J Med Syst (2007) 31:283287

DOI 10.1007/s10916-007-9066-z

Effects of Physical Environment on the Stress Levels

of Hemodialysis Nurses in Ankara Turkey
Sultan Uur & Ahmet M. Acuner & Bayram Gkta &
Birdal enolu

Received: 7 March 2007 / Accepted: 26 March 2007 / Published online: 8 June 2007
# Springer Science + Business Media, LLC 2007

Abstract This study has been planned and executed as a

field study for identifying the effect of physical environment on the stress levels of hemodialysis nurses who work
in the official and private hemodialysis centers in the capital
city of Turkey, Ankara (n=161). According to the results
obtained from the study, it has been seen that education
level and institution of employment of the hemodialysis
nurses are significantly related with the stress levels of the
hemodialysis nurses. Nurses age, marital status, number of
children, occupational seniority, years of working, employment status, husbands occupation and husbands educational levels are not significantly related with their stress
levels.
Keywords Stress . Hemodialysis nurses .
Physical environment

Introduction
Stress is defined as the bodys non-specific response to any
demand placed upon it [1]. It can cause exhaustion and
illness, either physical or psychological. This obviously has
S. Uur : A. M. Acuner
Department of Health Administration, Faculty of Health Sciences,
Ankara University, Ankara, Turkey
B. Gkta (*)
Cebeci School of Health, Ankara University, Plevne Caddesi,
No:5, 06340 Altndag, Ankara, Turkey
e-mail: bgoktas@ankara.edu.tr
B. enolu
Faculty of Science, Department of Statistics, Ankara University,
Ankara, Turkey

an effect on the working performance of the workers who

work in different branches of the service sector. In this
study, we focus on the effect of the stress on the
productivity and working performance of the nurses.
For the nurses physical and mental health, stress is very
important. Working in the profession of nursing is a
demanding and one of the most stressful occupation,
because there are various stressors results from their social
and physical environment. Stress causes less work satisfaction [2] and therefore an important negative impact on the
quality of nursing [3]. Therefore, identifying the relationship between the stress levels of the hemodialysis nurses
and the demographic characteristics of them is important so
that we can acknowledge it and prevent it from becoming
overwhelming. This provides health administrators to
develop strategies for eliminating the causes of stress
factors and to increase professional productivity of the
nurses.
The quality of the hemodialysis care depends on the
quality of the several factors, such as physicians, nurses,
technological equipments and physical factors. If we want
to improve the quality of the hemodialysis care, we should
improve the quality of these factors. However, in this study,
as mentioned above, we focus on the quality of nursing.
The quality of nurses life and therefore the quality of the
hemodialysis care can be improved by identifying and
eliminating the stressors for this occupation. Nurses who
are satisfied with their job may be more likely to engage in
desirable patient care, see [4] and [5]. They become more
relax and express empathy to their patients and this will
automatically improve the quality of the hemodialysis care.
There are various studies about the nursing stress. For
example, Rees [6] examined work-related stress in health
services employees. McNeely [7] identified various sources

284

of stress and coping strategies. Healy and McKay [8]

investigated the effects of coping strategies and job
satisfaction in a sample of Australian nurses. Bennett et
al. [9] examined the impact of a number of work stressors,
the coping strategies employed by nurses to cope with
them, and the managerial support available to them.
Stordeur et al. [10] examined the effect of work stressors
among hospital nursing staff. Harris [11] identified situations where stress at work can cause ill health and to
outline measures to address the causes and alleviate the
effect of prolonged occupational stress. Cottrell [12]
investigated occupational stress and job satisfaction in
mental health nursing. McVicar [13] investigated the
workplace stress in nursing. Xianyu and Lambert [14]
investigated the relationships among workplace stressors,
ways of coping, and the mental health of Chinese head
nurses.
In this study, we investigate the relationship between the
stress groups results from the physical environment and the
demographic characteristics of the hemodialysis nurses, e.g.,
age, marital status, number of children, educational level,
institution of employed, years of occupational seniority,
years of working in hemodialysis center, employment
status, husbands occupation, husbands education level,
see [15].

Materials and methods

A survey was conducted from April 1, 2003 to April 30,
2003 in the 18 hemodialysis units in the city centre of
Ankara, Turkey. From the 210 registered hemodialysis
nurses, 161 hemodialysis nurses responded. Of the nonresponding hemodialysis nurses 45 were ineligible because
two hospital administrations did not give permission for
applying questionnaire in their hospitals. Therefore, the
response rate in the study was 76.7%.
A 53 items questionnaire was given to each hemodialysis
nurses participating in the study. Those participated were
informed about the purpose of the study and they were
assured that their responses to questionnaire are confidential.
Respondents were asked to record on a five-point Likert
scale ranging from never to everytime. Here, 15
represents the severity of the stress, i.e. 1=none, 5=very
severe. The questionnaire included two sections. First, there
were ten items designed to provide a general information.
Rest of the items were designed to have an idea about
stressors results from social and physical environment.
However, in this study, we only concentrated stressors due
to physical environment. Therefore, only the questions
related with physical environment were used in the statistical
analysis. In this study, we have only five questions related

J Med Syst (2007) 31:283287

with the stressors results from physical environment. They

were about the noise pollution (for both inside and outside
the working place), smoking, unpleasant smells, physical
environment-pollution (such as, wastes).
This questionnaire was used in several studies in the
literature, see, for example, [16] and [17]. The reliability of
the questionnaire was found to be sufficient, because
Cronbachs (alpha) value was 0.8428.
In the statistical analysis, we sum up the scores for each
respondents. If the score of the respondent is between;
57 then she is put into the first group,
812 then she is put into the second group,
1317 then she is put into the third group,
1825 then she is put into the fourth group,
see [16]. Here, high scores represents high-stress level and
low scores represents low-stress level. In the Chi-square
analyses, we found that the number of observations in most
of the cells were less than five, therefore we decided to
combine the first, second and third groups. Fourth group
and the combined group were named as an high-stress
group and low-stress group, respectively. It should be
noted that the total of the scores changes between 5 and 25.
Because there are five questions and respondents are giving
scores to each question between 1 and 5.
Responses, the total scores for each nurses, were
examined using descriptive statistics (mean, standard deviation, frequency and percentage) for each demographic
characteristics. The Chi-square analysis was used to examine
the relationship between the stress groups (low, high) and
the demographic characteristics of the nurses.
All the statistical analyses were performed by using
SPSS 12.0.

Results
The means (x) and the standard deviations (s) for the
demographic characteristics of the hemodialysis nurses are
given in Table 1. Two third (73.9%) were aged under 30
and 47.2% were single and the 47.2% were married.
Around one third (32.9%) of the hemodialysis nurses have
no children. Majority of the hemodialysis nurses were high
school graduate. Only 1.9% of them have Master or Ph. D.
degree. 51.6% of the hemodialysis nurses were working in
the private sector and around half of them were working as
a nurse for 5 years or less. Years of working in
hemodialysis centers is generally less than 5 years
(68.9%). Most of the hemodialysis nurses husband
occupation is different and their husbands education level
is less or equal to secondary school. Only 3.7% of their
husbands have Master or Ph. D. degree.

J Med Syst (2007) 31:283287

Table 1 Demographic characteristics of the hemodialysis
nurses

For married, widowed and

divorced nurses.
b
Only for married nurses.

285

Characteristic
Age
24
2530
31
Marital status
Single
Married
Widowed
Divorced
Number of childrena
None
1
2
Education level
High school
Associates degree
School of nursing
Other
Institution of employment
Private
Ministry of Health
Institution of Social Insurance
University
Other
Years of occupational seniority
05
610
11
Years of working in hemodialysis center
05
610
11
Employment status
Head nurse
Nurse
Husbands occupationb
Same occupation
Different occupation
None
Husbands education levelb
Primary school
Secondary school
Associates degree
University
Graduate and other

It is clear from the x values summarized in Table 1 that

the hemodialysis nurses are in the high-stress group if they
&
&
&
&
&

have one child,

graduated from the high school,
employed by Institution of Social Insurance,
have occupational seniority between 610,
have husband who has a M.S. or Ph. D. Degree

and the others are in the low-stress group.

Percent

x (s)

63
56
42

39.1
34.8
26.1

17.52 (4.48)
17.82 (3.76)
17.14 (3.35)

76
76
1
8

47.2
47.2
0.6
5.0

17.78
17.18
25.00
17.50

28
34
23

32.9
40.0
27.1

16.46 (4.53)
18.03 (3.66)
17.26 (3.52)

81
59
18
3

50.3
36.6
11.2
1.9

18.36
17.00
15.83
15.67

(4.41)
(3.14)
(3.24)
(5.13)

83
20
19
24
15

51.6
12.4
11.8
14.9
9.3

17.49
16.35
20.37
16.54
17.27

(4.11)
(3.86)
(2.52)
(3.19)
(4.40)

75
46
40

46.6
28.6
24.8

17.41 (4.51)
18.00 (3.39)
17.20 (3.42)

111
32
18

68.9
19.9
11.2

17.46 (4.12)
17.78 (3.67)
17.50 (3.45)

20
141

12.4
87.6

17.45 (4.35)
17.54 (3.90)

8
67
2

5.0
41.6
1.2

17.14 (5.34)
17.27 (3.86)
14.50 (0.71)

4
36
12
18
6

2.5
22.4
7.5
11.2
3.7

17.25
17.03
16.75
17.06
19.33

(3.96)
(3.95)
()
(3.30)

(4.03)
(4.46)
(3.55)
(3.19)
(4.03)

It should be noted that there was only one widowed

nurse, therefore the standard deviation belongs to it
represented by ().
We used Pearsons Chi-square test for testing whether
there exists a relationship between the stress groups (low,
high) and demographic characteristics of the hemodialysis
nurses. In each of the hypothesis testing procedures
significance level of the test was taken to be =0.050. In
some of the testing procedures, the number of the

286

J Med Syst (2007) 31:283287

Table 2 Results of the Chi-square analysis

2

50.8
41.1
59.5

03.319

0.190

37
43

48.7
50.6

00.058

0.809

50.0
52.9
43.5

14
16
13

50.0
47.1
56.5

00.497

0.780

50
24
07

61.7
40.7
33.3

31
35
14

38.3
59.3
66.7

08.835

0.012

40
06
25
09

48.2
30.0
73.5
37.5

43
14
09
15

51.8
70.0
26.5
62.5

12.332

0.006

38
26
17

50.7
56.5
42.5

37
20
23

49.3
43.5
57.5

01.690

0.430

55
19
07

49.5
59.4
38.9

56
13
11

50.5
40.6
61.1

02.017

0.365

10
71

50.0
50.4

10
70

50.0
49.6

00.001

0.976

06
32

75.0
46.4

02
37

25.0
53.6

02.350

0.154

20
05
13

50.0
41.7
54.2

20
07
11

50.0
58.3
45.8

00.500

0.779

observations in each cell were not greater or equal to five,

therefore we combined some of the groups to obtain at least
five observations in each cell as mentioned above. Only in
one situation, the number of observations was still less than
five, therefore, in that case, we used Fishers exact test. The
results of the Chi-square analysis reveal that the relationship between the stress groups and the education level is
statistically significant. Similar statement is also true for the
demographic characteristic institution of employment.
The results are shown in Table 2.

Discussions

Characteristics

Age
24
2530
31
Marital status
Single
Married+widowed+divorced
Number of childrena
None
1
2
Education level
High school
Associates degree
School of nursing+other
Institution of employment
Private
Ministry of Health
Institution of Social Insurance+other
University
Years of occupational seniority
05
610
11
Years of working in hemodialysis center
05
610
11
Employment status
Head nurse
Nurse
Husbands occupationb
Same occupation
Different occupation+none
Husbands education levelb
Primary school+secondary school
Associates degree
University+graduate and other
a
b

High-stress group

Low-stress group

Percent

Percent

31
33
17

49.2
58.9
40.5

32
23
25

39
42

51.3
49.4

14
18
10

For married, widowed and divorced nurses.

Only for married nurses.

According to the results of the statistical analysis, we can

easily see that when the educational levels of the
hemodialysis nurses decreases their stress levels increases.
Sarp et. al. [18] studied the organizational stress factors of
the staff working in Ankara Hospital and their results are in
agreement with the results of this study. The institution of
employment is found to be another important source of the
stress for the hemodialysis nurses. The nurses working in

J Med Syst (2007) 31:283287

Institution of Social Insurance have much higher stress

levels than the others. The number of children, husbands education level and their years of occupational
seniority have an significant effect on the stress levels of
the hemodialysis nurses. This study shows that nurses
having only one child are in the high-stress group. If the
nurses husbands education level are in the highest group
(Master or Ph. D.), their stress levels are also high. Similar
statements are also true for the years of occupational
seniority. Nurses having a 610 years of occupational
seniority are in the high-stress group.
Nurses occupational stress decreases job satisfaction and
reduces nursing quality. This information is useful for the
hospital administrators to improve the working conditions of
hospitals and to improve the quality of the nurses life.
Improving the quality of the nurses life will automatically
increase the quality of the hemodialysis care. The effect of
social environment on the stress level of the hemodialysis
nurses in Ankara will be investigated in our future study.
Acknowledgement
comments.

We are grateful to referees for very helpful

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