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Stress And Job Satisfaction Of ICU Nurses

Stress is a concept describing the interrelatedness of person and environment. It is the response by a person to stressors in the environment. Selye's General Adaptation Theory (Selye, 1976) described stress response as biophysiologic in nature. When the person is subjected to a stressor, a characteristic syndrome of physical reactions will occur. The stress concept can also be seen as active in a holistic view of the person. The stress response can be physical, psychological, emotional or spiritual in nature and is usually a combination of these dimensions. Stress, similarly, can arise from one or more dimensions and can be either internal or external.

Lazarus and Folkman (1984) viewed stress as a dynamic and reciprocal relationship between the person and environment. In this theory, stressors can range from catastrophic events to irritating incidents. However, these stressors do not elicit a stress response in the individual until the person appraises it as exceeding the available resources.

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Stress and the negative outcomes of stress have been recognized as financially costly to any health care organization. Negative outcomes of job stress among nurses include illness, decline in overall quality of care, job dissatisfaction, absenteeism, and staff turnover (Schwab, 1996). Job stress describes the stress associated with the professional or work environment. Tension is created when the demands of the job or the job environment exceed the capacity of the person to respond effectively. Job stress varies with each work environment.

Various sources of job stress have been identified in the nursing work environment. Cohen-Mansfield (1995) divided work related stressors for nursing into three categories: the institutional level, the unit level and the patient level. Leveck and Jones (1996) used four categories of stressors modeled after Hinshaw and Atwood's Job Stress Scale (JSS) (1983). The JSS measures competence, physical work environment, staffing, and team respect. Other studies have identified heavy workload, urgency of work to be performed, dying and death of patients, role conflict, and lack of autonomy in practice, lack of social support, poor job fit, insufficient knowledge base, unsafe workplace, and a rapidly changing health care environment as stressors for nurses (Hemingway & Smith, 1999; Tovey & Adams, 1999; Van Servellen & Topf, 1994).

Job Satisfaction

Job satisfaction has been shown to be closely affected by job stress. In a metaanalysis of variables related to nurses' job satisfaction, Blegen (1993) identified the variables of age, autonomy, commitment, communication with peers and supervisors, education, fairness, locus of control, professionalism, recognition, stress and years of experience. Blegen's analysis found stress and commitment to have the strongest relationship with job satisfaction. Irvine and Evans (1995) also found a strong negative correlation between stress and job satisfaction although not as strong as that found by Blegen. Job satisfaction has also been negatively linked to intention to leave and actual turnover (Hinshaw & Atwood, 1983; Irvine & Evans, 1995; Price & Mueller, 1981). Although job satisfaction is a complex construct, the strong negative correlation to stress and behavioral intent to leave employment warrants the attention of nursing administrators. Attention to job satisfiers may not be sufficient to offset the job stress experienced by nurses thus leading to thoughts of leaving employment.

Significance of the Study

This study provides information to nursing administrators, and educators related to perceived job stress and job satisfaction of ICU nurses in SMC in Bahrain.

Understanding the relationship of job stress to job satisfaction will give direction to nurse administrators as to the relative importance of reducing stress or increasing other job satisfiers. Increased stress or decreased job satisfaction increases the likelihood of job injury, absenteeism, and staff turnover. This is expensive to the organization as overtime hours or per diem help must be used. Tzeng (2002) suggests that administrators should focus on those stressors or satisfiers over which they have the most influence to change.

For nurses in clinical practice, the rapid turnover of staff due to stress, lack of satisfaction, or both, reduces the quality of care as new staff must be oriented and group cohesiveness is weakened by constant changes in the group membership on a nursing unit. Increased understanding of both stress and satisfaction factors will prompt nurses to take personal measures to reduce stress, raise their level of expertise, and become proactively involved in improving the working environment of their organizations (Mee & Robinson, 2003).

Problem statement

What is the effect of occupational stress on job satisfaction of ICU nurses in SMC?

Purpose of the Study

The purpose of this study is to explore the relationship between occupational stress and job satisfaction of ICU nurses in SMC.


Based on literature review we assume that there are different sources of stress affect the level of satisfaction of ICU nurses.


Job stress reported by ICU nurses will be inversely related to job satisfaction.

Theoretical Framework

Roy Adaptation Model (RAM) (Roy, 1984) will be used as the theoretical framework for our study. Roy viewed the person as a holistic and complex adaptive system. In the RAM, the environment (stimulus or stressor) and the person (adaptation level) provided the system input. The response control processes were the coping mechanisms, regulator subsystem (physiologic adaptation), and cognator subsystem (cognitive & emotional appraisal). Effectors were physiological function,

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self-concept, role function, and interdependence. System output is either adaptation to the stimulus or ineffective response. The output then provided feedback as the adaptation level of system input.

In the current study, both external stressors associated with the job of nursing in the ICU environment and internal adaptive levels of the nurses in the sample provide the system input. The nurses' individual coping mechanisms and regulator and cognator subsystems control the psychological and emotional effectors that produce the output of effective or ineffective adaptation. Job satisfaction is the indicator of the effectiveness of adaptation in this population of nurses.

Conceptual and Operational Definitions

Job Stress

Conceptual Definition

Gray-Toft and Anderson (1981) stated that stress is "an internal cue in the physical, social, or psychological environment that threatens the equilibrium of an individual"

Operational Definition

Stress (independent variable) is an internal response to stimuli or pressures that challenge ICU nurse's ability to adapt or cope. This variable will be measured using the Expanded Nursing Stress Scale (ENSS) (see Appendices B) developed by French, Lenton, Walter, and Eyles (2000). This instrument is an expanded and updated version of the widely used Nursing Stress Scale (NSS) developed by Gray-Toft & Anderson (1981).

Job Satisfaction

Conceptual Definition

The contentment one feels when one has fulfilled a desire, need, or expectation.

Operational Definition

The degree of satisfaction (dependent variable) individual nurses feels toward their job. It will be measured using seven items from the Price and Mueller questionnaire developed to test the Professional Turnover Model (Appendix C).


The study might have several limitations. First, it will be limited by a small, convenience sample size. The use of a larger sample and random sample will strengthen future studies. A second limitation of the study will be the cross-sectional design. Depending on the moment in time during which data will be collected, factor such as changes in staffing could influence a positive or negative response.

Literature Review

Kirkcaldy & Martin (2000) examined the relationship between Job stress and satisfaction among nurses. The sample for this study consisted of 276 nurses working at a large urban general hospital in Northern Ireland.

A composite questionnaire was developed to gather information concerning demographic details, organizational stressors, personality variables, and outcome measures. In early 1996, questionnaires and a covering letter were distributed to every nurse (N 500) working at the hospital. Respondents were asked to return the completed questionnaires in pre-paid envelopes. A total of 287 questionnaires were returned, of which only 11 were incomplete. This yielded a response rate of 57.4 per cent (Kirkcaldy & Martin, 2000).

The results showed that confidence and competency in job role, as well as problems relating to the homework interface, and organizational support and involvement appeared as the most common pressures at work. Stressors such as work interruptions and time pressures appear less pertinent (Kirkcaldy & Martin, 2000).

Healy and McKay (1999) examined the impact of nursing work-related stressors and coping strategies on levels of job satisfaction and mood disturbance. The study was conducted in urban and regional medical institutions in Australia.

A volunteer sample of 129 registered nurses was recruited from Melbourne metropolitan and Victorian regional institutions (Australia) and surveyed using standardized questionnaires and open-ended questions. The sample consisted of 125 females and four males: 120 were division 1 nurses and nine were division 2. Their ages ranged from 20 to 59 years: mean age was 36á8 years. Places of employment included private hospitals 80 nurses (62%), public hospitals 24 (11%), nursing homes 11 (9%), nursing agencies 7 (5%), and community-based agencies 7 (5%). The length of nursing experience ranged from 6 months to 37 years with an average of 16 years of experience (Healy & McKay, 1999).

A Demographic Survey and five standardized questionnaires were given to the participants: (a) the Nursing Stress Scale (NSS), (b) the Ways of Coping Questionnaire (WOCQ), (c) the Coping Humour Scale (CHS), (d) the Job Satisfaction Scale of the Nurse Stress Index, and (e) the Profile of Mood States (POMS) (Healy & McKay, 1999).

Results from the NSS score indicated that `workload' was the highest perceived stressor in the nurses' working environment, which closely accords with the findings of two British studies (Tyler & Cushway 1992, 1995). The workload sub-scale of the NSS taps into issues arising from the physical environment, such as actual workload, inadequate staffing levels and insufficient time to complete nursing tasks. 'Conflict with other nurses' and `lack of staff support' were the least reported stressors on the NSS. The reliability coefficients obtained for the Nursing Stress Scale in this study were higher than those reported by Gray-Toft & Anderson (1981) (total scale coefficient 0.89 and sub-scales coefficients ranging from 0.64 to 0.77). Standard multiple regression was then used to examine the extent to which the independent variable, the Nursing Stress Scale factors, explained the variance in mood disturbance (POMS scores). The combined NSS factors accounted for 15% of the variance of POMS scores (F (7120) =ˆ4.16, P < 0.001). However, Workload was the only significant predictor of mood disturbance (Healy & McKay, 1999).

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The relative importance of occupational and non-occupational variables in the prediction of job satisfaction and psychological distress was investigated in a survey of hospital nurses (N = 376). Perceived relations with the head nurse, coworkers, physicians, and other units/departments, along with unit tenure and job/non-job conflict, were predictors of job satisfaction. Personal disposition (anxiety-trait), social integration, unit tenure, professional experience, position level, and job/non-job conflict, along with the relations with the head nurse and physicians were predictors of psychological distress. The relations with the head nurse and physicians, as well as unit tenure and job/non-job conflict, were predictors of both satisfaction and distress. The prediction by unit tenure is noteworthy. Unit tenure had a negative relationship to satisfaction and a positive one to distress, whereas total experience had a negative relationship to psychological distress and none with job satisfaction. The role of unit tenure in nurses' affective experiences warrants more attention in future research, along with the role of job/non-job conflict and other variables predictive of nurses' satisfaction and distress (Decker, 1997).

N. Flanagan & T. Flanagan (2002) examined the relationship between job satisfaction and job stress in correctional nurses.

A non-experimental correlational study was designed to measure job satisfaction and job stress in the correctional nurse population in a state prison system in the southwestern United States. There were 493 registered nurses employed by this correctional system in 56 units or facilities. A total of 287 surveys were returned, a response rate of 58%. The typical correctional nurse in this prison system in the southwestern United States was white (74%), female (83%), 46 years old (SD=9.01), and married (65%), with an associate's degree (51%) or bachelor's degree (30%). On average, these correctional nurses had been working in nursing for 16.7 years (SD=9.78), had been registered nurses for 14 years (SD=10.50), had been employed in correctional nursing for 5 years (SD=4.17), and had been assigned to their current facility for 3.6 years (SD=3.27). Correctional nurses brought a wide variety of nursing experience to their current positions (N. Flanagan & T. Flanagan, 2002).

This descriptive and cross-sectional study was conducted in April 2003, and included 180 nurses: 31 working in dialysis units, 100 in ICUs, and 49 in the most preferred wards of the same hospitals. The study candidates were assessed with the use of a questionnaire regarding their socio-demographic characteristics, work places, and views concerning their relations with and the opinions of their professional contacts. Other means of data collection were the Work-Related Strain Inventory (WRSI), the Maslach Burnout Inventory (MBI) and the Minnesota Work Satisfaction Questionnaire (MWSQ). Percentage estimations, the chi-square test, and variance analysis were used for statistical evaluation of the data; p >0.05 was accepted as significant (Fatma, 2007).

This study confirmed some established predictors of job satisfaction, work-related stress, and burnout and provided data on an unexplored area. Dialysis nurses appear to be at a decreased risk for job stress, burnout and premature retirement from nursing, with higher levels of job satisfaction. Further. the quality of relationships with physician co-workers and the opinions of professional contacts regarding the nursing profession as perceived by nurses may be related to job stress, burnout and work satisfaction (Fatma, 2007).

Design of the study

A quantitative, descriptive, cross-sectional, non-experimental research design will be used in this study. This design was chosen because randomization of groups won't be possible.

Sample of the study

Nurses for this study (N = 30) will be recruited from ICU in SMC. Inclusion criteria consisted of nurses who are (a) Registered nurses in ICU, (b) employed at the hospital at least 1 year. Exclusion criteria consisted of management personnel.

These criteria were chosen because the respondents would be well-oriented to the organization, past the initial stress of working in a new environment, and working in similar situations as they will be evaluated for the first six months. Nurses in management positions will be excluded because there are differences in stressors related to job responsibilities.

Setting of the study

The study will take place at ICU in SMC. SMC is a secondary hospital under ministry of health. ICU is an intensive care unit consists of 12 beds.

Instruments of the study

Instruments will be used in the study are the Expanded Nursing Stress Scale (see Appendix B) (ENSS) (French et al., 2000) and seven questions pertaining to job satisfaction from Price and Mueller's (1981) Professional Turnover questionnaire (see Appendix C). Permission to use these instruments will be obtained.

The ENSS measured the independent variable of job stress. The ENSS is an expanded and updated revision of the classic Nursing Stress Scale (NSS) developed by Gray-Toft & Anderson (1981). ENSS contained 57 items in nine subscales: (a) Death and Dying, (b) Conflict with Physicians, (c) Inadequate Emotional Preparation, (e) Problems Relating to Peers, (f) Problems Relating to Supervisors, (g) Work Load, (h) Uncertainty Concerning Treatment, (i) Patients and their Families, and (j) Discrimination. The 57 items were arranged in a 5 point Likert response scale. The responses were 'never stressful' (1), 'occasionally stressful' (2), 'frequently stressful' (3), 'extremely stressful' (4), and 'does not apply' (5). (French et al., 2000).

The independent variable of job satisfaction will be measured using seven items from the Price and Mueller (1981) Professional Turnover questionnaire.

Reliability and Validity

Instrument reliability will be calculated using Cronbach's coefficient alpha for the ENSS scale, each of the nine subscales, and the Job Satisfaction scale. Validity of the instruments will be examined using Content Validity. Statistician assistance will be asked.

Pilot study:

A pilot study will be conducted on 10 nurses who will be excluded from the actual sample.

Data collection methods

Permission to conduct the study will be granted by the research Technical Support Team (see Appendix A). We will distribute 30 information and survey packets to the nurses who will meet inclusion criteria. The packet will be contained a letter of explanation for the study (see Appendix D), an Informed Consent (see Appendix E), a Demographic Survey (see Appendix F), the Expanded Nursing Stress Scale Survey, and the Job Satisfaction questionnaire. Participants will be asked to return the questionnaires within the next two weeks and to place their sealed responses in the designated envelope available in the ICU. Surveys will not be numbered and respondents will be requested not to identify their responses with names or initials.

Ethical Considerations

As mentioned previously, Permission to conduct the study will be granted by the Research Technical Support Team. The participants will have full explanation regarding the study and an informed consent will be obtained. Surveys will not be numbered and respondents will be requested not to identify their responses with names or initials.

Data analysis

Data will be analyzed using both descriptive and inferential statistics. Demographic data will be analyzed to identify the relationship between respondent age and years worked in ICU. Means and standard deviations will be used to identify levels of job stress and job satisfaction. Statistician assistance will be asked.

Timeline and budgets:

This research study won't cost much. Time consuming and the cost of papers the only cost of this research.





Literature review

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Data collection process & finalization

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