerous

tudies, but depression among nurses themselves has beenelatively lacking [63]. Within the limited studies thatxplored stress and depression among clinical nurses, theirocus was mainly to examine the relationship between

licy 108 (2012) 149– 157 151

the prevalence of depression and the factors linking todemographics/socio-economics, such as age [65,66], gen-der [65,67], education [65], salary [65], and tenure [65].This explains why the identification of risk level amongdifferent medical units is mostly nonexistent. Nurses workunder different medical units, and consequently, the per-ception of stress and the risk of depression prevalencecannot be considered as uniform. Considerable differenceson stress were found among medical units, and previousresearch indicated that stress has a significant associationwith depression. Further exploration of this phenomenonis immediately needed in order to provide insight intothe effect of depression on nurses and their performance,and the ways to devise retention strategies of skillednurses.

3.3. Purpose of the present study

Taken together, stress and depression issues can havea serious effect on nurses’ intention to leave. However,although issues on stress and depression have been exten-sively studied in current literature, studies conductedamong nurses are relatively lacking. Only a few haveinvestigated the differences in the levels of stress, depres-sion, and intention to leave among nurses in varioushospital units as well as their interaction effects on demo-graphic characteristics. Therefore, the present study wasa pioneering effort to address these issues. The studyhas a threefold purpose: (1) to explore the relationshipsamong demographic characteristics, hospital units, stress,depression and intention to leave; (2) to investigate thedifferences among nurses in various medical departmentswith regards the levels of depression, stress and intentionto leave; and (3) to examine whether or not demo-graphic characteristics in the present study have significantinfluential effects on depression, stress, and intentionto leave among nurses employed in various medicalunits.

4. Method

4.1. Participants

A cross-sectional study was conducted to test the fre-quencies and correlations among Taiwanese clinical nursesworking in different medical units regarding stress, depres-sion, and intention to leave. Data came from self-reportquestionnaires completed by 314 clinical nurses who were99.4% female because of their higher prevalence. Theparticipants consisted of nurses recruited from northernarea Taiwan hospitals. With regard to medical units, thelargest percentage of nurses, 20.4%, belonged to outpa-tient services departments; internal medical ward (IMW)and external medical ward (EMW) accounted for 13.7%and 13.4%, respectively; pediatrics was 4.1% of the total

number; dialysis center was 9.2%; professional nursingwas 6.4%; and the obstetrics and gynecology departmentsaccounted for 1.3%. The characteristics of the participantsare described in Table 2.

152 Y.-M. Chiang, Y. Chang / Health Po

Table 2Demographic characteristics of Taiwanese nurses.

Demographic variables Clinical nurses (n = 314)N (%)

Age21–30 171(54.5)31–40 119(37.9)�40 21(6.7)Missing 3(1)GenderFemale 312(99.4)Missing 2(.6)EducationHigh school 21(6.7)Associate 223(71.0)University (above) 70(22.3)Marital statusSingle 135(43.0)Married 170(54.1)Divorce/lives apart 9(2.9)Working tenure<3 years 45(14.3)3–5 years 40(12.7)5–10 years 84(26.8)�10 years 145(46.2)Hospital unitsICU 43(13.7)OR 25(8.0)ER 29(9.2)Outpatient services 64(20.4)Internal medicine ward 43(13.7)External medicine ward 42(13.4)Pediatrics 13(4.1)Dialysis center 29(9.2)Professional nursing 20(6.4)Obstetrics and gynecology 6(1.9)LicenseRegistered nurse 148(47.1)Licensed vocational nurse 94(29.9)Nurse practitioners 72(22.9)Nurse period (month)

Mean (SD); range 104.52(72.76); 0–540Hospital period (month)Mean (SD); range 50.34(43.42); 0–204

4.2. Instruments

4.2.1. DepressionDepression was measured using a context-specific

adaptation of the Center for Epidemiological StudiesDepression Scale (CES-D) [68]. The CES-D is designedto measure different depressive symptoms, includingdepressed affect, positive affect, somatic symptoms, psy-chomotor retardation, and interpersonal activity, and hasbeen used in a variety of community and population-basedstudies [69]. The CES-D is a 20-item, 4-point Likert-typescale (1 refers to rarely or none of the time and 4 refers tomost or all of the time). Radloff [68] reported good internalconsistency with Cronbach’s alpha coefficients of .85 for thegeneral population and .90 for the psychiatric population.The coefficient alpha in the present study was .90.

4.2.2. StressStress was assessed using the Perceived Stress Scale,

10-item version (PSS-10) [70], which is widely used andhas been shown to be valid and reliable [71]. PSS-10 is ameasure of the degree to which situations in one’s life areappraised as stressful. A sample item is, “In the last week,

licy 108 (2012) 149– 157

how often have you been upset because of something thathappened unexpectedly?” Response options range from0 (never) to 4 (very often), with higher scores indicatinggreater stress. The coefficient reliabilities have been shownto range from .67 to .86. The coefficient alpha in the presentstudy was .82.

4.2.3. Intention to leaveIntention to leave was assessed using the 5-item version

of the intention to leave scale [72]. This scale is 4-pointLikert scale (1 refers to strongly disagree and 4 refers tostrongly agree). A sample item is, “Are you consideringleaving your current job in the coming year?” Lin [72]reported good internal consistency with Cronbach’s alphacoefficients of .83. The coefficient alpha in the present studywas .89.

4.3. Data analysis

All data were entered into the Statistical Package forthe Social Sciences, version 18.0. The independent vari-ables for the model were hospital units and demographiccharacteristics, including age, education, marital status,license status, and working tenure. Given that the analyzedconstructs are categorical variables in nature, Spearmancorrelation analyses were conducted. The statistically sig-nificant demographics variables will be considered forpredictors in the regression model. Second, a one-way anal-ysis of variance (ANOVA) was conducted to assess whetheror not the medical units were significant sources of vari-ance in terms of depression, stress, and intention to leave.Once a statistically significant F-value was obtained inANOVA, the post hoc test by Scheffe was employed duringthe second stage to determine which groups significantlydiffered from one another. Third, multiple dummy vari-ables were created to measure the nominal variable ofhospital units with the value of 1 or 0. Subsequently, multi-ple regression analysis was conducted to examine whetheror not the demographic characteristics identified in thepresent study have significant interaction effects withdepression, stress, and intention to leave among nursesemployed in various medical departments. An evaluationfor multi-collinearity and outliers was made for each mul-tiple regression analysis, and none were found.

5. Results

Table 3 presents the mean, standard deviations, reli-ability coefficients, and the Spearman’s correlations forall study variables. The nurses’ respective demographiccharacteristics, such as marital status, working tenure,education and age, showed significant correlations withdependent variables. For example, a nurse’s perceptionof stress was positively correlated to marital status(r = .205, p < .01) and education (r = .128, p < .05), andwas negatively correlated to working tenure (r = −.212,p < .01). Meanwhile, depression and intention to leave

were positively related to marital status (rdepression = .146,p < .01, rintention to leave = .134, p < .05), whereas negativelyrelated to working tenure (rdepression = −.167, p < .01,rintention to leave = −.178, p < .01) and age (rdepression = −.112,

Y.-M. Chiang, Y. Chang / Health Policy 108 (2012) 149– 157 153

Table 3Descriptive statistics and Spearman’s correlations for all variables (N = 314).

Mean SD 1 2 3 4 5 6 7 8 9

Unit 4.7 2.45License 1.8 .80 −.073Marital status 1.5 .56 −.090 .009Education 2.6 1.31 .012 −.153** .162**

Working tenure 3.1 1.08 .002 .021 −.292** −.231**

Age 2.5 .67 .137* .032 −.348** −.130* .631**

Depression 37.9 9.81 .023 −.022 .146** .095 −.167** −.112*

Intention to leave 5.9 2.32 .017 .029 .134* .086 −.178** −.157** .402**

.2 ** * ** ** **

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Stress 20.3 3.75 .004 −.037

* p < .05, two-tailed.** p < .01, two-tailed.

< .05, rintention to leave = −.157, p < .01). Both marital statusnd tenure were significantly related to all dependentariables. Consequently, marital status and tenure werenalyzed as predictors in the regression model. Regardinghe correlations among dependants, the intention toeave had a significantly positive relationship with stressr = .470, p < .01) and depression (r = .402, p < .01), indicat-ng the significant associations between stress, depression,nd the intention to leave.

Second, ANOVA was conducted in order to investigatend address the effects of the differences among groupsf nurses in medical departments with regards depres-ion, stress and intention to leave. The results of theNOVA tests revealed the significant differences (p < 0.05)

n the levels of stress, depression, and intention to leavemong nurses in various medical units (Table 4). Eachf these significant ANOVA tests was subjected to thecheffe post hoc analysis test to determine specific groupifferences within each of the units. The greatest differ-nce was found for depression [F(314) = 5.066, p < 0.001],ollowed by stress [F(314) = 4.411, p < 0.001], and inten-ion to leave [F(314) = 3.683, p < 0.001]. In terms of theevel of depression, the Scheffe post hoc test revealed thatnternal medical ward (IMW) nurses have higher scores

han emergency room (ER) nurses and professional nurs-ng practitioners. External medical ward (EMW) nurses alsoxperienced more severe depression than ER nurses. Withegards the comparison of perceived stress, both IMW and

able 4mount of depression, stress, and intention to leave experienced by nurses in me

Units Depression Stre

N (%) Mean SD N (%

1. ICU 43(13.7%) 38.53 9.38 43(12.OR 25(8.0%) 35.55 9.08 25(83. ER 29(9.2%) 32.00 8.55 29(94. Outpatient services 64(20.4%) 38.21 10.03 64(25. Internal medicine ward 43(13.7%) 43.52 8.75 43(16. External medicine ward 42(13.4%) 41.42 11.25 42(17. Pediatrics 13(4.1%) 34.57 6.45 13(48. Dialysis center 29(9.2%) 35.67 7.91 29(99. Professional nursing 20(6.4%) 32.68 7.73 20(610. Obstetrics and gynecology 6(1.9%) 40.67 8.66 6(1.Total 314(100%) 37.93 9.81 314

ANOVA F 5.066***

Post hoc test 5 > 3 5 > 9 6 > 3 5

*** p < .001.

05 .128 −.212 −.095 .520 .470

EMW nurses experienced significantly greater stress thanER and dialysis center nurses. IMW nurses also experiencedgreater stress than operating room (OR) nurses. In termsof the intention to leave, IMW nurses were significantlystronger than the nurses in the outpatient services depart-ments. Overall, ANOVA and Scheffe post hoc analysis testsindicated that nurses working in IMW showed consider-ably higher levels of depression, stress, and intention toleave from their current job. These findings supported ourhypothesis that the levels of nurses’ stress, depression, andthe intention to leave varied among medical units.

Third, multiple regressions were performed in orderto identify relationships among demographic characteris-tics, hospital units, and the three independent variables.The results are shown in Table 5. Model 1, using tenureand marital status as predictor variables, obtained 3.3% ofthe variance [F(314) = 6.275, p < 0.01] in depression, 14%of the variance [F(314) = 13.514, p < 0.001] in stress, and2.8% of the variance [F(314) = 5.439, p < 0.01] in intention toleave. Specifically, tenure had a significantly negative influ-ence on stress ( ̌ = −.187, p < 0.001), depression ( ̌ = −.147,p < 0.05), and intention to leave ( ̌ = −.147, p < 0.05). Thesefindings were consistent with those of previous studies[30,39], thus supporting the assumption that young and

inexperienced nurses were more likely to contribute to ahigher turnover rate in Taiwan.

In Model 2, ER, IMW, and professional nursing indi-viduals were significant predictors accounting for 10.5%

dical departments.

ss Intention to leave

) Mean SD N (%) Mean SD

3.7%) 20.74 2.57 43(13.7%) 5.60 1.90.0%) 19.03 2.64 25(8.0%) 5.75 2.13.2%) 18.84 2.85 29(9.2%) 6.14 2.520.4%) 19.72 3.18 64(20.4%) 5.31 2.143.7%) 22.23 4.29 43(13.7%) 7.19 2.213.4%) 21.83 4.53 42(13.4%) 6.57 2.23.1%) 21.13 4.04 13(4.1%) 6.99 2.89.2%) 18.39 3.47 29(9.2%) 5.03 2.40.4%) 20.12 4.49 20(6.4%) 5.15 2.35

9%) 20.83 3.31 6(1.9%) 5.83 2.14(100%) 20.33 3.75 314(100%) 5.93 2.32

4.411*** 3.683***

> 2 5 > 3 5 > 8 6 > 3 6 > 8 5 > 4

154 Y.-M. Chiang, Y. Chang / Health Policy 108 (2012) 149– 157

Table 5Results of regressions analysis of depression, stress, and intention to leave associated with different hospital units.

Predictors Depression Stress Intention to leave

Model 1 Model 2 Model 3 Model 1 Model 2 Model 3 Model 1 Model 2 Model 3

Working tenure −.147* −.047 −.187*** −.103 −.147* −.068Marital status .097 .043 .167** .128* .077 .054ICU .011 .008 .094 .084 .043 .039OR −.073 −.063 −.050 −.024 .052 .067ER −.183** −.177** −.068* −.050 .103 .112Outpatient services .000 .000 .000 .000 .000 .000Internal medicine ward .187** .174** .231*** .200** .278*** .260***

External medicine ward .112 .099 .192** .160* .185*** .167*

Pediatrics −.074 −.075 .075 .072 .144* .142*

Dialysis center −.075 −.058 −.102* −.059 −.035 −.011Professional nursing −.138* −.124** .026 .060 −.017 .001Obstetrics and gynecology −.034 −.032 −.041 −.036 −.031 −.028

F 6.275** 5.066*** 4.268*** 13.514*** 4.411*** 4.579*** 5.439** 3.683*** 3.250***

R2 .039 .130 .135 .080 .115 .143 .034 .098 .106�R2 .033 .105 .103 .143 .089 .112 .028 .072 .073

Model 1: working tenure, marital status; Model 2: medical units; Model 3: working tenure, marital status, and medical units.*

p < .05.

** p < .01.*** p < .001.

of variance in depression [F(314) = 5.066, p < 0.001]. Mean-while, ER, IMW, EMW, and the dialysis center nurseswere significant predictors, accounting for 8.9% of the vari-ance in stress [F(314) = 4.411, p < 0.001]. A total of 7.2%of variance in intention to leave [F(314) = 3.683, p < 0.001]was explained by IMW, EMW, and the pediatrics. How-ever, by adding the demographics variables in Model 3,the total variances in depression [F(314) = 4.268, p < 0.001]and in intention to leave [F(314) = 3.250, p < 0.001] slightlychanged. Only marital status, IMW, and EMW remainedas significantly positive predictors, accounting for 11%of variance in stress [F(314) = 4.579, p < 0.001]. Interest-ingly, the ̌ coefficient weights of tenure were significantin Model 1 (stress = −.187, p < .001, depression = −.147,p < .05, intention to leave = −.147, p < .05); in comparison,these were insignificant in Model 3 (stress = −.103, n.s.,depression = −.047, n.s., intention to leave = −.068, n.s.). Theresults indicated that tenure was associated with stress,depression and intention to leave among nurses fromdifferent medical units; however, it was not the maininfluential factor. In contrast, marital status was a sig-nificant predictor in the stress level of nurses in variousmedical units. Accordingly, with adding medical units aspredictors, the effect of marital status and working tenurewere insignificant except for the stress model, indicatingmedical units were showing dominant effect over othervariables. Taken together, based on the significant ̌ coeffi-cient weights, our findings emphasized that both IMW andEMW nurses showed higher stress levels and intention toleave, while IMW nurses had greater depression levels.

6. Discussion

Our findings highlighted the significant correlations

among demographic characteristics (i.e., tenure, maritalstatus, education, and age), medical units, and levels ofstress, depression, and intention to leave. Without tak-ing medical units into consideration, working tenure and

marital status served as significant predictors in depres-sion, stress, and intention to leave. Specifically, maritalstatus was a significant predictor in the stress levels ofnurses in various medical units. Previous studies demon-strated that young and inexperienced nurses with shortertenure are most vulnerable during the first years of theirnursing careers resulting from the demands and stressin their profession [30,39]. Meanwhile, Simon et al. [26]indicated work–family conflict as most pronounced at thebeginning of a nursing career and commonly occurringamong nurses between 30 and 40 years old. According toour review, in the context of the current nursing workforce,prospects in the nursing occupation vary in terms of staffshortage, excessive workload, day and night shifts, longwork hours, irregular work schedules, challenging workconditions, and job stress levels, making them particularlyprone to work–family conflicts during the post-NHI period.This is especially true for married women in the work-force, who still maintain majority of family and householdresponsibilities. Such conflicts contribute to heightenedstress and increased motivation to seek other professions.A growing body of empirical evidence suggests that socialsupport from nursing managers and the working commu-nity can encourage younger or married nurses to continuesuccessfully in their nursing careers [73,74]. Therefore,we strongly encourage relevant healthcare administersand nursing managers to pay further attention to the lessexperienced nurses and those with family responsibilities.Specifically, during workplace planning, mentoring sup-port can be initiated to supervise the newly qualified, andadditional childcare support can be offered to nurses withfamily responsibilities to embed their roles within theirlives.

Regarding the reduction and moderation of workloads,

several strategies can be implemented. For example, theestablishment of workload standards, flexible work hours,retention of nursing aides to perform nonprofessionalnursing duties, and nursing records simplification via

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omputer systems are possible interventions [75,76]. Theovernment and the national health organization can takehe supervisory responsibility to ensure these issues areddressed during the annual hospital evaluation process.ospitals that seriously take steps to improve nurses’orkload issues should be recognized and rewarded under

he NHI system.Meanwhile, one effective strategy in coping with

tress is recommended in the context of preventingegative work outcomes and depression among nurses23,24,28,46]. A growing body of empirical evidenceeveals the importance for schools and nursing facultyo integrate skill trainings into the current curriculums77,78]. For example, the student-centered curriculums cane created with a realistic view of nurses’ daily work-elated stressors to bridge the practice–education gap andecrease the shock and dissatisfaction with role transi-ion after graduation. Moreover, acquainting students withffective stress management skills like affect regulation,ealing with life changes, and practicing problem-solvingechniques is beneficial. Based on the preceding findingsnd discussion, if policymakers and nursing managersould influence work conditions and utilize educationalraining programs to enhance the stress management skillsf inexperienced nurses, more nurses could be retained,nd higher turnover rates could be prevented.

In comparing the groups of clinical nurses, differencesere strongly evident among medical units. Our findings

evealed that IMW and EMW nurses perceived significantlyigher stress levels than ER and dialysis center nurses;oreover, IMW nurses also perceived higher stress levels

han OR nurses. Nurses working in medical wards tradi-ionally focus on providing care to their patients over longeriods of time; they also engage in a specific range of careequired and a variety of other duties and expectations.hus, dual lines of authority can develop between the med-cal and the administrative system, resulting in conflict and

ultiple demands [47] for nurses. Govender [50] and Lam-ert et al. [24] mentioned that “workload” and “emotional

ssues related to death and dying” are major perceivedtressors in medical wards. Upon the implementation ofhe NHI system, the corresponding FFS payment systemontributed to higher healthcare coverage, more frequentatient visits, higher quality treatments (i.e., longer LOSnd new technology), and more effective rehabilitationervices [79]. To address the competition to attract moreatients, hospitals are pushed to acquire new technolo-ies and offer longer LOS, further increasing the numberf incoming patients. In relation to this, hospital nursesre required to attend to the growing number of patients,ignificantly increasing their workload and causing greaterersonal stress and intention to leave among them. More-ver, based on our review, inadequate staff employmentnd long working hours in medical wards were contribut-ng factors to high stress levels and intention to leave. As

result, due to increasing excessive workload and respon-ibilities, multiple demands and role conflicts between the

dministrative system and the patients, as well as nega-ive emotions related to death and dying, nurses workingn medical wards more frequently perceive work-relatedtress compared with ER or OR nurses who traditionally

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take care of patients within a shorter length of time andbenefit from various educational programs and psychoso-cial skills. Previous studies have also identified stress asan important predictor of depression [80,81]. Based onthe different effects of stress in medical units from ear-lier arguments, IMW and EMW nurses had greater levelsof depression than ER nurses. Accordingly, nurse policy-makers should aim to construct a more supportive workenvironment in internal and external medical wards, fea-turing reasonable work hours, sufficient number of nursesto share the workload and responsibilities and revision ofjob plans. Such an environment can effectively reduce jobstress and depression among nurses and encourage theirintention to continue in their profession. As mentionedabove, to attract patients under the FFS payment system,hospitals should offer better quality treatment and longerLOS. However, this has resulted in higher hospital expensesand heavier workload for the nurses. Therefore, hospitalmanagers must consider a shorter LOS to enhance cost-effective care and ensure a more improved nursing workenvironment.

7. Study limitations

There were some limitations to the present study. First,the study population was recruited from regional hospitalssystem in Northern Taiwan, which is considered as conve-nient sampling. Second, the sample sizes for the differentunits were not balanced; therefore, the results need to beconsidered with caution because they may lack general-izability. Although this was a relatively small-scale study,it highlighted pertinent issues in relation to severe nurs-ing shortage due to stress and reported depression. Futureresearchers are encouraged to enlarge the sample sizeto generalize our findings. Third, excepting for the mar-ital status, the result of the present study indicated thatdemographic characteristics (i.e., tenure, marital status,education, and age) were not mainly influential factorsin the level of stress, depression, and intention to leaveamong nurses in various medical units. Future researchersare encouraged to examine other potential moderating ormediating variables that may interfere with the results ofthis study. Moreover, although the significant differenceswere strongly evident among medical units with regardsto stress, depression, and intention to leave, unfortunately,the present study lacked the granularity to differentiatebetween depression and stress and possible confoundingfactors in various medical units. Future researchers areencouraged to take these forward subsequently. Finally,the present study was also a cross-sectional survey, andour findings were based on self-report screening instru-ments. Longitudinal studies should be carried out to gaina more detailed understanding of temporal factors, and forthe development of appropriate interventions for stressand depression reduction.

8. Conclusion

The most important finding of the present study refersto the different levels of reported stress, depression, andintention to leave among clinical nurses under the NHI

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156 Y.-M. Chiang, Y. Chang / H

system in Taiwan. Moreover, this study indicated thattenure and marital status are significant predictors ofstress, depression, and intention to leave. However, uponexamining the interaction effects, we find that both work-ing tenure and marital status are not the main influentialpredictors among the different medical units, except formarital status that still affects the perception of stress.With regards the differences in levels of stress, depres-sion and intention to leave among clinical nurses, IMW andEMW nurses are more stressed than those in ERs and dial-ysis centers. IMW nurses perceived more stress levels thanOR nurses. Both groups of IMW and EMW nurses scoredsignificantly higher depression levels compared with ERnurses, while IMW nurses also had higher depression lev-els than professional nursing practitioners. Finally, IMWnurses had a stronger intention to leave their job thanoutpatient services nurses. As a result, our findings notonly identified tenure and marital status as factors thatare significantly associated with stress, depression andnurses’ intention to leave, they also highlighted the factthat IMW and EMW nurses had the higher levels of stress,depression, and intention to leave. With these findings, weexpect to provide policymakers and nursing managers witha clearer direction on formulating policies that correctlyreflect proper nursing human resource management.

Contributions

YC and YMC contributed to study design and manuscriptpreparation; YC contributed to data collection; YMC con-tributed to data analysis.

Conflict of interest

The authors declare that they have no conflict of inter-ests.

Acknowledgements

Sincere appreciation is directed by the researchers tothe 314 nurses for their generous participation.

References

[1] American Organization of Nurse Executives. Acute care hospital sur-vey of RN vacancy and turnover rates in 2000. The HSM Group,Ltd.; 2002. Available at: http://www.wha.org/workforce/pdf/aone-surveyrnvacancy.pdf [accessed 6 April 2011].

[2] Department of Health. The statistical annual report of medical careinstitutions status & hospitals utilization 2009. Taipei: Departmentof Health, Executive Yuan, R.O.C. (Taiwan); 2009 [in Chinese].Available at: http://www.doh.gov.tw/CHT2006/DM/DM2 2.aspx?now fod list no=11689&class no=440&level no=4 [accessed 16April 2011].

[3] Department of Health. Statistics of general health. Taipei:Department of Health, Executive Yuan, R.O.C. (Taiwan); 2010.Available at: http://www.doh.gov.tw/EN2006/DM/DM2 p01.aspx?class no=390&now fod list no=12112&level no=3&doc no=83495[accessed 16 April 2011].

[4] International Council of Nurses. Safe staffing saves lives: infor-mation and action tool kit; 2006. Available at: http://www.

icn.ch/indkit2006.pdf [accessed 16 April 2011].

[5] Tsay SF, Wang HH. The making and development of policy concerningnurse practitioners in Taiwan. Hu Li Za Zhi 2007;54(6):5–10.

[6] Bluedorn AC. The theories of turnover: causes, effects, and meaning.Research in the Sociology of Organizations 1982;1:75–128.

[

licy 108 (2012) 149– 157

[7] Krausz M, Koslowsky M, Shalom N, Elyakim N. Predictors ofintentions to leave the ward, the hospital, and the nursing pro-fession: a longitudinal study. Journal of Organizational Behavior1995;16(3):277–88.

[8] Alexander JA, Lichtenstein R, Oh HJ, Ullman E. A causal model of vol-untary turnover among nursing personnel in long-term psychiatricsettings. Research in Nursing and Health 1998;21:415–27.

[9] Griffeth RW, Hom PW, Gaertner S. A meta-analysis of antecedentsand correlates of employee turnover: update, moderator tests, andresearch implications for the next millennium. Journal of Manage-ment 2000;26:463–88.

10] Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J, Buchan J, HughesF, Spence Laschinger HK, North N, Stone PW. Nurse turnover:a literature review. International Journal of Nursing Studies2006;43:237–63.

11] ROC Council for Economic Planning and Development. The reportof National Health Insurance Plan (the CEPD report). Taipei: Councilfor Economic Planning and Development, R.O.C. (Taiwan); 1990 [inChinese].

12] Department of Health. The National Health Insurance, annualstatistical report. Executive Yuan, Taipei: Department of Health,Executive Yuan, R.O.C. (Taiwan); 2011 [in Chinese]. Avail-able at: http://www.doh.gov.tw/CHT2006/DM/DM2 2.aspx?classno=440&level no=1 [accessed 6 April 2012].

13] Department of Health. The National Health Insurance, annual statis-tical report. Executive Yuan, Taipei: Department of Health, ExecutiveYuan, R.O.C. (Taiwan); 2005 [in Chinese].

14] Yin JC, Wu YH. The effect between nurse’s pay and performancebenefit. Report of Department of Health. Executive Yuan, Taipei:Department of Health, Executive Yuan, R.O.C. (Taiwan); 2007 [inChinese].

15] Cheng SH, Chiang TL. The effect of Universal Health Insurance onHealth Care Utilization in Taiwan: Results from a Natural Experiment.The Journal of the American Medical Association 1997;278(2):89–93.

16] Aiken LH, Clarke S, Sloane D, Sochalski J, Silber JH. Hospitalnurse staffing and patient mortality, nurse burnout, and job dis-satisfaction. The Journal of the American Medical Association2002;288(16):1987–93.

17] Clarke S, Aiken L. Failure to rescue: needless deaths are prime exam-ples of the need for more nurses at the bedside. American Journal ofNursing 2003;103(1):42–7.

18] Rivers PA, Tsai KL, Munchus G. The financial impacts of the nursingshortage. Journal of Health Care Finance 2005 Spring;31(3):52–64.

19] Chang EM, Hancock KM, Johnson A, Daly J, Jackson D. Role stress innurses: review of related factors and strategies for moving forward.Nursing and Health Sciences 2005;7(1):57–65.

20] Coomber B, Barriball KL. Impact of job satisfaction components onintent to leave and turnover for hospital-based nurses: a reviewof the research literature. International Journal of Nursing Studies2007;44:297–314.

21] Morrell K. Towards a typology of nursing turnover: the role ofshocks in nurses’ decision to leave. Journal of Advanced Nursing2005;49(3):315–22.

22] Baba VV, Galperin BL, Lituchy TR. Occupational mental health: a studyof work-related depression among nurses in the Caribbean. Interna-tional Journal of Nursing Studies 1999;36:163–9.

23] Lee JKL. Job stress, coping and health perceptions of Hong Kongprimary care nurses. International Journal of Nursing Practice2003;9:86–91.

24] Lambert V, Lambert C, Ito M. Workplace stressors, ways of copingand demographic characteristics as predictors of physical and mentalhealth of Japanese hospital nurses. International Journal of NursingStudies 2004;41(1):85–97.

25] Collins K, Jones ML, McDonnell A, Read S, Jones R, Cameron A. Do newroles contribute to job satisfaction and retention of staff in nursingand professions allied to medicine? Journal of Nursing Management2000;8(1):3–12.

26] Simon M, Kuemmerling A, Hasselhorn HM. Work–home conflict inthe European nursing profession. International Journal of Occupa-tional and Environmental Health 2004;10(4):384–91.

27] Zeytinoglu IU, Denton M, Davies S, Baumann A, Blythe J, Boos L.Retaining nurses in their employing hospitals and in the profession:effects of job preference, unpaid overtime, importance of earningsand stress. Health Policy 2006;79(1):57–72.

28] Callaghan P, Tak-Ying SA, Wyatt PA. Factors related to stress andcoping among Chinese in Hong Kong. Journal of Advanced Nursing

2000;31(6):1518–27.

29] Lu KY, Lin PL, Wu CM, Hsieh YL, Chang YY. The relationship amongturnover intentions, professional commitment, and job satisfactionof hospital nurses. Journal of Professional Nursing 2002;18(4):214–9.

ealth Po

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

coping behaviour and social support. Journal of Clinical Nursing

Y.-M. Chiang, Y. Chang / H

30] Kuokkanen L, Leino-Kilpi H, Katajisto J. Nurse empowerment, job-related satisfaction, and organizational commitment. Journal ofNursing Care Quality 2003;18(3):184–92.

31] Larrabee JH, Janney MA, Ostrow CL, Withrow ML, Hobbs Jr GR, BurantC. Predicting registered nurse job satisfaction and intent to leave.Journal of Nursing Administration 2003;33(5):271–83.

32] Lu H, While AE, Barriball KL. Job satisfaction among nurses:a literature review. International Journal of Nursing Studies2005;42:211–27.

33] Manojlovich M. Linking the practice environment to nurses’ job satis-faction through nurse–physician communication. Journal of NursingScholarship 2005;37(4):367–73.

34] Ma JC, Lee PH, Yang YC, Chang WY. Predicting factors relatedto nurses’ intention to leave, job satisfaction, and perceptionof quality of care in acute care hospitals. Nursing Economics2009;27(3):178–202.

35] Tai TW, Robinson CD. Reducing staff turnover: a case study of dialysisfacilities. Health Care Management Review 1998;23:21–42.

36] Chang CS, Du PL, Huang IC. Nurses’ perception of severe acute respi-ratory syndrome: relationship between commitment and intentionto leave nursing. Journal of Advanced Nursing 2006;54(2):171–9.

37] Lina L, Aukse E, Loreta G. Individual correlates of organizational com-mitment and intention to leave the organization. Baltic Journal ofManagement 2007;2(2):196–212.

38] Stone PW, Mooney-Kane C, Larson EL, Pastor DK, Zwanziger J, DickAW. Nurses working conditions, organizational climate, and intentto leave in ICUs: an instrumental variables approach. Health ServicesResearch 2007;42(3):1085–104.

39] Barron D, West E. Leaving nursing: an event-history analysisof nurses’ career. Journal of Health Services Research & Policy2005;10(3):150–7.

40] Flinkman M, Laine M, Leino-Kilpi H, Hasselhorn HM, Salanterä S.Explaining young registered Finnish nurses’ intention to leave theprofession: a questionnaire survey. International Journal of NursingStudies 2008;45:727–39.

41] Lazarus RS, Folkman S. Stress, appraisal and coping. New York:Springer; 1984.

42] Lim J, Bogossian F, Ahern K. Stress and coping in Australian nurses: asystematic review. International Nursing Review 2010;57:22–31.

43] Bohannan-Reed K, Dugan D, Huck B. Staying human under stress.Stress reduction and emotional support in the critical care setting.Critical Care Nurse 1983;3:26–30.

44] Vincent P, Coleman WF. Comparison of major stresses perceived byICU and non-ICU nurses. Critical Care Nurse 1986;6:64–9.

45] Anderson M, Chmboga D, Bailey J. Changes in management stressorsin ICU nurses. Dimensions of Critical Care Nursing 1988;7:111–7.

46] Kelly J, Cross D. Stress, coping behaviors, and recommendations forintensive care and medical-surgical ward registered nurses. Researchin Nursing and Health 1985;8:321–8.

47] Dewe PJ. Examination the nature of work stress: individualevaluation of stressful experiences and coping. Human Relation1989;42:993–1013.

48] Gray-Toft P, Anderson JG. Stress among hospital nursing staff: itscauses and effects. Social Science Medicine 1981;159:639–47.

49] Cole FL, Slocumb EM, Mastey JM. A measure of critical care nurses’post-code stress. Journal of Advanced Nursing 2001;34(3):281–8.

50] Govender K. An investigation of the role of perceived sources ofstress, perception of work environment, type of hospital ward andnurse rank in occupational distress, coping and burnout among prac-ticing nurses. Durban: Unpublished MA Dissertation, University ofNatal; 1995.

51] Healy CM, McKay MF. Nursing stress: the effects of coping strate-gies and job satisfaction in a sample of Australian nurses. Journal ofAdvanced Nursing 2000;31(3):681–8.

52] Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggressionin nursing: findings from an Australian study. Journal of AdvancedNursing 2006;55(6):778–87.

53] Lo R. A longitudinal study of perceived level of stress, coping andself-esteem of undergraduate nursing students: an Australian casestudy. Journal of Advanced Nursing 2002;39(2):119–26.

54] Bartram T, Joiner TA, Stanton P. Factors affecting the job stress andjob satisfaction of Australian nurses: implications for recruitmentand retention. Contemporary Nurse 2004;17(3):293–304.

55] Latack JC, Havlovic AJ. Coping with job stress: a conceptual evaluation

framework for coping measures. Journal of Organizational Behavior1992;13:479–508.

56] Welch JL, Austin JK. Stressors, coping and depression in haemodial-ysis patients. Journal of Advanced Nursing 2001;33(2):200–7.

[

licy 108 (2012) 149– 157 157

57] Chiriboga DA, Bailey J. Stress and burnout among critical care andmedical surgical nurses: a comparative study. Critical Care Quarterly1986;9(3):84–92.

58] Keller KL. The management of stress and prevention of burnout inemergency nurses. Journal of Emergency Nursing 1990;16(2):90–5.

59] Rowe MM, Sherlock H. Stress and verbal abuse in nursing: doburned out nurses eat their young. Journal of Nursing Management2005;13:242–8.

60] Wu S, Zhu W, Wang Z, Wang M, Lan Y. Relationship between burnoutand occupational stress among nurses in China. Journal of AdvancedNursing 2007;59(3):233–9.

61] Hsu HY, Chen SH, Yu HY, Lou JH. Job stress, achievement motivationand occupational burnout among male nurses. Journal of AdvancedNursing 2010;66(7):1592–601.

62] Hsiao YC, Chien LY, Wu LY, Chiang CM, Huang SY. Spiritual health,clinical practice stress, depressive tendency and health-promotingbehaviours among nursing students. Journal of Advanced Nursing2010;66(7):1612–22.

63] Chang Y, Wang PC, Li H-H, Liu YC. Relations among depression, self-efficacy, and optimism in a sample of nurses in Taiwan. Journal ofNursing Management 2011;19:769–76.

64] Gelsema TI, van der Doef M, Maes S, Akerboom S, Verhoeven C. Jobstress in the nursing profession: the influence of organizational andenvironmental conditions and job characteristics. International Jour-nal of Stress Management 2005;12:222–40.

65] Huang CY, Sousa VD, Tu SY, Hwang MY. Depressive symptomsand learned resourcefulness among Taiwanese female adolescents.Archives of Psychiatric Nursing 2005;19(3):133–40.

66] Lin LC, Wang TG, Chen MY, Wu SC, Portwood MJ. Depressive symp-toms in long-term care residents in Taiwan. Journal of AdvancedNursing 2005;51(1):30–7.

67] Fu CM, Parahoo K. Causes of depression: perceptions amongpeople recovering from depression. Journal of Advanced Nursing2009;65(1):101–9.

68] Radloff LS. The CES-D Scale: a self-report depression scale forresearch in the general population. Applied Psychological Measure-ment 1977;1:385–401.

69] Ross CE, Mirowsky J, Huber J. Dividing work, sharing work, and in-between: marriage patterns and depression. American SociologicalReview 1983;48:809–23.

70] Cohen S, Kamarck T, Mermelstein R. A global measure of perceivedstress. Journal of Health and Social Behavior 1983;24:385–96.

71] Cohen S, Williamson GM. Perceived stress in a probability sampleof the United States. In: Oskamp S, editor. The social psychologyof health: the Claremont symposium on applied social psychology.Newbury Park, CA, USA: Sage Publications; 1988. pp. 31-67.

72] Lin KJ, Kao CC, Cheng WK. The relationship between nursinghuman capital and turnover rate. Soochow Journal of Accounting2009;1(2):93–127 [in Chinese].

73] Thomas LT, Ganster DC. Impact of family-supportive work variableson work–family conflict and strain: a control perspective. Journal ofApplied Psychology 1995;80:6–15.

74] Yildirim D, Aycan Z. Nurses’ work demands and work–family con-flict: a questionnaire survey. International Journal of Nursing Studies2008;45:1366–78.

75] Liu HC, Hwang YF, Jong SY, Chang YJ. Project to improving the nursesworking overtime. Tzu Chi Nursing Journal 2011;10:74–82 [in Chi-nese].

76] Grunfeld A, Zitzelsberger L, Coristine M, Whelan TJ, Aspelund F, EvansWK. Job stress and job satisfaction of cancer care workers. Psycho-Oncology 2004;14:61–9.

77] Wu TY, Fox DP, Stokes C, Adam C. Work-related stress and inten-tion to quit in newly graduated nurses. Nurse Education Today2012;32(6):669–74.

78] Bakken S, Cook SS, Curtis L, Desjardins K, Hyun S, Jenkins M, John R,Klein WT, Paguntalan J, Roberts WD, Soupios M. Promoting patientsafety through informatics-based nursing education. InternationalJournal of Medical Informatics 2004;73(7–8):581–9.

79] Hung JH, Chang L. Has cost containment after the National HealthInsurance System been successful: determinants of Taiwan hospitalcosts? Health Policy 2008;85(3):321–35.

80] Lin HS, Probst JC, Hsu YC. Depression among female psychiatricnurses in southern Taiwan: main and moderating effects of job stress,

2010;19(15–16):2342–54.81] Dixon WA, Reid JK. Positive life events as a moderator of

stress-related depressive symptoms. Journal of Counseling andDevelopment 2000;78:343–7.