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School of Nursing
August 2007.
ABSTRACT
Introduction
The purpose of this study project was to determine the factors contributing to stress in
nurses within the first three years of work as a registered nurse in the speciality units and
general wards in Brunei Darussalam hospitals. It is expected that the findings of this
study would become the point of reference for nurses and Ministry of Health to identify
support strategies and resources that could be used to prepare nurses to cope with stresses
while working in todays complex clinical environment. Thus the findings are intended to
inform nurse educators, nurse managers and nurse administrators in Brunei Darussalam
regarding the levels and types of stressors among new graduate nurses in different areas.
Many studies have recognized that nursing is, by its nature, a stressful occupation
Some stressors for nurses consistently identified in the literature include work overload,
unpredictability of staffing levels, caring for dying patients, lack of time to give patients
emotional support, tiredness and conflict with doctors and supervisors. Others stressors
may also be associated with safety issues, lack of support and problems which occur
i
Method
This study used a descriptive correlational study design to examine new nurses within the
first three years of work as a registered nurses perception of stress and level of job
satisfaction in todays complex clinical nursing working environment. Data was collected
Expanded Nursing Stress Scale (French, Lenton, Walters and Eyles, 1995) and the two
part measurement tool of Index of Work Satisfaction Survey (Stamps, 2001). This
questionnaire was distributed to 120 new registered nurses working in Raja Isteri
Pengiran Anak Saleha Hospital (R.I.P.A.S.), the main referral hospital in Brunei
Darussalam. The sample consisted of both male and female registered nurses (RN) who
Results
Responses to the Expanded Nursing Stress Scale (ENSS) identified that the new
registered nurses rated their Uncertainty Concerning Treatment as highly stressful events
that frequently occurred in the workplace. The study findings also revealed that the level
of stress and the common stressors in new registered nurses within the first three years of
work as a registered nurses were similar irrespective of whether they were working in the
speciality units or in general wards. Results for Index Work Satisfaction Survey (IWSS)
Part A and B also suggested that there was no significant difference on the levels of job
satisfaction in both groups of new registered nurses, with the majority of nurse choosing
ii
Conclusion
Results of this study are likely to have important implications for nursing education,
strategies that might help in reducing the amount of stress experienced by the new
registered nurses in day to day challenging and demanding nursing roles. The study also
has the potential to have wider benefits to nursing practice not just at Brunei Darussalam.
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TABLES OF CONTENTS
Page
ABSTRACTS i
TABLE OF CONTENTS. iv
ACKNOWLEDGMENT. xi
INTRODUCTION. 1
BACKGROUND 1
Objectives. 8
Research Questions . 9
Hypotheses .. 9
Summary . 10
INTRODUCTION . 11
It Is Stress?........................................................................................ 11
iv
Work Related Stress and its Effects on Health.. 14
INTRODUCTION......... 24
Stress In Nursing 25
Role Conflict.. 30
Nurse.... 43
Summary.. 51
RESEARCH METHOD. 52
Research Design 52
v
Setting 52
Sample 55
Ethical Consideration. 57
Research Instrument... 59
Demographic Questions. 59
Pilot Study. 65
Introduction 68
Sample Characteristics.. 68
A) .......................... 97
vi
Index of Work Satisfaction: Rating of Satisfaction (Part B).. 101
Implications.................... 134
Conclusion . 139
References .. 141
Appendices .
vii
LIST OF TABLES Page
Figure 1 Conceptual model of Stress amongst new Registered Nurses. 23
Table 8 Ratings of Stress Associated with Dealing with Patients and their
Families 76
viii
Table 18 Relationship between Stress and Ratings of Confidence,
Competence and Organisation 96
Table 27 Component Score and the Component Mean Score for IWS Scales 114
Tables Appendix 10
37 - 60
ix
STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet requirement
for an award at this or any other higher education institution. To the best of my
knowledge and belief, the thesis contains no material previously published or written by
x
ACKNOWLEDGMENT
The undertaking of this thesis was not a solitary effort. I appreciate my supervisor,
colleagues, family and friends who helped me in so many ways; without them this thesis
would not have been completed. I wish to gratefully acknowledge the support and
Firstly, I express my deep and sincere thanks to my supervisor Professor Patsy Yates who
encouraged me through the Masters journey. Her continued guidance, support and
critical comments were a source of great encouragement. Thank you so much for being
instrumental in making this happens I benefited from your vision all along.
I would like to express particular thanks to my spouse, children and mother for their
patience and forbearance during recent months whilst I have been working so hard to
complete my study. It has been a mammoth task and I am very much aware that I have
neglected them in many different ways. I would also like to thank all those who have
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Government of His Majesty Sultan Haji Hassanal Bolkiah Mu'izzaddin Waddaulah, the
Sultan and Yang Di-Pertuan of Brunei Darussalam for the financial support and to all
academic, administrative and support staff from the Research Department, School of
Special thanks to other contributors, Peter Fell, Dr Diana Batistutta, Boni Macfarlane and
to all of my local and international PhD students/colleagues who have willingly shared
their knowledge and experiences during my study. I have had valuable assistance from
Ms Sheree Smith who worked so hard since she became my principal research supervisor
in April 2005 to August 2006. She spent a lot of time and energy which contributed to the
success of this study and she has kept me well informed of my progress.
I would as well like to thank the participants in the study and the nursing managers,
without their commitment this study would not have been possible. It was a great
pleasure and opportunity to work with them. Thank you to all of you.
My thanks also go to Hajah Thaibah binti PDPD DP Haji Abd Rahim- Principal College
of Nursing Brunei Darussalam, Haji Julaini bin Haji Latip-Deputy Principal College of
Nursing Brunei Darussalam, Haji Daud bin Haji Mahmud-Deputy Permanent Secretary-
Ministry of Education Brunei Darussalam, Pengiran Hajah Azizah binti Pengiran Haji
Tajuddin-Former Director of Nursing Services Brunei Darussalam, Dr. Haji Abdul Hamit
bin Haji Musa-Acting Director of Nursing Services Brunei Darussalam and Dr Awang
Haji Affendy bin Pehin Orang Kaya Saiful Mulok Dato Seri Paduka Haji Abidin-
xii
Director General Medical Services Brunei Darussalam for their support and permission
for this study to be conducted in RIPAS Hospital Ministry of Health Brunei Darussalam.
I would also like to acknowledge and thank Susan E. French, Rhonda Lenton, Vivienne
Walters and John Eyles from the School of Nursing McMaster University, Canada the
original authors of the Expanded Nursing Stress Scale (ENSS) and Professor Paula L.
Stamps and Market Street Research, Inc from University of Massachusetts, United State
of America the original owner of the Index of Work Satisfaction (IWS), for their
assistance and their permission to use the self-administered questionnaires as the data
Finally, this thesis is dedicated to my late father Awang Haji Damit Piut who departed
this life on the 11th March 2007 and my late Aunt Hajah Maimunah Piut who passed
away on the 21st of August 2006, whilst I was completing the final stages of my thesis. I
have had a considerable loss of key persons who can never be replaced, and who have
supported my study, living and took care of my children and family whilst I have been in
xiii
CHAPTER ONE
1.0. INTRODUCTION
1.1. BACKGROUND.
Nursing is, by its nature, a stressful occupation because of exposure to a wide range of
potentially stressful situations and conditions. Stressors for nurses consistently identified
in the literature include work overload, pressures associated with demands of the
staffing and scheduling, having to complete too many non-nursing tasks, and having to
make decisions under pressure (Fox, 2003; McVicar, 2003). In addition, watching a
patient suffer and feeling helpless in the case of a patient who fails to improve or who
may be dying may cause distress amongst nurses. Lack of time to give patients emotional
support, tiredness, criticism by doctors and conflicts with immediate supervisors (Huang,
2004; Healy and McKay, 1999; Tyler and Cushway, 1995:1992) can also create difficult
situations for nurses. Other factors which have been identified in the literature as
contributing to stress include concern about being isolated and discriminated against
because of race and ethnicity, or being sexually harassed by other nursing colleagues or
other healthcare professionals (Huang, 2004; Uzun, 2003; Sylvia 1996; Guppy and
Gutteridge, 1991).
While there are a considerable number of stressors associated with nursing work, stress is
1995). New nurses in particular are likely to face some unique stressors that make the
period of transition to the role of registered nurses (RN) an especially difficult time
(McVicar, 2003; Casey, Fink, Krugman and Propst, 2004). In addition to these stressors
1
associated with nursing work, new nurses may face additional stressors associated with
job loss and/or relocation (Moore, Kuhrik, Kuhrik, and Barry, 1996), fear of failure while
while performing procedures that patients experience as painful, and feeling inadequately
prepared to help meet the emotional needs of patients and the patients family (Gillespie
and Kermode, 2004; Healy and McKay, 1999). Stress has also been identified with
concerns about job security and stability, work dynamics, safety and self esteem issues
(World Health Organisation, 2004; Rainham, 1994). Poor work organisation, including
poor work design and work systems can also cause work stress (World Health
Organisation, 2004). Other stressors external to the workplace may exist, including
conflicts between home and work especially for those who have young children to care
Beginning level nurses may lack familiarity with the hospital and have limited experience
in dealing with the new complex working environment, medical emergencies, and the
operation and functioning of specialised equipment (Arnedo, Uranga, and Marin, 2005;
Jackson, 2005; Higgins, 2003; Tyler and Cushway, 1995:1992). Being in charge of
clinical situations with inadequate experience and not knowing what a patient or a
patients family ought to be told about the patients condition and its treatment may also
present stressors. Work which does not fulfil their needs and work tasks/responsibilities
over which new graduate nurses have little control or which are ambiguous are also found
occupational stress (Stordeur, Dhoore and Vandenberghe, 2001; Sylvia, 1995; Cox and
Griffiths, 1994).
2
According to the World Health Organisation, work related stress occurs in a wide range
of work circumstances. A healthy work environment is one in which the presence and
impact of such stressors are minimised, by ensuring the absence of harmful conditions
writers argue that health at work and healthy work environments are among the most
be an important moral imperative, not only to ensure the health of workers, but also to
contribute to positive productivity, quality of work, work motivation, job satisfaction and
to overall quality of life of individuals and society (World Health Organisation, 1995).
Importantly, evidence suggests that unhealthy work environments are one important
factor contributing to the worldwide nursing shortage (World Health Organisation, 2004).
Identifying strategies for improving the health and well-being of health workers is thus
crucial at this time. In response to these concerns, the International Council of Nurses in
2007 outlined the characteristics of positive practice environments for nurses. These
characteristics include:
Recognition programmes
3
Other key reports relating to the well-being of health workers similarly argue that the
more control workers have over their work and the way they do it, and the more they
participate in decision making in their job , the less likely they are to experience work
Such international policy documents highlight the importance of understanding the work
place factors that may contribute to adverse work environments, and developing local
approaches in accordance with countries priorities to ensure workers health and well-
To date, no research has been conducted to investigate level of stress and work
environments for nurses, and the implications of such stress for nursing services in
Brunei Darussalam. The purpose of this study is thus to examine stressors and work
satisfaction for nurses working in different practice environments within the first three
years of work as a registered nurse in Brunei Darussalam. This study is significant for a
number of reasons. Firstly, nurses comprise the largest group of health personnel
providing support services in primary, secondary and tertiary health care in Brunei
Darussalam. Moreover, with better education and improved living standards, the health
demands of the public have required sophisticated reforms and changes and
improvements to the quality nursing services (Ministry of Health, 2005). Such demands
are likely to cause new registered nurses in Brunei Darussalam to experience even more
4
challenging situations as they are required to cope with constant time pressures and the
need to maintain their competence in a rapidly changing field. For example, the impacts
medical technology advances in nursing have seen an increased pressure for new
registered nurses (Barnard and Gerber, 1999). As a result of this rapidly changing
workplace, new registered nurses may also frequently encounter new ethical dilemmas,
and face an increasing number of situations over which they have limited control
(Rainham, 1994).
Work related stress can result in workers being less productive, may impact on the
quality of services provided by health professionals, and may also place these nurses at
more risk of making errors (International Labour Organisation, 2005). Becky (1994)
distrust. The failure to identify these problems amongst nurses at an early stage is thus
likely to have a major impact on the effectiveness of nursing services and patient care.
musculoskeletal problems (Higgins, 2003; Cox, Griffiths and Cox, 1996; Santamaria,
1995). Murphy (2004) argues that if nurses feel stressed at work, their practice will
suffer, ultimately affecting the care of the patients. Cartwright and Cooper (1994)
suggest that there is a strong need for a proactive management approach that recognizes
5
1.3. PURPOSE OF THE STUDY
Stress in nursing has been well documented in the literature for many years yet it remains
nursing stress (Santamaria, 1994). There is also very limited research on such issues
outside of western countries. This lack of evidence regarding the experiences of nurses in
the first few years of work as a registered nurse presents many challenges, especially for
those who need to prepare future nurses to practice in the contemporary healthcare
Issues of work related stress and stressors are frequently discussed informally amongst
nurses at all levels in Brunei Darussalam hospitals. However, stress in the nursing
environment especially among registered nurses in Brunei Darussalam hospitals has not
yet been investigated. The primary aim of this study is to determine the sources and level
of stress and levels of work satisfaction among new registered nurses within the first
In addition, a secondary aim of this study is to compare the stressors and work
satisfaction experienced by nurses working in general and acute speciality care unit
responsible for ensuring that acutely and critically ill patients (highly vulnerable, unstable
and complex) and their families receive optimal care (American Association of Colleges
of Nursing, 2006). Speciality care units are surrounded by high tech medical machinery,
6
with many patients requiring specialised devices and equipment (Villaneuva, 1999),
thereby requiring intense and vigilant nursing care. Cooper and Scott (2003) suggest that
specialty care unit nurses skills and expertise are different to those of general wards
nurses, as their roles expand to include use of advanced and complex medical
technologies, and more specialised knowledge and skills (Aliso-Viejo, 2002). Due to the
nature of these different environments, this study sought to identify and compare
common stressors, sources and level of stress in these different settings for registered
In Brunei Darussalam, an 18 month transition program has been developed for new
registered nurses. There is, however, no data available to examine its relevance to the
needs of new graduates today, and ways to improve the program. As such, it is expected
that the findings of this study will become a point of reference for nurses and the Ministry
of Health to understand the levels, types and effect of stress on new nurses within the first
three years of work as a registered nurse, and to identify appropriate support strategies
and resources that could be used to prepare future nurses to cope with these stressors.
Thus the findings from this study will inform nurse educators, nurse managers and
hospital administrators regarding the levels and types of stressors in registered nurses in
different clinical areas of the hospital in their first few years as a registered nurse. The
study will also help to identify areas for further nursing research in Brunei Darussalam.
7
1.4. THE STUDY AIM
The primary aim of this study was to investigate perceptions of stress and level of job
satisfaction by registered nurses of less than three years experience, in todays complex
1.5. Objectives
1. Identify levels and sources of stress experienced by registered nurses with less
than three years experience working in speciality care units and general wards.
less than three years experience working in speciality care units and general
wards.
3. Explore the relationship between the levels of stress and job satisfaction
amongst registered nurses with less than three years experience working in
8
1.6. Research Questions
1. What are the stressors for registered nurses with less than three years experience
2. Do the sources of stress differ for registered nurses with less than three years
3. Do sources and levels of stress differ according to gender, marital status, working
4. Is there a relationship between level of stress and level of job satisfaction amongst
nurses with less than three years experience working in speciality care units and
general wards?
1.7. Hypotheses
In order to answer the research questions, the study set out to test the following
1. The stressors for registered nurses with less than three years experience are
similar between nurses working in speciality care units and general wards.
9
2. The sources of stress for registered nurses with less than three years experience
are similar between nurses working in speciality care units and general wards.
3. The sources and levels of stress for registered nurses with less than three years
levels of job satisfaction amongst registered nurses with less than three years
experience.
Summary
Chapter one has provided an overview of some of the stressors experienced by nurses in
Darussalam has been outlined and the research questions, hypotheses, aim and objectives
10
CHAPTER TWO
2.0. THEORETICAL PERSPECTIVES OF STRESS
2.1. INTRODUCTION
There is some evidence in the literature that a notable proportion of nurses report
ineffectiveness and failure (Ootim, 2002; Cole, Slocumb and Mastey, 2001; Black,
Hawks and Keens, 2001; ILO, 2001; Healy and McKay, 1999; Janet, 1995; Sylvia, 1995;
Santamaria, 1994). This chapter begins with an overview of the concept of stress, its
definitions, and its effects on health, the employing organisation and society at large. The
nature of and common sources of stress in the nursing profession are also discussed. The
chapter concludes with a summary of the strategies that might be useful in overcoming
the problems associated with stress amongst nurses, especially in the first few years work
as a registered nurse.
2.2. Is it Stress?
changes (Kristin, 1998). Hopkinson, Carson, Brown, Fagin, Bartlett and Leary (1998)
stress vary among stress investigators (Siegall, 1995). Stress has been defined as the
physiological and psychological reaction that occurs when people perceive an imbalance
between the level of demand placed upon them and their ability to meet that demand
11
(Rohleder, 1993). Omdahl and ODonnell (1999) define stress as an imbalance between
the perceived external demands on a person and his or her abilities to cope through the
Stress is your bodys instinctive response to situations that are mentally and physically
taxing (Gregory, 1999). Veccio (1995) described stress as the physical and psychological
Anger, frustration, guilt and hurt (Santamaria, 1994), anxiety, apathy, and illness (ILO,
2001) are the most universally observed emotional reactions to stress. Stress is
threatens an organisms existence and well being (Engel, 2004; Baum, Singer, and Baum,
1981). Becky (1994) stated that stress is a physical, psychological, or spiritual response to
Some of the early theorists in the area of stress emphasised this link between environment
mind and body. Seyle (1976) for example explained that stress results in physiological
demands. Lazarus and Folkman (1984) similarly view stress as a dynamic and reciprocal
relationship between the individual and his/her environment. Stress has thus come to be
viewed as a concept that is viewed by some psychologists as a generic term for a broad
area of human responses to any stimuli that produces stress reactions, both physiological
12
and psychological (Monat and Lazarus, 1991). Importantly responses to stress vary,
Lazarus and Folkmans (1984) model is useful for understanding perception of stress, the
factors that may contribute to or ameliorate it, and its effects on the person. The model is
important, as it highlights that stress is a very broad class of problems differentiated from
other problem areas because it deals with any demands which tax the physiological
system, the social system or the psychological system and the response of that system
(Lazarus, 1999).
In this context, stress is seen as multi-factorial and highly subjective (McVicar, 2003).
Although stress has been well investigated in the literature for years, it remains poorly
understood. Stress and threat are concepts used interchangeably in research, however, the
conceptual definitions of each are clearly different (Scholtz, 2000). Stress may be
Hiroshi (1994) notes that stress can affect everyone, and although it can serve as a useful
stimulus, excessive stress can lead to physical and mental illness. Stress is strictly a force
which, when applied to a system, modifies its form. Psychological and social forces and
pressure, in the form of events or situations, can be referred to as stressors when they
exert a distorting effect upon a persons equilibrium. Psychological tension can also be
referred to as stress; in this case the casual agent can be referred to as a stressor.
However, stress is not necessarily bad, since in small doses it can motivate us. A crisis,
13
for example, may provoke positive thinking to regain the upper hand and master the
situation, and very often to succeed. Selye (1976) also used the term eustress to refer to
Janet (1995) similarly argued that stress isnt all bad as it is a natural reaction to change
or feeling out of control. Stress isnt just that sinking feeling we get when we have too
much to do in too little time. Janet claimed it can also be that extra buzz we need to
achieve higher goals. As such, she argued that it is how stress is handled that makes the
stressors in an environment or situation, but also the meaning of the stressor, and
individuals ability to respond and manage the stressor and stress response. The
people are unable to invoke coping mechanisms which assist them to deal with the
Stress may have devastating effects on key areas of our lives including: personal/home,
work and finances (Janet, 1995). How people respond to differing stressors varies, and
stress may manifest itself in different ways. Some people know when their bodies are in a
heightened state of excitement: theyre aware of their pulse or they have difficulty in
swallowing. Others may have more subtle responses, such as difficulty in concentrating
or feeling angry or out of control (McConnell, 2000). Black, Hawks and Keens (2001)
explain that behavioural responses to stress include decreased ability to think clearly and
function, increased tobacco and alcohol use, overeating, and disrupted sleep pattern.
14
Black, Hawks and Keens (2001) argue that the physical and emotional demand that stress
places on individuals can have negative effects on health. These authors describe physical
responses to stress as being tight, sore neck and shoulder muscles, increased blood
pressure and heart rate, palpitations, chest discomfort, headaches, gastrointestinal upset
and fatigue. Usually, the effects of stress are short-lived and when this pressure on the
individual recedes there is a quick return to normal behaviour. However, in some cases,
where pressures are on going and intense, stress may lead to long-term psychological and
physical ill health (Harris, 2001). Kristin (1998) argues that prolonged consistent
and diabetes.
Job stress is defined as the harmful physical and emotional responses that occur when the
requirement of the job does not match the capabilities, resources, or needs of the worker.
According to the United Kingdom Health and Safety Commission (1999) the term stress
refers to the reaction people have to excessive pressure or other types of demands placed
on them. Over the past decades, there has been a growing belief that the experience of
stress at work has undesirable effects, both on the health and safety of workers and on the
1986). A review of the literature on physical ailments that are connected with work stress
have generally concluded that prolonged exposure to certain job demands result in a
variety of pathological outcomes, including mental and physical disorders (Ganster and
Schaubroeck, 1991), to the more serious immune system impairment disorders that lead
to arthritis, cancer or heart disease (OCornnor, 2002). Excessive stress can also lead to
15
physical and mental illness (Hiroshi, 1994), insomnia, sexual dysfunction, indigestion,
vomiting, ulcers, diarrhoea, headaches, high blood pressure, heart attacks, and stroke
(Janet, 1995). The ILO (2001) describe that workplace stress may also lead to the
effects of stressful job demands for 136 registered nurses employed in a medium-sized
private hospital in the Midwest USA identified several correlations between reports of
stress and physiological outcomes, including elevation in blood pressure both at work and
OConnor (2002) similarly describes emotional and behavioural symptoms that are
helplessness, loss of self-esteem, and general detachment from the unit or department.
Cole, Slocumb and Mastey (2001), also describes frustration, anger, guilt, resentment,
professional failure, personal loss, powerless, sorrow and burnout as being associated
Occupational stress has become a major issue and a problem not just for individuals in
terms of physical and mental disability. Work stress is implicated in 60% to 90% of
has major financial consequences (International Labour Organisation [ILO], 1998; 1993).
A survey in 1998 of 500 randomly selected members of the Institute of Directors in the
US identified that nearly 40% regarded stress as a serious problem for employees in their
16
organisation (Institute of Directors, 1998). In another report from the European Union
cited by the International Council of Nurses (2005), 28% of workers reported stress
related to the workplace and its associated problems cost organisations an estimated $200
$300 billion in the USA each year resulting from workers compensation claims of all
kinds (IEMR, 1999). Other studies have reported that the cost of stress-related illness in
the USA is estimated to be around $13,000 per employee each year (Bruhn, Chesney and
Salcido, 1995). As such, work related stress does contribute to economic burden, more
turnover, industrial relations difficulties, and poor quality control (Cooper, Liukkonen
and Cartwright, 1996). The National Mental Health Association in the USA reported that
almost $29 million is wasted each year by the general workforce from symptoms of
the UK estimates it loses seven million working days to stress related illness every year,
The cost of stress and its effect on the Brunei Darussalam economy is not well
recognised as being very costly to individuals and organisations (Murphy, 2004; Omdahl
inefficiency, as a result of sickness, decreased quality and quantity of care (Wheeler and
Riding, 1994), decreased job satisfaction (Ernst, Franco, Messmer, and Gonzalez, 2004),
high staff turnover, worker conflict, absenteeism, reduced productivity (Ganster and
17
Schaubroeck, 1991), demoralization and lack of motivation and more (Hiroshi, 1994).
Most organisations have no idea how much stress has cost them each year because they
fail to recognise and address triggers for stress effectively (Harris, 2001). While
contrasting study results have been reported with regard to the relationship between job
stress and job performance (AbuAlRub, 2004), stress has the potential to become an
inhibitive force that can cause diminished individual performance and satisfaction in
A review of the literature suggests that stress can cause burnout, high workforce turnover,
lowered morale and reduced efficiency (Hannigan, Edwards and Burnard, 2004), and can
lead to increased absenteeism, hostility, and aggression (Halvorsen, 2006). It can also
lead to poor time keeping, high turnover of staff, impaired productivity for those at work,
unsafe behaviour and negative health and safety culture in general (Harris, 2001;
associated with an increase in accident rates in the workplace, with one study reporting
that those experiencing high stress are 30% more likely to have accidents than those with
low stress (Lee, 1997). According to the Association of Operating Room Nurses Journal
(2006), situations that produce stress on nurses are more likely to increase the risk of
patients injury, and injuries in nurses (Smith, 1999). These injuries can include
contusions, scratches, sprains/strains and cuts/punctures. The authors also concluded that
nurses who experienced more role ambiguity were more likely to incur a reportable
injury at work. Owing to a lack of clarity regarding job responsibilities, nurses may be
performing roles for which they are not properly trained or qualified, thereby placing
18
themselves in unfamiliar situations where the potential for injury is greater. Regardless of
whether the stress is moderate or high, the cost of stress is enormous (Halvorsen, 2006).
Several studies have been undertaken to identify the factors leading to stress in nursing
(Higgins, 2003; Cottrell, 2000; Gray-Toft and Anderson, 1981). Studies conducted in the
1980s by Hingley and Cooper (1986) identified relationships with superiors, role conflict,
home /work conflict, career stress, and stress due to resource management as common
stressors in nursing. Fitter (1987) similarly identified eight factors that may contribute to
stress including responsibility, workload, physically arduous work, shift work, overtime
uncertainty and unpredictability, and keeping up with change. More recent studies
suggest such stressors continue to exist in nursing, with additional stressors emerging due
to the changing nature of todays health care system. Schroeder and Carter (2002), for
example, reported nurses found it challenging to meet the demands associated with their
evolving role, such as being a financial manager, resource manager and skilled
commentator. Des (2001) similarly described the difference between historical ideas of
what nursing was and the new image of what nursing has become, with conflicts between
such ideals and realities presenting particular challenges for nurses today.
Several studies have reported that less experienced registered nurses in particular report
work demands as being threatening, as the knowledge and skills provided during training
are sometimes not well matched to the demands of contemporary health care. Such
19
studies report that new nurses often feel their work does not meet the needs of the
patients, that they have very little control over their work, and that they receive very little
support from their supervisors and nurse managers (Casey, Fink, Krugman and Propst,
2004). These studies also suggest that nurses perceive that nursing is emotional work,
involving sharing an intense intimacy with others at their most vulnerable, dealing with
issues of right and wrong in human experiences, and the principles of the right of the
(2004) reports that nurses today also have to cope with the rapid changes and the
complex technological characteristics of the health care system, workload issues and lack
of support (team building and collaborative issues), all of which are major stressors
(Ropis, 2005).
Nursing has also been perceived as less attractive on some important occupational
with the increased demands on nurses within a very complex health care system, nurses
may perceive they have accountability with minimal control. Such situations require
nurses to possess exceptional coping skills (Bryant, 1994). Indeed, Duncan-Poitier (2003)
identifies that many nurses new to the profession feel they have too much autonomy, yet
These tensions are reported to be stressful for less experienced nurses. Findings from one
recent survey in the US identified that high levels of autonomy and support by managers
improved the nurses identification with the hospital and high levels of autonomy,
support by colleagues, and duties focused on traditional bedside care increased nurses
20
Stress theories such as those of Lazarus (1999) emphasise that there are many factors
which may influence a persons experience of the same stressor, including the meaning of
that stressor, and the strategies that a person may employ to cope with the stressor. For
the present study, the chief investigator will thus also examine what the registered nurses
believe to be helpful in their transition into the real workplace and avoid potential
stressors associated with their work. For example, in this context, strategies which may
mentoring, team building strategies, balancing priorities, enhancing social and peer
support programs, flexibility in working hours and protocols to deals with violence and
retention.
Figure one presents a conceptual model of stress in nursing that will be used to guide the
present study. The model is based on the core concepts of the Stress-Adaptation theory
originally described by Lazarus and Folkman (1984), and more recently modified by
Folkman (Folkman, Moskoawitz and Tedlie, 2007). Specifically, the model is organised
around two important processes: appraisal and coping. Appraisal refers to the individual's
evaluation of the significance of an event for his or her well-being and the adequacy of
resources for coping (Folkman, Moskoawitz and Tedlie, 2007). Situations that threaten or
harm well-being and that also tax or exceed the individual's coping resources are
appraised as stressful. For registered nurses early in their career, these situations may
include factors such as fear of failure, conflicts with supervisors and other healthcare
professionals, lack of support, lack of organisational skills, or limited experience with the
death and dying. Coping refers to thoughts and behaviours that people use to regulate
their emotions and address underlying problems (Folkman, Moskoawitz and Tedlie,
21
2007). For registered nurses early in their career, a range of programs and support
structures, such as mentoring programs, may promote positive coping that will help to
regulate the threat. Importantly, the model also emphasizes that when coping strategies
are inadequate for dealing with a stressor and its meaning to different individuals,
negative outcomes can occur for physical and psychological wellbeing. For stressors
associated with the workplace, these outcomes may include job satisfaction.
While Figure 1 depicts the major concepts that derive from stress-coping theory, this
study seeks to examine selected concepts only. Specifically, this study seeks to examine
stressors and how these are appraised by nurses in the first three years of work as a
registered nurse. The study also seeks to examine the relationship between these
preliminary investigation of nurses perceptions of the types of supports that may assist
their coping is also undertaken. As such, the primary purpose of this study is to provide
an indepth analysis of stressors and how they are appraised by nurses. Further research is
required to examine other key concepts and relationships in this model, such as the
22
Fig 1: Conceptual model of Stress amongst new Registered Nurses
Goals/
Favourable Positive
Structure Support and Emotion
Harm / Threat/ Challenge Coping Strategies Outcome
Identifies Stressors
- Fear of failure to carry out nursing task - Job Satisfaction
- Stress management training
- Fear of making mistake - Education
- Conflicts with supervisor and other healthcare professionals - Access to hospital resources
- Experience of being discriminated - Mentoring
- Minimum support from supervisors - Team building strategies
- Lack of organisational skills - Balancing priorities
- Limited experience dealing with the death and dying - Enhancing social and peer support
programs
- Flexibility in work hours
- Protocols to deal with violence and
Unfavourable Outcome
retention
- Burnout
- Attraction of nursing staff strategies.
-
-
Job dissatisfaction
Nursing staff turnover (shortages)
Distress
- Poor patients care
- Affect physical and psychological
23
24
CHAPTER 3
3.0. LITERATURE REVIEW
3.1. INTRODUCTION
The increasingly complex world of health care generates the need for nursing staff
members to learn and perform more complicated skills every day. In an era of cost
containment, todays hospitals are demanding efficient and effective delivery of nursing
services. Rapid changes in the healthcare system and restructuring of some areas of
health care have increased patients expectations of what nurses should do and provide
(Sylvia, 1996). Nurse administrators thus expect competent, efficient graduate nurses
upon entry into the organisation (Hamel, 1990). The beginner professional nurse is
required to have the necessary knowledge, skills, attitudes and values which enable them
to render efficient professional service and ensure quality health care delivery (Morolong
and Chabeli, 2005). However, there has been some degree of concern in many countries
across the world over what are perceived to be inadequate levels of skills in graduates
function in todays health care environment, it is important that educators have a sound
into being a registered nurse. Such information can assist with the development of
education and management support programs to assist nurses to function optimally. This
24
3.2. Stress in Nursing
Nursing is recognized as a stressful occupation (Higgins, 2003; Healy and McKay, 1999;
Laws and Hawkins, 1995; Tyler and Cushway 1995; 1992). There appears to be general
agreement that working in the nursing profession is demanding and often stressful when
compared to other professions, because nurses are more exposed to factors known to
cause stress such as role conflict, role ambiguity, and significant work demands (Sylvia,
1995). Halvorsen (2006) argues that stress affects nurses on a daily basis, and that crises
on the job occur frequently. One qualitative study of the resources and strategies used by
six perioperative nurses to cope with multiple demands upon their role revealed that all
participants expressed that they were experiencing stress (Schroeder and Carter, 2002).
Cox, Griffiths and Cox (1996) suggest that although nursing is acknowledged to be a
stressful profession, there is a need for nurses at all levels to understand the nature of the
stress, its potential sources, and the long and short-term effects on health and safety of an
individual and organisation. There are many factors that may contribute to the demands
placed on nurses. For example, the increasingly higher expectations of patients and
families may be placing greater demands on nurses (Hopkinson, Carson, Brown, Fagin,
Bartlett and Leary, 1998; Sylvia, 1995). Furthermore, the complexity of highly
interactive medical technology (Capka, 1997; Owen and Patton, 2003) means that many
nurses are faced with needing to operate highly specialized equipment with risks to
patient safety.
25
The nursing shortage, and cost containments in the health sector have also meant that
there may be insufficient nursing staff to adequately cover the unit (Baldwin, 1999).
Nurses may have to work through breaks and they may not have enough time to complete
their nursing tasks. These factors may create concerns amongst nurses about their ability
to provide high quality care (Aiken, Clarke, Sloan, Sochalski and Silber, 2002). One
study of 308 nurses in the USA reported that too much work and too little time,
/understanding from senior staff were rated as extremely stressful (Sylvia, 1995).
Nursing is also well-known for its irregular hours and the unsocial nature of its work
Council of Nurses (2007; 1995) has identified that shift work especially evening and
night shifts often introduces additional hardship on nurses providing services in complex
Moreover, nurses face a wide range of human emotions, for example listening or talking
Halvorsen, 2006). Working in the nursing profession often involves sharing the traumas
of illness, injury, and death, not only with the patients but with multiple family members
and friends (Gillespie and Kermode, 2004; Cox, Griffiths and Cox, 1996; Sylvia, 1995).
This can cause nurses to harbour emotions such as anxiety, depression, fear and anger
(Halvorsen, 2006). A study of National Health Service Trust staff in the United Kingdom
identified high levels of job-induced stress, depression, anxiety, sickness, absence and
26
(Quine, 1998). Other Australian studies have also reported that nurses are frequently, and
in some cases, excessively exposed to various traumatic incidents as a part of their daily
required to deal with the demands (Bass, 1990). Today nurses are expected to have a
wide range of skills from providing basic nursing care, to the ability to use highly
also deal with complex situations and ethical dilemmas (Rainham, 1994). Support to
continue to develop new knowledge and skills is therefore critical, however, there is often
a lack of time available for activities such as clinical supervision, or for peer support
Ward, 2002), work related stressors present in the nursing working environment and
problems occurring outside the nursing working environment (Rainham, 1994) all
nursing practice especially when workplace and roles of nurses are changing (McVicar,
2003), together with advances in medicines and health technology (Farley, 2004), may
occupational stress and nurses perceptions of the effects of modern medical technologies
27
on several aspects of their work life during the preceding three years in Victoria and New
South Wales. She found that there was a strong perception amongst the 433 nurses that
medical technologies had contributed to their increased workloads and higher levels of
stress (Johnstone, 1999). Another study aimed at assessing the different sources of job
stress for nurses in a number of public hospitals in Saudi Arabia identified six possible
sources of job stress for nurses in public hospitals. These included organisational
structure and climate, job itself, managerial role, interpersonal relationships, career and
The common stressors identified in many nursing studies include family, health,
financial, intellectual, social, spiritual, and professional issues (McConnell, 2000), sexual
harassment, office politics and unclear job roles, role conflicts, and role ambiguity
nursing staff (numerically and experientially), lack of equipment, work overload, role
overload, inadequate training opportunities in the use of new advanced technologies, and
aspects of organisational structure (Johnstone 1999). For example a study by Tyler and
Cushway (1992; 1995) noted that workload related to environmental issues which include
inadequate staffing levels and insufficient time to complete the work task was perceived
as the most frequently occurring source of stress in the workplace. Another study of 129
registered nurses in Victorian and regional institutions found that nurses ranked
uncertainty with treatment, dealing with medical emergencies, sudden and unexpected
deterioration of the patients conditions, and lack of support to deal with emergencies
were some of highly rated stressors in the nursing profession (Healy and McKay, 1999).
28
Additionally, Carroll and Adams (1994) noted that the multiple demands of the role were
rated as the most stressful component of all. These included the experience with conflict
which begins with novice, advance beginner, competent, proficient and expert.
Competence is the ability of a person to fulfil the nursing role effectively and/or expertly;
Barnard, 2001). The clinical competence of registered nurses relating to the care of
learned in the classroom with practice and the development of clinical skills. Its
foundation lies in the ability to identify and solve problems that emanate from critical
thinking, analytical reasoning and reflective practice (Moeti, Niekerk and Velden, 2004).
Importantly, Moeti, Niekerk and Velden (2004) found that many new registered nurses
have sufficient theoretical knowledge, but sometimes lack competency in basic nursing
skills and have difficulty correlating theory into practice. Ramritu and Barnard (2001)
further reported that new registered nurses preferred to care for less critically ill patients
and those who required less complex nursing treatment. Over the past few decades, a
number of authors have thus commented on the limited interface between university
schools of nursing and clinical practice agencies preparing registered nurses for the
29
practice setting and in evaluating their competence to perform in this setting (Alex and
therefore, that the many registered nurses may have concerns about their clinical
competence. This potential source of stress is especially important for new registered
nurses.
Conditions of work that are characterised by role conflict and excessive role demands are
particularly stressful (Wallace, 2002). Wallace argues that there is a potential for conflict
between professionals and the organisations when the values, goals and expectations of
the professional are incompatible with those of their employing organisation, especially
reported role conflict are associated with increased tension, lower work-related
Health professionals are often unprepared for organisational professional conflict, and as
such may find such conflicts create stress (WHO, 2004). These conflicts can arise from a
number of factors. For example, for new graduates, a common source of conflict can be
perceived differences between their ideal and the reality of contemporary health care, and
between expectations of managers and those of the graduate themselves (Pines, 1993).
Some writers suggest that a degree of role stress may also be advantageous leading to
better, integrative approaches to tasks (Siegall, 1995). Dawes (1999), for example, argues
that conflicts do not and should not be considered negative or detrimental in all
30
situations. By nature, conflict can be a primary motivator for change. However, such role
conflict often involves negative emotions. As such, conflict may result in low
productivity and can promote mediocre performance, boredom and apathy, thus creating
more stress (Dawes, 1999). Furthermore, for the new registered nurse, inconsistency
between the student role and the staff nurse role can create professional and personal
crossing borders, work setting and occupational groups. This has turned some workplaces
and occupations into high risk arenas where women are especially vulnerable. Reports of
workplace violence against healthcare personnel have thus been increasing and nursing
staff are often the target or most at risk of violence (Uzun, 2003; Hilton, Kottke and
Pfahler, 1994). Mayhew and Chappell (2001a) identified that nurses experienced more
occupational violence compared with allied health providers and GPs, regardless of the
reporting period or whether violence was experienced from patients, patients relatives,
or professional colleagues.
The nature of this violence varies substantially. For example, a study of 145 US operating
room nurses identified that the presence of sabotage is common. The most frequent
31
reprimanded in front of others and not being acknowledged for their own work (Dunn,
2003). Cook, Green and Topp (2001) similarly report that the most common form of
aggression is verbal abuse, with an incidence as high as 98.5% (Ergun and Karadakovan,
2005). Verbal abuse is a dysfunctional but common method of dealing with frustration
and anger that has been defined as those kinds of verbal behaviours that humiliate,
degrade, or otherwise indicate a lack of respect for the dignity and worth of another
individual (Cook, Green and Topp, 2001). Hamlin and Hoffman (2002) refer to this as
attractiveness. The offender uses his or her authority, dominance, or power to belittle,
humiliate, and refuse to promote, dismiss or demote someone. Cox (1991) explains
upon her or himself, professionally or personally. Such abuse may be the form of
Sofield and Salmond (2003) report that some of the causes of verbal abuse in a hospital
setting are related to the highly stressful situations and the power differentials or unequal
interpersonal relationships that are present. When such abuse is directed at co-workers
who are on the same level within an organisations hierarchy, it has been called
horizontal violence (Dunn, 2003). When it is comes from physician colleague to nurse, it
has been called vertical violence. Verbal abuse sometimes also comes from patients and
patients families, in some cases this can be extreme (Paul, 2001). A descriptive
correlational study of a randomly selected list of 1000 (33% of total population of nurses
32
in the system) registered nurses from a three-hospital health system in the Northeast of
USA was conducted to examine perceptions of verbal abuse and intent to leave the
organisation. The study identified that physicians were the most common overall source
of verbal abuse experienced in the past six months, followed by patients (56%), families
(48%), peers (28%), supervisors (16%), and subordinates (15%) (Sofield and Salmond,
2003).
Findings from recent research suggests that health care workers, in particular, nurses have
a higher incidence of stress-related illness, depression, fear, and job turnover, as well as
decreased self esteem, when working in stressful, abusive, and authoritative situations
(Cook, Green and Topp, 2001). One survey of around 1500 allied health professionals,
doctors, and nurses working in a rural area in eastern Australia reported that 68% of
nurses, compared to 47% of allied health providers and 48% of GPs, reported
experiencing violence in the workplace. The most frequent form of occupational violence
reported was verbal abuse, followed by threatening behaviour, physical violence and
These high rates of reported occupational violence, especially verbal abuse, are reported
across many countries. In a study of 600 nurses in the Toronto area, one-third had
experienced some form of abuse at work in the five days prior to the study (Whitehorn
and Nowlan, 1997). Another study in Turkey identified that of 72.3 % (141/195) of nurse
respondents had experienced some form of violence. Most of the respondents stated that
they had experienced verbal/emotional abuse (69.5 %), specific threats (53.2 %), and
33
physical action (8.5 %) (Ayranci, 2005). Similarly, a study of 467 nurses in three
hospitals in East Anatolia, Turkey identified that verbal abuse was prevalent in health
care settings, originating from patients relatives, patients, and physicians and even from
other nurses. Nurses perceived that it affected their ability to function, and that it
A recent study of more than 400 nurses in Nova Scotia reported that 63% had
experienced verbal abuse at work in the past year, while 35% had experienced attempts
of physical harm and 21% had been the victims of a physical attack (Whitehorn and
Nowlan, 1997). Another study that explored the prevalence of workplace violence
amongst 205 nurses in South Taiwan identified the verbal expressions of violence were
mainly due to misunderstanding and drunkenness on the part of patients and their
families, but also due to personal problems in the nurses relationships with doctors and
In the USA, a study of the prevalence and consequences of verbal abuse of staff nurses
by physicians amongst 130 staff nurses identified that 90% reported that they experienced
at least one episode of verbal abuse during the past year, with the average number of
reported incidents during the year being between 6 and 12. The most frequent and most
stressful types of verbal abuse came in the forms of abusive anger, ignoring and
verbal abuse during the past year. Of these 32 (45%) reported experiencing verbal abuse
34
several times per year; 16 (22.5%) reported experiencing verbal abuse once a month or
less; 4 (5.6%) reported experiencing verbal abuse once a week; 16 (22.5%) reported
experiencing verbal abuse several times per week and three (4.2%) reported experiencing
verbal abuse every day. Types of verbal abuse that caused the most stress and occurred
most frequently were abusive anger, condemnation, abuse disguised as jokes, ignoring,
accusing, blaming, judging, criticizing, blocking and diverting (Cook, Green, and Topp,
Hamlin and Hoffman (2002) argue that historically most nurses are represented by
women. Nurses have been socialised to adopt the traditional female or subordinate role
(caring helper), which is seen as secondary to the role of physician. The authors note that
although men also are victims of sexual harassment, the incidence is much lower. Nurses,
both male and female, have learned patterns of behaviour that include relinquishing
Additionally, nurses and physicians experience different economic, political and social
Hoffman, 2002). These power differentials thus create a relationship in which the use of
Occupational stress resulting from verbal abuse is thus a major problem for individuals,
organisations and affecting all industries including health care (Hannigan, Edwards, and
Burnard, 2004; Alexander, 2004).It is not surprising that the apparent frequent experience
35
Hoffman, 2002; International Labour Organisation, 1998). One UK study identified that
half of all nurses working in the National Health Services (NHS) trust reported workplace
stress resulting from bullying, harassment and abuse. The study authors estimated that
this cost NHS trusts an average of 450,000 pounds a year from staff feeling unwell
because of stress, with around 3.6 million pounds a year required to cover the resulting
sickness absence (Paton, 2005; Rodham and Bell, 2002). Other writers suggest that if not
dealt with, stress from workplace violence may contribute to an increased incidence of
errors, and low morale (Buback, 2004), or higher turnover (Webb, 2002). Importantly,
many incidents of violence remained unreported (83.5%), with most of the reported cases
Despite its potential importance as a stressor for nurses, violence against health care
have reported that workplace violence such as sexual harassment, physical assault and
verbal abuse experienced by nurses often comes from physicians, resulting in feeling of
(Sofield and Salmond, 2003; Dunn, 2003; Whitehorn and Nowlan, 1997; Ayranci, 2005;
Ergun and Karadakovan, 2005; Manderino and Berkey, 1997). Verbal abuse directed at
nurses is identified as being widespread and this negatively affects on patient care (Cook,
Green and Topp, 2001). One study reveals that the most severe long-term effects of
verbal abuse were a negative relationship with the offending physician and increasing job
dissatisfaction (Manderino and Berkey, 1997); lack of communication, lack of trust, all of
which negatively affect patient care due to hesitation to call regarding changes in
patients condition and hesitation to suggest improvements to care (Cook, Green and
36
Topp, 2001). At least 16 % of nursing turnover was identified as being directly related to
these factors (Cox, 1987). Moreover, studies suggest a large number of staff nurses
report having experienced being verbally abused by registrars and consultants and in
many cases, this abuse has lead to psychological distress, self-doubt and a significant
amount of loss of respect form colleagues and peers (Michael and Jenkins, 2001). Hilton,
Kottke and Pfahler (1994) similarly reported verbal abuse increased stress, produces
The inability to meet patients needs is a great concern because it goes to the very heart
of what nurses perceive as their role. The importance of the holistic approach to nursing,
providing psychological care and support alongside the physical care, has become widely
accepted over recent decades. However, nurses say that they are frequently unable to do
so because of staff shortages, which reduces the nursing time available to the individual
patient (Sylvia, 1996). One study of 433 Australian nurses, conducted in 1996, found the
main causes of stress were frequently linked with financial constraints. These may
overload and role overload, inadequate training opportunities in the use of new medical
The American Association of Colleges of Nursing (AACN) reported that the future of
professional nursing is threatened today by the current and impending shortage of nurses,
while the entire health care industry is affected, it is even more predominant in speciality
areas and if unresolved, the crisis will be even more significant in the future (AACN,
37
2002). The nationwide nursing shortage is expected to balloon from 6% currently to 29%
by 2020, straining hospitals finance and inhibiting quality (Health Care Strategic
not enough manpower to carry out the job, and inability to provide high quality patient
care (Aiken et al., 2001). One study found that nurses frequently stated that there are
insufficient staffs to cover illness and, if a nurse is sick they feel guilty because their
colleagues have to carry an even heavier burden (Sylvia, 1996). Dockery (2004)
identified that dissatisfaction with non-pay aspects of the job appears to have a stronger
influence on overall job satisfaction and on intention to leave the profession. Ernst,
Messmer, Franco and Gonzalez (2004) similarly identified that the factors which
influenced work satisfaction in a group of paediatric nurses in the USA included pay,
time to do nursing care, confidence in ones ability, and task requirements. Importantly, a
relationship between nurses job satisfaction and work organisation, job stress, and
Such results have led some organisations to suggest that financial incentives are one way
of defining the value of nursing services and continue to be a key factor in nurse
retention. Kirsch (2001) stated that salaries and financial benefits continue to be
indicated that nurses voice that their pay as not being commensurate and an important
reason for why they considered leaving nursing. Higher salary opportunities for
experienced nurses versus new registered nurses may lead to decreased turnover rates and
reward clinical expertise (Trossman, 2002). Another study indicated that nurses average
level of satisfaction with pay was the lowest of all the job climate satisfaction scale
38
means. About 45% disagreed or strongly disagreed with the statement, My present
salary is satisfactory. In contrast, about 20% agreed or strongly agreed with the views
(Duncan-Poitier, 2003). While pay may be an important factor in job satisfaction, the
relationship between concerns about pay, and the level of stress experienced by nurses
What is evident today is that health care settings are increasingly characterised by higher
patient acuity, shortened length of stay, and increased role responsibilities due to the
flattening of the nursing hierarchy. These changes, although very positive in some cases,
have caused a destabilization and disruption to the traditional nursing orientation models
(Higgins, 2004). These high job demands can lead to variety of pathological outcomes,
including mental and physical disorders, absenteeism, and reduced productivity (WHO,
2004). Studies report that nurses are struggling to cope with chronic staff shortages, ever-
increasing workloads, and expectations that they will continue to donate unpaid overtime
(Harulow, 2000). One early study reported that work overload were rated by nursing
respondents as the major contributing factor for nurses stress (Hipwell, Tyler and
(JCAHO) describe unrealistic and unsafe nurse-patient ratios and the excessive
paperwork demand by managed care and other insurers, have not enabled nurses to spend
quality time with patients, resulting in job dissatisfaction (2002). Studies report higher
levels of job dissatisfaction and emotional exhaustion among nurses were strongly related
to nurse-patient ratios (Aiken, Clarke, Sloane, Sochalski and Silber, 2002). Ernst, Franco
Messmer and Gonzalez (2004) found similar results, with pay, time to do nursing care,
confidence in ones ability, and task requirements being identified as factors influencing
39
nurses job and organisational work satisfaction. Heavy workloads, a lack of time to
spend with patients and feeling of being unvalued in their work are reported to contribute
to the high turnover of nurses from profession (Davison, 2002). In another study Moore,
Kuhrik, Kuhrik, and Barry (1996) reported that the level of stress perceived by registered
nurses negatively related to their organisational commitment, and that this stress resulted
In a review of the literature on role stress, work overload has been reported as one of the
main reasons for nurses leaving the workforce (Chang, Hancock, Johnson, Daly and
Jackson, 2005). Sylvia (1996) explained that workload which is shared among smaller
numbers of nursing staff leaves less time for the emotional and psychological caring
aspects of nursing. This increases nurses stress, often resulting in the failure to maintain
high nursing standards and dissatisfaction with their inability to meet what they perceive
as the patients needs. One study identified that eight of every ten nurses report they have
to work very hard in their jobs, close to two thirds reported that they have to work very
fast at their jobs, nearly one third of respondents indicated that they felt under great stress
almost every day, and another fifth reported feeling under great stress several days a
Most nurses caring for patients will encounter death as part of their work. This
experience often causes anxiety (Brisley and Wood, 2002). Providing care to acutely ill
or dying patients has been identified as one of the more common and important internal
40
sources of stress among nursing staff (Cole, Slocumb and Mastey, 2001; Moszczynski
Numerous studies have identified caring for dying patients to be an important stressor for
nurses. Edwards (1997) identified that should a normally healthy person die unexpectedly
in the operating theatre during routine surgery or as a result of trauma, this was especially
stressful. The death of patients in the operating room and post anaesthesia care unit is
sometimes an unexpected event that can cause grief, burnout and turnover among the
caregivers who work in the area (Gerber and Workman, 1995). According to Petit de
have anxieties related to death issues that can impact upon them psychologically,
physically, socially and spiritually. Death anxiety can be associated with lack of
experience and inadequate death education (Brisley and Wood, 2002). Gillespie and
Kermode (2004) reported that feelings of inadequacy, incompetence and self-blame were
Studies of the care dying people received in acute hospitals show that nurses experience
difficulties in meeting the patients and their families needs (McWhan, 1991). In most
cases new graduate nurses could not recall clearly the details of the education they
received regarding the care for dying patients and their relatives because they all found
that the reality was very different to the theory (Brisley and Wood, 2002). The limitations
of pre nursing registration preparation in care of dying results in difficulties in caring for
dying people (McWhan, 1991). To enable new graduate nurses to provide care for others
41
death issues. Formal and informal education needs to be made available early in the
under graduate program and continuing through transition programs in the workplace
Studies have reported new nurses in particular often feel angry that supervisors and co
worker had done little to increase their self esteem (Chapman, 1993). Dunn (2003)
described feelings of anger and frustration were often pointed towards nursing
administrators, surgeons and other nurses, as nurses viewed their administrators as being
absent from day-to day activities and as providing minimum support and recognition.
Moore, Kuhrik, Kuhrik and Barry (1996) surveyed 336 acute nurses who identified that
job stress was a consequence of non supportive supervisors and co workers, resulting in
Issues relating to supportive work environments are especially important for new
registered nurses. Byrne, Cantrell, Fletcher, McRaney and Morris (2004) noted that
concern has been raised by students and new registered nurses who experience being
isolated by experienced nurses who are reluctant to mentor. A qualitative study of new
registered nurses in South Australia identified a culture which was not conducive to new
rushed environment that was unpredictable, together with lack of support, were recurrent
themes from the nurses perspective (De Dellis, Longson, Glover and Hutton, 2001).
Moreover, a study of Swedish nursing students about where in the health care system
42
they would like to work as a registered nurse after graduation found that students were
often isolated during working with no apparent support system. This reinforced their own
ambivalence and reluctance towards future work in delivering care (Fagerberg, Winblad
Chapman (1993) identified major dissatisfaction with non supportive supervisors and co
workers as being primary reasons nurses leave hospitals. As such, she suggests that by
providing a supportive work group, for example by helping the person or sharing
work/task responsibilities, work stress can be reduced and job satisfaction increased.
Duncan (1997) similarly notes the importance of supportive work environments to new
nurses both before and after accepting the first registered nurse position. Ronsten,
Andersson and Gustafsson (2005) further identified that mentorship enabled novice
nurses to nurse in a more reflective and holistic way and was a crucial ingredient for
Expectations from the health care environment are that nurses rapidly function as a
competent practitioner (Casey, Fink, Krugman and Propst, 2004). Many nurses do
they developed organisational and prioritizing skills, find their own style and rhythm and
begin feeling a connection to the unit and institution. One study found that new registered
nurses often do not feel skilled, comfortable, and confident for as long as one year after
being hired, highlighting the need for healthcare organisations to provide extended
43
orientation and support programs for new graduate nurses to facilitate successful entry
into practice (Casey, Fink, Krugman and Propst, 2004). The first year of practice is often
characterised by the feeling of clinical inadequacy, making this a stressful situation for
new graduate nurses because their clinical expertise is often not at the level expected by
(Ganga, 1998).
Studies indicate that new registered nurses clinical competency generally significantly
increases overtime, as did their familiarity with work demands and the hospital
environment. As such a significant increase in their level of job satisfaction is often also
evident (Currie, 1994; Al-Ahmadi 2002). Importantly, the most important determinants
of job satisfaction amongst new nurses were recognition, technical aspects of supervision,
Some authors have described the transition year as providing a mediated entry into the
nursing profession, where the new graduate nurses infuse patterns of adjustment, learning
to cope, and understanding how and when to seek help and support (Clare and Van Loon
2003). When new registered nurses enter the working world they experience a range of
unfamiliar situations for which they may be unprepared due to their limited experience,
shortage of practical and managerial skills, feelings of lack of support and excessive
workloads (Huang, 2004; Maben, 1996). One study on the transition to being a registered
nurse in New Zealand identified five themes relating to the experience. These included:
44
critique their own practice, but they found it more difficult to challenge their colleagues
Kramer (1974) coined the term reality shock to describe the experience of new
registered nurses initial education being in conflict with the work world values. Kramer
(1968, 1974) theorized that the first job in a hospital setting was often marked by
dramatically conflicting value systems, namely, the idealism of pre service education and
the reality of nursing service. New registered nurses have to distinguish the values of
school which is previous work experiences and the current work culture when entering a
new organisation. According to Kramer (1974), nursing students are socialized in school
to a professional model of nursing practice which includes the concept of providing care.
This relies on the individuals use of her/his judgement, autonomy, knowledge and
decision making skills. This socialization process emphasizes the should and ought,
or ideals, of nursing practice. Upon entering the work world, however, the new
graduate encounters a part-task system of care and a culture which relies on the
get the job done and how values are put to work in the context of less than ideal
situations, such as staff shortages and emergencies (Currie, 1994). Having little warning
or knowledge of the values and expectations of the health care environment, new
registered nurses often experience conflicts and confusion during the initial process of
learning into the new social cultural system (Benner and Benner, 1975).
45
While the concept of reality shock was first described in the 1970s, studies suggest it still
has some relevance today. Godinez, Schweiger, Gruver and Ryan (1999) reported that the
first three months of employment are the most stressful time in nurses careers. This is
because the transition from school to the work world is considered as the loss of ones
familiar social setting which is replaced by a distinctly new culture (Hamel, 1990). The
transitional shift from nursing school to work organizations or from student nurse to
professional nursing is thus a difficult one. During this time the new registered nurse may
attempt to hold onto the school or previous departmental work values and this often
results in a clash between cultures (Higgins 2003). Socialization into a new nursing work
which the new registered nurses may find difficult (Myer, 1992). According to one
survey, half of the new registered nurses sampled felt the orientation period was too
care of patients with complex diagnoses were reported as overwhelming the new
the experiences of new graduates during the transition from student to practicing
registered nurse. Major themes that emerged were experiential learning, gendered work
relations, caring and giving care, and the influence of college on moral reasoning and
skills and self confidence. Their efforts to care and give care were compromised by
gendered work relations. Caring and giving care were dominant concerns throughout the
transition period. They were especially troubled by ethical dilemmas in regards to dying
46
patients. They believed that college taught them to recognise ethical dilemmas and to
that they cling to caring values in a sometimes indifferent work environment. Although
some new nurses adjusted their values to adapt to the work reality, others maintained
their ethic of caring and attempted to act on those values (Hulsmeyer, 1994).
Higgins (2004) stated that one of the most important transitions of adult life occurs when
facing the challenges of a new job in a new setting. Making the transition from nursing
student to practicing nurse requires the novice to master a wide range of complex nursing
skills (Hamel, 1990). As a result new graduate nurses experience difficulty in adjusting as
they navigate this challenging moment and found transition from nursing student to
newly graduate staff nurse as stressful (Huang, 2004). Transitions are complex and
(Meleis, Sawyer, Im, Messias and Schumacher, 2000). Oerman (1996) explains that
transitions allow new registered nurses to practice in real clinical situations. Such
transitions are essential because of the need to interact with variety of clients and other
health care professionals when providing care. These transitions may include the
opportunities to develop skills, apply scientific principles in providing care and make
Similarly a study on new graduate nurses who had completed their first year of clinical
practice after graduation in a Victorian private hospital, Australia identified three major
themes. The first steps described the unexpected shock and feelings of being
unprepared on entry to the work setting along with the reality of the unrealistic
47
expectations of colleagues. Stumbling blocks described the multiple role and personal
stressors that challenged the participants. Striding ahead described the factors that
facilitated the participants adaptation to the registered nurse (RN) role (Goh and Watt,
2003).
Hamels (1990) study of the influences of nursing subculture as perceived and understood
by new graduate nurses on entering the nursing profession also revealed some important
factors that may contribute to stress. These factors included fear of failure, fear of total
psychological interactions and placed value on efficiency and task-oriented nursing care,
and a clash between the new graduate nurses values and those of the work world. This
made integration into the nursing subculture at times unpleasant. Moreover, preceptors
providing minimal support to the new graduate nurses, largely because they did not
understand the preceptor role were also identified as potential stressors, as they found it
difficult to articulate the values, norms, beliefs, and expectations to new graduate nurses.
New nurses also reported difficulty with task self-esteem because of their lack of
New registered nurses entering professional practice may have somewhat limited mastery
of or familiarity with various nursing skills and only basic understanding of diseases
processes (Hardy and Conway, 1998). Kelly, Simpson and Brown (2002) therefore
concluded that newly qualified nurses required enormous support in further developing
48
their self confidence and professional competence. The transition between school and
work is a time of critical development for the beginning practitioner (Alex and
registered nurses during this transition period has thus resulted in increasing interest in
understanding the support and guidance required from their immediate supervisors and
more senior staff in order to effect and achieve a successful transition (Goh and Watt,
2003).
Transition support has been categorized into two categories. Material support for new
graduates may include money, tools, people and a supportive physical environment.
support can positively protect individuals from the deleterious effects of stressors
acceptance (RNAO, 2006). This support may also serve an informational function and
help individuals to interpret, comprehend and cope with potential stressors in functional
ways, and may also simply fulfil needs for social companionship and affiliation that may
function by providing individuals with the material resources and services needed to help
combat the source of stress (WHO 2004). One study that examined the relationship
between staff nurses perception of collegial support and job stressors within the hospital
revealed that by identifying and reinforcing effective coping mechanisms and developing
supportive relationship, individual perceptions of distress may be reduced and nurses may
49
Recognition of the particular support needs of new registered nurses has resulted in the
development of a range of transition programs for this group. Duncan (1997) reported
that student clinical and work-related experiences are available at many healthcare
organisations, however, very little is known about how these experiences may contribute
to the employer/nurse work relationship that begins after graduation. Wilson and Startup
(1991) argue that a more unified approach must be adopted to reduce the conflicts which
learners experiences. Amos (1993) similarly argue that to minimise the occurrence of
stress during the new graduates transition period, employers need to plan an orientation
program at a minimum of six months. During the orientation program the graduate is
introduced to the institutional culture including policies and procedures. Such programs
serve as support mechanism and allows for less stressful transition into nursing practice
Clinical supervision for new registered nurses was also identified as important in
encouraging nurses to think about their skills and professional development needs.
However, it appears that there is often a lack of time available for this in most areas
(Kelly and Simpson, 2002). Huff (2004) argues that mentoring offers a chance for growth
and development within the practice of nursing. Mentoring can offer professional
and producing future nursing leaders with the skill and passion to make a lifelong
have previously been promoted and have gone some way towards addressing the support
needs of registered nurses (Bain, 1996). One study investigated nurses satisfaction with
50
their work environment and moral stress following participation in a systematic clinical
nursing supervision program. Results of the study indicate that there is a significant
suggesting that support for nurses to develop personal qualities, integrated knowledge
and self-awareness was important and may be useful for developing the coping strategies
required for dealing with the stressors associated with being a new registered nurse
3.12. Summary
This chapter has presented a review of the literature relating to stressors in nursing. The
literature identifies a range of common stressors in nursing, associated with the nature of
nursing work and todays health care and the work environment. These sources of stress
include concerns about clinical competence as a new registered nurse, role conflicts,
violence and aggression, workload and resource constraints, care of dying patients, and
inadequate support from managers and colleagues. The particular experiences of new
registered nurses, and the stressors associated with this experience as they transitioned
into a new role were also reviewed. In addition, literature that has described some of the
key strategies that may assist with developing the coping strategies needed to cope with
these stressors has been reviewed. These strategies include both practical and
psychological supports for the new registered nurse, in many instances formalised into
51
CHAPTER FOUR
4.0. METHOD
This study used a descriptive correlational design to examine new registered nurses
(within the first three years of work as a registered nurse) perception of stress and level of
4.2. Setting
RIPAS hospital was officially opened in 1984. It has 555 beds, operating rooms, a
integrated Head and Neck Surgical Department, Gynaecology and Obstetric Department,
Darussalam government hospital managed by the Ministry of Health that is a not for
profit hospital, with all services provided being primarily funded through the general
RIPAS Hospital is the countrys main referral hospital where the majority of nurses are
learning takes place for nursing and medicine. Currently RIPAS Hospital has been
working collaboratively with the Pengiran Anak Puteri Rashidah Saadatul Bolkiah
52
(PAPRSB) College of Nursing of Brunei Darussalam, University Brunei Darussalam and
University of
Queensland Australia. The hospital is selected for this study because it is the largest
referral hospital among the other four main hospitals in the country and most of the
newly registered nurses (target population) are placed in this hospital. The overall total
number of nurses in the country is 1,675 (Ministry of Health, 2006), with the majority of
nurses at that time were taught skills of basic bedside nursing, equivalent to Enrolled
Nurse Certification in the United Kingdom (PAPRSB College of Nursing Reports, 1991).
Progress in nursing education continued since that time, with the development of new
programs that emphasized practical skills and good bedside nursing, including anatomy
and physiology taught as a basis of nursing practice. The courses developed at a higher
academic level, and were extended to three year programs. The curriculum was based on
the recommendations of the General Nursing Council for England and Wales, and was
modified to suit local needs. After successful completion of all theoretical and practical
components of the program, the students were awarded the Brunei Trained Nurses
In November 1982, the School of Nursing moved to the new Raja Isteri Pengiran Saleha
Hospital and was named the Nurses and Midwives Training Centre. The Centre
continued with the responsibility for the training of Brunei Trained Nurses, Assistant
53
Nurses and Trained Midwives. When the College of Nursing was established in 1986,
intakes for Brunei Trained Nurses were discontinued. The establishment of the Pengiran
Anak Puteri Rashidah Saadatul Bolkiah College of Nursing under the auspices of the
Ministry of Education was seen as the first step towards the professional education for
nurses in Brunei Darussalam (MOH, 2007). The moved into higher education was
undertaken in response to changing demands in health care needs of the population and
academic linkage was negotiated by the Ministry of Education with the Department of
purpose of the linkage was to ensure academic credibility of the new college acquiring
courses, advice on new developments in the United Kingdom and elsewhere, and access
On completion of the three year nursing program, students are awarded a Diploma in
Nursing and qualified as a Brunei Darussalam Staff Nurse. The College of Nursing
continues to provide opportunity for the nurses to enrol into a higher speciality nursing
professionalism to function safely in the context of speciality nursing. After they have
obtained some experience as a staff nurse in the wards or other departments, nurses may
be promoted to Senior Staff Nurse and from time to time the Senior Staff Nurse
undertaking the duties of the ward Sister (Nursing Officer) in the latters absence.
Nursing Officers (Ward Sisters) have to have had considerable experience in nursing and
54
may be in administrative charge of the Unit (such as that described in the Section
depending upon the size and policy of the hospital). A Senior Nursing Officer (Matron) is
a Senior Charge Nurse of very considerable experience whose chief function is to control
and co-ordinate the work and training of the nursing staff within a nursing department
(MOH, 2006). The next level, Principal Nursing Officer, has responsibility is to assist the
following diagram.
Principal Nursing Officer (B2-EB3) Education Officer/ Senior Nursing Officer (B2-EB 3)
4.3. Sample
The eligible sample for this study consisted of all male and female registered nurses (RN)
with less than 3 years working experience as a registered nurse and working in acute
speciality care units and general wards, who can speak, write and understand English
language proficiently as a second language. English language is widely spoken and used
55
as the medium of instruction in primary, secondary, tertiary and higher institutions that
include nursing education in Brunei Darussalam. All nurses identified from the duty
roster of these wards who met these criteria were eligible to participate in the study.
The duty rosters were thus used as a sampling frame. A sample of 120 nurses (66.67%)
out of 180 eligible registered nurses on this roster were invited to participate in the study,
with the remaining 60 nurses being unavailable due to leave arrangements associated
with the Brunei Darussalam National Day Celebration procession. Table 1 present the
numbers of registered nurses involved in the survey from the various clinical departments
of the hospital. They consisted of 52 nurses (43.33%) from acute speciality care units and
As soon as approval to conduct the study was obtained from the Human Research Ethics
56
Brunei Darussalam (Appendix 1 and 2), eligible nurses were invited to participate
voluntarily in the study. To ensure that the rights of research participants were protected
and that they had full understanding of the study, the chief investigator introduced
himself and explained the nature, purpose, objectives and expectations of the study to
each unit/ward nursing officer, managers and staff nurses. Questionnaires together with
information sheets were given to all eligible participants and the chief investigator
assumed implied consent if the nurse returned the completed questionnaires (Polit and
Beck, 2006).
Procedures were implemented for safeguarding the participants privacy and to ensure
they received adequate information regarding the study (Polit and Beck, 2006). Nurses
were informed that participation was purely voluntary, and their response would be
completely confidential. To allay any fears arising from the study, volunteers were also
informed that they were free to withdraw from the study at any time and that there are no
right or wrong answers. The instructions were standardised and written in plain English
Language for all participants and each participant was thanked for their participation
(Appendix 5). Questionnaires were distributed to participants by hand and through the
ward/unit nursing officers, managers and nurses in charge. Nurses were asked to
complete the survey in their own time or outside their working hours within two weeks.
Participants were asked to return the completed questionnaires to the chief investigator by
mail using the pre stamped envelope provided or the respondents could leave them at the
nurses station in each unit. No identifying information was included with the
questionnaires. After the initial explanation of the study the chief investigator had no
direct contact with the participants during the data collection period.
57
As humans (nurses) were used as the study participants, ethical considerations were
protected. These meant freedom from any physical, psychological or economic harm. It
also meant freedom from exploitation. In anticipation of potential risks, such as feelings
information was kept in strictest confidence, stored and locked securely and only
enhancing participation and gaining consent from the participants in the study, a quiet,
polite, unhurried and assertive approach was used when explaining the study. Sufficient
time (three weeks) was given to allow the potential participants to have an adequate
research procedures, aims and objectives. The study participants were informed that the
findings would be shared through nursing seminars, conferences and workshops held at a
future date.
58
In this section, respondents were asked to fill in demographic information by simply
shading or ticking the relevant bubbles that matched their responses. The demographic
information obtained was essential to identify personal and social factors outside of work
that may contribute to workplace stress among new graduate nurses in RIPAS Hospital
Brunei Darussalam. The information was thus obtained to examine if particular groups of
nurses experienced more or less stress. Demographic information collected included age,
gender, ethnicity, standard of living, length of working experience, number and ages of
the children they care for and the support they received at home.
This section was used to assess the overall level of participants confidence, competence
and organisational skills while carrying out their day-to-day working tasks or roles as
registered nurses. Respondents were asked to rate on separate five-point likert-type scale
ranging from 1 strongly disagree to 5 strongly agree the extent to which they
agreed that they were confident, competent and organised. The higher the score the more
The ENSS (French, Lenton, Walters and Eyles, 1995) is a self report questionnaire that
takes no longer than thirty minutes to complete. Permission to use the survey was
59
obtained from the original author, Susan E. French, McMaster University, Canada
[Appendix 3].
The Expanded Nursing Stress Scale (ENSS) was developed using a factor analysis of
responses to nurses ratings of a list of stressful nursing situations that had been identified
in previous research on nursing stress (Healy and McKay, 1999; Tyler and Cushway,
1995: 1992; Gray Toft and Anderson, 1981). The Expanded Nursing Stress Scale (ENSS)
incorporates 59 items with nine sub-scales. Each item required respondents to rate on a
does not apply. The higher the score, the more the respondent agrees that the situation
was stressful. Total and sub-scale score can be derived from this instrument.
(2) Conflicts with others healthcare professionals such as surgeons and physicians
(3) Feeling inadequately prepare to help with the emotional needs of a patient or
patients family
(5) Conflicts with supervisor and receiving minimum support by the charge nurse,
(6) Work load due to lack of organisational skills, familiarity with the units,
unpredictable
60
(8) The fear of failure to carry out the nursing tasks/responsibilities because patients and
(9) Experience of being discriminated and isolated by other nursing colleagues and other
healthcare professionals
(French, Lenton, Walters and Eyles, 2000: 1995; Higgins, 2003; Gray-Toft and Anderson
1981).
The total stress score that provides the overall levels of stress among new graduate nurses
was obtained by adding all the scores on 59 items together. French, Lenton, Walters and
Eyles (2000) explained that there are two items (number 6 and 14) that did not appear to
be related to any of the nine subscales that emerged in the original study of Ontario
The Expanded Nursing Stress Scale (ENSS) was designed in a simple and understandable
English language form and there was no need to translate the original questionnaires into
the respondents mother tongue (Malay). The Expanded Nursing Stress Scale (ENSS) is
well validated with good test retest reliability. The reliability a coefficient for ENSS and
its subscales has been calculated by using Cronbachs alpha, with good internal
consistency scores demonstrated. One study conducted with 129 nurses recruited from
coefficient of 0.89 for the total scale, and coefficients ranging from 0.64 to 0.77 for the
The self-report scale, Index of Work Satisfaction (IWS) developed by Stamps (2001), is
designed to assess nurses level of satisfaction with their work. This self report survey
61
questionnaire takes no longer than thirty minutes to complete. Permission to use this
Index of Work Satisfaction Survey (IWS) was obtained when purchasing the IWS from
States of America and Doreen Masi, Market Street Research Inc, Pleasant Street
The Index of Work Satisfaction (IWS) was designed in a simple and understandable
English language form. Similar to the Expanded Nursing Stress Scale (ENSS), the IWS
did not require translation of its original questions statements into the respondents
mother tongue (Malay). This minimised the risk of misinterpretation of some of the
measurement tool (Part A and B), that make up the self-administered instrument
(1) Pay (dollar remuneration and fringe benefits received for work done)
(2) Autonomy (amount of job related independence, initiative, and freedom, either
permitted
(3) Task requirements (tasks or activities that must be done as a regular part of the job)
(4) Organizational policies (management policies and procedures put forward by the
hospital
(5) Professional status (overall importance or significance of their job, both in their
62
(6) Interaction and formal social and professional contacts during work hours
opportunities
presented for both formal and informal social and professional contact during
working
hours
(Stamps,
2001).
Part A of the Index of Work Satisfaction (IWS) was designed to rank how the
participants feel about their work situation. Here, the investigator was interested in
participants as being of most importance to them. A total of 15 pairs were presented and
positively and negatively worded statements. A positively worded statement was one
which the respondent marked Strongly Agreed when they were very satisfied. A
negatively worded statement was one which the respondent marked Strongly Disagreed
when they were very dissatisfied (Table 2). The response which indicated the most
satisfied respondents was given the most points. An example of this is presented in Table
3. Part B thus measures the current level of satisfaction for each of six components, as
63
Table 2 List of Items for Each Component in the IWS
Convergent validity, discriminant validity, and face validity were assessed during the
development of the tool and through further comparative analysis of 21 studies with
nursing staff. The reliability and validity of the instrument were supported. The
instrument was first tested by Stamps and Piedmonte (1986) with a sample of 246 nurses.
64
The Cronbachs alpha Coefficient for the six sub-scales was acceptable, and ranged from
.52 to .81, with the reliability for the total score of being .81. More recently another
major academic 500-bed teaching hospital in the US, similarly reported the Cronbachs
alpha scores for the six subscales ranged from a low of .55 for the subscale task
requirements to a high of .89 for interactions. The Cronbachs alpha for the total scale
Pre-testing of the data collection instrument was undertaken to trial run the study. A pilot
study involving a sample with similar characteristics to the sample used for actual study
was undertaken. This involved 15 Post Basic speciality nursing students who are
Program at the Pengiran Anak Puteri Rashidah Saadatul Bolkiah College of Nursing
Brunei Darussalam. Nurses involved in the pilot sample did not take part in the main
study. The pilot study was used to: determine the feasibility of the major study; identify
problems in the research design; refine the data collection and analysis plan; test the
instrument to be used in the major study; and give the investigator some experience with
the subjects, research method and instruments (Roberts and Taylor, 2002). The pilot
study also enabled the investigator to ascertain the clarity of items and participants
respondents to fill in the questionnaires. The pilot sample was invited to give their
comments, ideas and views for the improvement of the instrument based on a Brunei
65
Darussalam perspective. Issues raised by the pilot sample were that there were too many
questions in each section and that the time required to respond to the questionnaires was
more than 30 minutes. No participants raised any issue about lack of clarity or ambiguity
of questions in the questionnaire. While the feedback about the length of the
questionnaire was considered, participants in the pilot sample indicated that this was not
Data collected from the self- report questionnaires, the Expanded Nursing Stress Scale
(ENSS) and Index Work Satisfaction (IWS), were analysed to describe stressors and job
satisfaction perceived by nurses within the first three years of works as a registered nurse
working in speciality care units and general wards in RIPAS Hospital, Brunei
Darussalam.
All returned questionnaires were checked for consistency and omissions to minimise
missing values. Completed questionnaires with missing values were examined carefully
demographic section the respondents were asked to state their ethnic group as Malay,
Others. These were later categorised as Indigenous, because participants stated their
ethnic origin as Iban and Dusun. Two responses who ticked Single for their marital
status were corrected to Married because both claimed they received Good Support
from Their Husband to care for their children. Confusion was also noted in Question 8,
66
where the participants were asked to declare whether they have children to care for. Many
of the single new graduate nurses indicated No when this should have been Not
Applicable. Once errors had been rectified further inspection was conducted to confirm
the entire N=94 (78.3%) responses out of 120 distributed questionnaires were valid and
usable. The survey data has been kept safely in the investigators personal computer and
locked cabinet.
The data collected from the study sample was coded and entered into the database of
Statistical Package Social Science Software (SPSS) Graduate Pack version 14. The data
were checked for errors including outliers and wild codes. The procedures carried out
included inspecting the frequency distribution values, for example, gender was coded as
1=female and 2=male. If other codes appeared, a data entry error would have been made.
The second strategy was to compare the entered data with the hard copy record available.
deviations for each variables. Bivariate (two-variable) analyses were then undertaken to
describe the relationships between variable in each group. Contingency tables were used
for categorical variables in which the frequencies of the two variables were cross-
tabulated.
67
CHAPTER FIVE
5.0. RESULTS
5.1 Introduction
This chapter presents the findings of the study. Firstly, a description of the characteristics
of the study sample is presented. Data relating to each of the key research questions is
then presented.
The demographic profile of the sample is presented in Table 4. For this study the total
number of respondents who returned the questionnaire were 94 (78.3%), out of 120 the
distributed questionnaires. Response rates for nurses from speciality units were similar to
those responses from general surgical and medical wards (78.8 % and 77.9 %
respectively). The sample was primarily female (80.9%). Participants ages ranged from
There were only ten (10.6%) participants with an extra nursing qualification - Registered
Nurse + Post Basic Nursing Diploma (Nursing Specialist). Nine out of ten new graduate
nurses with this additional diploma qualification were from the intensive care units. Even
though more than half of the participants have a minimum of one year working
experience in nursing, a large number in both groups (64% general and 22% ICU) have
less than a year working experience in the current units. The majority of participants were
Malays (N=83; 88.3%) This is consistent with the population in Brunei, where Malays
constitutes the major ethnic group of population in the country, numbering 237, 100 of
68
Table 4 Demographic Characteristics of the Sample
The social demographic characteristics of the sample are presented in Table 5. The
majority of the respondents were single (N=75; 79.8%). Twelve (12.8% of the total
sample) of the married study respondents had pre school age children, and almost all of
these reported that they received very good support from their spouses (husband/wife),
housemaid, their parents or in-law and from their sister/brother in-laws to care for their
children. From the total study respondents, 75 (79.8%) were still living in their parents
dwelling.
69
Table. 5. Social Demographic Characteristics of the Sample
70
5.4. Participants Confidence about Clinical Practice
Respondents were requested to rate how they felt about their overall clinical practice in
terms of feeling confident, competent and organised with their responsibilities and roles
as a RN. They were asked to rate a five-point likert-type ranging from 1 strongly
disagree to 5 strongly agree. The higher the score the more they agreed with the
statement. Nearly all respondents (86.1%) agreed that they felt confident about their
overall clinical practice. Most (74.4%) also agreed that they felt competent and that they
were well organised in their overall clinical practice (62.8%). The results are presented in
Table 6.
71
5.5. Sources and Level of Stress Scale
The 59 item Expanded Nursing Stress Scale (ENSS) study instrument was used to assess stressful
situations and experiences. Each item required respondents to rate a five-point likert-type scale by
shading or ticking the relevant bubbles on a scale ranging from to 1 never stressful to 4
extremely stressful, with 0 does not apply. The higher the score, the more the respondent
agrees that the situation was stressful. Total and sub-scale score can be derived from this
instrument.
In order to compute the total stress score, all 59 items were added together. Scores for each nine
ENSS subscales were also calculated by adding scores for the items comprising the subscale. For
example, Uncertainty Concerning Treatment Component is the sum of the average scores for items
7, 16, 20, 26, 31, 35, 38, 41, and 45. In all cases, the category Not Applicable was scored as 0.
Reliability coefficients were calculated using Cronbachs alpha for the total ENSS and each of the
nine subscales components. For this study, the total ENSS 59 item scale had a reliability
coefficient of r = 0.96, with reliability coefficients for the subscales ranging from r = 0.58 to 0.83.
On average, responses to items in the Uncertainty Concerning Patient Treatment were rated by the
study sample as the most frequent stressful events. Table 7 presents responses to items in this
subscale. Responses indicate the majority of items in the scale were often stressful to registered
nurses within the first three years of workings as a registered nurse in this sample. In particular,
fear of making a mistake in treating a patient was rated as the most frequently occurring stressful
72
event. Being in charge with inadequate experience, and physician not being present in a medical
emergency were also rated as frequently resulting in stress. The least stressful events rated by the
registered nurses within the first three years of working as a registered nurse were uncertainty
regarding the operation and functioning of specialised equipment and a physician ordering
inappropriate treatment, although these still had high mean scores (2.57 and 2.59 respectively on
73
Table 7 Ratings of Stress associated with Uncertainty Concerning Treatment
UNCERTAINTY CONCERNING TREATMENT = 0.81
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
7 Inadequate information from 7.3 31.7 29.3 26.8 4.9 2.66 1.11 5.7 15.1 39.6 32.1 7.5 2.83 1,17 6.4 22.3 35.1 29.8 6.4 2.76 1.14
a physician regarding the (3) (13) (12) (11) (2) (3) (8) (21) (17) (4) (6) (21) (33) (28) (6)
medical condition of a patient
16 A physician ordering what 7.3 31.7 36.6 17.1 7.3 2.49 1.10 3.8 26.4 24.5 34 11.3 2.66 1.30 5.3 28.7 29.8 26.6 9.6 2.59 1.21
appears to be inappropriate (3) (13) (15) (7) (3) (2) (14) (13) (18) (6) (5) (27) (28) (25) (9)
treatment for a patient
20 Fear of making a mistake in 0 46.3 26.8 22 4.9 2.61 1.0 5.7 15.1 22.6 54.7 1.9 3.23 1.03 3.2 28.7 24.5 40.4 3.2 2.96 1.06
treating a patient (0) (19) (11) (9) (2) (3) (8) (12) (29) (1) (3) (27) (23) (38) (3)
26 A physician not being present 2.4 17.1 12.2 53.7 14.6 2.88 1.47 5.7 7.5 26.4 47.2 (13.2 2.89 1.41 4.3 11.7 20.2 50.0 13.8 2.88 1.43
in a medical emergency (1) (7) (5) (22) (6) (3) (4) (14) (25) ) (4) (11) (19) (47) (13)
(7)
31 Feeling inadequately trained 9.8 41.5 17.1 29.3 2.4 2.61 1.09 3.8 20.8 30.2 41.5 3.8 3.02 1.07 6.4 29.8 24.5 36.2 3.3 2.84 1.09
for what I have to do (4) (17) (7) (12) (1) (2) (11) (16) (22) (2) (6) (28) (23) (34) (3)
35 Not knowing what a patient 12.2 39 24.4 22 2.4 2.51 1.05 9.4 24.5 30.2 30.2 5.7 2.70 1.17 10.6 30.9 27.7 26.6 4.3 2.62 1.12
or a patient's family ought to (5) (16) (10) (9) (1) (5) (13) (16) (16) (3) (10) (29) (26) (25) (4)
be told about the patient's
condition and its treatment
38 Being exposed to health and 9.8 26.8 34.1 26.8 2.4 2.73 1.05 9.4 18.9 34 34 3.8 2.85 1.11 9.6 22.3 34.0 30.9 3.2 2.80 1.08
safety hazards (4) (11) (14) (11) (1) (5) (10) (18) (18) (2) (9) (21) (32) (29) (3)
41 Being in charge with 7.3 14.6 19.5 43.9 14.6 2.71 1.47 7.5 15.1 13.2 56.6 7.5 3.04 1.32 7.4 14.9 16.0 51.1 10.6 2.89 1.39
inadequate experience (3) (6) (8) (18) (6) (4) (8) (7) (30) (4) (7) (14) (15) (48) (10)
45 Uncertainty regarding the 7.3 34.1 17.1 29.3 12.2 2.44 1.32 1.9 24.5 32.1 30.2 11.3 2.68 1.25 4.3 28.7 25.5 29.8 11.7 2.57 1.28
operation and functioning of (3) (14) (7 ) (12) (5) (1) (13) (17) (16) (6) (4) (27) (24) (28) (11)
specialized equipment
Total Mean Score = 2.63 Total Mean Score = 2.88 Total Mean Score = 2.77
74
On average, responses indicate items in the Dealing with Patients and Their Families
were rated as the second most frequently stressful events. Table 8 presents responses to
items assessing dealing with this subscale. Responses indicate patients family making
unreasonable demands was rated as the most frequently occurring stressful events. Being
blamed for anything that goes wrong was ranked as next most stressful, followed by
patient making unreasonable demands. Respondents also reported having to deal with
abusive patients and abusive patients families were the least frequently resulting in
stress, although these still had a high mean score (2.07 and 2.09 respectively).
75
Table 8 Ratings of Stress Associated with Dealing with Patients and their Families
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
8 Patients making 2.4 26.8 22 43.9 4.9 2.98 1.13 7.5 15.1 34 39.6 3.8 2.98 1.10 5.3 20.2 28.7 41.5 4.3 2.98 1.11
unreasonable demands (1) (11) (9) (18) (2) (4) (8) (18) (21) (2) (5) (19) (27) (39) (4)
17 Patients' families making 2.4 9.8 36.6 48.8 2.4 3.27 .92 11. 5.7 37.7 43.3 1.9 3.09 1.06 7.4 7.4 37.2 45.7 2.1 3.17 1.0
unreasonable demands (1 ) (4) (15) (20) (1) 3 (3) (20) (23) (1) (7) (7) (35) (43) (2)
(6)
27 Being blamed for anything 0 14.6 9.8 61 14.6 3.02 1.46 1.9 15.1 15.1 56.6 11.3 3.04 1.36 1.1 14.9 12.8 58.5 12.8 3.03 1.4
that goes wrong (0) (6) (4) (25) (6) (1) (8) (8) (30) (6) (1) (14) (12) (55) (12)
36 Being the one that has to deal 14.6 14.6 29.3 31.7 9.8 2.59 1.34 5.7 11.3 35.8 39.6 7.5 2.94 1.20 9.6 12.8 33.0 36.2 8.5 2.79 1.27
with patients' families (6) (6) (12) (13) (4) (3) (6) (19) (21) (4) (9) (12) (31) (34) (8)
37 Having to deal with violent 0 24.4 26.8 29.3 19.5 2.46 1.43 3.8 13.2 24.5 41.5 17 2.70 1.48 2.1 18.1 25.5 36.2 18.1 2.60 1.45
patients (0) (10) (11) (12) (8) (2) (7) (13) (22) (9) (2) (17) (24) (34) (17)
46 Having to deal with abusive 12.2 31.7 19.5 17.1 19.5 2.02 1.35 5.7 17 32.1 18.9 26.4 2.11 1.49 8.5 23.4 26.6 18.1 23.4 2.07 1.42
patients (5) (13) (8) (7) (8) (3) (9) (17) (10) (14) (8) (22) (25) (17) (22)
54 Having to deal with abuse 7.3 14.6 17.1 22 39) 1.76 1.64 3.8 15.1 18.9 35.8 26.4 2.34 1.63 5.3 14.9 18.1 29.8 31.9 2.09 1.65
from patients' families (3) (6) (7) (9) (16) (2) (8) (10) (19) (14) (5) (14) (17) (28) (30)
58 Not knowing whether 2.4 22 17.1 31.7 26.8 2.24 1.59 7.5 15.1 26.4 45.3 5.7 2.98 1.201 5.3 18.1 22.3 39.4 14.9 2.66 1.43
patients' families will report (1) (9) (7) (13) (11) (4) (8) (14) (24) (3) (5) (17) (21) (37) (14)
you for inadequate care
Total Mean Score = 2.54 Total Mean Score = 2.77 Total Mean Score = 2.67
76
Table 9 presents responses to item assessing stress associated with Workload subscale.
Responses indicate situations of work overload were rated on average as third most often
stressful events for registered nurses within the first three years of works as a registered
nurse. In particular not having enough staff to adequately cover the unit was rated as the
most stressful event. In this subscale unpredictable staffing and scheduling and not
having enough time to complete all the nursing tasks were also rated stressful. The least
77
Table 9 Ratings of Stress associated with Workload
Workload = 0.78
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
15 Unpredictable staffing and 0 29.3 24.4 41.5 4.9 2.98 1.08 3.8 17 35.8 37.7 5.7 2.96 1.11 2.1 22.3 30.9 39.4 5.3 2.97 1.09
scheduling (0) (12) (10) (17) (2) (2) (9) (19) (20) (3) (2) (21) (29) (37) (5)
25 Not enough time to provide 14.6 41.5 17.1 22 4.9 2.37 1.14 7.5 34 30.2 22.6 5.7 2.57 1.10 10.6 37.2 24.5 22.3 5.3 2.48 1.11
emotional support to the (6) (17) (7) (9) (2) (4) (18) (16) (12) (3) (10) (35) (23) (21) (5)
patient
34 Not enough time to complete 2.4 29.3 19.5 39 9.8 2.76 1.28 5.7 20.8 22.6 43.3 7.5 2.89 1.25 4.3 24.5 21.3 41.5 8.5 2.83 1.26
all of my nursing tasks (1) (12) (8) (16) (4) (3) (11) (12) (23) (4) (4) (23) (20) (39) (8)
43 Too many non-nursing tasks 0 22 29.3 34.1 14.6 2.68 1.35 3.8 24.5 32.1 26.4 13.2 2.55 1.29 2.1 23.4 30.9 29.8 13.8 2.61 1.31
required, such as clerical (0) (9) (12) (14) (6) (2) (13) (17) (14) (7) (2) (22) (29) (28) (13)
work
44 Not enough staff to 0 14.6 22 61 2.4 3.39 .92 0 22.6 22.6 50.9 3.8 3.17 1.03 0 19.1 22.3 55.3 3.2 3.27 .99
adequately cover the unit (0) (6) (9) (25) (1) (0) (12) (12) (27) (2) (0) (18) (21) (52) (3)
47 Not enough time to respond to 9.8 36.6 29.3 7.3 17.1 2.00 1.18 11. 26.4 39.6 17 5.7 2.51 1.09 10.6 30.9 35.1 12.8 10.6 2.29 1.15
the needs of patients' families (4) (15) (12) (3) (7) 3 (14) (21) (9) (3) (10) (29) (33) (12) (10)
(6)
53 Demands of patient 26.8 24.4 12.2 14.6 22 1.71 1.35 7.5 26.4 32.1 13.2 20.8 2.09 1.33 16.0 25.5 23.4 13.8 21.3 1.93 1.35
classification system (11) (10) (5) (6) (9) (4) (14) (17) (7) (11) (15) (24) (22) (13) (20)
57 Having to work through 12.2 22 22 36.6 7.3 2.68 1.29 11. 20.8 30.2 32.1 5.7 2.72 1.2 11.7 21.3 26.6 34.0 6.4 2.70 1.23
breaks (5) (9) (9) (15) (3) 3 (11) (16) (17) (3) (11) (20) (25) (32) (6)
(6)
59 Having to make decisions 2.4 24.4 26.8 26.8 19.5 2.39 1.43 5.7 18.9) 18.9 47.2 9.4 2.89 1.33 4.3 21.3 22.3 38.3 13.8 2.67 1.39
under pressure (1) (10) (11) (11) (8) (3) (10) (10) (25) (5) (4) (20) (21) (36) (13)
Total Mean Score = 2.55 Total Mean Score = 2.70 Total Mean Score = 2.64
78
On average, responses to items in the Inadequate Emotional Preparation were rated as
the fourth most frequently occurring stressful events. Table 10 presents responses to item
particular being asked a question by a patient for which the nurses do not have a
satisfactory answer was rated as the most frequently occurring stressful event in this
subscale. Feeling inadequately prepared to help with the emotional needs of a patient was
also rated frequently stressful. Least stressful events in this area were feeling
inadequately prepared to help with the emotional needs of a patients family, although the
79
Table 10 Rating of Stress Associated with Inadequate Emotional Preparation
Inadequate Emotional Preparation = 0.58
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
3 Feeling inadequately 9.8) 39) 31.7) 14.6) 4.9) 2.41 1.04 5.7 47.2 30.2 15.1 1.9 2.51 .89 7.4 43.6 30.9 14.9 3.2 2.47 .95
prepared to help with the (4) (16) (13) (6) (2) (3) (25) (16) (8) (1) (7) (41) (29) (14) (3)
emotional needs of a patient's
family
12 Being asked a question by a 4.9 36.6 29.3 26.8 2.4 2.73 1.0 5.7 20.8 34 34 5.7 2.85 1.13 5.3 27.7 31.9 30.9 4.3 2.80 1.07
patient for which I do not (2) (15) (12) (11) (1) (3) (11) (18) (18) (3) (5) (26) (30) (29) (4)
have a satisfactory answer
21 Feeling inadequately 7.3 41.5 34.1 12.2 4.9 2.41 .97 11. 22.6 35.8 26.4 3.8 2.70 1.10 9.6 30.9 35.1 20.2 4.3 2.57 1.05
prepared to help with the (3) (17) (14) (5) (2) 3 (12) (19) (14) (2) (9) (29) (33) (19) (4)
emotional needs of a patient (6)
Total Mean Score = 2.52 Total Mean Score = 2.69 Total Mean Score = 2.61
80
Table 11 presents responses to item assessing stress associated with Conflicts with
Doctors (Physicians) subscale. Mean scores for this area was ranked as the fifth most
often stressful for registered nurses within the first three years works as a registered
nurse. In particular criticism by a physician was the most frequently occurring stressful
event in this subscale. This is followed by making a decision concerning a patient when
the physician is unavailable in second place and conflict with a physician in third. The
least stressful occurring events rated by new registered nurses were disagreement with the
81
Table 11 Rating of Stress Associated with Conflicts with Doctors
Conflicts With Doctors (Physicians) = 0.69
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
2 Criticism by a physician 2.4 29.3 51.2 9.8 7.3 2.54 .98 3.8 24.5 22.6 41.5 7.5 2.87 1.23 3.2 26.6 35.1 27.7 7.4 2.72 1.13
(1) (12) (21) (4) (3) (2) (13) (12) (22) (4) (3) (25) (33) (26) (7)
11 Conflict with a physician 2.4 31.7 29.3 14.6 22 2.12 1.35 0 28.3 26.4 32.1 13.2 2.64 1.3 1.1 29.8 27.7 24.5 17.0 2.41 1.34
(1) (13) (12) (6) (9) (0) (15) (14) (17) (7) (1) (28) (26) (23) (16)
30 Disagreement concerning the 12.2 43.9 26.8 9.8 7.3 2.20 1.03 5.7 17 37.7 17 22.6 2.21 1.42 8.5 28.7 33.0 13.8 16.0 2.20 1.26
treatment of a patient (5) (18) (11) (4) (3) (3) (9) (20) (9) (12) (8) (27) (31) (13) (15)
40 Making a decision concerning 9.8 17.1 17.1 39 17.1 2.51 1.52 1.9 15.1 22.6 41.5 18.9 2.66 1.51 5.3 16.0 20.2 40.4 18.1 2.60 1.51
a patient when the physician (4) (7) (7) (16) (7) (1) (8) (12) (22) (10) (5) (15) (19) (38) (17)
is unavailable
50 Having to organize doctors' 0 14.6 19.5 34.1 31.7 2.24 1.69 7.5 13.2 18.9 32.1 28.3 2.19 1.64 4.3 13.8 19.1 33.0 29.8 2.21 1.65
work (0) (6) (8) (14) (13) (4) (7) (10) (17) (15) (4) (13) (18) (31) (28)
Total Mean Score = 2.32 Total Mean Score = 2.51 Total Mean Score = 2.43
82
Table 12 presents responses to item assessing Problems Relating to Supervisors.
sixth most often stressful for registered nurses within the first three years of work as a
registered nurse. In particular, lack of support by nursing administration was rated as the
most frequently occurring stressful event in todays complex clinical nursing working
environment. This is followed by lack of support from other health care administration in
the second place and criticism by nursing administration rated in third position. The least
stressful events rated by new registered nurses were conflict with a supervisor, although
83
Table 12 Rating of Stress Associated with Supervisors
Problems Relating to Supervisors = 0.83
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
5 Conflict with a supervisor 4.9 29.3 14.6 22) 29.3 1.95 1.52 11. 35.8 13.2 22.6 17 2.13 1.36 8.5 33.0 13.8 22.3 22.3 2.05 1.43
(2) (12) (6) (9) (12) 3 (19) (7) (12) (9) (8) (31) (13) (21) (21)
(6)
32 Lack of support from my 2.4 29.3 29.3 17.1 22 2.17 1.38 13. 11.3 32.1 30.2 13.2 2.53 1.4 8.5 19.1 30.9 24.5 17.0 2.37 1.39
immediate supervisor (1) (12) (12) (7) (9) 2 (6) (17) (16) (7) (8) (18) (29) (23) (16)
(7)
33 Criticism by a supervisor 4.9 36.6 24.4 17.1 17.1 2.20 1.29 17 22.6 22.6 28.3 9.4 2.43 1.32 11.7 28.7 23.4 23.4 12.8 2.33 1.31
(2) (15) (10) (7) (7) (9) (12) (12) (15) (5) (11) (27) (22) (22) (12)
42 Lack of support by nursing 4.9 17.1 26.8 34.1 17.1 2.56 1.45 5.7 17 22.6 39.6 15.1 2.66 1.44 5.3 17.0 24.5 37.2 16.0 2.62 1.44
administrators (2) (7) (11) (14) (7) (3) (9) (12) (21) (8) (5) (16) (23) (35) (15)
48 Being held accountable for 4.9 19.5 24.4 24.4 26.8 2.5 1.54 9.4 20.8 20.8 32.1 17 2.42 1.46 7.4 20.2 22.3 28.7 21.3 2.30 1.49
things over which I have no (2) (8) (10) (10) (11) (5) (11) (11) (17) (9) (7) (19) (21) (27) (20)
control
51 Lack of support from other 4.9 14.6 19.5 36.6 24.4 2.39 1.61 1.9 20.8 24.5 35.8 17 2.60 1.43 3.2 18.1 22.3 36.2 20.2 2.51 1.51
health care administrators (2) (6) (8) (15) (10) (1) (11) (13) (19) (9) (3) (17) (21) (34) (19)
56 Criticism by nursing 12.2 26.8 14.6 26.8 19.5 2.17 1.47 7.5 15.1 30.2 34 13.2 2.64 1.37 9.6 20.2 23.4 30.9 16.0 2.44 1.43
administration (5) (11) (6) (11) (8) (4) (8) (16) (18) (7) (9) (19) (22) (29) (15)
Total Mean Score = 2.23 Total Mean Score = 2.49 Total Mean Score = 2.37
84
Table 13 presents responses to item assessing stress associated with Death and Dying
subscale. Responses indicate situations of caring for Dying patients whilst on duty were
ranked as the seventh most often stressful for registered nurses within the first three years
of works as a registered nurse. In particular watching a patient suffer was the most
frequently occurring stressful event in this area. This was followed by feeling helpless in
the case of a patient who fails to improve and the death of a patient with whom they have
developed a close relationship. The least stressful occurring events in this area were
85
Table 13 Rating of Stress Associated with Death and Dying
Death and Dying = 0.78
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
1 Performing procedures that (9.8 (43.9 (26.8 (17.1 (2.4 2.46 .98 11. 47.2 32.1 3.8 5.7 2.17 .89 10.6 45.7 29.8 9.6 4.3 2.30 .94
patients experience as painful 4) 18) 11) 7) 1) 3 (25) (17) (2) (3) (10) (43) (28) (9) (4)
(6)
10 Feeling helpless in the case of (7.3 (34.1 (29.3 (17.1 (12.2 2.32 1.21 7.5 30.2 26.4 24.5 11.3 2.45 1.26 7.4 31.9 27.7 21.3 11.7 2.39 1.24
a patient who fails to improve 3) 14) 12) 7) 5) (4) (16) (14) (13) (6) (7) (30) (26) (20) (11)
19 Listening or talking to a (14.6 (29.3 (14.6 (7.3 (34.1 1.46 1.31 18. 28.3 22.6 17 13.2 2.11 1.28 17.0 28.7 19.1 12.8 22.3 1.83 1.33
patient about his/her 6) 12) 6) 3) 14) 9 (15) (12) (9) (7) (16) (27) (18) (12) (21)
approaching death (10
)
29 The death of a patient (26.8 (26.8 (22 (17.1 (7.3 2.15 1.22 18. 22.6 24.5 20.8 13.2 2.21 1.34 22.3 24.5 23.4 19.1 10.6 2.18 1.28
11) 11) 9) 7) 3) 9 (12) (13) (11) (7) (21) (23) (22) (18) (10)
(10
)
39 The death of a patient with (7.3 (19.5 (19.5 (26.8 (26.8 2.12 1.57 11. 9.4 24.5 37.7 17 2.55 1.51 9.6 13.8 22.3 33.0 21.3 2.36 1.54
whom you developed a close 3) 8) 8) 11) 11) 3 (5) (13) (20) (9) (9) (13) (21) (31) (20)
relationship (6)
49 Physician(s) not being (2.4 (22 (14.6 (29.3 (31.7 2.07 1.63 9.4 1.9 22.6 37.7 28.3 2.32 1.71 6.4 10.6 19.1 34.0 29.8 2.21 1.67
present when a patient dies 1) 9) 6) 12) 13) (5) (1) (12) (20) (15) (6) (10) (18) (32) (28)
55 Watching a patient suffer (9.8 (39 (34.1 (9.8 (7.3 2.29 1.03 5.7 13.2 30.2 37.7 13.2 2.74 1.38 7.4 24.5 31.9 25.5 10.6 2.54 1.25
4) 16) 14) 4) 3) (3) (7) (16) (20) (7) (7) (23) (30) (24) (10)
Total Mean Score = 2.13 Total Mean Score = 2.36 Total Mean Score = 2.26
86
Table 14 presents responses to item assessing stress associated with conflict relating to
peers. Responses indicate situations of conflict relating to peers were ranked as the
eighth most often stressful for registered nurses within the first three years of work as a
registered nurse. In particular difficulty in working with a particular nurse (or nurses)
inside their immediate work setting were rated as the most frequently occurring stressful
event in the work place. This was followed by lack of opportunity to talk openly with
other personnel about problems in the work setting and difficulty in working with a
particular nurse (or nurses) outside their immediate work setting. The least stressful
events in this area were difficulty in working with nurses of the opposite sex, receiving a
87
Table 14 Rating of Stress Associated with Conflicts with Peers
Conflicts Relating to Peers = 0.71
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
4 Lack of opportunity to talk 7.3 41.5 26.8 14.6 9.8 2.29 1.12 11. 22.6 28.3 32.1 5.7 2.70 1.20 9.6 30.9 27.7 24.5 7.4 2.52 1.18
openly with other personnel (3) (17) (11) (6) (4) 3 (12) (15) (17) (3) (9) (29) (26) (23) (7)
about problems in the work (6)
setting
13 Lack of opportunity to share 14.6 46.3 9.8 12.2 17.1 1.85 1.2 7.5 34 26.4 24.5 7.5 2.53 1.17 10.6 39.4 19.1 19.1 11.7 2.23 1.22
experiences and feelings with (6) (19) (4) (5) (7) (4) (18) (14) (13) (4) (10) (37) (18) (18) (11)
other personnel in the work
setting
22 Lack of an opportunity to 14.6 34.1 19.5 4.9 26.8 1.61 1.22 13. 35.8 17 11.3 22.6 1.81 1.29 13. 8 35.1 18.1 24.5 1.72 1.26
express to other personnel on (6) (14) (8) (2) (11) 2 (19) (9) (6) (12) (13) (33) (17) (8) (23)
the unit my negative feelings (7)
towards patients
23 Difficulty in working with a 9.8 39 9.8 34.1 7.3 2.54 1.27 9.4 20.8 18.9 43.3 7.5 2.81 1.30 9.6 28. 7 14.9 39.4 7.4 2.69 1.29
particular nurse (or nurses) (4) (16) (4) (14) (3) (5) (11) (10) (23) (4) (9) (27) (14) (37) (7)
inside my immediate work
setting
24 Difficulty in working with a 19.5 31.7 14.6 24.4 9.8 2.24 1.30 5.7 26.4 20.8 30.2 17 2.42 1.42 11.7 28.7 18.1 27.7 13.8 2.34 1.36
particular nurse (or nurses) (8) (13) (6) (10) (4) (3) (14) (11) (16) (9) (11) (27) (17) (26) (13)
outside my immediate work
setting
52 Difficulty in working with 58.5 19.5 0 0 22 .98 .65 34 24.5 15.1 1.9 24.5 1.36 1.08 44.7 22.3 8.5 1.1 23.4 1.19 .93
nurses of the opposite sex (24) (8) (0) (0) (9) (18 (13) (8) (1) (13) (42) (21) (8) (1) (22)
)
Total Mean Score = 1.92 Total Mean Score = 2.27 Total Mean Score = 2.12
88
Table 15 presents responses to item assessing stress associated with Discrimination.
Responses indicate situations of being discriminated were ranked as the ninth most often
stressful for registered nurses within the first three years of work as a registered nurse. In
discrimination because of the basis of sex in second place. The least stressful occurring
events rated by registered nurses were being sexually harassed, with a mean score of
1.18. Importantly, while almost 60% of the sample indicated this later item did apply,
around 40% of the sample responded that this experience had resulted in stress. Of those
who responded to this item as if it did apply (38 respondents) almost 66% indicated this
89
Table 15 Rating of Stress Associated with Discrimination
Discrimination = 0.60
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful
Occasional Stressful
Occasional Stressful
Frequently Stressful
Frequently Stressful
Frequently Stressful
Does Not Apply = 0
Extremely Stressful
Extremely Stressful
Extremely Stressful
Never Stressful = 1
Never Stressful
Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4
Mean
Mean
Mean
SD
SD
SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
9 Being sexually harassed 4.9 4.9 14.6 9.8 65.9 .98 1.49 7.5 9.4 5.7 22.6 54.7 1.34 1.69 6.4 7.4 9.6 17.0 59.6 1.18 1.61
(2) (2) (6) (4) (27) (4) (5) (3) (12) (29) (6) (7) (9) (16) (56)
18 Experiencing discrimination 14.6 26.8 14.6 2.4 41.5 1.22 1.22 15. 28.3 15.1 9.4 32.1 1.55 1.34 14.9 27.7 14.9 6.4 36.2 1.40 1.29
because of race or ethnicity (6) (11) (6) (1) (17) 1 (15) (8) (5) (17) (14) (26) (14) (6) (34)
(8)
28 Experiencing discrimination 9.8 14.6 14.6 9.8 51.2 1.22 1.46 9.4 13.2 17 13.2 47.2 1.40 1.54 9.6 13.8 16.0 11.7 48.9 1.32 1.50
on the basis of sex (4) (6) (6) (4) (21) (5) (7) (9) (7) (25) (9) (13) (15) (11) (46)
Total Mean Score = 1.14 Total Mean Score = 1.43 Total Mean Score = 1.30
90
5.6. Comparison of Stress by Practice Setting
Table 16 presents a comparison of the mean subscale scores for each of the nine
subscales for nurses in the different practice settings. Results indicate that the common
stressors and sources of stress for registered nurses within the first three years of work as
a registered nurse were similar irrespective whether they were working in the speciality
units or in the general medical and surgical wards. Both groups of new graduate nurses
frequent stressor, followed by Dealing with Patients and Their Families, then Work
Overload. Discrimination was also rated by both groups as the least frequently occurring
stressor. The only statistically significant difference between groups was for problems
relating to peers, where general nurses reported higher mean scores than those reported
91
Table 16 Expanded Nursing Stress Scale Scores by Practice Setting
Speciality General
Expanded Nursing Stress Scale Total Sample
Unit Nurses Nurses N =
Total (1-59) N=94
N=41 53
Mean Range (1-4)
Mean SD Mean SD Mean SD t
Uncertainty Concerning
Treatment
2.63 .74 2.88 .77 2.77 .77 t(92)= -1.59, p .116
Patient And Their Families 2.54 .90 2.77 .87 2.67 .88 t(92)= -1.26, p .211
Workload 2.55 .70 2.70 .75 2.64 .73 t(92)= -1.02, p .312
Inadequate Emotional
Preparation
2.52 .78 2.69 .74 2.61 .76 t(92)= -1.05, p .296
Conflict With Physician 2.32 .79 2.51 1.02 2.43 .93 t(92)= -.99, p .324
Problem Relating To Supervisor 2.23 .98 2.49 1.02 2.37 1.01 t(92)= -1.25, p .214
Death And Dying 2.13 .75 2.36 .97 2.26 .88 t(92)= -1.30, p .196
Problem Relating To Peers 1.92 .67 2.27 .82 2.12 .77 t(92)= -2.23, p .028*
Discrimination 1.14 .98 1.43 1.17 1.30 1.09 t(92)= -1.28, p .205
ENSS (Total Scale) 2.31 .63 2.55 .73 2.44 .70 t(92)= -1.63, p .106
*p<.05
92
5.7. Comparison of Stress by Demographic Variables
Due to small numbers in various demographic groups, including age, gender, educational
background, working experience in the current units, ethnic group, number and ages of
their children, support they received to care for their children, and home ownership
status, the relationship between these variables and ENSS scores were not assessed in
these study. The only bivariate analysis that was conducted was working experience in
nursing. Since the values of the variables were normally distributed, ANOVA was used
Table 17 presents the findings of the bivariate analysis using ANOVA between Expanded
Nursing Stress Scale and its nine components subscales with the independent variable of
working experience in nursing. These results indicate that nurses with less than 1 year
experience reported higher mean stress scores for the Uncertainty Concerning Treatment,
93
Table 17.
N 43 24 27
Problem Relating To Mean 2.64 2.18 2.12 F91=2.86, p .063
Supervisors SD 1.06 .92 .92
Min 0 0 0
Max 4 4 4
94
Table 18 presents comparison of stress by feeling confident, competent and organised
about their overall clinical practice variables. Results indicate were significant negative
correlations for feeling organised about their clinical practice uncertainty concerning
patient treatment, dealing with patients and their families, work overload, conflict with
doctors, problems relating to supervisors and discrimination. There was also a significant
negative correlation between feeling organised and the total ENSS scale scores. There
were no significant relations between feeling confident and competent and stress scores,
except for a significant negative correlation between the feeling of confidence about their
95
Table 18 Relationship between Stress and Ratings of
Confidence,
Competence and Organisation
Practice
Practice
Practice
Mean
** Correlation is significant at the
SD
N
0.01 level (2-tailed).
Uncertainty Pearson
-.170 -.066 -.253(*)
Concerning Correlation 2.77 .77
94
Treatment
Sig. (2-tailed) .101 .529 .014
Pearson
-.095 -.054 -.208(*)
Patient And Their Correlation
94 2.67 .88
Families
Sig. (2-tailed) .361 .603 .044
Pearson
-.187 -.160 -.218(*)
Workload Correlation
94 2.64 .73
Sig. (2-tailed)
.072 .125 .035
Pearson
-.015 .020 -.116
Inadequate Correlation
94 2.61 .76
Emotional
Sig. (2-tailed) .883 .852 .267
Preparation
Pearson
-.043 -.104 -.327(**)
Conflict With Correlation
94 2.43 .93
Doctors
Sig. (2-tailed) .682 .317 .001
(Physicians)
Pearson
-.242(*) -.121 -.326(**)
Problems Relating Correlation
94 2.37 1.01
To Supervisors
Sig. (2-tailed) .019 .244 .001
Pearson
.011 .022 -.190
Death And Dying Correlation
94 2.26 .88
Sig. (2-tailed) .914 .832 .066
Pearson
-.169 -.069 -.110
Conflict Relating To Correlation
94 2.12 .77
Peers Sig. (2-tailed)
.104 .506 .290
Pearson
-.063 -.061 -.212(*)
Discrimination Correlation
94 1.30 1.09
Sig. (2-tailed) .546 .557 .040
Pearson
-.156 -.096 -.283(**) 94 2.44 .70
ENSS Correlation
Sig. (2-tailed)
.133 .360 .006
96
5.8. Index of Work Satisfaction: Importance of Work Components (Part A)
This section identifies how important each of the six components of work satisfactions
were to the registered nurses in this study. The importance rankings developed in this
stage are used to develop weights for each of the satisfaction components (Component
components of satisfaction were arranged in pairs with one other component and the
nurses were asked to select which one of each pair was more important to them. Tables
were formed and the results obtained were tabulated according to the number of times
each component was chosen. Results of these calculations are presented in Table 19. The
raw count was transformed to a percentage of the whole study sample. The percentages
were then converted into standard deviations based on a normal distribution of responses,
using a standard Z-table provided with the package. This was an important part of the
which were strongly preferred by the study sample. The Z-table thus generated a single
As shown in Table 19, results for IWS Part A demonstrate that for speciality unit nurses,
the component Autonomy (70.7%) was most important, followed by Professional Status
(65.9%) and Organisational Policies (61%). Task Requirement and Interaction were
ranked in the fourth and fifth places respectively by specialty unit nurses. The least
97
Table 19. Frequency Matrix for IWS Components by Work Area
Most Important
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total (N=94)
Organisation
Organisation
Organisation
Requirement
Requirement
Requirement
Professional
Professional
Professional
Interaction
Interaction
Interaction
al Policies
al Policies
al Policies
Autonomy
Autonomy
Autonomy
Status
Status
Status
Task
Task
Task
Pay
Pay
Pay
Least Important
% (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n)
Pay 70.7 56.1 61.0 51.2 46.3 62.3 49.1 54.7 64.2 47.2 66.0 52.1 57.4 58.5 46.8
(29) (23) (25) (21) (19) (33) (26) (29) (34) (25) (62) (49) (54) (55) (44)
Autonomy 29.3 48.8 61.0 43.9 51.2 37.8 52.8 54.7 43.4 56.6 34.0 51.1 57.4 43.6 54.3
(12) (20) (25) (18) (21) (20) (28) (29) (23) (30) (32) (48) (54) (41) (51)
Task Requirement 43.9 51.2 51.2 65.9 43.9 50.9 47.2 37.7 64.2 50.9 47.9 48.9 43.6 64.9 47.9
(18) (21) (21) (27) (18) (27) (25) (20) (34) (27) (45) (46) (41) (61) (45)
Organisational 39.0 39.0 48.8 61.0 56.1 45.3 45.3 62.3 64.2 69.8 42.6 42.6 56.4 62.8 63.8
Policies (16) (16) (20) (25) (23) (24) (24) (33) (34) (37) (40) (40) (53) (59) (60)
Professional Status 48.8 56.1 34.1 39.0 51.2 35.8 56.6 35.8 35.8 47.2 41.5 56.4 35.1 37.2 48.9
(20) (23) (14) (16) (21) (19) (30) (19) (19) (25) (39) (53) (33) (35) (46)
Interaction 53.7 48.8 56.1 43.9 48.8 52.8 43.4 49.1 30.2 52.8 53.2 45.7 52.1 36.2 51.1
(22) (20) (23) (18) (20) (28) (23) (26) (16) (28) (50) (43) (49) (34) (48)
98
For new registered respondent nurses from the general wards however, Interaction
(69.8%) was the most important component. General ward nurses ranked Professional
Status, followed by Autonomy and Task Requirement in second, third and fourth place
respectively. Organisational Policies and Pay were ranked in fifth and sixth place.
The next step of analysis involved placing the weights for each of the six components on
a normal distribution by using the table of Z values. All percentages in Table 19 were
converted into 3 decimal places (Table 33, Appendix 6) then to Z-matrix values from the
Z table available (Table 34, Appendix 7). The Z-matrix values for each pair are the same
values, but with opposite signs. An example of this is the intensive care units nurses
ranking of Pay versus Autonomy are scored -0.545 for Pay and +0.545 for Autonomy. To
calculate for the Component Weighting Coefficient, the Z values in each column in
(Table 34, Appendix 7) were added and the mean value (average) for each column was
divided by five (that is, the number of comparisons made). In order to eliminate the
negative values a constant was added. Since the largest possible negative Z value was -
3.090, the constant used was +3.100 added. This was added to each of the mean values to
give the Component Weighting Coefficient. Table 20 presents the Component Weighting
Coefficients for nurses in this study. Results indicate that the Component Weighting
Coefficient for Professional Status and Interaction were highest, indicating these
Requirement and Organisational Policies were ranked in third, fourth and fifth order of
importance. The least most important component rated by respondents was Pay.
99
Table 20 IWS Component Weightings by Work Area
Speciality Units Nurses (N= 41) General Wards Nurses (N= 53) Total Sample of Nurses (N= 94)
100
5.9. Index of Work Satisfaction: Rating of Satisfaction (Part B)
Part B of the Index of Work Satisfaction (IWS) measures the satisfaction of the nurse
respondents using a series of attitude statements about each component. Each statement
uses a 7-point scale that ranges from 1- Strongly Agree 2 Moderately Agree 3-
Disagree. This scale was designed that half of the items on the scale were phrased
Responses to item in the component Professional Status is presented in Table 21. More
than half of the 94 study respondents nurses 60 (63.8%) believed that most people
appreciate the importance of nursing care to hospital patients, and 53 (56.4%) agreed that
they are proud to talk to other people about what they do as nurses. The majority (75.6%)
agreed that there is no doubt whatever in their mind that what they do on their job was
really important. Most nurses (74.2%) agreed that nursing really required much skill or
know-how, and (38%) disagreed that their job does not add up to anything really
significant. Over half, the sample (51.1%) would still go into nursing, if they had the
decision to make all over again. On the other hand n=56 (60.4%) also believe that
101
Table 21 Index of Work Satisfaction: Professional Status
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
7 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
9. Most people 17.1 22.0 19.5 24.4 4.9 4.9 7.3 13.2 22.6 32.1 11.3 11.3 3.8 5.7 14.9 22.3 26.6 17.0 8.5 4.3 6.4
appreciate the (7) (9) (8) (10) (2) (2) (3) (7) (12) (17) (6) (6) (2) (3) (14) (21) (25) (16) (8) (4) (6)
importance of nursing
care to hospital
patients.
11. There is no doubt 29.3 19.5 22.0 24.4 2.4 0 2.4 28.3 13.2 37.7 13.2 1.9 1.9 3.8 28.7 16.0 30.9 18.9 2.1 1.1 3.2
whatever in my mind (12) (8) (9) (10) (1) (0) (1) (15) (7) (20) (7) (1) (1) (2) (27) (15) (29) (17) (2) (1) (3)
that what I do on my job
is really important.
34. It makes me proud to 14.6 7.3 36.6 24.4 4.9 7.3 4.9 15.1 13.2 26.4 22.6 11.3 3.8 7.6 14.9 10.6 30.9 23.4 8.5 5.3 6.4
talk to other people (6) (3) (15) (10) (2) (3) (2) (8) (7) (14) (12) (6) (2) (4) (14) (10) (29) (22) (8) (5) (6)
about what I do on my
job.
38. If I had the decision 14.6 14.6 26.8 21.9 9.8 2.4 9.8 11.3 11.3 24.5 18.9 15.1 3.8 15.1 12.8 12.8 25.5 20.2 12.8 3.2 12.8
to make all over again, I (6) (6) (11) (9) (4) (1) (4) (6) (6) (13) (10) (8) (2) (8) (12) (12) (24) (19) (12) (3) (12)
would still go into
nursing.
** 2. Nursing is not 17.1 24.4 14.6 4.9 17.1 7.3 14.6 24.5 17.0 20.8 5.7 15.1 3.8 13.2 21.3 20.2 18.9 5.3 16.0 5.3 13.8
widely recognized as (7) (10) (6) (2) (7) (3) (6) (13) (9) (11) (3) (8) (2) (7) (20) (19) (17) (5) (15) (5) (13)
being an important
profession
** 27. What I do on my 4.9 4.9 9.8 31.7 34.1 4.9 9.8 3.8 13.2 16.9 32.1 18.9 13.2 1.9 4.3 9.6 13.8 31.9 25.5 9.6 5.3
job does not add up to (2) (2) (4) (13) (14) (2) (4) (2) (7) (9) (17) (10) (7) (1) (4) (9) (13) (30) (24) (9) (5)
anything really
significant.
** 41. My particular job 2.4 2.4 4.9 17.1 9.8 31.7 31.7 3.8 3.8 9.4 9.4 24.5 11.3 37.7 3.2 3.2 7.4 12.8 18.9 20.2 35.1
really doesnt require (1) (1) (2) (7) (4) (13) (13) (2) (2) (5) (5) (13) (6) (20) (3) (3) (7) (12) (17) (19) (33)
much skill or know-
how.
102
Responses to items in the component Interaction are presented in Table 22. Results
indicate that the majority of respondents (71.2%) agreed that the nursing personnel in
their wards/units always help one another out when things get in a rush. More than half,
(60.7%) agreed that there is a good deal of teamwork and cooperation between various
(71%) expressed that it is hard for new nurses to feel at home in the wards/unit. This
was because of concerns such as a lot of rank consciousness where nurses seldom
mingle with those with less experience or different types of educational background.
Around 40% agreed that the nursing personnel where they work are not as friendly and
Additionally, nearly all (87.2%) agreed the physicians in their ward/units should show
more respect for the skill and knowledge of the nursing staff, although around (41.5%)
agreed that physicians at this hospital generally understand and appreciate what nursing
staff do. Over half, (63.3%) agreed that the physicians at this hospital look down too
much on the nursing staff, although (63.7%) of the respondents agreed there is a lot of
teamwork between nurses and doctors on their own wards/unit, and (59.6%) agreed that
103
Table 22 Index of Work Satisfaction: Interaction
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
10 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
3. The nursing personnel on 22.0 31.7 19.5 22.0 4.9 0 0 18.9 20.8 30.2 18.9 7.5 3.8 0 20.2 25.5 25.5 20.2 6.4 2.1 0
my service pitch in and help (9) (13) (8) (9) (2) (0) (0) (10) (11) (16) (10) (4) (2) (0) (19) (24) (24) (19) (6) (2) (0)
one another out when things
get in a rush.
6. Physicians in general 9.8 26.8 24.4 29.3 4.9 4.9 0 9.4 9.4 39.6 22.6 7.5 7.5 3.8 9.6 17.0 33.0 25.5 6.4 6.4 2.1
cooperate with nursing staff (4) (11) (10) (12) (2) (2) (0) (5) (5) (21) (12) (4) (4) (2) (9) (16) (31) (24) (6) (6) (2)
on my unit
16. There is a good deal of 17.1 26.8 31.7 17.1 4.9 0 2.4 17.0 28.3 13.2 7.5 17.0 7.5 9.4 17.0 27.7 21.3 11.7 11.7 4.3 6.4
teamwork and cooperation (7) (11) (13) (7) (2) (0) (1) (9) (15) (7) (4) (9) (4) (5) (16) (26) (20) (11) (11) (4) (6)
between various levels of
nursing personnel on my
service.
19. There is a lot of 17.1 26.8 19.5 14.6 14.6 4.9 2.4 13.2 32.1 18.9 11.3 18.9 3.8 1.9 14.9 29.7 19.1 12.8 17.0 4.3 2.1
teamwork between nurses (7) (11) (8) (6) (6) (2) (1) (7) (17) (10) (6) (10) (2) (1) (14) (28) (18) (12) (16) (4) (2)
and doctors on my own unit.
37. Physicians at this 7.3 12.2 22.0 24.4 17.1 12.2 4.9 5.7 9.4 26.4 18.9 22.6 11.3 5.7 6.4 10.6 24.5 21.3 20.2 11.7 5.3
hospital generally (3) (5) (9) (10) (7) (5) (2) (3) (5) (14) (10) (12) (6) (3) (6) (10) (23) (20) (19) (11) (5)
understand and appreciate
what the nursing staffs does.
** 10. It is hard for new 19.5 17.1 29.3 14.6 7.3 4.9 7.3 24.5 34.0 17.0 13.2 5.7 1.9 3.8 22.3 26.6 22.3 13.8 6.4 3.2 5.3
nurses to feel at home in my (8) (7) (12) (6) (3) (2) (3) (13) (18) (9) (7) (3) (1) (2) (21) (25) (21) (13) (6) (3) (5)
unit.
** 23. The nursing personnel 2.4 4.9 14.6 36.6 14.6 17.1 9.8 15.1 13.2 11.3 20.8 18.9 13.2 7.5 9.6 9.6 12.8 27.7 17.0 14.9 8.5
on my service are not as (1) (2) (6) (15) (6) (7) (4) (8) (7) (6) (11) (10) (7) (4) (9) (9) (12) (26) (16) (14) (8)
friendly and outgoing as I
would like.
** 28. There is a lot of rank 7.3 12.2 12.2 39.2 14.6 4.9 9.8 18.9 11.3 16.9 13.2 24.5 9.4 5.7 13.8 11.7 14.9 24.5 20.2 7.4 7.4
consciousness on my unit: (3) (5) (5) (16) (6) (2) (4) (10) (6) (9) (7) (13) (5) (3) (13) (11) (14) (23) (19) (7) (7)
nurses seldom mingle with
those with less experience or
different types of educational
preparation.
** 35. I wish the physicians 43.9 29.3 9.8 14.6 0 0 2.4 47.2 15.1 28.3 5.7 0 1.9 1.9 45.7 21.3 20.2 9.6 0 1.1 2.1
here would show more (18) (12) (4) (6) (0) (0) (1) (25) (8) (15) (3) (0) (1) (1) (43) (20) (19) (9) (0) (1) (2)
respect for the skill and
knowledge of the nursing
staff.
** 39. The physicians at this 17.1 19.5 24.4 24.4 7.3 7.3 0 18.9 17.0 26.4 13.2 15.1 3.8 5.7 18.9 18.9 25.5 18.9 11.7 5.3 3.2
hospital look down too much (7) (8) (10) (10) (3) (3) (0) (10) (9) (14) (7) (8) (2) (3) (17) (17) (24) (17) (11) (5) (3)
on the nursing staff.
104
Responses to items in the component Autonomy are presented in Table 23. These results
indicate that 44 out of 94 respondents (46.7%) agreed that they have sufficient input into
the program of care for each of their patients, with only 28 respondents agreeing that
there was unnecessary close supervision (29.7%). Less than half (44%) of respondents
agreed that they have freedom in their work to make decisions as they see fit, and can
count on their supervisor for back up. However, 41.5% agreed that all activities seem to
be programmed for them. More than half of the respondents (62.7%) experienced too
much responsibility but were not given enough authority, with a further (25.5%) being
undecided. More than half the sample agreed they sometimes were required to do things
105
Table 23 Index of Work Satisfaction: Autonomy
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
8 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
13. I feel I have sufficient 4.9 4.9 39.0 29.3 19.5 2.4 0 11.3 11.3 22.6 28.3 13.2 5.7 7.5 8.5 8.5 29.7 28.7 16.0 4.3 4.3
input into the program of (2) (2) (16) (12) (8) (1) (0) (6) (6) (12) (15) (7) (3) (4) (8) (8) (28) (27) (15) (4) (4)
care for each of my
patients.
26. A great deal of 4.9 4.9 17.1 65.9 7.3 0 0 3.8 7.5 26.4 39.6 15.1 3.8 3.8 4.3 6.4 22.3 51.1 11.7 2.1 2.1
independence is permitted, (2) (2) (7) (27) (3) (0) (0) (2) (4) (14) (21) (8) (2) (2) (4) (6) (21) (48) (11) (2) (2)
if not required, of me.
43. I have the freedom in 7.3 4.9 34.1 31.7 7.3 9.8 4.9 7.6 13.2 26.4 18.9 15.1 11.3 7.5 7.4 9.6 29.7 24.5 11.7 10.6 6.4
my work to make (3) (2) (14) (13) (3) (4) (2) (4) (7) (14) (10) (8) (6) (4) (7) (9) (28) (23) (11) (10) (6)
important decisions as I
see fit, and can count on
my supervisors to back me
up.
** 7. I feel that I am 2.4 4.9 14.6 63.4 7.3 0 7.3 7.6 9.4 18.9 17.0 20.8 15.1 11.3 5.3 7.4 17.0 37.2 14.9 8.5 9.6
supervised more closely (1) (2) (6) (26) (3) (0) (3) (4) (5) (10) (9) (11) (8) (6) (5) (7) (16) (35) (14) (8) (9)
than is necessary.
** 17. I have too much 22.0 17.1 26.8 31.7 2.4 0 0 16.9 24.5 18.9 20.8 7.6 1.9 9.4 19.1 21.3 22.3 25.5 5.3 1.1 5.3
responsibility and not (9) (7) (11) (13) (1) (0) (0) (9) (13) (10) (11) (4) (1) (5) (18) (20) (21) (24) (5) (1) (5)
enough authority.
** 20. On my service, my 7.3 2.4 19.5 39.2 19.5 12.2 0 7.5 15.1 22.6 15.1 30.2 9.4 0 7.4 9.6 21.3 25.5 25.5 10.6 0
supervisors make all the (3) (1) (8) (16) (8) (5) (0) (4) (8) (12) (8) (16) (5) (0) (7) (9) (20) (24) (24) (10) (0)
decisions. I have little
direct control over my
own work.
** 30. I am sometimes 0 12.2 24.4 36.6 7.3 9.8 9.8 9.4 7.6 28.3 13.2 26.4 5.7 9.4 5.3 9.6 26.6 23.4 18.9 7.4 9.6
frustrated because all of (0) (5) (10) (15) (3) (4) (4) (5) (4) (15) (7) (14) (3) (5) (5) (9) (25) (22) (17) (7) (9)
my activities seem
programmed for me.
** 31. I am sometimes 4.9 9.8 39.2 22.0 14.6 7.3 2.4 11.3 15.1 26.4 20.8 13.2 9.4 3.8 8.5 12.8 31.9 21.3 13.8 8.5 3.2
required to do things on (2) (4) (16) (9) (6) (3) (1) (6) (8) (14) (11) (7) (5) (2) (8) (12) (30) (20) (13) (8) (3)
my job that are against my
better professional
nursing judgment.
106
Responses to item in the component Task Requirements are presented in Table 24.
Results indicate that around two-third of nurses were satisfied with their job activities
(63.8%), however, 60.4% expressed that there was too much clerical and paperwork
required of nursing personnel in the hospital. Almost half of the 94 respondents (45.7%)
agreed that they do not have sufficient time for direct patient care and 55.3% agreed that
they do not have plenty of time and opportunity to discuss patient care problems with
other nursing personnel. Nearly all of the sample (88.3%) agreed that they could deliver
much better care if they had more time with each patient.
107
Table 24 Index of Work Satisfaction: Task Requirements
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
6 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
22. I am satisfied with the 14.6 22.0 39.0 12.2 12.2 0 0 9.4 18.9 26.4 26.4 9.4 5.7 3.8 11.7 20.2 31.9 20.2 10.6 3.2 2.1
types of activities that I do (6) (9) (16) (5) (5) (0) (0) (5) (10) (14) (14) (5) (3) (2) (11) (19) (30) (19) (10) (3) (2)
on my job.
24. I have plenty of time 0 4.9 19.5 26.8 36.6 4.9 7.3 3.8 7.5 15.1 13.2 35.9 11.3 13.2 2.1 6.4 17.0 19.1 36.2 8.5 10.6
and opportunity to discuss (0) (2) (8) (11) (15) (2) (3) (2) (4) (8) (7) (19) (6) (7) (2) (6) (16) (18) (34) (8) (10)
patient care problems with
other nursing service
personnel.
29. I have sufficient time 4.9 7.3 19.5 24.4 29.3 7.3 7.3 3.8 13.2 22.6 13.2 34.0 7.5 5.7 4.3 10.6 21.3 18.9 31.9 7.4 6.4
for direct patient care. (2) (3) (8) (10) (12) (3) (3) (2) (7) (12) (7) (18) (4) (3) (4) (10) (20) (17) (30) (7) (6)
** 4. There is too much 17.1 12.2 22.0 29.3 12.2 4.9 2.4 18.9 18.9 28.3 18.9 9.4 1.9 3.8 18.9 16.0 25.5 23.4 10.6 3.2 3.2
clerical and paperwork (7) (5) (9) (12) (5) (2) (1) (10) (10) (15) (10) (5) (1) (2) (17) (15) (24) (22) (10) (3) (3)
required of nursing
personnel in this hospital.
** 15. I think I could do a 29.3 17.1 22.0 17.1 4.9 4.9 4.9 22.6 30.2 11.3 15.1 11.3 3.8 5.7 25.5 24.5 16.0 16.0 8.5 4.3 5.3
better job if I did not have (12) (7) (9) (7) (2) (2) (2) (12) (16) (6) (8) (6) (2) (3) (24) (23) (15) (15) (8) (4) (5)
so much to do all the time.
** 36. I could deliver much 34.1 36.6 17.1 4.9 4.9 0 2.4 41.5 18.9 28.3 7.5 1.9 0 1.9 38.3 26.6 23.4 6.4 3.2 0 2.1
better care if I had more (14) (15) (7) (2) (2) (0) (1) (22) (10) (15) (4) (1) (0) (1) (36) (25) (22) (6) (3) (0) (2)
time with each patient.
108
Responses to the items on the component Organisational Policies are presented in Table
25. Results indicate that around half of the respondents (49.9%) agreed that nursing staff
had sufficient control over scheduling their own shifts in the hospital. However, 38
(40.3%) raised concerns that nursing administrators did not generally consult with staff
on daily problems and procedures. Around one-third (39.4%) agreed that their voice in
planning policies and procedures for the hospital and the unit where they work was not
regarded as what they want. Around (65.9%) agreed that there is a great gap between the
administration of this hospital and the daily problems of the nursing service, and around
half believed that the administrative decisions at the hospital interfere too much with
daily patient care (45.8%). The majority of respondents (63.8%) agreed there are not
109
Table 25 Index of Work Satisfaction: Organisational Policies
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
7 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
5. The nursing staff has 4.9 19.5 22.0 26.8 14.6 4.9 7.3 5.7 18.9 28.3 9.4 15.1 13.2 9.4 5.3 19.1 25.5 17.0 14.9 9.6 8.5
sufficient control over (2) (8) (9) (11) (6) (2) (3) (3) (10) (15) (5) (8) (7) (5) (5) (18) (24) (16) (14) (9) (8)
scheduling their own
shifts in my hospital.
25. There is ample 4.9 7.3 17.1 51.2 12.2 4.9 2.4 0 11.3 24.5 32.1 17.0 7.5 7.5 2.1 9.6 21.3 40.4 14.9 6.4 5.3
opportunity for nursing (2) (3) (7) (21) (5) (2) (1) (0) (6) (13) (17) (9) (4) (4) (2) (9) (20) (38) (14) (6) (5)
staff to participate in the
administrative decision-
making process.
40. I have all the voice 2.4 9.8 14.6 43.9 9.8 12.2 7.3 3.8 1.9 9.4 37.7 18.9 11.3 17.0 3.2 5.3 11.7 40.4 14.9 11.7 12.8
in planning policies and (1) (4) (6) (18) (4) (5) (3) (2) (1) (5) (20) (10) (6) (9) (3) (5) (11) (38) (14) (11) (12)
procedures for this
hospital and my unit
that I want
42. The nursing 2.4 7.3 17.1 31.7 14.6 14.6 12.2 13.2 3.8 22.6 20.8 22.6 7.5 9.4 8.5 5.3 20.2 25.5 19.1 10.6 10.6
administrators (1) (3) (7) (13) (6) (6) (5) (7) (2) (12) (11) (12) (4) (5) (8) (5) (19) (24) (18) (10) (10)
generally consult with
the staff on daily
problems and
procedures.
** 12. There is a great 19.5 22.0 24.4 19.5 9.8 4.9 0 30.2 18.9 17.0 22.6 1.9 5.7 3.8 25.5 20.2 20.2 21.3 5.3 5.3 2.1
gap between the (8) (9) (10) (8) (4) (2) (0) (16) (10) (9) (12) (1) (3) (2) (24) (19) (19) (20) (5) (5) (2)
administration of this
hospital and the daily
problems of the nursing
service.
** 18. There are not 9.8 17.1 34.1 19.5 17.1 0 2.4 18.9 17.0 30.2 18.9 13.2 1.9 0 14.9 17.0 31.9 19.1 14.9 1.1 1.1
enough opportunities (4) (7) (14) (8) (7) (0) (1) (10) (9) (16) (10) (7) (1) (0) (14) (16) (30) (18) (14) (1) (1)
for advancement of
nursing personnel at
this hospital.
** 33. Administrative 14.6 4.9 21.9 46.3 4.9 4.9 2.4 9.4 13.2 26.4 32.1 11.3 5.7 1.9 11.7 9.6 24.5 38.3 8.5 5.3 2.1
decisions at this (6) (2) (9) (19) (2) (2) (1) (5) (7) (14) (17) (6) (3) (1) (11) (9) (23) (36) (8) (5) (2)
hospital interfere too
much with patient care.
110
Responses to items for the component Pay are shown in Table 26. Results indicate that
only 28 out of 94 nurses were satisfied with their present salary (29.7%), and 64.9% did
not agree with the present rate of increase in pay for nursing service personnel. Nearly all
respondents (85.2%) believed that an upgrading of the pay schedule for nursing personnel
is needed. Around half the sample (53.1%) disagreed that the pay they received is
111
Table 26 Index of Work Satisfaction: Pay Component
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
6 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree ** Reverse
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 Scored
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) Statement.
1. My present salary is 2.4 9.8 12.2 19.5 19.5 4.9 31.7 7.5 17.0 9.4 17.0 24.5 7.6 16.9 5.3 13.8 10.6 18.9 22.3 6.4 23.4
satisfactory. (1) (4) (5) (8) (8) (2) (13) (4) (9) (5) (9) (13) (4) (9) (5) (13) (10) (17) (21) (6) (22)
14. Considering what 2.4 7.3 7.3 29.3 22.0 14.6 17.1 5.7 11.3 9.4 22.6 18.9 20.8 11.3 4.3 9.6 8.5 25.5 20.2 18.9 13.8
is expected of nursing (1) (3) (3) (12) (9) (6) (7) (3) (6) (5) (12) (10) (11) (6) (4) (9) (8) (24) (19) (17) (13)
service personnel at
this hospital, the pay
we get is reasonable.
32. From what I hear 2.4 9.8 9.8 31.7 19.5 12.2 14.6 9.4 9.4 9.4 32.1 26.4 5.7 7.6 6.4 9.6 9.6 31.9 23.4 8.5 10.6
about nursing service (1) (4) (4) (13) (8) (5) (6) (5) (5) (5) (17) (14) (3) (4) (6) (9) (9) (30) (22) (8) (10)
personnel at other
hospitals, we at this
hospital are being
fairly paid.
** 8. It is my 17.1 19.5 26.8 19.5 7.3 4.9 4.9 22.6 20.8 15.1 22.6 9.4 1.9 7.5 20.2 20.2 20.2 21.3 8.5 3.2 6.4
impression that a lot (7) (8) (11) (8) (3) (2) (2) (12) (11) (8) (12) (5) (1) (4) (19) (19) (19) (20) (8) (3) (6)
of nursing personnel
at this hospital are
dissatisfied with their
pay.
** 21. The present 24.4 7.3 34.1 29.3 4.9 0 0 16.9 22.6 24.5 18.9 7.5 5.7 3.8 20.2 16.0 28.7 23.4 6.4 3.2 2.1
rate of increase in pay (10) (3) (14) (12) (2) (0) (0) (9) (12) (13) (10) (4) (3) (2) (19) (15) (27) (22) (6) (3) (2)
for nursing service
personnel at this
hospital is not
satisfactory.
** 44. An upgrading 39.0 24.4 19.5 12.2 0 2.4 2.4 39.6 18.9 28.3 5.7 3.8 0 3.8 39.4 21.3 24.5 8.5 2.1 1.1 3.2
of pay schedules for (16) (10) (8) (5) (0) (1) (1) (21) (10) (15) (3) (2) (0) (2) (37) (20) (23) (8) (2) (1) (3)
nursing personnel is
needed at this
hospital.
112
5.10. Computing the Component Scores.
To calculate the Component Scores, a table was created for each component, using the
formula described by the authors of the IWSS. The scoring system can be found in
Appendix 10. Positively worded statement were given the maximum number of points (7)
for a strongly agree and points of (1) for strongly disagree response. For every negatively
worded statement, the maximum number of points (7) was given for a response of
In order to get the Component Score, the obtained Average Scores for all items in the
component subscale were added, and the mean component subscale score calculated by
dividing this number by the number of items measuring the component. Table 27 presents
the Component Score and the Component Mean Score for each of the six components of
the IWSS.
113
Table 27 Component Score and the Component Mean Score for IWS Scales
114
Table 28 provides responses for each of the six components scores. Results indicate that
Component Score for Professional Status, received the highest satisfaction scores
followed by Interaction, then Autonomy in third place. Organisational Policies and Task
Requirement components were rated fourth and fifth, while the component Pay scored
115
Table 28 Ranking of Satisfaction with IWSS Work Components
116
Finally using weightings derived from the ranking of importance derived in part A of the
questionnaire, satisfaction scores are adjusted to reflect the relative importance of these
various components to this study sample. This is achieved by multiplying the Component
Weighting Coefficient for each component from (Part A) by the Mean Satisfaction Score
for each component from (Part B). The results represent the weights of satisfaction
Component Adjusted Score, for the six components based on the level of importance
placed on each component by the study respondents (see Table 29). According to the
authors of the scale, scores on this scale range from 0.9 to 37.1, with most scores falling
As illustrated in Table 29, there were no changes in the rank of satisfaction following
adjustment for importance, with Professional Status continuing to be the highest area of
117
Table 29 IWS Components Weighted Scores
Speciality Units Nurses (N= 41) General Wards Nurses (N=53) Total Sample (N=94)
Component
weighting Coefficient
weighting Coefficient
weighting Coefficient
Component Adjusted
Component Adjusted
Component Adjusted
(PART B)
(PART B)
(PART B)
Component Mean
Component Mean
Component Mean
111 (PART B)
111 (PART B)
111 (PART B)
Component Scale
Component Scale
Component Scale
1 Component
1 Component
1 Component
Score (Average)
Score (Average)
Score (Average)
Scale Score
Scale Score
Scale Score
(Part A)
(Part A)
(Part A)
Scores
Scores
Scores
1V
1V
1V
11
11
11
Pay 2.92 18.27 3.05 8.91 2.96 19.76 3.29 9.74 2.94 18.97 3.16 9.31
Autonomy 3.18 31.38 3.92 12.47 3.13 31.32 3.92 12.27 3.15 31.35 3.92 12.35
Task 3.07 20.95 3.49 10.71 3.1 20.12 3.35 10.39 3.08 20.46 3.41 10.51
Requirement
Organisational 3.13 25.56 3.65 11.42 2.91 24.52 3.50 10.19 3.00 25 3.57 10.71
Policies
Professional 3.21 32.88 4.70 15.09 3.30 31.45 4.49 14.82 3.26 31.54 4.51 14.7
Status
Interaction 3.1 41.54 4.15 12.87 3.21 38.62 3.86 12.4 3.16 39.82 3.98 12.58
Total Scale Mean Scale Score 3.9 (170.6 / 44) Mean Scale Score 3.8 (165.8 /44) Mean Scale Score 3.79 (167.1/44)
Score
Index of Work Satisfaction: 11.91 [71.47/6] Index of Work Satisfaction: 11.64 Index of Work Satisfaction: 11.69 [70.16 / 6]
[69.81/6]
118
Table 30 present t-tests for all the six IWS components to compare levels of satisfaction
between nurses in general and speciality settings. Since the values of the variables were
normally distributed, Independent sample t-test was used. This analysis revealed no
SPU General
Mean SD Mean SD T test
1 Professional 26.2 4.05 25.8 4.26 T92=.436, p.664
Status
2 Interaction 32.1 5.56 32.3 6.23 T92=.154, p .878
between the total Expanded Nursing Stress Scale score and its nine subscales, and the
IWSS and its six components. Findings indicate that the Component Autonomy was
significantly correlated with the total ENSS score, and ENSS subscales Patient and Their
119
Table 31 Correlations between IWSS and ENSS (n=94)
Organizational
Requirement
Professional
Interaction
Autonomy
policies
status
Task
IWS
Pay
Pearson Correlation -.204(*) -.080 -.159 -.056 -.017 -.071 -.168
ENSS
Sig. (2-tailed) .049 .441 .125 .593 .870 .494 .107
Pearson Correlation -.179 -.059 -.136 -.035 -.048 -.067 -.148
Conflict with Physician
Sig. (2-tailed) .084 .572 .191 .738 .646 .523 .156
Pearson Correlation -.143 -.038 -.189 -.157 -.006 .021 -.140
Death and Dying
Sig. (2-tailed) .169 .713 .068 .130 .957 .844 .179
Pearson Correlation -.100 -.060 -.014 .101 -.023 -.132 -.070
Discrimination
Sig. (2-tailed) .336 .569 .895 .331 .826 .204 .500
Inadequate Emotional Pearson Correlation .018 .013 -.093 .106 -.024 -.026 -.002
Preparation
Sig. (2-tailed) .865 .898 .374 .310 .816 .805 .987
Pearson Correlation -.238(*) -.091 -.145 -.090 -.005 -.136 -.200
Patient and Their Families
Sig. (2-tailed) .021 .381 .164 .386 .961 .191 .053
Pearson Correlation -.084 -.003 -.065 .022 .003 -.075 -.056
Problem Relating to Peers
Sig. (2-tailed) .423 .976 .532 .831 .976 .474 .591
Problem Relating to Pearson Correlation -.224(*) -.072 -.151 .032 -.073 .011 -.139
Supervisor
Sig. (2-tailed) .030 .489 .146 .756 .484 .918 .181
Pearson Correlation -.182 -.056 -.167 -.112 .001 -.052 -.158
Uncertainty
Sig. (2-tailed) .079 .591 .109 .282 .992 .618 .128
Pearson Correlation -.210(*) -.096 -.091 -.078 .008 -.083 -.159
Workload
Sig. (2-tailed) .043 .357 .385 .456 .942 .428 .126
*p<.05
120
5.11. Strategies that are believed to be helpful in assisting the new nurses transition
into
In this section the respondents were requested to rate how helpful they believe each of a
series of items would be in assisting their transition with the new responsibilities in the
workplace as a newly graduated staff nurse (RN) working in todays complex clinical
nursing working environment. They were asked to rate a seven-point likert-type scale by
shading or ticking the relevant bubbles on a scale ranging from 1 to 3 (not helpful at
all); 4 (uncertain); 5 to 7
(extremely helpful). The higher the score the more they agreed with the statement.
Responses to strategies that are believed to be helpful in assisting the new graduates
transition into the workplace as a new graduate nurse are presented in Table 32. Results
indicate that most of the respondents (86.2%) chose Education as the most helpful
strategies in assisting their transition with the new responsibilities in the workplace.
81.9% of the study respondents favoured Team Building Strategies in the second place
and third most common choice was Access to hospital resources with 73 (77.7%). Proper
Mentoring for new graduates by more experienced senior nurses, Flexibility in working
hours, Balancing priorities were also rated highly be more than 75% of the sample. More
than half (65.9%) agreed that Stress management training, and enhancing social and peer
support programs would also benefit strategies. The least most favoured was Protocols to
deals with violence and retention. As illustrated in Table 32, responses from nurses in
121
Table 32: Ratings of Helpfulness of Strategies for Assisting Transition
Please rate how helpful you believe each of the following items would be in assisting your transition into the workplace as a new graduate nurse
Not at all helpful Extremely helpful Not at all helpful Extremely helpful Not at all helpful Extremely helpful
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
No Items % % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
1 Education 0 0 0 7.3 14.6 19.5 58.5 0 7.5 0 11.3 26.4 13.2 41.5 0 4.3 0 9.6 21.3 16.0 48.9
(0) (0) (0) (3) (6) (8) (24) (0) (4) (0) (6) (14) (7) (22) (0) (4) (0) (9) (20) (15) (46)
2 Team building
0 0 0 14.6 19.5 19.5 46.3 5.7 1.9 1.9 11.3 17.0 17.0 45.3 3.2 1.1 1.1 12.8 18.1 18.1 45.7
strategies
(0) (0) (0) (6) (8) (8) (19) (3) (1) (1) (6) (9) (9) (24) (3) (1) (1) (12) (17) (17) (43)
3 Access to hospital
2.4 2.4 2.4 14.6 24.4 24.4 29.3 0 3.8 7.5 11.3 28.3 17.0 32.1 1.1 3.2 5.3 12.8 26.6 20.2 30.9
resources
(1) (1) (1) (6) (10) (10) (12) (0) (2) (4) (6) (15) (9) (17) (1) (3) (5) (12) (25) (19) (29)
4 Mentoring
2.4 0 0 17.1 26.8 29.3 24.4 3.8 0 5.7 7.5 22.6 26.4 34.0 3.2 0 3.2 11.7 24.5 27.7 29.8
(1) (0) (0) (7) (11) (12) (10) (2) (0) (3) (4) (12) (14) (18) (3) (0) (3) (11) (23) (26) (28)
5 Flexibility in working
0 4.9 4.9 19.5 22.0 22.0 26.8 1.9 1.9 3.8 15.1 18.9 28.3 30.2 1.1 3.2 4.3 17.0 20.2 25.5 28.7
hours
(0) (2) (2) (8) (9) (9) (11) (1) (1) (2) (8) (10) (15) (16) (1) (3) (4) (16) (19) (24) (27)
6 Balancing priorities
0 0 2.4 22.0 31.7 29.3 14.6 1.9 3.8 1.9 13.2 22.6 22.6 34.0 1.1 2.1 2.1 17.0 26.6 25.5 25.5
(0) (0) (1) (9) (13) (12) (6) (1) (2) (1) (7) (12) (12) (18) (1) (2) (2) (16) (25) (24) (24)
7 Stress management
12.2 2.4 2.4 14.6 24.4 22.0 22.0 3.8 5.7 3.8 22.6 20.8 15.1 28.3 7.4 4.3 3.2 19.1 22.3 18.1 25.5
training
(5) (1) (1) (6) (10) (9) (9) (2) (3) (2) (12) (11) (8) (15) (7) (4) (3) (18) (21) (17) (24)
8 Enhancing social and
peer support 2.4 0 0 22.0 26.8 31.7 17.1 0 3.8 1.9 20.8 18.9 34.0 20.8 1.1 2.1 1.1 21.3 22.3 33.0 19.1
programs (1) (0) (0) (9) (11) (13) (7) (0) (2) (1) (11) (10) (18) (11) (1) (2) (1) (20) (21) (31) (18)
9 Protocols to deals
with violence and 4.9 0 0 31.7 22.0 22.0 19.5 3.8 5.7 5.7 13.2 28.3 24.5 18.9 4.3 3.2 3.2 21.3 25.5 23.4 19.1
retention (2) (0) (0) (13) (9) (9) (8) (2) (3) (3) (7) (15) (13) (10) (4) (3) (3) (20) (24) (22) (18)
122
5.12 Summary
Despite several studies having addressed stress in nursing, this issue continues to be a
popular topic amongst researchers because of its consequences to individual health and
the organization. For this study, registered nurses with less than three years experience
were surveyed to determine the factors contributing to stress that are frequently occurring
in the workplace. The study also investigated job satisfaction among registered nurses
with less than three years experience working in specialty units and general wards in
Brunei Darussalam.
Responses to the ENSS indicate new registered nurses experience a range of stressful
events while at work. The most common stressful events were uncertainty concerning
patient treatment, and dealing with the patient and their families. The new registered
nurses also rated the stress associated with workload highly. Responses indicated that
problems relating to peers and the experience of being discriminated against in the
workplace were the least stressful events. No significant differences were observed
between the level and sources of stress experienced by registered nurses with less than
Responses to Index Work Satisfaction Scale (IWS) indicated that new nurses rated the
component professional status as being the most important aspect of work, followed by
the component interaction. The least important of all six components was pay.
123
Study participants agreed that education (48.9%), team building (45.7%), access to
balancing priorities (25.5%), stress management training (25.5%), enhancing social and
peer support programs (19.1%) and protocols to deals with violence and retention
(19.1%) would be extremely helpful in assisting their transition into the workplace as a
graduate nurse.
124
CHAPTER SIX
6.0. Discussion
The primary aim of this descriptive correlational study was to investigate perceptions of
stress and levels of job satisfaction of registered nurses within the first three years of
Findings of the study suggest that registered nurses during their early years as a nurse
have been frequently, and in some case, excessively exposed to stressful situations as part
of their daily work. The major stressors they experienced according to most stressful to
the least stressful events as perceived by respondents were assessed by the Expanded
Nurses Stress Scale. Specifically, common sources of stress were uncertainty concerning
patient treatment, dealing with patients and their families, work overload, inadequate
emotional preparation, conflicts with doctors, problems relating to supervisors, death and
dying, conflict relating to peers, and discrimination. These findings are consistent with
those from numerous other studies that suggest that stress in nursing can be derived from
The findings of this study are similar to those of others which have used the Nursing
Stress Scale (e.g., Healy and McKay 1999; Tyler and Cushway 1995; 1992). More
specifically, the most common stressful events that arose for nurses in this study resulted
from factors including Uncertainty Concerning Patient Treatment, in particular the fear
125
of making a mistake in treating a patient, being in charge with inadequate experience, and
fear that the physician would not being present in a medical emergency. Murphy (2004)
similarly identified that newly registered nurses often felt under pressure to take charge
when they were not ready. At these times, their lack of knowledge and experience
frustrated them, as they felt they were not able to give patients correct information.
Murphy also reported that new graduates rated feeling inadequately trained for what they
have to do and being exposed to health and safety hazards as highly stressful events that
are frequently occurring in the nursing working environment. Providing less experienced
nurses with the support needed to develop their knowledge and apply this to their practice
may be helpful.
Issues of Dealing with Patients and Their Families, also commonly provided a source of
stress for nurses. In particular, when the patients family made unreasonable demands,
when nurses were blamed for anything that goes wrong, and when they did not know
whether the patients family will report them for inadequate care placed the nurses in
especially difficult situations. Of much concern to many new registered nurses is the
stress experienced when dealing with abusive patients and abusive patients families. It
is likely that impact of such experience will lead to psychological distress, self doubt and
a significant amount of loss of respect (Michael and Jenkins, 2001). A study by Lin and
Liu (2005) reported that violence occurring in hospitals was mainly due to
mentally unstable. Tabone (2001) suggests the solution for these problems is to identify
the sources of this violence, and advocate on behalf of nurses to ensure the quality of the
126
work environment and patient care. Having clear written policies as a guideline for
dealing with abusive patients and patients (Johnson, Moss, Clarke, and Armistead, 1996)
Nurses in this study also reported that Work Overload was common, in particular not
having enough staff to adequately cover the unit as a result of unpredictable staffing and
scheduling. Shift work often introduces additional hardship on nurses providing services
who were burdened with extra responsibilities such as having too many non nursing
tasks, having to work through breaks, and in some case having to make decisions under
pressure are important concerns that require attention. Many nurses in this study reported
that there was not enough staff to get the work done, and that this resulted in them not
having enough time to provide emotional support to the patient and to respond to patient
needs.
Work satisfaction levels for nurses in this study were at a moderate to high level for most
components. Specifically, the component Professional Status was chosen as the most
important component of work satisfaction. Despite its importance, many nurses in this
study reported that they believed that nursing is not widely recognised as being an
Nursing roles are rapidly expanding in areas including performing minor surgery,
prescribing medicines and treatments, making and receiving direct referrals, admitting
127
and discharging patients for specified conditions, managing patient caseloads, running
clinics and taking a lead in the way local health services are organised (Hilpern, 2002).
While presenting significant challenges, responses of nurses in this study indicate that
many nurses did not hold the view that their job does not add up to anything really
significant. This high level of satisfaction with the nursing role may reflect the increasing
value being placed on some aspects of nursing, due to the growing demand for nursing
services associated with the ageing population growth and increased opportunities for
2006; Mee and Robinson, 2003; Spratley et. al 2002). When nurses are satisfied in their
jobs, they are more likely to remain in nursing (Roberts, Jones and Lynn, 2004). The
importance of nursing work to health care thus needs to continue to be supported and
promoted.
Respondents also reported that the component Interaction was important to job
satisfaction. New registered nurses agreed that the nursing personnel in their wards/units
always help one another out when things get in a rush and they also agreed that there is a
good deal of teamwork and cooperation between various levels of nursing personnel in
tenure in an organization is one process that has been recognized to promote job
work setting or country, it is very important for nurses to share and be committed to a
holistic philosophy of care. This perhaps more than anything else that shapes their
128
Not surprisingly, new registered nurses expressed that it was hard for them to feel at
limited interaction with experienced nurses and staff. Jackson (2005) identified that new
registered nurses were striving to develop a level of care and competency and unlike
expert nurses, they did not have vast experience and knowledge to work effectively as
part of the team. Numerous writers have suggested that manager behaviours can have a
subordinate relationship is the most commonly reported cause of stress within a work
team, and this appears to be associated with a reduction in performance (De Dreu and
Weingart, 2003). Attention to these issues is therefore important in any transition support
Many respondents agreed with statements that the physicians in their ward/units should
show more respect for the skill and knowledge of the nursing staff. Because studies have
found that role conflict and ambiguity are positively correlated with job dissatisfaction,
and can generate low organizational commitment and increased psychological and
relationships (Sherman, 1998). While most nurses reported that physicians at this hospital
generally understood and appreciated what nursing staff do, and would cooperate and
work as part of a team, many still perceived physicians as looking down too much on the
129
The findings of this study also indicate nurses rated the component Autonomy as an
important component of their job satisfaction. Nearly half agreed that they have sufficient
input into the program of care for each of their patients, and that they dont require close
supervision. Registered nurses in this study agreed that they have freedom in their work
to make decisions as they see fit, and can count on their supervisor for back up.
Transition programs specifically designed to bridge the gap between the academic and
service setting and to prepare novice nurses to utilize critical thinking skills in the
management of acutely ill patients are therefore likely to be important to ensure nurses
are confident to deal with the degree of autonomy they are required to demonstrate as a
registered nurse (Halfer, 2007). Indeed, some authors argue that such programs are
especially helpful for developing effective decision making power and improving a new
Moreover, satisfaction with autonomy in the workplace has been identified in this study
as being especially important, since it is moderately correlated with the overall stress
score, and with ENSS subscales of patients and families, problems with supervisors and
workload. Specifically, higher levels of satisfaction with autonomy were associated with
lower levels of stress in all these domains. Similarly, nurses perceptions of their level of
organization was associated with several ENSS subscales, including stress associated
with treatment uncertainty, patients and families, workload, conflict with doctors,
registered nurse.
130
Task Requirements were also rated by nurses in this study as an important component of
job satisfaction. The majority of respondents were satisfied with their job activities
however, a notable proportion expressed concern that there was too much clerical and
Nurses (2007) reports argue that nurses today are often stressed because of heavy
workloads. Such work related stressors are reported to be correlated with increases in job
1994).
Of particular note, almost half the nurses in this study believed that they did not have
sufficient time for direct patient care and they did not have plenty of time and opportunity
to discuss patient care problems with other nursing personnel. Many also believed that
they could deliver much better care if they had more time with each patient. Studies
suggest that perceptions of the quality of ones work are related to job satisfaction
(Murphy, 2004), and that higher job satisfaction is associated with increased attention to
patient psychological and educational needs (Perumal and Sehgal, 2003). Moreover, high
patient-to-nurse ratios have been linked to higher patient mortality and lower nurse job
satisfaction (Aiken, Clarke, Sloane, Sochalski and Silber, 2002). The current shortages of
nurses will thus continue to challenge the ability of nurses to meet the needs of their
patients (ICN, 2007), thereby potentially providing a situation where levels of work
131
With respect to the Organizational Policies component of job satisfaction, most of the
respondents reported having sufficient control over scheduling their own shifts in the
hospital. However, many raised concerns that nursing administrators did not generally
consult with the staff on daily problems and procedures and that their voice in planning
policies and procedures for the hospital and the unit where they work was not regarded as
what they want. Many nurses in this study also agreed that there is a gap between the
administration of the hospital and the daily problems of the nursing service. Such factors
may contribute to decreased job satisfaction and an employees disengagement from the
conducive to a supportive and flexible work environment are important considerations for
administrators and policy makers if work satisfaction levels are to be high (Kovner,
The International Council of Nurses (2007) has also outlined the characteristics of
positive practice environments that are needed to deal with these situations. These
environment.
Findings also indicate that t Pay was important, although it was the area with which
nurses were least satisfied. Although nurses were satisfied with their present salary, the
majority of them did not agree with the present rate of pay increases for nursing service
132
personnel. Many agreed that an upgrading of pay schedule for nursing personnel is
needed at the hospital, and most disagreed that the pay they received is reasonable given
reported that job dissatisfaction among nurses were worsened by migration of nurses in
search for better working conditions, quality of life and higher paying jobs in richer
countries. In Ghana, for instance the migration of nurses was double than the number of
nursing graduates in the year of 2000, resulting in a major nursing workforce crisis
(ICN). The impact of nurse migration on nursing in Brunei is not well described.
A key finding of this study was that no significant differences were noted in levels of
stress or work satisfaction for nurses working in specialty areas of practice compared to
those in general medical/surgical units. While the sample size for this study was small,
such findings emphasise that the experience of stress for registered nurses in the first few
years following graduation has some common elements, no matter what the work
environment. Such stressors seemed to be common across nurses with different years of
nurses with less than 1 year experience reported higher mean stress scores for the
Relating to Peers subscales. Nurses with less experience also reported higher total stress
scores than nurses with more than 1 year experience. These results emphasise that
registered nurse.
133
As mentioned in the earlier chapters, nursing manpower comprises the largest component
of the health care workforce in Brunei Darussalam hospitals (MOH, 2007). Nurses
vigilance is crucial to keeping patients and the community safe and healthy. The stability
and quality of Brunei Darussalam health care system relies on a sufficient supply of well-
educated and skilled nurses. Increasing job stress and low job satisfaction among nurses
in hospitals in Brunei Darussalam may therefore place the system at risk of lower quality
unsafe practices. Brunei is experiencing rapid population growth in several districts, and
an increasingly diverse population requiring better health care services (MOH, 2008).
The shortage of nursing manpower is occurring when the majority of experienced nurses
are retiring and their place is being taken up by inexperience nurses. This study has
identified areas of job stresses and job satisfaction experienced by nurses in hospitals and
clinics in Brunei Darussalam that may have important implications for managers and
educators.
6.1. Implications
In this current study, the findings have several important implications for nursing practice
and education. There is also a need for more research to be carried out. Perhaps the most
important implication is the need for collaboration between education and service sectors
in the development of programs which address the types of stressors and concerns
reported by nurses in this study. The findings of this study allow educators to redesign
educational approaches to support the role transition of new graduate nurse. At the same
time, the nursing service personnel need to consider a redesign of their internship
134
program to assist nurses to overcome challenges associated with stressors such as
uncertainty of treatments, and relationships with other health professionals. For example,
additional mentoring strategies may assist to promote critical thinking, foster peer
networking and discussion, and support professional role transition throughout the few
The United Kingdom Central Council has highlighted the importance of continuing
nursing education together with close clinical supervision by mentors for new registered
nurses to enable them to adjust to the demands of nursing profession during the critical
12 to 18 months taking up their career (UKCC, 1996). The findings of this study will
assist hospital administrators, educators and others nursing leaders in formulating the
future professional nurses (RN). More specifically, nurses in this study have highlighted
registered nurse. These include education, team building, access to hospital resources to
nurses also identified that organisational policies that are flexible and which assist with
positive practice environments: (1) a climate of safety for nurses and patients
system and reporting system); (2) a climate of organisational support for life long
135
learning (encourage life long learning by supporting professional development and the
mutual sharing of knowledge, they become learning organisation); and (3) a climate of
employees, nurses express greater job satisfaction and patients achieve better outcomes).
Programs of support for registered nurses need to include educational, team based,
organisational, and professional activities that will create this type of climate.
This study has several limitations. Most importantly, the study has addressed only
selected concepts important to our understanding of stress. The scope of this study
included an examination of perceived sources of stress and its links with work
satisfaction only. It was beyond the scope of this study to undertaken a comprehensive
analysis of other key concepts on stress theory, such as appraisal and coping. It was also
beyond the scope of this study to examine the implications of stress and coping for the
health and well being of nurses in this study, and the impact on the quality of care
provided. Such research is urgently needed to better understand the types of intervention
strategies that are needed at the system, organizational and individual level to minimise
There are also a number of methodological limitations of this study. The study includes
non-probability random sampling of new registered nurses who have experienced the
136
complex clinical nursing working environment in one hospital setting. Though the sample
involved all new graduate nurses (N=120) working in the general surgical and medical
and specialty units at the time of survey, and a high response rate was achieved, it is
relatively small in number as participation was voluntary. Moreover, the sample excluded
nurses who were on leave at the time of data collection. While it is unlikely that this
Nearly all of the samples were past students of the investigator, as they had recently
completed their nursing education in Pengiran Anak Puteri Rashidah Saadatul Bolkiah
resulting from the previous ex-students-teacher relationship, as the respondents may wish
to respond in socially desirable ways. In order to avoid this, the investigator assured all
participants of privacy and anonymity throughout the study. All nurses who were selected
as the study sample were aware that participation was voluntary. The participants
opportunity to receive an explanation of the nature and purpose of the study in a small
group presentation in units and wards three days prior to conducting the study, and
Participants were given sufficient time to complete the survey questionnaires at their own
pace or outside their working hours within three weeks and return the completed
questionnaires to the investigator either by mail using the pre stamped envelopes
137
provided or by placing them in sealed boxes at the nurses station in each unit. During the
data collection period, the investigator had no direct contact with the study participants.
The advantages of using self administered questionnaires as data collecting tool for this
study was that they were relatively less costly, offered complete anonymity for
collecting self reported data on stress and coping assumes that the study respondents have
clearly understood the questions and that they are able to define their stressors
(Wegmann, 1992), even if they understand and are able to speak English as their second
more superficial largely because they typically contain mostly a fixed number of closed-
ended items. Much of the richness and complexity of respondents experiences are lost or
unanswered. In reality, some stressors are taboo, and recall of others may cause
discomfort and therefore are not readily recalled (Gillespie and Kermode, 2004).
The study findings reported here reflect the experiences of registered nurses with less
than three years experience from the specialty units and general surgical and medical
wards RIPAS Hospital, Brunei Darussalam. These findings provide nurse managers,
educators and hospital administrators in the country with findings that will assist with
several areas that require future research. These may include another replication study
138
carried out at multiple sites with different sample of nurses, and more in-depth enquires
into each major stress source that has been identified in this study. In addition, further
are needed to better understand concepts such as the influence of stress appraisal, and the
relationships between various coping strategies and positive outcomes for nurses.
6.4. Conclusion
It appears from previous studies that the nursing workplace is often stressful and that this
issue should not be ignored. Ganga (1998) argues it is obvious that nurses experience
stress in the clinical setting, and that there are no easy solutions to the problems of stress
in nursing education and practice. It is the role of the nurse educators, managers, and
administrators to find ways to make the nursing workplace more harmonious, pleasant
and less stressful, especially to new graduate nurses. The findings of this limited study
will assist nursing educators, directors and human resources managers to determine
coping strategies that might help in reducing amounts of stress experienced by new
graduate nurses in their day to day challenging and demanding nursing roles.
Stress is an unavoidable part of human life. Some stress may be normal and necessary,
but too much of it may affect the quality of life and health (WHO, 2004). The effects of
stress can be reduced by early identification of its problems, understanding its potential
contributing factors and finding effective coping strategies In this study, registered nurses
with less than three years experience were asked to nominate what they believed to be the
139
most effective ways to relieve the workplace stress and what would be extremely helpful
in assisting the new registered nurses transition as a practicing professional nurse. Ways
to reduce and avoid unnecessary stress that were suggested by participants in this present
enhancing social and peer support programs and, finally, protocols to deal with violence
administrators to ensure positive practice environments for nurses, and the best outcomes
140
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Appendix 1
PERKHIDMATAN KEJURURAWATAN
PEJABAT PENGARAH PERKHIDMATAN KEJURURAWATAN
JALAN MENTERI BESAR
Telephone: 3820 18 BANDAR SERI BEGAWAN BB3910
NEGARA BRUNEI DARUSSALAM
381640 ext 7727
NURSING SERVICES
Fax 380687 DIRECTOR OF NURSING SERVICES OFFICE
JALAN MENTERI BESAR
BANDAR SERI BEGAWAN BB3910
BRUNEI DARUSSALAM
Rujukan Kami :
PPK/lNT/39/2000 1 4 September 2005
Our Reference :
Mr Rahim Damit
Room N-602 (level 6)
QUT School of Nursing
Victoria Park, Kelvin Grove
Queensland 4059
Australia
Following the review of the information stated in the letter with regards to the proposed
topic, the objectives, target sample and sample size, the setting and site, the department
considered them as sufficient and appropriate. The Department also foresees the potential
benefit of the proposed study towards enhancement of working environment in the context
of practice delivery. I wish you could share the finding with us after you complete the study
later.
I would like to state that there is no Ethics Committee as yet within the Ministry, However,
the Director General of Medical Services has no objection to your proposal and permission
is being granted for you to undertake the proposed study with conditions that you adhere to
the ethical aspects and other related issues that need to be observed in conducting the
research.
Dear Mr Damit,
Re: REQUEST FOR NEW DATE / TIME LINE FOR CONDUCTING
RESEARCH PROJECT
Referring to your letter dated 27th February 2006 regarding the above to conduct the
research project at Raja Isteri Pengiran Anak Saleha Hospital, Ministry of Health.
In relation to that, I have no objection to your proposed change of date (6th ~ 30th March
2006) and duration in order to enable you to conduct and complete the project, and
involving the specified number of nurses within the Hospital setting.
I look forward for you to share the finding of your research later as it is important for the
improvement of the service delivery at the Raja Isteri Pengiran Anak Saleha Hospital.
Sincerely
To:
Director General
Medical Services Department
Ministry of Health
Brunei Darussalam
16th August 2005.
Dear Dr Haji/Sir,
The primary aim of this study is to investigate new graduate nurses perceptions of
stress in todays complex clinical working environment.
1. Identify and describe levels and sources of stress experienced by new graduate
nurses
2. Compare levels of stress experienced by new graduate nurses working in
operating theatre and surgical units and intensive care units.
3. Explore the relationship between workload, new complex working environment
and levels of stress among new graduate nurses in operating theatre and surgical
units and intensive care units.
I am, therefore requesting a permission to carry out a research project in Raja Isteri
Pengiran Anak Saleha (RIPAS) Hospital. The project will be commencing on the 1st
December 2005 and expected to be complete by 27th February 2006. Some of 200 new
graduate nurses with less than 2 years working experience as staff nurse in the new complex
clinical working environment will be involved in the project. These may include nurses
working in the speciality areas such as Operating Theatre, Surgical, Medical Units/Wards,
Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU), Surgical Intensive Care
Unit (SICU), Paediatric Intensive Care Unit (PICU), Special Care Baby Unit (SCBU),
Otorhinolaryngology and integrated Head and Neck Department, and Accident and
Emergency Department (A&E). The research findings will be used to plan for the future
needs for the improvement of our Nursing Education; Clinical Nursing Practice, Generating
New Knowledge as well as to plan in creating good nursing working environment in Brunei
Darussalam.
Appendix 1
If you have any concerns or require further information about the project and have
any questions, please contact;
Your permission and consideration for me to carry out this project is highly
appreciated. Your response to this letter can be address to:
I would like to take the opportunity in advance to say thank you for your
consideration and any information that you can give me.
Yours sincerely
Mr Rahim Damit
Appendix 1
cc.
Director of Nursing Services, Nursing Services Department, Brunei Darussalam. Ministry of Health.
Director of Medical Services. Medical Services. Ministry of Health.
Director of Technical Education, Technical and Vocational Department. Ministry of Education.
Principal, Pengiran Anak Puteri Rashidah Saadatul Bolkiah College of Nursing.
Chief Executive Officer, RIPAS Hospital. Ministry of Health.
Principal Nursing Officer, RIPAS Hospital. Ministry of Health.
Senior Nursing Officers, OT; MICU; CCU; ORL; PICU; SICU; SCBU; A & E; Surgical Wards/Units.
RIPAS Hospital. Ministry of Health.
Appendix 1
Faculty of Health
School of Nursing
Queensland University of Technology
To:
Director General
Medical Services Department
Ministry of Health
Brunei Darussalam
27th February 2006.
Dear Dr Haji/Sir,
The new proposed date for the project to be commencing is on the 6th March 2006
and expected to be complete by 30th March 2006. Some of 200 new graduate nurses with less
than 3 years working experience as staff nurse in the new complex clinical working
environment will be involved in the project. These may include nurses working in the
speciality areas such as Operating Theatre, Surgical, Medical Units/Wards, Medical Intensive
Care Unit (MICU), Coronary Care Unit (CCU), Surgical Intensive Care Unit (SICU),
Paediatric Intensive Care Unit (PICU), Special Care Baby Unit (SCBU), Otorhinolaryngology
and integrated Head and Neck Department, and Accident and Emergency Department (A&E).
The research findings will be used to plan for the future needs for the improvement of our
Nursing Education; Clinical Nursing Practice, Generating New Knowledge as well as to plan
in creating good nursing working environment in Brunei Darussalam.
I am very grateful of the support from Dr Haji and the Ministry of Health Brunei
Darussalam to be able to undertake this important project so that the health care system can
benefit from this new knowledge.
I would like to take the opportunity in advance to say thank you for your
consideration.
Yours sincerely
Mr Rahim Damit
Room N-602 (level 6)
School of Nursing
Queensland University of Technology (QUT), Brisbane Australia.
Phone : 8891226
Home : 2447512
Fax : 2447512
Appendix 2
Date: Wed 7 Mar 13:39:28 EST 2007
From: "Janette Lamb" <jd.lamb@qut.edu.au> Add To Address Book | This is
Spam
Subject: re ethics clearance -- 0600000023
To: <h.hajidamit@student.qut.edu.au>
Dear Abd
Thank you for providing the Progress Report in relation to ethical clearance for your
project, QUT Ref 0600000023 Stress in new graduate nurses: a comparative analysis
between intensive care units and general wards.
Information regarding the completion of this project will be provided to the University
Human Research Ethics Committee at its next meeting. I will only contact you again in
relation to this matter if the Committee raises any additional questions or concerns.
Please do not hesitate to contact me if you have any further queries in relation to this
matter.
Yours sincerely
Janette Lamb
Research Ethics Support | Office of Research
If you have any queries regarding this email please call or email,
however,
it would be appreciated if communication regarding the status of your
Appendix 2
application could be held over until the outcome period has passed,
unless
approval is required urgently.
Kind regards
David Wiseman
Research Ethics Officer
Appendix 2
Date: Tue 24 Oct 11:21:00 EST 2006
From: "Lisa Reyes" <l.reyes@qut.edu.au> Add To Address Book | This is Spam
Subject: RDC Reply: OS Fieldwork - Abd Rahim DAMIT (#5142555/HL84)
To: <h.hajidamit@student.qut.edu.au>
Cc: "Kristy Bensley" <k.bensley@qut.edu.au>, "Team E QUT International"
<qut.intadmission-e@qut.edu.au>, "MS Sheree Smith"
<sm.smith@qut.edu.au>
Hi Abd Rahim
OVERSEAS FIELDWORK
The Research Degrees Committee and the International Students Business Services
have approved your request for Overseas Fieldwork from 13August 2006 to 30
March 2007.
This leave does not affect your Candidature Milestone Dates. You can access your
milestones on the student portal Portia. Portia can be accessed via QUT Virtual and
you will need your QUT Access username and password - log in as Student and use
the first 10 digits of your current QUT student password.
Please contact your Faculty Research Administration Officer or the Research Student
Centre if you have any queries relating to your candidature.
Regards
Lisa
Appendix 3
Date: Mon 18 Jul 09:10:53 EST 2005
From: Sheree Smith <sm.smith@qut.edu.au> Add To Address Book | This is Spam
Subject: Fwd: ENSS
To: h.hajidamit@student.qut.edu.au
Dear Sheree
I am sending you a copy of the ENSS, directions for usage and information on the
grouping og the items.
If you wish to use the instrument you have our permission to do so.
Susan
Sheree M S Smith
Lecturer,
Queensland University of Technology,
Kelvin Grove Campus,
Kelvin Grove,
AUSTRALIA 4059
email: sm.smith@qut.edu.au
telephone 61+ 7 + 38643905
Appendix 3
by
1995
1
School of Nursing, McMaster University
2
Department of Sociology, McMaster University
3
Department of Geography, McMaster University
Appendix 3
Expanded Nursing Stress Scale
Below is a list of situations that commonly occur in a work setting. For each situation you
have encountered in your PRESENT WORK SETTING, would you indicate HOW
STRESSFUL it has been for you:
(Enter the number in the right hand column that best applies to you. If you have not
encountered the situation, write 0'.)
37. The death of a patient with whom you developed a close relationship. ___
38. Making a decision concerning a patient when the
physician is unavailable. ___
39. Being in charge with inadequate experience. ___
40. Lack of support by nursing administration ___
41. Too many non-nursing tasks required, such as clerical work ... ___
42. Not enough staff to adequately cover the unit.. ___
43. Uncertainty regarding the operation and functioning
of specialised equipment.. ___
44. Having to deal with abusive patients ___
Appendix 3
Never Occasionally Frequently Extremely Does Not
Stressful Stressful Stressful Stressful Apply
1 2 3 4 5
45. Not enough time to respond to the needs of patients families.. ___
46. Being held accountable for things over which I have no control.. ___
47. Physician(s) not being present when a patient dies... ___
48. Having to organise doctors work. ___
There are a total of 59 items in the Expanded Nursing Stress Scale. Two items (#6
and #14) did not appear to be related to any of the nine subscales that emerged in
the original study of Ontario nurses (Susan French, Rhonda Lenton, John Eyles and
Vivienne Walters. "An Empirical Evaluation of an Expanded Nursing Stress Scale".
Journal of Nursing Measurement, Vol. 8, No. 2, 2000), but we suggest retaining
those items for now. Subsequent applications would be able to assess whether
these two items load on the subscales in any situations or among different
populations of nurses. The nine subscales that have emerged, and the items in each
subscale are as follows:
In order to compute total stress score, we added together the scores on all 59 items.
In order to measure scores on specific subscales, the appropriate items should be
added together. In all cases, the category not applicable was scored as 0.
Addressing missing data depends on the extent of the problem. While several
options are available (some more complicated, such as using a regression method to
estimate missed scores), we substituted missing values with mean scores for
individual items, and proceeded to calculate the subscale score for any individual
who had answered the majority of items in any subscale. In the case of the Death
and Dying subscale, for example, an individual would have to have answered at
least 4 of the 7 items that comprise the subscale. Otherwise, the subscale was not
constructed, and the individual received was scored missing for that specific
subscale.
Items were scored so that the higher the score, the greater the stress on any
subscale.
It would be appreciated if you would forward a copy of your analysis of the ENSS to
Dr. Lenton, at York University, and to Dr. Susan French at McGill University, so that
we are able to monitor the assessment of the ENSS.
Criticism by a physician.
Conflict with a physician.
Disagreement concerning the treatment of a patient.
Making a decision concerning a patient when the physician is unavailable.
Having to organize physicians work.
Feeling inadequately prepared to help with the emotional needs of a patients family.
Being asked a question by a patient for which I do not have a satisfactory answer.
Feeling inadequately prepared to help with the emotional needs of a patient.
Lack of an opportunity to talk openly with other unit personnel about problems in the work setting.
Lack of an opportunity to share experiences and feelings with other personnel in the work setting.
Lack of an opportunity to express to other personnel on the unit my negative feelings toward patients.
Difficulty in working with a particular nurse (or nurses) outside my immediate work setting.
Difficulty in working with a particular nurse (or nurses) inside my immediate work setting.
Difficulty in working with nurses of the opposite sex.
Factor 9: Discrimination
Department of
Community Health Studies
MASS.
voice: 413.545.1312
fax: 413.545.6536
Phoneorders: 301-362-6905
FAX # 301-206-9789
ISBN #1 -56793-061-1
The IWS questionnaire is a copyrighted measurement tool, with the copyright held by
myself and Market Street Research, Inc., a full-service marketing research and evaluation
firm located in Northampton, Massachusetts. If you wish to use the IWS questionnaire, a
fee of $30.00 payable to Market Street Research covers permission to use the
questionnaire, a print-ready hard copy formatted for use in your study, and an IBM-
compatible floppy diskette which you can use in the event you wish to add questions of
interest to your particular area of research. Other services available from Market Street
Research include:
A step-by step instruction manual so you can score the IWS yourself
Data entry services; scoring assistance and basic data analysis
Technical assistance in modifying or expanding the questionnaire
I have enclosed a complete description of these services as well as a price list. Please
send any checks directly to Market Street Research, using the order form I have included.
If you do decide to use the IWS in your study, you will need the scoring manual unless
you would like for Market Street Research to do the scaring for you. This scoring service
comes with a basic analysis and results are available quickly. If you have any questions
about the IWS or any of the support services available for users of the IWS, please call
either myself or Market Street Research. Market Street Research does not need a separate
letter from you.
I would very much appreciate hearing about your results, as I am keeping a file of the
types of research for which people are using the IWS. Good luck with your study and feel
free to contact me for any additional information.
Sincerely,
2. Scoring instructions. A packet that gives step-by-step instructions for scoring the IWS is
available for $60.00. The packet describes the method for scoring both parts of the
questionnaire. The instructions for each part are given separately for those who are using
only one part of the scale. These instructions may be used by researchers to create their
own computerized scoring programs, if desired.
3. Scoring service with data entry. For those who do not wish to score their own
questionnaires, completed questionnaires can be scored by Market Street Research. The
fee will vary depending on the number of questionnaires to be entered and analyzed, the
degree to which researchers added to or otherwise modified the IWS, and the level of
analysis. If the copyrighted IWS questionnaire is used as is, the baseline fee for a sample
size of 50 nurses is $975.00 plus $2.30 per additional questionnaire. This fee includes data
entry and scoring, with users receiving a summary of the scores and a data file on diskette.
4. Scaring service without data entry. Some organizations have the ability to do their own
data entry of completed questionnaires, but would like assistance in scoring the IWS.
Market Street Research will provide these researchers with instructions an formatting the
data appropriately. The fee far simple scoring of the IWS is $775.00 per data set.
5. Technical assistance in design. Although many studies using the IWS are
straightforward, some involve more complicated designs. Some studies using the IWS
involve management or job redesign initiatives and are primarily concerned with evaluation.
Assistance is available in designing these studies and interpreting the results. Management
consulting, the creation of altemative managerial systems, and evaluation and marketing
research services are also available. Prices for this are determined based on individual
requirements.
Users must receive permission to use the copyrighted version of the IWS in order to
access the support servicesprovided by Market Street Research, In addition, researchers who
request IWS scoring services will be asked to submit summary information for their research
projects to Market Street Rasearch, which will be incorporated in a national data base that we
are developing. Your results will be held strictly confidential, and will be combined with those of
other research projects in order to build a better understanding of the variations in IWS results
among diverse institutions. For questions relating to use of the national data base, please
contact Paula Stamps.
Appendix 4
Name:
Organization:
Address:
Phone: Fax:
TYPE OF ORGANIZATION:
hospital managed care organization
This letter gives Abd Rahim Damit permission to use the copyrighted Index of Work
Satisfaction. It maybe re-published in its original form or a modified form.
Sincerely,
Doreen Masi
Market Street Research
Appendix 4
Date: Tue 22 Nov 03:20:17 EST 2005
From: Doreen Masi <dmasi@marketstreetresearch.com> Add To Address
Book | This is Spam
Subject: Your Index of Work Satisfaction Order
To: h.hajidamit@student.qut.edu.au
Hello Abd,
My name is Doreen Masi, I work at Market Street Research. I received
your order for IWS questionnaire and Scoring Manual in Friday's mail.
To make things easier, I could send you both items via email to this
email address. I wanted to check in with you before doing so. If
you
could reply to this email and let me know if I can send off the items
via email, that would be great. The questionnaire would be in Word
6.0
and the scoring manual would be a pdf file. Please let me know how
to
proceed.
I look forward to hearing back from you,
Doreen
--
Doreen Masi
Office Manager
Market Street Research
2 Maple Avenue, Suite 52
Northampton, MA 01060
413-584-0465
fax: 413-582-1206
dmasi@marketstreetresearch.com
Appendix 4
Date: Wed 23 Nov 05:01:21 EST 2005
From: Doreen Masi <dmasi@marketstreetresearch.com> Add To Address
Book | This is Spam
Subject: Re: Your Index of Work Satisfaction Order
To: h.hajidamit@student.qut.edu.au
Hi Rahim,
I'm very glad you liked my idea and hopefully this will speed things
along for you. Attached you will find the questionnaire and the
scoring manual. I have also included a letter of permission to use
the survey, just in case you need to submit a document such as this
with your study. If I can be of further assistance, do not hesitate
to contact me.
h.hajidamit@student.qut.edu.au wrote:
Thanks a lot. That would be great. Yes you could send those
items to this email address.
Kindly regards,
Rahim Damit
h.hajidamit@student.qut.edu.au
+614 2495 4660
+617 3252 0250
H67
Cathedral Place
41 Gotha Street
FORTITUDE VALLEY
QLD 4006
Brisbane
Queensland
Australia
Doreen Masi
Office Manager
Market Street Research
2 Maple Avenue, Suite 52
Northampton, MA 01060
413-584-0465
fax: 413-582-1206
dmasi@marketstreetresearch.com
Please carefully read the definitions for each factor as given below:
Pay -- dollar remuneration and fringe benefits received for work done
It will be difficult for you to make choices in some cases. However, please
do try to select the factor which is more important to you. Please make an
effort to answer every item; do not go back to change any of your answers.
Instructions: Please circle the number that most closely indicates how
you feel about each statement. The left set of numbers indicates degrees of
agreement. The right set of numbers indicates degrees of disagreement.
For example, if you strongly agree with the first item, circle 1; if you agree
with this item, circle 2; if you moderately agree with the first statement, circle
3. The middle response (4) is reserved for feeling neutral or undecided.
Please use it as little as possible. If you moderately disagree with this first
item, you should circle 5; to disagree, circle 6; and to strongly disagree,
circle 7.
IWS Questionnaire 2
Appendix 4
Part B (Attitude Questionnaire, Continued)
Remember: The more strongly you feel about the statement, the further
from the center you should circle, with agreement to the left and
disagreement to the right. Use 4 for neutral or undecided if needed, but
please try to use this number as little as possible.
Agree Disagree
1. My present salary is satisfactory. 1 2 3 4 5 6 7
2. Nursing is not widely recognized as being an
important profession.
1 2 3 4 5 6 7
3. The nursing personnel on my service pitch in and
help one another out when things get in a rush.
1 2 3 4 5 6 7
4. There is too much clerical and paperwork required
of nursing personnel in this hospital.
1 2 3 4 5 6 7
5. The nursing staff has sufficient control over
scheduling their own shifts in my hospital.
1 2 3 4 5 6 7
6. Physicians in general cooperate with nursing staff
on my unit.
1 2 3 4 5 6 7
7. I feel that I am supervised more closely than is
necessary.
1 2 3 4 5 6 7
8. It is my impression that a lot of nursing personnel at
this hospital are dissatisfied with their pay.
1 2 3 4 5 6 7
9. Most people appreciate the importance of nursing
care to hospital patients.
1 2 3 4 5 6 7
10. It is hard for new nurses to feel at home in my unit. 1 2 3 4 5 6 7
11. There is no doubt whatever in my mind that what I
do on my job is really important.
1 2 3 4 5 6 7
12. There is a great gap between the administration of
this hospital and the daily problems of the nursing 1 2 3 4 5 6 7
service.
13. I feel I have sufficient input into the program of care
for each of my patients.
1 2 3 4 5 6 7
14. Considering what is expected of nursing service
personnel at this hospital, the pay we get is 1 2 3 4 5 6 7
reasonable.
15. I think I could do a better job if I did not have so
much to do all the time. 1 2 3 4 5 6 7
16. There is a good deal of teamwork and cooperation
between various levels of nursing personnel on my 1 2 3 4 5 6 7
service.
IWS Questionnaire 3
Appendix 4
Part B (Attitude Questionnaire, Continued)
Remember: The more strongly you feel about the statement, the further
from the center you should circle, with agreement to the left and
disagreement to the right. Use 4 for neutral or undecided if needed, but
please try to use this number as little as possible.
Agree Disagree
17. I have too much responsibility and not enough
authority. 1 2 3 4 5 6 7
18. There are not enough opportunities for
advancement of nursing personnel at this hospital.
1 2 3 4 5 6 7
19. There is a lot of teamwork between nurses and
doctors on my own unit.
1 2 3 4 5 6 7
20. On my service, my supervisors make all the
decisions. I have little direct control over my own 1 2 3 4 5 6 7
work.
21. The present rate of increase in pay for nursing
service personnel at this hospital is not satisfactory.
1 2 3 4 5 6 7
22. I am satisfied with the types of activities that I do on
my job.
1 2 3 4 5 6 7
23. The nursing personnel on my service are not as
friendly and outgoing as I would like.
1 2 3 4 5 6 7
24. I have plenty of time and opportunity to discuss
patient care problems with other nursing service 1 2 3 4 5 6 7
personnel.
25. There is ample opportunity for nursing staff to
participate in the administrative decision-making 1 2 3 4 5 6 7
process.
26. A great deal of independence is permitted, if not
required, of me.
1 2 3 4 5 6 7
27. What I do on my job does not add up to anything
really significant.
1 2 3 4 5 6 7
28. There is a lot of rank consciousness on my unit:
nurses seldom mingle with those with less
experience or different types of educational
1 2 3 4 5 6 7
preparation.
29. I have sufficient time for direct patient care. 1 2 3 4 5 6 7
30. I am sometimes frustrated because all of my
activities seem programmed for me.
1 2 3 4 5 6 7
31. I am sometimes required to do things on my job
that are against my better professional nursing 1 2 3 4 5 6 7
judgment.
IWS Questionnaire 4
Appendix 4
Part B (Attitude Questionnaire, Continued)
Remember: The more strongly you feel about the statement, the further
from the center you should circle, with agreement to the left and
disagreement to the right. Use 4 for neutral or undecided if needed, but
please try to use this number as little as possible.
Agree Disagree
32. From what I hear about nursing service personnel
at other hospitals, we at this hospital are being fairly 1 2 3 4 5 6 7
paid.
33. Administrative decisions at this hospital interfere
too much with patient care.
1 2 3 4 5 6 7
34. It makes me proud to talk to other people about
what I do on my job.
1 2 3 4 5 6 7
35. I wish the physicians here would show more
respect for the skill and knowledge of the nursing 1 2 3 4 5 6 7
staff.
36. I could deliver much better care if I had more time
with each patient.
1 2 3 4 5 6 7
37. Physicians at this hospital generally understand
and appreciate what the nursing staff does.
1 2 3 4 5 6 7
38. If I had the decision to make all over again, I would
still go into nursing.
1 2 3 4 5 6 7
39. The physicians at this hospital look down too much
on the nursing staff.
1 2 3 4 5 6 7
40. I have all the voice in planning policies and
procedures for this hospital and my unit that I want
1 2 3 4 5 6 7
41. My particular job really doesnt require much skill or
know-how.
1 2 3 4 5 6 7
42. The nursing administrators generally consult with
the staff on daily problems and procedures.
1 2 3 4 5 6 7
43. I have the freedom in my work to make important
decisions as I see fit, and can count on my 1 2 3 4 5 6 7
supervisors to back me up.
44. An upgrading of pay schedules for nursing
personnel is needed at this hospital.
1 2 3 4 5 6 7
IWS Questionnaire 5
Appendix 5
Faculty of Health
School of Nursing
Queensland University of Technology
Dear Colleagues,
I am a student, currently undertaking HL84 Master of Applied Science (Research) at the Queensland
University of Technology (QUT), Brisbane Queensland Australia. As part of this degree I am working on my
major study supported by academic staff from the School of Nursing, at QUTs Faculty of Health.
The primary aim of this study is to investigate new graduate nurses perceptions of stress in todays
complex clinical working environment.
Your participation in this project is voluntary and if you do feel any discomfort regarding questions in
this survey, you are free to withdraw from the study at any time. There are no right or wrong answers and the
information that you are going to provide will be confidential, no identifying information is required. If you
require further information about the project or have any questions, please contact me on +673 8891226 (mp)
Brunei Darussalam or +61732520250(hp/Fax); +61424954660 (hp) email: h.hajidamit@student.qut.edu.au
Australia Haji Abd Rahim bin Haji Damit as the chief investigator.
I would like to take the opportunity in advance to say thank you for your consideration and any
information that you can give me. I enclose a stamped addressed envelope for returning of the survey.
Alternatively, you may drop them into the box provided in each unit.
Yours sincerely
----------------------------------------------------------------------------------------------------
I confirm that (Mr Rahim Damit) is currently enrolled in the HL84 Master of Applied Science
(Research) Degree in the Faculty of Health, School of Nursing at the Queensland University of Technology,
Brisbane Queensland Australia and any assistance given by you would be very much appreciated.
Date: .
Thank you for agreeing to participate in this study. Work situations typically experienced and
encountered by nurses in day to day practice may be stressful. The valuable information you provide will assist
me as the project chief investigator to investigate new graduate nurses perceptions of stress in the new complex
clinical working environment.
Please read the subject information sheet carefully. If you are a staff nurse who currently works in Raja
Isteri Pengiran Anak Saleha (RIPAS) Hospital and you have less than 36 months (3 years), experience working
as a hospital staff nurse then you are invited to participate.
Be assured that all your responses are confidential and no information about the project will be
published in any form that would allow any individual to be recognised. All information is coded so that you will
remain anonymous. Your participation is voluntary. Completion of the questionnaire should take no longer than
thirty minutes.
If you wish to discuss any aspect of this study feel free to contact Abd Rahim Damit on +673 8891226
or +614 2495 4660. You may also contact the project chief investigators supervisor Sheree Smith on +617 3864
3905 or Queensland University of Technology, Research Ethics Officer on +617 3864 2340 or Director General,
Medical Services Department, Ministry of Health, Brunei Darussalam on +673 2381887 Fax.
For your convenience, you may return the complete questionnaire to me by post using the
enclosed pre-paid envelop. Alternatively, you may drop them into the box provided in each unit.
Male Female
5. How long have you been working in this unit as a Registered Nurse?
6. Marital Status
Married
Divorced
Widowed
Malay
Chinese
Indian
Indigenous
Yes
No
Not Applicable
Two
Three
Not Applicable
Pre School Age (0 less than 5 years) number of children in this range
Not Applicable
Not Applicable
VERY
GOOD POOR NO
GOOD AVERAGE
SUPPORT SUPPORT SUPPORT
SUPPORT
1 2 3 4 5
1 HUSBAND
2 HOUSE MAID
3 PARENTS / IN LAW
SISTER/ BROTHER/ IN
4
LAW
Owned Outright
Renting
SECTION: 2
This part of the questionnaire relates to HOW YOU FEEL ABOUT YOUR OVERALL CLINICAL
PRACTICE as a new graduate staff nurse. Please tick ( / ) or darken the bubble underneath the numbers in the
right hand column on your choice to indicate on the following scale that includes "(1) Strongly Disagree", "(2)
Disagree", "(3) Uncertain" "(4) Agree" and (5) Strongly Agree.
STRONGLY
DISAGREE UNCERTAIN AGREE STRONGLY
DISAGREE
AGREE
1 2 3 4 5
1 CONFIDENT
2 COMPETENT
3 ORGANISED
Occasionally Stressful
Frequently Stressful
Extremely Stressful
Below is a list of situations that commonly occur in a work setting. For each
No Items 1 2 3 4 0
1 Performing procedures that patients experience as painful
2 Criticism by a physician
6 Breakdown of computer
12 Being asked a question by a patient for which I do not have a satisfactory answer
Lack of opportunity to share experiences and feelings with other personnel in the
13
work setting
14 Floating to other units/services that are short-staffed
Occasionally Stressful
Frequently Stressful
Extremely Stressful
Below is a list of situations that commonly occur in a work setting. For each situation
1 2 3 4 0
18 Experiencing discrimination because of race or ethnicity
33 Criticism by a supervisor
Not knowing what a patient or a patient's family ought to be told about the patient's
35
condition and its treatment
36 Being the one that has to deal with patients' families
Occasionally Stressful
Frequently Stressful
Extremely Stressful
Below is a list of situations that commonly occur in a work setting. For each
1 2 3 4 0
41 Being in charge with inadequate experience
58 Not knowing whether patients' families will report you for inadequate care
Listed and briefly defined below are six terms or factors that are involved in how people feel about
their work situation. Each factor has something to do with work satisfaction. We are interested in
determining which of these is most important to you in relation to the others.
Please carefully read the definitions for each factor as given below:
Pay -- dollar remuneration and fringe benefits received for work done
Autonomy -- amount of job related independence, initiative, and freedom, either permitted or
required in daily work activities.
Task Requirements -- tasks or activities that must be done as a regular part of the job
Organizational Policies -- management policies and procedures put forward by the hospital
and nursing administration of this hospital
Interaction -- opportunities presented for both formal and informal social and professional
contact during working hours
Professional Status -- overall importance or significance felt about your job, both in your view
and in the view of others
Instructions: These factors are presented in pairs on the next page. A total of 15 pairs are
presented: this is every set of combinations. No pair is repeated or reversed. For each pair of
terms, decide which one is more important for your job satisfaction or morale, and check the
appropriate box. For example, if you feel that Pay (as defined above) is more important than
Autonomy (as defined above), check the box for Pay.
It will be difficult for you to make choices in some cases. However, please do try to select the factor
which is more important to you. Please make an effort to answer every item; do not go back to
change any of your answers.
10
6. Pay or Autonomy
11
Instructions: Please tick ( / )or darken the number that most closely indicates how you feel about
each statement. The LEFT set of numbers indicates degrees of AGREEMENT. The RIGHT set of
numbers indicates degrees of DISAGREEMENT. For example, if you strongly agree with the first
item, tick ( / ) or darken no 1; if you agree with this item, tick ( / ) or darken no 2; if you moderately
agree with the first statement, tick ( / ) or darken no 3. The middle response (4) is reserved for feeling
neutral or undecided. Please use it as little as possible. If you moderately disagree with this first item,
you should tick ( / ) or darken no 5; to disagree, tick ( / ) or darken no 6; and to strongly disagree, tick
( / ) or darken no 7.
Remember: The more strongly you feel about the statement, the further from the center you should
darken or tick ( / ), with agreement to the left and disagreement to the right. Use 4 for neutral or
undecided if needed, but please try to use this number as little as possible.
Strongly Strongly
N
Agree Disagree
1 2 3 4 5 6 7
1. My present salary is satisfactory.
12
Please rate how helpful you believe each of the following items Not at all Extremely
would be in assisting your transition into the workplace as a new helpful helpful
graduate nurse
1 2 3 4 5 6 7
No Items
2 Education
4 Mentoring
6 Balancing priorities
14
No Section Items
1 1 12
2 2 4
3 3 59
4 4.1 15
5 4.2 44
6 5 10
Total 144
NOTE:
The IWS Questionnaire used by permiion of Paula L. Stamps, Ph.D., Market Street Research, Inc.,
Northampton, Massachusetts.
@ e ENSS Expanded Nursing Stress Scales used by permission of Susan E. French, Rhonda Lenton,
Vivienne Walters and John Eyles, School of Nursing Department of Sociology and Department of
Geography. McMaster University Canada.
15
SECTION: 1
Frequency Matrix
Most Important
Intensive Care Units a Sample of 41 General Wards Nurses Sample of 53 The Whole Nurses
Organisation
Organisation
Organisation
Requirement
Requirement
Requirement
Professional
Professional
Professional
Interaction
Interaction
Interaction
al Policies
al Policies
al Policies
Autonomy
Autonomy
Autonomy
Status
Status
Status
Task
Task
Task
Pay
Pay
Pay
LEAST IMPORTANT
Pay .707 .561 .610 .512 .463 .623 .491 .547 .642 .472 .660 .521 .574 .585 .468
Autonomy .293 .488 .610 .439 .512 .378 .528 .547 .434 .566 .340 .511 .574 .436 .543
Task Requirement .439 .512 .512 .659 .439 .509 .472 .377 .642 .509 .479 .489 .436 .649 .479
Organisational .390 .390 .488 .610 .561 .453 .453 .623 .642 .698 .426 .426 .564 .628 .638
Policies
Professional Status .488 .561 .341 .390 .512 .358 .566 .358 .358 .472 .415 .564 .351 .372 .489
Interaction .537 .488 .561 .439 .488 .528 .434 .491 .302 .528 .532 .457 .521 .362 .511
Appendix 7
Table 34 Matrix of Z-Values - Component Weighting Coefficient
Most Important
Intensive Care Units a Sample of 41 General Wards Nurses Sample of 53 The Whole Nurses
Organisation
Organisation
Organisation
Requirement
Requirement
Requirement
Professional
Professional
Professional
Interaction
Interaction
Interaction
al Policies
al Policies
al Policies
Autonomy
Autonomy
Autonomy
Status
Status
Status
Task
Task
Task
Pay
Pay
Pay
LEAST IMPORTANT
Pay 0.545 0.154 0.279 0.030 - 0.093 0.313 -0.023 0.118 0.364 -0.070 .412 .053 .187 .215 -.080
Autonomy -0.545 -0.030 0.279 -0.154 0.030 -0.313 0.070 0.118 -0.166 0.166 -.412 .028 .187 -.161 .108
Task Requirement -0.154 0.030 0.030 0.410 -0.154 0.023 -0.070 -0.313 0.364 0.023 -.053 -.028 -.161 .383 -.053
Organisational -0.279 -0.279 -0.030 0.279 0.154 -0.118 -0.118 0.313 0.364 0.519 -.187 -.187 .161 .327 .353
Policies
Professional Status -0.030 0.154 -0.410 -0.279 0.030 -0.364 0.166 -0.364 -0.364 -0.07 -.215 .161 -.383 -.327 -.028
Interaction 0.093 -0.030 0.154 -0.154 -0.030 0.070 -0.166 -0.023 -0.519 0.070 .080 -.108 .053 -.353 .028
Sum -0.915 0.42 -0.162 0.155 0.535 -0.033 -0.702 0.125 -0.027 -0.96 0.996 0.568 -0.79 0.25 -0.09 - 0.47 0.792 0.3
Mean -0.183 0.084 -0.032 0.031 0.107 -0.006 -0.140 0.025 -0.005 -0.192 0.1992 0.114 -0.16 0.05 -0.02 0.093 0.158 0.06
Component Weighting 2.917 3.184 3.067 3.131 3.207 3.1 2.96 3.125 3.095 2.908 3.299 3.214 2.94 3.15 3.08 3.001 3.258 3.16
Coefficient
Appendix 8
Table 35 Index of Work Satisfaction: Nurse-Nurse
Intensive Care Units Nurses (N= 41) General Wards Nurses (N= 53) Whole Sample 94 Nurses
Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
5 items 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
3. The nursing personnel 22.0 31.7 19.5 22.0 4.9 0 0 18.9 20.8 30.2 18.9 7.5 3.8 0 20.2 25.5 25.5 20.2 6.4 2.1 0
on my service pitch in and (9) (13) (8) (9) (2) (0) (0) (10) (11) (16) (10) (4) (2) (0) (19) (24) (24) (19) (6) (2) (0)
help one another out when
things get in a rush.
16. There is a good deal of 17.1 26.8 31.7 17.1 4.9 0 2.4 17.0 28.3 13.2 7.5 17.0 7.5 9.4 17.0 27.7 21.3 11.7 11.7 4.3 6.4
teamwork and cooperation (7) (11) (13) (7) (2) (0) (1) (9) (15) (7) (4) (9) (4) (5) (16) (26) (20) (11) (11) (4) (6)
between various levels of
nursing personnel on my
service.
** 10. It is hard for new 19.5 17.1 29.3 14.6 7.3 4.9 7.3 24.5 34.0 17.0 13.2 5.7 1.9 3.8 22.3 26.6 22.3 13.8 6.4 3.2 5.3
nurses to feel at home in (8) (7) (12) (6) (3) (2) (3) (13) (18) (9) (7) (3) (1) (2) (21) (25) (21) (13) (6) (3) (5)
my unit.
** 23. The nursing 2.4 4.9 14.6 36.6 14.6 17.1 9.8 15.1 13.2 11.3 20.8 18.9 13.2 7.5 9.6 9.6 12.8 27.7 17.0 14.9 8.5
personnel on my service (1) (2) (6) (15) (6) (7) (4) (8) (7) (6) (11) (10) (7) (4) (9) (9) (12) (26) (16) (14) (8)
are not as friendly and
outgoing as I would like.
** 28. There is a lot of 7.3 12.2 12.2 39.2 14.6 4.9 9.8 18.9 11.3 16.9 13.2 24.5 9.4 5.7 13.8 11.7 14.9 24.5 20.2 7.4 7.4
rank consciousness on (3) (5) (5) (16) (6) (2) (4) (10) (6) (9) (7) (13) (5) (3) (13) (11) (14) (23) (19) (7) (7)
my unit: nurses seldom
mingle with those with less
experience or different
types of educational
preparation.
Intensive Care Units Nurses (N= 41) General Wards Nurses (N= 53) Whole Sample 94 Nurses
5 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
6. Physicians in general 9.8 26.8 24.4 29.3 4.9 4.9 0 9.4 9.4 39.6 22.6 7.5 7.5 3.8 9.6 17.0 33.0 25.5 6.4 6.4 2.1
cooperate with nursing (4) (11) (10) (12) (2) (2) (0) (5) (5) (21) (12) (4) (4) (2) (9) (16) (31) (24) (6) (6) (2)
staff on my unit
19. There is a lot of 17.1 26.8 19.5 14.6 14.6 4.9 2.4 13.2 32.1 18.9 11.3 18.9 3.8 1.9 14.9 29.7 19.1 12.8 17.0 4.3 2.1
teamwork between nurses (7) (11) (8) (6) (6) (2) (1) (7) (17) (10) (6) (10) (2) (1) (14) (28) (18) (12) (16) (4) (2)
and doctors on my own
unit.
37. Physicians at this 7.3 12.2 22.0 24.4 17.1 12.2 4.9 5.7 9.4 26.4 18.9 22.6 11.3 5.7 6.4 10.6 24.5 21.3 20.2 11.7 5.3
hospital generally (3) (5) (9) (10) (7) (5) (2) (3) (5) (14) (10) (12) (6) (3) (6) (10) (23) (20) (19) (11) (5)
understand and appreciate
what the nursing staffs
does.
** 35. I wish the 43.9 29.3 9.8 14.6 0 0 2.4 47.2 15.1 28.3 5.7 0 1.9 1.9 45.7 21.3 20.2 9.6 0 1.1 2.1
physicians here would (18) (12) (4) (6) (0) (0) (1) (25) (8) (15) (3) (0) (1) (1) (43) (20) (19) (9) (0) (1) (2)
show more respect for the
skill and knowledge of the
nursing staff.
** 39. The physicians at 17.1 19.5 24.4 24.4 7.3 7.3 0 18.9 17.0 26.4 13.2 15.1 3.8 5.7 18.9 18.9 25.5 18.9 11.7 5.3 3.2
this hospital look down too (7) (8) (10) (10) (3) (3) (0) (10) (9) (14) (7) (8) (2) (3) (17) (17) (24) (17) (11) (5) (3)
much on the nursing staff.
Score 7 1 7 1 7 1
Strongly
Agree
# of resp 1 7 1 10 1 16
subtotal
7 7 7 10 7 16
Score 6 2 6 2 6 2
Agree
# of resp 4 8 3 3 4 10
Subtotal 24 16 6 24 20
18
Score 5 3 5 3 5 3
Moderately
Agree
# of resp 5 11 3 14 4 8
subtotal 25 33 15 42 20 24
Score 4 4 4 4 4 4
Undecided
# of resp 8 8 12 12 13 5
subtotal 32 32 48 48 52 20
# of resp 8 3 9 2 8 0
subtotal 24 15 27 10 24 5
Score 2 6 2 6 2 6
# of resp 2 2 6 0 5 1
4
subtotal 12 12 0 10 6
Score 1 7 1 7 1 7
Disagree
Strongly
# of resp 13 2 7 0 6 1
13 14 7 0 6 7
subtotal
Total # of Resp. 41 41 41 41 41 41
Average Score 3.146 3.146 3.268 2.829 3.488 2.390 18. 3.0
27 45
Appendix 10
Table 38
Score 1 7 7 1 7 7 1
Strongly
# of resp 7 7 12 2 6 6 1
Agree
subtotal
7 49 84 2 42 42 1
Score 2 6 6 2 6 6 2
Agree
# of resp 10 9 8 2 3 6 1
Subtotal
20 54 48 4 18 36 2
Score 3 5 5 3 5 5 3
Moderately
Agree
# of resp 6 8 9 4 15 11 1
subtotal
18 40 45 12 75 55 3
Score 4 4 4 4 4 4 4
Undecided
# of resp 2 10 10 13 10 9 8
# of resp 7 2 1 14 2 4 4
subtotal
Score 6 2 2 6 2 2 6
Disagree
# of resp 3 2 0 2 3 1 13
subtotal
18 4 0 12 6 2 78
Score 7 1 1 7 1 1 7
Disagree
Strongly
# of resp 6 3 1 4 2 4 13
subtotal
42 3 1 28 2 4 91
Total # of Resp. 41 41 41 41 41 41 41
Average Score 3.61 4.780 5.390 4.39 4.61 4.56 5.54 32.8 4.69
8 7
Appendix 10
Table 39
Score 1 7 1 1 7 1 1 7
Strongly
# of resp 1 2 9 3 2 0 2 3
Agree
subtotal 1 14 9 3 14 0 2 21
Score 2 6 2 2 6 2 2 6
Agree
# of resp 2 2 7 1 2 5 4 2
Subtotal 4 12 14 2 12 10 8 12
Score 3 5 3 3 5 3 3 5
Moderately
Agree
# of resp 6 16 11 8 7 10 16 14
subtotal 18 80 33 24 35 30 48 70
Score 4 4 4 4 4 4 4 4
Undecided
# of resp 26 12 13 16 27 15 9 13
Score 5 3 5 5 3 5 5 3
Moderately
Disagree
# of resp 3 8 1 8 3 3 6 3
subtotal 15 24 5 40 9 15 30 9
# of resp 0 1 0 5 0 4 3 4
subtotal 0 2 0 30 0 24 18 8
Score 7 1 7 7 1 7 7 1
Disagree
Strongly
# of resp 3 0 0 0 0 4 1 2
subtotal 21 0 0 0 0 28 7 2
Total of Item 163 180 113 163 178 167 149 174
Total # of Resp. 41 41 41 41 41 41 41 41
Average Score 3.976 4.39 2.756 3.976 4.341 4.073 3.63 4.24 31.3 3.92
8 3
Appendix 10
Table 40
Score 7 1 1 7 1 7 7
Strongly
# of resp 2 8 4 2 6 1 1
Agree
subtotal 14 8 4 14 6 7 7
Score 6 2 2 6 2 6 6
Agree
# of resp 8 9 7 3 2 4 3
Subtotal 48 18 14 18 4 24 18
Score 5 3 3 5 3 5 5
Moderately
Agree
# of resp 9 10 14 7 9 6 7
subtotal 45 30 42 35 27 30 35
Score 4 4 4 4 4 4 4
Undecided
# of resp 11 8 8 21 19 18 13
Score 3 5 5 3 5 3 3
Moderately
Disagree
# of resp 6 4 7 5 2 4 6
18 20
subtotal 35 15 10 12 18
# of resp 2 2 0 2 2 5 6
subtotal 4 12 0 4 12 10 12
Score 1 7 7 1 7 1 1
Disagree
Strongly
# of resp 3 0 1 1 1 3 5
subtotal 3 0 7 1 7 3 5
Total # of Resp. 41 41 41 41 41 41 41
Average Score 4.29 2.927 3.27 4.171 3.463 3.85 3.59 25.5 3.65
6
Appendix 10
Table 41
Score 1 1 7 7 7 1
Strongly
# of resp 7 12 6 0 2 14
Agree
subtotal 7 12 42 0 14 14
Score 2 2 6 6 6 2
Agree
# of resp 5 7 9 2 3 15
Subtotal 10 14 54 12 18 30
Score 3 3 5 5 5 3
Moderately
Agree
# of resp 9 9 16 8 8 7
subtotal 27 27 80 40 40 21
Score 4 4 4 4 4 4
Undecided
# of resp 12 7 5 11 10 2
Score 5 5 3 3 3 5
Moderately
Disagree
# of resp 5 2 5 15 12 2
subtotal 25 10 15 45 36 10
# of resp 2 2 0 2 3 0
subtotal 12 12 0 4 6 0
Score 7 7 1 1 1 7
Disagree
Strongly
# of resp 1 2 0 3 3 1
subtotal 7 14 0 3 3 7
Total # of Resp. 41 41 41 41 41 41
Average Score 3.317 2.854 5.146 3.61 3.829 2.195 20.95 3.492
Appendix 10
Table 42
Interaction Item # Item# Item # Item# Item# Item# 6 Item # Item# Item# Item#
3 10 16 23 28 19 35 37 39
Score 7 1 7 1 1 7 7 1 7 1
Strongly Agree
# of 9 8 7 1 3 4 7 18 3 7
resp
63 8 49 1 3 28 49 18 21 7
subtotal
Score 6 2 6 2 2 6 6 2 6 2
# of 13 7 11 2 5 12 11 12 5 8
Agree
resp
78 14 66 4 10 72 66 24 30 16
Subtotal
Score 5 3 5 3 3 5 5 3 5 3
Moderately
# of 8 12 13 6 5 10 8 4 9 10
Agree
resp 36 50 40 12
40 65 18 15 45 30
subtotal
Score 4 4 4 4 4 4 4 4 4 4
Undecided
# of 9 6 7 15 16 12 6 6 10 10
resp
36 24 28 60 64 48 24 24 40 40
subtotal
Score 3 5 3 5 5 3 3 5 3 5
Moderately
Disagree
# of 2 3 2 6 6 2 6 0 7 3
resp 15
6 6 30 30 6 18 0 21 15
subtotal
# of 0 2 0 7 2 2 2 0 5 3
Disagree
resp
0 12 0 42 12 4 4 0 10 18
Component Score (Sum of average score)
subtotal
Score 1 7 1 7 7 1 1 7 1 7
# of 0 3 1 4 4 0 1 1 2 0
Disagree
Strongly
resp
0 21 1 28 28 0 1 7 2 0
subtotal
Total of Item 223 130 215 183 162 208 202 85 169 126
Total # of 41 41 41 41 41 41 41 41 41 41
Resp.
Average 5.439 3.171 5.244 4.463 3.95 5.073 4.927 2.073 4.122 3.073 41.54 4.154
Score
Appendix 10
Table 43
Score 7 1 7 1 1
Strongly # of resp 9 8 7 1 3
Agree
subtotal 63 8 49 1 3
Score 6 2 6 2 2
Agree
# of resp 13 7 11 2 5
Subtotal 78 14 66 4 10
Score 5 3 5 3 3
Moderately
Agree
# of resp 8 12 13 6 5
subtotal 40 36 65 18 15
Score 4 4 4 4 4
Undecided
# of resp 9 6 7 15 16
Score 3 5 3 5 5
Moderately
Disagree
# of resp 2 3 2 6 6
subtotal 6 15 6 30 30
# of resp 0 2 0 7 2
subtotal 0 12 0 42 12
Score 1 7 1 7 7
Disagree
Strongly
# of resp 0 3 1 4 4
subtotal 0 21 1 28 28
Total # of Resp. 41 41 41 41 41
Average Score 5.439 3.171 5.244 4.463 3.95 22.2 4.45
7
Appendix 10
Table 44
# of resp 4 7 18 3 7
Agree
subtotal 28 49 18 21 7
Score 6 6 2 6 2
Agree
# of resp 12 11 12 5 8
Subtotal 72 66 24 30 16
Score 5 5 3 5 3
Moderately
Agree
# of resp 10 8 4 9 10
subtotal 50 40 12 45 30
Score 4 4 4 4 4
Undecided
# of resp 12 6 6 10 10
Score 3 3 5 3 5
Moderately
Disagree
# of resp 2 6 0 7 3
subtotal 6 18 0 21 15
# of resp 2 2 0 5 3
subtotal 4 4 0 10 18
Score 1 1 7 1 7
Disagree
Strongly
# of resp 0 1 1 2 0
subtotal 0 1 7 2 0
Total # of Resp. 41 41 41 41 41
Average Score 5.073 4.927 2.073 4.122 3..073 19.2 3.85
7
Appendix 10
Table 45
Score 7 1 7 1 7 1
Strongly
Agree
# of resp 4 12 3 9 5 21
subtotal
28 12 21 9 35 21
Score 6 2 6 2 6 2
Agree
# of resp 9 11 6 12 5 10
Subtotal 54 24
22 36 30 20
Score 5 3 5 3 5 3
Moderately
Agree
# of resp 5 8 5 13 5 15
subtotal 25 24 25 39 25 45
Score 4 4 4 4 4 4
Undecided
# of resp 9 12 12 10 17 3
subtotal
36 48 48 40 68 12
# of resp 13 5 10 4 14 2
subtotal
39 25 30 20 42 10
Score 2 6 2 6 2 6
# of resp 4 1 11 3 3 0
subtotal
8 6 22 18 6 0
Score 1 7 1 7 1 7
Disagree
Strongly
# of resp 9 4 6 2 4 2
subtotal
9 28 6 14 4 14
Total of Item 199 165 188 164 210 122
Total # of Resp. 53 53 53 53 53 53
Average Score 3.75 3.11 3.55 3.09 3.96 2.30 19. 3.2
76 9
Appendix 10
Table 46
Score 1 7 7 1 7 7 1
Strongly
# of resp 13 7 15 2 8 6 2
Agree
subtotal
13 49 105 2 56 42 2
Score 2 6 6 2 6 6 2
Agree
# of resp 9 12 7 7 7 6 2
Subtotal
18 72 42 14 42 36 4
Score 3 5 5 3 5 5 3
Moderately
Agree
# of resp 11 17 20 9 14 13 5
subtotal
33 85 100 27 70 65 15
Score 4 4 4 4 4 4 4
Undecided
# of resp 3 6 7 17 12 10 5
# of resp 8 6 1 10 6 8 13
subtotal
Score 6 2 2 6 2 2 6
Disagree
# of resp 2 2 1 7 2 2 6
subtotal
12 4 2 42 4 4 36
Score 7 1 1 7 1 1 7
Disagree
Strongly
# of resp 7 3 2 1 4 8 20
subtotal
49 3 2 7 4 8 140
Total # of Resp. 53 53 53 53 53 53 53
Average Score 3.34 4.81 5..32 3.96 4.57 4.13 5..32 31.4 4.49
5
Appendix 10
Table 47
# of 4 6 9 4 2 5 6 4
resp
4 42 9 4 14 5 6 28
subtotal
Score 2 6 2 2 6 2 2 6
# of 5 6 13 8 4 4 8 7
Agree
resp
10 36 26 16 24 8 16 42
Subtotal
Score 3 5 3 3 5 3 3 5
Moderately
# of 10 12 10 12 14 15 14 14
Agree
resp
30 60 30 36 70 45 42 70
subtotal
Score 4 4 4 4 4 4 4 4
Undecided
# of 9 15 11 8 21 7 11 10
resp
36 44 32 84 28 44 40
subtotal 60
# of 11 7 4 16 8 14 7 8
resp
55 21 20 80 24 70 35 24
subtotal
Score 6 2 6 6 2 6 6 2
# of 8 3 1 5 2 3 5 6
resp
48 6 30 4 18 30 12
subtotal 6
Score 7 1 7 7 1 7 7 1
# of 6 4 5 0 2 5 2 4
Disagree
Strongly
resp
42 4 35 0 2 35 14 4
subtotal
Total of Item 225 229 170 198 222 209 187 220
Total # of 53 53 53 53 53 53 53 53
Resp.
Average 4.25 4.32 3.20 3.74 4.19 3.94 3.53 4.15 31.32 3.92
Score
Appendix 10
Table 48
Score 7 1 1 7 1 7 7
Strongly
# of resp 3 16 10 0 5 2 7
Agree
subtotal 21 16 10 0 5 14 49
Score 6 2 2 6 2 6 6
Agree
# of resp 10 10 9 6 7 1 2
12
Subtotal 60 20 18 36 14 6
Score 5 3 3 5 3 5 5
Moderately
Agree
# of resp 15 9 16 13 14 5 12
subtotal 75 27 48 65 42 25 60
Score 4 4 4 4 4 4 4
Undecided
# of resp 5 12 10 17 17 20 11
Score 3 5 5 3 5 3 3
Moderately
Disagree
# of resp 8 1 7 9 6 10 12
24 5
subtotal 35 27 30 30 36
# of resp 7 3 1 4 3 6 4
subtotal 14 18 6 8 18 12 8
Score 1 7 7 1 7 1 1
Disagree
Strongly
# of resp 5 2 0 4 1 9 5
subtotal 5 14 0 4 7 9 5
Total # of Resp. 53 53 53 53 53 53 53
Average Score 4.13 2.79 2.96 3.92 3.47 3.32 4.038 24.5 3.50
2 2
Appendix 10
Table 49
Score 1 1 7 7 7 1
Strongly
# of resp 10 12 5 2 2 22
Agree
subtotal 10 12 35 14 14 22
Score 2 2 6 6 6 2
Agree
# of resp 10 16 10 4 7 10
Subtotal 20 32 60 24 42 20
Score 3 3 5 5 5 3
Moderately
Agree
# of resp 15 6 14 8 12 15
subtotal 45 18 70 40 60 45
Score 4 4 4 4 4 4
Undecided
# of resp 10 8 14 7 7 4
Score 5 5 3 3 3 5
Moderately
Disagree
# of resp 5 6 5 19 18 1
subtotal 25 30 15 57 54 5
# of resp 1 2 3 6 4 0
subtotal 6 12 6 12 8 0
Score 7 7 1 1 1 7
Disagree
Strongly
# of resp 2 3 2 7 3 1
subtotal 14 21 2 7 3 7
Total # of Resp. 53 53 53 53 53 53
Average Score 3.02 2.96 4.60 3.43 3.94 2.17 20.12 3.35
Appendix 10
Table 50
Interaction Item # Item# Item # Item# Item# Item# 6 Item # Item# Item# Item#
3 10 16 23 28 19 35 37 39
Score 7 1 7 1 1 7 7 1 7 1
Strongly Agree
# of 10 13 9 8 10 5 7 25 3 10
resp
70 13 63 8 10 35 49 25 21 10
subtotal
Score 6 2 6 2 2 6 6 2 6 2
# of 11 18 15 7 6 5 17 8 5 9
Agree
resp
66 36 90 14 12 30 102 16 30 18
Subtotal
Score 5 3 5 3 3 5 5 3 5 3
Moderately
# of 16 9 7 6 9 21 10 15 14 14
Agree
resp 27 105 50 45
80 35 18 27 70 42
subtotal
Score 4 4 4 4 4 4 4 4 4 4
Undecided
# of 10 7 4 11 7 12 6 3 10 7
resp
40 28 16 44 28 48 24 12 40 28
subtotal
Score 3 5 3 5 5 3 3 5 3 5
Moderately
Disagree
# of 4 3 9 10 13 4 10 0 12 8
resp 15
12 27 50 65 12 30 0 36 40
subtotal
# of 2 1 4 7 5 4 2 1 6 2
Disagree
resp
4 6 8 42 30 8 4 6 12 12 Component Score (Sum of average score)
subtotal
Score 1 7 1 7 7 1 1 7 1 7
# of 0 2 5 4 3 2 1 1 3 3
Disagree
Strongly
resp
0 14 5 28 21 2 1 7 3 21
subtotal
Total of Item 272 139 244 204 193 240 260 111 212 171
Total # of 53 53 53 53 53 53 53 53 53 53
Resp.
Average 5.13 2.62 4.60 3.85 3.64 4.53 4.91 2.09 4 3.23 38.6 3.86
Score
Appendix 10
Table 51
Score 7 1 7 1 1
Strongly
# of resp 10 13 9 8 10
Agree
subtotal 70 13 63 8 10
Score 6 2 6 2 2
Agree
# of resp 11 18 15 7 6
Subtotal 66 36 90 14 12
Score 5 3 5 3 3
Moderately
Agree
# of resp 16 9 7 6 9
subtotal 80 27 35 18 27
Score 4 4 4 4 4
Undecided
# of resp 10 7 4 11 7
Score 3 5 3 5 5
Moderately
Disagree
# of resp 4 3 9 10 13
subtotal 12 15 27 50 65
# of resp 2 1 4 7 5
subtotal 4 6 8 42 30
Score 1 7 1 7 7
Disagree
Strongly
# of resp 0 2 5 4 3
subtotal 0 14 5 28 21
Total # of Resp. 53 53 53 53 53
Score 7 7 1 7 1
Strongly
# of resp 5 7 25 3 10
Agree
subtotal 35 49 25 21 10
Score 6 6 2 6 2
Agree
# of resp 5 17 8 5 9
Subtotal 30 102 16 30 18
Score 5 5 3 5 3
Moderately
Agree
# of resp 21 10 15 14 14
subtotal 105 50 45 70 42
Score 4 4 4 4 4
Undecided
# of resp 12 6 3 10 7
Score 3 3 5 3 5
Moderately
Disagree
# of resp 4 10 0 12 8
subtotal 12 30 0 36 40
# of resp 4 2 1 6 2
subtotal 8 4 6 12 12
Score 1 1 7 1 7
Disagree
Strongly
# of resp 2 1 1 3 3
subtotal 2 1 7 3 21
Total # of Resp. 53 53 53 53 53
Score 7 1 7 1 7 1
Strongly
Agree
# of resp 5 19 4 19 6 37
subtotal
35 9 28 19 42 37
Score 6 2 6 2 6 2
Agree
# of resp 13 19 9 15 9 20
Subtotal 78 30
38 54 54 40
Score 5 3 5 3 5 3
Moderately
Agree
# of resp 10 19 8 27 9 23
subtotal 50 57 40 81 45 69
Score 4 4 4 4 4 4
Undecided
# of resp 17 20 24 22 30 8
subtotal
68 80 96 88 120 32
# of resp 21 8 19 6 22 2
subtotal
63 40 57 30 66 10
Score 2 6 2 6 2 6
# of resp 6 3 17 3 8 1
subtotal
12 18 34 18 16 6
Score 1 7 1 7 1 7
Disagree
Strongly
# of resp 22 6 13 2 10 3
subtotal
22 42 13 14 10 21
Total of Item 328 284 322 280 353 215
Total # of Resp. 94 94 94 94 94 94
Average Score 3.49 3.02 3.43 2.98 3.76 2.29 18. 3.1
97 62
Appendix 10
Table 54
Score 1 7 7 1 7 7 1
Strongly
# of resp 20 14 27 4 14 12 3
Agree
subtotal
20 98 189 4 98 84 3
Score 2 6 6 2 6 6 2
Agree
# of resp 19 21 15 9 10 12 3
Subtotal
38 126 90 18 60 72 6
Score 3 5 5 3 5 5 3
Moderately
Agree
# of resp 17 25 29 13 29 24 7
subtotal
51 125 145 39 145 120 21
Score 4 4 4 4 4 4 4
Undecided
# of resp 5 16 17 30 22 19 12
# of resp 15 8 2 24 8 12 17
subtotal
Score 6 2 2 6 2 2 6
Disagree
# of resp 5 4 1 9 5 3 19
subtotal
30 8 2 54 10 6 114
Score 7 1 1 7 1 1 7
Disagree
Strongly
# of resp 13 6 3 5 6 12 33
subtotal
91 6 3 35 6 12 231
Total # of Resp. 94 94 94 94 94 94 94
Average Score 3.46 4.8 5.35 3.62 4.59 4.32 5.4 31.5 4.51
4
Appendix 10
Table 55
# of 5 8 18 7 4 5 8 7
resp
5 56 18 7 28 5 8 49
subtotal
Score 2 6 2 2 6 2 2 6
# of 7 8 20 9 6 9 12 9
Agree
resp
14 48 40 18 36 18 24 54
Subtotal
Score 3 5 3 3 5 3 3 5
Moderately
# of 16 28 21 20 21 25 30 28
Agree
resp
48 140 63 60 105 75 90 140
subtotal
Score 4 4 4 4 4 4 4 4
Undecided
# of 35 27 24 24 48 22 20 23
resp
140 96 96 192 88 80 92
subtotal 108
# of 14 15 5 24 11 17 13 11
resp
70 45 25 120 33 85 65 33
subtotal
Score 6 2 6 6 2 6 6 2
# of 8 4 1 10 2 7 8 10
resp
48 6 60 4 42 48 20
subtotal 8
Score 7 1 7 7 1 7 7 1
# of 9 4 5 0 2 9 3 6
Disagree
Strongly
resp
63 4 35 0 2 63 21 6
subtotal
Total of Item 388 409 283 361 400 376 336 394
Total # of 94 94 94 94 94 94 94 94
Resp.
Average 4.13 4.35 3.01 3.84 4.26 4 3.57 4.19 31.35 3.92
Score
Appendix 10
Table 56
Score 7 1 1 7 1 7 7
Strongly
# of resp 5 24 14 2 11 3 8
Agree
subtotal 35 24 14 14 11 21 56
Score 6 2 2 6 2 6 6
Agree
# of resp 18 19 16 9 9 5 5
30
Subtotal 108 38 32 54 18 30
Score 5 3 3 5 3 5 5
Moderately
Agree
# of resp 24 19 30 20 23 11 19
Score 4 4 4 4 4 4 4
Undecided
# of resp 16 20 18 38 36 38 24
Score 3 5 5 3 5 3 3
Moderately
Disagree
# of resp 14 5 14 14 8 14 18
42 25
subtotal 70 42 40 42 54
# of resp 9 5 1 6 5 11 10
subtotal 18 30 6 12 30 22 20
Score 1 7 7 1 7 1 1
Disagree
Strongly
# of resp 8 2 1 5 2 12 10
subtotal 8 14 7 5 14 12 10
Total # of Resp. 94 94 94 94 94 94 94
Average Score 4.2 2.85 3.1 4.03 3.47 3.55 3.8 25 3.57
Appendix 10
Table 57
Score 1 1 7 7 7 1
Strongly
# of resp 17 24 11 2 4 36
Agree
subtotal 17 22 77 14 28 36
Score 2 2 6 6 6 2
Agree
# of resp 15 23 19 6 10 25
Subtotal 30 46 114 36 60 50
Score 3 3 5 5 5 3
Moderately
Agree
# of resp 24 15 30 16 20 22
Score 4 4 4 4 4 4
Undecided
# of resp 22 15 19 18 17 6
Score 5 5 3 3 3 5
Moderately
Disagree
# of resp 10 8 10 34 30 3
subtotal 50 40 30 102 90 15
# of resp 3 4 3 8 7 0
subtotal 18 24 6 16 14 0
Score 7 7 1 1 1 7
Disagree
Strongly
# of resp 3 5 2 10 6 2
subtotal 21 35 2 10 6 14
Total # of Resp. 94 94 94 94 94 94
Average Score 3.15 2.89 4.84 3.51 3.89 2.18 20.46 3.41
Appendix 10
Table 58
Interaction Item # 3 Item# Item # Item# 23 Item# Item# 6 Item # Item# Item# 37 Item#
10 16 28 19 35 39
Score 7 1 7 1 1 7 7 1 7 1
Strongly Agree
# of 19 21 16 9 13 9 14 43 6 17
resp 112
133 21 9 13 63 98 43 42 17
subtotal
Score 6 2 6 2 2 6 6 2 6 2
# of 24 25 26 9 11 16 28 20 10 17
Agree
resp 156 96
144 50 18 22 168 40 60 34
Subtotal
Score 5 3 5 3 3 5 5 3 5 3
Moderately
# of 24 21 20 12 14 31 18 19 23 24
Agree
Score 4 4 4 4 4 4 4 4 4 4
Undecided
# of 19 13 11 26 23 24 12 9 20 17
resp 104
76 52 44 92 96 48 36 80 68
subtotal
Score 3 5 3 5 5 3 3 5 3 5
Moderately
Disagree
# of 6 6 11 16 19 6 16 0 19 11
resp 30
18 33 80 95 18 48 0 57 55
subtotal
# of 2 3 4 14 7 6 4 1 11 5
Disagree
resp
4 18 8 84 42 12 8 6 22 30
subtotal Component Score (Sum of average score)
Score 1 7 1 7 7 1 1 7 1 7
# of 0 5 6 8 7 2 2 2 5 3
Disagree
Strongly
resp
0 35 6 56 49 2 2 14 5 21
subtotal
Total of Item 495 269 459 387 355 442 462 196 381 297
Total # of 94 94 94 94 94 94 94 94 94 94
Resp.
Average 5.27 2.86 4.88 4.12 3.78 4.7 4.91 2.09 4.05 3.16 39.82 3.98
Score
Appendix 10
Table 59
Score 7 1 7 1 1
Strongly
# of resp 19 21 16 9 13
Agree
112
subtotal 133 21 9 13
Score 6 2 6 2 2
Agree
# of resp 24 25 26 9 11
156
Subtotal 144 50 18 22
Score 5 3 5 3 3
Moderately
Agree
# of resp 24 21 20 12 14
63 100 36
subtotal 120 42
Score 4 4 4 4 4
Undecided
# of resp 19 13 11 26 23
104
subtotal 76 52 44 92
Score 3 5 3 5 5
Moderately
Disagree
Score 2 6 2 6 6
Disagree
subtotal 4 18 8 84 42
Score 1 7 1 7 7
Disagree
Strongly
# of resp 0 5 6 8 7
subtotal 0 35 6 56 49
Total # of Resp. 94 94 94 94 94
Score 7 7 1 7 1
Strongly
# of resp 9 14 43 6 17
Agree
subtotal 63 98 43 42 17
Score 6 6 2 6 2
Agree
# of resp 16 28 20 10 17
96
Subtotal 168 40 60 34
Score 5 5 3 5 3
Moderately
Agree
# of resp 31 18 19 23 24
155 90 57
subtotal 115 72
Score 4 4 4 4 4
Undecided
# of resp 24 12 9 20 17
subtotal 96 48 36 80 68
Score 3 3 5 3 5
Moderately
Disagree
subtotal 18 48 0 57 55
Score 2 2 6 2 6
Disagree
subtotal 12 8 6 22 30
Score 1 1 7 1 7
Disagree
Strongly
# of resp 2 2 2 5 3
subtotal 2 2 14 5 21
Total # of Resp. 94 94 94 94 94