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A DISSERTATION
BIRMINGHAM, ALABAMA
2010
Copyright by
Rose Chalo Nabirye
2010
ii
OCCUPATIONAL STRESS, JOB SATISFACTION, AND JOB PERFORMANCE
AMONG HOSPITAL NURSES IN KAMPALA, UGANDA
SCHOOL OF NURSING
ABSTRACT
professionals especially nurses. Occupational stress has been reported to affect job
satisfaction and job performance among nurses, thus compromising nursing care and
placing patients’ lives at risk. Stress is a complex phenomenon resulting from the
differences in occupational stress, job satisfaction and job performance among nurses
The aims of the study were to: 1) examine the relationships between
occupational stress, job satisfaction and job performance among hospital nurses in
affect the relationships between occupational stress, job satisfaction and job
nurses from four hospitals completed the Nurse Stress Index, the Job Satisfaction
Survey, and the Six-Dimensional Scale of Nurse Performance scales. Study findings
job satisfaction and job performance between the public and private not-for- profit
iii
hospitals. Nurses in the public hospital reported higher levels of occupational stress
and lower levels of job satisfaction and performance. There were significant negative
occupational stress and job satisfaction. Nursing experience, type of hospital, and
job satisfaction and job performance. Type of hospital (public versus private), ward
(obstetrics/gynecology versus other ward types), and job satisfaction were significant
stress and factors that enhance job satisfaction among hospital nurses in Uganda.
Future research is needed to examine best practices for human resource managers to
iv
DEDICATION
In loving memory of my late father Mr. Nathan Gusongoirye Waako who always
encouraged me to study hard and sacrificed the little resources he had in order to
v
ACKNOWLEDGEMENTS
First and foremost, I am most grateful to the Almighty God for giving me this
ICER Training Grant through Dr. Eric Chamot for the initial grant which enabled me
to enroll in the program. I convey my heartfelt gratitude to all the staff in the Fogarty
office, especially Heather White and Alexis MacLean for the untiring patience and
support accorded to me while at UAB. My gratitude to Sigma Theta Tau, the Gladys
Development and Training Division for additional grants which enabled me complete
the program, and to Makerere University School of Graduate Studies for funding the
study. Sincere gratitude also goes to the Good Health Program of Birmingham and
Deep South Center for Occupational Health and Safety, UAB and Auburn University,
for providing the pens which were distributed to the participants during data
collection.
supervisor and Dissertation Committee Chair for the guidance, support and continuous
advice not only on academic matters but on social issues as well. I sincerely
appreciated her patience and commitment to see me through the PhD program.
My sincere gratitude also goes to Dr. Erica Pryor, for the continuous advice,
support and expertise in statistics and for always being there for me whenever I
Elizabeth Maples, Dr. Connie Kohler and Dr. Na-Jin Park for their support,
vi
encouragement and guidance throughout the doctoral program and dissertation
writing.
I thank Dr. Isaac Okullo, my Ugandan supervisor, for his advice and
for the professional advice and guidance, despite his busy schedule. My sincere
gratitude also goes to Dr. D. K. Sekimpi for the support and encouragement
I am so grateful to all UAB School of Nursing Faculty and other staff, whoever
I came in contact with, but most especially Drs. Lynda Wilson and Jacqueline Moss,
for giving me encouragement and advice which kept me “hanging in there.” To the
PhD nursing students in academic years 2006/2007-2008/2009, I say thank you all for
the support you gave me. Tracy, I thank you so much for providing the sisterly support
Damrongsak Brown for “showing me the ropes” and always being there for me.
I am sincerely grateful to my friends Pat Yeilding and family, Sandy and Bill
Myers, and family for always being there for me. The words of encouragement,
spiritual and other forms of support, the love you showed me and prayers surely kept
and beyond, most especially Dr. Kabagambe Edmond and family, Sarah, Vincy,
Jacqueline Makaaru, Jacqueline Mulundika and Margaret for the family atmosphere
which made me “feel at home away from home” throughout my stay in Birmingham.
Professor Nelson Sewankambo for the continuous support and advice especially on
vii
faculty and staff for the support and encouragement not only to me but to my family
during my absence.
University, for the support and advice especially for writing the literature review and
dissertation report. I thank Mr. Yovani Lubaale and Dr. Nazarius Mbona of Makerere
University Institute of Statistics and School of Public Health respectively for the
Hospital, the Senior Nursing Officers and the Medical Directors of Mengo, Kibuli and
Rubaga Hospitals for the support during preparation and actual data collection. To the
dear nurses who participated in the study, I am so grateful for your precious time to
complete the questionnaires. Many thanks also go to the research assistants including
Godfrey, Scovia, Allen and Richard for the support, interest, and diligence they
brothers David, Robert, Charles, Peter, Dan, Edward and sister in-law Mrs. Joyce
Nankinga Gusongoirye. I thank you for your endless love, prayers and moral support.
And last but not least, my beloved children, Doreen, Ellen, Pauline, Solomon
and Derrick, thank you for being such wonderful children. In spite of missing
motherly love and care, you gave me unconditional love, support and encouragement
viii
TABLE OF CONTENTS
Page
COPYRIGHT................................................................................................................. ii
ABSTRACT..................................................................................................................iii
DEDICATION ............................................................................................................... v
CHAPTER
1 INTRODUCTION
Health Care System in Uganda ............................................................................ 3
Statement of the Problem..................................................................................... 4
Significance of the Study ..................................................................................... 6
Specific Aims of the Study .................................................................................. 7
Research Questions .............................................................................................. 7
Operational Definitions........................................................................................ 8
Conceptual Framework ........................................................................................ 9
Assumptions for the Study ................................................................................. 10
ix
3 METHODOLOGY ............................................................................................... 33
Study Design ...................................................................................................... 33
Ethical Considerations ....................................................................................... 33
Setting ................................................................................................................ 34
Study Sample ..................................................................................................... 35
Inclusion Criteria ...................................................................................... 35
Exclusion Criteria ..................................................................................... 36
Sample Size........................................................................................................ 36
Instruments......................................................................................................... 37
The Nurse Stress Index (NSI) ................................................................... 37
The Job Satisfaction Survey (JSS) ............................................................ 38
The Six Dimension Scale of Nursing Performance (6-DSNP) ................. 39
Pilot-testing of Instruments ................................................................................ 39
Data Collection Procedures ............................................................................... 40
Data Safety and Integrity ................................................................................... 41
Data Analysis ..................................................................................................... 42
Limitations of the Study .................................................................................... 43
x
Implications ....................................................................................................... 83
Implications for Nursing Education .......................................................... 83
Implications for Nursing Practice ............................................................. 83
Recommendations .............................................................................................. 84
xi
LIST OF TABLES
Table Page
3 Number of Items and Cronbach’s Alphas for the NSI Sub-scales ......................... 47
4 Number of Items and Cronbach’s Alphas for the JSS Sub-scales.......................... 48
5 Number of Items and Cronbach’s Alphas for the 6-DSNP Sub-scales .................. 49
6 Range of Possible Scores, Mean Scores and Standard Deviations for NSI ........... 50
7 Range of Possible Scores, Mean Scores and Standard Deviations for JSS ............ 51
8 Range of Possible Scores, Mean Scores and Standard Deviations for 6-DSNP .... 52
17 Correlations for Job Performance, Job Satisfaction with Occupational Stress ..... 64
19 The Final Predictive Model for Self-Rated Job Performance ............................... 67
20 The Mediating Role of Job Satisfaction between Occupational Stress and Job
Performance.......................................................................................................... 69
21 Means for Occupational Stress, Job Satisfaction and Job Performance for the
Different Hospitals ............................................................................................... 70
xii
22 Influence of Type of Hospital on Job Performance, Job Satisfaction and
Occupational Stress .............................................................................................. 71
xiii
LIST OF FIGURES
Figure Page
xiv
LIST OF ABBREVIATIONS
EM Enrolled Midwife
EN Enrolled Nurse
M Mean
RM Registered Midwife
RN Registered Nurse
xv
RPN Registered Pediatric Nurse
SD standard deviation
UK United Kingdom
US United States
xvi
1
CHAPTER 1
INTRODUCTION
responses that occur when the requirements of the job do not match the resources,
capabilities and needs of the worker (Alves, 2005; Bianchi, 2004; Lindholm, 2006;
Nakasis & Ouzouni, 2008). The International Labor Organization (ILO) asserts that
all countries, professions and all categories of workers, families and societies are
affected by occupational stress (Ogon, 2001). According to Alves (2005), 40% of all
American workers perceive their jobs as being extremely stressful. Similar findings
are noted in the United Kingdom, where occupational stress is estimated to be the
research has demonstrated that as workload and work-associated stress increase, turn-
over rates of workers are also noted to increase. Thus, occupational stress results in
litigation and rapid turn-over, and lack of job satisfaction, has been reported to cause
significant monetary costs to the National Health Service [NHS] Trusts in the UK
(Cottrell, 2001; Mackay, Cousins, Kelly, Lee, & McCaig, 2004). Alves (2005)
outcomes including physical injuries at work and absenteeism; while the World
Health Organization (WHO, 2002) estimates the cost of stress and stress-related
Job stressors and low job control have also been shown to be risk factors for
patient safety and to lead to poor job performance including reduced quality of
nursing care (Sveinsdottir, Biering, & Ramel, 2006). Occupational stress has also
musculoskeletal disorders, physical injuries and cancers (Alves, 2005; Bradly &
Cartwright, 2002). Mental illness and serious health compromising behaviors such as
increased risk for suicide, substance abuse (such as smoking and alcohol
consumption), poor diet and lack of exercise are also associated with occupational
literature are from the perspective of American and European workers. Since
occupational stress has been reported to affect all societies and professions (Ogon,
occupational stress, its levels and effects vary greatly depending on local forces such
as nature of work, work setting and cultural orientation. Thus, significant differences
in occupational stress among nurses in different countries may exist due to different
work settings and levels of social support (Evans, 2002). At present, there are scant
data about sources of occupational stress and its relationship with job satisfaction and
need to understand the predictors of occupational stress and the levels and inter-
3
Africa. The country is bordered by Kenya in the east, Sudan in the north, Democratic
Republic of Congo in the west, Tanzania in the south and Rwanda in the southwest
For example, life expectancy (in years) at birth for males and females is 48 and 51
respectively and the infant mortality rate is 136 per 1000 live births; with 7.6 % of
gross domestic product (GDP) expenditure on health (WHO, 2005). The health
infrastructure in Uganda is composed of hospitals, health centers and aid posts which
referral or district/rural hospitals. The health centers are graded as health center IV,
III, II according to level of service, which is at the county, sub-county, and parish
levels respectively. There are a number of training schools and universities which
nurses depending on the educational level of entry to the program and the length of
the program. Enrolled Nurses or Midwives (EN or EM) training lasts two and a half
years and eligible students must have acquired a Uganda Certificate of Education or
4
its equivalent. This level of training has been phased out, but the cadre of nurses still
exists in the hospitals. The registered level training is a three year program and
eligible students must have a Uganda Advanced Level Certificate of Education or its
equivalent. Graduates at this level can be general nurses (RN), midwives (RM),
In the past, registered level nurses could complete further education in any
other discipline of interest to get an equivalent certificate diploma after practicing for
preparation and vice versa and train for one and a half years, creating another cadre of
nurses, the Registered Nurse/Midwives (RN/M) or double trained nurses. This type of
midwife to registered level was termed vertical training. Double training has been
phased out and nurses are encouraged to pursue further education in the same line,
which is, general nursing, midwifery, pediatrics, etc. The Public Health Nurse (PHN)
program is a two year program only offered to nurses who have done at least two
disciplines at the registered level. The BSN is a four year university level program
plus an additional one year internship. The BSN program prepares nurses to acquire
research.
due to the macroeconomic and governing factors. A shortage of nursing staff has
been reported with a ratio of one nurse (nurses and midwives combined) to a
population of 3,065. It has also been reported that despite employing 30,000 health
5
care workers in 2004, an extra 5,000 qualified staff were needed to address the serious
staff shortage (Dieleman, et al., 2007). The situation has been compounded by the
There are continuous complaints by Ugandan nurses about work overload, and
the demand for nurses continues to grow as many drop out of work with very little
intervention seen. It has been reported that there is lack of enough space in the
hospitals and they are overcrowded with very sick patients. The situation is worsened
by lack of facilities and shortage of nurses, which is likely to cause stress to the nurses
(Ojoatre, 2008). For example, according to the government newspaper (New Vision),
one of the senior staff in Mulago Hospital reported that there were only 8-12 staff
members including nurses, midwives and doctors for five wards in the department of
Obstetrics and Gynecology at any one time. The staff manages the patient load which
is three times the load that is expected for 24 staff members on one ward.
At the First Global Forum on Human Resources for Health that took place in
Uganda in 2008 it was observed that there was an imbalance between the number of
nurses trained in the country and those who register to practice. It was speculated that
nurses have migrated to other countries, have joined other fields, or sit at home due to
the poor work conditions. Nurses also complain of working all day long despite the
high numbers of very seriously ill patients who require more attention. They have
further complained that their work is very stressful citing the very high nurse-patient
the 1:2 or 1:5 recommended by the World Health Organization for fatal complications
Nurses have also observed that working when tired results in mistakes for
which they are blamed; therefore, they would rather not go to work under the
circumstances. This is in addition to the public outcry about the deteriorating nursing
care in Ugandan hospitals. Since there are no established occupational health services
due to limited resources and lack of occupational health professionals, there is a risk
of continuous loss of nurses, either due to stress related diseases or attrition due to
conducted among nurses in the United States and Europe. However, stress is a
complex phenomenon which results from interaction between an individual and the
stress among nurses may exist due to different work settings and levels of social
support (Evans, 2002). It was further asserted that occupational stress is a function of
local forces, pressures and cultures that requires customized interventions (Muscroft
& Hicks, 1998). Therefore, this study examined associations between occupational
stress, job satisfaction and job performance among hospital nurses in Uganda.
The results of this study may be used to guide policy makers and nurse
situation. Prevention and management of occupational stress among nurses will not
only improve their health but may improve job satisfaction and nursing care, which
will in turn reduce costs for the healthcare organizations as well as individuals.
7
Kampala, Uganda.
based) hospitals.
Research Questions
4. Does job satisfaction mediate the relationship between occupational stress and
5. Are there differences in levels of occupational stress, job satisfaction and job
Operational Definitions
Uganda.
work characteristics: age, gender, marital status, number of children, hospital, ward/
demographic questionnaire.
that occur when the requirements of the job do not match the resources, capabilities
and needs of the worker (Alves, 2005). Occupational stress was measured by the
Job satisfaction refers to the level or degree to which employees like their jobs
(Spector, 1997). Hospital nurses’ job satisfaction was measured by the Job
roles and responsibilities related to his/her job (AbuAlRub, 2004). The Six Dimension
nurses’ job performance or effectiveness in carrying out their roles and frequencies of
Conceptual Framework
used to guide the study of occupational stress and coping are Lazarus and Folkman’s
cognitive theory of stress and coping (Lazarus & Folkman, 1984) and Karasek’s
(1984) cognitive theory of stress and coping, stress is defined by the interaction
between the individual and the environment. Demands from the environment
theory that guided this research are personal and workplace characteristics. Workplace
may facilitate the individual nurse’s ability to carry out the process of appraisal of the
stressors. Occupational stress and coping will result accordingly, depending on the
level of appraisal. The individual’s perception of how much control he/she has is a
controllable.
of objective work load demands in the environment and the employee’s decision
latitude to meet the demands. Decision latitude is defined as the authority which the
individual employee has to make job decisions and the opportunity to utilize and
develop skills on the job (Karasek, 1979). Long term exposure to situations with
increased demands but with low control leads to low productivity and health related
problems. The assumption in the model is that psychological strain results from joint
effects of work demands and the decision-making freedom available for the employee
10
facing the demands. In other words, jobs with high demands but with low control
increase the risk of stress-related illness. The variables in this model which guided the
Environmental
Stressors (Workplace
factors)
- Type of hospital
- Ward/unit
- Responsibility
- Hours worked on a
typical day OCCUPATIONAL
STRESS
JOB
PERFORMANCE
Personal
Characteristics:
JJ
- Age JOB
- Sex SATISFACTION
- Nursing Education
- Nursing experience
- Marital Status
- Number of children
2. Stressors occur in life and work environments and individuals react to these
stressors.
3. Nurses work in stressful environments that each individual nurse appraises and
reacts to differently.
11
CHAPTER 2
LITERATURE REVIEW
satisfaction, and job performance among nurses of all specialties in or outside the
hospital. The first section of the review is related to sources and effects of
occupational stress. The second section includes a review of factors that affect job
satisfaction and the third section reviews factors related to job performance.
satisfaction and job performance among nurses in the United States (U.S.), Europe,
and Asia, but very little in Africa. It should be noted that even the limited research in
Africa was conducted only in South Africa and no research was reported on in east,
west, north or central African nurses. This phenomenon was observed by Adejumo
where 68.3% of the publications in the past two decades were from South Africa,
5.2% from West Africa, and 3.3% from East Africa. These findings may be due to the
fact that African nurses outside of South Africa have limited research skills and rarely
publish.
Occupational Stress
professions in the U.S, Europe and Asia. Researchers have examined effects of stress
result of their studies, these authors, have also suggested management and prevention
strategies (Bianchi, 2004; Bradley & Cartwright, 2002; Chen, Chen, Tsai, & Lo,
professions throughout the world. The National Health Services (NHS) in the United
Kingdom and in Australia reported that occupational stress occurred among health
2002; Cottrell, 2001). This higher level of stress in health service has been attributed
to the nature of the work of health professionals in which nurses, physicians and
crises (Tyson & Pongruengphant, 2004). Nursing has been shown to be a strenuous
Sunday Times in 1997 reported that nursing was the sixth most stressful profession.
This literature review will examine the sources of identified occupational stress and
Sources of stress for nurses can be divided into four areas: workload,
is rare that only one source of stress is present. Sources of stress are frequently
interrelated and synergistic effects are observed due to a variety of sources of stress.
issues. Research has demonstrated that sources of occupational stress among nurses
individuals. This has been attributed to the different health systems, their culture,
13
employment contract, work experience and personality traits (Lee & Wang, 2002;
Individual differences affect the perception of the stressful situations and the
use of coping strategies. For example, in a study comparing Guatemalan and U.S.
nurses’ attitudes towards nursing, Guatemalan nurses were discontent with the lack of
resources to treat patients while the U.S. nurses were discontent with the work
researchers found that younger public health nurses in the U.S., those with shorter
length of current working experience, a higher level of education, and less pre-job or
job continuing education perceived more occupational stress (Kirkcaldy & Martin,
2000; Lee & Wang, 2002). It can be argued that these less experienced and younger
public health nurses may have lacked enough experience at their current job. This
may lead to lack of confidence and or competence in their work roles, thus the higher
perception of occupational stress. However, it is not clear why those with a higher
level of education perceive more occupational stress, but it may be due to role
ambiguity. In contrast, Kirkcaldy and Martin (2000), in their study of job stress and
job satisfaction among hospital nurses in Northern Ireland, found that older nurses
reported more stress while younger nurses experienced better psychological health.
This could be a result of more social responsibility for the older nurses which could
Workload
(Callaghan, Shiu, & Wyatt, 2000; Khowaja, Merchant, & Hirani, 2005; Li & Lambert,
14
2008). In a study of 102 nurses in a Chinese intensive care unit, excessive workload
was the most frequently cited source of workplace stress. This was a result of the
nursing shortage with fewer nurses to care for more patients (Li & Lambert, 2008).
Work load, shift work, overtime, and covering for absent colleagues were the most
common identified stressors in other studies (Begat, Ellefsen, & Severinsson, 2005;
Cottrell, 2001; Xianyu & Lambert, 2006). Lee and Wang (2002) investigated
perceived occupational stress and related factors among public health nurses, and
reported that personal responsibility and workloads were the major sources of
occupational stress. Excessive work load was also included as a major contributor to
stress among hospital based Brazilian nurses (Stacciarini & Troccoli, 2004). Heavy
workload may be due to the physically arduous work of nursing jobs, as well as due to
competence in the nursing role can have a synergistic relationship with work load,
study of job stress, coping and health perceptions of Hong Kong primary care nurses
to higher stress reported by those working in acute care settings (Lee & Wang, 2002).
This is expected as nurses working in acute care settings deal with very sick patients,
reported that nurse managers and clinical directors had a significant probability of a
high level of work stress because they were exposed to high job demands. In addition,
significantly greater job stress was reported among medical-surgical nurses than those
Organizational Pressure
Organizational pressure and management issues are common causes for stress
(McGrath, Reid, & Boore, 2003; Tyson, Pongruengphant, & Aggarwal, 2002). Stress
lack of competence and confidence, lack of communication and guidance, and low
salaries or absent reward systems are organizational and management issues. Lee and
Wang (2002) reported personal responsibility, inadequate guidance and support, lack
manpower, and having to take risks to complete tasks as sources of institutional stress.
(Begat, Ellefsen, & Severinsson, 2005; Cottrell, 2001; Xianyu & Lambert, 2006).
it was reported that certified nurse anesthetists perceived that responsibilities related
to patient care and anesthesia were inherently stressful (Roberts, 2005). Nurse
anesthetists care for patients who are usually unconscious and who require critical
nursing care and often contribute to work anxiety. Other significant stressors for the
(2004) identified institutional work conditions as the major source of stress for nurses.
16
Makinen and colleagues similarly reported that occupational stress due to work social
Kivimaki, Elovainio, & Virtanen, 2003). Makinen and colleagues further reported that
the patient-focused nursing modes reduced the interpersonal problems among the
staff, thus decreasing work stress (2003). Evans (2002) identified six major nurse
image, reward systems, and human resource systems and recommended that
Working with difficult patients, the nurses’ feelings about death and dying,
interpersonal conflicts, managing the patients’ pain and the presence of the family
Tyson, et al., 2002). The HIV epidemic and high mortality rates have contributed to
South Africa, health risks posed by contact with HIV/AIDS patients, lack of
recognition for the job they are doing, and insufficient staff were identified as the
most common stressors for nurses (Rothmann, van der Colf, & Rothmann, 2006).
These findings are consistent with literature about the effect of the HIV/AIDS
pandemic on the health care workforce, with reports of increased emotional burden
and stress among health workers due to anxiety and fears of occupational exposure
(Dieleman, et al., 2007; WHO, 2005). Dieleman and colleagues found specifically in
Uganda that 83% of the staff interviewed had increased fear of occupational exposure
as a health worker, 36% had had a potential exposure injury in the past year, and the
17
only resource available for nurses was to wash the area under running water
(Dieleman, et al., 2007). Eighty-six percent of the staff also reported that an increase
emotional burden with burnout in caring for very sick patients who do not respond to
therapy, and increases concern about being stigmatized if they do contract HIV/AIDS.
The majority of the staff continued to report a significant fear of getting infected even
though there was adequate protection available in the hospital. It was found that
hospital administrators were haphazard in addressing this staff issue, with no written
policies to prevent or mitigate the impact of HIV/AIDS, and that this affected working
Professionalism
Professional issues have also been reported to lead to stress among nurses. For
perception of occupational stress, found that job image and reward systems were
among the six major stress factors for the nurses. In another study of perceived
occupational stress and related factors in public health nurses in Taipei City, Taiwan,
Lee and Wang (2002) found that lack of recognition in the workplace was a
significant stressor among nurses. Likewise, Stacciarini and Troccoli (2004) in their
study of occupational stress, job satisfaction and state of health in Brazilian nurses,
reported that lack of recognition, lack of status of the nursing profession, lack of
autonomy, low salaries, lack of resources, and assignments outside the individual’s
Ethical conflicts have also been identified as sources of job related stress and
anxiety (Begat, et al., 2005). According to Begat and colleagues, ethical dilemmas
18
arise because of nurses’ values and desires to provide high-quality care. This is in
agreement with McGrath, Reid and Boore’s (2003) findings that too little time to
perform duties to one’s satisfaction and rationing of resources and services resulted in
stressors and work relations of the certified nurse anesthetist, perceived occupational
stress were related to patient care and anesthesia work in general (Roberts, 2004).
These stressors included patient complications and unexpected patient outcomes such
as death of a patient on the operating table. Lack of competence and confidence in the
nursing role has also been identified as a stressor (Kirkcaldy & Martin, 2000). The
nurse who lacks confidence and who is not competent in the role may be concerned
for health care systems (Cottrell, 2001; Evans, 2002). This is due to lack of
retention problems, burnout, absenteeism, litigation, and rapid turnover. The World
Health Organization (WHO, 2002) estimates the cost of stress and stress related
spend $3,189 annually on health care expenses as compared with $ 1,679 for a non-
accumulated short-term disability days resulted in 20 million more lost work days per
year than non-depressed workers (Cottrell, 2001). Although litigation cases are not
increasingly aware of their rights and starting to sue health institutions for health
increase in health care ministries in these countries not only in terms of medications
and other supplies but also in litigation cases. It is also likely to increase individual
nurses’ stress as they will be working with anxiety and fear of litigation in the event
Individual effort-reward imbalance has been associated with burnout, which results
from prolonged intense stress. In a study of burnout among nurses in Germany, the
nurses who experienced effort-reward imbalance reported higher levels on two of the
three core dimensions of burnout (Bakker, Killmer, Siegrist, & Schaufeli, 2000).
Bakker and colleagues found that the nurses who identified a negative imbalance
between efforts spent on their job and the reward they felt from the job reported
feeling more emotionally drained than those who did not. The feelings of personal
accomplishment were lowest among nurses who had a mismatch between demands
and rewards, and who had high intrinsic effort in their jobs.
examined demanding work schedules and mental health in nursing assistants working
in nursing homes, and reported that working two or more double shifts per month was
associated with an increased risk for all negative mental health indicators (Brown,
Zijlstra, & Lyons, 2006). Furthermore, working 6-7 days per week was associated
with depression and somatization. In a study of stress, coping and managerial support
and work demand among nurses, consistent relationships between work stress and
depression, anxiety and job satisfaction were identified (Bennett, Lowe, Matthews,
20
Dourali, & Tattersall, 2001) They suggested that lack of management support, having
job overspill, making decisions under time pressure and lack of recognition by the
organization were key predictors of negative effect. Chronic health problems such as
also been associated with occupational stress (Alves, 2005). Mental illness and
serious health compromising behaviors such as increased risk for suicide, substance
abuse (such as smoking and alcohol consumption), poor diet, and lack of exercise
2006).
(Cottrell, 2001; Sveinsdottir, et al., 2006). The high turnover of nurses results in a
shortage of nurses, which leads to work overload for the remaining nurses and
becomes a vicious cycle. The high turnover of nurses is attributed to a lack of job
satisfaction which is associated with occupational stress. For example, Flanagan and
Flanagan (2002) in a study of job satisfaction and job stress reported that the NSI was
the strongest explanatory variable accounting for 30.3% of job satisfaction. Tyson and
colleagues, who also utilized the NSI to measure occupational stress in their study of
coping with organizational stress among hospital nurses in Southern Ontario, reported
a negative correlation between job stress and job satisfaction (Tyson, et al., 2002).
The shortage of nurses has also been reported to affect nursing care negatively.
In a study on hospital nurse staffing and patient mortality, nurse burnout and job
risk-adjusted 30 day mortality and failure to rescue when the patient-to-nurse ratio
was high (Aiken, Clerke, & Sloane, 2002). Patients were more at risk of dying in a
30-day period because the nurses could not rescue them when hospital units were
21
understaffed. In the same study, nurses were more likely to experience burnout and
job dissatisfaction when the patient-to-nurse ratio was high. Lack of job satisfaction
lateness or reduced effort and increased error rate (Ackerman & Bezuidenhout, 2007).
This is a manifestation of poor nursing care which places patients’ lives at risk.
Sveinsdottir and others (2006) also reported that job stressors and low job control lead
to poor job performance, reduced quality of nursing care, and concerns for patient
safety.
phenomenon for nurses to work double shifts or to work for seven days or more
without “off duty.” Nurses stand in for colleagues who fail to report for duty due to
sick leave or other social problems. Due to poor remuneration in their primary job,
nurses prolong their work schedules when they want to accumulate vacation days in
Kyadondo and Whyte (2003), public sector reforms and poor remuneration have
supplementary sources of income outside the health care system. Kyadondo and
Whyte further observed that while other professionals in Uganda supplemented their
salaries by engaging in agriculture, beer brewing or trade, health workers were found
in small storefront clinics, drug shops and laboratories. This means that health
workers end up overworked if they continue to work in the public sector as well as in
private enterprises. Further research is needed to examine stress and related factors
Job satisfaction is defined as the level or degree to which employees like their
jobs (Spector, 1997). Numerous components of job satisfaction have been identified
including including satisfaction with pay, potential for creativity, autonomy, task
between perceived stress and job satisfaction, that is, as job satisfaction increases,
stress decreases (Flanagan & Flanagan, 2002; Sveinsdottir, et al., 2006; Zangaro &
Soeken, 2007).
findings of Bradley and Cartwright’s study of social support, job stress, health and job
organizational support was related to nurses’ health and job satisfaction (Bradley &
private hospital in South Africa, the results indicated that dissatisfaction was due to
lack of resources, poor remuneration, an inflexible time system, and staff shortages
positive leadership has also been reported as important factors for nurse job
correlated with job satisfaction and job stress among nurses. This meta-analysis,
conducted in the U.S. included 31 studies published between 1991 and 2003.
However, although the meta-analysis was conducted in the U.S., it is not clear
whether all the reviewed research was conducted in the U.S. Therefore it is not
possible to assess whether the observations could be generalized only to nurses in the
In a study of factors influencing stress and job satisfaction for nurses working
in psychiatric units in Greece, the findings indicated that job satisfaction was
(Nakasis & Ouzouni, 2008). In a study among Australian nurses, role discrepancy
especially task delegation practice contributed to nurses’ intention to quit their jobs
(Takase, Maude & Maniase, 2006). This report supports the above observation that
dissatisfaction.
intrinsic and extrinsic factors. Intrinsic factors, also known as motivators are those
factors inherent to the nursing job itself, while extrinsic or hygienic factors refer to
conditions of work and work environment. While some research has reported that
nurses may be stressed due to the nature of their job (intrinsic factors), other studies
indicate that nurses are satisfied with the intrinsic factors. For example, Lephoko and
colleagues reported that nursing management and nursing staff in selected hospitals in
Mpumalanga province, South Africa were content with the intrinsic factors of their
jobs but were dissatisfied with the extrinsic factors of the organizational climate
(Lephoko, Bezuidenhout, & Roos, 2006). On the other hand, (Salebi & Minnaar,
24
2007) in a study of nurses in a public hospital in South Africa, reported that more
of their job as compared to only 22% who experienced low satisfaction with hygiene
(extrinsic) aspects of the job. The intrinsic motivational components of this study
recognition while the extrinsic hygiene factors were relationships in the work place,
security and salaries. Extrinsic organizational climate in the Lephoko and colleagues
The results of the above two studies conducted in the same country of South
Africa are contradictory. This is an indication that like occupational stress, job
agreed upon definition of intrinsic and extrinsic factors is needed to better compare
reported that the most important extrinsic factor that caused job dissatisfaction among
nurses was their salary (Lephalala, Ehiers, & Oosthuizen, 2008). Salaries between
private hospitals and the National Health Service varied considerably and salaries
within one hospital were also not uniform. In the same study, nurses were satisfied
supervision and interpersonal relations. These findings are inconsistent with those of
Lephoko and colleagues (2006) in South Africa in which nurses were dissatisfied with
25
reflection of cultural and economic differences and the level of development of the
health care systems. In the same study, Lephoko et al., (2006) reported that lack of
policy making were the most important intrinsic factors influencing nurses’ job
satisfaction among nurses in the private hospitals studied. This also contradicts other
studies emphasizing that each hospital or health care environment has its own milieu
job satisfaction. In a study exploring nurses’ views and experience in mainland China,
it was reported that organizational commitment had the strongest positive impact on
job satisfaction (Lu, While, & Barriball, 2007). In the same study, organizational
exploratory study confirmed the hypotheses that there was a negative correlation
between work-family conflict and job satisfaction and that spousal support was
positively correlated with job satisfaction (Patel, Beekhan, Paruk, & Ramgoon, 2008).
According to Patel and colleagues, these findings indicated that nurses who are more
satisfied with their jobs were less likely to allow work to encroach on their family
lives. This conclusion is in agreement with the available literature which reports that
an employee who perceives himself or herself to have job control has higher job
satisfaction (Chinweuba, 2007; Sveinsdottir, et al., 2006). Although this study did not
nurses, one of the sub-scales in the Nurse Stress Index contains items related to
Job satisfaction among nurses has also been studied in relation to working
the majority of respondents were dissatisfied with working conditions and emotional
climate of the hospital, but fairly satisfied with the social climate (Kekana, Rand, &
challenges of the job. Emotional working climate referred to the level of autonomy
experienced by nurses, how they conceive themselves as nurses and their professional
commitment. The social work climate referred to the personal interactions at work,
group cohesiveness and team spirit. Under working conditions, 83% of the
participants rated workload and the degree of fair remuneration as highly dissatisfying
while 82% rated pressure under which they worked as the most highly dissatisfying
These findings were consistent with previous reports that heavy workload is a
source of occupational stress which leads to low job satisfaction. However, the factors
which are related to job satisfaction may be influenced by the differences between
study populations, the design and conditions under which the studies are conducted.
For example, in a study of nurses in Southern Taiwan which examined the effects of
job rotation and role stress on job satisfaction and organizational commitment, nurses
reported that job rotation had an effect on job satisfaction (Ho, Chang, Shih, & Liang,
2009). This differs from the previous studies cited above. However, it is clear that
frequent rotation on the job may not allow nurses to develop the required individual
satisfaction followed by personality traits and job involvement (Chu, Hsu, Price, &
workload resulted in absenteeism in the work place (Nyathi & Jooste, 2008). As such,
these findings are in agreement with Selebi and Minnar (2007) who report that
routinization, role ambiguity and lack of delegation autonomy do not give opportunity
for innovations and creativity by the employees, and may result in job dissatisfaction.
It has been reported in the literature that there is a negative link between job
satisfaction, intention to leave, and actual turnover (AbuAlRub & Al-Zaru, 2008).
Work related stress has been found to increase turnover rate of workers due to less job
significant predictor for nurse retention (Wilson, Squires, Widger, Cranley, &
Tourangeau, 2008). Cottrell (2001) reported that over 30,000 nurses in the UK left
their profession in 1997 alone. Such a loss, coupled with the recruitment crisis, results
Job stress and job satisfaction have also been reported to be influenced by
personal characteristics such as age and experience of nurses. For example, significant
inverse correlations were reported between job satisfaction and age, and years of
nursing experience with job stress (Ernst, Franco, Messmer, & Gonzalez, 2004).
Other personal characteristics such as mental and physical health, marital status,
28
education level, rural/urban setting, and perceived HIV stigma were reported to have
in job satisfaction scores among five countries in a study of HIV stigma and nurse job
satisfaction in five African countries (Chirwa, et al., 2008). These results reinforce
the fact that there are many factors which affect job satisfaction.
In another study of the relationship between job stress and job satisfaction
the relationship between job stress and job satisfaction (Chinweuba, 2007). This result
was attributed to the fact that the nurse educators with a higher education had a higher
chance of securing a desired and satisfying job. The education qualification has also
been reported to affect the employees’ role perception, professional commitment and
role conflict, thus affecting job satisfaction indirectly (Lu, et al., 2007). Chinweuba
rightly observes that nurse educators with less qualifications have less chance of
securing satisfying jobs, have more role conflicts role ambiguity and work overload or
under load. This means that they have less control of their work days, poor promotion
opportunities and low levels of salaries. The two reports highlight the importance of
It has been reported in the literature that employees who have job
Ackerman and Bezuidenhout observed that while some employees may react by
leaving the organization, others may actively and constructively attempt to improve
the conditions by voicing their concerns. Further, others may wait passively for
well as researchers. It is not known what proportion of the reported shortage of nurses
in Uganda is due to lack of job satisfaction, occupational stress, or any other cause. It
improve the quality of nursing care in these hospitals. It is noted that studies of job
satisfaction among nurses have utilized various instruments. The JSS developed by
Spector (1997) was used to measure job satisfaction in the current study because its
sub-scales and items include factors that may be related to the work environment for
Ugandan nurses.
Occupational stress and low job control have been shown to be risk factors for
patient safety and to lead to poor job performance (AbuAlRub, 2004). Using the Six-
Taskase and colleagues found that the quality of job performance was reduced when
job dissatisfaction was present (Takase, Maude, & Manias, 2005). A high level of
occupational stress has been found to reduce nursing quality. A shortage of nursing
staff due to turnover as a result of occupational stress was associated with increased
in a study on job stress, recognition, job performance and intention to stay at work
performance had a direct and buffering effect on job stress and the level of intention
to stay at work (AbuAlRub & Al-Zaru, 2008). This is consistent with available
literature which has reported that recognition leads to job satisfaction and nurses
seeing no reason to leave their jobs (Cartledge, 2001). Higher occupational stress
levels have also been significantly associated with poorer self-rated and supervisor-
30
rated job performance, more sick days, and more reported absences for mental health
reasons.
management, it was found that performance increased where supervisor support was
support had a negative impact on nurses’ performance. This means that supervisor
study, Abu Al Rub (2004) reported that perceived social support from co-workers
enhanced the level of reported job performance, and lowered the level of job stress
quality of nursing behaviors over time (Roud, Giddings, & Koziol-McLain, 2005).
The researchers concluded that new graduate nurses can successfully integrate
knowledge gained during training into clinical practice when provided with time and
support. This is probably true for all employees because the longer one stays on the
job, the more confident and competent one becomes in the skills required for the job.
supervision, positive feedback, and good communication. Perceptions that they are
valued, job satisfaction and organization commitment may lead to improved work
place efficiency and output (Stapleton, et al., 2007). Career commitment has also been
emotionally attached to the organizations and accept their goals and values (Mrayyan
& Al-Faouri, 2008). With the acceptance of organizational goals and values,
employees may remain in the organizations. This not only improves job performance
Many researchers have studied occupational stress, job satisfaction and job
performance among nurses. However, the studies have been either in individual
private or public hospitals and very few compared these variables across both public
and private hospitals. In a five year follow-up study of stress among nurses in public
and private hospitals in Thailand, nurses in public hospitals reported more stress than
those in private hospitals. However, job satisfaction did increase over time,
Religious beliefs have also been reported to affect performance and service
delivery. In a study to evaluate the service delivery given by religious health care
providers in Uganda, it was reported that religious not-for-profit facilities hire medical
staff below the market wage but the workers provide better quality care than their
providers to provide quality care to the poor. This finding is similar to the findings of
(Mrayyan & Al-Faouri, 2008) who observed that employees who are emotionally
attached to the organizations and accept their goals and values are satisfied with their
jobs.
32
There are indications that nursing care in hospitals in Uganda has deteriorated.
This is reflected in various newspaper complaints about neglect of patients and poor
nursing care in the Ugandan hospitals. It is therefore assumed that nurses’ job
performance does not meet public and administrative expectations. No study has been
performance and the factors which are associated with it. This will guide policy
makers and nurse managers in developing strategies for improving job performance in
Ugandan hospitals.
Summary of Literature
Based on the review of the literature, occupational stress, job satisfaction, and
job performance are the major factors associated with retention of nurses and quality
of care. Additionally, occupational stress has been found to differ among professions
and work settings. The majority of the research studies regarding sources of
occupational stress and job satisfaction have been conducted on American and
European nurses and their work settings. The conceptual model guiding this study
indicated that cultural templates influence the appraisal of job demands, job
satisfaction, and job performance (Lazarus & Folkman, 1984). Therefore, given the
diversity of reported stressors for nurses, there is a need to identify the relationships
among occupational stress, job satisfaction and job performance of nurses in the
Ugandan hospitals.
33
CHAPTER 3
METHODOLOGY
of the study. The study design, data collection instruments, subjects, procedure for
Study Design
research questions. The relationships among occupational stress, job satisfaction, and
job performance were explored. The effects of personal characteristics such as age,
marital status, nursing education, nursing experience and type of unit on occupational
stress, job satisfaction and job performance were also explored. Further, differences
occupational stress, job satisfaction and job performance were also examined.
Ethical Considerations
large public hospital and three private not-for-profit faith-based hospitals, all situated
in Kampala, Uganda. Consent was also sought from the nurses and nurses who
volunteered to fill the questionnaires were assumed to have given consent. A form
explaining the purpose of the study and the rights of the participants to withdraw from
34
the study anytime without penalty was attached to the questionnaires to ensure
and confidentiality. Only aggregate data were reported, individual data were kept in
Setting
Referral and Teaching hospital, and three private not-for-profit (faith-based) hospitals
medical, nursing, pharmacy and other health professional students. The Directorate of
who is assisted in her managerial duties by several Area Managers or Senior Nursing
Officers (SNOs). Each Area Manager is responsible for an area which is composed of
several units/wards. These areas include: Accident and Emergency, Medical, Surgical,
Private Wing), Community Health Services, Operating Theatres and Special Clinics
Health Nurses (PHN), Enrolled Nurses (EN) and Enrolled Midwives (EM) work in
Ugandan hospitals. The nurses are allocated to the various units according to their
availability and consideration of the expected workload on the unit. The hospital
nursing staff includes 1000 nurses and the hospital has a bed capacity of 1,500
35
assistants/nursing aides and nursing students from the various nursing schools.
Gynecology, Outpatient Clinics, but no specialized clinics are available. The total
number of nurses in each hospital varies between 150-200 nurses and includes
Enrolled Nurses (EN), Enrolled Midwives (EM), Registered Nurses and Midwives
(RN/M), Tutors, Public Health Nurses (PHN) and Diploma Trained nurses. These
hospitals have bed capacity from 300 to 360 and have training schools for nurses and
Study Sample
The target population in this study was all nurses working in the four selected
hospitals namely; the national public referral and teaching hospital and three private
Inclusion Criteria
Subjects in this study had to fulfill the following conditions: (a) must have
been a qualified nurse (BSN, RN, RM, RN/M, PHN, EN or EM), (b) a fulltime
employee of the hospital included in the study for at least six months by the time of
the study, (c) between 20 and 60 years of age, (d) willing to participate in the study,
and (e) working in the general surgical, medical, pediatrics, or obstetrics and
gynecology wards.
36
Exclusion Criteria
The following categories of nurses were excluded from the study: (a) those
nurses who were currently enrolled in advanced educational study, (b) nurses who
were working on contractual terms (above the retirement age of 60 years), and (c)
tutors and nurses working in Operating Theatres, specialized ward/units like intensive
care units (ICU), Heart Institute or burn units. The nurses working on these units were
assumed to be extremely busy and that other factors may influence nurses’ working
conditions. For example, while functional or task-oriented nursing is the major mode
for nursing care in the hospitals, some of the specialized wards/units have acquired
different modes of nursing care. In addition, some of the specialized units operate
under different projects whose working conditions are totally different from the
general wards/units.
Sample Size
The required sample size was calculated based on a power analysis for partial
correlation and regression analyses (Cohen & Cohen, 1983). The conventional
standard level of significance (.05) and power (.80) was utilized to calculate sample
size (Polit & Beck, 2004). According to Polit and Beck (2004) nursing studies usually
have modest effects; therefore a relatively modest effect size of .20 was utilized and
the adequate sample size calculated for the study was 321. However, the
questionnaires were distributed to a total of 400 nurses who met the inclusion criteria
and volunteered to participate in the study in order to account for non-responses and
Instruments
occupational stress, job satisfaction and job performance. The instruments utilized
included the Nurse Stress Index [NSI] (Harris, 1989), Job Satisfaction Survey [JSS]
(Spector, 1997), and the Six Dimension Scale of Nursing Performance [6-DSNP]
(Schwirian, 1978). The three instruments were part of a questionnaire with sections,
and assess personal characteristics such as age, gender, nursing education (registered,
diploma, BScN, masters), nursing experience, and the department where the nurse
works. This was because personal characteristics have been reported to have an
The NSI (Harris, 1989) aims at identifying sources of stress among nurses in
hospital and community settings. The 30 item instrument consists of six subscales
which each include five items. The sub-scales include: workload pressures related to
insufficient time (Managing Workload 1), items 1-5; workload pressures due to
Organizational Support and Involvement, items 11-15; Dealing with Patients and
Relatives, items 16-20; Home and Work Conflicts, items 21-25; and Confidence and
Competence in Role items 26-30 (see appendix D). Respondents are asked to rate
extreme pressure. The NSI is self-reported and the respondents read and circle the
= high pressure, and 5 = extreme pressure for each item. A total score can be
computed ranging from 30-150 and means of subscales can be calculated to assess
relative importance of sources of stress. The scores can also be derived from each sub-
(Harris, 1989). Acceptable levels of reliability and validity of the NSI were
The JSS aims at assessing the degree to which people like their jobs (Spector,
1997). The JSS is a self-report instrument which provides an overall job satisfaction
score after assessing nine facets or sub-scales, namely; pay, promotion, supervision,
slightly, 4 agree slightly, 5 agree moderately, and 6 agree very much. Each sub-scale
has four items resulting in a total of 36 items; however, some items are worded
positively while others are worded negatively (see appendix D). This implies
therefore that agreement for a positively worded item and disagreement with a
negatively worded item indicates job satisfaction and vice versa. Reverse scoring
therefore is necessary for the negatively worded items making 1 represent much
agreement and 6 represent very much disagreement. The numbered responses are
summed after reversing the negative items to get the total satisfaction score of the 36
items ranging from 36-216. Reliability and validity of the instrument was established
nurses’ job performance. This is the person’s effectiveness in carrying out his/her
consisting of six sub-scales and 52 items. The sub-scales include: Leadership, Critical
items as to how often (column A) and how well (column B) they perform the
rate the items on a 4-point scale with 1 = not expected in this job; 2 = never or
with 1 = not very well; 2 = satisfactorily; 3 = well and 4 = very well. However, the
items on the professional development sub-scale are assessed for quality only. Since
the sub-scales are of different lengths ranging from 5 to 12 items, their scores are
assumed that higher scores indicate better performance (Schwirian, 1978). Reliability
and validity of the 6-DSNP was established and Cronbach’s alpha coefficients for
Pilot-testing of Instruments
Since the data collection instruments were based on American and European
cultures in previous studies, instruments for this study were pilot-tested to validate
40
their appropriateness to the Ugandan situation before actual data collection. The
researcher and a small group (n=4) of nurses at the level of Senior Nursing Officers
reviewed and assessed whether the questions were clear and appropriate to the
Ugandan situation. It was agreed that all items were clear and understandable by the
Ugandan nurses and the tools were adapted and adopted for use in the study.
The study was conducted after getting approval from the Institutional Review
Permission to conduct the study was also sought from the administrators of the four
hospitals. Four meetings, one per hospital, were organized with the nurses through the
Directors of the hospitals and the Directors of Nursing Services. The purpose of the
study, the methods of data collection and time frame for the study were explained to
the nurses at the meetings. It was explained to the nurses that they were free to
withdraw from the study at any time without penalty. It was also made clear that there
was no financial or any other form of gain from the nurses’ participation. The nurses
were then invited to participate in the study and the questionnaires were distributed to
recruited and trained four BSN prepared research assistants. The research assistants
were responsible for distributing and collecting the completed questionnaires from the
nurses in the various wards/units who did not attend the meetings but volunteered to
participate in the study. A sealed wooden box was placed at each ward/unit in which
nurses dropped the completed questionnaires. The research assistants collected the
consent form. It was explained that any nurse who volunteered to complete the data
study, the time frame for the study and assurance that the information given was to be
utilized for study purposes only and strict confidentiality was to be observed. The
information sheet also included instructions to the participants not to write their
names or any identifiers on the questionnaires. Further, the information sheet had
instructions for the participants to place the completed questionnaires in the boxes
The investigator developed and maintained a codebook for each item on the
questionnaires and all questionnaires were assigned a serial number. Four research
assistants were recruited and trained to distribute and collect the already completed
The questionnaires were kept under lock and key in the principal investigator’s office.
Data Analysis
Data analysis was conducted using Windows SPSS version 16.0. The data
were entered in the Windows SPSS data base by two data entry clerks (double entry)
to enhance the quality of data entry process and for quality control in the data entry
process. The data were assessed for completeness, consistency, and missing values. A
questionnaire was required to have 80% of the questions completed before it could be
were imputed using the multiple imputation method. The internal consistency of the
study instruments and instrument subscales was evaluated using Cronbach’s alpha.
The study variables were analyzed using descriptive statistics appropriate for
controlling for personal and work characteristics. The following assumptions were
evaluated for the multiple regression analyses: that the expected value of the
dependent variable is a linear function of the independent variables (linearity), that the
models were also assessed for potential problems with multicollinearity using
variance inflation factor (VIF) values. The potential mediating effect of job
satisfaction on the relationship between occupational stress and job performance was
43
assessed using the approach of Baron and Kenny (1986). The level of significance
other hospitals and health centers in the rural areas. Therefore, the results from
assessments.
4. The instruments utilized in this study were based on American and European
populations and may not have been culturally appropriate for the Ugandan
nurses.
44
CHAPTER 4
FINDINGS
This chapter presents the findings of the study. The first section presents the
demographic and work characteristics including age, gender, marital status, number of
children, hospital and ward/unit where participants work, nursing education, nursing
experience, responsibility on the ward/unit, and hours worked on a typical day. The
second section includes reliabilities of instruments used in the study. The third section
presents descriptive analyses related to the study variables while section four includes
Demographic Characteristics
A total of 400 eligible nurses attended the meetings and were invited to
participate in the study. Although all eligible nurses agreed to participate in the study,
a total of 333 nurses (response rate 83%) returned completed valid questionnaires that
were included in the analyses. The age range was 20 to 60 years with a mean age of
36 years (SD = 9.1). A majority of the participants were female (95%), 61% were
married while 25% had never married. More than a third (41%) had between 1-2
children and 29% had between 3-4 children. The average number of children per
Table 1
Characteristic Frequency %
Agea
20-29 91 27.33
30-39 135 40.54
40-49 71 21.32
50-60 36 10.81
Gender
Female 317 95.20
Male 16 4.80
Marital status
Married 206 61.86
Divorced/Separated 32 9.61
Widow/Widower 11 3.30
Never married 84 25.23
Number of childrenb
0 68 20.42
1-2 138 41.44
3-4 98 29.43
>5 29 8.71
a M = 36.02; SD = + 9.11
b M = 2.19; SD = + 1.84
Work Characteristics
Two-thirds of the participants (59%) were from the public hospital and the
remaining participants were from the three private, faith-based hospitals (21%, 12%,
and 8% respectively). The majority of participants (60%) were at the Registered level
(RN, RM or RN/M), followed by the Enrolled level (36%), with only 4.5% at the
Graduate level (BSN and above). Almost two-thirds of the participants were nurses
with less than 14 years of nursing experience. Twenty percent of the participants
longer hours than a standard shift on a typical day, with 43% working more than eight
46
Table 2
Characteristic Frequency %
Hospital
Private 1 25 7.51
Private 2 71 21.32
Private 3 41 12.31
Public 196 58.86
Nursing Education
Enrolled Nurse (EN) 77 23.12
Enrolled Midwife (EM) 42 12.61
Registered Nurse (RN) 100 30.03
Registered Midwife (RM) 49 14.71
Double Trained (RN/M) 50 15.02
BSN and above 15 4.50
Ward/Unit
Medical 117 35.14
Surgical 57 17.12
Obstetrics/Gynecology 102 30.63
Pediatrics 57 17.12
Responsibility
Ward/Unit In-charge 123 36.94
None 210 63.06
Instrument Reliability
The internal consistencies of the Nurse Stress Index (NSI), Job Satisfaction
Survey (JSS) and the Six-Dimension Scale of Nursing Performance (6-DSNP) were
assessed using Cronbach’s alpha coefficients. The reliability estimates for all the three
instruments were acceptable, ranging from .81 for the Job Satisfaction Survey to .93
The Cronbach’s alphas for the six sub-scales of the NSI ranged from .54 for the Home
and Work Conflicts scale to .80 for the Organizational Support and Involvement
scale.
Table 3
The JSS sub-scales Cronbach’s alphas ranged from -.02 for the Promotion
sub-scale to .59 for the Supervision sub-scale. The Cronbach’s alpha for the total scale
Table 4
2. Promotion 4 -.02
3. Supervision 4 .59
7. Co-workers 4 .49
9. Communication 4 .53
The 6-DSNP scale examines both the self-rated frequency (Column A) and
sub-scales ranged from .61 to .79 for the Leadership and Teaching/Collaboration sub-
scales respectively. The total scale overall Cronbach’s alpha was .93.
Table 5
3. Teaching/Collaboration 11 .79
4. Planning/Evaluation 7 .74
The observed means for the NSI sub-scales ranged from 12.69 for the
Leadership sub-scale to 14.42 for the Managing Workload 1 sub-scale. The overall
mean score for the NSI was 82.18 with an SD of 21.63 as shown in table 6.
Table 6
Range of Possible Scores, Mean Scores and Standard Deviations for NSI
The means for the JSS sub-scales ranged from 9.17 for the Fringe Benefits
sub-scale to 18.80 for the Co-workers sub-scale. The overall mean score for the JSS
Table 7
Range of Possible Scores, Mean Scores and Standard Deviations for the JSS
ambivalent or dissatisfaction categories. For the 36-item total, where possible scores
range from 36-216, the ranges 36-108 represent dissatisfaction, 108-144 ambivalence
were ambivalent (undecided) as to whether they were satisfied with their jobs or not
52
(68%) while 17.42% reported satisfaction with their job. Almost 15% reported
Table 8
Dissatisfied 47 14.11
Satisfied 58 17.42
Two separate measures from the 6-DSNP were calculated for each subject: the
total 52 item scale score for Column B (performance quality) and a mean of the six-
subscale mean scores for Column B. The measures were highly correlated (r=.997, p
The observed mean total scores for the 6-DSNP (for Column B) ranged from
scales respectively. The total score mean was 158.66 with a standard deviation of
Table 9
Range of Possible Scores, Mean Total Scores and Standard Deviations for the 6-
DSNP Sub-scales (Column B)
Table 10 presents the mean sub-scale ratings (as opposed to mean total scores)
for the Six-Dimensional Scale of Nursing Performance. As shown in table 10, the
sub-scales for frequency (Column A) had similar mean scores. The IPR/
Communication, Critical Care and Planning/ Evaluation sub-scales for the frequency
of performance measure had the highest mean scores of 3.52, 3.51 and 3.50
frequency score of 3.17. The total mean score for Column A was 3.42. The
The mean scores for the quality or how well the nurses performed their
nursing activities ranged from 2.76 for the Teaching/Collaboration scale to 3.23 for
IPR/Communication sub-scales had an equal mean of 3.17, while the Planning and
54
Evaluation sub-scale had a mean score of 2.98. The overall mean score for the total
Table 10
Sub-scale Means and Standard Deviations for the Nurse Performance Scale (6-
DSNP)
NSI) by age, gender, marital status and number of children are presented in Table 11.
Overall, all age groups reported high stress with mean scores ranging from 75.51 to
90.34. The older age group of 50 to 60 years reported the highest mean score of
90.34 followed by the 40-49 years age group with a mean score of 84.97. There was
a significant difference in occupational stress mean scores among the age groups (F =
4.99, p = .002). Post hoc tests revealed that the youngest age group (20-29 years) was
significantly less stressed than the 30-39 or the 40-49 year old age groups (all p <
.05). The categories for number of children also had a significant differences in mean
55
scores for occupational stress (F = 3.56, p = .015), with post hoc results indicating
that nurses with no children had significantly lower occupational stress than those
who had 1-2 or 3-4 children (all p <.05). There were no significant differences in
occupational stress mean scores for gender (F = 1.53, p = .217) or marital status
Table 11
a typical day) and is presented in Table 12. The public hospital had the highest mean
56
score of occupational stress (M = 88.27, SD 20.87) while the three private hospitals
had almost similar mean scores (73.35 to 76.09). There was a significant difference in
mean scores of stress among the different hospitals (F = 14.46, p < .001).
The mean stress levels for nurses with higher educational level (RN, RM,
RNM, and BSN and above) reported the highest stress levels with the means ranging
from 82.42 to 91.61 for the BSN and above group and the Double Trained group
respectively. As seen in Table 12, there were significant differences in stress levels
among the different education level groups (F = 4.16, p = .001). There was no
significant difference in levels of stress among the different wards/units with means
The nurses who had worked for more than 20 years reported the highest levels
significant (F = 6.663, p < 001). Post hoc results revealed that occupational stress
levels for nurses with 1-5 years of experience were significantly lower than for nurses
with 6-10, 11-15 or 21 or more years of experience (all p <.05). The mean stress
levels for those without extra responsibilities (not ward/unit in-charges) and those
who had extra responsibility (ward/unit in-charges) ranged from 81.60 to 83.16 with
SD of 21.82 and 21.34 respectively. The results indicated that there was no significant
difference in mean stress levels between the two groups (F = 0.394, p = .530).
typical day ranged from 78.21 (SD = 21.61) to 88.48 (SD = 19.65). The relationship
between hours worked on a typical day and occupational stress was statistically
Table 12
presented in table 13. The mean scores for job satisfaction among the age groups were
58
statistically different (F = 5.623, p = .001). Post hoc results revealed that nurses in the
20-29 year s age group had statistically higher job satisfaction than the 30-39 or 40-49
years age groups (all p < .05). There were no significant relationships between gender
Table 13
The job satisfaction mean scores ranged from 123.00 (SD = 18.79) for the
public hospital to 136.95 (SD = 16.46) for private hospital 2. As presented in table 14,
there was a significant difference in levels of job satisfaction among the hospitals (F =
59
11.30, p < 001). The Registered Nurses reported the least job satisfaction with a mean
score of 123.14 (SD = 16.34)) followed by the double trained nurses and BSN and
above with job satisfaction mean scores of 123.84 (SD = 23.34) and 126.27 (SD =
19.23) respectively. The Enrolled Nurses and Midwives reported the highest levels of
job satisfaction with mean scores of 134.27 (SD = 20.18) and 132.07 (SD = 17.26)
satisfaction levels by level of nursing education (F = 3.961, p = .002). Nurses with 1-5
years of experience reported the highest level of job satisfaction (Mean = 135.53, SD
= 19.58), while those with 11-15 years of experience reported the least job satisfaction
among the years of nursing experience groups (F = 6.597; p < .001). Post hoc results
revealed that nurses with 1-5 years of nursing experience had more job satisfaction
than nurses with 6-10 or 11-15 years of experience (all p < .05).
reported a slightly higher level of job satisfaction than those with this responsibility.
However, the difference in mean levels of satisfaction between the two groups was
not significant (F = 0.311, p = .577). Nurses working in the surgical and pediatric
wards/units reported lower levels of satisfaction with mean scores of 123.95 (SD =
Table 14
Job performance was assessed using column B scores of the 6-DSNP. The
mean of the sub-scale scores between the age groups ranged from 2.95 (SD = .51) for
the 40-49 years age group to 3.13 for the 20-29 years age group (SD = .39). The
results indicated no significant differences in the mean scores for job performance
61
among the different age groups. Further, as shown in Table 15, there were no
significant differences in mean scores for the gender (F = 0.04, p = .842) and marital
status (F = 2.073, p = .104)). Number of children mean scores ranged from 2.97 (SD =
.36) for those having 5 or more children to 3.21 (SD = .39) for those without children.
These results indicated a significant difference in job performance means among the
Table 15
As shown in Table 16, the public hospital had the lowest mean score for job
performance (Mean = 2.9, SD = .45) and private hospital 1 has the highest (M = 3.32,
62
SD .40). There was a significant difference in means for the different hospitals (F =
7.95, p < .001). The means for nursing education ranged from 2.84 (SD = .49) for the
Table 16
The results indicated that there were significant differences in means for nurse
performance among the nursing education groups (F = 3.60, p = .004) and type of
Charge nurses) and those without extra responsibility (F = .0006, p .980) or for
The analyses presented above were on the mean subscale score for the 6-
DSNP. The same descriptive analyses by demographic and work characteristics were
repeated on the 52-item total score. The results were congruent regarding statistically
This section presents results of the study in relation to the research questions.
Pearson correlation was utilized to answer question one, while multiple regression
analyses were utilized to answer questions two and three. The fourth and fifth
Research Question 1
stress (as measured by the NSI) and job performance, measured as how well the
participants performed their activities (r = -.131, p = .018). This indicated that higher
64
stress levels were associated with lower levels of self-rated job performance quality.
Research Question 2
The relationship between occupational stress and job satisfaction (JSS) of the
nurses was also investigated using Pearson correlation coefficient, as shown in table
17. A significant inverse relationship was found between occupational stress and job
satisfaction (r = -.501, p = .000). This indicated that high stress levels resulted in low
job satisfaction.
Table 17
r p value
Job Performance
Research Question 3
occupational stress, job satisfaction and job performance among hospital nurses in
Kampala, Uganda?
satisfaction and job performance. Number of children was used a proxy indicator for
family responsibility. The response variable was job performance, measured using the
The primary predictor variables were occupational stress (as measured by the
NSI) and job satisfaction (as measured by the JSS). Both predictors were significant
in separate simple linear regression models (R2 = .021, F = 6.87, p = .009; R2 = .033, F
The covariates included in the initial multiple regression model were selected
analyses (see tables 15 and 16), the only personal characteristic included was number
of children. The work characteristics included as covariates were type of hospital and
ward and nursing education. Based on the ANOVA results, hospitals were grouped
into public and private for analysis. Reference-cell coded indicator variables (Unit 1,
Unit 2 and Unit 3) were created to represent the different type of wards, with the
medical ward as the reference group. Nursing education was recorded into four
of variances were conducted using standard techniques and no serious violations were
noted. Initial models were also evaluated for problems with multicollinearity using
variance inflation factor (VIF) values, and again no problems were noted (Munro,
The set of covariates was entered in the first block, followed by occupational
stress at the second step, then job satisfaction at the third step. Individual predictors
and the changes in adjusted R-squared values for each step were evaluated for
Table 18
Several smaller models were evaluated. As shown in Table 19, the best
predictive model for job performance included type of hospital (public/private), type
of ward/unit, and job satisfaction. The model including type of ward/unit and type of
satisfaction was added to the model with type of unit and type of hospital, the model
Table 19
All models were re-run with the job performance 52-item total score as the
outcome. The predictors selected for the initial model based on bivariate analyses
were the same. No differences in significant predictors in the initial and final models
Research Question 4
Does job satisfaction mediate the relationship between occupational stress and
(Baron & Kenny, 1986) with occupational stress as the independent variable, job
satisfaction as the potential mediator and job performance as the dependent variable.
For this analysis, the 52 item total score for the 6-DSNP (Column B) was used. In
step 1, a simple regression analysis with occupational stress (X) predicting job
In the third step, a simple regression analysis of job satisfaction predicting job
Based on the significant results of step 1 to 3, a fourth step was conducted with
occupational stress and job satisfaction predicting job performance (Baron & Kenny,
1986). As showed in table 20, occupational stress was not significant after controlling
for job satisfaction (beta = -.047, t = -.748, p =.455) indicating full mediation by job
Table 20
The Mediating Role of Job Satisfaction between Occupational Stress and Job
Performance
Research Question 5
Are there differences in levels of occupational stress, job satisfaction and job
As shown in table 21, the public hospital had the highest mean score for
76.09, SD = 23.49). However, private hospital 1 had the highest mean score for job
SD = 17.12). The job satisfaction mean score for the public hospital was the lowest
(M = 123.00, SD = 18.80) while private hospital 2 had the highest mean score (M =
Table 21
Means for Occupational Stress, Job Satisfaction and Job Performance for the
different hospitals
using the mean 52-item total score (for Column B). Assumptions of normality and
violations. There were statistically significant differences at the p value < .05 level in
job performance (F = 7.234, p-value = .000) for the different hospitals as shown in
71
Table 22
Post Hoc comparisons using the Tukey HSD test indicated that the mean score
for occupational stress for the public hospital was significantly and positively
different from all three private not-for-profit hospitals. Mean differences were as
follows: public and private 1 = 12.19, S.E = 4.58, p = .041; public and private 2 =
16.12, S.E = 2.86, p < .001 and public and private 3 = 14.93, S.E = 3.5, p = .000. As
seen in table 19, the differences in job satisfaction scores for public hospital from
the mean score for job performance for public hospital was significantly different
differences for occupational stress, job satisfaction and job performance between the
Table 23
Dependent variable Hospital (I) Hospital (J) Mean Difference (I-J) p-value
Occupational Public Private 1 12.19* .041
Stress
Private 2 16.12* .000
CHAPTER 5
AND RECOMMENDATIONS
occupational stress, job satisfaction and job performance among hospital nurses in
Kampala, Uganda. This chapter presents the discussion, conclusions, implications and
recommendations based on the results of the study. The interpretation of key findings
is discussed in section one. The second section includes an outline of the conclusions.
The third section presents the implications for nursing practice, nursing education and
Discussion
Occupational Stress
More than half of the nurses (54%) reported moderate to extreme stress on the
job while almost half (45%) reported high stress in the past one month. This is
consistent with previous research which indicated that occupational stress occurs at
high levels among health professionals. The results indicated that these Ugandan
In this study, the older age groups, 40-49 and 50 years and above, and nurses
with more than 20 years of experience reported the highest stress scores. These results
contradict previous studies in the United States in which young public health nurses
and those with less experience perceived more occupational stress than older nurses
unique to the Ugandan situation. For example, nurses with no children also had
significantly lower levels of occupational stress than those who had 1-2 or 3-5
children. This may indicate that older nurses in Uganda may report more job stress
due to social responsibilities such as caring for family members. In the US, on the
other hand, the younger nurses could be stressed due to lack of experience on the job.
In Uganda, as nurses gain more experience in the profession, they also have
their extended families as is the case for many Ugandans. In Uganda, an adult who is
earning a living is culturally and socially expected to provide for immediate and
extended family members. The financial burden experienced by older Ugandan nurses
may explain the increased stress reported by this age group. In addition, it was
observed by Kyadondo and Whyte that public sector reforms and poor remuneration
supplementary sources of income outside the health care system (Kyaddondo &
stress.
Furthermore, those who had the highest educational level (BScN and above)
reported the highest perceived stress levels. This is in agreement with previous
research (Kirkcaldy & Martin, 2000; Lee & Wang, 2002). It is not clear why nurses
with higher education perceived more stress but one possible explanation could be
role ambiguity. It has been reported that organizational and management attributes of
nurses (Sveinsdottir et al., 2005). Takase and colleagues also observed that role
Maude & Manias, 2006). This could be the case for the Ugandan nurses because
BScN and above prepared nurses have no clear roles even in the public hospitals. Role
conflict and role ambiguity may contribute to stress for these nurses. However, since
the current study did not explore organizational factors related to occupational stress,
there is a need for further research to identify sources of stress for nurses with highest
different units. Nurses who worked in pediatric units reported the highest levels of
stress. This finding may be due to the nature of the work in pediatric units and
interaction with parents or guardians. Usually these units have many children who are
very ill creating situations which may lead to emotional attachment and unrealistic
desires to provide high quality care in adverse situations (Begat, et al., 2005).
Job Satisfaction
occupational stress and job satisfaction (r = -.501, p-value = .000). These results are in
between perceived occupational stress and job satisfaction (Flanagan & Flanagan,
2002; Sveinsdottir, Bierring et al., 2006; Zangaro & Soeken, 2007). Many factors
influence the perceptions of occupational stress and job satisfaction. For example, in a
study of satisfaction and intent to stay among current health workers in Uganda,
respondents reported health care for dependants as a more important satisfying factor
than their salaries (Ministry of Health, The Republic of Uganda, 2007). However, as
mentioned earlier, identification of the sources of occupational stress for the nurses in
76
Ugandan hospitals was not an aim of this study. Therefore, a need exists to conduct
reported the highest levels of job satisfaction (53%) while those with higher education
qualifications (RN, BScN and above) reported the lowest levels of job satisfaction.
phenomenon was attributed to the fact that nurses with higher educational
qualifications have chances of securing desired satisfying jobs. It is not clear why
nurses with higher educational qualifications in Ugandan hospitals perceive their jobs
as highly stressed and less satisfying. However, it could be due to role conflict and
ambiguity or lack of recognition as explained above. It has also been reported in the
literature that routine jobs with limited challenges results in less job satisfaction
(Selebi & Minnar, 2007). This could be the case for nurses with higher education in
Uganda. However, this phenomenon also calls for further research to understand the
factors influencing the nurses’ perceptions of occupational stress and job satisfaction.
Regarding nursing experience, results of this study indicated that nurses with
little experience of 1-5 years had the highest level of job satisfaction (30%) while
those with 11-15 years reported the least job satisfaction (7%). These findings
contradict a Uganda health workforce study in which older respondents were more
satisfied than younger ones (MoH, 2007). In this Uganda Ministry of Health study,
the older respondents reported strong attachment to the facilities and communities
where they worked, had better relationships with their supervisors, and reported
receiving more recognition for good work. It is not clear why the more experienced
nurses in the current study reported less satisfaction on their jobs. It should be noted
77
that the Uganda health workforce study involved all professionals in healthcare, while
the current study involved only nurses. It is therefore difficult to compare the two
studies. However, it can be argued that nurses with less experience are usually
younger and have less responsibility especially in the social context of Uganda. More
experienced nurses are older and may have larger families to care for with associated
stress and the possible perception that work could be interfering with their family
lives (Patel et al., 2008). It could also be due to the fact that nurses who have worked
for more than 10 years would be seeking promotion or advanced opportunities. They
could also be interested in becoming involved in decision and policy making at their
workplace. Previous literature has demonstrated that nurses are likely to report low
(Laphalala et al., 2006). This explanation was also alluded to in the Uganda health
workforce study (MoH, 2007) in which respondents complained of working for many
The findings of the current study indicated that there was a small negative
relationship between occupational stress as indicated by the NSI and job performance
(r = -.124, p value = .025). These findings concur with previous studies, including an
and low job control lead to poor job performance and were risk factors for patient
safety. However, in the same study, a U-shaped relationship between stress and job
performance was found. Nurses with low or higher stress performed better on their
jobs than nurses with moderate stress (AbuAlRub, 2004). It has been argued that
some employees are motivated to perform when there is a lot of pressure. However,
78
stress in the best work environment may need to be controlled since excessive
pressure is known to result in negative effects for the patients, nurses or organizations.
Because more than half of the participants (54%) reported moderate to extreme
Therefore, there is a need to investigate the factors which lead to the moderate to
extreme pressures for the nurses and address them, so that performance is improved.
differences in occupational stress, job satisfaction and job performance among nurses
by age, nursing experience, and nursing education. These results are consistent with
Enst, Franco et al. (2004) who reported an inverse relationship between job
satisfaction, age and nursing education level and are consistent with Roud and
satisfaction and job performance were investigated in this study, other factors such as
al., 2002). Further, the variables age and nursing experience are interrelated, and it is
investigate the interrelations of these factors and how they influence the relationships
demonstrated that the factors leading to occupational stress and job satisfaction are
many and interrelated and that that employees react differently to job dissatisfaction
79
satisfaction.
hospital, ward/unit, and number of children. The number of children had the most
satisfaction and hospital respectively. The number of children or the size of the family
has financial implications for the nurse in the Ugandan context. This again reflects
the importance of the family in relation to job satisfaction and job performance.
relationship between occupational stress and job performance (beta = .154, t – 2.422,
performance after controlling for job satisfaction. Very little has been reported about
the mediating effect of job satisfaction on the relationship between occupational stress
and job performance. Factors which influence job satisfaction may influence job
performance. It is important to note that retention of health workers on their jobs has
various factors. Some of the factors reported to influence job satisfaction include pay,
and working conditions. Nurses’ perceptions and experiences are influenced by the
In this study, job satisfaction was found to have a full mediation effect on the
relationship between occupational stress and job performance, indicating that job
satisfaction had an indirect effect on the relationship between occupational stress and
job performance. These results emphasize the importance of nurses’ job satisfaction in
improving nursing care and nurse retention in Ugandan hospitals. Therefore, there is
need for further research to identify factors that would enhance job satisfaction among
occupational stress, job satisfaction, and job performance in the different hospitals. A
post-hoc comparison using the Tukey HSD test indicated that the public hospital was
significantly different from the other hospitals in all three variables under study. The
mean score for occupational stress for the public hospital (M = 88.28, SD = 20.88)
was higher and this was statistically different from mean stress scores of the private 1,
private 2 and private 3 hospital nurses. The results also indicated that the mean score
for job satisfaction for the public hospital (M = 123.00, SD = 18.00) was significantly
lower than those of private 2 and private 3 hospitals. In addition, the mean score for
job performance for the public hospital (M = 154.00, SD = 23.35) was significantly
lower than the mean job performance scores of nurses in private hospitals 2 and 3.
However, no difference was observed for the three variables between the three private
not-for-profit hospitals.
81
satisfaction and job performance between public and private not-for-profit hospitals.
According to Reinikka and Svensson (2003), religious hospitals provide better quality
Reinika and Svensson attributed this to the religious beliefs and values of the
employees of these hospitals. While this could be true, other factors may also
contribute to the differences in stress, job satisfaction and job performance levels
between the public and the private hospitals. Most services in the public hospital are
expected to be rendered free of charge while small reasonable fees are paid for
services in the other three hospitals. This payment structure could contribute to
overcrowding and work overload for nurses in the public hospital. Further, the nurses
may face the challenge of utilizing limited resources for many patients resulting in
occupational stress, low job satisfaction and subsequent poor job performance. It can
also be argued that Mulago Hospital, as a national referral hospital, may care for the
patients with the most serious conditions and nurses employed at a referral hospital
may experience emotional stress because of inability to give the necessary care
patients.
Based on the findings of this study, there is support for the use of Lazarus and
Folkman’s cognitive theory of stress and coping (Lazarus & Folkman, 1984) and
demonstrate that the workplace acts as the environment in which nurses’ experience
different levels of stress and job satisfaction. The hospital where nurses worked also
82
influenced the level of occupational stress, job satisfaction, and job performance.
Further, the findings demonstrated that the reaction or appraisal of stress is related to
and the number of children. This suggested that the social cultural context affects the
Stress and job satisfaction were found to influence job performance. Both the
Lazarus and Folkman and Karasek conceptual frameworks depict the individual
nurses as appraising the situation and behaving accordingly, whether they are satisfied
with their jobs or not. In the appraisal, nurses decide whether they have control or not,
become stressed, get no satisfaction with their jobs and perform well or poorly on
their jobs.
Conclusions
job satisfaction and job performance among hospital nurses in Kampala Uganda were
drawn:
at work.
2. The younger hospital nurses in Kampala were more satisfied with their jobs
3. Hospital nurses in Kampala with more nursing experience were more stressed
and less satisfied with their jobs than nurses with fewer years of experience.
6. The nurses in the public hospital experienced more occupational stress than
7. Nurses in the public hospital reported less job satisfaction than nurses in the
8. The nurses in the public hospital had lower perceptions of their job
Implications
The findings of this study indicate that nursing students need to understand
affects job satisfaction and performance. Therefore, Ugandan nursing school curricula
research and practice. In addition, nursing students should have clinical experiences in
both public and not-for-profit hospitals to expose them to differences in the work
occupational stress and job satisfaction, nurses should be able to assess these factors
and give each other support in order to improve performance and nursing care to their
84
patients. The Ministry of Health and nurses in managerial roles should try to improve
those factors, such as good communication and recognition for excellent work, which
may reduce occupational stress and increase job satisfaction among their nurses.
Nurse leaders should also advocate for better working conditions which would
improve nurse satisfaction with their jobs such as better pay, fringe benefits, provision
of adequate resources, hiring more nurses to reduce on the work overload, or better
promotion policies. Appointed nurse managers and other managers in health care
Recommendations
Based on the findings, conclusions, and implications which arose from the
satisfaction and job performance based on self reports by the respondents; therefore,
other methods of assessment should be utilized to obtain objective data. For example,
occupational stress and factors that enhance job satisfaction for the hospital nurses in
Uganda.
occupational stress and job performance, studies to identify factors which influence
job satisfaction among the hospital nurses in Uganda should be conducted in order to
4. Since there were significant differences between the public and private not-
for-profit hospitals for all the three major variables, more studies should be conducted
hospitals.
86
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APPENDICES
93
Dear Rose: I am very pleased that you find the 6-D Scale useful for your
Dissertation research. You certainly have my permission to use it in your
work. Do you have (1) the article that describes the scoring strategy and
(2) the Scales themselves. Since the instrument is pretty old, it is
sometimes hard to find. I will be glad to e-mail you the 6-D forms as
attachments and FAX you the Nursing Research article if you give me your FAX
number. Best of luck in your research work.
pms
-----Original Message-----
From: nabirye rose [mailto:rnabiryechalo@yahoo.co.uk]
Sent: Tuesday, February 26, 2008 2:07 PM
To: schwirian.1@osu.edu
Subject: Permission to use the Six Dimension scale of Nursing Performance
for dissertation work
Yours Sincerely,
Rose Nabirye
PhD student
School of Nursing
University of Alabama at Birmingham
109
Appendix C: Instruments
110
111
Reference: Harris, P. (1989) The Nurse Stress Index. Work and Stress. Vol. 3, No.
4, 335-346
Permission to reproduce the NSI from the original article was sought and obtained from
Michelle Whittaker, Permissions Administrator, Taylor & Francis (UK) Journals
ITEMS RATE
1. Time pressures and deadlines 1 2 3 4 5
6. Fluctuations in workload 1 2 3 4 5
5
14. I only get feedback when my performance is 1 2 3 4
unsatisfactory
1 2 3 4 5
15. Relationships with superiors
112
Instructions: Please rate by circling the number that corresponds to the amount of
pressure you feel from each item.
1. - No pressure
2. - Very little pressure
3. - Moderate pressure
4. - High pressure
5. - Extreme pressure
Disagree moderately
PLEASE CIRCLE THE ONE NUMBER FOR EACH
Agree moderately
Agree very much
Disagree slightly
QUESTION THAT COMES CLOSEST TO
Agree slightly
REFLECTING YOUR OPINION
ABOUT IT.
5 When I do a good job, I receive the recognition for it that I should receive. 1 2 3 4 5 6
6 Many of our rules and procedures make doing a good job difficult. 1 2 3 4 5 6
11 Those who do well on the job stand a fair chance of being promoted. 1 2 3 4 5 6
Disagree moderately
Disagree very mcuh
Agree moderately
Agree very much
Disagree slightly
QUESTION THAT COMES CLOSEST TO
Agree slightly
REFLECTING YOUR OPINION
ABOUT IT.
Copyright Paul E. Spector 1994, All rights reserved.
19 I feel unappreciated by the organization when I think about what they pay 1 2 3 4 5 6
me.
20 People get ahead as fast here as they do in other places. 1 2 3 4 5 6
25 I enjoy my coworkers. 1 2 3 4 5 6
26 I often feel that I do not know what is going on with the organization. 1 2 3 4 5 6
30 I like my supervisor. 1 2 3 4 5 6
31 I have too much paperwork. 1 2 3 4 5 6
32 I don't feel my efforts are rewarded the way they should be. 1 2 3 4 5 6
35 My job is enjoyable. 1 2 3 4 5 6
36 Work assignments are not fully explained. 1 2 3 4 5 6
115
1. IN COLUMN A: please enter the number that best describes how often
you perform the activities in the performance of your current job.
2. IN COLUMN B: for those activities that you perform please enter the
number that best describes how well you perform them.
COLUMN A COLUMN B
How often do you perform these How well do you perform these activities
activities in your current job? in your current job?
1- Not expected in this job 1- Not very well
2- Never or seldom 2- Satisfactorily
3- Occasionally 3- Well
4- Frequently 4- Very Well
Column A Column B
1. Teach a patient's family members about the
patient's needs.
2. Coordinate the plan of nursing care with the
medical plan of care.
3. Give praise and recognition for achievement
to those under his/her direction
4. Teach preventive health measure to patients
and their families.
5. Identity and use community resources in
developing a plan of care for a patient and
his/her family.
6. Identify and include in nursing care plans
anticipated changes in patient's conditions.
116
COLUMN A COLUMN B
How often do you perform these How well do you perform these
activities in your current job? activities in your current job?
Column A Column B
7. Evaluate results of nursing care.
COLUMN A COLUMN B
How often do you perform these How well do you perform these activities
activities in your current job? in your current job?
1- Not expected in this job 1- Not very well
2- Never or seldom 2- Satisfactorily
3- Occasionally 3- Well
4- Frequently 4- Very Well
Column A Column B
21. Promote the patients' rights to privacy.
Column A Column B
How often do you perform these activities in How well do you perform these
your current job? activities in your current job?
Column A Column B
35. Help a patient meet his/her emotional
needs.
36. Contribute to the plan of nursing care for a
patient.
37. Recognize and meet the emotional needs
of a dying patient.
38. Communicate facts, ideas, and
professional opinions in writing to patients
and their families.
39. Plan for the integration of patient needs
with family needs.
40. Function calmly and competently in
emergency situations.
41. Remain open to the suggestions of those
under his/her direction and use them when
appropriate.
42. Use opportunities for patient teaching
when they arise.
119
Column B
How well do you perform these
activities in your current job?
Column B
******************************************************************
Reference: Schwirian, P.M. (1978). Evaluating the performance of nurses: A multi-
dimensional approach. Nursing Research, 27, 347- 351.
120