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Nurses' Perceived Job Related Stress and Job Satisfaction in Amman Private Hospitals

Authors: Ayman ALnems RN, Fouad Aboads RN, Murad AL-Yousef RN, Nabeel AL-Yateem RN, Nazih Abotabar RN

June, 2005

2 Nurses' Perceived Job Related Stress and Job Satisfaction in Amman Private Hospitals Background. Job dissatisfaction is becoming an increasingly large disorder. There has been little research on nurse job satisfaction and job related stress in Jordan. Interest in job related stress is renewed with each cycle of nursing shortage. Aims. To identify variables of Jordanian nurses job satisfaction and job related stress. Methods. A descriptive correlational cross sectional design using surveys guided this study through convenience sample of 73 nurses. Data were analyzed using descriptive and inferential statistics. Results. The lack of enough staff to adequately cover the unit is the most stressful event perceived by the staff nurses as indicated by the Mean ( N= 73, Mean= 3.03). The experiencing discrimination on the basis of sex and break down of the computer is the least stressful events perceived by the staff nurses as indicated in the Mean (N= 73, Mean= 1.60). The total job satisfaction for the staff nurses had been calculated using the mean and the standard deviation measures and the result was (N= 73, Mean= 1.85); and this is an indication of dissatisfaction. There is a significant negative relationship between the perceived job related stress and the job satisfaction of the staff nurses in private hospital in Amman Discussion. The most stressful subscale for staff nurses is the uncertainty concerning treatment, the major factor of high level of stress is the lack of autonomy and independency in making decisions. Shortage of staff and lack of resource in the work settings was also felt acutely and was frequently stressful. There is a significant negative relationship between job related stress and job satisfaction. Conclusion. This study indicates the importance of adopting strategies to reduce the perceived job related stress and also adopting strategies to demonstrate more social support for the staff nurses in the work place in the private hospitals in Amman. Keywords: job satisfaction, Jordan, nurse, job related stress, validity, reliability

3 INTRODUCTION Job Satisfaction The widespread nursing shortage and nurses high turnover has become a global issue (Kingma, 2001) which is of increasing importance to both the developed and developing countries (Cavanagh, 1990; Blegen, 1993; Hancock, 1998; Lee, 1998; Aiken et al., 2001; Fang, 2001; Lu et al., 2002). In light of this, concern about recruitment and retention of nursing staff is increasing in a number of countries (Lundh, 1999). While numerous factors have been linked to nurses turnover, job satisfaction is the most frequently cited (Cavanagh and Coffin, 1992; Blegen, 1993; Irvine and Evans, 1995), and therefore merits attention. In the 1980s and 1990s, many researchers have been addressed nurse job satisfaction. The understanding of nurse job satisfaction and its contributing variables are important for any health care organization to exist and prosper. Job satisfaction is defined as the degree to which employees enjoy their jobs (McCloskey & McCain 1987). Nurse Job satisfaction is a multidimensional phenomenon that is influenced by many variables. Autonomy has been identified as the strongest predictor of nurse job satisfaction, which in turn reflects positively on nurse retention (Boyle et al. 1999, Chaboyer et al. 1999, 2001, ORouke et al. 2000, Upenieks 2000, Finn 2001). Sengin (2003) supported Hinshaw and Atwood (1984), who are in a comprehensive literature review identified variables that influence nurse job satisfaction. These factors included: (1) demographic variables: education, experience, and position in the hierarchy; (2) job characteristics: autonomy, tasks repetitiveness, and salaries; and (3) organizational environment factors: degree of professionalization, type of unit, and nursing care delivery model. Recent research identified new variables that influence nurse job satisfaction such as environment and job settings (Shaver & Lacey 2003). Non-supportive work environments increase nurses stress and job dissatisfaction (Sims 2003), which negatively influence nurse retention. Stamps and Piedmontes (1986) work on job satisfaction among nurses; Stamps and Piedmontes conceptualization of job satisfaction was based on Vrooms (1964) multiplicative need

4 fulfillment theory, a widely used theoretical model from organizational psychology. In brief, according to need fulfillment theory, work satisfaction is related to the extent to which the work setting fulfills important personal needs. In this perspective the salience of needs varies, and the greater the need, the more satisfied the individual will be when that need is fulfilled (Stamps & Piedmonte, 1986). Maslows theory of human needs served as a guide for the identification of needs. Stamps and Piedmonte also linked need fulfillment theory with social reference group theory, which significantly departs from the need fulfillment theory because it stresses the importance of what other people feel in shaping the individuals stated needs (Stamps & Piedmonte, 1986, p. 3). In linking these theoretical perspectives, Stamps and Piedmonte combined the concepts of discrepancy (defined as the difference between an individuals needs and the extent to which the job fulfills those needs) and the social context of work (expected outcomes are determined by a person comparing his or her work and rewards to those of others doing a similar job). This formulation of job satisfaction thus combines psychological and sociological perspectives on work. Stamps and Piedmonte (1986) conceptualized job satisfaction as comprising six components: pay, autonomy, task requirements, organizational policies, interaction, and professional status. Pay is defined as the dollar remuneration and fringe benefits received for work done. Autonomy is the amount of job-related independence, initiative, and freedom either permitted or required in daily activities. Tasks or activities that must be done as a regular part of the job are considered task requirements. Organizational policies are the management policies and procedures put forward by the hospital and nursing administration of the hospital. Interaction is defined as the opportunities presented for both formal and informal social and professional contact during working hours. Professional status includes both the individuals and the communitys definitions of the importance of a job. For Stamps and Piedmonte, job satisfaction derives from the congruence of workers expectations about these six components of satisfaction and the degree to which the job fulfills those expectations (reward). Conversely, discrepancy between expectations and fulfillment leads to lower job satisfaction. The perceived importance or significance of the job, including the

5 viewpoints of the individual and of others (the social context), is also related to job satisfaction. In addition, demographic factors that Stamps and Piedmonte considered cogent to the study of work satisfaction include age, marital status, and type of education. Harris (1989) developed a self-report measure of nurse stress. Harriss research was derived from the work of stress response theorists beginning with Selye (1956). Selye conceptualized stress as a response to disequilibrating stimuli encountered in the social environment. In the stress response perspective discerning the nature and importance of these stressors is critical to understanding and diagnosing stress and to developing strategies to deal with its potentially deleterious physiological and psychological effects. Harris (1989) found that difficulties in managing workload, conflicts among staff, lack of involvement in decision making, perceived lack of support, and poor communication were important dimensions of occupational stress among experienced nurses working in a variety of hospital and community settings in southwestern England. In addition, perceived lack of preparation for the role and dealing with death and dying were cited by Harris as sources of stress among nurses. Harris postulated that consequences of perceived work-related stress include depression and that the resulting depression is inversely related to composure, quality of patient care, and interpersonal and cognitive effectiveness. Hinshaw and Atwood (1983) utilized a similar conceptualization of job stress in research on nursing staff turnover: Job stress involves those demands encountered within the roles and functions of employment (p. 141). Hinshaw and Atwoods review of influential factors in job stress among nurses included many of the dimensions of nursing practice used in Harriss instrument development. Stress and job satisfaction among nurses has been the subject of extensive research for many reasons, including the relationship of these occupational attitudes to measures of job performance (Ivancevich & Matteson, 1980; Jex, 1998). In addition, Hinshaw and Atwood (1983) and Lucas, Atwood, and Hagaman (1993) reported that job stress and job satisfaction were important correlates of anticipated and actual job turnover among nurses. Aiken et al. (2001) found job dissatisfaction among nurses was highest in the United States (41%) followed by Scotland (38%), England (36%), Canada (33%) and Germany (17%). One third

6 of nurses in England and Scotland and more than one fifth in the United States planned on leaving their job within 12 months of data collection. More striking, however, was that 2754% of nurses less than 30 years of age planned on leaving within 12 months of data collection in all countries. Regarding the work climate, only about one third of nurses in Canada and Scotland felt that they participated in developing their own work schedules in comparison with more than half in the other three countries. When compared with other countries, the nurses in Germany (61%) reported that they were more satisfied with the opportunities for advancement while the nurses in the United States (57%) and Canada (69%) felt more satisfied with their salaries. Stress Stress in the workplace is often referred to as occupational stresses. The basic rationale underpinning the concept is that the work situation has certain demands, and that problems in meeting these can lead to illness or psychological distress. Occupational stress is a major health problem for both individual employees and organizations, and can lead to burnout, illness, labour turnover, absenteeism, poor morale and reduced efficiency and performance (Sutherland & Cooper 1990). Work-related stress is estimated to be the biggest occupational health problem in the United Kingdom (UK), after musculoskeletal disorders such as back problems and stress related sickness absences cost an estimated 4 billion annually (Gray 2000). Stress is part of everyday life for health professionals such as nurses, physicians, and hospital administrators since their main responsibility focuses upon providing help to patients who are usually encountering life crises. Typically, nurses from both public and private hospitals report a similar pattern of stressful experiences (Dewe, 1987; Hingley and Cooper, 1986). Nurses rated high workloads and dealing with death and dying as their major stressful events (Hipwell et al., 1989). In addition to pressures due to insufficient time and resources to complete nursing tasks, organizational factors within the hospital appear to be major sources of stress and determining factors of job satisfaction (Humphrey, 1992). Hospitals throughout the world are currently undergoing massive changes to their organizational structure in an effort to reduce costs (Yin and

7 Yang, 2002). In some cases, organizational change means hospital closure, job loss, reduced employee status, and higher levels of workload (Burke and Greenglass, 2000). With shrinking health care budgets, cutbacks in the workforce, and increasing demands for healthcare, nurses were hypothesized to respond by experiencing increased levels of stress and reduced job satisfaction. Nursing is an occupation characterized by a number of features not experienced in most other professions. These include not only dealing with situations involving death and dying (on a regular basis), but also more `mundane' stressors such as working long hours, and working shifts and weekends. This provides an indication of the complex and demanding nature of this profession and has encouraged much recent research on specific issues, including shift systems, work organization, and violence in the workplace (Kundi M, Koller M, Stefan H, Lehner L, Kaindlsdorfer S, Rottenbucher S., 1995). What is common to most of this research is the desire to establish the impact and consequences of such pressures on the quality of working life and well-being of nurses. The nursing profession and the stress commonly associated with it has been the subject of considerable research for decades. This is perhaps not surprising given that nursing is widely perceived to be one of the most inherently stressful of occupations, often characterized by high rates of staff turnover, absenteeism and burnout (Dewe, 1987; Jamal, 1992). Research has also found that stress has been commonly cited by nurses as a primary reason for choosing to leave the profession (McGrath A, Reid N, Boore J., 1989) Most studies on nurses have focused on those employed in hospitals or closely related health care organizations. Of the earlier studies, it is those of Gray-Toft which have repeatedly attracted attention. These authors identified seven sources of stress 1. Dealing with death and dying; 2. Conflict with physicians; 3. Inadequate preparation to deal with the emotional needs of patients and their families; 4. Lack of staff support; 5. Conflict with other nurses and supervisors; 6. Workload; 7. Uncertainly concerning treatment. In conclusion, job satisfaction of nurses is an important concept as levels of job satisfaction may impact upon the global nursing workforce. Although the reported studies differed regarding levels

8 of job satisfaction among nurses, the literature reveals that the sources of job satisfaction are relatively similar, e.g., physical working conditions, relationships with fellow workers and managers, pay, promotion, job security, responsibility, the recognition from managers and hours of work. Furthermore, it seems that nurses who had received tertiary education felt less satisfied with their jobs than those who had not received tertiary education. Most published research from various countries indicates that job satisfaction is a significant predictor of nursing absenteeism, burnout, turnover and intention to quit; however, there have been some inconsistent findings. Much research has revealed that job satisfaction of hospital nurses is closely related to job stress, role conflict and ambiguity, organizational commitment and professional commitment. METHODOLOGY The sample The study population includes all staff nurses in private hospitals (Specialty hospital, Islamic hospital, Arab heart center) in Jordan. Criteria for inclusion into the study is to be a registered nurse ( staff nurse ), working in the same area for at least 6 months, full time employment and able to read, write, and comprehend the English language in a competent way. The exclusion criteria is to be a head nurse or supervisor, working in the same area less than 6 months, part time employment staff nurse, and nurses who are permanent on one shift (A, B or C shift) . The nature of supervisors and head nurses work and activities is different from the nature of staff nurses work and activities. also, the stabilization of the staff nurse in the same area for a long period of time (more than 6 months) will enable him/her to identify the stressors and it will give him/her the ability to judge his/her job satisfaction appropriately. Also, the part time employment and to be permanent on one shift (A, B or C shift) will not give an accurate picture on the job related stress and job satisfaction. The criteria are derived from a research study conducted to investigate the effect of job related stress on job performance among hospital nurses (Abualrub, 2004). The convenience sampling method was used because it is easy for the researcher to reach the sample participants; however, the researchers acknowledge that this type of non probability

9 sampling method will provide little opportunity to control for biases. Based on a formulation of 80 % power, and medium effect size of (0.25), for a significant level of = 0.025, the estimated

1 sample is 73 nurses according to the formula n = Z1 + Z1 1 2 (Leidly and Weissgeld, 1991) ( = effect size, = 1- power, Z= from Z tables). The medium effect
size is the accepted effect size used for the most applied researches (as cited in Pilot, and Hungler, 1995). Setting Data was collected from the intensive care units, cardiac care units, floors, and the operation rooms of the main private hospitals in Amman Specialty hospital, Islamic hospital, and Arab medical center. The three hospital are of the main private hospitals in Amman; Specialty hospital with a capacity of 200 beds and 12 ICU beds. The Islamic hospital with a capacity of 300 beds and 18 ICU beds. The Arab medical center with a capacity of 145 beds, 8 ICU beds, and 8 CCU beds. Design In this study, descriptive correlational method was used to examine the main job related stressors affect the staff nurses and to examine the relationship between job related stress and job satisfaction. Instrument Two instruments were used to elicit information about job related stress and the level of job satisfaction (Appendices A&B) among staff nurses in Amman private hospitals. Job related stress, defined as any work situation perceived by the participant as threatening because of the mismatch between the situations demands and the individuals coping abilities, was measured with the 34items nursing stress scale (Gray-Toft & Anderson, 1981). Because stressors related to patients and families are not included in the nursing stress scale but are considered among the stressors that nurse experience (Hatrick & Hill, 1993), the eight items of the subscale on patients and families of the expanded nursing stress scale were added to nursing stress scale ( French, Lenton, Walters, & Eyles, 2000). The alpha coefficient for the whole scale was 0.92. It was 0.76 for the "death and

10 dying" subscale, 0.70 for the "conflict with a physicians," 0.73 for the "in adequate preparation," 0.71 for the "lack of support," 0.70 for the "conflict with other nurses," 0.79 for "work load," 0.76 for "uncertainty concerning treatment," and 0.87 for "patients and families"(Abualrub, 2004). The job satisfaction among staff nurses was measured by Job Satisfaction Survey. The Job Satisfaction Survey, JSS is a 36 item, nine facet scales to assess employee attitudes about the job and aspects of the job. Each facet is assessed with four items, and a total score is computed from all items. A summated rating scale format is used, with five choices per item ranging from "disagree very much" to agree very much. Items are written in both directions, so about half must be reverse scored. The nine facets are Pay, Promotion, Supervision, Fringe Benefits, Contingent Rewards (performance based rewards), Operating Procedures (required rules and procedures), Coworkers, Nature of Work, and Communication. Below are internal consistency reliabilities (coefficient alpha), based on a sample of 2,870 (Spector 1994). Table 1 Internal consistency reliabilities (coefficient alpha) of Job Satisfaction Survey. Scale Alpha Description Pay Promotion Supervision Fringe Benefits Contingent Rewards Operating Procedures Coworkers Nature of Work Communication Total .75 .73 .82 .73 .76 .62 .60 .78 .71 .91 Pay and remuneration Promotion opportunities Immediate supervisor Monetary and nonmonetary fringe benefits Appreciation, recognition, and rewards for good work Operating policies and procedures People you work with Job tasks themselves Communication within the organization Total of all facets

11 Data collection procedures Formal approval from the hospitals to conduct the study was gained before starting data collection; also a permission from the authors to use the tools was gained. Participation in the study is voluntary and based on the staff nurses ability to give informed consent, and then the staff nurses will be invited to participate. All gathered data and information were strictly confidential and will not be accessed by any other party without prior permission of the participant. More over, the participant has the right to withdraw any time they cannot complete the questionnaire. Before giving the informed consent, data collectors explained the purpose of the study and it was mentioned expressly to the participants that their responses will be treated confidentially and anonymously, and that their participation is voluntary. The participants also were informed that it would be impossible to identify individual answers, and they have the right to withhold their responses if, for example, the questions were too private. The staff nurses from the selected hospitals were asked to fill two questionnaires. The first questionnaire aims to measure Job related stress, the second aims to measure job satisfaction. The staff nurses were informed that the questionnaire will be given and collected during their working shift (8 hours) and the researchers were present during that time for any questions. Ethical consideration The study was reviewed by the Ethics Committee of the Faculty of Nursing at the University of Jordan. Approval from clinical faculty, intended hospitals, IRB, and subjects was gained. Several Strategies were utilized to protect the subject's rights who agree to participate in this study. First, oral written consent of the subjects was obtained prior to the administration of the questionnaire. The subjects were informed of the purpose of the study, that the participation is voluntary, and that they have the right to refuse to participate. Further, the subjects were told that they can refrain from answering any questions and can terminate the interview at any time. Anonymity of the subjects was maintained at all times. Data was organized by subject's codes, and the investigators keep the

12 telephone numbers of the subjects in a separate locked file. The names and addresses of the subjects will remain unknown to investigator RESULTS Descriptive results Of the 73 nurses who responded, 42 nurses (57.5%) were male and 31 nurses (42.5 %) were female nurses. 60.2% were younger than 25 years old, 26% were aged between 25-30 years, 4.1% were aged between 31-35 years, 8.2% were aged between 35-40 years, and 1.3 % were more than 40 years. The nursing samples were, therefore, youthful nurses (the majority is younger than 25 years old). 31.5% of the sample is from the specialty hospital, 34.2% of the sample is from Islamic hospital, and 34.2% of the sample is from the medical Arab center. 30.1% of the sample is working in the ICU setting, 23.3% of the sample is working in the CCU setting, 23.3% of the sample is working in the floor setting, and 23.3% of the sample is working in the operation room. During filling the questionnaires 42.5% of the nurses were on A-shift, 31.5% of the nurses were on B-shift, and 26% of the nurses were on C-shift during filling the questionnaires. Expanded nursing stress scale (perceived job related stress) To achieve the purpose of the study, the mean and the standard deviation were calculated for the items and the subscales of the expanded nursing stress scale. The descriptive analysis indicates that lack of enough staff to adequately cover the unit is the most stressful event perceived by the staff nurses in the private hospitals as indicated by the Mean ( N= 73, Mean= 3.03). And the experiencing discrimination on the basis of sex and break down of the computer is the least stressful events perceived by the staff nurses in the private hospitals as indicated in the Mean (N= 73, Mean= 1.60). The results have shown that the most stressful subscale is the uncertainty concerning treatment (Inadequate information from a physician regarding the medical condition of a patient, A physician ordering what appears to be inappropriate treatment for a patient, A physician not being present in a medical emergency, Not knowing what a patient or a patient's family ought to be told

13 about the patient's condition and its treatment, Uncertainty regarding the operation and functioning of specialized equipment) as indicated by the Mean ( N= 73, Mean= 2.558), and the least stressful subscale is the inadequate preparation (Feeling inadequately prepared to help with the emotional needs of a patient's family, Being asked a question by a patient for which I do not have a satisfactory answer, Feeling inadequately prepared to help with the emotional needs of a patient) as indicated by Mean ( N= 73, Mean= 2.16). Table-2 demonstrates the most stressful subscales and the least stressful subscale for the staff nurses: Table 2 The most stressful subscales and the least stressful subscale for the staff nurses Descriptive Statistics

Mean

Std. Deviation

Uncertainty by concerning treatment conflict with physician Work Load Death and dying conflict with other nurses Lack of staff Support Inadequate preparation Valid N (list wise)

73 73 73 73 73 73 73 73

2.5589 2.5096 2.4247 2.4070 2.3890 2.2603 2.1644

.6027 .4899 .4932 .6347 .5695 .6787 .7139

The total perceived job related stress among the staff nurses in the private hospitals in Amman has been calculated using the mean and the standard deviation measures and the result was (N= 73, Mean=2.41). This is an indication that the staff nurses in the private hospitals are (occasionally too frequently) perceiving the previous listed items as stressful events for them.

14 Job satisfaction scale (Job satisfaction among staff nurses in the private hospitals in Amman): The total job satisfaction for the staff nurses in the private hospitals has been calculated using the mean and the standard deviation measures and the result was (N= 73, Mean= 1.85). And this is an indication of dissatisfaction. In job satisfaction scale the majority of the nurses have expressed the highest level of satisfaction regarding (the people they work with) as indicated by the Mean (N= 73, Mean= 3.16) and they have expressed the lowest level of satisfaction regarding (the duties that they have to do or accomplish at work) as indicated by the Mean (N= 73, Mean= 1.11). Correlations results The effect of demographic variables Two tailed T-test (independent sample test) had been used to investigate the effect of gender on the perceived job related stress and job satisfaction (There were more male nurses 57.5% than female nurses 42.5%). There were no significant statistical differences in perceived job related stress due to gender as indicated by (t = - 1.468, sig. = .147 > 0.05) and no significant statistical differences in job satisfaction due to gender as indicated by (t = .751, sig. = .455 > 0.05); Hence male and female doesnt differ. One way ANOVA test had been used to investigate the effect of age, shift rotation ( A, B, or C shift ), and the work place ( ICU, CCU, Floor, Operating room) on the perceived job related stress and job satisfaction. There were no significant statistical differences in job related stress due to age as indicated by (F= 1.133, sig. = .348 > 0.05).And no significant differences in job satisfaction due to age as indicated by (F= 2.044, sig. = .098 > 0.05). There were no significant statistical differences in perceived job related stress due to shift rotation (A, B, or C shift) as indicated by (F= .427, sig. = .654 > 0.05) and no significant statistical differences in job satisfaction due to shift rotation (A, B, or C shift) as indicated by (F= 1.299, sig. = .279 > 0.05). Also, There were no significant statistical differences in perceived job related stress due to work place (ICU, CCU, Floor, Operation room) as indicated by (F= .539, sig. = .657 > 0.05) but there is significant statistical differences in job satisfaction due to work place as indicated by (F= 3.711, sig. = .015 <

15 0.05).To know which work places have made this significant relation, a Post Hoc Test had been used, the results have shown that CCU and Floor nurse contribute to this significant statistical difference. These results indicate that the CCU and Floor nurses are under a high level of stress and this contribute to high level of dissatisfaction between them. The effect of perceived job related stress on job satisfaction To achieve the purpose of identifying the effect of perceived job related stress on job satisfaction of the staff nurses in the private hospitals in Amman, a Pearson correlation test has been performed. There is a significant negative relationship between the perceived job related stress and the job satisfaction of the staff nurses in private hospital in Amman as indicated by (Pearson correlation = -.283, sig. = .015 < 0.05). And this correspondent with results of the researches that have studied the relationship between jobs related stress and job satisfaction. DISCUSSION The purpose of the study was to describe the main stressors affecting staff nurses in private hospitals in Amman. Researchers have found that the most stressful subscale for staff nurses is the uncertainty concerning treatment (Inadequate information from a physician regarding the medical condition of a patient, A physician ordering what appears to be inappropriate treatment for a patient, A physician not being present in a medical emergency, Not knowing what a patient or a patient's family ought to be told about the patient's condition and its treatment, Uncertainty regarding the operation and functioning of specialized equipment). Researchers can conclude from the previous mentioned results that the major factor of high level of stress is lack of autonomy and independency in making decisions. The majority of the nurses felt unable to make decisions at least sometimes, and powerless to change unsatisfactorily situations. Although some of the nurses felt inadequately trained or equipped for their job, it was also felt that the nurses did not always utilize their training and experience. In relation to the stressors in nursing itself, many of the nurses experienced too little time in which to undertake their work. Shortage of staff and lack of resource in the work setting was also felt acutely and was frequently stressful.

16 And the least stressful subscale is the inadequate preparation (Feeling inadequately prepared to help with the emotional needs of a patient's family, being asked a question by a patient for which I do not have a satisfactory answer, Feeling inadequately prepared to help with the emotional needs of a patient). It may be of the most important findings of this study. The results clearly suggest that nurses are avoiding emotional demands of the patients as evidenced by least mean (N=73, Mean = 2.164 for the inadequate preparation to meet emotional need of the patient). So, it is suggested that a coping mechanism specific to nursing may be that nurses unconsciously reduce stress in their job by setting a nursing objectives as physical objectives and avoid the emotional objectives in their job and thats opposing the philosophy of holistic care in nursing and converting the nurses into machines regarding the performance of their work. It is indeed time of care for staff nurses and the time to look for the main stressors and reducing it to achieve the concept of holistic care in nursing (the physical, emotional, social and spiritual aspect of care).Ways in which this caring could be achieved are to enhance the ability of the work groups to support each other, and to have more counseling services. Because poor clinical structure, poor relationships with other professions and lack of a higher level of education for nurses may all lead to lower levels of confidence and higher stress levels, these issues need to be confronted as a means of caring for staff. The recently agreed clinical structure (more clearly related to the preparation for the role) may lead to increased autonomy and satisfaction. Better relationships with other professions (e.g. physician/nurse) may also relieve stress. This could be achieved through closer integration during parts of training to enhance understanding of each others roles. A higher level of education for nurses will lead to increased confidence and an ability to discuss issues as equals with professional colleagues. Seeking strategies to relieve the stressors that are affecting the staff nurse in the private hospitals is one of the major tasks that the private hospitals should concern to achieve a higher level of satisfaction for the staff nurses and for the customers (patients and their families in the organization).Also, when there is adequate job satisfaction between the staff nurse, there will be more stability and more retention for the staff nurses in the organization.

17 One of the interesting findings in this study on the staff nurses in the private hospitals is that there is a significant statistical difference in job satisfaction due to the workplace (ICU, CCU, Floor, Operation room) as indicated by (F= 3.711, sig. = .015). To know which work places have made this significant statistical difference, a Post Hoc Test has been done and the results have shown that CCU and Floor nurse contribute to this significant statistical difference. These results indicate that the CCU and Floor nurses are under a high level of stress and this contribute to high level of dissatisfaction between them. These results putting the CCU and Floor nurse under the microscope to see the main stressors made them unsatisfied on their job. To achieve the holistic care, we have to care for the nurses who are providing the care and to relieve their stressors to enable them providing the emotional aspect of care as equal as physical aspect of care Stress and job satisfaction among nurses has been the subject of extensive research for many reasons, including the relationship of these occupational attitudes to measures of job performance (Ivancevich & Matteson, 1980; Jex, 1998). In addition, Hinshaw and Atwood (1983) and Lucas, Atwood, and Hagaman (1993) reported that job stress and job satisfaction were important correlates of anticipated and actual job turnover among nurses. The results that investigate the relationship between perceived job related stress and job satisfaction have shown that there is a significant negative relationship between job related stress and job satisfaction among staff nurses in private hospitals in Amman as indicated by (Pearson correlation = -.283, sig. = .015 < 0.05). And this correspondent with results of the researches that have studied the relationship between jobs related stress and job satisfaction. This study indicates the importance of adopting strategies to reduce the perceived job related stress and also adopting strategies to demonstrate more social support for the staff nurses in the work place in the private hospitals in Amman. Nurse Managers should promote an organizational culture characterized by cooperation, social integration, and team work among nurses to reduce the stressors and thus achieve the holistic care provided by the nurses and improve the quality of care provided for the patients in the private hospitals. Moreover, researchers recommend to foster

18 cooperation, social interaction concepts, and effective coping mechanism among nursing students for future behaviors. Students who learn the importance of cooperation and social integration during their education might better understand the significance of coworker support in the work place. Limitation of the study The main limitation of the study is the convenience sampling method which increases the probability of systemic sampling error, and reduces the power of the study. Also, the presence of more than one researcher in data collection procedure, could affect the results, and the consistency of the instrument. The use of a long questionnaire as a data collection method could affect the process of sample recruitment and thus decrease the response rate among staff nurses. Also, the time and funding limitation could affect the result of the study.

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23 APPENDICES A. Expanded nursing stress scale (questionnaire 1). B. Job satisfaction survey (questionnaire 2).

24 APPENDIX (A): EXPANDED NURSING STRESS SCALE Age: .. What is your sex? A) Male B) Female

What is the highest level of nursing education that you have? A) RN B) Others

In which type of setting do you work? A) ICU B) CCU C) Floor D) Operation Room Below is a list of situations that commonly occur in a work setting. For each situation you Have encountered in your presenting work setting, would you indicate how stressful it has Been for you: 1 = Never stressful. 2 = occasionally stressful. 3 = frequently stressful. 4 = extremely stressful. 0 = doesnt apply.

25 APPENDIX (A): EXPANDED NURSING STRESS SCALE (ENSS). Expanded Nursing Stress Scale (ENSS) Occasionally stressful

Frequently stressful

Never stressful

Please circle the one number for each question that comes closest to reflecting your opinion About it.

Extremely stressful 3 3 3 3 3 3 3 3 3 3 3 3

1 2 3

Performing procedures that patients experience as painful Criticism by a physician Feeling inadequately prepared to help with the emotional needs of a patient's

0 0

1 1

2 2

4 4

0 family 4 Lack of opportunity to talk openly with other personnel about problems in the 0 work setting. 5 6 7 Conflict with a supervisor Breakdown of computer Inadequate information from a physician regarding the medical condition of a 0 patient 8 9 10 11 12 Patients making unreasonable demands Being sexually harassed Feeling helpless in the case of a patient who fails to improve. Conflict with a physician Being asked a question by a patient for which I do not have a satisfactory answer 0 0 0 0 0 0 0

1 1

2 2

4 4

1 1 1 1 1

2 2 2 2 2

4 4 4 4 4

Doesnt Apply

26 13 Lack of opportunity to share experiences and feelings with other personnel in the 0 work setting 14 15 16 17 18 19 20 21 22 Floating to other units/services that are short-staffed Unpredictable staffing and scheduling A physician ordering what appears to be inappropriate treatment for a patient Patients' families making unreasonable demands Experiencing discrimination because of race or ethnicity Listening or talking to a patient about his/her approaching death Fear of making a mistake in treating a patient Feeling inadequately prepared to help with the emotional needs of a patient Lack of an opportunity to express to other personnel on the unit my negative 0 feelings towards patients 23 Difficulty in working with a particular nurse (or nurses) in my immediate work 0 setting 24 Difficulty in working with a particular nurse (or nurses) outside my immediate 0 work setting 25 26 27 28 29 Not enough time to provide emotional support to the patient A physician not being present in a medical emergency Being blamed for anything that goes wrong Experiencing discrimination on the basis of sex The death of a patient 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 1 2 3 4 1 2 3 4 1 2 3 4 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 1 2 3 4

27 30 31 32 33 34 35 Disagreement concerning the treatment of a patient Feeling inadequately trained for what I have to do Lack of support from my immediate supervisor Criticism by a supervisor Not enough time to complete all of my nursing tasks Not knowing what a patient or a patient's family ought to be told about the 0 patient's condition and its treatment 36 37 38 39 40 41 42 43 44 45 46 47 48 Being the one that has to deal with patients' families Having to deal with violent patients Being exposed to health and safety hazards The death of a patient with whom you developed a close relationship Making a decision concerning a patient when the physician is unavailable Being in charge with inadequate experience Lack of support by nursing administrators Too many non-nursing tasks required, such as clerical work Not enough staff to adequately cover the unit Uncertainty regarding the operation and functioning of specialized equipment Having to deal with abusive patients Not enough time to respond to the needs of patients' families Being held accountable for things over which I have no control 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 1 2 3 4 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4

28 49 50 51 52 53 54 55 56 57 58 59 Physician(s) not being present when a patient dies Having to organize doctors' work Lack of support from other health care administrators Difficulty in working with nurses of the opposite sex Demands of patient classification system Having to deal with abuse from patients' families Watching a patient suffer Criticism by nursing administration Having to work through breaks Not knowing whether patients' families will report you for inadequate care Having to make decisions under pressure 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4

29 APPENDIX (B): JOB SATISFACTION SURVEY JOB SATISFACTION SURVEY Paul E. Spector Department of Psychology University of South Florida Copyright Paul E. Spector 1994, All rights reserved. Disagree very much Disagree moderately

Agree moderately 3 3 3 3 3 3 3 3 3 3 3 3

Please circle the one number for each question that comes closest to reflecting your opinion About it.

1 2 3 4 5 6 7 8 9 10 11 12

I feel I am being paid a fair amount for the work I do. There is really too little chance for promotion on my job. My supervisor is quite competent in doing his/her job. I am not satisfied with the benefits I receive. When I do a good job, I receive the recognition for it that I should receive. Many of our rules and procedures make doing a good job difficult. I like the people I work with. I sometimes feel my job is meaningless. Communications seem good within this organization. Raises are too few and far between. Those who do well on the job stand a fair chance of being promoted. My supervisor is unfair to me.

0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2

4 4 4 4 4 4 4 4 4 4 4 4

Agree very much

Disagree slightly

30 13 14 15 16 The benefits we receive are as good as most other organizations offer. I do not feel that the work I do is appreciated. My efforts to do a good job are seldom blocked by red tape. I find I have to work harder at my job because of the incompetence of people 0 I work with. 17 18 19 I like doing the things I do at work. The goals of this organization are not clear to me. I feel unappreciated by the organization when I think about what they pay 0 me. 20 21 22 23 24 25 26 27 28 29 30 People get ahead as fast here as they do in other places. My supervisor shows too little interest in the feelings of subordinates. The benefit package we have is equitable. There are few rewards for those who work here. I have too much to do at work. I enjoy my coworkers. I often feel that I do not know what is going on with the organization. I feel a sense of pride in doing my job. I feel satisfied with my chances for salary increases. There are benefits we do not have which we should have. I like my supervisor. 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 1 2 3 4 0 0 1 1 2 2 3 3 4 4 1 2 3 4 0 0 0 1 1 1 2 2 2 3 3 3 4 4 4

31 31 32 33 34 35 36 I have too much paperwork. I don't feel my efforts are rewarded the way they should be. I am satisfied with my chances for promotion. There is too much bickering and fighting at work. My job is enjoyable. Work assignments are not fully explained. 0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4

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