Queensland University of Technology

School of Nursing

Centre for Health Research

Identifying Sources of Stress and Level of Job

Satisfaction amongst Registered Nurses
within the First Three Years of Work as a
Registered Nurse in Brunei Darussalam

Abd Rahim Damit

RN, Cert.Ed. B.Ed.

Submitted for the award of Master of Applied Science Research

August 2007.
ABSTRACT

Introduction

The purpose of this study project was to determine the factors contributing to stress in

nurses within the first three years of work as a registered nurse in the speciality units and

general wards in Brunei Darussalam hospitals. It is expected that the findings of this

study would become the point of reference for nurses and Ministry of Health to identify

support strategies and resources that could be used to prepare nurses to cope with stresses

while working in todays complex clinical environment. Thus the findings are intended to

inform nurse educators, nurse managers and nurse administrators in Brunei Darussalam

regarding the levels and types of stressors among new graduate nurses in different areas.

Background to the study

Many studies have recognized that nursing is, by its nature, a stressful occupation

because of exposure to a wide range of potentially stressful situations and conditions.

Some stressors for nurses consistently identified in the literature include work overload,

unpredictability of staffing levels, caring for dying patients, lack of time to give patients

emotional support, tiredness and conflict with doctors and supervisors. Others stressors

may also be associated with safety issues, lack of support and problems which occur

outside of work and conflicts between home and work.

i
Method

This study used a descriptive correlational study design to examine new nurses within the

first three years of work as a registered nurses perception of stress and level of job

satisfaction in todays complex clinical nursing working environment. Data was collected

through distribution of self administered questionnaires, which comprised 59 items of

Expanded Nursing Stress Scale (French, Lenton, Walters and Eyles, 1995) and the two

part measurement tool of Index of Work Satisfaction Survey (Stamps, 2001). This

questionnaire was distributed to 120 new registered nurses working in Raja Isteri

Pengiran Anak Saleha Hospital (R.I.P.A.S.), the main referral hospital in Brunei

Darussalam. The sample consisted of both male and female registered nurses (RN) who

had less than three years working experience in nursing.

Results

Responses to the Expanded Nursing Stress Scale (ENSS) identified that the new

registered nurses rated their Uncertainty Concerning Treatment as highly stressful events

that frequently occurred in the workplace. The study findings also revealed that the level

of stress and the common stressors in new registered nurses within the first three years of

work as a registered nurses were similar irrespective of whether they were working in the

speciality units or in general wards. Results for Index Work Satisfaction Survey (IWSS)

Part A and B also suggested that there was no significant difference on the levels of job

satisfaction in both groups of new registered nurses, with the majority of nurse choosing

Professional Status as the most important component.

ii
Conclusion

Results of this study are likely to have important implications for nursing education,

administration, management, organisation, practice, knowledge, and research. The study

findings have the potential to make a significant contribution to determining coping

strategies that might help in reducing the amount of stress experienced by the new

registered nurses in day to day challenging and demanding nursing roles. The study also

has the potential to have wider benefits to nursing practice not just at Brunei Darussalam.

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 TABLES OF CONTENTS

Page

ABSTRACTS i

TABLE OF CONTENTS. iv

LIST OF TABLES . viii

STATEMENT OF ORIGINAL AUTHORSHIP. x

ACKNOWLEDGMENT. xi

CHAPTER ONE BACKGROUND AND OVERVIEW

INTRODUCTION. 1

BACKGROUND 1

SIGNIFICANCE OF THE STUDY.. 4

PURPOSE OF THE STUDY. 6

THE STUDY AIM 8

Aims of the Study 8

Objectives. 8

Research Questions . 9

Hypotheses .. 9

Summary . 10

CHAPTER TWO THEORETICAL PERSPECTIVE OF STRESS

INTRODUCTION . 11

It Is Stress?........................................................................................ 11

iv
 Work Related Stress and its Effects on Health.. 14

Is Work Related Stress Costly 16

STRESS IN NURSING: A CONCEPTUAL MODEL 19

Conceptual Model of Stress Amongst New Registered Nurses. 23

CHAPTER THREE LITERATURE REVIEW

INTRODUCTION......... 24

Stress In Nursing 25

Multiple Sources of Stress. 27

Concerns about Clinical Competence 29

Role Conflict.. 30

Violence and Aggression.. 31

Workload and Resource Constraints. 37

The Role of Nurses Providing Care to the Dying Patient..... 40

Support From Managers and Colleagues.. 42

Stressors Associated with the Transition to being a Registered

Nurse.... 43

Coping and Support Strategies. 48

Summary.. 51

CHAPTER FOUR METHOD

RESEARCH METHOD. 52

Research Design 52

v
 Setting 52

Sample 55

Ethical Consideration. 57

Research Instrument... 59

Demographic Questions. 59

Rating of Clinical Practice.. 59

The Expanded Nursing Stress Scale (ENSS)........ 60

The Index of Work Satisfaction (IWS).. 62

Pilot Study. 65

Data Management and Analysis 66

CHAPTER FIVE - RESULTS

Introduction 68

Sample Characteristics.. 68

Social Demographic Characteristics of the Sample.. 69

Participants Confidence about Clinical Practice.. 71

Sources and Level of Stress Scale. 72

Comparison of Stress by Practice Setting. 91

Comparison of Stress by Demographic Variables. 93

Index of Work Satisfaction: Importance of Work Components (Part

A) .......................... 97

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 Index of Work Satisfaction: Rating of Satisfaction (Part B).. 101

Computing the Component Sources 113

Strategies That Are Believed to be Helpful in Assisting the New

Nurses Transition into the Workplace as a New Registered Nurse 121

Summary ......... 123

CHAPTER SIX DISCUSSION AND CONCLUSIONS

Discussion of The Study Findings... 125

Implications.................... 134

Study Limitations 136

Future Research.. 138

Conclusion . 139

References .. 141

Appendices .

vii
 LIST OF TABLES Page
Figure 1 Conceptual model of Stress amongst new Registered Nurses. 23

Figure 2 The Nursing Structure in Brunei Darussalam. 55

Table 1 Practice Setting for Nurses in the Study Sample. 56

Table 2 List of Items for Each Component in the IWS 64

Table 3 Example of Scoring System for Positively and Negatively Phrased

Items in the IWS.. 64

Table 4 Demographic Characteristics of the Sample 69

Table 5 Social Demographic Characteristics of the Sample. 70

Table 6 Participants Confidence about Clinical Practice 71

Table 7 Ratings of Stress associated with Uncertainty Concerning

Treatment. 74

Table 8 Ratings of Stress Associated with Dealing with Patients and their
Families 76

Table 9 Ratings of Stress associated with Workload 78

Table 10 Rating of Stress Associated with Inadequate Emotional

Preparation . 80

Table 11 Rating of Stress Associated with Conflicts with Doctors.. 82

Table 12 Rating of Stress Associated with Supervisors 84

Table 13 Rating of Stress Associated with Death and Dying 86

Table 14 Rating of Stress Associated with Conflicts with Peers 88

Table 15 Rating of Stress Associated with Discrimination. 90

Table 16 Expanded Nursing Stress Scale Scores by Practice Setting.. 92

Table 17 Comparison of Stress by Demographic Variables. 94

viii
Table 18 Relationship between Stress and Ratings of Confidence,
Competence and Organisation 96

Table 19 Frequency Matrix for IWS Components by Work Area. 98

Table 20 IWS Component Weightings by Work Area. 100

Table 21 Index of Work Satisfaction: Professional Status.. 102

Table 22 Index of Work Satisfaction: Interaction 104

Table 23 Index of Work Satisfaction: Autonomy 106

Table 24 Index of Work Satisfaction: Task Requirements.. 108

Table 25 Index of Work Satisfaction: Organisational Policies. 110

Table 26 Index of Work Satisfaction: Pay Component 112

Table 27 Component Score and the Component Mean Score for IWS Scales 114

Table 28 Ranking of Satisfaction with IWSS Work Components.. 116

Table 29 IWS Components Weighted Scores. 118

Table 30 Components T-test 119

Table 31 Correlations between IWSS and ENSS .. 120

Table 32 Ratings of Helpfulness of Strategies for Assisting Transition.. 122

Table 33 Frequency Matrix Appendix 6

Table 34 Matrix of Z-Values - Component Weighting Coefficient Appendix 7

Table 35 Index of Work Satisfaction: Nurse-Nurse Appendix 8

Table 36 Index of Work Satisfaction: Nurse-Physician Appendix 9

Tables Appendix 10
37 - 60

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 STATEMENT OF ORIGINAL AUTHORSHIP

The work contained in this thesis has not been previously submitted to meet requirement

for an award at this or any other higher education institution. To the best of my

knowledge and belief, the thesis contains no material previously published or written by

another except where due reference is made

Signature Date: 7th August 2007.

Abd Rahim Damit

x
 ACKNOWLEDGMENT

The undertaking of this thesis was not a solitary effort. I appreciate my supervisor,

colleagues, family and friends who helped me in so many ways; without them this thesis

would not have been completed. I wish to gratefully acknowledge the support and

kindness of the following individuals and organisations:

Firstly, I express my deep and sincere thanks to my supervisor Professor Patsy Yates who

encouraged me through the Masters journey. Her continued guidance, support and

critical comments were a source of great encouragement. Thank you so much for being

instrumental in making this happens I benefited from your vision all along.

I would like to express particular thanks to my spouse, children and mother for their

patience and forbearance during recent months whilst I have been working so hard to

complete my study. It has been a mammoth task and I am very much aware that I have

neglected them in many different ways. I would also like to thank all those who have

contributed ideas and constructive views for my development. A special thanks to

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Government of His Majesty Sultan Haji Hassanal Bolkiah Mu'izzaddin Waddaulah, the

Sultan and Yang Di-Pertuan of Brunei Darussalam for the financial support and to all

academic, administrative and support staff from the Research Department, School of

Nursing, Faculty of Health, Queensland University of Technology, Australia, who

worked so hard to enable me to complete my study.

Special thanks to other contributors, Peter Fell, Dr Diana Batistutta, Boni Macfarlane and

to all of my local and international PhD students/colleagues who have willingly shared

their knowledge and experiences during my study. I have had valuable assistance from

Ms Sheree Smith who worked so hard since she became my principal research supervisor

in April 2005 to August 2006. She spent a lot of time and energy which contributed to the

success of this study and she has kept me well informed of my progress.

I would as well like to thank the participants in the study and the nursing managers,

without their commitment this study would not have been possible. It was a great

pleasure and opportunity to work with them. Thank you to all of you.

My thanks also go to Hajah Thaibah binti PDPD DP Haji Abd Rahim- Principal College

of Nursing Brunei Darussalam, Haji Julaini bin Haji Latip-Deputy Principal College of

Nursing Brunei Darussalam, Haji Daud bin Haji Mahmud-Deputy Permanent Secretary-

Ministry of Education Brunei Darussalam, Pengiran Hajah Azizah binti Pengiran Haji

Tajuddin-Former Director of Nursing Services Brunei Darussalam, Dr. Haji Abdul Hamit

bin Haji Musa-Acting Director of Nursing Services Brunei Darussalam and Dr Awang

Haji Affendy bin Pehin Orang Kaya Saiful Mulok Dato Seri Paduka Haji Abidin-

xii
Director General Medical Services Brunei Darussalam for their support and permission

for this study to be conducted in RIPAS Hospital Ministry of Health Brunei Darussalam.

I would also like to acknowledge and thank Susan E. French, Rhonda Lenton, Vivienne

Walters and John Eyles from the School of Nursing McMaster University, Canada the

original authors of the Expanded Nursing Stress Scale (ENSS) and Professor Paula L.

Stamps and Market Street Research, Inc from University of Massachusetts, United State

of America the original owner of the Index of Work Satisfaction (IWS), for their

assistance and their permission to use the self-administered questionnaires as the data

collecting tools for this study.

Finally, this thesis is dedicated to my late father Awang Haji Damit Piut who departed

this life on the 11th March 2007 and my late Aunt Hajah Maimunah Piut who passed

away on the 21st of August 2006, whilst I was completing the final stages of my thesis. I

have had a considerable loss of key persons who can never be replaced, and who have

supported my study, living and took care of my children and family whilst I have been in

Australia since April 2005.

Abd Rahim Damit

August 2007.

xiii
 CHAPTER ONE
1.0. INTRODUCTION

1.1. BACKGROUND.

Nursing is, by its nature, a stressful occupation because of exposure to a wide range of

potentially stressful situations and conditions. Stressors for nurses consistently identified

in the literature include work overload, pressures associated with demands of the

contemporary work environment (World Health Organisation, 2004), unpredictability of

staffing and scheduling, having to complete too many non-nursing tasks, and having to

make decisions under pressure (Fox, 2003; McVicar, 2003). In addition, watching a

patient suffer and feeling helpless in the case of a patient who fails to improve or who

may be dying may cause distress amongst nurses. Lack of time to give patients emotional

support, tiredness, criticism by doctors and conflicts with immediate supervisors (Huang,

2004; Healy and McKay, 1999; Tyler and Cushway, 1995:1992) can also create difficult

situations for nurses. Other factors which have been identified in the literature as

contributing to stress include concern about being isolated and discriminated against

because of race and ethnicity, or being sexually harassed by other nursing colleagues or

other healthcare professionals (Huang, 2004; Uzun, 2003; Sylvia 1996; Guppy and

Gutteridge, 1991).

While there are a considerable number of stressors associated with nursing work, stress is

highly subjective and there is substantial variation in experiences of stress (Santamaria,

1995). New nurses in particular are likely to face some unique stressors that make the

period of transition to the role of registered nurses (RN) an especially difficult time

(McVicar, 2003; Casey, Fink, Krugman and Propst, 2004). In addition to these stressors

1
associated with nursing work, new nurses may face additional stressors associated with

job loss and/or relocation (Moore, Kuhrik, Kuhrik, and Barry, 1996), fear of failure while

carrying out nursing tasks/responsibilities, fear of making mistakes or harming patients

while performing procedures that patients experience as painful, and feeling inadequately

prepared to help meet the emotional needs of patients and the patients family (Gillespie

and Kermode, 2004; Healy and McKay, 1999). Stress has also been identified with

concerns about job security and stability, work dynamics, safety and self esteem issues

(World Health Organisation, 2004; Rainham, 1994). Poor work organisation, including

poor work design and work systems can also cause work stress (World Health

Organisation, 2004). Other stressors external to the workplace may exist, including

conflicts between home and work especially for those who have young children to care

for (Lu and Shiau, 1997; Rainham, 1994).

Beginning level nurses may lack familiarity with the hospital and have limited experience

in dealing with the new complex working environment, medical emergencies, and the

operation and functioning of specialised equipment (Arnedo, Uranga, and Marin, 2005;

Jackson, 2005; Higgins, 2003; Tyler and Cushway, 1995:1992). Being in charge of

clinical situations with inadequate experience and not knowing what a patient or a

patients family ought to be told about the patients condition and its treatment may also

present stressors. Work which does not fulfil their needs and work tasks/responsibilities

over which new graduate nurses have little control or which are ambiguous are also found

to be significantly associated with increased levels of emotional exhaustion leading to

occupational stress (Stordeur, Dhoore and Vandenberghe, 2001; Sylvia, 1995; Cox and

Griffiths, 1994).

2
According to the World Health Organisation, work related stress occurs in a wide range

of work circumstances. A healthy work environment is one in which the presence and

impact of such stressors are minimised, by ensuring the absence of harmful conditions

and an abundance of health-promoting ones (World Health Organisation, 2007). Some

writers argue that health at work and healthy work environments are among the most

valuable assets of individuals, communities and countries. Occupational health is seen to

be an important moral imperative, not only to ensure the health of workers, but also to

contribute to positive productivity, quality of work, work motivation, job satisfaction and

to overall quality of life of individuals and society (World Health Organisation, 1995).

Importantly, evidence suggests that unhealthy work environments are one important

factor contributing to the worldwide nursing shortage (World Health Organisation, 2004).

Identifying strategies for improving the health and well-being of health workers is thus

crucial at this time. In response to these concerns, the International Council of Nurses in

2007 outlined the characteristics of positive practice environments for nurses. These

characteristics include:

Innovative policy frameworks focused on recruitment and retention

Strategies for continuing education and upgrading

Adequate employee compensation

Recognition programmes

Sufficient equipment and supplies

A safe working environment.

3
Other key reports relating to the well-being of health workers similarly argue that the

more control workers have over their work and the way they do it, and the more they

participate in decision making in their job , the less likely they are to experience work

stress (WHO, 2004).

Such international policy documents highlight the importance of understanding the work

place factors that may contribute to adverse work environments, and developing local

approaches in accordance with countries priorities to ensure workers health and well-

being (World Health Assembly, 2007).

1.2. THE SIGNIFICANCE OF THE STUDY

To date, no research has been conducted to investigate level of stress and work

environments for nurses, and the implications of such stress for nursing services in

Brunei Darussalam. The purpose of this study is thus to examine stressors and work

satisfaction for nurses working in different practice environments within the first three

years of work as a registered nurse in Brunei Darussalam. This study is significant for a

number of reasons. Firstly, nurses comprise the largest group of health personnel

providing support services in primary, secondary and tertiary health care in Brunei

Darussalam. Moreover, with better education and improved living standards, the health

demands of the public have required sophisticated reforms and changes and

improvements to the quality nursing services (Ministry of Health, 2005). Such demands

are likely to cause new registered nurses in Brunei Darussalam to experience even more

4
challenging situations as they are required to cope with constant time pressures and the

need to maintain their competence in a rapidly changing field. For example, the impacts

of developments in science and bio-technologies in treatment of many illnesses, and

medical technology advances in nursing have seen an increased pressure for new

registered nurses (Barnard and Gerber, 1999). As a result of this rapidly changing

workplace, new registered nurses may also frequently encounter new ethical dilemmas,

and face an increasing number of situations over which they have limited control

(Rainham, 1994).

Work related stress can result in workers being less productive, may impact on the

quality of services provided by health professionals, and may also place these nurses at

more risk of making errors (International Labour Organisation, 2005). Becky (1994)

describes negative behaviours of stressed employees to include apathy, paranoia, and

distrust. The failure to identify these problems amongst nurses at an early stage is thus

likely to have a major impact on the effectiveness of nursing services and patient care.

Such stressors may also contribute to an increase in psychiatric morbidity such as

depression, as well as an increase in some forms of physical illness, such as

musculoskeletal problems (Higgins, 2003; Cox, Griffiths and Cox, 1996; Santamaria,

1995). Murphy (2004) argues that if nurses feel stressed at work, their practice will

suffer, ultimately affecting the care of the patients. Cartwright and Cooper (1994)

suggest that there is a strong need for a proactive management approach that recognizes

an organisational responsibility to manage and effectively identify and minimise potential

stressors in the workplace.

5
1.3. PURPOSE OF THE STUDY

Stress in nursing has been well documented in the literature for many years yet it remains

a poorly understood problem. This is in part due to theoretical and methodological

constraints in the investigation of this phenomenon and the multi-factorial nature of

nursing stress (Santamaria, 1994). There is also very limited research on such issues

outside of western countries. This lack of evidence regarding the experiences of nurses in

the first few years of work as a registered nurse presents many challenges, especially for

those who need to prepare future nurses to practice in the contemporary healthcare

setting, in particular social and cultural contexts.

Issues of work related stress and stressors are frequently discussed informally amongst

nurses at all levels in Brunei Darussalam hospitals. However, stress in the nursing

environment especially among registered nurses in Brunei Darussalam hospitals has not

yet been investigated. The primary aim of this study is to determine the sources and level

of stress and levels of work satisfaction among new registered nurses within the first

three years of work as a registered nurse in Brunei Darussalam.

In addition, a secondary aim of this study is to compare the stressors and work

satisfaction experienced by nurses working in general and acute speciality care unit

settings. A speciality care nurse is defined as a licensed professional nurse who is

responsible for ensuring that acutely and critically ill patients (highly vulnerable, unstable

and complex) and their families receive optimal care (American Association of Colleges

of Nursing, 2006). Speciality care units are surrounded by high tech medical machinery,

6
with many patients requiring specialised devices and equipment (Villaneuva, 1999),

thereby requiring intense and vigilant nursing care. Cooper and Scott (2003) suggest that

specialty care unit nurses skills and expertise are different to those of general wards

nurses, as their roles expand to include use of advanced and complex medical

technologies, and more specialised knowledge and skills (Aliso-Viejo, 2002). Due to the

nature of these different environments, this study sought to identify and compare

common stressors, sources and level of stress in these different settings for registered

nurses within the first three years of work as a registered nurse.

In Brunei Darussalam, an 18 month transition program has been developed for new

registered nurses. There is, however, no data available to examine its relevance to the

needs of new graduates today, and ways to improve the program. As such, it is expected

that the findings of this study will become a point of reference for nurses and the Ministry

of Health to understand the levels, types and effect of stress on new nurses within the first

three years of work as a registered nurse, and to identify appropriate support strategies

and resources that could be used to prepare future nurses to cope with these stressors.

Thus the findings from this study will inform nurse educators, nurse managers and

hospital administrators regarding the levels and types of stressors in registered nurses in

different clinical areas of the hospital in their first few years as a registered nurse. The

study will also help to identify areas for further nursing research in Brunei Darussalam.

7
1.4. THE STUDY AIM

Aim of the Study

The primary aim of this study was to investigate perceptions of stress and level of job

satisfaction by registered nurses of less than three years experience, in todays complex

clinical nursing working environment in Brunei Darussalam hospitals.

1.5. Objectives

For nurses in Brunei Darussalam, The study objectives are to:-

1. Identify levels and sources of stress experienced by registered nurses with less

than three years experience working in speciality care units and general wards.

2. Compare levels and sources of stress experienced by registered nurses with

less than three years experience working in speciality care units and general

wards.

3. Explore the relationship between the levels of stress and job satisfaction

amongst registered nurses with less than three years experience working in

speciality care units and general wards.

8
1.6. Research Questions

The research questions for this study are:

1. What are the stressors for registered nurses with less than three years experience

working in speciality care units and general wards?

2. Do the sources of stress differ for registered nurses with less than three years

experience working in speciality care units and general wards?

3. Do sources and levels of stress differ according to gender, marital status, working

experience in nursing, and perceptions of confidence, and level of competence

with their overall clinical practice?

4. Is there a relationship between level of stress and level of job satisfaction amongst

nurses with less than three years experience working in speciality care units and

general wards?

1.7. Hypotheses

In order to answer the research questions, the study set out to test the following

hypotheses for nurses in Brunei Darussalam:

1. The stressors for registered nurses with less than three years experience are

similar between nurses working in speciality care units and general wards.

9
 2. The sources of stress for registered nurses with less than three years experience

are similar between nurses working in speciality care units and general wards.

3. The sources and levels of stress for registered nurses with less than three years

experience, irrespective of working environment, are similar according to gender,

marital status, working experience in nursing, perceptions of confidence, and

level of competence with their overall clinical practice.

4. There is a significant relationship between increased level of stress and lower

levels of job satisfaction amongst registered nurses with less than three years

experience.

Summary

Chapter one has provided an overview of some of the stressors experienced by nurses in

todays healthcare environment. The significance of the study to nursing in Brunei

Darussalam has been outlined and the research questions, hypotheses, aim and objectives

of the study have been presented.

10
 CHAPTER TWO
2.0. THEORETICAL PERSPECTIVES OF STRESS

2.1. INTRODUCTION

There is some evidence in the literature that a notable proportion of nurses report

overwhelming exhaustion, feelings of frustration, anger and cynicism; and a sense of

ineffectiveness and failure (Ootim, 2002; Cole, Slocumb and Mastey, 2001; Black,

Hawks and Keens, 2001; ILO, 2001; Healy and McKay, 1999; Janet, 1995; Sylvia, 1995;

Santamaria, 1994). This chapter begins with an overview of the concept of stress, its

definitions, and its effects on health, the employing organisation and society at large. The

nature of and common sources of stress in the nursing profession are also discussed. The

chapter concludes with a summary of the strategies that might be useful in overcoming

the problems associated with stress amongst nurses, especially in the first few years work

as a registered nurse.

2.2. Is it Stress?

Stress is largely subjective. Nevertheless, it does prompt a series of marked physiological

changes (Kristin, 1998). Hopkinson, Carson, Brown, Fagin, Bartlett and Leary (1998)

describe stress as a subjectively real experience, the meaning of which, although

generally not exact, is understood by a wide variety of people. Specific definitions of

stress vary among stress investigators (Siegall, 1995). Stress has been defined as the

physiological and psychological reaction that occurs when people perceive an imbalance

between the level of demand placed upon them and their ability to meet that demand

11
(Rohleder, 1993). Omdahl and ODonnell (1999) define stress as an imbalance between

the perceived external demands on a person and his or her abilities to cope through the

employment of cognitive, behavioural and physiological adaptation.

Stress is your bodys instinctive response to situations that are mentally and physically

taxing (Gregory, 1999). Veccio (1995) described stress as the physical and psychological

reactions experienced by an individual when confronted by a threatening situation.

Anger, frustration, guilt and hurt (Santamaria, 1994), anxiety, apathy, and illness (ILO,

2001) are the most universally observed emotional reactions to stress. Stress is

considered to be a process in which environmental events or forces, called stressors,

threatens an organisms existence and well being (Engel, 2004; Baum, Singer, and Baum,

1981). Becky (1994) stated that stress is a physical, psychological, or spiritual response to

a stressor that may be a reaction to issues such as overwork, decreased support or

appreciation, and limited supervision.

Some of the early theorists in the area of stress emphasised this link between environment

mind and body. Seyle (1976) for example explained that stress results in physiological

responses to the stressors, or a reaction to disturbing or noxious agents or environmental

demands. Lazarus and Folkman (1984) similarly view stress as a dynamic and reciprocal

relationship between the individual and his/her environment. Stress has thus come to be

viewed as a concept that is viewed by some psychologists as a generic term for a broad

area of human responses to any stimuli that produces stress reactions, both physiological

12
and psychological (Monat and Lazarus, 1991). Importantly responses to stress vary,

depending on the perceived situation (Siegall, 1995).

Lazarus and Folkmans (1984) model is useful for understanding perception of stress, the

factors that may contribute to or ameliorate it, and its effects on the person. The model is

important, as it highlights that stress is a very broad class of problems differentiated from

other problem areas because it deals with any demands which tax the physiological

system, the social system or the psychological system and the response of that system

(Lazarus, 1999).

In this context, stress is seen as multi-factorial and highly subjective (McVicar, 2003).

Although stress has been well investigated in the literature for years, it remains poorly

understood. Stress and threat are concepts used interchangeably in research, however, the

conceptual definitions of each are clearly different (Scholtz, 2000). Stress may be

perceived as an environmental stimulus that evokes a myriad of emotions. It can be either

a positive or a negative stimulus that necessitates adaptation (Lazarus, 1999).

Hiroshi (1994) notes that stress can affect everyone, and although it can serve as a useful

stimulus, excessive stress can lead to physical and mental illness. Stress is strictly a force

which, when applied to a system, modifies its form. Psychological and social forces and

pressure, in the form of events or situations, can be referred to as stressors when they

exert a distorting effect upon a persons equilibrium. Psychological tension can also be

referred to as stress; in this case the casual agent can be referred to as a stressor.

However, stress is not necessarily bad, since in small doses it can motivate us. A crisis,

13
for example, may provoke positive thinking to regain the upper hand and master the

situation, and very often to succeed. Selye (1976) also used the term eustress to refer to

desirable forms of stress, usually relating to positive events in ones life.

Janet (1995) similarly argued that stress isnt all bad as it is a natural reaction to change

or feeling out of control. Stress isnt just that sinking feeling we get when we have too

much to do in too little time. Janet claimed it can also be that extra buzz we need to

achieve higher goals. As such, she argued that it is how stress is handled that makes the

difference. Managing stress effectively therefore requires an understanding not only of

stressors in an environment or situation, but also the meaning of the stressor, and

individuals ability to respond and manage the stressor and stress response. The

physiological and psychological manifestations of stress thus become apparent when

people are unable to invoke coping mechanisms which assist them to deal with the

stressor in a constructive way.

2.3. Work Related Stress and its Effects on Health.

Stress may have devastating effects on key areas of our lives including: personal/home,

work and finances (Janet, 1995). How people respond to differing stressors varies, and

stress may manifest itself in different ways. Some people know when their bodies are in a

heightened state of excitement: theyre aware of their pulse or they have difficulty in

swallowing. Others may have more subtle responses, such as difficulty in concentrating

or feeling angry or out of control (McConnell, 2000). Black, Hawks and Keens (2001)

explain that behavioural responses to stress include decreased ability to think clearly and

function, increased tobacco and alcohol use, overeating, and disrupted sleep pattern.

14
Black, Hawks and Keens (2001) argue that the physical and emotional demand that stress

places on individuals can have negative effects on health. These authors describe physical

responses to stress as being tight, sore neck and shoulder muscles, increased blood

pressure and heart rate, palpitations, chest discomfort, headaches, gastrointestinal upset

and fatigue. Usually, the effects of stress are short-lived and when this pressure on the

individual recedes there is a quick return to normal behaviour. However, in some cases,

where pressures are on going and intense, stress may lead to long-term psychological and

physical ill health (Harris, 2001). Kristin (1998) argues that prolonged consistent

exposure to stress does prompt a series of marked physiological changes, leading to

certain illnesses including heart disease, hypertension, depression, immune suppression

and diabetes.

Job stress is defined as the harmful physical and emotional responses that occur when the

requirement of the job does not match the capabilities, resources, or needs of the worker.

According to the United Kingdom Health and Safety Commission (1999) the term stress

refers to the reaction people have to excessive pressure or other types of demands placed

on them. Over the past decades, there has been a growing belief that the experience of

stress at work has undesirable effects, both on the health and safety of workers and on the

health and effectiveness of their organisations (International Labour Organisation, [ILO]

1986). A review of the literature on physical ailments that are connected with work stress

have generally concluded that prolonged exposure to certain job demands result in a

variety of pathological outcomes, including mental and physical disorders (Ganster and

Schaubroeck, 1991), to the more serious immune system impairment disorders that lead

to arthritis, cancer or heart disease (OCornnor, 2002). Excessive stress can also lead to

15
physical and mental illness (Hiroshi, 1994), insomnia, sexual dysfunction, indigestion,

vomiting, ulcers, diarrhoea, headaches, high blood pressure, heart attacks, and stroke

(Janet, 1995). The ILO (2001) describe that workplace stress may also lead to the

development of musculoskeletal problems, disability and even death. A study of the

effects of stressful job demands for 136 registered nurses employed in a medium-sized

private hospital in the Midwest USA identified several correlations between reports of

stress and physiological outcomes, including elevation in blood pressure both at work and

after work (Fox, Dwyer and Ganster, 1993).

OConnor (2002) similarly describes emotional and behavioural symptoms that are

related to workplace stress to include complaints of fatigue, heartburn, headache, and

insomnia; irritability, avoidance of co workers, conflicts with supervisors, feelings of

helplessness, loss of self-esteem, and general detachment from the unit or department.

Cole, Slocumb and Mastey (2001), also describes frustration, anger, guilt, resentment,

professional failure, personal loss, powerless, sorrow and burnout as being associated

with workplace stress.

2.4. Is Work Related Stress Costly?

Occupational stress has become a major issue and a problem not just for individuals in

terms of physical and mental disability. Work stress is implicated in 60% to 90% of

medical problems (Information Education Management Resolution, 1999), and as such

has major financial consequences (International Labour Organisation [ILO], 1998; 1993).

A survey in 1998 of 500 randomly selected members of the Institute of Directors in the

US identified that nearly 40% regarded stress as a serious problem for employees in their

16
organisation (Institute of Directors, 1998). In another report from the European Union

cited by the International Council of Nurses (2005), 28% of workers reported stress

related health problems, costing about 41 million Euro (ICN, 2005).

Similarly, Information Education Management Resolution (1999) reported that stress

related to the workplace and its associated problems cost organisations an estimated $200

$300 billion in the USA each year resulting from workers compensation claims of all

kinds (IEMR, 1999). Other studies have reported that the cost of stress-related illness in

the USA is estimated to be around $13,000 per employee each year (Bruhn, Chesney and

Salcido, 1995). As such, work related stress does contribute to economic burden, more

turnover, industrial relations difficulties, and poor quality control (Cooper, Liukkonen

and Cartwright, 1996). The National Mental Health Association in the USA reported that

almost $29 million is wasted each year by the general workforce from symptoms of

reduced productivity related to stress (OConnor, 2002). The Department of Health, in

the UK estimates it loses seven million working days to stress related illness every year,

at a cost of 5 billion pounds sterling (UKCC, 2001).

The cost of stress and its effect on the Brunei Darussalam economy is not well

documented. Stress is becoming an increasingly global phenomenon that has been

recognised as being very costly to individuals and organisations (Murphy, 2004; Omdahl

and ODonnell, 1999). The consequences of stress can contribute to organisational

inefficiency, as a result of sickness, decreased quality and quantity of care (Wheeler and

Riding, 1994), decreased job satisfaction (Ernst, Franco, Messmer, and Gonzalez, 2004),

high staff turnover, worker conflict, absenteeism, reduced productivity (Ganster and

17
Schaubroeck, 1991), demoralization and lack of motivation and more (Hiroshi, 1994).

Most organisations have no idea how much stress has cost them each year because they

fail to recognise and address triggers for stress effectively (Harris, 2001). While

contrasting study results have been reported with regard to the relationship between job

stress and job performance (AbuAlRub, 2004), stress has the potential to become an

inhibitive force that can cause diminished individual performance and satisfaction in

work (Healy and McKay, 2000).

A review of the literature suggests that stress can cause burnout, high workforce turnover,

lowered morale and reduced efficiency (Hannigan, Edwards and Burnard, 2004), and can

lead to increased absenteeism, hostility, and aggression (Halvorsen, 2006). It can also

lead to poor time keeping, high turnover of staff, impaired productivity for those at work,

unsafe behaviour and negative health and safety culture in general (Harris, 2001;

Information Education Management Resolution, 1999). Stress is also significantly

associated with an increase in accident rates in the workplace, with one study reporting

that those experiencing high stress are 30% more likely to have accidents than those with

low stress (Lee, 1997). According to the Association of Operating Room Nurses Journal

(2006), situations that produce stress on nurses are more likely to increase the risk of

patients injury, and injuries in nurses (Smith, 1999). These injuries can include

contusions, scratches, sprains/strains and cuts/punctures. The authors also concluded that

nurses who experienced more role ambiguity were more likely to incur a reportable

injury at work. Owing to a lack of clarity regarding job responsibilities, nurses may be

performing roles for which they are not properly trained or qualified, thereby placing

18
themselves in unfamiliar situations where the potential for injury is greater. Regardless of

whether the stress is moderate or high, the cost of stress is enormous (Halvorsen, 2006).

2.5. STRESS IN NURSING: A CONCEPTUAL MODEL

Several studies have been undertaken to identify the factors leading to stress in nursing

(Higgins, 2003; Cottrell, 2000; Gray-Toft and Anderson, 1981). Studies conducted in the

1980s by Hingley and Cooper (1986) identified relationships with superiors, role conflict,

home /work conflict, career stress, and stress due to resource management as common

stressors in nursing. Fitter (1987) similarly identified eight factors that may contribute to

stress including responsibility, workload, physically arduous work, shift work, overtime

and covering absent colleagues, interpersonal conflicts, responsibility for training,

uncertainty and unpredictability, and keeping up with change. More recent studies

suggest such stressors continue to exist in nursing, with additional stressors emerging due

to the changing nature of todays health care system. Schroeder and Carter (2002), for

example, reported nurses found it challenging to meet the demands associated with their

evolving role, such as being a financial manager, resource manager and skilled

commentator. Des (2001) similarly described the difference between historical ideas of

what nursing was and the new image of what nursing has become, with conflicts between

such ideals and realities presenting particular challenges for nurses today.

Several studies have reported that less experienced registered nurses in particular report

work demands as being threatening, as the knowledge and skills provided during training

are sometimes not well matched to the demands of contemporary health care. Such

19
studies report that new nurses often feel their work does not meet the needs of the

patients, that they have very little control over their work, and that they receive very little

support from their supervisors and nurse managers (Casey, Fink, Krugman and Propst,

2004). These studies also suggest that nurses perceive that nursing is emotional work,

involving sharing an intense intimacy with others at their most vulnerable, dealing with

issues of right and wrong in human experiences, and the principles of the right of the

individual versus the common good (Sumner, Townsend-Rocchiccioli, 2003). AbuAlRub

(2004) reports that nurses today also have to cope with the rapid changes and the

complex technological characteristics of the health care system, workload issues and lack

of support (team building and collaborative issues), all of which are major stressors

(Ropis, 2005).

Nursing has also been perceived as less attractive on some important occupational

characteristics such as job independence (Grumbach, 2006). This can be problematic, as

with the increased demands on nurses within a very complex health care system, nurses

may perceive they have accountability with minimal control. Such situations require

nurses to possess exceptional coping skills (Bryant, 1994). Indeed, Duncan-Poitier (2003)

identifies that many nurses new to the profession feel they have too much autonomy, yet

at the same time, may not be in a position to be supported to practice autonomously.

These tensions are reported to be stressful for less experienced nurses. Findings from one

recent survey in the US identified that high levels of autonomy and support by managers

improved the nurses identification with the hospital and high levels of autonomy,

support by colleagues, and duties focused on traditional bedside care increased nurses

identification with the nursing profession (Fox, 2003).

20
Stress theories such as those of Lazarus (1999) emphasise that there are many factors

which may influence a persons experience of the same stressor, including the meaning of

that stressor, and the strategies that a person may employ to cope with the stressor. For

the present study, the chief investigator will thus also examine what the registered nurses

believe to be helpful in their transition into the real workplace and avoid potential

stressors associated with their work. For example, in this context, strategies which may

be helpful to include stress management training, education, access to hospital resources,

mentoring, team building strategies, balancing priorities, enhancing social and peer

support programs, flexibility in working hours and protocols to deals with violence and

retention.

Figure one presents a conceptual model of stress in nursing that will be used to guide the

present study. The model is based on the core concepts of the Stress-Adaptation theory

originally described by Lazarus and Folkman (1984), and more recently modified by

Folkman (Folkman, Moskoawitz and Tedlie, 2007). Specifically, the model is organised

around two important processes: appraisal and coping. Appraisal refers to the individual's

evaluation of the significance of an event for his or her well-being and the adequacy of

resources for coping (Folkman, Moskoawitz and Tedlie, 2007). Situations that threaten or

harm well-being and that also tax or exceed the individual's coping resources are

appraised as stressful. For registered nurses early in their career, these situations may

include factors such as fear of failure, conflicts with supervisors and other healthcare

professionals, lack of support, lack of organisational skills, or limited experience with the

death and dying. Coping refers to thoughts and behaviours that people use to regulate

their emotions and address underlying problems (Folkman, Moskoawitz and Tedlie,

21
2007). For registered nurses early in their career, a range of programs and support

structures, such as mentoring programs, may promote positive coping that will help to

regulate the threat. Importantly, the model also emphasizes that when coping strategies

are inadequate for dealing with a stressor and its meaning to different individuals,

negative outcomes can occur for physical and psychological wellbeing. For stressors

associated with the workplace, these outcomes may include job satisfaction.

While Figure 1 depicts the major concepts that derive from stress-coping theory, this

study seeks to examine selected concepts only. Specifically, this study seeks to examine

stressors and how these are appraised by nurses in the first three years of work as a

registered nurse. The study also seeks to examine the relationship between these

appraisals and work satisfaction, one important outcome in todays environment of

workforce shortages and increasing demands on the nursing workforce. Some

preliminary investigation of nurses perceptions of the types of supports that may assist

their coping is also undertaken. As such, the primary purpose of this study is to provide

an indepth analysis of stressors and how they are appraised by nurses. Further research is

required to examine other key concepts and relationships in this model, such as the

relationships between stress appraisal, coping, and psychological well being.

22
 Fig 1: Conceptual model of Stress amongst new Registered Nurses

Appraisal Coping Event Outcome Emotion Outcome

Event
AREA OF STUDY: TRANSITION EXPERIENCE

Goals/
Favourable Positive
Structure Support and Emotion
Harm / Threat/ Challenge Coping Strategies Outcome
Identifies Stressors
- Fear of failure to carry out nursing task - Job Satisfaction
- Stress management training
- Fear of making mistake - Education
- Conflicts with supervisor and other healthcare professionals - Access to hospital resources
- Experience of being discriminated - Mentoring
- Minimum support from supervisors - Team building strategies
- Lack of organisational skills - Balancing priorities
- Limited experience dealing with the death and dying - Enhancing social and peer support
programs
- Flexibility in work hours
- Protocols to deal with violence and
Unfavourable Outcome
retention
- Burnout
- Attraction of nursing staff strategies.
-
-
Job dissatisfaction
Nursing staff turnover (shortages)
Distress
- Poor patients care
- Affect physical and psychological

(Adapted from Lazarus and Folkman, 1984)

23
24
 CHAPTER 3
3.0. LITERATURE REVIEW

3.1. INTRODUCTION

The increasingly complex world of health care generates the need for nursing staff

members to learn and perform more complicated skills every day. In an era of cost

containment, todays hospitals are demanding efficient and effective delivery of nursing

services. Rapid changes in the healthcare system and restructuring of some areas of

health care have increased patients expectations of what nurses should do and provide

(Sylvia, 1996). Nurse administrators thus expect competent, efficient graduate nurses

upon entry into the organisation (Hamel, 1990). The beginner professional nurse is

required to have the necessary knowledge, skills, attitudes and values which enable them

to render efficient professional service and ensure quality health care delivery (Morolong

and Chabeli, 2005). However, there has been some degree of concern in many countries

across the world over what are perceived to be inadequate levels of skills in graduates

from undergraduate programs (Holloway, 1999). To adequately prepare nurses to

function in todays health care environment, it is important that educators have a sound

understanding of the stressors and challenges experienced by nurses as they transition

into being a registered nurse. Such information can assist with the development of

education and management support programs to assist nurses to function optimally. This

chapter presents a summary of the empirical literature on stress in nursing.

24
3.2. Stress in Nursing

Nursing is recognized as a stressful occupation (Higgins, 2003; Healy and McKay, 1999;

Laws and Hawkins, 1995; Tyler and Cushway 1995; 1992). There appears to be general

agreement that working in the nursing profession is demanding and often stressful when

compared to other professions, because nurses are more exposed to factors known to

cause stress such as role conflict, role ambiguity, and significant work demands (Sylvia,

1995). Halvorsen (2006) argues that stress affects nurses on a daily basis, and that crises

on the job occur frequently. One qualitative study of the resources and strategies used by

six perioperative nurses to cope with multiple demands upon their role revealed that all

participants expressed that they were experiencing stress (Schroeder and Carter, 2002).

Cox, Griffiths and Cox (1996) suggest that although nursing is acknowledged to be a

stressful profession, there is a need for nurses at all levels to understand the nature of the

stress, its potential sources, and the long and short-term effects on health and safety of an

individual and organisation. There are many factors that may contribute to the demands

placed on nurses. For example, the increasingly higher expectations of patients and

families may be placing greater demands on nurses (Hopkinson, Carson, Brown, Fagin,

Bartlett and Leary, 1998; Sylvia, 1995). Furthermore, the complexity of highly

interactive medical technology (Capka, 1997; Owen and Patton, 2003) means that many

nurses are faced with needing to operate highly specialized equipment with risks to

patient safety.

25
The nursing shortage, and cost containments in the health sector have also meant that

there may be insufficient nursing staff to adequately cover the unit (Baldwin, 1999).

Nurses may have to work through breaks and they may not have enough time to complete

their nursing tasks. These factors may create concerns amongst nurses about their ability

to provide high quality care (Aiken, Clarke, Sloan, Sochalski and Silber, 2002). One

study of 308 nurses in the USA reported that too much work and too little time,

inadequate staffing, inability to meet patients needs, and inadequate support

/understanding from senior staff were rated as extremely stressful (Sylvia, 1995).

Nursing is also well-known for its irregular hours and the unsocial nature of its work

(Santamaria, 1995), due to unpredictable staffing and scheduling. The International

Council of Nurses (2007; 1995) has identified that shift work especially evening and

night shifts often introduces additional hardship on nurses providing services in complex

working environments and demanding interpersonal situations.

Moreover, nurses face a wide range of human emotions, for example listening or talking

to a patient about his/her approaching death (Sumner and Townsend-Rocchiccioli, 2003;

Halvorsen, 2006). Working in the nursing profession often involves sharing the traumas

of illness, injury, and death, not only with the patients but with multiple family members

and friends (Gillespie and Kermode, 2004; Cox, Griffiths and Cox, 1996; Sylvia, 1995).

This can cause nurses to harbour emotions such as anxiety, depression, fear and anger

(Halvorsen, 2006). A study of National Health Service Trust staff in the United Kingdom

identified high levels of job-induced stress, depression, anxiety, sickness, absence and

propensity to leave, associated with the presence of greater occupational demands

26
(Quine, 1998). Other Australian studies have also reported that nurses are frequently, and

in some cases, excessively exposed to various traumatic incidents as a part of their daily

work (Gillespie and Kermode, 2004).

The occurrence of stress is common in individuals or groups when their situation is

overly complex, ambiguous, unclear, or highly demanding with regards to competence or

required to deal with the demands (Bass, 1990). Today nurses are expected to have a

wide range of skills from providing basic nursing care, to the ability to use highly

technological equipment, through to bereavement counselling (Ropis, 2005). Nurses must

also deal with complex situations and ethical dilemmas (Rainham, 1994). Support to

continue to develop new knowledge and skills is therefore critical, however, there is often

a lack of time available for activities such as clinical supervision, or for peer support

(Kelly, Simpson, and Brown, 2002).

3.3. Multiple Sources of Stress

The combination of changing work responsibilities (Beynon, Gromshaw, Rubery and

Ward, 2002), work related stressors present in the nursing working environment and

problems occurring outside the nursing working environment (Rainham, 1994) all

contribute to stressful feelings experienced by nurses (Sylvia, 1995). The complexity of

nursing practice especially when workplace and roles of nurses are changing (McVicar,

2003), together with advances in medicines and health technology (Farley, 2004), may

result in variation between nurses in their perception, interpretation of events and

emotions (McConnell, 2000). Johnstones (1999) study investigated the causes of

occupational stress and nurses perceptions of the effects of modern medical technologies

27
on several aspects of their work life during the preceding three years in Victoria and New

South Wales. She found that there was a strong perception amongst the 433 nurses that

medical technologies had contributed to their increased workloads and higher levels of

stress (Johnstone, 1999). Another study aimed at assessing the different sources of job

stress for nurses in a number of public hospitals in Saudi Arabia identified six possible

sources of job stress for nurses in public hospitals. These included organisational

structure and climate, job itself, managerial role, interpersonal relationships, career and

achievement and homework interface (Al-Aameri, 2003).

The common stressors identified in many nursing studies include family, health,

financial, intellectual, social, spiritual, and professional issues (McConnell, 2000), sexual

harassment, office politics and unclear job roles, role conflicts, and role ambiguity

(Smith, 1999; Information Education Management Resolution, 1999), insufficient

nursing staff (numerically and experientially), lack of equipment, work overload, role

overload, inadequate training opportunities in the use of new advanced technologies, and

aspects of organisational structure (Johnstone 1999). For example a study by Tyler and

Cushway (1992; 1995) noted that workload related to environmental issues which include

inadequate staffing levels and insufficient time to complete the work task was perceived

as the most frequently occurring source of stress in the workplace. Another study of 129

registered nurses in Victorian and regional institutions found that nurses ranked

workload, interpersonal conflict in professional relationships with working colleagues,

uncertainty with treatment, dealing with medical emergencies, sudden and unexpected

deterioration of the patients conditions, and lack of support to deal with emergencies

were some of highly rated stressors in the nursing profession (Healy and McKay, 1999).

28
Additionally, Carroll and Adams (1994) noted that the multiple demands of the role were

rated as the most stressful component of all. These included the experience with conflict

resolution, counselling and performance management. In Brunei Darussalam stressors in

nursing have not been investigated.

3.4. Concerns about Clinical Competence

In 1984, Benner defined professional nursing competence as stages of skill achievement

which begins with novice, advance beginner, competent, proficient and expert.

Competence is the ability of a person to fulfil the nursing role effectively and/or expertly;

it can also be considered as made up of a set of separate competencies (Ramritu and

Barnard, 2001). The clinical competence of registered nurses relating to the care of

individual clients is dependent on the nurses ability to correlate theoretical knowledge

learned in the classroom with practice and the development of clinical skills. Its

foundation lies in the ability to identify and solve problems that emanate from critical

thinking, analytical reasoning and reflective practice (Moeti, Niekerk and Velden, 2004).

Importantly, Moeti, Niekerk and Velden (2004) found that many new registered nurses

have sufficient theoretical knowledge, but sometimes lack competency in basic nursing

skills and have difficulty correlating theory into practice. Ramritu and Barnard (2001)

further reported that new registered nurses preferred to care for less critically ill patients

and those who required less complex nursing treatment. Over the past few decades, a

number of authors have thus commented on the limited interface between university

schools of nursing and clinical practice agencies preparing registered nurses for the

29
practice setting and in evaluating their competence to perform in this setting (Alex and

MacFarlance, 1992). When considering issues of stress in nursing, it is important

therefore, that the many registered nurses may have concerns about their clinical

competence. This potential source of stress is especially important for new registered

nurses.

3.5. Role Conflict

Conditions of work that are characterised by role conflict and excessive role demands are

particularly stressful (Wallace, 2002). Wallace argues that there is a potential for conflict

between professionals and the organisations when the values, goals and expectations of

the professional are incompatible with those of their employing organisation, especially

when professionals are employed in highly bureaucratic organisations. High levels of

reported role conflict are associated with increased tension, lower work-related

satisfaction, intent to leave, and poorer job performance (Wu, 1994).

Health professionals are often unprepared for organisational professional conflict, and as

such may find such conflicts create stress (WHO, 2004). These conflicts can arise from a

number of factors. For example, for new graduates, a common source of conflict can be

perceived differences between their ideal and the reality of contemporary health care, and

between expectations of managers and those of the graduate themselves (Pines, 1993).

Some writers suggest that a degree of role stress may also be advantageous leading to

better, integrative approaches to tasks (Siegall, 1995). Dawes (1999), for example, argues

that conflicts do not and should not be considered negative or detrimental in all

30
situations. By nature, conflict can be a primary motivator for change. However, such role

conflict often involves negative emotions. As such, conflict may result in low

productivity and can promote mediocre performance, boredom and apathy, thus creating

more stress (Dawes, 1999). Furthermore, for the new registered nurse, inconsistency

between the student role and the staff nurse role can create professional and personal

conflicts that new registered nurses often find devastating.

3.6. Violence and Aggression

Work-related violence is a serious global, multifaceted phenomenon that presents

challenges to nursing management. The International Labour Organisation (1998) reports

that workplace violence, whether it is physical or psychological, has become global,

crossing borders, work setting and occupational groups. This has turned some workplaces

and occupations into high risk arenas where women are especially vulnerable. Reports of

workplace violence against healthcare personnel have thus been increasing and nursing

staff are often the target or most at risk of violence (Uzun, 2003; Hilton, Kottke and

Pfahler, 1994). Mayhew and Chappell (2001a) identified that nurses experienced more

occupational violence compared with allied health providers and GPs, regardless of the

reporting period or whether violence was experienced from patients, patients relatives,

or professional colleagues.

The nature of this violence varies substantially. For example, a study of 145 US operating

room nurses identified that the presence of sabotage is common. The most frequent

method of sabotage was being expected to do anothers work followed by being

31
reprimanded in front of others and not being acknowledged for their own work (Dunn,

2003). Cook, Green and Topp (2001) similarly report that the most common form of

aggression is verbal abuse, with an incidence as high as 98.5% (Ergun and Karadakovan,

2005). Verbal abuse is a dysfunctional but common method of dealing with frustration

and anger that has been defined as those kinds of verbal behaviours that humiliate,

degrade, or otherwise indicate a lack of respect for the dignity and worth of another

individual (Cook, Green and Topp, 2001). Hamlin and Hoffman (2002) refer to this as

behaviour that is unwanted or unwelcome by the recipient. It is an illegitimate exercise of

power; neither flattering nor complimentary, and it is not determined by physical

attractiveness. The offender uses his or her authority, dominance, or power to belittle,

humiliate, and refuse to promote, dismiss or demote someone. Cox (1991) explains

verbal abuse is any communication a nurse perceives to be a harsh, condemnatory attack

upon her or himself, professionally or personally. Such abuse may be the form of

devaluing, discouraging, scapegoating, backstabbing, complaining, and other forms of

non therapeutic and destructive communication directed at co workers.

Sofield and Salmond (2003) report that some of the causes of verbal abuse in a hospital

setting are related to the highly stressful situations and the power differentials or unequal

interpersonal relationships that are present. When such abuse is directed at co-workers

who are on the same level within an organisations hierarchy, it has been called

horizontal violence (Dunn, 2003). When it is comes from physician colleague to nurse, it

has been called vertical violence. Verbal abuse sometimes also comes from patients and

patients families, in some cases this can be extreme (Paul, 2001). A descriptive

correlational study of a randomly selected list of 1000 (33% of total population of nurses

32
in the system) registered nurses from a three-hospital health system in the Northeast of

USA was conducted to examine perceptions of verbal abuse and intent to leave the

organisation. The study identified that physicians were the most common overall source

of verbal abuse experienced in the past six months, followed by patients (56%), families

(48%), peers (28%), supervisors (16%), and subordinates (15%) (Sofield and Salmond,

2003).

Findings from recent research suggests that health care workers, in particular, nurses have

a higher incidence of stress-related illness, depression, fear, and job turnover, as well as

decreased self esteem, when working in stressful, abusive, and authoritative situations

(Cook, Green and Topp, 2001). One survey of around 1500 allied health professionals,

doctors, and nurses working in a rural area in eastern Australia reported that 68% of

nurses, compared to 47% of allied health providers and 48% of GPs, reported

experiencing violence in the workplace. The most frequent form of occupational violence

reported was verbal abuse, followed by threatening behaviour, physical violence and

obscene behaviour (Alexander, 2004).

These high rates of reported occupational violence, especially verbal abuse, are reported

across many countries. In a study of 600 nurses in the Toronto area, one-third had

experienced some form of abuse at work in the five days prior to the study (Whitehorn

and Nowlan, 1997). Another study in Turkey identified that of 72.3 % (141/195) of nurse

respondents had experienced some form of violence. Most of the respondents stated that

they had experienced verbal/emotional abuse (69.5 %), specific threats (53.2 %), and

33
physical action (8.5 %) (Ayranci, 2005). Similarly, a study of 467 nurses in three

hospitals in East Anatolia, Turkey identified that verbal abuse was prevalent in health

care settings, originating from patients relatives, patients, and physicians and even from

other nurses. Nurses perceived that it affected their ability to function, and that it

increased the likelihood of staff turnover (Uzun, 2003).

A recent study of more than 400 nurses in Nova Scotia reported that 63% had

experienced verbal abuse at work in the past year, while 35% had experienced attempts

of physical harm and 21% had been the victims of a physical attack (Whitehorn and

Nowlan, 1997). Another study that explored the prevalence of workplace violence

amongst 205 nurses in South Taiwan identified the verbal expressions of violence were

mainly due to misunderstanding and drunkenness on the part of patients and their

families, but also due to personal problems in the nurses relationships with doctors and

co-workers (Lin and Liu HE, 2005).

In the USA, a study of the prevalence and consequences of verbal abuse of staff nurses

by physicians amongst 130 staff nurses identified that 90% reported that they experienced

at least one episode of verbal abuse during the past year, with the average number of

reported incidents during the year being between 6 and 12. The most frequent and most

stressful types of verbal abuse came in the forms of abusive anger, ignoring and

condescension (Manderino and Berkey, 1997). In another study in Northwest Ohio of 78

perioperative experiences, 91% reported experiencing at least one episode of physician

verbal abuse during the past year. Of these 32 (45%) reported experiencing verbal abuse

34
several times per year; 16 (22.5%) reported experiencing verbal abuse once a month or

less; 4 (5.6%) reported experiencing verbal abuse once a week; 16 (22.5%) reported

experiencing verbal abuse several times per week and three (4.2%) reported experiencing

verbal abuse every day. Types of verbal abuse that caused the most stress and occurred

most frequently were abusive anger, condemnation, abuse disguised as jokes, ignoring,

accusing, blaming, judging, criticizing, blocking and diverting (Cook, Green, and Topp,

2001). The rate of such abuse in Brunei Darussalam is currently unknown.

Hamlin and Hoffman (2002) argue that historically most nurses are represented by

women. Nurses have been socialised to adopt the traditional female or subordinate role

(caring helper), which is seen as secondary to the role of physician. The authors note that

although men also are victims of sexual harassment, the incidence is much lower. Nurses,

both male and female, have learned patterns of behaviour that include relinquishing

power to the physician and adopting a passive communication style. As a result, an

unequal distribution of power has been perpetuated in the nurse-physician relationship.

Additionally, nurses and physicians experience different economic, political and social

status, which further contributes to an uneven distribution of power (Hamlin and

Hoffman, 2002). These power differentials thus create a relationship in which the use of

violence in many different forms may be more common.

Occupational stress resulting from verbal abuse is thus a major problem for individuals,

organisations and affecting all industries including health care (Hannigan, Edwards, and

Burnard, 2004; Alexander, 2004).It is not surprising that the apparent frequent experience

of occupational violence is one factor contributing to workplace stress (Hamlin and

35
Hoffman, 2002; International Labour Organisation, 1998). One UK study identified that

half of all nurses working in the National Health Services (NHS) trust reported workplace

stress resulting from bullying, harassment and abuse. The study authors estimated that

this cost NHS trusts an average of 450,000 pounds a year from staff feeling unwell

because of stress, with around 3.6 million pounds a year required to cover the resulting

sickness absence (Paton, 2005; Rodham and Bell, 2002). Other writers suggest that if not

dealt with, stress from workplace violence may contribute to an increased incidence of

errors, and low morale (Buback, 2004), or higher turnover (Webb, 2002). Importantly,

many incidents of violence remained unreported (83.5%), with most of the reported cases

not resulting in legal action (Ergun and Karadakovan, 2005).

Despite its potential importance as a stressor for nurses, violence against health care

personnel remains poorly researched or understood (Ferns, 2005). Nurse researchers

have reported that workplace violence such as sexual harassment, physical assault and

verbal abuse experienced by nurses often comes from physicians, resulting in feeling of

insecurity, frustration, attitude problems, stress, situational difficulties, or lack of time

(Sofield and Salmond, 2003; Dunn, 2003; Whitehorn and Nowlan, 1997; Ayranci, 2005;

Ergun and Karadakovan, 2005; Manderino and Berkey, 1997). Verbal abuse directed at

nurses is identified as being widespread and this negatively affects on patient care (Cook,

Green and Topp, 2001). One study reveals that the most severe long-term effects of

verbal abuse were a negative relationship with the offending physician and increasing job

dissatisfaction (Manderino and Berkey, 1997); lack of communication, lack of trust, all of

which negatively affect patient care due to hesitation to call regarding changes in

patients condition and hesitation to suggest improvements to care (Cook, Green and

36
Topp, 2001). At least 16 % of nursing turnover was identified as being directly related to

these factors (Cox, 1987). Moreover, studies suggest a large number of staff nurses

report having experienced being verbally abused by registrars and consultants and in

many cases, this abuse has lead to psychological distress, self-doubt and a significant

amount of loss of respect form colleagues and peers (Michael and Jenkins, 2001). Hilton,

Kottke and Pfahler (1994) similarly reported verbal abuse increased stress, produces

negative attitudes and poorer self confidence.

3.7. Workload and Resource Constraints

The inability to meet patients needs is a great concern because it goes to the very heart

of what nurses perceive as their role. The importance of the holistic approach to nursing,

providing psychological care and support alongside the physical care, has become widely

accepted over recent decades. However, nurses say that they are frequently unable to do

so because of staff shortages, which reduces the nursing time available to the individual

patient (Sylvia, 1996). One study of 433 Australian nurses, conducted in 1996, found the

main causes of stress were frequently linked with financial constraints. These may

include insufficient staff (numerically and experimentally), lack of equipment, work

overload and role overload, inadequate training opportunities in the use of new medical

technologies and aspects of organisational structure (Johnstone,1999).

The American Association of Colleges of Nursing (AACN) reported that the future of

professional nursing is threatened today by the current and impending shortage of nurses,

while the entire health care industry is affected, it is even more predominant in speciality

areas and if unresolved, the crisis will be even more significant in the future (AACN,

37
2002). The nationwide nursing shortage is expected to balloon from 6% currently to 29%

by 2020, straining hospitals finance and inhibiting quality (Health Care Strategic

Management, 2003). The shortages of nurses have resulted in dissatisfaction because of

not enough manpower to carry out the job, and inability to provide high quality patient

care (Aiken et al., 2001). One study found that nurses frequently stated that there are

insufficient staffs to cover illness and, if a nurse is sick they feel guilty because their

colleagues have to carry an even heavier burden (Sylvia, 1996). Dockery (2004)

identified that dissatisfaction with non-pay aspects of the job appears to have a stronger

influence on overall job satisfaction and on intention to leave the profession. Ernst,

Messmer, Franco and Gonzalez (2004) similarly identified that the factors which

influenced work satisfaction in a group of paediatric nurses in the USA included pay,

time to do nursing care, confidence in ones ability, and task requirements. Importantly, a

relationship between nurses job satisfaction and work organisation, job stress, and

recognition was found.

Such results have led some organisations to suggest that financial incentives are one way

of defining the value of nursing services and continue to be a key factor in nurse

retention. Kirsch (2001) stated that salaries and financial benefits continue to be

important themes in combating nurse turnover. A study reported by McDowell (1992)

indicated that nurses voice that their pay as not being commensurate and an important

reason for why they considered leaving nursing. Higher salary opportunities for

experienced nurses versus new registered nurses may lead to decreased turnover rates and

reward clinical expertise (Trossman, 2002). Another study indicated that nurses average

level of satisfaction with pay was the lowest of all the job climate satisfaction scale

38
means. About 45% disagreed or strongly disagreed with the statement, My present

salary is satisfactory. In contrast, about 20% agreed or strongly agreed with the views

(Duncan-Poitier, 2003). While pay may be an important factor in job satisfaction, the

relationship between concerns about pay, and the level of stress experienced by nurses

has not been investigated in great depth.

What is evident today is that health care settings are increasingly characterised by higher

patient acuity, shortened length of stay, and increased role responsibilities due to the

flattening of the nursing hierarchy. These changes, although very positive in some cases,

have caused a destabilization and disruption to the traditional nursing orientation models

(Higgins, 2004). These high job demands can lead to variety of pathological outcomes,

including mental and physical disorders, absenteeism, and reduced productivity (WHO,

2004). Studies report that nurses are struggling to cope with chronic staff shortages, ever-

increasing workloads, and expectations that they will continue to donate unpaid overtime

(Harulow, 2000). One early study reported that work overload were rated by nursing

respondents as the major contributing factor for nurses stress (Hipwell, Tyler and

Wilson, 1989). The Joint Commission on Accreditation of Healthcare Organisations

(JCAHO) describe unrealistic and unsafe nurse-patient ratios and the excessive

paperwork demand by managed care and other insurers, have not enabled nurses to spend

quality time with patients, resulting in job dissatisfaction (2002). Studies report higher

levels of job dissatisfaction and emotional exhaustion among nurses were strongly related

to nurse-patient ratios (Aiken, Clarke, Sloane, Sochalski and Silber, 2002). Ernst, Franco

Messmer and Gonzalez (2004) found similar results, with pay, time to do nursing care,

confidence in ones ability, and task requirements being identified as factors influencing

39
nurses job and organisational work satisfaction. Heavy workloads, a lack of time to

spend with patients and feeling of being unvalued in their work are reported to contribute

to the high turnover of nurses from profession (Davison, 2002). In another study Moore,

Kuhrik, Kuhrik, and Barry (1996) reported that the level of stress perceived by registered

nurses negatively related to their organisational commitment, and that this stress resulted

primarily from work overload, changing assignments and lack of resources.

In a review of the literature on role stress, work overload has been reported as one of the

main reasons for nurses leaving the workforce (Chang, Hancock, Johnson, Daly and

Jackson, 2005). Sylvia (1996) explained that workload which is shared among smaller

numbers of nursing staff leaves less time for the emotional and psychological caring

aspects of nursing. This increases nurses stress, often resulting in the failure to maintain

high nursing standards and dissatisfaction with their inability to meet what they perceive

as the patients needs. One study identified that eight of every ten nurses report they have

to work very hard in their jobs, close to two thirds reported that they have to work very

fast at their jobs, nearly one third of respondents indicated that they felt under great stress

almost every day, and another fifth reported feeling under great stress several days a

week (Duncan-Poitier, 2003).

3.8. The Role of Nurses Providing Care to Dying Patients.

Most nurses caring for patients will encounter death as part of their work. This

experience often causes anxiety (Brisley and Wood, 2002). Providing care to acutely ill

or dying patients has been identified as one of the more common and important internal

40
sources of stress among nursing staff (Cole, Slocumb and Mastey, 2001; Moszczynski

and Haney, 2002).

Numerous studies have identified caring for dying patients to be an important stressor for

nurses. Edwards (1997) identified that should a normally healthy person die unexpectedly

in the operating theatre during routine surgery or as a result of trauma, this was especially

stressful. The death of patients in the operating room and post anaesthesia care unit is

sometimes an unexpected event that can cause grief, burnout and turnover among the

caregivers who work in the area (Gerber and Workman, 1995). According to Petit de

Mange (1998) death anxiety is a complex multi-factorial phenomenon where individuals

have anxieties related to death issues that can impact upon them psychologically,

physically, socially and spiritually. Death anxiety can be associated with lack of

experience and inadequate death education (Brisley and Wood, 2002). Gillespie and

Kermode (2004) reported that feelings of inadequacy, incompetence and self-blame were

commonly described by nurses in relation to incidents which culminated in patient death.

Studies of the care dying people received in acute hospitals show that nurses experience

difficulties in meeting the patients and their families needs (McWhan, 1991). In most

cases new graduate nurses could not recall clearly the details of the education they

received regarding the care for dying patients and their relatives because they all found

that the reality was very different to the theory (Brisley and Wood, 2002). The limitations

of pre nursing registration preparation in care of dying results in difficulties in caring for

dying people (McWhan, 1991). To enable new graduate nurses to provide care for others

and themselves, it is necessary that a safe environment be provided in which to explore

41
death issues. Formal and informal education needs to be made available early in the

under graduate program and continuing through transition programs in the workplace

(Brisley and Wood, 2002).

3.9. Support from Managers and Colleagues

Studies have reported new nurses in particular often feel angry that supervisors and co

worker had done little to increase their self esteem (Chapman, 1993). Dunn (2003)

described feelings of anger and frustration were often pointed towards nursing

administrators, surgeons and other nurses, as nurses viewed their administrators as being

absent from day-to day activities and as providing minimum support and recognition.

Moore, Kuhrik, Kuhrik and Barry (1996) surveyed 336 acute nurses who identified that

job stress was a consequence of non supportive supervisors and co workers, resulting in

dissatisfaction with their position and intention to leave their job.

Issues relating to supportive work environments are especially important for new

registered nurses. Byrne, Cantrell, Fletcher, McRaney and Morris (2004) noted that

concern has been raised by students and new registered nurses who experience being

isolated by experienced nurses who are reluctant to mentor. A qualitative study of new

registered nurses in South Australia identified a culture which was not conducive to new

registered nurses ongoing learning, consolidation of skills and application, to practice. A

rushed environment that was unpredictable, together with lack of support, were recurrent

themes from the nurses perspective (De Dellis, Longson, Glover and Hutton, 2001).

Moreover, a study of Swedish nursing students about where in the health care system

42
they would like to work as a registered nurse after graduation found that students were

often isolated during working with no apparent support system. This reinforced their own

ambivalence and reluctance towards future work in delivering care (Fagerberg, Winblad

and Ekman, 2000).

Chapman (1993) identified major dissatisfaction with non supportive supervisors and co

workers as being primary reasons nurses leave hospitals. As such, she suggests that by

providing a supportive work group, for example by helping the person or sharing

work/task responsibilities, work stress can be reduced and job satisfaction increased.

Duncan (1997) similarly notes the importance of supportive work environments to new

nurses both before and after accepting the first registered nurse position. Ronsten,

Andersson and Gustafsson (2005) further identified that mentorship enabled novice

nurses to nurse in a more reflective and holistic way and was a crucial ingredient for

maintaining quality standards in nursing.

3.10. Stressors associated with the Transition to being a Registered Nurse

Expectations from the health care environment are that nurses rapidly function as a

competent practitioner (Casey, Fink, Krugman and Propst, 2004). Many nurses do

however experience difficulty in adjustment, with confidence gradually increasing as

they developed organisational and prioritizing skills, find their own style and rhythm and

begin feeling a connection to the unit and institution. One study found that new registered

nurses often do not feel skilled, comfortable, and confident for as long as one year after

being hired, highlighting the need for healthcare organisations to provide extended

43
orientation and support programs for new graduate nurses to facilitate successful entry

into practice (Casey, Fink, Krugman and Propst, 2004). The first year of practice is often

characterised by the feeling of clinical inadequacy, making this a stressful situation for

new graduate nurses because their clinical expertise is often not at the level expected by

nursing administrators, other nursing staff, physicians and hospital administrators

(Ganga, 1998).

Studies indicate that new registered nurses clinical competency generally significantly

increases overtime, as did their familiarity with work demands and the hospital

environment. As such a significant increase in their level of job satisfaction is often also

evident (Currie, 1994; Al-Ahmadi 2002). Importantly, the most important determinants

of job satisfaction amongst new nurses were recognition, technical aspects of supervision,

work conditions, utilization of skills, pay and job advancement.

Some authors have described the transition year as providing a mediated entry into the

nursing profession, where the new graduate nurses infuse patterns of adjustment, learning

to cope, and understanding how and when to seek help and support (Clare and Van Loon

2003). When new registered nurses enter the working world they experience a range of

unfamiliar situations for which they may be unprepared due to their limited experience,

shortage of practical and managerial skills, feelings of lack of support and excessive

workloads (Huang, 2004; Maben, 1996). One study on the transition to being a registered

nurse in New Zealand identified five themes relating to the experience. These included:

accepting responsibility, accepting their level of knowledge, becoming a team member,

professional standards and workplace conditions. Graduates reported an ability to

44
critique their own practice, but they found it more difficult to challenge their colleagues

practice and the wider agency culture (Walker, 1998).

Kramer (1974) coined the term reality shock to describe the experience of new

registered nurses initial education being in conflict with the work world values. Kramer

(1968, 1974) theorized that the first job in a hospital setting was often marked by

dramatically conflicting value systems, namely, the idealism of pre service education and

the reality of nursing service. New registered nurses have to distinguish the values of

school which is previous work experiences and the current work culture when entering a

new organisation. According to Kramer (1974), nursing students are socialized in school

to a professional model of nursing practice which includes the concept of providing care.

This relies on the individuals use of her/his judgement, autonomy, knowledge and

decision making skills. This socialization process emphasizes the should and ought,

or ideals, of nursing practice. Upon entering the work world, however, the new

graduate encounters a part-task system of care and a culture which relies on the

bureaucratic characteristics of efficiency, organisation, responsibility, and cooperation.

The hospital socialization process emphasizes the compromises or shortcuts required to

get the job done and how values are put to work in the context of less than ideal

situations, such as staff shortages and emergencies (Currie, 1994). Having little warning

or knowledge of the values and expectations of the health care environment, new

registered nurses often experience conflicts and confusion during the initial process of

learning into the new social cultural system (Benner and Benner, 1975).

45
While the concept of reality shock was first described in the 1970s, studies suggest it still

has some relevance today. Godinez, Schweiger, Gruver and Ryan (1999) reported that the

first three months of employment are the most stressful time in nurses careers. This is

because the transition from school to the work world is considered as the loss of ones

familiar social setting which is replaced by a distinctly new culture (Hamel, 1990). The

transitional shift from nursing school to work organizations or from student nurse to

professional nursing is thus a difficult one. During this time the new registered nurse may

attempt to hold onto the school or previous departmental work values and this often

results in a clash between cultures (Higgins 2003). Socialization into a new nursing work

culture involves demonstrating competency and proficiency in delivering patient care

which the new registered nurses may find difficult (Myer, 1992). According to one

survey, half of the new registered nurses sampled felt the orientation period was too

short. Increased technology, complicated medical interventions, inadequate staffing, and

care of patients with complex diagnoses were reported as overwhelming the new

registered nurses (Floyd, 2003).

Hulsmeyer (1994) conducted a qualitative study of 15 new registered nurses to examine

the experiences of new graduates during the transition from student to practicing

registered nurse. Major themes that emerged were experiential learning, gendered work

relations, caring and giving care, and the influence of college on moral reasoning and

nursing practice. Experiential learning was vital to participants acquisition of technical

skills and self confidence. Their efforts to care and give care were compromised by

gendered work relations. Caring and giving care were dominant concerns throughout the

transition period. They were especially troubled by ethical dilemmas in regards to dying

46
patients. They believed that college taught them to recognise ethical dilemmas and to

think critically. However, different comments by participants at points in time suggest

that they cling to caring values in a sometimes indifferent work environment. Although

some new nurses adjusted their values to adapt to the work reality, others maintained

their ethic of caring and attempted to act on those values (Hulsmeyer, 1994).

Higgins (2004) stated that one of the most important transitions of adult life occurs when

facing the challenges of a new job in a new setting. Making the transition from nursing

student to practicing nurse requires the novice to master a wide range of complex nursing

skills (Hamel, 1990). As a result new graduate nurses experience difficulty in adjusting as

they navigate this challenging moment and found transition from nursing student to

newly graduate staff nurse as stressful (Huang, 2004). Transitions are complex and

multidimensional as a result of changes in life, health, relationships and environment

(Meleis, Sawyer, Im, Messias and Schumacher, 2000). Oerman (1996) explains that

transitions allow new registered nurses to practice in real clinical situations. Such

transitions are essential because of the need to interact with variety of clients and other

health care professionals when providing care. These transitions may include the

opportunities to develop skills, apply scientific principles in providing care and make

clinical judgement in real situations.

Similarly a study on new graduate nurses who had completed their first year of clinical

practice after graduation in a Victorian private hospital, Australia identified three major

themes. The first steps described the unexpected shock and feelings of being

unprepared on entry to the work setting along with the reality of the unrealistic

47
expectations of colleagues. Stumbling blocks described the multiple role and personal

stressors that challenged the participants. Striding ahead described the factors that

facilitated the participants adaptation to the registered nurse (RN) role (Goh and Watt,

2003).

Hamels (1990) study of the influences of nursing subculture as perceived and understood

by new graduate nurses on entering the nursing profession also revealed some important

factors that may contribute to stress. These factors included fear of failure, fear of total

responsibility, and fear of making mistakes, a subculture which de-emphasized

psychological interactions and placed value on efficiency and task-oriented nursing care,

and a clash between the new graduate nurses values and those of the work world. This

made integration into the nursing subculture at times unpleasant. Moreover, preceptors

providing minimal support to the new graduate nurses, largely because they did not

understand the preceptor role were also identified as potential stressors, as they found it

difficult to articulate the values, norms, beliefs, and expectations to new graduate nurses.

New nurses also reported difficulty with task self-esteem because of their lack of

organisational skills (Hamel, 1990).

3.11. Coping and Support Strategies

New registered nurses entering professional practice may have somewhat limited mastery

of or familiarity with various nursing skills and only basic understanding of diseases

processes (Hardy and Conway, 1998). Kelly, Simpson and Brown (2002) therefore

concluded that newly qualified nurses required enormous support in further developing

48
their self confidence and professional competence. The transition between school and

work is a time of critical development for the beginning practitioner (Alex and

MacFarlane, 1992). This increasing understanding of the stressors experienced by new

registered nurses during this transition period has thus resulted in increasing interest in

understanding the support and guidance required from their immediate supervisors and

more senior staff in order to effect and achieve a successful transition (Goh and Watt,

2003).

Transition support has been categorized into two categories. Material support for new

graduates may include money, tools, people and a supportive physical environment.

Psychological support is primarily in terms of expert cognitive advice from supervisors,

emotional support from counsellors, or behavioural support (Chapman, 1993). Such

support can positively protect individuals from the deleterious effects of stressors

associated with the work environment, by contributing to feelings of self-esteem and

acceptance (RNAO, 2006). This support may also serve an informational function and

help individuals to interpret, comprehend and cope with potential stressors in functional

ways, and may also simply fulfil needs for social companionship and affiliation that may

contribute to feelings of belongingness. Moreover, this support may serve an instrumental

function by providing individuals with the material resources and services needed to help

combat the source of stress (WHO 2004). One study that examined the relationship

between staff nurses perception of collegial support and job stressors within the hospital

revealed that by identifying and reinforcing effective coping mechanisms and developing

supportive relationship, individual perceptions of distress may be reduced and nurses may

be able to provide safe nursing care (Chapman, 1993).

49
Recognition of the particular support needs of new registered nurses has resulted in the

development of a range of transition programs for this group. Duncan (1997) reported

that student clinical and work-related experiences are available at many healthcare

organisations, however, very little is known about how these experiences may contribute

to the employer/nurse work relationship that begins after graduation. Wilson and Startup

(1991) argue that a more unified approach must be adopted to reduce the conflicts which

learners experiences. Amos (1993) similarly argue that to minimise the occurrence of

stress during the new graduates transition period, employers need to plan an orientation

program at a minimum of six months. During the orientation program the graduate is

introduced to the institutional culture including policies and procedures. Such programs

serve as support mechanism and allows for less stressful transition into nursing practice

(Begat, Severinsson and Berggren, 1997).

Clinical supervision for new registered nurses was also identified as important in

encouraging nurses to think about their skills and professional development needs.

However, it appears that there is often a lack of time available for this in most areas

(Kelly and Simpson, 2002). Huff (2004) argues that mentoring offers a chance for growth

and development within the practice of nursing. Mentoring can offer professional

replenishment to expert nurses, thus contributing to the retention of experienced nurses

and producing future nursing leaders with the skill and passion to make a lifelong

commitment to professional development and nursing growth. Preceptorship approaches

have previously been promoted and have gone some way towards addressing the support

needs of registered nurses (Bain, 1996). One study investigated nurses satisfaction with

50
their work environment and moral stress following participation in a systematic clinical

nursing supervision program. Results of the study indicate that there is a significant

relationship between moral sensitivity and systematic nursing clinical supervision,

suggesting that support for nurses to develop personal qualities, integrated knowledge

and self-awareness was important and may be useful for developing the coping strategies

required for dealing with the stressors associated with being a new registered nurse

(Severinsson and Kamaker, 1999).

3.12. Summary

This chapter has presented a review of the literature relating to stressors in nursing. The

literature identifies a range of common stressors in nursing, associated with the nature of

nursing work and todays health care and the work environment. These sources of stress

include concerns about clinical competence as a new registered nurse, role conflicts,

violence and aggression, workload and resource constraints, care of dying patients, and

inadequate support from managers and colleagues. The particular experiences of new

registered nurses, and the stressors associated with this experience as they transitioned

into a new role were also reviewed. In addition, literature that has described some of the

key strategies that may assist with developing the coping strategies needed to cope with

these stressors has been reviewed. These strategies include both practical and

psychological supports for the new registered nurse, in many instances formalised into

structured transition programs and clinical supervision activities.

51
 CHAPTER FOUR
4.0. METHOD

4.1. Research Design

This study used a descriptive correlational design to examine new registered nurses

(within the first three years of work as a registered nurse) perception of stress and level of

job satisfaction in a complex clinical nursing working environment in Brunei

Darussalam. A self-report survey was used for this study.

4.2. Setting

RIPAS hospital was officially opened in 1984. It has 555 beds, operating rooms, a

number of speciality units and surgical wards. These include an Otorhinolaryngology

integrated Head and Neck Surgical Department, Gynaecology and Obstetric Department,

Anaesthetics Department, Urology Department, General Surgical Department,

Orthopaedic Department and Neurology Surgical Department. RIPAS is a Brunei

Darussalam government hospital managed by the Ministry of Health that is a not for

profit hospital, with all services provided being primarily funded through the general

treasury (Ministry of Health, 2007).

RIPAS Hospital is the countrys main referral hospital where the majority of nurses are

employed. It is recognised as a tertiary hospital where the majority of teaching and

learning takes place for nursing and medicine. Currently RIPAS Hospital has been

working collaboratively with the Pengiran Anak Puteri Rashidah Saadatul Bolkiah

52
(PAPRSB) College of Nursing of Brunei Darussalam, University Brunei Darussalam and

University of

Queensland Australia. The hospital is selected for this study because it is the largest

referral hospital among the other four main hospitals in the country and most of the

newly registered nurses (target population) are placed in this hospital. The overall total

number of nurses in the country is 1,675 (Ministry of Health, 2006), with the majority of

them located in this hospital.

Formal nursing education programs commenced in Brunei Darussalam in 1946, with

UNICEF/WHO introducing courses to Brunei Darussalam General Hospital. The student

nurses at that time were taught skills of basic bedside nursing, equivalent to Enrolled

Nurse Certification in the United Kingdom (PAPRSB College of Nursing Reports, 1991).

Progress in nursing education continued since that time, with the development of new

programs that emphasized practical skills and good bedside nursing, including anatomy

and physiology taught as a basis of nursing practice. The courses developed at a higher

academic level, and were extended to three year programs. The curriculum was based on

the recommendations of the General Nursing Council for England and Wales, and was

modified to suit local needs. After successful completion of all theoretical and practical

components of the program, the students were awarded the Brunei Trained Nurses

Certificate (PAPRSB College of Nursing Reports, 1996).

In November 1982, the School of Nursing moved to the new Raja Isteri Pengiran Saleha

Hospital and was named the Nurses and Midwives Training Centre. The Centre

continued with the responsibility for the training of Brunei Trained Nurses, Assistant

53
Nurses and Trained Midwives. When the College of Nursing was established in 1986,

intakes for Brunei Trained Nurses were discontinued. The establishment of the Pengiran

Anak Puteri Rashidah Saadatul Bolkiah College of Nursing under the auspices of the

Ministry of Education was seen as the first step towards the professional education for

nurses in Brunei Darussalam (MOH, 2007). The moved into higher education was

undertaken in response to changing demands in health care needs of the population and

changes in nursing education internationally. In order to ensure academic credibility, an

academic linkage was negotiated by the Ministry of Education with the Department of

Nursing Studies, University of Wales College of Medicine, United Kingdom. The

purpose of the linkage was to ensure academic credibility of the new college acquiring

the assistance of an academic advisor through the development and accreditation of

courses, advice on new developments in the United Kingdom and elsewhere, and access

to an external examination. The medium of instruction in delivering the curriculum is

English Language (PAPRSB College of Nursing, 2006).

On completion of the three year nursing program, students are awarded a Diploma in

Nursing and qualified as a Brunei Darussalam Staff Nurse. The College of Nursing

continues to provide opportunity for the nurses to enrol into a higher speciality nursing

program to enable them to develop knowledge, understanding, practical skills and

professionalism to function safely in the context of speciality nursing. After they have

obtained some experience as a staff nurse in the wards or other departments, nurses may

be promoted to Senior Staff Nurse and from time to time the Senior Staff Nurse

undertaking the duties of the ward Sister (Nursing Officer) in the latters absence.

Nursing Officers (Ward Sisters) have to have had considerable experience in nursing and

54
may be in administrative charge of the Unit (such as that described in the Section

Division of the Department, or a small Surgical or Medical Nursing Department

depending upon the size and policy of the hospital). A Senior Nursing Officer (Matron) is

a Senior Charge Nurse of very considerable experience whose chief function is to control

and co-ordinate the work and training of the nursing staff within a nursing department

(MOH, 2006). The next level, Principal Nursing Officer, has responsibility is to assist the

Director of Nursing Services. The nursing structure in Brunei is presented in the

following diagram.

Fig. 1 The Nursing Structure in Brunei Darussalam

Nursing Services Ministry of Health College of Nursing (Education)

Director of Nursing Services Principal

Principal Nursing Officer (B2-EB3) Education Officer/ Senior Nursing Officer (B2-EB 3)

Senior Nursing Officer /Matron (M12) Nursing Officer Teaching B2

Nursing Officer (M11) Nursing Officer Teaching (M11)

Senior Staff Nurse (M9-EB10) Senior Staff Nurse (M9-EB10)

Staff Nurse Staff Nurse (Clinical Instructor)

Assistant Nurse Student Nurse

4.3. Sample

The eligible sample for this study consisted of all male and female registered nurses (RN)

with less than 3 years working experience as a registered nurse and working in acute

speciality care units and general wards, who can speak, write and understand English

language proficiently as a second language. English language is widely spoken and used

55
as the medium of instruction in primary, secondary, tertiary and higher institutions that

include nursing education in Brunei Darussalam. All nurses identified from the duty

roster of these wards who met these criteria were eligible to participate in the study.

The duty rosters were thus used as a sampling frame. A sample of 120 nurses (66.67%)

out of 180 eligible registered nurses on this roster were invited to participate in the study,

with the remaining 60 nurses being unavailable due to leave arrangements associated

with the Brunei Darussalam National Day Celebration procession. Table 1 present the

numbers of registered nurses involved in the survey from the various clinical departments

of the hospital. They consisted of 52 nurses (43.33%) from acute speciality care units and

68 nurses (56.67%) from general medical and surgical wards.

Table 1 Practice Setting for Nurses in the Study Sample

Clinical Departments by Groups No of Nurses

Speciality Units
- Operating Theatre Department (OT) 2 nurses
- Medical Intensive Care Unit (MICU) 3 nurses
- Surgical Intensive Care Unit (SICU) 22 nurses
- Otorhinolaryngology, Integrated Head and Neck Surgical 7 nurses
Unit (ORL)
- Accident and Emergency Department (A/E) 12 nurses
- Special Care Baby Unit (SCBU) 6 nurses
Total 52 nurses
Surgical Wards (General Wards)
- Ward 1, Ward 2, Ward 4, Ward 6, Ward 7, Ward 8 41 nurses
Ward 9.
Medical (General Wards)
- Ward 19, Ward 20, Ward 21 and Ward 22. 27 nurses
Total 68 nurses
120 nurses
4.4. Ethical Considerations

As soon as approval to conduct the study was obtained from the Human Research Ethics

Committee at the Queensland University of Technology and the Ministry of Health

56
Brunei Darussalam (Appendix 1 and 2), eligible nurses were invited to participate

voluntarily in the study. To ensure that the rights of research participants were protected

and that they had full understanding of the study, the chief investigator introduced

himself and explained the nature, purpose, objectives and expectations of the study to

each unit/ward nursing officer, managers and staff nurses. Questionnaires together with

information sheets were given to all eligible participants and the chief investigator

assumed implied consent if the nurse returned the completed questionnaires (Polit and

Beck, 2006).

Procedures were implemented for safeguarding the participants privacy and to ensure

they received adequate information regarding the study (Polit and Beck, 2006). Nurses

were informed that participation was purely voluntary, and their response would be

completely confidential. To allay any fears arising from the study, volunteers were also

informed that they were free to withdraw from the study at any time and that there are no

right or wrong answers. The instructions were standardised and written in plain English

Language for all participants and each participant was thanked for their participation

(Appendix 5). Questionnaires were distributed to participants by hand and through the

ward/unit nursing officers, managers and nurses in charge. Nurses were asked to

complete the survey in their own time or outside their working hours within two weeks.

Participants were asked to return the completed questionnaires to the chief investigator by

mail using the pre stamped envelope provided or the respondents could leave them at the

nurses station in each unit. No identifying information was included with the

questionnaires. After the initial explanation of the study the chief investigator had no

direct contact with the participants during the data collection period.

57
As humans (nurses) were used as the study participants, ethical considerations were

identified and appropriate strategies implemented to ensure participants rights were

protected. These meant freedom from any physical, psychological or economic harm. It

also meant freedom from exploitation. In anticipation of potential risks, such as feelings

of discomfort, or worries about responses being known by their supervisor or unit

managers, no personal or identifying information was included in the questionnaire. All

information was kept in strictest confidence, stored and locked securely and only

accessible by the chief investigator. For the purpose of avoiding misunderstandings,

enhancing participation and gaining consent from the participants in the study, a quiet,

polite, unhurried and assertive approach was used when explaining the study. Sufficient

time (three weeks) was given to allow the potential participants to have an adequate

opportunity to ask questions regarding the research questionnaires or details of the

research procedures, aims and objectives. The study participants were informed that the

findings would be shared through nursing seminars, conferences and workshops held at a

future date.

4.5. Research Instrument

4.5.1. Demographic Questions.

58
In this section, respondents were asked to fill in demographic information by simply

shading or ticking the relevant bubbles that matched their responses. The demographic

information obtained was essential to identify personal and social factors outside of work

that may contribute to workplace stress among new graduate nurses in RIPAS Hospital

Brunei Darussalam. The information was thus obtained to examine if particular groups of

nurses experienced more or less stress. Demographic information collected included age,

gender, ethnicity, standard of living, length of working experience, number and ages of

the children they care for and the support they received at home.

4.5.2. Ratings of Clinical Practice

This section was used to assess the overall level of participants confidence, competence

and organisational skills while carrying out their day-to-day working tasks or roles as

registered nurses. Respondents were asked to rate on separate five-point likert-type scale

ranging from 1 strongly disagree to 5 strongly agree the extent to which they

agreed that they were confident, competent and organised. The higher the score the more

they agreed with the statement.

4.5.3. The Expanded Nursing Stress Scale (ENSS)

The ENSS (French, Lenton, Walters and Eyles, 1995) is a self report questionnaire that

takes no longer than thirty minutes to complete. Permission to use the survey was

59
obtained from the original author, Susan E. French, McMaster University, Canada

[Appendix 3].

The Expanded Nursing Stress Scale (ENSS) was developed using a factor analysis of

responses to nurses ratings of a list of stressful nursing situations that had been identified

in previous research on nursing stress (Healy and McKay, 1999; Tyler and Cushway,

1995: 1992; Gray Toft and Anderson, 1981). The Expanded Nursing Stress Scale (ENSS)

incorporates 59 items with nine sub-scales. Each item required respondents to rate on a

five-point likert-type ranging from 1 never stressful to 4 extremely stressful and 0

does not apply. The higher the score, the more the respondent agrees that the situation

was stressful. Total and sub-scale score can be derived from this instrument.

The sub-scales include:

(1) Limited experience dealing with the death and dying

(2) Conflicts with others healthcare professionals such as surgeons and physicians

(3) Feeling inadequately prepare to help with the emotional needs of a patient or

patients family

(4) Problems relating to peers

(5) Conflicts with supervisor and receiving minimum support by the charge nurse,

immediate supervisor and administrators

(6) Work load due to lack of organisational skills, familiarity with the units,

unpredictable

staffing and scheduling within the new complex working environment

(7) Uncertainty concerning treatment and inadequate information from physicians

regarding the medical condition of a patient

60
(8) The fear of failure to carry out the nursing tasks/responsibilities because patients and

their families make unreasonable demands

(9) Experience of being discriminated and isolated by other nursing colleagues and other

healthcare professionals

(French, Lenton, Walters and Eyles, 2000: 1995; Higgins, 2003; Gray-Toft and Anderson

1981).

The total stress score that provides the overall levels of stress among new graduate nurses

was obtained by adding all the scores on 59 items together. French, Lenton, Walters and

Eyles (2000) explained that there are two items (number 6 and 14) that did not appear to

be related to any of the nine subscales that emerged in the original study of Ontario

nurses, but they recommended retaining the two items.

The Expanded Nursing Stress Scale (ENSS) was designed in a simple and understandable

English language form and there was no need to translate the original questionnaires into

the respondents mother tongue (Malay). The Expanded Nursing Stress Scale (ENSS) is

well validated with good test retest reliability. The reliability a coefficient for ENSS and

its subscales has been calculated by using Cronbachs alpha, with good internal

consistency scores demonstrated. One study conducted with 129 nurses recruited from

Victorian metropolitan and regional institutions in Australia reported a reliability

coefficient of 0.89 for the total scale, and coefficients ranging from 0.64 to 0.77 for the

subscales (Healy and McKay, 1999).

4.5.4. The Index of Work Satisfaction (IWS)

The self-report scale, Index of Work Satisfaction (IWS) developed by Stamps (2001), is

designed to assess nurses level of satisfaction with their work. This self report survey

61
questionnaire takes no longer than thirty minutes to complete. Permission to use this

Index of Work Satisfaction Survey (IWS) was obtained when purchasing the IWS from

the cooperative owner, Professor Paula Stamps, University of Massachusetts, United

States of America and Doreen Masi, Market Street Research Inc, Pleasant Street

Northampton, Massachusetts, United State of America [Appendix 4].

The Index of Work Satisfaction (IWS) was designed in a simple and understandable

English language form. Similar to the Expanded Nursing Stress Scale (ENSS), the IWS

did not require translation of its original questions statements into the respondents

mother tongue (Malay). This minimised the risk of misinterpretation of some of the

words or questions asked. The Index of Work Satisfaction (IWS), is a two-part

measurement tool (Part A and B), that make up the self-administered instrument

measuring six components of job satisfaction. These six components are:

(1) Pay (dollar remuneration and fringe benefits received for work done)

(2) Autonomy (amount of job related independence, initiative, and freedom, either

permitted

or require in daily work activities)

(3) Task requirements (tasks or activities that must be done as a regular part of the job)

(4) Organizational policies (management policies and procedures put forward by the

hospital

and nursing administration of the hospital)

(5) Professional status (overall importance or significance of their job, both in their

view and in the view of others)

62
(6) Interaction and formal social and professional contacts during work hours

opportunities

presented for both formal and informal social and professional contact during

working

hours

(Stamps,

2001).

Part A of the Index of Work Satisfaction (IWS) was designed to rank how the

participants feel about their work situation. Here, the investigator was interested in

determining which of these six job satisfaction components were perceived by

participants as being of most importance to them. A total of 15 pairs were presented and

no pair was repeated or reversed.

Part B of the Index of Work Satisfaction (IWS), incorporates 44 randomly ordered,

positively and negatively worded statements. A positively worded statement was one

which the respondent marked Strongly Agreed when they were very satisfied. A

negatively worded statement was one which the respondent marked Strongly Disagreed

when they were very dissatisfied (Table 2). The response which indicated the most

satisfied respondents was given the most points. An example of this is presented in Table

3. Part B thus measures the current level of satisfaction for each of six components, as

well as overall satisfaction.

63
Table 2 List of Items for Each Component in the IWS

. Number of Range of Component Negatively Worded Items: Positively Worded Items:

Items Scores Strongly Agree=1 Strongly Agree = 7
Component Strongly Disagree= 7 Strongly Disagree= 1

Pay 6 6 to 42 8, 21, 44 1, 14, 32

Professional Status 7 7 to 49 2, 27, 41 9, 11, 34, 38

Autonomy 8 8 to 56 7, 17, 20, 30, 31 13, 26, 43

Organisational Policies 7 7 to 49 12 ,18, 33 5, 25, 40, 42

Task Requirement 6 6 to 42 4, 15, 36 22, 24, 29

Interaction 10 10 to 70 10, 23, 28, 35, 39 3, 6, 16, 19, 37

Nurse-Nurse 5 5 to 35 10, 23, 28 3, 16

Nurse-Physician 5 5 to 35 35, 39 6, 19, 37

Table 3 Example of Scoring System for Positively and

Negatively Phrased Items in the IWS

Phrasing Pay S/ Agree N S/ Disagree

POSITIVE My present salary is satisfactory. 7 6 5 4 3 2 1

It is my impression that a lot of nursing personnel

NEGATIVE at this hospital are dissatisfied with their pay. 1 2 3 4 5 6 7

Convergent validity, discriminant validity, and face validity were assessed during the

development of the tool and through further comparative analysis of 21 studies with

nursing staff. The reliability and validity of the instrument were supported. The

instrument was first tested by Stamps and Piedmonte (1986) with a sample of 246 nurses.

64
The Cronbachs alpha Coefficient for the six sub-scales was acceptable, and ranged from

.52 to .81, with the reliability for the total score of being .81. More recently another

study conducted by Woods (2003) with 45 Academic Nurse Residency Participants in a

major academic 500-bed teaching hospital in the US, similarly reported the Cronbachs

alpha scores for the six subscales ranged from a low of .55 for the subscale task

requirements to a high of .89 for interactions. The Cronbachs alpha for the total scale

score was .78.

4.6. Pilot Study

Pre-testing of the data collection instrument was undertaken to trial run the study. A pilot

study involving a sample with similar characteristics to the sample used for actual study

was undertaken. This involved 15 Post Basic speciality nursing students who are

currently enrolled in Operating Theatre Nursing and Otorhinolaryngology Nursing

Program at the Pengiran Anak Puteri Rashidah Saadatul Bolkiah College of Nursing

Brunei Darussalam. Nurses involved in the pilot sample did not take part in the main

study. The pilot study was used to: determine the feasibility of the major study; identify

problems in the research design; refine the data collection and analysis plan; test the

instrument to be used in the major study; and give the investigator some experience with

the subjects, research method and instruments (Roberts and Taylor, 2002). The pilot

study also enabled the investigator to ascertain the clarity of items and participants

understanding of the instruments (Nieswiadomy, 1993), and the time required by

respondents to fill in the questionnaires. The pilot sample was invited to give their

comments, ideas and views for the improvement of the instrument based on a Brunei

65
Darussalam perspective. Issues raised by the pilot sample were that there were too many

questions in each section and that the time required to respond to the questionnaires was

more than 30 minutes. No participants raised any issue about lack of clarity or ambiguity

of questions in the questionnaire. While the feedback about the length of the

questionnaire was considered, participants in the pilot sample indicated that this was not

likely to prevent them from participating in the study.

4.7. Data Management and Analysis

Data collected from the self- report questionnaires, the Expanded Nursing Stress Scale

(ENSS) and Index Work Satisfaction (IWS), were analysed to describe stressors and job

satisfaction perceived by nurses within the first three years of works as a registered nurse

working in speciality care units and general wards in RIPAS Hospital, Brunei

Darussalam.

All returned questionnaires were checked for consistency and omissions to minimise

missing values. Completed questionnaires with missing values were examined carefully

to assess for any misinterpretation or inconsistency in responses. For example in the

demographic section the respondents were asked to state their ethnic group as Malay,

Chinese, Indian, Indigenous and Others. Two of the respondents answered

Others. These were later categorised as Indigenous, because participants stated their

ethnic origin as Iban and Dusun. Two responses who ticked Single for their marital

status were corrected to Married because both claimed they received Good Support

from Their Husband to care for their children. Confusion was also noted in Question 8,

66
where the participants were asked to declare whether they have children to care for. Many

of the single new graduate nurses indicated No when this should have been Not

Applicable. Once errors had been rectified further inspection was conducted to confirm

the entire N=94 (78.3%) responses out of 120 distributed questionnaires were valid and

usable. The survey data has been kept safely in the investigators personal computer and

locked cabinet.

The data collected from the study sample was coded and entered into the database of

Statistical Package Social Science Software (SPSS) Graduate Pack version 14. The data

were checked for errors including outliers and wild codes. The procedures carried out

included inspecting the frequency distribution values, for example, gender was coded as

1=female and 2=male. If other codes appeared, a data entry error would have been made.

The second strategy was to compare the entered data with the hard copy record available.

This procedure was undertaken with all surveys.

Descriptive analyses were employed to summarise frequencies, means and standard

deviations for each variables. Bivariate (two-variable) analyses were then undertaken to

describe the relationships between variable in each group. Contingency tables were used

for categorical variables in which the frequencies of the two variables were cross-

tabulated.

67
 CHAPTER FIVE
5.0. RESULTS
5.1 Introduction

This chapter presents the findings of the study. Firstly, a description of the characteristics

of the study sample is presented. Data relating to each of the key research questions is

then presented.

5.2. Sample Characteristics

The demographic profile of the sample is presented in Table 4. For this study the total

number of respondents who returned the questionnaire were 94 (78.3%), out of 120 the

distributed questionnaires. Response rates for nurses from speciality units were similar to

those responses from general surgical and medical wards (78.8 % and 77.9 %

respectively). The sample was primarily female (80.9%). Participants ages ranged from

20 years to 30 years old.

There were only ten (10.6%) participants with an extra nursing qualification - Registered

Nurse + Post Basic Nursing Diploma (Nursing Specialist). Nine out of ten new graduate

nurses with this additional diploma qualification were from the intensive care units. Even

though more than half of the participants have a minimum of one year working

experience in nursing, a large number in both groups (64% general and 22% ICU) have

less than a year working experience in the current units. The majority of participants were

Malays (N=83; 88.3%) This is consistent with the population in Brunei, where Malays

constitutes the major ethnic group of population in the country, numbering 237, 100 of

357, 800 persons (Brunei Government, 2007).

68
Table 4 Demographic Characteristics of the Sample

General n=53 SPU n=41 Total n=94

Dichotomous / Categorical n (%) n (%) n (%)
Gender
Female 44 (83.0) 32 (78.0) 76 (80.9)
Male 9 (17.0) 9 (22.0) 18 (19.1)
Educational Background
Registered Nurse (Diploma in Nursing) 52 (98.1) 32 (78.0) 84 (89.4)
Registered Nurse + Post Basic Diploma 1 (1.9) 9 (22.0) 10 (10.6)
(Nursing Specialist)
Working Experience in Nursing
0 -Less Than 1 Year 34 (64.2) 9 (22.0) 43 (45.7)
1 Year - Less Than 2 Years 8 (15.1) 19 (46.3) 27 (28.7)
2 Years - Less Than 3 years 11 (20.8) 13 (31.7) 24 (25.5)
Working Experience in the Units
0 -Less Than 1 Year 37 (69.8) 23 (56.1) 60 (63.8)
1 Year - Less Than 2 Years 7 (13.2) 9 (22.0) 16 (17.0)
2 Years - Less Than 3 years 9 (17.0) 9 (22.0) 18 (19.1)
Marital Status
Single 47 (88.7) 28 (68.3) 75 (79.8)
Married 6 (11.3) 13 (31.7) 19 (20.2)
Ethnic Group
Malay 47 (88.7) 36 (87.8) 83 (88.3)
Others (Chinese, Indian, Indigenous) 6 (11.4) 5 (12.2) 11 (11.7)

5.3. Social Demographic Characteristics of the Sample

The social demographic characteristics of the sample are presented in Table 5. The

majority of the respondents were single (N=75; 79.8%). Twelve (12.8% of the total

sample) of the married study respondents had pre school age children, and almost all of

these reported that they received very good support from their spouses (husband/wife),

housemaid, their parents or in-law and from their sister/brother in-laws to care for their

children. From the total study respondents, 75 (79.8%) were still living in their parents

dwelling.

69
Table. 5. Social Demographic Characteristics of the Sample

General n=53 SPU n=41 Total n=94

Categorical/ Ordinal n (%) n (%) n (%)
Support From Husband or Wife to Care for
Their Children
Not Applicable 48 (90.6) 34 (82.9) 82 (87.2)
Very Good support 3 (5.7) 3 (7.3) 6 (6.4)
Good Support 2 (3.8) 3 (7.3) 5 (5.3)
Average 0 (0.0) 1 (2.4) 1 (1.1)
Support from House Maid to Care for Their
Children
Not Applicable 50 (94.3) 35 (85.4) 85 (90.4)
Very Good support 1 (1.9) 0 (0.0) 1 (1.1)
Good Support 2 (3.8) 4 (9.8) 6 (6.4)
Poor Support 0 (0.0) 0 (0.0) 0 (0.0)
No Support 0 (0.0) 2 (4.9) 2 (2.1)
Support From Their Parents or in-Law to
Care for Their Children
Not Applicable 48 (90.6) 34 (82.9) 82 (87.2)
Very Good support 1 (1.9) 1 (2.4) 2 (2.1)
Good Support 2 (3.8) 2 (4.9) 4 (4.3)
Average 2 (3.8) 4 (9.8) 6 (6.4)
Support from Their Sister/Brother in-laws to
Care for Their Children
Not Appropriate 48 (90.6) 34 (82.9) 82 (87.2)
Very Good support 1 (1.9) 1 (2.4) 2 (2.1)
Good Support 1 (1.9) 1 (2.4) 2 (2.1)
Average 2 (3.8) 4 (9.8) 6 (6.4)
Poor Support 1 (1.9) 1 (2.4) 2 (2.1)
Home Ownership
Owned Outright 0 (0.0) 2 (4.9) 2 (2.1)
Renting 0 (0.0) 2 (4.9) 2 (2.1)
Living in Parents Dwelling 46 (86.8) 29 (70.7) 75 (79.8)
Government Residence (Flat/House) 7 (13.2) 8 (19.5) 15 (16.0)
Having Children
Yes 5 (9.4) 7 (17.1) 12 (12.8)
No 1 (1.9) 6 (14.6) 7 (7.4)
Not Applicable 47 (88.7) 28 (68.3) 75 (79.8)
No of Children
One 5 (9.4) 6 (14.6) 11 (11.7)
Two 0 (0.0) 1 (2.4) 1 (1.1)
Not Applicable 48 (90.6) 34 (82.9) 82 (87.2)
Ages of Their Children
Pre School Age (0 - Less than 5 years) 5 (9.4) 7 (17.1) 12 (12.8)
Not Applicable 48 (90.6) 34 (82.9) 82 (87.2)

70
5.4. Participants Confidence about Clinical Practice

Respondents were requested to rate how they felt about their overall clinical practice in

terms of feeling confident, competent and organised with their responsibilities and roles

as a RN. They were asked to rate a five-point likert-type ranging from 1 strongly

disagree to 5 strongly agree. The higher the score the more they agreed with the

statement. Nearly all respondents (86.1%) agreed that they felt confident about their

overall clinical practice. Most (74.4%) also agreed that they felt competent and that they

were well organised in their overall clinical practice (62.8%). The results are presented in

Table 6.

Table 6. Participants Confidence about Clinical Practice

General n=53 SPU n=41 Total n=94

Categorical/Ordinal n (%) n (%) n (%)
Feeling Confident About Their Overall
Clinical Practice
Strongly Disagree 1 (1.9) 0 (0.0) 1 (1.1)
Disagree 0 (0.0) 1 (2.4) 1 (1.1)
Uncertain 7 (13.2) 4 (9.8) 11 (11.7)
Agree 40 (75.5) 31 (75.6) 71 (75.5)
Strongly Agree 5 (9.4) 5 (12.2) 10 (10.6)
Feeling Competent About Their Overall
Clinical Practice
Strongly Disagree 0 (0.0) 0 (0.0) 0 (0.0)
Disagree 2 (3.8) 2 (4.9) 4 (4.3)
Uncertain 14 (26.4) 6 (14.6) 20 (21.3)
Agree 32 (60.4) 31 (75.6) 63 (67.0)
Strongly Agree 5 (9.4) 2 (4.9) 7 (7.4)
Feeling Organized About Their Overall
Clinical Practice
Strongly Disagree 0 (0.0) 0 (0.0) 0 (0.0)
Disagree 3 (5.7) 1 (2.4) 4 (4.3)
Uncertain 19 (35.8) 12 (29.3) 31 (33.0)
Agree 26 (49.1) 27 (65.9) 53 (56.4)
Strongly Agree 5 (9.4) 1 (2.4) 5 (6.4)

71
5.5. Sources and Level of Stress Scale

The 59 item Expanded Nursing Stress Scale (ENSS) study instrument was used to assess stressful

situations and experiences. Each item required respondents to rate a five-point likert-type scale by

shading or ticking the relevant bubbles on a scale ranging from to 1 never stressful to 4

extremely stressful, with 0 does not apply. The higher the score, the more the respondent

agrees that the situation was stressful. Total and sub-scale score can be derived from this

instrument.

In order to compute the total stress score, all 59 items were added together. Scores for each nine

ENSS subscales were also calculated by adding scores for the items comprising the subscale. For

example, Uncertainty Concerning Treatment Component is the sum of the average scores for items

7, 16, 20, 26, 31, 35, 38, 41, and 45. In all cases, the category Not Applicable was scored as 0.

Reliability coefficients were calculated using Cronbachs alpha for the total ENSS and each of the

nine subscales components. For this study, the total ENSS 59 item scale had a reliability

coefficient of r = 0.96, with reliability coefficients for the subscales ranging from r = 0.58 to 0.83.

On average, responses to items in the Uncertainty Concerning Patient Treatment were rated by the

study sample as the most frequent stressful events. Table 7 presents responses to items in this

subscale. Responses indicate the majority of items in the scale were often stressful to registered

nurses within the first three years of workings as a registered nurse in this sample. In particular,

fear of making a mistake in treating a patient was rated as the most frequently occurring stressful

72
event. Being in charge with inadequate experience, and physician not being present in a medical

emergency were also rated as frequently resulting in stress. The least stressful events rated by the

registered nurses within the first three years of working as a registered nurse were uncertainty

regarding the operation and functioning of specialised equipment and a physician ordering

inappropriate treatment, although these still had high mean scores (2.57 and 2.59 respectively on

the scale ranging from 0 - 4).

73
 Table 7 Ratings of Stress associated with Uncertainty Concerning Treatment
UNCERTAINTY CONCERNING TREATMENT = 0.81
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:

Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
7 Inadequate information from 7.3 31.7 29.3 26.8 4.9 2.66 1.11 5.7 15.1 39.6 32.1 7.5 2.83 1,17 6.4 22.3 35.1 29.8 6.4 2.76 1.14
a physician regarding the (3) (13) (12) (11) (2) (3) (8) (21) (17) (4) (6) (21) (33) (28) (6)
medical condition of a patient
16 A physician ordering what 7.3 31.7 36.6 17.1 7.3 2.49 1.10 3.8 26.4 24.5 34 11.3 2.66 1.30 5.3 28.7 29.8 26.6 9.6 2.59 1.21
appears to be inappropriate (3) (13) (15) (7) (3) (2) (14) (13) (18) (6) (5) (27) (28) (25) (9)
treatment for a patient
20 Fear of making a mistake in 0 46.3 26.8 22 4.9 2.61 1.0 5.7 15.1 22.6 54.7 1.9 3.23 1.03 3.2 28.7 24.5 40.4 3.2 2.96 1.06
treating a patient (0) (19) (11) (9) (2) (3) (8) (12) (29) (1) (3) (27) (23) (38) (3)

26 A physician not being present 2.4 17.1 12.2 53.7 14.6 2.88 1.47 5.7 7.5 26.4 47.2 (13.2 2.89 1.41 4.3 11.7 20.2 50.0 13.8 2.88 1.43
in a medical emergency (1) (7) (5) (22) (6) (3) (4) (14) (25) ) (4) (11) (19) (47) (13)
(7)
31 Feeling inadequately trained 9.8 41.5 17.1 29.3 2.4 2.61 1.09 3.8 20.8 30.2 41.5 3.8 3.02 1.07 6.4 29.8 24.5 36.2 3.3 2.84 1.09
for what I have to do (4) (17) (7) (12) (1) (2) (11) (16) (22) (2) (6) (28) (23) (34) (3)

35 Not knowing what a patient 12.2 39 24.4 22 2.4 2.51 1.05 9.4 24.5 30.2 30.2 5.7 2.70 1.17 10.6 30.9 27.7 26.6 4.3 2.62 1.12
or a patient's family ought to (5) (16) (10) (9) (1) (5) (13) (16) (16) (3) (10) (29) (26) (25) (4)
be told about the patient's
condition and its treatment
38 Being exposed to health and 9.8 26.8 34.1 26.8 2.4 2.73 1.05 9.4 18.9 34 34 3.8 2.85 1.11 9.6 22.3 34.0 30.9 3.2 2.80 1.08
safety hazards (4) (11) (14) (11) (1) (5) (10) (18) (18) (2) (9) (21) (32) (29) (3)

41 Being in charge with 7.3 14.6 19.5 43.9 14.6 2.71 1.47 7.5 15.1 13.2 56.6 7.5 3.04 1.32 7.4 14.9 16.0 51.1 10.6 2.89 1.39
inadequate experience (3) (6) (8) (18) (6) (4) (8) (7) (30) (4) (7) (14) (15) (48) (10)

45 Uncertainty regarding the 7.3 34.1 17.1 29.3 12.2 2.44 1.32 1.9 24.5 32.1 30.2 11.3 2.68 1.25 4.3 28.7 25.5 29.8 11.7 2.57 1.28
operation and functioning of (3) (14) (7 ) (12) (5) (1) (13) (17) (16) (6) (4) (27) (24) (28) (11)
specialized equipment
Total Mean Score = 2.63 Total Mean Score = 2.88 Total Mean Score = 2.77

74
On average, responses indicate items in the Dealing with Patients and Their Families

were rated as the second most frequently stressful events. Table 8 presents responses to

items assessing dealing with this subscale. Responses indicate patients family making

unreasonable demands was rated as the most frequently occurring stressful events. Being

blamed for anything that goes wrong was ranked as next most stressful, followed by

patient making unreasonable demands. Respondents also reported having to deal with

abusive patients and abusive patients families were the least frequently resulting in

stress, although these still had a high mean score (2.07 and 2.09 respectively).

75
 Table 8 Ratings of Stress Associated with Dealing with Patients and their Families

DEALING WITH PATIENTS AND THEIR FAMILIES = 0.81

Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:

Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
8 Patients making 2.4 26.8 22 43.9 4.9 2.98 1.13 7.5 15.1 34 39.6 3.8 2.98 1.10 5.3 20.2 28.7 41.5 4.3 2.98 1.11
unreasonable demands (1) (11) (9) (18) (2) (4) (8) (18) (21) (2) (5) (19) (27) (39) (4)

17 Patients' families making 2.4 9.8 36.6 48.8 2.4 3.27 .92 11. 5.7 37.7 43.3 1.9 3.09 1.06 7.4 7.4 37.2 45.7 2.1 3.17 1.0
unreasonable demands (1 ) (4) (15) (20) (1) 3 (3) (20) (23) (1) (7) (7) (35) (43) (2)
(6)
27 Being blamed for anything 0 14.6 9.8 61 14.6 3.02 1.46 1.9 15.1 15.1 56.6 11.3 3.04 1.36 1.1 14.9 12.8 58.5 12.8 3.03 1.4
that goes wrong (0) (6) (4) (25) (6) (1) (8) (8) (30) (6) (1) (14) (12) (55) (12)

36 Being the one that has to deal 14.6 14.6 29.3 31.7 9.8 2.59 1.34 5.7 11.3 35.8 39.6 7.5 2.94 1.20 9.6 12.8 33.0 36.2 8.5 2.79 1.27
with patients' families (6) (6) (12) (13) (4) (3) (6) (19) (21) (4) (9) (12) (31) (34) (8)

37 Having to deal with violent 0 24.4 26.8 29.3 19.5 2.46 1.43 3.8 13.2 24.5 41.5 17 2.70 1.48 2.1 18.1 25.5 36.2 18.1 2.60 1.45
patients (0) (10) (11) (12) (8) (2) (7) (13) (22) (9) (2) (17) (24) (34) (17)

46 Having to deal with abusive 12.2 31.7 19.5 17.1 19.5 2.02 1.35 5.7 17 32.1 18.9 26.4 2.11 1.49 8.5 23.4 26.6 18.1 23.4 2.07 1.42
patients (5) (13) (8) (7) (8) (3) (9) (17) (10) (14) (8) (22) (25) (17) (22)

54 Having to deal with abuse 7.3 14.6 17.1 22 39) 1.76 1.64 3.8 15.1 18.9 35.8 26.4 2.34 1.63 5.3 14.9 18.1 29.8 31.9 2.09 1.65
from patients' families (3) (6) (7) (9) (16) (2) (8) (10) (19) (14) (5) (14) (17) (28) (30)
58 Not knowing whether 2.4 22 17.1 31.7 26.8 2.24 1.59 7.5 15.1 26.4 45.3 5.7 2.98 1.201 5.3 18.1 22.3 39.4 14.9 2.66 1.43
patients' families will report (1) (9) (7) (13) (11) (4) (8) (14) (24) (3) (5) (17) (21) (37) (14)
you for inadequate care
Total Mean Score = 2.54 Total Mean Score = 2.77 Total Mean Score = 2.67

76
Table 9 presents responses to item assessing stress associated with Workload subscale.

Responses indicate situations of work overload were rated on average as third most often

stressful events for registered nurses within the first three years of works as a registered

nurse. In particular not having enough staff to adequately cover the unit was rated as the

most stressful event. In this subscale unpredictable staffing and scheduling and not

having enough time to complete all the nursing tasks were also rated stressful. The least

stressful events in this area were demands of patient classification system.

77
 Table 9 Ratings of Stress associated with Workload
Workload = 0.78
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:

Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
15 Unpredictable staffing and 0 29.3 24.4 41.5 4.9 2.98 1.08 3.8 17 35.8 37.7 5.7 2.96 1.11 2.1 22.3 30.9 39.4 5.3 2.97 1.09
scheduling (0) (12) (10) (17) (2) (2) (9) (19) (20) (3) (2) (21) (29) (37) (5)

25 Not enough time to provide 14.6 41.5 17.1 22 4.9 2.37 1.14 7.5 34 30.2 22.6 5.7 2.57 1.10 10.6 37.2 24.5 22.3 5.3 2.48 1.11
emotional support to the (6) (17) (7) (9) (2) (4) (18) (16) (12) (3) (10) (35) (23) (21) (5)
patient
34 Not enough time to complete 2.4 29.3 19.5 39 9.8 2.76 1.28 5.7 20.8 22.6 43.3 7.5 2.89 1.25 4.3 24.5 21.3 41.5 8.5 2.83 1.26
all of my nursing tasks (1) (12) (8) (16) (4) (3) (11) (12) (23) (4) (4) (23) (20) (39) (8)

43 Too many non-nursing tasks 0 22 29.3 34.1 14.6 2.68 1.35 3.8 24.5 32.1 26.4 13.2 2.55 1.29 2.1 23.4 30.9 29.8 13.8 2.61 1.31
required, such as clerical (0) (9) (12) (14) (6) (2) (13) (17) (14) (7) (2) (22) (29) (28) (13)
work
44 Not enough staff to 0 14.6 22 61 2.4 3.39 .92 0 22.6 22.6 50.9 3.8 3.17 1.03 0 19.1 22.3 55.3 3.2 3.27 .99
adequately cover the unit (0) (6) (9) (25) (1) (0) (12) (12) (27) (2) (0) (18) (21) (52) (3)

47 Not enough time to respond to 9.8 36.6 29.3 7.3 17.1 2.00 1.18 11. 26.4 39.6 17 5.7 2.51 1.09 10.6 30.9 35.1 12.8 10.6 2.29 1.15
the needs of patients' families (4) (15) (12) (3) (7) 3 (14) (21) (9) (3) (10) (29) (33) (12) (10)
(6)
53 Demands of patient 26.8 24.4 12.2 14.6 22 1.71 1.35 7.5 26.4 32.1 13.2 20.8 2.09 1.33 16.0 25.5 23.4 13.8 21.3 1.93 1.35
classification system (11) (10) (5) (6) (9) (4) (14) (17) (7) (11) (15) (24) (22) (13) (20)

57 Having to work through 12.2 22 22 36.6 7.3 2.68 1.29 11. 20.8 30.2 32.1 5.7 2.72 1.2 11.7 21.3 26.6 34.0 6.4 2.70 1.23
breaks (5) (9) (9) (15) (3) 3 (11) (16) (17) (3) (11) (20) (25) (32) (6)
(6)
59 Having to make decisions 2.4 24.4 26.8 26.8 19.5 2.39 1.43 5.7 18.9) 18.9 47.2 9.4 2.89 1.33 4.3 21.3 22.3 38.3 13.8 2.67 1.39
under pressure (1) (10) (11) (11) (8) (3) (10) (10) (25) (5) (4) (20) (21) (36) (13)

Total Mean Score = 2.55 Total Mean Score = 2.70 Total Mean Score = 2.64

78
On average, responses to items in the Inadequate Emotional Preparation were rated as

the fourth most frequently occurring stressful events. Table 10 presents responses to item

assessing stress associated with Inadequate Emotional Preparation Subscale. In

particular being asked a question by a patient for which the nurses do not have a

satisfactory answer was rated as the most frequently occurring stressful event in this

subscale. Feeling inadequately prepared to help with the emotional needs of a patient was

also rated frequently stressful. Least stressful events in this area were feeling

inadequately prepared to help with the emotional needs of a patients family, although the

mean score was still at a high level with a mean of 2.47.

79
 Table 10 Rating of Stress Associated with Inadequate Emotional Preparation
Inadequate Emotional Preparation = 0.58
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
3 Feeling inadequately 9.8) 39) 31.7) 14.6) 4.9) 2.41 1.04 5.7 47.2 30.2 15.1 1.9 2.51 .89 7.4 43.6 30.9 14.9 3.2 2.47 .95
prepared to help with the (4) (16) (13) (6) (2) (3) (25) (16) (8) (1) (7) (41) (29) (14) (3)
emotional needs of a patient's
family
12 Being asked a question by a 4.9 36.6 29.3 26.8 2.4 2.73 1.0 5.7 20.8 34 34 5.7 2.85 1.13 5.3 27.7 31.9 30.9 4.3 2.80 1.07
patient for which I do not (2) (15) (12) (11) (1) (3) (11) (18) (18) (3) (5) (26) (30) (29) (4)
have a satisfactory answer
21 Feeling inadequately 7.3 41.5 34.1 12.2 4.9 2.41 .97 11. 22.6 35.8 26.4 3.8 2.70 1.10 9.6 30.9 35.1 20.2 4.3 2.57 1.05
prepared to help with the (3) (17) (14) (5) (2) 3 (12) (19) (14) (2) (9) (29) (33) (19) (4)
emotional needs of a patient (6)
Total Mean Score = 2.52 Total Mean Score = 2.69 Total Mean Score = 2.61

80
Table 11 presents responses to item assessing stress associated with Conflicts with

Doctors (Physicians) subscale. Mean scores for this area was ranked as the fifth most

often stressful for registered nurses within the first three years works as a registered

nurse. In particular criticism by a physician was the most frequently occurring stressful

event in this subscale. This is followed by making a decision concerning a patient when

the physician is unavailable in second place and conflict with a physician in third. The

least stressful occurring events rated by new registered nurses were disagreement with the

treatment of a patient and having to organise doctors work.

81
 Table 11 Rating of Stress Associated with Conflicts with Doctors
Conflicts With Doctors (Physicians) = 0.69
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:

Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
2 Criticism by a physician 2.4 29.3 51.2 9.8 7.3 2.54 .98 3.8 24.5 22.6 41.5 7.5 2.87 1.23 3.2 26.6 35.1 27.7 7.4 2.72 1.13
(1) (12) (21) (4) (3) (2) (13) (12) (22) (4) (3) (25) (33) (26) (7)

11 Conflict with a physician 2.4 31.7 29.3 14.6 22 2.12 1.35 0 28.3 26.4 32.1 13.2 2.64 1.3 1.1 29.8 27.7 24.5 17.0 2.41 1.34
(1) (13) (12) (6) (9) (0) (15) (14) (17) (7) (1) (28) (26) (23) (16)

30 Disagreement concerning the 12.2 43.9 26.8 9.8 7.3 2.20 1.03 5.7 17 37.7 17 22.6 2.21 1.42 8.5 28.7 33.0 13.8 16.0 2.20 1.26
treatment of a patient (5) (18) (11) (4) (3) (3) (9) (20) (9) (12) (8) (27) (31) (13) (15)

40 Making a decision concerning 9.8 17.1 17.1 39 17.1 2.51 1.52 1.9 15.1 22.6 41.5 18.9 2.66 1.51 5.3 16.0 20.2 40.4 18.1 2.60 1.51
a patient when the physician (4) (7) (7) (16) (7) (1) (8) (12) (22) (10) (5) (15) (19) (38) (17)
is unavailable
50 Having to organize doctors' 0 14.6 19.5 34.1 31.7 2.24 1.69 7.5 13.2 18.9 32.1 28.3 2.19 1.64 4.3 13.8 19.1 33.0 29.8 2.21 1.65
work (0) (6) (8) (14) (13) (4) (7) (10) (17) (15) (4) (13) (18) (31) (28)

Total Mean Score = 2.32 Total Mean Score = 2.51 Total Mean Score = 2.43

82
Table 12 presents responses to item assessing Problems Relating to Supervisors.

Responses indicate situations of Problems Relating to Supervisors were ranked as the

sixth most often stressful for registered nurses within the first three years of work as a

registered nurse. In particular, lack of support by nursing administration was rated as the

most frequently occurring stressful event in todays complex clinical nursing working

environment. This is followed by lack of support from other health care administration in

the second place and criticism by nursing administration rated in third position. The least

stressful events rated by new registered nurses were conflict with a supervisor, although

this item still had a high mean score at 2.05.

83
 Table 12 Rating of Stress Associated with Supervisors
Problems Relating to Supervisors = 0.83
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
5 Conflict with a supervisor 4.9 29.3 14.6 22) 29.3 1.95 1.52 11. 35.8 13.2 22.6 17 2.13 1.36 8.5 33.0 13.8 22.3 22.3 2.05 1.43
(2) (12) (6) (9) (12) 3 (19) (7) (12) (9) (8) (31) (13) (21) (21)
(6)
32 Lack of support from my 2.4 29.3 29.3 17.1 22 2.17 1.38 13. 11.3 32.1 30.2 13.2 2.53 1.4 8.5 19.1 30.9 24.5 17.0 2.37 1.39
immediate supervisor (1) (12) (12) (7) (9) 2 (6) (17) (16) (7) (8) (18) (29) (23) (16)
(7)
33 Criticism by a supervisor 4.9 36.6 24.4 17.1 17.1 2.20 1.29 17 22.6 22.6 28.3 9.4 2.43 1.32 11.7 28.7 23.4 23.4 12.8 2.33 1.31
(2) (15) (10) (7) (7) (9) (12) (12) (15) (5) (11) (27) (22) (22) (12)

42 Lack of support by nursing 4.9 17.1 26.8 34.1 17.1 2.56 1.45 5.7 17 22.6 39.6 15.1 2.66 1.44 5.3 17.0 24.5 37.2 16.0 2.62 1.44
administrators (2) (7) (11) (14) (7) (3) (9) (12) (21) (8) (5) (16) (23) (35) (15)

48 Being held accountable for 4.9 19.5 24.4 24.4 26.8 2.5 1.54 9.4 20.8 20.8 32.1 17 2.42 1.46 7.4 20.2 22.3 28.7 21.3 2.30 1.49
things over which I have no (2) (8) (10) (10) (11) (5) (11) (11) (17) (9) (7) (19) (21) (27) (20)
control
51 Lack of support from other 4.9 14.6 19.5 36.6 24.4 2.39 1.61 1.9 20.8 24.5 35.8 17 2.60 1.43 3.2 18.1 22.3 36.2 20.2 2.51 1.51
health care administrators (2) (6) (8) (15) (10) (1) (11) (13) (19) (9) (3) (17) (21) (34) (19)

56 Criticism by nursing 12.2 26.8 14.6 26.8 19.5 2.17 1.47 7.5 15.1 30.2 34 13.2 2.64 1.37 9.6 20.2 23.4 30.9 16.0 2.44 1.43
administration (5) (11) (6) (11) (8) (4) (8) (16) (18) (7) (9) (19) (22) (29) (15)

Total Mean Score = 2.23 Total Mean Score = 2.49 Total Mean Score = 2.37

84
Table 13 presents responses to item assessing stress associated with Death and Dying

subscale. Responses indicate situations of caring for Dying patients whilst on duty were

ranked as the seventh most often stressful for registered nurses within the first three years

of works as a registered nurse. In particular watching a patient suffer was the most

frequently occurring stressful event in this area. This was followed by feeling helpless in

the case of a patient who fails to improve and the death of a patient with whom they have

developed a close relationship. The least stressful occurring events in this area were

listening or talking to a patient about his/her approaching death.

85
 Table 13 Rating of Stress Associated with Death and Dying
Death and Dying = 0.78
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale: Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
1 Performing procedures that (9.8 (43.9 (26.8 (17.1 (2.4 2.46 .98 11. 47.2 32.1 3.8 5.7 2.17 .89 10.6 45.7 29.8 9.6 4.3 2.30 .94
patients experience as painful 4) 18) 11) 7) 1) 3 (25) (17) (2) (3) (10) (43) (28) (9) (4)
(6)
10 Feeling helpless in the case of (7.3 (34.1 (29.3 (17.1 (12.2 2.32 1.21 7.5 30.2 26.4 24.5 11.3 2.45 1.26 7.4 31.9 27.7 21.3 11.7 2.39 1.24
a patient who fails to improve 3) 14) 12) 7) 5) (4) (16) (14) (13) (6) (7) (30) (26) (20) (11)
19 Listening or talking to a (14.6 (29.3 (14.6 (7.3 (34.1 1.46 1.31 18. 28.3 22.6 17 13.2 2.11 1.28 17.0 28.7 19.1 12.8 22.3 1.83 1.33
patient about his/her 6) 12) 6) 3) 14) 9 (15) (12) (9) (7) (16) (27) (18) (12) (21)
approaching death (10
)
29 The death of a patient (26.8 (26.8 (22 (17.1 (7.3 2.15 1.22 18. 22.6 24.5 20.8 13.2 2.21 1.34 22.3 24.5 23.4 19.1 10.6 2.18 1.28
11) 11) 9) 7) 3) 9 (12) (13) (11) (7) (21) (23) (22) (18) (10)
(10
)
39 The death of a patient with (7.3 (19.5 (19.5 (26.8 (26.8 2.12 1.57 11. 9.4 24.5 37.7 17 2.55 1.51 9.6 13.8 22.3 33.0 21.3 2.36 1.54
whom you developed a close 3) 8) 8) 11) 11) 3 (5) (13) (20) (9) (9) (13) (21) (31) (20)
relationship (6)
49 Physician(s) not being (2.4 (22 (14.6 (29.3 (31.7 2.07 1.63 9.4 1.9 22.6 37.7 28.3 2.32 1.71 6.4 10.6 19.1 34.0 29.8 2.21 1.67
present when a patient dies 1) 9) 6) 12) 13) (5) (1) (12) (20) (15) (6) (10) (18) (32) (28)

55 Watching a patient suffer (9.8 (39 (34.1 (9.8 (7.3 2.29 1.03 5.7 13.2 30.2 37.7 13.2 2.74 1.38 7.4 24.5 31.9 25.5 10.6 2.54 1.25
4) 16) 14) 4) 3) (3) (7) (16) (20) (7) (7) (23) (30) (24) (10)

Total Mean Score = 2.13 Total Mean Score = 2.36 Total Mean Score = 2.26

86
Table 14 presents responses to item assessing stress associated with conflict relating to

peers. Responses indicate situations of conflict relating to peers were ranked as the

eighth most often stressful for registered nurses within the first three years of work as a

registered nurse. In particular difficulty in working with a particular nurse (or nurses)

inside their immediate work setting were rated as the most frequently occurring stressful

event in the work place. This was followed by lack of opportunity to talk openly with

other personnel about problems in the work setting and difficulty in working with a

particular nurse (or nurses) outside their immediate work setting. The least stressful

events in this area were difficulty in working with nurses of the opposite sex, receiving a

mean score of 1.19 only.

87
 Table 14 Rating of Stress Associated with Conflicts with Peers
Conflicts Relating to Peers = 0.71
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
4 Lack of opportunity to talk 7.3 41.5 26.8 14.6 9.8 2.29 1.12 11. 22.6 28.3 32.1 5.7 2.70 1.20 9.6 30.9 27.7 24.5 7.4 2.52 1.18
openly with other personnel (3) (17) (11) (6) (4) 3 (12) (15) (17) (3) (9) (29) (26) (23) (7)
about problems in the work (6)
setting
13 Lack of opportunity to share 14.6 46.3 9.8 12.2 17.1 1.85 1.2 7.5 34 26.4 24.5 7.5 2.53 1.17 10.6 39.4 19.1 19.1 11.7 2.23 1.22
experiences and feelings with (6) (19) (4) (5) (7) (4) (18) (14) (13) (4) (10) (37) (18) (18) (11)
other personnel in the work
setting
22 Lack of an opportunity to 14.6 34.1 19.5 4.9 26.8 1.61 1.22 13. 35.8 17 11.3 22.6 1.81 1.29 13. 8 35.1 18.1 24.5 1.72 1.26
express to other personnel on (6) (14) (8) (2) (11) 2 (19) (9) (6) (12) (13) (33) (17) (8) (23)
the unit my negative feelings (7)
towards patients
23 Difficulty in working with a 9.8 39 9.8 34.1 7.3 2.54 1.27 9.4 20.8 18.9 43.3 7.5 2.81 1.30 9.6 28. 7 14.9 39.4 7.4 2.69 1.29
particular nurse (or nurses) (4) (16) (4) (14) (3) (5) (11) (10) (23) (4) (9) (27) (14) (37) (7)
inside my immediate work
setting
24 Difficulty in working with a 19.5 31.7 14.6 24.4 9.8 2.24 1.30 5.7 26.4 20.8 30.2 17 2.42 1.42 11.7 28.7 18.1 27.7 13.8 2.34 1.36
particular nurse (or nurses) (8) (13) (6) (10) (4) (3) (14) (11) (16) (9) (11) (27) (17) (26) (13)
outside my immediate work
setting
52 Difficulty in working with 58.5 19.5 0 0 22 .98 .65 34 24.5 15.1 1.9 24.5 1.36 1.08 44.7 22.3 8.5 1.1 23.4 1.19 .93
nurses of the opposite sex (24) (8) (0) (0) (9) (18 (13) (8) (1) (13) (42) (21) (8) (1) (22)
)
Total Mean Score = 1.92 Total Mean Score = 2.27 Total Mean Score = 2.12

88
Table 15 presents responses to item assessing stress associated with Discrimination.

Responses indicate situations of being discriminated were ranked as the ninth most often

stressful for registered nurses within the first three years of work as a registered nurse. In

particular experiencing discrimination because of race or ethnicity were the most

frequently occurring stressful events in the workplace. This is followed by experiencing

discrimination because of the basis of sex in second place. The least stressful occurring

events rated by registered nurses were being sexually harassed, with a mean score of

1.18. Importantly, while almost 60% of the sample indicated this later item did apply,

around 40% of the sample responded that this experience had resulted in stress. Of those

who responded to this item as if it did apply (38 respondents) almost 66% indicated this

was frequently an extremely stressful event.

89
 Table 15 Rating of Stress Associated with Discrimination
Discrimination = 0.60
Speciality Unit Nurses N=41 General Ward nurses N=53 Total Sample of Nurses N=94
Scale:
Occasional Stressful

Occasional Stressful

Occasional Stressful
Frequently Stressful

Frequently Stressful

Frequently Stressful
Does Not Apply = 0

Extremely Stressful

Extremely Stressful

Extremely Stressful
Never Stressful = 1

Does Not Apply

Does Not Apply

Does Not Apply

Never Stressful

Never Stressful

Never Stressful
Occasional Stressful = 2
Frequently Stressful = 3
Extremely Stressful = 4

Mean

Mean

Mean
SD

SD

SD
No Items % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
9 Being sexually harassed 4.9 4.9 14.6 9.8 65.9 .98 1.49 7.5 9.4 5.7 22.6 54.7 1.34 1.69 6.4 7.4 9.6 17.0 59.6 1.18 1.61
(2) (2) (6) (4) (27) (4) (5) (3) (12) (29) (6) (7) (9) (16) (56)

18 Experiencing discrimination 14.6 26.8 14.6 2.4 41.5 1.22 1.22 15. 28.3 15.1 9.4 32.1 1.55 1.34 14.9 27.7 14.9 6.4 36.2 1.40 1.29
because of race or ethnicity (6) (11) (6) (1) (17) 1 (15) (8) (5) (17) (14) (26) (14) (6) (34)
(8)
28 Experiencing discrimination 9.8 14.6 14.6 9.8 51.2 1.22 1.46 9.4 13.2 17 13.2 47.2 1.40 1.54 9.6 13.8 16.0 11.7 48.9 1.32 1.50
on the basis of sex (4) (6) (6) (4) (21) (5) (7) (9) (7) (25) (9) (13) (15) (11) (46)

Total Mean Score = 1.14 Total Mean Score = 1.43 Total Mean Score = 1.30

90
5.6. Comparison of Stress by Practice Setting

Table 16 presents a comparison of the mean subscale scores for each of the nine

subscales for nurses in the different practice settings. Results indicate that the common

stressors and sources of stress for registered nurses within the first three years of work as

a registered nurse were similar irrespective whether they were working in the speciality

units or in the general medical and surgical wards. Both groups of new graduate nurses

ranked the component subscale Uncertainty Concerning Patient Treatment as most

frequent stressor, followed by Dealing with Patients and Their Families, then Work

Overload. Discrimination was also rated by both groups as the least frequently occurring

stressor. The only statistically significant difference between groups was for problems

relating to peers, where general nurses reported higher mean scores than those reported

by nurses in speciality units.

91
Table 16 Expanded Nursing Stress Scale Scores by Practice Setting

Speciality General
Expanded Nursing Stress Scale Total Sample
Unit Nurses Nurses N =
Total (1-59) N=94
N=41 53
Mean Range (1-4)
Mean SD Mean SD Mean SD t
Uncertainty Concerning
Treatment
2.63 .74 2.88 .77 2.77 .77 t(92)= -1.59, p .116
Patient And Their Families 2.54 .90 2.77 .87 2.67 .88 t(92)= -1.26, p .211

Workload 2.55 .70 2.70 .75 2.64 .73 t(92)= -1.02, p .312
Inadequate Emotional
Preparation
2.52 .78 2.69 .74 2.61 .76 t(92)= -1.05, p .296

Conflict With Physician 2.32 .79 2.51 1.02 2.43 .93 t(92)= -.99, p .324

Problem Relating To Supervisor 2.23 .98 2.49 1.02 2.37 1.01 t(92)= -1.25, p .214

Death And Dying 2.13 .75 2.36 .97 2.26 .88 t(92)= -1.30, p .196

Problem Relating To Peers 1.92 .67 2.27 .82 2.12 .77 t(92)= -2.23, p .028*

Discrimination 1.14 .98 1.43 1.17 1.30 1.09 t(92)= -1.28, p .205

ENSS (Total Scale) 2.31 .63 2.55 .73 2.44 .70 t(92)= -1.63, p .106
*p<.05

92
5.7. Comparison of Stress by Demographic Variables

Due to small numbers in various demographic groups, including age, gender, educational

background, working experience in the current units, ethnic group, number and ages of

their children, support they received to care for their children, and home ownership

status, the relationship between these variables and ENSS scores were not assessed in

these study. The only bivariate analysis that was conducted was working experience in

nursing. Since the values of the variables were normally distributed, ANOVA was used

for this categorical independent variable.

Table 17 presents the findings of the bivariate analysis using ANOVA between Expanded

Nursing Stress Scale and its nine components subscales with the independent variable of

working experience in nursing. These results indicate that nurses with less than 1 year

experience reported higher mean stress scores for the Uncertainty Concerning Treatment,

Inadequate Emotional Preparation and Problem Relating to Peers subscales.

93
Table 17.

Comparison of Stress by Demographic Variables Total Sample (94)

0 less 1 yr 1- less 2 yrs 2 less 3 yrs F
N 43 24 27
Uncertainty Mean 3.03 2.60 2.49 F91= 5.42, p .006
SD .69 .78 .75
Min 2 1 1
Max 4 4 4

Mean 2.80 2.61 2.53

Patient And Their Families SD .88 .99 .80 F91=.83, p .438
Min 1 0 1
Max 4 4 4

Mean 2.79 2.52 2.51

Workload SD .73 .86 .57 F91= 1.66, p .196
Min 1 1 1
Max 4 4 4

Inadequate Emotional Mean 2.81 2.28 2.60

Preparation SD .80 .79 .56 F91=4.01, p .021
Min 1 1 1
Max 4 4 4

Mean 2.62 2.35 2.19

Conflict With Physician SD 1.00 .92 .77 F91= 1.95, p .148
Min 0 0 0
Max 4 4 4

N 43 24 27
Problem Relating To Mean 2.64 2.18 2.12 F91=2.86, p .063
Supervisors SD 1.06 .92 .92
Min 0 0 0
Max 4 4 4

Mean 2.37 2.16 2.18

Death and Dying SD .94 .90 .78 F91=.56, p .571
Min 0 1 0
Max 4 4 3

Mean 2.39 1.88 1.90

Problem Relating To Peers SD .78 .70 .72 F91=5.29, p .007
Min 1 1 1
Max 4 4 4

Mean 1.43 1.26 1.12

Discrimination SD 1.24 .98 .93 F91= .68, p .507
Min 0 0 0
Max 4 3 3

Mean 2.63 2.31 2.27

ENSS SD .69 .73 .62 F91=3.04, p .053
Min 1 1 1
Max 4 4 4

94
Table 18 presents comparison of stress by feeling confident, competent and organised

about their overall clinical practice variables. Results indicate were significant negative

correlations for feeling organised about their clinical practice uncertainty concerning

patient treatment, dealing with patients and their families, work overload, conflict with

doctors, problems relating to supervisors and discrimination. There was also a significant

negative correlation between feeling organised and the total ENSS scale scores. There

were no significant relations between feeling confident and competent and stress scores,

except for a significant negative correlation between the feeling of confidence about their

overall clinical practice and problems relating to supervisors.

95
 Table 18 Relationship between Stress and Ratings of
Confidence,
Competence and Organisation

Total Sample N=94

* Correlation is significant at the

Feeling Competent About

Feeling Organized About

Feeling Confident About
Their Overall Clinical

Their Overall Clinical

Their Overall Clinical

0.05 level (2-tailed).

Practice

Practice

Practice

Mean
** Correlation is significant at the

SD
N
0.01 level (2-tailed).

Uncertainty Pearson
-.170 -.066 -.253(*)
Concerning Correlation 2.77 .77
94
Treatment
Sig. (2-tailed) .101 .529 .014
Pearson
-.095 -.054 -.208(*)
Patient And Their Correlation
94 2.67 .88
Families
Sig. (2-tailed) .361 .603 .044
Pearson
-.187 -.160 -.218(*)
Workload Correlation
94 2.64 .73
Sig. (2-tailed)
.072 .125 .035
Pearson
-.015 .020 -.116
Inadequate Correlation
94 2.61 .76
Emotional
Sig. (2-tailed) .883 .852 .267
Preparation
Pearson
-.043 -.104 -.327(**)
Conflict With Correlation
94 2.43 .93
Doctors
Sig. (2-tailed) .682 .317 .001
(Physicians)
Pearson
-.242(*) -.121 -.326(**)
Problems Relating Correlation
94 2.37 1.01
To Supervisors
Sig. (2-tailed) .019 .244 .001
Pearson
.011 .022 -.190
Death And Dying Correlation
94 2.26 .88
Sig. (2-tailed) .914 .832 .066
Pearson
-.169 -.069 -.110
Conflict Relating To Correlation
94 2.12 .77
Peers Sig. (2-tailed)
.104 .506 .290
Pearson
-.063 -.061 -.212(*)
Discrimination Correlation
94 1.30 1.09
Sig. (2-tailed) .546 .557 .040
Pearson
-.156 -.096 -.283(**) 94 2.44 .70
ENSS Correlation
Sig. (2-tailed)
.133 .360 .006

96
5.8. Index of Work Satisfaction: Importance of Work Components (Part A)

This section identifies how important each of the six components of work satisfactions

were to the registered nurses in this study. The importance rankings developed in this

stage are used to develop weights for each of the satisfaction components (Component

Weighting Coefficients). To determine these importance ratings, each of the six

components of satisfaction were arranged in pairs with one other component and the

nurses were asked to select which one of each pair was more important to them. Tables

were formed and the results obtained were tabulated according to the number of times

each component was chosen. Results of these calculations are presented in Table 19. The

raw count was transformed to a percentage of the whole study sample. The percentages

were then converted into standard deviations based on a normal distribution of responses,

using a standard Z-table provided with the package. This was an important part of the

theoretical basis of scoring, since it enables weighting to be given to those components

which were strongly preferred by the study sample. The Z-table thus generated a single

number for each component, called the Component Weighting Coefficient.

As shown in Table 19, results for IWS Part A demonstrate that for speciality unit nurses,

the component Autonomy (70.7%) was most important, followed by Professional Status

(65.9%) and Organisational Policies (61%). Task Requirement and Interaction were

ranked in the fourth and fifth places respectively by specialty unit nurses. The least

important of all six components by speciality units nurses was Pay.

97
 Table 19. Frequency Matrix for IWS Components by Work Area

Most Important
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total (N=94)

Organisation

Organisation

Organisation
Requirement

Requirement

Requirement
Professional

Professional

Professional
Interaction

Interaction

Interaction
al Policies

al Policies

al Policies
Autonomy

Autonomy

Autonomy
Status

Status

Status
Task

Task

Task
Pay

Pay

Pay
Least Important

% (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n) % (n)
Pay 70.7 56.1 61.0 51.2 46.3 62.3 49.1 54.7 64.2 47.2 66.0 52.1 57.4 58.5 46.8
(29) (23) (25) (21) (19) (33) (26) (29) (34) (25) (62) (49) (54) (55) (44)
Autonomy 29.3 48.8 61.0 43.9 51.2 37.8 52.8 54.7 43.4 56.6 34.0 51.1 57.4 43.6 54.3
(12) (20) (25) (18) (21) (20) (28) (29) (23) (30) (32) (48) (54) (41) (51)
Task Requirement 43.9 51.2 51.2 65.9 43.9 50.9 47.2 37.7 64.2 50.9 47.9 48.9 43.6 64.9 47.9
(18) (21) (21) (27) (18) (27) (25) (20) (34) (27) (45) (46) (41) (61) (45)
Organisational 39.0 39.0 48.8 61.0 56.1 45.3 45.3 62.3 64.2 69.8 42.6 42.6 56.4 62.8 63.8
Policies (16) (16) (20) (25) (23) (24) (24) (33) (34) (37) (40) (40) (53) (59) (60)
Professional Status 48.8 56.1 34.1 39.0 51.2 35.8 56.6 35.8 35.8 47.2 41.5 56.4 35.1 37.2 48.9
(20) (23) (14) (16) (21) (19) (30) (19) (19) (25) (39) (53) (33) (35) (46)
Interaction 53.7 48.8 56.1 43.9 48.8 52.8 43.4 49.1 30.2 52.8 53.2 45.7 52.1 36.2 51.1
(22) (20) (23) (18) (20) (28) (23) (26) (16) (28) (50) (43) (49) (34) (48)

98
For new registered respondent nurses from the general wards however, Interaction

(69.8%) was the most important component. General ward nurses ranked Professional

Status, followed by Autonomy and Task Requirement in second, third and fourth place

respectively. Organisational Policies and Pay were ranked in fifth and sixth place.

The next step of analysis involved placing the weights for each of the six components on

a normal distribution by using the table of Z values. All percentages in Table 19 were

converted into 3 decimal places (Table 33, Appendix 6) then to Z-matrix values from the

Z table available (Table 34, Appendix 7). The Z-matrix values for each pair are the same

values, but with opposite signs. An example of this is the intensive care units nurses

ranking of Pay versus Autonomy are scored -0.545 for Pay and +0.545 for Autonomy. To

calculate for the Component Weighting Coefficient, the Z values in each column in

(Table 34, Appendix 7) were added and the mean value (average) for each column was

divided by five (that is, the number of comparisons made). In order to eliminate the

negative values a constant was added. Since the largest possible negative Z value was -

3.090, the constant used was +3.100 added. This was added to each of the mean values to

give the Component Weighting Coefficient. Table 20 presents the Component Weighting

Coefficients for nurses in this study. Results indicate that the Component Weighting

Coefficient for Professional Status and Interaction were highest, indicating these

components are ranked as the most important by respondents. Autonomy, Task

Requirement and Organisational Policies were ranked in third, fourth and fifth order of

importance. The least most important component rated by respondents was Pay.

99
Table 20 IWS Component Weightings by Work Area

Component Weighting Coefficient According to Ranking

Speciality Units Nurses (N= 41) General Wards Nurses (N= 53) Total Sample of Nurses (N= 94)

1 Professional Status 3.20 1 Professional Status 3.30 1 Professional Status 3.26

2 Autonomy 3.18 2 Interaction 3.21 2 Interaction 3.16

3 Organisational Policies 3.13 3 Autonomy 3.13 3 Autonomy 3.15

4 Interaction 3.10 4 Task Requirement 3.10 4 Task Requirement 3.08

5 Task Requirement 3.07 5 Pay 2.96 5 Organisational 3.001

Policies
6 Pay 2.92 6 Organisational Policies 2.91 6 Pay 2.94

100
5.9. Index of Work Satisfaction: Rating of Satisfaction (Part B)

Part B of the Index of Work Satisfaction (IWS) measures the satisfaction of the nurse

respondents using a series of attitude statements about each component. Each statement

uses a 7-point scale that ranges from 1- Strongly Agree 2 Moderately Agree 3-

Agree 4- Neutral 5- Disagree 6- Moderately Disagree and 7- Strongly

Disagree. This scale was designed that half of the items on the scale were phrased

positively and half were phrased negatively to minimise a response bias.

Responses to item in the component Professional Status is presented in Table 21. More

than half of the 94 study respondents nurses 60 (63.8%) believed that most people

appreciate the importance of nursing care to hospital patients, and 53 (56.4%) agreed that

they are proud to talk to other people about what they do as nurses. The majority (75.6%)

agreed that there is no doubt whatever in their mind that what they do on their job was

really important. Most nurses (74.2%) agreed that nursing really required much skill or

know-how, and (38%) disagreed that their job does not add up to anything really

significant. Over half, the sample (51.1%) would still go into nursing, if they had the

decision to make all over again. On the other hand n=56 (60.4%) also believe that

nursing is not widely recognised as being an important profession.

101
Table 21 Index of Work Satisfaction: Professional Status

Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
7 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
9. Most people 17.1 22.0 19.5 24.4 4.9 4.9 7.3 13.2 22.6 32.1 11.3 11.3 3.8 5.7 14.9 22.3 26.6 17.0 8.5 4.3 6.4
appreciate the (7) (9) (8) (10) (2) (2) (3) (7) (12) (17) (6) (6) (2) (3) (14) (21) (25) (16) (8) (4) (6)
importance of nursing
care to hospital
patients.
11. There is no doubt 29.3 19.5 22.0 24.4 2.4 0 2.4 28.3 13.2 37.7 13.2 1.9 1.9 3.8 28.7 16.0 30.9 18.9 2.1 1.1 3.2
whatever in my mind (12) (8) (9) (10) (1) (0) (1) (15) (7) (20) (7) (1) (1) (2) (27) (15) (29) (17) (2) (1) (3)
that what I do on my job
is really important.
34. It makes me proud to 14.6 7.3 36.6 24.4 4.9 7.3 4.9 15.1 13.2 26.4 22.6 11.3 3.8 7.6 14.9 10.6 30.9 23.4 8.5 5.3 6.4
talk to other people (6) (3) (15) (10) (2) (3) (2) (8) (7) (14) (12) (6) (2) (4) (14) (10) (29) (22) (8) (5) (6)
about what I do on my
job.
38. If I had the decision 14.6 14.6 26.8 21.9 9.8 2.4 9.8 11.3 11.3 24.5 18.9 15.1 3.8 15.1 12.8 12.8 25.5 20.2 12.8 3.2 12.8
to make all over again, I (6) (6) (11) (9) (4) (1) (4) (6) (6) (13) (10) (8) (2) (8) (12) (12) (24) (19) (12) (3) (12)
would still go into
nursing.

** 2. Nursing is not 17.1 24.4 14.6 4.9 17.1 7.3 14.6 24.5 17.0 20.8 5.7 15.1 3.8 13.2 21.3 20.2 18.9 5.3 16.0 5.3 13.8
widely recognized as (7) (10) (6) (2) (7) (3) (6) (13) (9) (11) (3) (8) (2) (7) (20) (19) (17) (5) (15) (5) (13)
being an important
profession
** 27. What I do on my 4.9 4.9 9.8 31.7 34.1 4.9 9.8 3.8 13.2 16.9 32.1 18.9 13.2 1.9 4.3 9.6 13.8 31.9 25.5 9.6 5.3
job does not add up to (2) (2) (4) (13) (14) (2) (4) (2) (7) (9) (17) (10) (7) (1) (4) (9) (13) (30) (24) (9) (5)
anything really
significant.
** 41. My particular job 2.4 2.4 4.9 17.1 9.8 31.7 31.7 3.8 3.8 9.4 9.4 24.5 11.3 37.7 3.2 3.2 7.4 12.8 18.9 20.2 35.1
really doesnt require (1) (1) (2) (7) (4) (13) (13) (2) (2) (5) (5) (13) (6) (20) (3) (3) (7) (12) (17) (19) (33)
much skill or know-
how.

** Reverse Scored Statement.

102
Responses to items in the component Interaction are presented in Table 22. Results

indicate that the majority of respondents (71.2%) agreed that the nursing personnel in

their wards/units always help one another out when things get in a rush. More than half,

(60.7%) agreed that there is a good deal of teamwork and cooperation between various

levels of nursing personnel in their wards/units. However, quite a number of nurses

(71%) expressed that it is hard for new nurses to feel at home in the wards/unit. This

was because of concerns such as a lot of rank consciousness where nurses seldom

mingle with those with less experience or different types of educational background.

Around 40% agreed that the nursing personnel where they work are not as friendly and

outgoing as they thought.

Additionally, nearly all (87.2%) agreed the physicians in their ward/units should show

more respect for the skill and knowledge of the nursing staff, although around (41.5%)

agreed that physicians at this hospital generally understand and appreciate what nursing

staff do. Over half, (63.3%) agreed that the physicians at this hospital look down too

much on the nursing staff, although (63.7%) of the respondents agreed there is a lot of

teamwork between nurses and doctors on their own wards/unit, and (59.6%) agreed that

physicians in general cooperate with nursing staff on their unit.

103
 Table 22 Index of Work Satisfaction: Interaction
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
10 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
3. The nursing personnel on 22.0 31.7 19.5 22.0 4.9 0 0 18.9 20.8 30.2 18.9 7.5 3.8 0 20.2 25.5 25.5 20.2 6.4 2.1 0
my service pitch in and help (9) (13) (8) (9) (2) (0) (0) (10) (11) (16) (10) (4) (2) (0) (19) (24) (24) (19) (6) (2) (0)
one another out when things
get in a rush.
6. Physicians in general 9.8 26.8 24.4 29.3 4.9 4.9 0 9.4 9.4 39.6 22.6 7.5 7.5 3.8 9.6 17.0 33.0 25.5 6.4 6.4 2.1
cooperate with nursing staff (4) (11) (10) (12) (2) (2) (0) (5) (5) (21) (12) (4) (4) (2) (9) (16) (31) (24) (6) (6) (2)
on my unit
16. There is a good deal of 17.1 26.8 31.7 17.1 4.9 0 2.4 17.0 28.3 13.2 7.5 17.0 7.5 9.4 17.0 27.7 21.3 11.7 11.7 4.3 6.4
teamwork and cooperation (7) (11) (13) (7) (2) (0) (1) (9) (15) (7) (4) (9) (4) (5) (16) (26) (20) (11) (11) (4) (6)
between various levels of
nursing personnel on my
service.
19. There is a lot of 17.1 26.8 19.5 14.6 14.6 4.9 2.4 13.2 32.1 18.9 11.3 18.9 3.8 1.9 14.9 29.7 19.1 12.8 17.0 4.3 2.1
teamwork between nurses (7) (11) (8) (6) (6) (2) (1) (7) (17) (10) (6) (10) (2) (1) (14) (28) (18) (12) (16) (4) (2)
and doctors on my own unit.
37. Physicians at this 7.3 12.2 22.0 24.4 17.1 12.2 4.9 5.7 9.4 26.4 18.9 22.6 11.3 5.7 6.4 10.6 24.5 21.3 20.2 11.7 5.3
hospital generally (3) (5) (9) (10) (7) (5) (2) (3) (5) (14) (10) (12) (6) (3) (6) (10) (23) (20) (19) (11) (5)
understand and appreciate
what the nursing staffs does.

** 10. It is hard for new 19.5 17.1 29.3 14.6 7.3 4.9 7.3 24.5 34.0 17.0 13.2 5.7 1.9 3.8 22.3 26.6 22.3 13.8 6.4 3.2 5.3
nurses to feel at home in my (8) (7) (12) (6) (3) (2) (3) (13) (18) (9) (7) (3) (1) (2) (21) (25) (21) (13) (6) (3) (5)
unit.
** 23. The nursing personnel 2.4 4.9 14.6 36.6 14.6 17.1 9.8 15.1 13.2 11.3 20.8 18.9 13.2 7.5 9.6 9.6 12.8 27.7 17.0 14.9 8.5
on my service are not as (1) (2) (6) (15) (6) (7) (4) (8) (7) (6) (11) (10) (7) (4) (9) (9) (12) (26) (16) (14) (8)
friendly and outgoing as I
would like.
** 28. There is a lot of rank 7.3 12.2 12.2 39.2 14.6 4.9 9.8 18.9 11.3 16.9 13.2 24.5 9.4 5.7 13.8 11.7 14.9 24.5 20.2 7.4 7.4
consciousness on my unit: (3) (5) (5) (16) (6) (2) (4) (10) (6) (9) (7) (13) (5) (3) (13) (11) (14) (23) (19) (7) (7)
nurses seldom mingle with
those with less experience or
different types of educational
preparation.
** 35. I wish the physicians 43.9 29.3 9.8 14.6 0 0 2.4 47.2 15.1 28.3 5.7 0 1.9 1.9 45.7 21.3 20.2 9.6 0 1.1 2.1
here would show more (18) (12) (4) (6) (0) (0) (1) (25) (8) (15) (3) (0) (1) (1) (43) (20) (19) (9) (0) (1) (2)
respect for the skill and
knowledge of the nursing
staff.
** 39. The physicians at this 17.1 19.5 24.4 24.4 7.3 7.3 0 18.9 17.0 26.4 13.2 15.1 3.8 5.7 18.9 18.9 25.5 18.9 11.7 5.3 3.2
hospital look down too much (7) (8) (10) (10) (3) (3) (0) (10) (9) (14) (7) (8) (2) (3) (17) (17) (24) (17) (11) (5) (3)
on the nursing staff.

** Reverse Scored Statement.

104
Responses to items in the component Autonomy are presented in Table 23. These results

indicate that 44 out of 94 respondents (46.7%) agreed that they have sufficient input into

the program of care for each of their patients, with only 28 respondents agreeing that

there was unnecessary close supervision (29.7%). Less than half (44%) of respondents

agreed that they have freedom in their work to make decisions as they see fit, and can

count on their supervisor for back up. However, 41.5% agreed that all activities seem to

be programmed for them. More than half of the respondents (62.7%) experienced too

much responsibility but were not given enough authority, with a further (25.5%) being

undecided. More than half the sample agreed they sometimes were required to do things

that are against their professional nursing judgement.

105
Table 23 Index of Work Satisfaction: Autonomy
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
8 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
13. I feel I have sufficient 4.9 4.9 39.0 29.3 19.5 2.4 0 11.3 11.3 22.6 28.3 13.2 5.7 7.5 8.5 8.5 29.7 28.7 16.0 4.3 4.3
input into the program of (2) (2) (16) (12) (8) (1) (0) (6) (6) (12) (15) (7) (3) (4) (8) (8) (28) (27) (15) (4) (4)
care for each of my
patients.
26. A great deal of 4.9 4.9 17.1 65.9 7.3 0 0 3.8 7.5 26.4 39.6 15.1 3.8 3.8 4.3 6.4 22.3 51.1 11.7 2.1 2.1
independence is permitted, (2) (2) (7) (27) (3) (0) (0) (2) (4) (14) (21) (8) (2) (2) (4) (6) (21) (48) (11) (2) (2)
if not required, of me.
43. I have the freedom in 7.3 4.9 34.1 31.7 7.3 9.8 4.9 7.6 13.2 26.4 18.9 15.1 11.3 7.5 7.4 9.6 29.7 24.5 11.7 10.6 6.4
my work to make (3) (2) (14) (13) (3) (4) (2) (4) (7) (14) (10) (8) (6) (4) (7) (9) (28) (23) (11) (10) (6)
important decisions as I
see fit, and can count on
my supervisors to back me
up.

** 7. I feel that I am 2.4 4.9 14.6 63.4 7.3 0 7.3 7.6 9.4 18.9 17.0 20.8 15.1 11.3 5.3 7.4 17.0 37.2 14.9 8.5 9.6
supervised more closely (1) (2) (6) (26) (3) (0) (3) (4) (5) (10) (9) (11) (8) (6) (5) (7) (16) (35) (14) (8) (9)
than is necessary.
** 17. I have too much 22.0 17.1 26.8 31.7 2.4 0 0 16.9 24.5 18.9 20.8 7.6 1.9 9.4 19.1 21.3 22.3 25.5 5.3 1.1 5.3
responsibility and not (9) (7) (11) (13) (1) (0) (0) (9) (13) (10) (11) (4) (1) (5) (18) (20) (21) (24) (5) (1) (5)
enough authority.
** 20. On my service, my 7.3 2.4 19.5 39.2 19.5 12.2 0 7.5 15.1 22.6 15.1 30.2 9.4 0 7.4 9.6 21.3 25.5 25.5 10.6 0
supervisors make all the (3) (1) (8) (16) (8) (5) (0) (4) (8) (12) (8) (16) (5) (0) (7) (9) (20) (24) (24) (10) (0)
decisions. I have little
direct control over my
own work.
** 30. I am sometimes 0 12.2 24.4 36.6 7.3 9.8 9.8 9.4 7.6 28.3 13.2 26.4 5.7 9.4 5.3 9.6 26.6 23.4 18.9 7.4 9.6
frustrated because all of (0) (5) (10) (15) (3) (4) (4) (5) (4) (15) (7) (14) (3) (5) (5) (9) (25) (22) (17) (7) (9)
my activities seem
programmed for me.
** 31. I am sometimes 4.9 9.8 39.2 22.0 14.6 7.3 2.4 11.3 15.1 26.4 20.8 13.2 9.4 3.8 8.5 12.8 31.9 21.3 13.8 8.5 3.2
required to do things on (2) (4) (16) (9) (6) (3) (1) (6) (8) (14) (11) (7) (5) (2) (8) (12) (30) (20) (13) (8) (3)
my job that are against my
better professional
nursing judgment.

** Reverse Scored Statement.

106
Responses to item in the component Task Requirements are presented in Table 24.

Results indicate that around two-third of nurses were satisfied with their job activities

(63.8%), however, 60.4% expressed that there was too much clerical and paperwork

required of nursing personnel in the hospital. Almost half of the 94 respondents (45.7%)

agreed that they do not have sufficient time for direct patient care and 55.3% agreed that

they do not have plenty of time and opportunity to discuss patient care problems with

other nursing personnel. Nearly all of the sample (88.3%) agreed that they could deliver

much better care if they had more time with each patient.

107
Table 24 Index of Work Satisfaction: Task Requirements
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
6 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
22. I am satisfied with the 14.6 22.0 39.0 12.2 12.2 0 0 9.4 18.9 26.4 26.4 9.4 5.7 3.8 11.7 20.2 31.9 20.2 10.6 3.2 2.1
types of activities that I do (6) (9) (16) (5) (5) (0) (0) (5) (10) (14) (14) (5) (3) (2) (11) (19) (30) (19) (10) (3) (2)
on my job.
24. I have plenty of time 0 4.9 19.5 26.8 36.6 4.9 7.3 3.8 7.5 15.1 13.2 35.9 11.3 13.2 2.1 6.4 17.0 19.1 36.2 8.5 10.6
and opportunity to discuss (0) (2) (8) (11) (15) (2) (3) (2) (4) (8) (7) (19) (6) (7) (2) (6) (16) (18) (34) (8) (10)
patient care problems with
other nursing service
personnel.
29. I have sufficient time 4.9 7.3 19.5 24.4 29.3 7.3 7.3 3.8 13.2 22.6 13.2 34.0 7.5 5.7 4.3 10.6 21.3 18.9 31.9 7.4 6.4
for direct patient care. (2) (3) (8) (10) (12) (3) (3) (2) (7) (12) (7) (18) (4) (3) (4) (10) (20) (17) (30) (7) (6)

** 4. There is too much 17.1 12.2 22.0 29.3 12.2 4.9 2.4 18.9 18.9 28.3 18.9 9.4 1.9 3.8 18.9 16.0 25.5 23.4 10.6 3.2 3.2
clerical and paperwork (7) (5) (9) (12) (5) (2) (1) (10) (10) (15) (10) (5) (1) (2) (17) (15) (24) (22) (10) (3) (3)
required of nursing
personnel in this hospital.
** 15. I think I could do a 29.3 17.1 22.0 17.1 4.9 4.9 4.9 22.6 30.2 11.3 15.1 11.3 3.8 5.7 25.5 24.5 16.0 16.0 8.5 4.3 5.3
better job if I did not have (12) (7) (9) (7) (2) (2) (2) (12) (16) (6) (8) (6) (2) (3) (24) (23) (15) (15) (8) (4) (5)
so much to do all the time.
** 36. I could deliver much 34.1 36.6 17.1 4.9 4.9 0 2.4 41.5 18.9 28.3 7.5 1.9 0 1.9 38.3 26.6 23.4 6.4 3.2 0 2.1
better care if I had more (14) (15) (7) (2) (2) (0) (1) (22) (10) (15) (4) (1) (0) (1) (36) (25) (22) (6) (3) (0) (2)
time with each patient.

** Reverse Scored Statement.

108
Responses to the items on the component Organisational Policies are presented in Table

25. Results indicate that around half of the respondents (49.9%) agreed that nursing staff

had sufficient control over scheduling their own shifts in the hospital. However, 38

(40.3%) raised concerns that nursing administrators did not generally consult with staff

on daily problems and procedures. Around one-third (39.4%) agreed that their voice in

planning policies and procedures for the hospital and the unit where they work was not

regarded as what they want. Around (65.9%) agreed that there is a great gap between the

administration of this hospital and the daily problems of the nursing service, and around

half believed that the administrative decisions at the hospital interfere too much with

daily patient care (45.8%). The majority of respondents (63.8%) agreed there are not

enough opportunities for advancement of nursing personnel at this hospital.

109
Table 25 Index of Work Satisfaction: Organisational Policies
Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
7 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
5. The nursing staff has 4.9 19.5 22.0 26.8 14.6 4.9 7.3 5.7 18.9 28.3 9.4 15.1 13.2 9.4 5.3 19.1 25.5 17.0 14.9 9.6 8.5
sufficient control over (2) (8) (9) (11) (6) (2) (3) (3) (10) (15) (5) (8) (7) (5) (5) (18) (24) (16) (14) (9) (8)
scheduling their own
shifts in my hospital.
25. There is ample 4.9 7.3 17.1 51.2 12.2 4.9 2.4 0 11.3 24.5 32.1 17.0 7.5 7.5 2.1 9.6 21.3 40.4 14.9 6.4 5.3
opportunity for nursing (2) (3) (7) (21) (5) (2) (1) (0) (6) (13) (17) (9) (4) (4) (2) (9) (20) (38) (14) (6) (5)
staff to participate in the
administrative decision-
making process.
40. I have all the voice 2.4 9.8 14.6 43.9 9.8 12.2 7.3 3.8 1.9 9.4 37.7 18.9 11.3 17.0 3.2 5.3 11.7 40.4 14.9 11.7 12.8
in planning policies and (1) (4) (6) (18) (4) (5) (3) (2) (1) (5) (20) (10) (6) (9) (3) (5) (11) (38) (14) (11) (12)
procedures for this
hospital and my unit
that I want
42. The nursing 2.4 7.3 17.1 31.7 14.6 14.6 12.2 13.2 3.8 22.6 20.8 22.6 7.5 9.4 8.5 5.3 20.2 25.5 19.1 10.6 10.6
administrators (1) (3) (7) (13) (6) (6) (5) (7) (2) (12) (11) (12) (4) (5) (8) (5) (19) (24) (18) (10) (10)
generally consult with
the staff on daily
problems and
procedures.

** 12. There is a great 19.5 22.0 24.4 19.5 9.8 4.9 0 30.2 18.9 17.0 22.6 1.9 5.7 3.8 25.5 20.2 20.2 21.3 5.3 5.3 2.1
gap between the (8) (9) (10) (8) (4) (2) (0) (16) (10) (9) (12) (1) (3) (2) (24) (19) (19) (20) (5) (5) (2)
administration of this
hospital and the daily
problems of the nursing
service.
** 18. There are not 9.8 17.1 34.1 19.5 17.1 0 2.4 18.9 17.0 30.2 18.9 13.2 1.9 0 14.9 17.0 31.9 19.1 14.9 1.1 1.1
enough opportunities (4) (7) (14) (8) (7) (0) (1) (10) (9) (16) (10) (7) (1) (0) (14) (16) (30) (18) (14) (1) (1)
for advancement of
nursing personnel at
this hospital.
** 33. Administrative 14.6 4.9 21.9 46.3 4.9 4.9 2.4 9.4 13.2 26.4 32.1 11.3 5.7 1.9 11.7 9.6 24.5 38.3 8.5 5.3 2.1
decisions at this (6) (2) (9) (19) (2) (2) (1) (5) (7) (14) (17) (6) (3) (1) (11) (9) (23) (36) (8) (5) (2)
hospital interfere too
much with patient care.

** Reverse Scored Statement.

110
Responses to items for the component Pay are shown in Table 26. Results indicate that

only 28 out of 94 nurses were satisfied with their present salary (29.7%), and 64.9% did

not agree with the present rate of increase in pay for nursing service personnel. Nearly all

respondents (85.2%) believed that an upgrading of the pay schedule for nursing personnel

is needed. Around half the sample (53.1%) disagreed that the pay they received is

reasonable given what is expected of nursing personnel.

111
Table 26 Index of Work Satisfaction: Pay Component

Speciality Units Nurses (N= 41) General Wards Nurses ( N=53) Total Sample (N=94)
6 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree ** Reverse
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 Scored
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) Statement.
1. My present salary is 2.4 9.8 12.2 19.5 19.5 4.9 31.7 7.5 17.0 9.4 17.0 24.5 7.6 16.9 5.3 13.8 10.6 18.9 22.3 6.4 23.4
satisfactory. (1) (4) (5) (8) (8) (2) (13) (4) (9) (5) (9) (13) (4) (9) (5) (13) (10) (17) (21) (6) (22)
14. Considering what 2.4 7.3 7.3 29.3 22.0 14.6 17.1 5.7 11.3 9.4 22.6 18.9 20.8 11.3 4.3 9.6 8.5 25.5 20.2 18.9 13.8
is expected of nursing (1) (3) (3) (12) (9) (6) (7) (3) (6) (5) (12) (10) (11) (6) (4) (9) (8) (24) (19) (17) (13)
service personnel at
this hospital, the pay
we get is reasonable.
32. From what I hear 2.4 9.8 9.8 31.7 19.5 12.2 14.6 9.4 9.4 9.4 32.1 26.4 5.7 7.6 6.4 9.6 9.6 31.9 23.4 8.5 10.6
about nursing service (1) (4) (4) (13) (8) (5) (6) (5) (5) (5) (17) (14) (3) (4) (6) (9) (9) (30) (22) (8) (10)
personnel at other
hospitals, we at this
hospital are being
fairly paid.

** 8. It is my 17.1 19.5 26.8 19.5 7.3 4.9 4.9 22.6 20.8 15.1 22.6 9.4 1.9 7.5 20.2 20.2 20.2 21.3 8.5 3.2 6.4
impression that a lot (7) (8) (11) (8) (3) (2) (2) (12) (11) (8) (12) (5) (1) (4) (19) (19) (19) (20) (8) (3) (6)
of nursing personnel
at this hospital are
dissatisfied with their
pay.
** 21. The present 24.4 7.3 34.1 29.3 4.9 0 0 16.9 22.6 24.5 18.9 7.5 5.7 3.8 20.2 16.0 28.7 23.4 6.4 3.2 2.1
rate of increase in pay (10) (3) (14) (12) (2) (0) (0) (9) (12) (13) (10) (4) (3) (2) (19) (15) (27) (22) (6) (3) (2)
for nursing service
personnel at this
hospital is not
satisfactory.
** 44. An upgrading 39.0 24.4 19.5 12.2 0 2.4 2.4 39.6 18.9 28.3 5.7 3.8 0 3.8 39.4 21.3 24.5 8.5 2.1 1.1 3.2
of pay schedules for (16) (10) (8) (5) (0) (1) (1) (21) (10) (15) (3) (2) (0) (2) (37) (20) (23) (8) (2) (1) (3)
nursing personnel is
needed at this
hospital.

112
5.10. Computing the Component Scores.

To calculate the Component Scores, a table was created for each component, using the

formula described by the authors of the IWSS. The scoring system can be found in

Appendix 10. Positively worded statement were given the maximum number of points (7)

for a strongly agree and points of (1) for strongly disagree response. For every negatively

worded statement, the maximum number of points (7) was given for a response of

strongly disagree and (1) points for strongly agree.

In order to get the Component Score, the obtained Average Scores for all items in the

component subscale were added, and the mean component subscale score calculated by

dividing this number by the number of items measuring the component. Table 27 presents

the Component Score and the Component Mean Score for each of the six components of

the IWSS.

113
Table 27 Component Score and the Component Mean Score for IWS Scales

PAY PROFESSIONAL AUTONOMY

STATUS
Item ICU GW Total Item ICU GW Total Item ICU GW Total
1 3.15 3.75 3.49 2 3.61 3.34 3.46 7 3.98 4.25 4.13
8 3.15 3.11 3.02 9 4.78 4.81 4.8 13 4.39 4.32 4.35
14 3.27 3.55 3.43 11 5.39 5..32 5.35 17 2.76 3.20 3.01
21 2.83 3.09 2.98 27 4.39 3.96 3.62 20 3.98 3.74 3.84
32 3.49 3.96 3.76 34 4.61 4.57 4.59 26 4.34 4.19 4.26
44 2.39 2.30 2.29 38 4.56 4.13 4.32 30 4.07 3.94 4
41 5.54 5..32 5.4 31 3.63 3.53 3.57
43 4.24 4.15 4.19
Component 18.27 19.76 18.97 32.88 31.45 31.54 31.38 31.32 31.35
Score
Mean 3.05 3.29 3.16 4.697 4.49 4.51 3.92 3.92 3.92
Score

ORGANIZATIONAL TASK REQUIREMENT INTERACTION

POLICIES
Item ICU GW Total Item ICU GW Total Item ICU GW Total
5 4.29 4.13 4.2 4 3.32 3.02 3.15 3 5.44 5.13 5.27
12 2.93 2.79 2.85 15 2.85 2.96 2.89 10 3.17 2.62 2.86
18 3.27 2.96 3.1 22 5.15 4.60 4.84 16 5.24 4.60 4.88
25 4.17 3.92 4.03 24 3.61 3.43 3.51 23 4.46 3.85 4.12
33 3.46 3.47 3.47 29 3.83 3.94 3.89 28 3.95 3.64 3.78
40 3.85 3.32 3.55 36 2.20 2.17 2.18 6 5.07 4.53 4.7
42 3.59 4.04 3.8 19 4.93 4.91 4.91
35 2.07 2.09 2.09
37 4.12 4 4.05
39 3.07 3.23 3.16
Component 25.56 24.52 25 20.95 20.12 20.46 41.54 38.6 39.82
Score
Mean 3.65 3.50 3.57 3.49 3.35 3.41 4.15 3.86 3.98
Score

114
Table 28 provides responses for each of the six components scores. Results indicate that

Component Score for Professional Status, received the highest satisfaction scores

followed by Interaction, then Autonomy in third place. Organisational Policies and Task

Requirement components were rated fourth and fifth, while the component Pay scored

the lowest of all satisfaction ratings.

115
Table 28 Ranking of Satisfaction with IWSS Work Components

Speciality Units Nurses General Wards Nurses Total Sample (N=94)

(N= 41) (N=53)
Component Component Component Component Component Component Component
Scale Score Mean Score Scale Score Mean Score Scale Score Mean Score
Professional 32.88 4.70 31.45 4.49 31.54 4.51
Status
Interaction 41.54 4.15 38.62 3.86 39.82 3.98
Autonomy 31.38 3.92 31.32 3.92 31.35 3.92
Organisational 25.56 3.65 24.52 3.50 25 3.57
Policies
Task Requirement 20.95 3.49 20.12 3.35 20.46 3.41
Pay 18.27 3.05 19.76 3.29 18.97 3.16

Nurse-Nurse 22.27 4.45 19.84 3.97 20.91 4.18

Nurse-Physician 19.27 3.85 18.76 3.75 18.91 3.78
Total Scale Mean Scale Total Scale Mean Total Scale Mean Scale
Score Score Score Scale Score Score Score
170.6 3.9 165.8 3.8 167.1 3.8

116
Finally using weightings derived from the ranking of importance derived in part A of the

questionnaire, satisfaction scores are adjusted to reflect the relative importance of these

various components to this study sample. This is achieved by multiplying the Component

Weighting Coefficient for each component from (Part A) by the Mean Satisfaction Score

for each component from (Part B). The results represent the weights of satisfaction

Component Adjusted Score, for the six components based on the level of importance

placed on each component by the study respondents (see Table 29). According to the

authors of the scale, scores on this scale range from 0.9 to 37.1, with most scores falling

somewhere around 12.

As illustrated in Table 29, there were no changes in the rank of satisfaction following

adjustment for importance, with Professional Status continuing to be the highest area of

satisfaction and Pay the lowest.

117
Table 29 IWS Components Weighted Scores

Speciality Units Nurses (N= 41) General Wards Nurses (N=53) Total Sample (N=94)
Component

weighting Coefficient

weighting Coefficient

weighting Coefficient
Component Adjusted

Component Adjusted

Component Adjusted
(PART B)

(PART B)

(PART B)
Component Mean

Component Mean

Component Mean
111 (PART B)

111 (PART B)

111 (PART B)
Component Scale

Component Scale

Component Scale
1 Component

1 Component

1 Component
Score (Average)

Score (Average)

Score (Average)
Scale Score

Scale Score

Scale Score
(Part A)

(Part A)

(Part A)
Scores

Scores

Scores
1V

1V

1V
11

11

11
Pay 2.92 18.27 3.05 8.91 2.96 19.76 3.29 9.74 2.94 18.97 3.16 9.31
Autonomy 3.18 31.38 3.92 12.47 3.13 31.32 3.92 12.27 3.15 31.35 3.92 12.35
Task 3.07 20.95 3.49 10.71 3.1 20.12 3.35 10.39 3.08 20.46 3.41 10.51
Requirement
Organisational 3.13 25.56 3.65 11.42 2.91 24.52 3.50 10.19 3.00 25 3.57 10.71
Policies
Professional 3.21 32.88 4.70 15.09 3.30 31.45 4.49 14.82 3.26 31.54 4.51 14.7
Status
Interaction 3.1 41.54 4.15 12.87 3.21 38.62 3.86 12.4 3.16 39.82 3.98 12.58

Total Scale Mean Scale Score 3.9 (170.6 / 44) Mean Scale Score 3.8 (165.8 /44) Mean Scale Score 3.79 (167.1/44)
Score
Index of Work Satisfaction: 11.91 [71.47/6] Index of Work Satisfaction: 11.64 Index of Work Satisfaction: 11.69 [70.16 / 6]
[69.81/6]

118
Table 30 present t-tests for all the six IWS components to compare levels of satisfaction

between nurses in general and speciality settings. Since the values of the variables were

normally distributed, Independent sample t-test was used. This analysis revealed no

statistically significant differences between groups in any component.

Table 30 Components T-test

SPU General
Mean SD Mean SD T test
1 Professional 26.2 4.05 25.8 4.26 T92=.436, p.664
Status
2 Interaction 32.1 5.56 32.3 6.23 T92=.154, p .878

3 Autonomy 29.4 3.63 30.0 5.27 T92= -.610, p .543

4 Organisationa 25.8 3.97 25.8 4.49 T92= -.062, p .951

l Policies
5 Task 19.8 3.73 20.2 3.97 T92= -.484, p .629
Requirement
6 Pay 22.3 4.22 21.3 3.65 T92= 1.350, p .180

7 IWS 155.6 16.59 155.3 15.60 T92=.083, p .934

Table 31 presents Pearson Correlation statistics calculated to assess the relationship

between the total Expanded Nursing Stress Scale score and its nine subscales, and the

IWSS and its six components. Findings indicate that the Component Autonomy was

significantly correlated with the total ENSS score, and ENSS subscales Patient and Their

Families, Problem Relating to Supervisors and Workload. No other significant

associations were identified between stress and work satisfaction.

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Table 31 Correlations between IWSS and ENSS (n=94)

Organizational

Requirement

Professional
Interaction
Autonomy

policies

status
Task

IWS
Pay
Pearson Correlation -.204(*) -.080 -.159 -.056 -.017 -.071 -.168
ENSS
Sig. (2-tailed) .049 .441 .125 .593 .870 .494 .107
Pearson Correlation -.179 -.059 -.136 -.035 -.048 -.067 -.148
Conflict with Physician
Sig. (2-tailed) .084 .572 .191 .738 .646 .523 .156
Pearson Correlation -.143 -.038 -.189 -.157 -.006 .021 -.140
Death and Dying
Sig. (2-tailed) .169 .713 .068 .130 .957 .844 .179
Pearson Correlation -.100 -.060 -.014 .101 -.023 -.132 -.070
Discrimination
Sig. (2-tailed) .336 .569 .895 .331 .826 .204 .500

Inadequate Emotional Pearson Correlation .018 .013 -.093 .106 -.024 -.026 -.002
Preparation
Sig. (2-tailed) .865 .898 .374 .310 .816 .805 .987
Pearson Correlation -.238(*) -.091 -.145 -.090 -.005 -.136 -.200
Patient and Their Families
Sig. (2-tailed) .021 .381 .164 .386 .961 .191 .053
Pearson Correlation -.084 -.003 -.065 .022 .003 -.075 -.056
Problem Relating to Peers
Sig. (2-tailed) .423 .976 .532 .831 .976 .474 .591

Problem Relating to Pearson Correlation -.224(*) -.072 -.151 .032 -.073 .011 -.139
Supervisor
Sig. (2-tailed) .030 .489 .146 .756 .484 .918 .181
Pearson Correlation -.182 -.056 -.167 -.112 .001 -.052 -.158
Uncertainty
Sig. (2-tailed) .079 .591 .109 .282 .992 .618 .128
Pearson Correlation -.210(*) -.096 -.091 -.078 .008 -.083 -.159
Workload
Sig. (2-tailed) .043 .357 .385 .456 .942 .428 .126

*p<.05

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5.11. Strategies that are believed to be helpful in assisting the new nurses transition

into

the workplace as a new Registered nurse.

In this section the respondents were requested to rate how helpful they believe each of a

series of items would be in assisting their transition with the new responsibilities in the

workplace as a newly graduated staff nurse (RN) working in todays complex clinical

nursing working environment. They were asked to rate a seven-point likert-type scale by

shading or ticking the relevant bubbles on a scale ranging from 1 to 3 (not helpful at

all); 4 (uncertain); 5 to 7

(extremely helpful). The higher the score the more they agreed with the statement.

Responses to strategies that are believed to be helpful in assisting the new graduates

transition into the workplace as a new graduate nurse are presented in Table 32. Results

indicate that most of the respondents (86.2%) chose Education as the most helpful

strategies in assisting their transition with the new responsibilities in the workplace.

81.9% of the study respondents favoured Team Building Strategies in the second place

and third most common choice was Access to hospital resources with 73 (77.7%). Proper

Mentoring for new graduates by more experienced senior nurses, Flexibility in working

hours, Balancing priorities were also rated highly be more than 75% of the sample. More

than half (65.9%) agreed that Stress management training, and enhancing social and peer

support programs would also benefit strategies. The least most favoured was Protocols to

deals with violence and retention. As illustrated in Table 32, responses from nurses in

general and speciality areas were similar.

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Table 32: Ratings of Helpfulness of Strategies for Assisting Transition

Please rate how helpful you believe each of the following items would be in assisting your transition into the workplace as a new graduate nurse

Not at all helpful Extremely helpful Not at all helpful Extremely helpful Not at all helpful Extremely helpful

1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
No Items % % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)

1 Education 0 0 0 7.3 14.6 19.5 58.5 0 7.5 0 11.3 26.4 13.2 41.5 0 4.3 0 9.6 21.3 16.0 48.9
(0) (0) (0) (3) (6) (8) (24) (0) (4) (0) (6) (14) (7) (22) (0) (4) (0) (9) (20) (15) (46)
2 Team building
0 0 0 14.6 19.5 19.5 46.3 5.7 1.9 1.9 11.3 17.0 17.0 45.3 3.2 1.1 1.1 12.8 18.1 18.1 45.7
strategies
(0) (0) (0) (6) (8) (8) (19) (3) (1) (1) (6) (9) (9) (24) (3) (1) (1) (12) (17) (17) (43)
3 Access to hospital
2.4 2.4 2.4 14.6 24.4 24.4 29.3 0 3.8 7.5 11.3 28.3 17.0 32.1 1.1 3.2 5.3 12.8 26.6 20.2 30.9
resources
(1) (1) (1) (6) (10) (10) (12) (0) (2) (4) (6) (15) (9) (17) (1) (3) (5) (12) (25) (19) (29)
4 Mentoring
2.4 0 0 17.1 26.8 29.3 24.4 3.8 0 5.7 7.5 22.6 26.4 34.0 3.2 0 3.2 11.7 24.5 27.7 29.8
(1) (0) (0) (7) (11) (12) (10) (2) (0) (3) (4) (12) (14) (18) (3) (0) (3) (11) (23) (26) (28)
5 Flexibility in working
0 4.9 4.9 19.5 22.0 22.0 26.8 1.9 1.9 3.8 15.1 18.9 28.3 30.2 1.1 3.2 4.3 17.0 20.2 25.5 28.7
hours
(0) (2) (2) (8) (9) (9) (11) (1) (1) (2) (8) (10) (15) (16) (1) (3) (4) (16) (19) (24) (27)
6 Balancing priorities
0 0 2.4 22.0 31.7 29.3 14.6 1.9 3.8 1.9 13.2 22.6 22.6 34.0 1.1 2.1 2.1 17.0 26.6 25.5 25.5
(0) (0) (1) (9) (13) (12) (6) (1) (2) (1) (7) (12) (12) (18) (1) (2) (2) (16) (25) (24) (24)
7 Stress management
12.2 2.4 2.4 14.6 24.4 22.0 22.0 3.8 5.7 3.8 22.6 20.8 15.1 28.3 7.4 4.3 3.2 19.1 22.3 18.1 25.5
training
(5) (1) (1) (6) (10) (9) (9) (2) (3) (2) (12) (11) (8) (15) (7) (4) (3) (18) (21) (17) (24)
8 Enhancing social and
peer support 2.4 0 0 22.0 26.8 31.7 17.1 0 3.8 1.9 20.8 18.9 34.0 20.8 1.1 2.1 1.1 21.3 22.3 33.0 19.1
programs (1) (0) (0) (9) (11) (13) (7) (0) (2) (1) (11) (10) (18) (11) (1) (2) (1) (20) (21) (31) (18)

9 Protocols to deals
with violence and 4.9 0 0 31.7 22.0 22.0 19.5 3.8 5.7 5.7 13.2 28.3 24.5 18.9 4.3 3.2 3.2 21.3 25.5 23.4 19.1
retention (2) (0) (0) (13) (9) (9) (8) (2) (3) (3) (7) (15) (13) (10) (4) (3) (3) (20) (24) (22) (18)

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5.12 Summary

Despite several studies having addressed stress in nursing, this issue continues to be a

popular topic amongst researchers because of its consequences to individual health and

the organization. For this study, registered nurses with less than three years experience

were surveyed to determine the factors contributing to stress that are frequently occurring

in the workplace. The study also investigated job satisfaction among registered nurses

with less than three years experience working in specialty units and general wards in

Brunei Darussalam.

Responses to the ENSS indicate new registered nurses experience a range of stressful

events while at work. The most common stressful events were uncertainty concerning

patient treatment, and dealing with the patient and their families. The new registered

nurses also rated the stress associated with workload highly. Responses indicated that

problems relating to peers and the experience of being discriminated against in the

workplace were the least stressful events. No significant differences were observed

between the level and sources of stress experienced by registered nurses with less than

three years experience according to practice setting.

Responses to Index Work Satisfaction Scale (IWS) indicated that new nurses rated the

component professional status as being the most important aspect of work, followed by

the component interaction. The least important of all six components was pay.

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Study participants agreed that education (48.9%), team building (45.7%), access to

hospital resources (30.9%), mentoring (29.8%), flexibility in working hours (28.7%),

balancing priorities (25.5%), stress management training (25.5%), enhancing social and

peer support programs (19.1%) and protocols to deals with violence and retention

(19.1%) would be extremely helpful in assisting their transition into the workplace as a

graduate nurse.

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 CHAPTER SIX
6.0. Discussion

The primary aim of this descriptive correlational study was to investigate perceptions of

stress and levels of job satisfaction of registered nurses within the first three years of

employment in Brunei Darussalam hospitals. This enquiry examined the common

stressors, sources and levels of stress and level of job satisfaction.

Findings of the study suggest that registered nurses during their early years as a nurse

have been frequently, and in some case, excessively exposed to stressful situations as part

of their daily work. The major stressors they experienced according to most stressful to

the least stressful events as perceived by respondents were assessed by the Expanded

Nurses Stress Scale. Specifically, common sources of stress were uncertainty concerning

patient treatment, dealing with patients and their families, work overload, inadequate

emotional preparation, conflicts with doctors, problems relating to supervisors, death and

dying, conflict relating to peers, and discrimination. These findings are consistent with

those from numerous other studies that suggest that stress in nursing can be derived from

numerous areas, including job content, resources issues, professional concerns,

professional working relationships and extrinsic factors (Murphy, 1994).

The findings of this study are similar to those of others which have used the Nursing

Stress Scale (e.g., Healy and McKay 1999; Tyler and Cushway 1995; 1992). More

specifically, the most common stressful events that arose for nurses in this study resulted

from factors including Uncertainty Concerning Patient Treatment, in particular the fear

125
of making a mistake in treating a patient, being in charge with inadequate experience, and

fear that the physician would not being present in a medical emergency. Murphy (2004)

similarly identified that newly registered nurses often felt under pressure to take charge

when they were not ready. At these times, their lack of knowledge and experience

frustrated them, as they felt they were not able to give patients correct information.

Murphy also reported that new graduates rated feeling inadequately trained for what they

have to do and being exposed to health and safety hazards as highly stressful events that

are frequently occurring in the nursing working environment. Providing less experienced

nurses with the support needed to develop their knowledge and apply this to their practice

may be helpful.

Issues of Dealing with Patients and Their Families, also commonly provided a source of

stress for nurses. In particular, when the patients family made unreasonable demands,

when nurses were blamed for anything that goes wrong, and when they did not know

whether the patients family will report them for inadequate care placed the nurses in

especially difficult situations. Of much concern to many new registered nurses is the

stress experienced when dealing with abusive patients and abusive patients families. It

is likely that impact of such experience will lead to psychological distress, self doubt and

a significant amount of loss of respect (Michael and Jenkins, 2001). A study by Lin and

Liu (2005) reported that violence occurring in hospitals was mainly due to

misunderstandings, drunkenness, and personal problems, or from patients who were

mentally unstable. Tabone (2001) suggests the solution for these problems is to identify

the sources of this violence, and advocate on behalf of nurses to ensure the quality of the

126
work environment and patient care. Having clear written policies as a guideline for

dealing with abusive patients and patients (Johnson, Moss, Clarke, and Armistead, 1996)

is highlighted by the findings of this study.

Nurses in this study also reported that Work Overload was common, in particular not

having enough staff to adequately cover the unit as a result of unpredictable staffing and

scheduling. Shift work often introduces additional hardship on nurses providing services

in complex environments and demanding interpersonal situations. New registered nurses

who were burdened with extra responsibilities such as having too many non nursing

tasks, having to work through breaks, and in some case having to make decisions under

pressure are important concerns that require attention. Many nurses in this study reported

that there was not enough staff to get the work done, and that this resulted in them not

having enough time to provide emotional support to the patient and to respond to patient

needs.

Work satisfaction levels for nurses in this study were at a moderate to high level for most

components. Specifically, the component Professional Status was chosen as the most

important component of work satisfaction. Despite its importance, many nurses in this

study reported that they believed that nursing is not widely recognised as being an

important profession (Ma, Samuels, and Alexander, 2004).

Nursing roles are rapidly expanding in areas including performing minor surgery,

prescribing medicines and treatments, making and receiving direct referrals, admitting

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and discharging patients for specified conditions, managing patient caseloads, running

clinics and taking a lead in the way local health services are organised (Hilpern, 2002).

While presenting significant challenges, responses of nurses in this study indicate that

many nurses did not hold the view that their job does not add up to anything really

significant. This high level of satisfaction with the nursing role may reflect the increasing

value being placed on some aspects of nursing, due to the growing demand for nursing

services associated with the ageing population growth and increased opportunities for

expanded scope of practice (ICN, 2007; American Association of Colleges of Nursing,

2006; Mee and Robinson, 2003; Spratley et. al 2002). When nurses are satisfied in their

jobs, they are more likely to remain in nursing (Roberts, Jones and Lynn, 2004). The

importance of nursing work to health care thus needs to continue to be supported and

promoted.

Respondents also reported that the component Interaction was important to job

satisfaction. New registered nurses agreed that the nursing personnel in their wards/units

always help one another out when things get in a rush and they also agreed that there is a

good deal of teamwork and cooperation between various levels of nursing personnel in

their wards/units. Good communication regardless of age, experience, and length of

tenure in an organization is one process that has been recognized to promote job

satisfaction (Manojlovich and Laschinger, 2002). Regardless of their types of practice,

work setting or country, it is very important for nurses to share and be committed to a

holistic philosophy of care. This perhaps more than anything else that shapes their

expectation and fit within todays challenging workplace (ICN, 2007).

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Not surprisingly, new registered nurses expressed that it was hard for them to feel at

home in the wards/unit because of concerns such as a lot of rank consciousness or

limited interaction with experienced nurses and staff. Jackson (2005) identified that new

registered nurses were striving to develop a level of care and competency and unlike

expert nurses, they did not have vast experience and knowledge to work effectively as

part of the team. Numerous writers have suggested that manager behaviours can have a

significant impact on health outcomes of subordinates (WHO, 2007). The manager-

subordinate relationship is the most commonly reported cause of stress within a work

team, and this appears to be associated with a reduction in performance (De Dreu and

Weingart, 2003). Attention to these issues is therefore important in any transition support

program for new registered nurses.

Many respondents agreed with statements that the physicians in their ward/units should

show more respect for the skill and knowledge of the nursing staff. Because studies have

found that role conflict and ambiguity are positively correlated with job dissatisfaction,

and can generate low organizational commitment and increased psychological and

physiological stress, it is important that attention be given to improving nurse-physician

relationships (Sherman, 1998). While most nurses reported that physicians at this hospital

generally understood and appreciated what nursing staff do, and would cooperate and

work as part of a team, many still perceived physicians as looking down too much on the

nursing staff (Tabone, 2001).

129
The findings of this study also indicate nurses rated the component Autonomy as an

important component of their job satisfaction. Nearly half agreed that they have sufficient

input into the program of care for each of their patients, and that they dont require close

supervision. Registered nurses in this study agreed that they have freedom in their work

to make decisions as they see fit, and can count on their supervisor for back up.

Transition programs specifically designed to bridge the gap between the academic and

service setting and to prepare novice nurses to utilize critical thinking skills in the

management of acutely ill patients are therefore likely to be important to ensure nurses

are confident to deal with the degree of autonomy they are required to demonstrate as a

registered nurse (Halfer, 2007). Indeed, some authors argue that such programs are

especially helpful for developing effective decision making power and improving a new

graduates level of work performance (Bond and Bunce, 2001).

Moreover, satisfaction with autonomy in the workplace has been identified in this study

as being especially important, since it is moderately correlated with the overall stress

score, and with ENSS subscales of patients and families, problems with supervisors and

workload. Specifically, higher levels of satisfaction with autonomy were associated with

lower levels of stress in all these domains. Similarly, nurses perceptions of their level of

organization was associated with several ENSS subscales, including stress associated

with treatment uncertainty, patients and families, workload, conflict with doctors,

problems relating to supervisors and discrimination. These findings underscore the

importance of developing nurses skills and confidence in their ability to function as a

registered nurse.

130
Task Requirements were also rated by nurses in this study as an important component of

job satisfaction. The majority of respondents were satisfied with their job activities

however, a notable proportion expressed concern that there was too much clerical and

paperwork required of nursing personnel in the hospital. The International Council of

Nurses (2007) reports argue that nurses today are often stressed because of heavy

workloads. Such work related stressors are reported to be correlated with increases in job

dissatisfaction, health complaints and absenteeism of nurses (Landeweerd and Boumans,

1994).

Of particular note, almost half the nurses in this study believed that they did not have

sufficient time for direct patient care and they did not have plenty of time and opportunity

to discuss patient care problems with other nursing personnel. Many also believed that

they could deliver much better care if they had more time with each patient. Studies

suggest that perceptions of the quality of ones work are related to job satisfaction

(Murphy, 2004), and that higher job satisfaction is associated with increased attention to

patient psychological and educational needs (Perumal and Sehgal, 2003). Moreover, high

patient-to-nurse ratios have been linked to higher patient mortality and lower nurse job

satisfaction (Aiken, Clarke, Sloane, Sochalski and Silber, 2002). The current shortages of

nurses will thus continue to challenge the ability of nurses to meet the needs of their

patients (ICN, 2007), thereby potentially providing a situation where levels of work

related stress increase and work satisfaction decreases.

131
With respect to the Organizational Policies component of job satisfaction, most of the

respondents reported having sufficient control over scheduling their own shifts in the

hospital. However, many raised concerns that nursing administrators did not generally

consult with the staff on daily problems and procedures and that their voice in planning

policies and procedures for the hospital and the unit where they work was not regarded as

what they want. Many nurses in this study also agreed that there is a gap between the

administration of the hospital and the daily problems of the nursing service. Such factors

may contribute to decreased job satisfaction and an employees disengagement from the

organization (Lopopopo, 2002). Hence, developing organizational policies that are

conducive to a supportive and flexible work environment are important considerations for

administrators and policy makers if work satisfaction levels are to be high (Kovner,

Brewer, Yow-Wu, Ying, Miho, 2006).

The International Council of Nurses (2007) has also outlined the characteristics of

positive practice environments that are needed to deal with these situations. These

characteristics innovative policy frameworks focused on recruitment and retention,

strategies for continuing education and upgrading, adequate employee compensation,

recognition programmes, sufficient equipment and supplies, and a safe working

environment.

Findings also indicate that t Pay was important, although it was the area with which

nurses were least satisfied. Although nurses were satisfied with their present salary, the

majority of them did not agree with the present rate of pay increases for nursing service

132
personnel. Many agreed that an upgrading of pay schedule for nursing personnel is

needed at the hospital, and most disagreed that the pay they received is reasonable given

what is expected of nursing personnel. The International Council of Nurses (2007)

reported that job dissatisfaction among nurses were worsened by migration of nurses in

search for better working conditions, quality of life and higher paying jobs in richer

countries. In Ghana, for instance the migration of nurses was double than the number of

nursing graduates in the year of 2000, resulting in a major nursing workforce crisis

(ICN). The impact of nurse migration on nursing in Brunei is not well described.

A key finding of this study was that no significant differences were noted in levels of

stress or work satisfaction for nurses working in specialty areas of practice compared to

those in general medical/surgical units. While the sample size for this study was small,

such findings emphasise that the experience of stress for registered nurses in the first few

years following graduation has some common elements, no matter what the work

environment. Such stressors seemed to be common across nurses with different years of

experience, although analysis of sources of stress by years of experience identified that ,

nurses with less than 1 year experience reported higher mean stress scores for the

Uncertainty Concerning Treatment, Inadequate Emotional Preparation and Problem

Relating to Peers subscales. Nurses with less experience also reported higher total stress

scores than nurses with more than 1 year experience. These results emphasise that

particular attention needs to be given to supporting nurses in the early years as a

registered nurse.

133
As mentioned in the earlier chapters, nursing manpower comprises the largest component

of the health care workforce in Brunei Darussalam hospitals (MOH, 2007). Nurses

vigilance is crucial to keeping patients and the community safe and healthy. The stability

and quality of Brunei Darussalam health care system relies on a sufficient supply of well-

educated and skilled nurses. Increasing job stress and low job satisfaction among nurses

in hospitals in Brunei Darussalam may therefore place the system at risk of lower quality

unsafe practices. Brunei is experiencing rapid population growth in several districts, and

an increasingly diverse population requiring better health care services (MOH, 2008).

The shortage of nursing manpower is occurring when the majority of experienced nurses

are retiring and their place is being taken up by inexperience nurses. This study has

identified areas of job stresses and job satisfaction experienced by nurses in hospitals and

clinics in Brunei Darussalam that may have important implications for managers and

educators.

6.1. Implications

In this current study, the findings have several important implications for nursing practice

and education. There is also a need for more research to be carried out. Perhaps the most

important implication is the need for collaboration between education and service sectors

in the development of programs which address the types of stressors and concerns

reported by nurses in this study. The findings of this study allow educators to redesign

educational approaches to support the role transition of new graduate nurse. At the same

time, the nursing service personnel need to consider a redesign of their internship

134
program to assist nurses to overcome challenges associated with stressors such as

uncertainty of treatments, and relationships with other health professionals. For example,

additional mentoring strategies may assist to promote critical thinking, foster peer

networking and discussion, and support professional role transition throughout the few

years of employment (Graf, 2006).

The United Kingdom Central Council has highlighted the importance of continuing

nursing education together with close clinical supervision by mentors for new registered

nurses to enable them to adjust to the demands of nursing profession during the critical

12 to 18 months taking up their career (UKCC, 1996). The findings of this study will

assist hospital administrators, educators and others nursing leaders in formulating the

direction of appropriate support and organisational structures for the development of

future professional nurses (RN). More specifically, nurses in this study have highlighted

particular areas that may be of assistance to their transition to being a competent

registered nurse. These include education, team building, access to hospital resources to

support professional development, mentoring, and stress management training. Many

nurses also identified that organisational policies that are flexible and which assist with

balancing priorities may be useful.

The International Council of Nurses (2007) outline three important characteristics of

positive practice environments: (1) a climate of safety for nurses and patients

(organizational commitment, management involvement, employee empowerment, reward

system and reporting system); (2) a climate of organisational support for life long

135
learning (encourage life long learning by supporting professional development and the

mutual sharing of knowledge, they become learning organisation); and (3) a climate of

leadership (when the organisational climate enhances the empowerment of individual

employees, nurses express greater job satisfaction and patients achieve better outcomes).

Programs of support for registered nurses need to include educational, team based,

organisational, and professional activities that will create this type of climate.

6.2. Study Limitations

This study has several limitations. Most importantly, the study has addressed only

selected concepts important to our understanding of stress. The scope of this study

included an examination of perceived sources of stress and its links with work

satisfaction only. It was beyond the scope of this study to undertaken a comprehensive

analysis of other key concepts on stress theory, such as appraisal and coping. It was also

beyond the scope of this study to examine the implications of stress and coping for the

health and well being of nurses in this study, and the impact on the quality of care

provided. Such research is urgently needed to better understand the types of intervention

strategies that are needed at the system, organizational and individual level to minimise

the deleterious effects of stress.

There are also a number of methodological limitations of this study. The study includes

non-probability random sampling of new registered nurses who have experienced the

recent transition from student to practicing professional nurse working in todays

136
complex clinical nursing working environment in one hospital setting. Though the sample

involved all new graduate nurses (N=120) working in the general surgical and medical

and specialty units at the time of survey, and a high response rate was achieved, it is

relatively small in number as participation was voluntary. Moreover, the sample excluded

nurses who were on leave at the time of data collection. While it is unlikely that this

created a systematic bias, the limits of the sample need to be acknowledged.

Nearly all of the samples were past students of the investigator, as they had recently

completed their nursing education in Pengiran Anak Puteri Rashidah Saadatul Bolkiah

(PAPRSB) College of Nursing, Brunei Darussalam. There was a possibility of bias

resulting from the previous ex-students-teacher relationship, as the respondents may wish

to respond in socially desirable ways. In order to avoid this, the investigator assured all

participants of privacy and anonymity throughout the study. All nurses who were selected

as the study sample were aware that participation was voluntary. The participants

confidentiality and dignity was maintained and respected, by ensuring no identifying

information was included on the questionnaire. All respondents were given an

opportunity to receive an explanation of the nature and purpose of the study in a small

group presentation in units and wards three days prior to conducting the study, and

written information was provided in an information letter attached to the survey.

Participants were given sufficient time to complete the survey questionnaires at their own

pace or outside their working hours within three weeks and return the completed

questionnaires to the investigator either by mail using the pre stamped envelopes

137
provided or by placing them in sealed boxes at the nurses station in each unit. During the

data collection period, the investigator had no direct contact with the study participants.

The advantages of using self administered questionnaires as data collecting tool for this

study was that they were relatively less costly, offered complete anonymity for

respondents and resulted in no interaction bias. However, it is acknowledged that

collecting self reported data on stress and coping assumes that the study respondents have

clearly understood the questions and that they are able to define their stressors

(Wegmann, 1992), even if they understand and are able to speak English as their second

language. Moreover, information obtained from self-administered questionnaires can be

more superficial largely because they typically contain mostly a fixed number of closed-

ended items. Much of the richness and complexity of respondents experiences are lost or

unanswered. In reality, some stressors are taboo, and recall of others may cause

discomfort and therefore are not readily recalled (Gillespie and Kermode, 2004).

6.3. Future Research

The study findings reported here reflect the experiences of registered nurses with less

than three years experience from the specialty units and general surgical and medical

wards RIPAS Hospital, Brunei Darussalam. These findings provide nurse managers,

educators and hospital administrators in the country with findings that will assist with

developing appropriate professional support programs. Importantly, this study opens up

several areas that require future research. These may include another replication study

138
carried out at multiple sites with different sample of nurses, and more in-depth enquires

into each major stress source that has been identified in this study. In addition, further

research that is more closely guided by contemporary theoretical understandings of stress,

are needed to better understand concepts such as the influence of stress appraisal, and the

relationships between various coping strategies and positive outcomes for nurses.

6.4. Conclusion

It appears from previous studies that the nursing workplace is often stressful and that this

issue should not be ignored. Ganga (1998) argues it is obvious that nurses experience

stress in the clinical setting, and that there are no easy solutions to the problems of stress

in nursing education and practice. It is the role of the nurse educators, managers, and

administrators to find ways to make the nursing workplace more harmonious, pleasant

and less stressful, especially to new graduate nurses. The findings of this limited study

will assist nursing educators, directors and human resources managers to determine

coping strategies that might help in reducing amounts of stress experienced by new

graduate nurses in their day to day challenging and demanding nursing roles.

Stress is an unavoidable part of human life. Some stress may be normal and necessary,

but too much of it may affect the quality of life and health (WHO, 2004). The effects of

stress can be reduced by early identification of its problems, understanding its potential

contributing factors and finding effective coping strategies In this study, registered nurses

with less than three years experience were asked to nominate what they believed to be the

139
most effective ways to relieve the workplace stress and what would be extremely helpful

in assisting the new registered nurses transition as a practicing professional nurse. Ways

to reduce and avoid unnecessary stress that were suggested by participants in this present

study, indicating education; team building strategies; access to hospital resources;

mentoring; flexibility in working hours; stress management training; balancing priorities;

enhancing social and peer support programs and, finally, protocols to deal with violence

and retention. Such recommendations are worthy of attention by educators and

administrators to ensure positive practice environments for nurses, and the best outcomes

for those who require nursing services.

140
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 Appendix 1
PERKHIDMATAN KEJURURAWATAN
PEJABAT PENGARAH PERKHIDMATAN KEJURURAWATAN
JALAN MENTERI BESAR
Telephone: 3820 18 BANDAR SERI BEGAWAN BB3910
NEGARA BRUNEI DARUSSALAM
381640 ext 7727
NURSING SERVICES
Fax 380687 DIRECTOR OF NURSING SERVICES OFFICE
JALAN MENTERI BESAR
BANDAR SERI BEGAWAN BB3910
BRUNEI DARUSSALAM

Rujukan Kami :
PPK/lNT/39/2000 1 4 September 2005
Our Reference :

Mr Rahim Damit
Room N-602 (level 6)
QUT School of Nursing
Victoria Park, Kelvin Grove
Queensland 4059
Australia

Dear Mr. R. Damit

Re: PROPOSED STUDY ON "THE NEW GRADUATE NURSE'S

PERCEPTIONS OF STRESS IN THE NEW COMPLEX CLINICAL
WORKING ENVIRONMENT"

I am referring to your letter addressed to the Director General of Medical Services,

Department of Medical Services, Ministry of Health dated 16 th August 2005 which is being
referred to the Department of Nursing for comment and action.

Following the review of the information stated in the letter with regards to the proposed
topic, the objectives, target sample and sample size, the setting and site, the department
considered them as sufficient and appropriate. The Department also foresees the potential
benefit of the proposed study towards enhancement of working environment in the context
of practice delivery. I wish you could share the finding with us after you complete the study
later.

I would like to state that there is no Ethics Committee as yet within the Ministry, However,
the Director General of Medical Services has no objection to your proposal and permission
is being granted for you to undertake the proposed study with conditions that you adhere to
the ethical aspects and other related issues that need to be observed in conducting the
research.

I wish you success with your undertaking. Kind regards.

Acting Director of Nursing

c.c. Director General of Medical Services: Ministry of Health

 Appendix 1
Tel. : 2382031
Fax : 2380687
E-mail : Moh_gms@hotmail.com
General Office : 2381640
MEDICAL HEADQUARTERS
MINISTRY OF HEALTH
BANDAR SERI BEGAWAN BB3510
BRUNEI DARUSSALAM
Our Ref. : JKPPP/8/2000/K March 2006
Your Ref. : Date : ...........................................20......

Mr. Rahim Damit

Room N - 602 (level 6)
School of Nursing
Queensland University of Technology (QUT)
Brisbane, Australia

Dear Mr Damit,
Re: REQUEST FOR NEW DATE / TIME LINE FOR CONDUCTING
RESEARCH PROJECT

Referring to your letter dated 27th February 2006 regarding the above to conduct the
research project at Raja Isteri Pengiran Anak Saleha Hospital, Ministry of Health.
In relation to that, I have no objection to your proposed change of date (6th ~ 30th March
2006) and duration in order to enable you to conduct and complete the project, and
involving the specified number of nurses within the Hospital setting.
I look forward for you to share the finding of your research later as it is important for the
improvement of the service delivery at the Raja Isteri Pengiran Anak Saleha Hospital.

Sincerely

(Dr. Haji Affendy bin POKSM DSP Haji Abidin)

Director General
Medical Services Department
Ministry of Health.
C.C.
Director of Hospital Services
Director of Nursing Services
Chief Executive Officer, RIPAS Hospital
Appendix 1

To:
Director General
Medical Services Department
Ministry of Health
Brunei Darussalam
16th August 2005.

Dear Dr Haji/Sir,

I am a student, currently undertaking HL84 Master of Applied Science (Research)

at the Queensland University of Technology (QUT), Brisbane Queensland Australia. I am
working on my major study for this degree under the supervision of academic staff from the
School of Nursing QUTs Faculty of Health. I am very grateful of the support from ministry
to be able to undertake this important project so that the health care system can benefit from
this new knowledge.

The primary aim of this study is to investigate new graduate nurses perceptions of
stress in todays complex clinical working environment.

The study objectives are to:

1. Identify and describe levels and sources of stress experienced by new graduate
nurses
2. Compare levels of stress experienced by new graduate nurses working in
operating theatre and surgical units and intensive care units.
3. Explore the relationship between workload, new complex working environment
and levels of stress among new graduate nurses in operating theatre and surgical
units and intensive care units.

I am, therefore requesting a permission to carry out a research project in Raja Isteri
Pengiran Anak Saleha (RIPAS) Hospital. The project will be commencing on the 1st
December 2005 and expected to be complete by 27th February 2006. Some of 200 new
graduate nurses with less than 2 years working experience as staff nurse in the new complex
clinical working environment will be involved in the project. These may include nurses
working in the speciality areas such as Operating Theatre, Surgical, Medical Units/Wards,
Medical Intensive Care Unit (MICU), Coronary Care Unit (CCU), Surgical Intensive Care
Unit (SICU), Paediatric Intensive Care Unit (PICU), Special Care Baby Unit (SCBU),
Otorhinolaryngology and integrated Head and Neck Department, and Accident and
Emergency Department (A&E). The research findings will be used to plan for the future
needs for the improvement of our Nursing Education; Clinical Nursing Practice, Generating
New Knowledge as well as to plan in creating good nursing working environment in Brunei
Darussalam.
Appendix 1
If you have any concerns or require further information about the project and have
any questions, please contact;

Chief Investigator: Mr Abd Rahim Damit

Room N-602 (level 6)
QUT School of Nursing
Phone : +614 2495 4660
: +617 3357 4741
: +617 3357 4741 Fax
email : h.hajidamit@student.qut.edu.au

Principal Supervisor Sheree Smith

Room N-537 (Level 5)
QUT School of Nursing
Phone : +617 3864 3905
email : sm.smith@qut.edu.au

Associate Supervisor Professor Patsy Yates

Room N-334
QUT School of Nursing
Phone : +617 3864 3835
email : p.yates@qut.edu.au

Queensland Research Ethics Officer

University Phone : +617 3864 2340
of Technology email : ethicscontact@qut.edu.au

Your permission and consideration for me to carry out this project is highly
appreciated. Your response to this letter can be address to:

Mr Haji Abd Rahim bin Haji Damit

2/ 80
Thistle Street
Gordon Park
Brisbane
Queensland 4031
Australia
Fax: +617 3357 4741
Tel: +614 2495 4660

I would like to take the opportunity in advance to say thank you for your
consideration and any information that you can give me.

Yours sincerely

Mr Rahim Damit
Appendix 1
cc.

Director of Nursing Services, Nursing Services Department, Brunei Darussalam. Ministry of Health.
Director of Medical Services. Medical Services. Ministry of Health.
Director of Technical Education, Technical and Vocational Department. Ministry of Education.
Principal, Pengiran Anak Puteri Rashidah Saadatul Bolkiah College of Nursing.
Chief Executive Officer, RIPAS Hospital. Ministry of Health.
Principal Nursing Officer, RIPAS Hospital. Ministry of Health.
Senior Nursing Officers, OT; MICU; CCU; ORL; PICU; SICU; SCBU; A & E; Surgical Wards/Units.
RIPAS Hospital. Ministry of Health.
Appendix 1
Faculty of Health
School of Nursing
Queensland University of Technology

To:
Director General
Medical Services Department
Ministry of Health
Brunei Darussalam
27th February 2006.

Dear Dr Haji/Sir,

With reference to Dr Haji letter of permission PPK/INT/39/2000 dated on the 14th

September 2005, I am therefore requesting permission for a new date timeline for conducting
a research project in RIPAS Hospital as I am still waiting for an approval letter from the
Queensland University of Technology (QUT), Research Ethic Committee.

The new proposed date for the project to be commencing is on the 6th March 2006
and expected to be complete by 30th March 2006. Some of 200 new graduate nurses with less
than 3 years working experience as staff nurse in the new complex clinical working
environment will be involved in the project. These may include nurses working in the
speciality areas such as Operating Theatre, Surgical, Medical Units/Wards, Medical Intensive
Care Unit (MICU), Coronary Care Unit (CCU), Surgical Intensive Care Unit (SICU),
Paediatric Intensive Care Unit (PICU), Special Care Baby Unit (SCBU), Otorhinolaryngology
and integrated Head and Neck Department, and Accident and Emergency Department (A&E).
The research findings will be used to plan for the future needs for the improvement of our
Nursing Education; Clinical Nursing Practice, Generating New Knowledge as well as to plan
in creating good nursing working environment in Brunei Darussalam.

I am very grateful of the support from Dr Haji and the Ministry of Health Brunei
Darussalam to be able to undertake this important project so that the health care system can
benefit from this new knowledge.

I would like to take the opportunity in advance to say thank you for your
consideration.

Yours sincerely

Mr Rahim Damit
Room N-602 (level 6)
School of Nursing
Queensland University of Technology (QUT), Brisbane Australia.
Phone : 8891226
Home : 2447512
Fax : 2447512
Appendix 2
Date: Wed 7 Mar 13:39:28 EST 2007
From: "Janette Lamb" <jd.lamb@qut.edu.au> Add To Address Book | This is
Spam
Subject: re ethics clearance -- 0600000023
To: <h.hajidamit@student.qut.edu.au>

Dear Abd

Thank you for providing the Progress Report in relation to ethical clearance for your
project, QUT Ref 0600000023 Stress in new graduate nurses: a comparative analysis
between intensive care units and general wards.

I have noted on the ethics database:

The project has been completed;

The project was carried out in accordance with the original application and the
National Statement on Ethical Conduct in Research Involving Humans;
No unforeseen risks were identified; and
No other ethical concerns have emerged from the study.

Information regarding the completion of this project will be provided to the University
Human Research Ethics Committee at its next meeting. I will only contact you again in
relation to this matter if the Committee raises any additional questions or concerns.

Please do not hesitate to contact me if you have any further queries in relation to this
matter.

Yours sincerely

Janette Lamb
Research Ethics Support | Office of Research

Queensland University of Technology

Level 3 O Block Podium | Gardens Point

GPO Box 2434 | BRISBANE QLD 4001

Appendix 2
Date: Wed 1 Feb 10:21:40 EST 2006
From: "Research Ethics" <ethicscontact@qut.edu.au> Add To Address
Book | This is Spam
Subject: Ethics Application Received Stress in new graduate nurses: a
comparative analysis between intensive care units and general wards
To: "Mr Haji Abd Rahim Haji Damit" <h.hajidamit@student.qut.edu.au>
Cc: "Research Ethics" <ethicscontact@qut.edu.au>
Dear Mr Haji Haji Damit ,

Re: Stress in new graduate nurses: a comparative analysis between

intensive
care units and general wards

This email is to advise that your application has been received by

the
Research Ethics Office. Dependant on the type of application the
following
general process will occur:

- Human Level 1 (Low Risk) - applications in this category are

forwarded to
the Chairperson of the UHREC for consideration. You should expect to
receive details of outcome within 7-14 days;

- Human Level 2 (Expedited) - applications in this category are

forwarded
to a representative panel of the UHREC for consideration. You should
expect
to receive details of outcome within 14-21 days;

- Human Level 3 (Full Application) - applications in this

category are
forwarded to the UHREC Committee for consideration at a meeting.
Details
of meeting dates can be found on the Research Ethics website at
http://www.research.qut.edu.au/oresearch/ethics/meet.jsp. You should expect
to receive details of outcome within 7-14 days;

- Animal Ethics Application - applications in this category are

forwarded
to the UAEC Committee for consideration at a meeting. Details of
meeting
dates can be found on the Research Ethics website at
http://www.research.qut.edu.au/oresearch/ethics/meet.jsp. You should expect
to receive details of outcome within 7-14 days;

- Biosafety/GMO Application - applications in this category are

forwarded
to the IBC Committee for consideration at a meeting. Details of
meeting
dates can be found on the Research Ethics website at
http://www.research.qut.edu.au/oresearch/ethics/meet.jsp. You should expect
to receive details of outcome within 7-14 days;

If you have any queries regarding this email please call or email,
however,
it would be appreciated if communication regarding the status of your
Appendix 2
application could be held over until the outcome period has passed,
unless
approval is required urgently.

Please quote application number 0600000023 in any communication

with the
office.

Kind regards

David Wiseman
Research Ethics Officer
Appendix 2
Date: Tue 24 Oct 11:21:00 EST 2006
From: "Lisa Reyes" <l.reyes@qut.edu.au> Add To Address Book | This is Spam
Subject: RDC Reply: OS Fieldwork - Abd Rahim DAMIT (#5142555/HL84)
To: <h.hajidamit@student.qut.edu.au>
Cc: "Kristy Bensley" <k.bensley@qut.edu.au>, "Team E QUT International"
<qut.intadmission-e@qut.edu.au>, "MS Sheree Smith"
<sm.smith@qut.edu.au>

Hi Abd Rahim

OVERSEAS FIELDWORK

The Research Degrees Committee and the International Students Business Services
have approved your request for Overseas Fieldwork from 13August 2006 to 30
March 2007.

This leave does not affect your Candidature Milestone Dates. You can access your
milestones on the student portal Portia. Portia can be accessed via QUT Virtual and
you will need your QUT Access username and password - log in as Student and use
the first 10 digits of your current QUT student password.

Please contact your Faculty Research Administration Officer or the Research Student
Centre if you have any queries relating to your candidature.

Regards

Lisa
Appendix 3
Date: Mon 18 Jul 09:10:53 EST 2005
From: Sheree Smith <sm.smith@qut.edu.au> Add To Address Book | This is Spam
Subject: Fwd: ENSS
To: h.hajidamit@student.qut.edu.au

From: "Susan French" <susan.french@mcgill.ca>

To: <sm.smith@qut.edu.au>
Subject: ENSS
Date: Fri, 10 Jun 2005 18:04:07 -0400
X-Mailer: Microsoft Outlook Express 6.00.2900.2180
X-Junkmail-Status: score=20/50, host=mail-router02.qut.edu.au

Dear Sheree

I am sending you a copy of the ENSS, directions for usage and information on the
grouping og the items.

If you wish to use the instrument you have our permission to do so.

Susan

Sheree M S Smith
Lecturer,
Queensland University of Technology,
Kelvin Grove Campus,
Kelvin Grove,
AUSTRALIA 4059

email: sm.smith@qut.edu.au
telephone 61+ 7 + 38643905
Appendix 3

Expanded Nursing Stress Scale

(Final Version)

by

Susan E. French, RN, PhD1

Rhonda Lenton, PhD2
Vivienne Walters, PhD2
John Eyles, PhD3

1995

1
School of Nursing, McMaster University
2
Department of Sociology, McMaster University
3
Department of Geography, McMaster University
Appendix 3
Expanded Nursing Stress Scale

Below is a list of situations that commonly occur in a work setting. For each situation you
have encountered in your PRESENT WORK SETTING, would you indicate HOW
STRESSFUL it has been for you:

(Enter the number in the right hand column that best applies to you. If you have not
encountered the situation, write 0'.)

Never Occasionally Frequently Extremely Does Not

Stressful Stressful Stressful Stressful Apply
1 2 3 4 5

1. Performing procedures that patients experience as painful... ___

2. Criticism by a physician ___
3. Feeling inadequately prepared to help with the emotional
needs of a patients family ___
4. Lack of opportunity to talk openly with other personnel about problems
in the work setting ___

5. Conflict with a supervisor.. ___

6. Inadequate information from a physician regarding
the medical condition of a patient.. ___
7. Patients making unreasonable demands.___
8. Being sexually harassed. ___

9. Feeling helpless in the case of a patient who fails to improve.. ___

10. Conflict with a physician... ___
11. Being asked a question by a patient for which I do not have a
satisfactory answer. ___
12. Lack of opportunity to share experiences and feelings with other
personnel in the work setting. ___

13. Unpredictable staffing and scheduling.. ___

14. A physician ordering what appears to be inappropriate
treatment for a patient ___
15. Patients families making unreasonable demands. ___
16. Experiencing discrimination because of race or ethnicity. ___

17. Listening or talking to a patient about his/her approaching death. ___

18. Fear of making a mistake in treating a patient... ___
Appendix 3

Never Occasionally Frequently Extremely Does Not

Stressful Stressful Stressful Stressful Apply
1 2 3 4 5

19. Feeling inadequately prepared to help with the emotional needs

of a patient. ___
20. Lack of an opportunity to express to other personnel
on the unit my negative feelings towards patients. ___

21. Difficulty in working with a particular nurse (or nurses)

in my immediate work setting.. ___
22. Difficulty in working with a particular nurse (or nurses)
outside my immediate work setting... ___
23. Not enough time to provide emotional support to the patient... ___
24. A physician not being present in a medical emergency. ___

25. Being blamed for anything that goes wrong.. ___

26. Experiencing discrimination on the basis of sex___
27. The death of a patient ___
28. Disagreement concerning the treatment of a patient. ___

29. Feeling inadequately trained for what I have to do___

30. Lack of support of my immediate supervisor ... ___
31. Criticism by a supervisor... ___
32. Not enough time to complete all of my nursing tasks... ___

33. Not knowing what a patient or a patients family ought

to be told about the patients condition and its treatment.. ___
34. Being the one that has to deal with the patients families. ___
35. Having to deal with violent patients.. ___
36. Being exposed to health and safety hazards.. ___

37. The death of a patient with whom you developed a close relationship. ___
38. Making a decision concerning a patient when the
physician is unavailable. ___
39. Being in charge with inadequate experience. ___
40. Lack of support by nursing administration ___

41. Too many non-nursing tasks required, such as clerical work ... ___
42. Not enough staff to adequately cover the unit.. ___
43. Uncertainty regarding the operation and functioning
of specialised equipment.. ___
44. Having to deal with abusive patients ___
Appendix 3
Never Occasionally Frequently Extremely Does Not
Stressful Stressful Stressful Stressful Apply
1 2 3 4 5

45. Not enough time to respond to the needs of patients families.. ___
46. Being held accountable for things over which I have no control.. ___
47. Physician(s) not being present when a patient dies... ___
48. Having to organise doctors work. ___

49. Lack of support from other health care administrators.. ___

50. Difficulty in working with nurses of the opposite sex... ___
51. Demands of patient classification system.. ___
52. Having to deal with abuse from patients families ___

53. Watching a patient suffer... ___

54. Criticism from nursing administration... ___
55. Having to work through breaks..___
56. Not knowing whether patients families will report you for
inadequate care.. ___

57. Having to make decisions under pressure. ___

Appendix 3
Instructions for the Scoring of the ENSS

There are a total of 59 items in the Expanded Nursing Stress Scale. Two items (#6
and #14) did not appear to be related to any of the nine subscales that emerged in
the original study of Ontario nurses (Susan French, Rhonda Lenton, John Eyles and
Vivienne Walters. "An Empirical Evaluation of an Expanded Nursing Stress Scale".
Journal of Nursing Measurement, Vol. 8, No. 2, 2000), but we suggest retaining
those items for now. Subsequent applications would be able to assess whether
these two items load on the subscales in any situations or among different
populations of nurses. The nine subscales that have emerged, and the items in each
subscale are as follows:

a) Death and Dying - items 1, 10, 19, 29, 39, 49 and 55

b) Conflict with physicians - items 2, 11, 30, 40, and 50
c) Inadequate preparation - items 3, 12, and 21
d) Problems with peers - items 4, 13, 22, 23, 24, 52
e) Problems with supervisors - items 33, 42, 48, 51, and 56
f) Workload - items 15, 25, 34, 43, 44, 47, 53, 57, and 59
g) Uncertainty concerning treatment - items 7, 16, 26, 31, 35, 38, 41 and 45
h) Patients and their families - items 8, 17, 27, 36, 37, 46, 54, and 58
i) Discrimination - items 9, 18, and 28

In order to compute total stress score, we added together the scores on all 59 items.
In order to measure scores on specific subscales, the appropriate items should be
added together. In all cases, the category not applicable was scored as 0.
Addressing missing data depends on the extent of the problem. While several
options are available (some more complicated, such as using a regression method to
estimate missed scores), we substituted missing values with mean scores for
individual items, and proceeded to calculate the subscale score for any individual
who had answered the majority of items in any subscale. In the case of the Death
and Dying subscale, for example, an individual would have to have answered at
least 4 of the 7 items that comprise the subscale. Otherwise, the subscale was not
constructed, and the individual received was scored missing for that specific
subscale.

Items were scored so that the higher the score, the greater the stress on any
subscale.

It would be appreciated if you would forward a copy of your analysis of the ENSS to
Dr. Lenton, at York University, and to Dr. Susan French at McGill University, so that
we are able to monitor the assessment of the ENSS.

Rhonda Lenton, PhD (Sociology)

Susan E. French, R.N., PhD e-mail address: susan.french@mcgill.ca

Appendix 3
Grouping of Items Within Factors in the Expanded Nursing Stress Scale

Factor 1: Death and Dying

Performing procedures that patients experience as painful.

Feeling helpless in the case of a patient who fails to improve.
Listening or talking to a patient about his/her approaching death.
The death of a patient.
The death of a patient with whom you have developed a close relationship.
Physician not being present when a patient dies.
Watching a patient suffer.

Factor 2: Conflict with Physicians

Criticism by a physician.
Conflict with a physician.
Disagreement concerning the treatment of a patient.
Making a decision concerning a patient when the physician is unavailable.
Having to organize physicians work.

Factor 3: Inadequate Emotional Preparation

Feeling inadequately prepared to help with the emotional needs of a patients family.
Being asked a question by a patient for which I do not have a satisfactory answer.
Feeling inadequately prepared to help with the emotional needs of a patient.

Factor 4: Problems Relating to Peers

Lack of an opportunity to talk openly with other unit personnel about problems in the work setting.
Lack of an opportunity to share experiences and feelings with other personnel in the work setting.
Lack of an opportunity to express to other personnel on the unit my negative feelings toward patients.
Difficulty in working with a particular nurse (or nurses) outside my immediate work setting.
Difficulty in working with a particular nurse (or nurses) inside my immediate work setting.
Difficulty in working with nurses of the opposite sex.

Factor 5: Problems Relating to Supervisors

Conflict with a supervisor.

Lack of support from my immediate supervisor.
Lack of support by nursing administrators.
Lack of support by other health care administrators.
Criticism by a supervisor.
Being held accountable for things over which I have no control.
Criticism by nursing administration.

Factor 6: Work Load

Unpredictable staffing and scheduling.

Too many non-nursing tasks required such as clerical work.
Not enough time to provide emotional support to a patient.
Not enough time to complete all of my nursing tasks.
Not enough staff to adequately cover the unit.
Not having enough time to respond to the needs of the patients families.
Demands of patient classification system.
Having to work through breaks.
Appendix 3
Having to make decisions under pressure.

Factor 7: 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.
Fear of making a mistake in treating a patient.
A physician not being present in a medical emergency.
Not knowing what a patient or a patients family ought to be told about the patients condition and its
treatment.
Being exposed to health and safety hazards.
Uncertainty regarding the operation and functioning of specialized equipment.
Feeling in adequately trained for what I have to do.
Being in charge with inadequate experience

Factor 8: Patients and their Families

Patients making unreasonable demands.

Patients families making unreasonable demands.
Being blamed for anything that goes wrong.
Being the one who has to deal with patients families.
Having to deal with violent patients.
Having to deal with abusive patients.
Having to deal with abuse from patients families.
Not knowing whether patients families will report you for inadequate care.

Factor 9: Discrimination

Being sexually harassed.

Experiencing discrimination because of race or ethnicity.
Experiencing discrimination on the basis of sex.
 School of Public Health
Appendix 4 and Health S c i e n c e s

Department of
Community Health Studies
MASS.
voice: 413.545.1312
fax: 413.545.6536

October 10, 2005

Haji Abd Rahim Haji Damit
School of Nursing
Queensland University of Technology
Victoria Park Road
Kelvin Grove 4059
AUSTRALIA

Dear Mr. Damit:

I appreciate receiving your request for permission to use the Index of Work Satisfaction
(IWS) in the very interesting research project described in your recent letter. The second
edition of my book Nurses and Work Satisfaction: An Index of Measurement, 2nd Edition
(1997) gives the most recent version of the IWS, along with the statistical description of
the scale itself. Also included in this volume are results from over 80 studies that have
used the IWS. Several investigators write about their experiences using this measurement
tool. The book may be ordered by you or your school's library from Health
Administration Press (US $43.00) by mail, telephone or fax:

Health Administration Press

P.O. Box 401
Annapolis Junction, MD 20701-0401

Phoneorders: 301-362-6905
FAX # 301-206-9789
ISBN #1 -56793-061-1

The IWS questionnaire is a copyrighted measurement tool, with the copyright held by
myself and Market Street Research, Inc., a full-service marketing research and evaluation
firm located in Northampton, Massachusetts. If you wish to use the IWS questionnaire, a
fee of $30.00 payable to Market Street Research covers permission to use the
questionnaire, a print-ready hard copy formatted for use in your study, and an IBM-
compatible floppy diskette which you can use in the event you wish to add questions of

@Printed on Recycled Paper

 Appendix 4

interest to your particular area of research. Other services available from Market Street
Research include:

A step-by step instruction manual so you can score the IWS yourself
Data entry services; scoring assistance and basic data analysis
Technical assistance in modifying or expanding the questionnaire

I have enclosed a complete description of these services as well as a price list. Please
send any checks directly to Market Street Research, using the order form I have included.
If you do decide to use the IWS in your study, you will need the scoring manual unless
you would like for Market Street Research to do the scaring for you. This scoring service
comes with a basic analysis and results are available quickly. If you have any questions
about the IWS or any of the support services available for users of the IWS, please call
either myself or Market Street Research. Market Street Research does not need a separate
letter from you.

I would very much appreciate hearing about your results, as I am keeping a file of the
types of research for which people are using the IWS. Good luck with your study and feel
free to contact me for any additional information.

Sincerely,

Paula Stamps, Ph.D.

University of Massachusetts
Phone: (413) 545-6880
Fax: (413) 545-6536
Email: pstamps@sover.net
 Appendix 4

INDEX OF WORK SATISFACTION DESCRIPTION OF SERVICES

Market Street Research, Inc. is a full-service, independent marketing research firm
based in Northampton, Massachusetts, with over 20 years of experience in providing state-of-
the-art, custom-designed marketing and evaluation research services to clients within a wide
range of health care settings, Far the past three years, Market Street Research has worked
closely with Paula Stamps, Ph.D., to develop services which will support users of the Index of
Work Satisfaction (IWS). The following services are available from Market Street Research
and/or Paula Stamps:

1. Questionnaires: The copyrighted version of the IWS questionnaire is available as a print-

ready paper copy and on an IBM-compatible floppy diskette for $30.00. Users may
customize the questionnaires by adding items or with minor changes in wording to reflect
local institutional characteristics. Market Street Research or Paula Stamps can also provide
technical assistance in questionnaire design or data collection methods at a consulting rate
oof $150.00 per hour.

2. Scoring instructions. A packet that gives step-by-step instructions for scoring the IWS is
available for $60.00. The packet describes the method for scoring both parts of the
questionnaire. The instructions for each part are given separately for those who are using
only one part of the scale. These instructions may be used by researchers to create their
own computerized scoring programs, if desired.

3. Scoring service with data entry. For those who do not wish to score their own
questionnaires, completed questionnaires can be scored by Market Street Research. The
fee will vary depending on the number of questionnaires to be entered and analyzed, the
degree to which researchers added to or otherwise modified the IWS, and the level of
analysis. If the copyrighted IWS questionnaire is used as is, the baseline fee for a sample
size of 50 nurses is $975.00 plus $2.30 per additional questionnaire. This fee includes data
entry and scoring, with users receiving a summary of the scores and a data file on diskette.

4. Scaring service without data entry. Some organizations have the ability to do their own
data entry of completed questionnaires, but would like assistance in scoring the IWS.
Market Street Research will provide these researchers with instructions an formatting the
data appropriately. The fee far simple scoring of the IWS is $775.00 per data set.

5. Technical assistance in design. Although many studies using the IWS are
straightforward, some involve more complicated designs. Some studies using the IWS
involve management or job redesign initiatives and are primarily concerned with evaluation.
Assistance is available in designing these studies and interpreting the results. Management
consulting, the creation of altemative managerial systems, and evaluation and marketing
research services are also available. Prices for this are determined based on individual
requirements.

Users must receive permission to use the copyrighted version of the IWS in order to
access the support servicesprovided by Market Street Research, In addition, researchers who
request IWS scoring services will be asked to submit summary information for their research
projects to Market Street Rasearch, which will be incorporated in a national data base that we
are developing. Your results will be held strictly confidential, and will be combined with those of
other research projects in order to build a better understanding of the variations in IWS results
among diverse institutions. For questions relating to use of the national data base, please
contact Paula Stamps.
Appendix 4

FOR MORE INFORMATION, CONTACT:

Attn: IWS Support

Market Street Research, Inc.
2 Maple Ave., Suite 52
Northampton,MA 01060
Phone: (413) 584-0465
Fax:(413) 582-1206
Ernaii: dmasi@marketstreetresearch.com
Appendix 4

IWS ORDER FORM FOR PRODUCTS AND SERVICES

(valid through May 2003)

* Not available without initial purchase of copyrighted IWS questionnaire.

** Make checks payable to: Market Street Research, Inc.

Name:

Organization:

Address:

City: State: Zip:

Phone: Fax:

TYPE OF ORGANIZATION:
hospital managed care organization

hospital/healthsystem graduate student

visiting nurse association college or university faculty

other home health care organization other:

MAIL ORDERS TO: Attn: IWS Orders

Market Street Research, Inc.
2 Maple Avenue, Suite 52
Northampton, MA 01060
Appendix 4

November 22, 2005

Abd Rahim Damit

No 23 A
Simpang 97, 97-23
Jalan Kiarong
Kampong Kiulap
BE 1518
Negara Brunei Darussalam

To Whom It May Concern:

This letter gives Abd Rahim Damit permission to use the copyrighted Index of Work
Satisfaction. It maybe re-published in its original form or a modified form.

Sincerely,

Doreen Masi
Market Street Research
Appendix 4
Date: Tue 22 Nov 03:20:17 EST 2005
From: Doreen Masi <dmasi@marketstreetresearch.com> Add To Address
Book | This is Spam
Subject: Your Index of Work Satisfaction Order
To: h.hajidamit@student.qut.edu.au
Hello Abd,
My name is Doreen Masi, I work at Market Street Research. I received
your order for IWS questionnaire and Scoring Manual in Friday's mail.

To make things easier, I could send you both items via email to this
email address. I wanted to check in with you before doing so. If
you
could reply to this email and let me know if I can send off the items
via email, that would be great. The questionnaire would be in Word
6.0
and the scoring manual would be a pdf file. Please let me know how
to
proceed.
I look forward to hearing back from you,
Doreen

--
Doreen Masi
Office Manager
Market Street Research
2 Maple Avenue, Suite 52
Northampton, MA 01060
413-584-0465
fax: 413-582-1206
dmasi@marketstreetresearch.com
Appendix 4
Date: Wed 23 Nov 05:01:21 EST 2005
From: Doreen Masi <dmasi@marketstreetresearch.com> Add To Address
Book | This is Spam
Subject: Re: Your Index of Work Satisfaction Order
To: h.hajidamit@student.qut.edu.au
Hi Rahim,
I'm very glad you liked my idea and hopefully this will speed things
along for you. Attached you will find the questionnaire and the
scoring manual. I have also included a letter of permission to use
the survey, just in case you need to submit a document such as this
with your study. If I can be of further assistance, do not hesitate
to contact me.

I wish you luck!

Doreen

h.hajidamit@student.qut.edu.au wrote:

Dear Doreen Masi,

Thanks a lot. That would be great. Yes you could send those
items to this email address.

I appreciate you brilliant idea.

Kindly regards,
Rahim Damit
h.hajidamit@student.qut.edu.au
+614 2495 4660
+617 3252 0250

H67
Cathedral Place
41 Gotha Street
FORTITUDE VALLEY
QLD 4006
Brisbane
Queensland
Australia

Doreen Masi
Office Manager
Market Street Research
2 Maple Avenue, Suite 52
Northampton, MA 01060
413-584-0465
fax: 413-582-1206
dmasi@marketstreetresearch.com

Attachment: IWS-quest-ver6-0.doc (206k bytes) Open

Attachment: IWS Score Manual.pdf (236k bytes) Open

Attachment: Permission_letter.doc (63k bytes) Open

Appendix 4
The Index of Work Satisfaction Questionnaire

Part A (Paired Comparisons)

Listed and briefly defined below are six terms or factors that are involved in
how people feel about their work situation. Each factor has something to do
with work satisfaction. We are interested in determining which of these is
most important to you in relation to the others.

Please carefully read the definitions for each factor as given below:

Pay -- dollar remuneration and fringe benefits received for work done

Autonomy -- amount of job related independence, initiative, and

freedom, either permitted or required in daily work activities.

Task Requirements -- tasks or activities that must be done as a regular

part of the job

Organizational Policies -- management policies and procedures put

forward by the hospital and nursing administration of this hospital

Interaction -- opportunities presented for both formal and informal social

and professional contact during working hours

Professional Status -- overall importance or significance felt about your

job, both in your view and in the view of others

Instructions: These factors are presented in pairs on the next page. A

total of 15 pairs are presented: this is every set of combinations. No pair is
repeated or reversed. For each pair of terms, decide which one is more
important for your job satisfaction or morale, and check the appropriate box.
For example, if you feel that Pay (as defined above) is more important than
Autonomy (as defined above), check the box for Pay.

It will be difficult for you to make choices in some cases. However, please
do try to select the factor which is more important to you. Please make an
effort to answer every item; do not go back to change any of your answers.

The IWS Questionnaire is used by permission of Paula L. Stamps, Ph.D., and

Market Street Research, Inc., Northampton, Massachusetts.
Appendix 4
Part A (Paired Comparisons, Continued)
Please choose the one member of the pair which is most important to you.

1. Professional Status or Organizational Policies

2. Pay Requirements or Task Requirements
3. Organizational Policies or Interaction
4. Task Requirements or Organizational Policies
5. Professional Status or Task Requirements
6. Pay or Autonomy
7. Professional Status or Interaction
8. Professional Status or Autonomy
9. Interaction or Task Requirements
10. Interaction or Pay
11. Autonomy or Task Requirements
12. Organizational Policies or Autonomy
13. Pay or Professional Status
14. Interaction or Autonomy
15. Organizational Policies or Pay

Part B (Attitude Questionnaire)

The following items represent statements about how satisfied you are with
your current nursing job. Please respond to each item. It may be very
difficult to fit your responses into the seven categories; in that case, select
the category that comes closest to your response to the statement. It is
very important that you give your honest opinion. Please do not go back
and change any of your answers.

Instructions: Please circle the number that most closely indicates how
you feel about each statement. The left set of numbers indicates degrees of
agreement. The right set of numbers indicates degrees of disagreement.
For example, if you strongly agree with the first item, circle 1; if you agree
with this item, circle 2; if you moderately agree with the first statement, circle
3. The middle response (4) is reserved for feeling neutral or undecided.
Please use it as little as possible. If you moderately disagree with this first
item, you should circle 5; to disagree, circle 6; and to strongly disagree,
circle 7.

IWS Questionnaire 2
 Appendix 4
Part B (Attitude Questionnaire, Continued)
Remember: The more strongly you feel about the statement, the further
from the center you should circle, with agreement to the left and
disagreement to the right. Use 4 for neutral or undecided if needed, but
please try to use this number as little as possible.

Agree Disagree
1. My present salary is satisfactory. 1 2 3 4 5 6 7
2. Nursing is not widely recognized as being an
important profession.
1 2 3 4 5 6 7
3. The nursing personnel on my service pitch in and
help one another out when things get in a rush.
1 2 3 4 5 6 7
4. There is too much clerical and paperwork required
of nursing personnel in this hospital.
1 2 3 4 5 6 7
5. The nursing staff has sufficient control over
scheduling their own shifts in my hospital.
1 2 3 4 5 6 7
6. Physicians in general cooperate with nursing staff
on my unit.
1 2 3 4 5 6 7
7. I feel that I am supervised more closely than is
necessary.
1 2 3 4 5 6 7
8. It is my impression that a lot of nursing personnel at
this hospital are dissatisfied with their pay.
1 2 3 4 5 6 7
9. Most people appreciate the importance of nursing
care to hospital patients.
1 2 3 4 5 6 7
10. It is hard for new nurses to feel at home in my unit. 1 2 3 4 5 6 7
11. There is no doubt whatever in my mind that what I
do on my job is really important.
1 2 3 4 5 6 7
12. There is a great gap between the administration of
this hospital and the daily problems of the nursing 1 2 3 4 5 6 7
service.
13. I feel I have sufficient input into the program of care
for each of my patients.
1 2 3 4 5 6 7
14. Considering what is expected of nursing service
personnel at this hospital, the pay we get is 1 2 3 4 5 6 7
reasonable.
15. I think I could do a better job if I did not have so
much to do all the time. 1 2 3 4 5 6 7
16. There is a good deal of teamwork and cooperation
between various levels of nursing personnel on my 1 2 3 4 5 6 7
service.

IWS Questionnaire 3
 Appendix 4
Part B (Attitude Questionnaire, Continued)
Remember: The more strongly you feel about the statement, the further
from the center you should circle, with agreement to the left and
disagreement to the right. Use 4 for neutral or undecided if needed, but
please try to use this number as little as possible.

Agree Disagree
17. I have too much responsibility and not enough
authority. 1 2 3 4 5 6 7
18. There are not enough opportunities for
advancement of nursing personnel at this hospital.
1 2 3 4 5 6 7
19. There is a lot of teamwork between nurses and
doctors on my own unit.
1 2 3 4 5 6 7
20. On my service, my supervisors make all the
decisions. I have little direct control over my own 1 2 3 4 5 6 7
work.
21. The present rate of increase in pay for nursing
service personnel at this hospital is not satisfactory.
1 2 3 4 5 6 7
22. I am satisfied with the types of activities that I do on
my job.
1 2 3 4 5 6 7
23. The nursing personnel on my service are not as
friendly and outgoing as I would like.
1 2 3 4 5 6 7
24. I have plenty of time and opportunity to discuss
patient care problems with other nursing service 1 2 3 4 5 6 7
personnel.
25. There is ample opportunity for nursing staff to
participate in the administrative decision-making 1 2 3 4 5 6 7
process.
26. A great deal of independence is permitted, if not
required, of me.
1 2 3 4 5 6 7
27. What I do on my job does not add up to anything
really significant.
1 2 3 4 5 6 7
28. There is a lot of rank consciousness on my unit:
nurses seldom mingle with those with less
experience or different types of educational
1 2 3 4 5 6 7
preparation.
29. I have sufficient time for direct patient care. 1 2 3 4 5 6 7
30. I am sometimes frustrated because all of my
activities seem programmed for me.
1 2 3 4 5 6 7
31. I am sometimes required to do things on my job
that are against my better professional nursing 1 2 3 4 5 6 7
judgment.

IWS Questionnaire 4
 Appendix 4
Part B (Attitude Questionnaire, Continued)
Remember: The more strongly you feel about the statement, the further
from the center you should circle, with agreement to the left and
disagreement to the right. Use 4 for neutral or undecided if needed, but
please try to use this number as little as possible.

Agree Disagree
32. From what I hear about nursing service personnel
at other hospitals, we at this hospital are being fairly 1 2 3 4 5 6 7
paid.
33. Administrative decisions at this hospital interfere
too much with patient care.
1 2 3 4 5 6 7
34. It makes me proud to talk to other people about
what I do on my job.
1 2 3 4 5 6 7
35. I wish the physicians here would show more
respect for the skill and knowledge of the nursing 1 2 3 4 5 6 7
staff.
36. I could deliver much better care if I had more time
with each patient.
1 2 3 4 5 6 7
37. Physicians at this hospital generally understand
and appreciate what the nursing staff does.
1 2 3 4 5 6 7
38. If I had the decision to make all over again, I would
still go into nursing.
1 2 3 4 5 6 7
39. The physicians at this hospital look down too much
on the nursing staff.
1 2 3 4 5 6 7
40. I have all the voice in planning policies and
procedures for this hospital and my unit that I want
1 2 3 4 5 6 7
41. My particular job really doesnt require much skill or
know-how.
1 2 3 4 5 6 7
42. The nursing administrators generally consult with
the staff on daily problems and procedures.
1 2 3 4 5 6 7
43. I have the freedom in my work to make important
decisions as I see fit, and can count on my 1 2 3 4 5 6 7
supervisors to back me up.
44. An upgrading of pay schedules for nursing
personnel is needed at this hospital.
1 2 3 4 5 6 7

IWS Questionnaire 5
Appendix 5
Faculty of Health
School of Nursing
Queensland University of Technology

SUBJECT INFORMATION SHEET

JOB STRESS PROJECT

Chief Investigator: Mr Abd Rahim Damit

Room N-602 (level 6)
QUT School of Nursing
Phone : +614 2495 4660
: +673 8891226
: +617 3252 0250 Fax
: h.hajidamit@student.qut.edu.au

Principal Supervisor Sheree Smith

Room N-537 (Level 5)
QUT School of Nursing
Phone : +617 3864 3905
: sm.smith@qut.edu.au

Associate Supervisor Professor Patsy Yates

Room N-334
QUT School of Nursing
Phone : +617 3864 3835
: p.yates@qut.edu.au

Dear Colleagues,
I am a student, currently undertaking HL84 Master of Applied Science (Research) at the Queensland
University of Technology (QUT), Brisbane Queensland Australia. As part of this degree I am working on my
major study supported by academic staff from the School of Nursing, at QUTs Faculty of Health.
The primary aim of this study is to investigate new graduate nurses perceptions of stress in todays
complex clinical working environment.

The study objectives are to:

1. Identify levels and sources of stress experienced by new graduate nurses

2. Compare levels and sources of stress experienced by new graduate nurses working in operating
theatre, surgical, medical and intensive care units.
3. Explore the relationship between the levels of stress among new graduate nurses in operating
theatre, surgical, medical and intensive care units and
o fear of failure to carry out nursing tasks,
o fear of making mistakes,
o conflicts with supervisor and other healthcare professionals,
o experience of being discriminated,
o perceived support from supervisors,
o perceived organisational skills,
o experience dealing with the death and dying and new complex working environment.
1

hard, 2005 -2006.

Master of Applied Science Research Student, QUT, Brisbane, Australia.
Appendix 5
I am writing to you because you are a new graduate working in the clinical departments of interest to
this study. I hope that you will be able to help me with this project. I am, therefore requesting you to take a few
minutes of your time to complete the attached questionnaire and return it to me no later than Friday, 17th March
2006. Your feedback will be used to plan for future improvements to our nursing education programs and to
assist with creating a good working environment for new graduates.

Your participation in this project is voluntary and if you do feel any discomfort regarding questions in
this survey, you are free to withdraw from the study at any time. There are no right or wrong answers and the
information that you are going to provide will be confidential, no identifying information is required. If you
require further information about the project or have any questions, please contact me on +673 8891226 (mp)
Brunei Darussalam or +61732520250(hp/Fax); +61424954660 (hp) email: h.hajidamit@student.qut.edu.au
Australia Haji Abd Rahim bin Haji Damit as the chief investigator.

I would like to take the opportunity in advance to say thank you for your consideration and any
information that you can give me. I enclose a stamped addressed envelope for returning of the survey.
Alternatively, you may drop them into the box provided in each unit.

Yours sincerely

(Mr Rahim Damit)

----------------------------------------------------------------------------------------------------

I confirm that (Mr Rahim Damit) is currently enrolled in the HL84 Master of Applied Science
(Research) Degree in the Faculty of Health, School of Nursing at the Queensland University of Technology,
Brisbane Queensland Australia and any assistance given by you would be very much appreciated.

Signed.............................. Ms Sheree Smith. Project principal investigators supervisor

email: sm.smith@qut.edu.au

Date: .

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Appendix 5

INFORMATION FOR JOB STRESS PROJECT PARTICIPANTS

Thank you for agreeing to participate in this study. Work situations typically experienced and
encountered by nurses in day to day practice may be stressful. The valuable information you provide will assist
me as the project chief investigator to investigate new graduate nurses perceptions of stress in the new complex
clinical working environment.

Please read the subject information sheet carefully. If you are a staff nurse who currently works in Raja
Isteri Pengiran Anak Saleha (RIPAS) Hospital and you have less than 36 months (3 years), experience working
as a hospital staff nurse then you are invited to participate.

Be assured that all your responses are confidential and no information about the project will be
published in any form that would allow any individual to be recognised. All information is coded so that you will
remain anonymous. Your participation is voluntary. Completion of the questionnaire should take no longer than
thirty minutes.

If you wish to discuss any aspect of this study feel free to contact Abd Rahim Damit on +673 8891226
or +614 2495 4660. You may also contact the project chief investigators supervisor Sheree Smith on +617 3864
3905 or Queensland University of Technology, Research Ethics Officer on +617 3864 2340 or Director General,
Medical Services Department, Ministry of Health, Brunei Darussalam on +673 2381887 Fax.

Thank you again for your cooperation.

Participant information sheet read

SURVEY NUMBER OT, MICU.SICU,CCU, A&E, PICU,ORL,WARDS 1,2,3,4,6,7,8,9,10,11,19,20,21,22

For your convenience, you may return the complete questionnaire to me by post using the
enclosed pre-paid envelop. Alternatively, you may drop them into the box provided in each unit.

Date Received: CONFIDENTIAL

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Appendix 5
This part of the questionnaire is about your DEMOGRAPHIC INFORMATION. For each of the following
items, please tick ( / ) or darken the bubble on your choice that matches your response in relationship to your
staff nurse position.

1. In what year were you born? 19

2. What is your sex?

Male Female

3. What is the highest level of nursing education that you have?

Registered Nurse (Diploma in Nursing)

Registered Nurse + Post Basic Diploma (Nursing Speciality)

Registered Nurse + Bachelor Degree in Nursing/ Honours

Registered Nurse + Postgraduate Certificate (Nursing Speciality)

Registered Nurse + Postgraduate Diploma (Nursing Speciality)

4. How long have you been working as a Registered Nurse?

0 less than 1 year

1 Year less than 2 years

2 Years less than 3 years

5. How long have you been working in this unit as a Registered Nurse?

0 less than 1 year

1 Year less than 2 years

2 Years less than 3 years

6. Marital Status

Single (never married)

Married

Divorced

Widowed

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Appendix 5
7. Which ethnic group you belong to

Malay

Chinese

Indian

Indigenous

Others, please state

8. Do you have children?

Yes

No

Not Applicable

9. How many children do you have?

One

Two

Three

More than four

Not Applicable

10. How old are your children?

Pre School Age (0 less than 5 years) number of children in this range

School Age (5 less than 10 years) number of children in this range

Teenager (10 less than 20 years) number of children in this range

Adult (20 or above) number of children in this range

Not Applicable

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE

5

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Appendix 5
11. If you have children, how much support do you have at home to care for them?

Not Applicable

VERY
GOOD POOR NO
GOOD AVERAGE
SUPPORT SUPPORT SUPPORT
SUPPORT

1 2 3 4 5
1 HUSBAND
2 HOUSE MAID
3 PARENTS / IN LAW
SISTER/ BROTHER/ IN
4
LAW

12. Home ownership status

Owned Outright

Renting

Living in Parents Dwelling

Government Residence (Flat/House)

SECTION: 2

This part of the questionnaire relates to HOW YOU FEEL ABOUT YOUR OVERALL CLINICAL
PRACTICE as a new graduate staff nurse. Please tick ( / ) or darken the bubble underneath the numbers in the
right hand column on your choice to indicate on the following scale that includes "(1) Strongly Disagree", "(2)
Disagree", "(3) Uncertain" "(4) Agree" and (5) Strongly Agree.

STRONGLY
DISAGREE UNCERTAIN AGREE STRONGLY
DISAGREE
AGREE
1 2 3 4 5
1 CONFIDENT

2 COMPETENT

3 ORGANISED

PLEASE ADD ANY

COMMENTS HERE TO
4
ELABORATE ON YOUR
ANSWERS

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE

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Appendix 5
SECTION: 3

Occasionally Stressful

Frequently Stressful

Extremely Stressful
Below is a list of situations that commonly occur in a work setting. For each

Does Not Apply

Never Stressful
situation you have encountered in your PRESENT WORK SETTING, would you
indicate HOW STRESSFUL it has been for you: Tick ( / ) or darken the bubble
underneath the numbers in the right hand column that best applies to you. If you
have not encountered the situation, Tick ( / ) or darken the bubble underneath '0'.

No Items 1 2 3 4 0
1 Performing procedures that patients experience as painful

2 Criticism by a physician

Feeling inadequately prepared to help with the emotional needs of a patient's

3
family
Lack of opportunity to talk openly with other personnel about problems in the
4
work setting
5 Conflict with a supervisor

6 Breakdown of computer

Inadequate information from a physician regarding the medical condition of a

7
patient
8 Patients making unreasonable demands

9 Being sexually harassed

10 Feeling helpless in the case of a patient who fails to improve

11 Conflict with a physician

12 Being asked a question by a patient for which I do not have a satisfactory answer
Lack of opportunity to share experiences and feelings with other personnel in the
13
work setting
14 Floating to other units/services that are short-staffed

15 Unpredictable staffing and scheduling

16 A physician ordering what appears to be inappropriate treatment for a patient

17 Patients' families making unreasonable demands

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE

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Appendix 5

Occasionally Stressful

Frequently Stressful

Extremely Stressful
Below is a list of situations that commonly occur in a work setting. For each situation

Does Not Apply

Never Stressful
you have encountered in your PRESENT WORK SETTING, would you indicate HOW
STRESSFUL it has been for you: Tick ( / ) or darken the bubble underneath the
numbers in the right hand column that best applies to you. If you have not encountered
the situation, Tick ( / ) or darken the bubble underneath '0'.

1 2 3 4 0
18 Experiencing discrimination because of race or ethnicity

19 Listening or talking to a patient about his/her approaching death

20 Fear of making a mistake in treating a patient

21 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

22
feelings towards patients
Difficulty in working with a particular nurse (or nurses) inside my immediate work
23
setting
Difficulty in working with a particular nurse (or nurses) outside my immediate work
24
setting
25 Not enough time to provide emotional support to the patient

26 A physician not being present in a medical emergency

27 Being blamed for anything that goes wrong

28 Experiencing discrimination on the basis of sex

29 The death of a patient

30 Disagreement concerning the treatment of a patient

31 Feeling inadequately trained for what I have to do

32 Lack of support from my immediate supervisor

33 Criticism by a supervisor

34 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 patient's
35
condition and its treatment
36 Being the one that has to deal with patients' families

37 Having to deal with violent patients

38 Being exposed to health and safety hazards

39 The death of a patient with whom you developed a close relationship

40 Making a decision concerning a patient when the physician is unavailable

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE 8

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Appendix 5

Occasionally Stressful

Frequently Stressful

Extremely Stressful
Below is a list of situations that commonly occur in a work setting. For each

Does Not Apply

Never Stressful
situation you have encountered in your PRESENT WORK SETTING, would you
indicate HOW STRESSFUL it has been for you: Tick ( / ) or darken the bubble
underneath the numbers in the right hand column that best applies to you. If you
have not encountered the situation, Tick ( / ) or darken the bubble underneath '0'.

1 2 3 4 0
41 Being in charge with inadequate experience

42 Lack of support by nursing administrators

43 Too many non-nursing tasks required, such as clerical work

44 Not enough staff to adequately cover the unit

45 Uncertainty regarding the operation and functioning of specialized equipment

46 Having to deal with abusive patients

47 Not enough time to respond to the needs of patients' families

48 Being held accountable for things over which I have no control

49 Physician(s) not being present when a patient dies

50 Having to organize doctors' work

51 Lack of support from other health care administrators

52 Difficulty in working with nurses of the opposite sex

53 Demands of patient classification system

54 Having to deal with abuse from patients' families

55 Watching a patient suffer

56 Criticism by nursing administration

57 Having to work through breaks

58 Not knowing whether patients' families will report you for inadequate care

59 Having to make decisions under pressure

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE

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Appendix 5
SECTION: 4

The Index of Work Satisfaction Questionnaire

Part A (Paired Comparisons)

Listed and briefly defined below are six terms or factors that are involved in how people feel about
their work situation. Each factor has something to do with work satisfaction. We are interested in
determining which of these is most important to you in relation to the others.

Please carefully read the definitions for each factor as given below:

Pay -- dollar remuneration and fringe benefits received for work done

Autonomy -- amount of job related independence, initiative, and freedom, either permitted or
required in daily work activities.

Task Requirements -- tasks or activities that must be done as a regular part of the job

Organizational Policies -- management policies and procedures put forward by the hospital
and nursing administration of this hospital

Interaction -- opportunities presented for both formal and informal social and professional
contact during working hours

Professional Status -- overall importance or significance felt about your job, both in your view
and in the view of others

Instructions: These factors are presented in pairs on the next page. A total of 15 pairs are
presented: this is every set of combinations. No pair is repeated or reversed. For each pair of
terms, decide which one is more important for your job satisfaction or morale, and check the
appropriate box. For example, if you feel that Pay (as defined above) is more important than
Autonomy (as defined above), check the box for Pay.

It will be difficult for you to make choices in some cases. However, please do try to select the factor
which is more important to you. Please make an effort to answer every item; do not go back to
change any of your answers.

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE

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Appendix 5
SECTION: 4.1
Part A (Paired Comparisons)
Please choose the one member of the pair which is MOST IMPORTANT to you.

1. Professional Status or Organizational Policies

2. Pay Requirements or Task Requirements

3. Organizational Policies or Interaction

4. Task Requirements or Organizational Policies

5. Professional Status or Task Requirements

6. Pay or Autonomy

7. Professional Status or Interaction

8. Professional Status or Autonomy

9. Interaction or Task Requirements

10. Interaction or Pay

11. Autonomy or Task Requirements

12. Organizational Policies or Autonomy

13. Pay or Professional Status

14. Interaction or Autonomy

15. Organizational Policies or Pay

PLEASE ANSWER QUESTIONS ON THE NEXT PAGE

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 Appendix 5
SECTION: 4.2
Part B (Attitude Questionnaire)
The following items represent statements about how satisfied you are with your current nursing job.
Please respond to each item. It may be very difficult to fit your responses into the seven categories;
in that case, select the category that comes closest to your response to the statement. It is very
important that you give your honest opinion. Please do not go back and change any of your
answers.

Instructions: Please tick ( / )or darken the number that most closely indicates how you feel about
each statement. The LEFT set of numbers indicates degrees of AGREEMENT. The RIGHT set of
numbers indicates degrees of DISAGREEMENT. For example, if you strongly agree with the first
item, tick ( / ) or darken no 1; if you agree with this item, tick ( / ) or darken no 2; if you moderately
agree with the first statement, tick ( / ) or darken no 3. The middle response (4) is reserved for feeling
neutral or undecided. Please use it as little as possible. If you moderately disagree with this first item,
you should tick ( / ) or darken no 5; to disagree, tick ( / ) or darken no 6; and to strongly disagree, tick
( / ) or darken no 7.
Remember: The more strongly you feel about the statement, the further from the center you should
darken or tick ( / ), with agreement to the left and disagreement to the right. Use 4 for neutral or
undecided if needed, but please try to use this number as little as possible.

Strongly Strongly
N
Agree Disagree
1 2 3 4 5 6 7
1. My present salary is satisfactory.

2. Nursing is not widely recognized as being an important

profession.
3. The nursing personnel on my service pitch in and help one
another out when things get in a rush.
4. There is too much clerical and paperwork required of
nursing personnel in this hospital.
5. The nursing staff has sufficient control over scheduling their
own shifts in my hospital.
6. Physicians in general cooperate with nursing staff on my unit.

7. I feel that I am supervised more closely than is necessary.

8. It is my impression that a lot of nursing personnel at this

hospital are dissatisfied with their pay.
9. Most people appreciate the importance of nursing care to
hospital patients.
10. It is hard for new nurses to feel at home in my unit.

11. There is no doubt whatever in my mind that what I do on my

job is really important.
12. There is a great gap between the administration of this
hospital and the daily problems of the nursing service.
13. I feel I have sufficient input into the program of care for each
of my patients.
14. Considering what is expected of nursing service personnel at
this hospital, the pay we get is reasonable.
15 I think I could do a better job if I did not have so much to do all
the time.
16. There is a good deal of teamwork and cooperation between
various levels of nursing personnel on my service.
17. I have too much responsibility and not enough authority.

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Master of Applied Science Research Student, QUT, Brisbane, Australia.
 Appendix 5
Strongly Strongly
N
Agree Disagree
1 2 3 4 5 6 7
18. There are not enough opportunities for advancement of
nursing personnel at this hospital.
19. There is a lot of teamwork between nurses and doctors on my
own unit.
20. On my service, my supervisors make all the decisions. I have
little direct control over my own work.
21. The present rate of increase in pay for nursing service
personnel at this hospital is not satisfactory.
22. I am satisfied with the types of activities that I do on my job.

23. The nursing personnel on my service are not as friendly and

outgoing as I would like.
24. I have plenty of time and opportunity to discuss patient care
problems with other nursing service personnel.
25. There is ample opportunity for nursing staff to participate in
the administrative decision-making process.
26. A great deal of independence is permitted, if not required, of
me.
27. What I do on my job does not add up to anything really
significant.
28. There is a lot of rank consciousness on my unit: nurses
seldom mingle with those with less experience or different
types of educational preparation.
29. I have sufficient time for direct patient care.

30. I am sometimes frustrated because all of my activities seem

programmed for me.
31. I am sometimes required to do things on my job that are
against my better professional nursing judgment.
32. From what I hear about nursing service personnel at other
hospitals, we at this hospital are being fairly paid.
33. Administrative decisions at this hospital interfere too much
with patient care.
34. It makes me proud to talk to other people about what I do on
my job.
35. I wish the physicians here would show more respect for the
skill and knowledge of the nursing staff.
36. I could deliver much better care if I had more time with each
patient.
37. Physicians at this hospital generally understand and
appreciate what the nursing staff does.
38. If I had the decision to make all over again, I would still go
into nursing.
39. The physicians at this hospital look down too much on the
nursing staff.
40. I have all the voice in planning policies and procedures for this
hospital and my unit that I want
41. My particular job really doesnt require much skill or know-
how.
42. The nursing administrators generally consult with the staff on
daily problems and procedures.
43. I have the freedom in my work to make important decisions as
I see fit, and can count on my supervisors to back me up.
44. An upgrading of pay schedules for nursing personnel is
needed at this hospital.

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 Appendix 5
Section 5.

Please rate how helpful you believe each of the following items Not at all Extremely
would be in assisting your transition into the workplace as a new helpful helpful
graduate nurse
1 2 3 4 5 6 7
No Items

1 Stress management training

2 Education

3 Access to hospital resources

4 Mentoring

5 Team building strategies

6 Balancing priorities

7 Enhancing social and peer support programs

8 Flexibility in working hours

9 Protocols to deals with violence and retention

10 Other (Please specify)

14

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Appendix 5

Please make sure you have ANSWERED ALL QUESTIONS.

No Section Items
1 1 12
2 2 4
3 3 59
4 4.1 15
5 4.2 44
6 5 10
Total 144

Thank you very much for your participation in this study.

Be assured that all your RESPONSES ARE COMPLETELY CONFIDENTIAL.

NOTE:

The IWS Questionnaire used by permiion of Paula L. Stamps, Ph.D., Market Street Research, Inc.,
Northampton, Massachusetts.

@ e ENSS Expanded Nursing Stress Scales used by permission of Susan E. French, Rhonda Lenton,
Vivienne Walters and John Eyles, School of Nursing Department of Sociology and Department of
Geography. McMaster University Canada.

15

SECTION: 1

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Master of Applied Science Research Student, QUT, Brisbane, Australia.
 Appendix 6
Table 33

Frequency Matrix

Most Important
Intensive Care Units a Sample of 41 General Wards Nurses Sample of 53 The Whole Nurses

Organisation

Organisation

Organisation
Requirement

Requirement

Requirement
Professional

Professional

Professional
Interaction

Interaction

Interaction
al Policies

al Policies

al Policies
Autonomy

Autonomy

Autonomy
Status

Status

Status
Task

Task

Task
Pay

Pay

Pay
LEAST IMPORTANT

Pay .707 .561 .610 .512 .463 .623 .491 .547 .642 .472 .660 .521 .574 .585 .468

Autonomy .293 .488 .610 .439 .512 .378 .528 .547 .434 .566 .340 .511 .574 .436 .543

Task Requirement .439 .512 .512 .659 .439 .509 .472 .377 .642 .509 .479 .489 .436 .649 .479

Organisational .390 .390 .488 .610 .561 .453 .453 .623 .642 .698 .426 .426 .564 .628 .638
Policies
Professional Status .488 .561 .341 .390 .512 .358 .566 .358 .358 .472 .415 .564 .351 .372 .489

Interaction .537 .488 .561 .439 .488 .528 .434 .491 .302 .528 .532 .457 .521 .362 .511
 Appendix 7
Table 34 Matrix of Z-Values - Component Weighting Coefficient

Most Important
Intensive Care Units a Sample of 41 General Wards Nurses Sample of 53 The Whole Nurses

Organisation

Organisation

Organisation
Requirement

Requirement

Requirement
Professional

Professional

Professional
Interaction

Interaction

Interaction
al Policies

al Policies

al Policies
Autonomy

Autonomy

Autonomy
Status

Status

Status
Task

Task

Task
Pay

Pay

Pay
LEAST IMPORTANT

Pay 0.545 0.154 0.279 0.030 - 0.093 0.313 -0.023 0.118 0.364 -0.070 .412 .053 .187 .215 -.080

Autonomy -0.545 -0.030 0.279 -0.154 0.030 -0.313 0.070 0.118 -0.166 0.166 -.412 .028 .187 -.161 .108

Task Requirement -0.154 0.030 0.030 0.410 -0.154 0.023 -0.070 -0.313 0.364 0.023 -.053 -.028 -.161 .383 -.053

Organisational -0.279 -0.279 -0.030 0.279 0.154 -0.118 -0.118 0.313 0.364 0.519 -.187 -.187 .161 .327 .353
Policies
Professional Status -0.030 0.154 -0.410 -0.279 0.030 -0.364 0.166 -0.364 -0.364 -0.07 -.215 .161 -.383 -.327 -.028

Interaction 0.093 -0.030 0.154 -0.154 -0.030 0.070 -0.166 -0.023 -0.519 0.070 .080 -.108 .053 -.353 .028

Sum -0.915 0.42 -0.162 0.155 0.535 -0.033 -0.702 0.125 -0.027 -0.96 0.996 0.568 -0.79 0.25 -0.09 - 0.47 0.792 0.3

Mean -0.183 0.084 -0.032 0.031 0.107 -0.006 -0.140 0.025 -0.005 -0.192 0.1992 0.114 -0.16 0.05 -0.02 0.093 0.158 0.06

Component Weighting 2.917 3.184 3.067 3.131 3.207 3.1 2.96 3.125 3.095 2.908 3.299 3.214 2.94 3.15 3.08 3.001 3.258 3.16
Coefficient
Appendix 8
Table 35 Index of Work Satisfaction: Nurse-Nurse

Intensive Care Units Nurses (N= 41) General Wards Nurses (N= 53) Whole Sample 94 Nurses
Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
5 items 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
3. The nursing personnel 22.0 31.7 19.5 22.0 4.9 0 0 18.9 20.8 30.2 18.9 7.5 3.8 0 20.2 25.5 25.5 20.2 6.4 2.1 0
on my service pitch in and (9) (13) (8) (9) (2) (0) (0) (10) (11) (16) (10) (4) (2) (0) (19) (24) (24) (19) (6) (2) (0)
help one another out when
things get in a rush.
16. There is a good deal of 17.1 26.8 31.7 17.1 4.9 0 2.4 17.0 28.3 13.2 7.5 17.0 7.5 9.4 17.0 27.7 21.3 11.7 11.7 4.3 6.4
teamwork and cooperation (7) (11) (13) (7) (2) (0) (1) (9) (15) (7) (4) (9) (4) (5) (16) (26) (20) (11) (11) (4) (6)
between various levels of
nursing personnel on my
service.

** 10. It is hard for new 19.5 17.1 29.3 14.6 7.3 4.9 7.3 24.5 34.0 17.0 13.2 5.7 1.9 3.8 22.3 26.6 22.3 13.8 6.4 3.2 5.3
nurses to feel at home in (8) (7) (12) (6) (3) (2) (3) (13) (18) (9) (7) (3) (1) (2) (21) (25) (21) (13) (6) (3) (5)
my unit.
** 23. The nursing 2.4 4.9 14.6 36.6 14.6 17.1 9.8 15.1 13.2 11.3 20.8 18.9 13.2 7.5 9.6 9.6 12.8 27.7 17.0 14.9 8.5
personnel on my service (1) (2) (6) (15) (6) (7) (4) (8) (7) (6) (11) (10) (7) (4) (9) (9) (12) (26) (16) (14) (8)
are not as friendly and
outgoing as I would like.
** 28. There is a lot of 7.3 12.2 12.2 39.2 14.6 4.9 9.8 18.9 11.3 16.9 13.2 24.5 9.4 5.7 13.8 11.7 14.9 24.5 20.2 7.4 7.4
rank consciousness on (3) (5) (5) (16) (6) (2) (4) (10) (6) (9) (7) (13) (5) (3) (13) (11) (14) (23) (19) (7) (7)
my unit: nurses seldom
mingle with those with less
experience or different
types of educational
preparation.

** Reverse Worded Statement.

Appendix 9
Table 36 Index of Work Satisfaction: Nurse-Physician

Intensive Care Units Nurses (N= 41) General Wards Nurses (N= 53) Whole Sample 94 Nurses
5 items Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree Strongly Agree Strongly Disagree
1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7 1 2 3 4(N) 5 6 7
% % % % % % % % % % % % % % % % % % % % %
(n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n) (n)
6. Physicians in general 9.8 26.8 24.4 29.3 4.9 4.9 0 9.4 9.4 39.6 22.6 7.5 7.5 3.8 9.6 17.0 33.0 25.5 6.4 6.4 2.1
cooperate with nursing (4) (11) (10) (12) (2) (2) (0) (5) (5) (21) (12) (4) (4) (2) (9) (16) (31) (24) (6) (6) (2)
staff on my unit
19. There is a lot of 17.1 26.8 19.5 14.6 14.6 4.9 2.4 13.2 32.1 18.9 11.3 18.9 3.8 1.9 14.9 29.7 19.1 12.8 17.0 4.3 2.1
teamwork between nurses (7) (11) (8) (6) (6) (2) (1) (7) (17) (10) (6) (10) (2) (1) (14) (28) (18) (12) (16) (4) (2)
and doctors on my own
unit.
37. Physicians at this 7.3 12.2 22.0 24.4 17.1 12.2 4.9 5.7 9.4 26.4 18.9 22.6 11.3 5.7 6.4 10.6 24.5 21.3 20.2 11.7 5.3
hospital generally (3) (5) (9) (10) (7) (5) (2) (3) (5) (14) (10) (12) (6) (3) (6) (10) (23) (20) (19) (11) (5)
understand and appreciate
what the nursing staffs
does.

** 35. I wish the 43.9 29.3 9.8 14.6 0 0 2.4 47.2 15.1 28.3 5.7 0 1.9 1.9 45.7 21.3 20.2 9.6 0 1.1 2.1
physicians here would (18) (12) (4) (6) (0) (0) (1) (25) (8) (15) (3) (0) (1) (1) (43) (20) (19) (9) (0) (1) (2)
show more respect for the
skill and knowledge of the
nursing staff.
** 39. The physicians at 17.1 19.5 24.4 24.4 7.3 7.3 0 18.9 17.0 26.4 13.2 15.1 3.8 5.7 18.9 18.9 25.5 18.9 11.7 5.3 3.2
this hospital look down too (7) (8) (10) (10) (3) (3) (0) (10) (9) (14) (7) (8) (2) (3) (17) (17) (24) (17) (11) (5) (3)
much on the nursing staff.

** Reverse Worded Statement.

 Appendix 10
Table 37

PAY Item # 1 Item# 8 Item # 14 Item # 21 Item # 32 Item # 44

Score 7 1 7 1 7 1
Strongly
Agree

# of resp 1 7 1 10 1 16

subtotal
7 7 7 10 7 16
Score 6 2 6 2 6 2
Agree

# of resp 4 8 3 3 4 10

Subtotal 24 16 6 24 20
18
Score 5 3 5 3 5 3
Moderately
Agree

# of resp 5 11 3 14 4 8

subtotal 25 33 15 42 20 24

Score 4 4 4 4 4 4
Undecided

# of resp 8 8 12 12 13 5

subtotal 32 32 48 48 52 20

Component Mean Score (component score / number of items)

Score 3 5 3 5 3 5
Moderately
Disagree

# of resp 8 3 9 2 8 0

subtotal 24 15 27 10 24 5

Score 2 6 2 6 2 6

Component Score (Sum of average score)

Disagree

# of resp 2 2 6 0 5 1
4
subtotal 12 12 0 10 6

Score 1 7 1 7 1 7
Disagree
Strongly

# of resp 13 2 7 0 6 1
13 14 7 0 6 7
subtotal

Total of Item 129 129 134 116 143 98

Total # of Resp. 41 41 41 41 41 41

Average Score 3.146 3.146 3.268 2.829 3.488 2.390 18. 3.0
27 45
 Appendix 10
Table 38

PROFESS- Item # 2 Item# 9 Item # 11 Item# 27 Item# 34 Item# 38 Item# 41

IONAL
STATUS

Score 1 7 7 1 7 7 1
Strongly

# of resp 7 7 12 2 6 6 1
Agree

subtotal
7 49 84 2 42 42 1
Score 2 6 6 2 6 6 2
Agree

# of resp 10 9 8 2 3 6 1

Subtotal
20 54 48 4 18 36 2
Score 3 5 5 3 5 5 3
Moderately
Agree

# of resp 6 8 9 4 15 11 1

subtotal
18 40 45 12 75 55 3
Score 4 4 4 4 4 4 4
Undecided

# of resp 2 10 10 13 10 9 8

Component Mean Score (component score / number of items)

subtotal
8 40 40 52 40 36 32
Score 5 3 3 5 3 3 5
Moderately
Disagree

# of resp 7 2 1 14 2 4 4

subtotal

Component Score (Sum of average score)

35 6 3 70 6 12 20

Score 6 2 2 6 2 2 6
Disagree

# of resp 3 2 0 2 3 1 13

subtotal
18 4 0 12 6 2 78

Score 7 1 1 7 1 1 7
Disagree
Strongly

# of resp 6 3 1 4 2 4 13

subtotal
42 3 1 28 2 4 91

Total of Item 148 196 221 180 189 187 227

Total # of Resp. 41 41 41 41 41 41 41
Average Score 3.61 4.780 5.390 4.39 4.61 4.56 5.54 32.8 4.69
8 7
 Appendix 10
Table 39

AUTONOMY Item # 7 Item# 13 Item # 17 Item# 20 Item# 26 Item# 30 Item # 31 Item # 43

Score 1 7 1 1 7 1 1 7
Strongly

# of resp 1 2 9 3 2 0 2 3
Agree

subtotal 1 14 9 3 14 0 2 21

Score 2 6 2 2 6 2 2 6
Agree

# of resp 2 2 7 1 2 5 4 2

Subtotal 4 12 14 2 12 10 8 12

Score 3 5 3 3 5 3 3 5
Moderately
Agree

# of resp 6 16 11 8 7 10 16 14

subtotal 18 80 33 24 35 30 48 70

Score 4 4 4 4 4 4 4 4
Undecided

# of resp 26 12 13 16 27 15 9 13

Component Mean Score (component score / number of items)

subtotal 104 52 64 108 60 36 52
48

Score 5 3 5 5 3 5 5 3
Moderately
Disagree

# of resp 3 8 1 8 3 3 6 3

subtotal 15 24 5 40 9 15 30 9

Component Score (Sum of average score)

Score 6 2 6 6 2 6 6 2
Disagree

# of resp 0 1 0 5 0 4 3 4

subtotal 0 2 0 30 0 24 18 8

Score 7 1 7 7 1 7 7 1
Disagree
Strongly

# of resp 3 0 0 0 0 4 1 2

subtotal 21 0 0 0 0 28 7 2

Total of Item 163 180 113 163 178 167 149 174

Total # of Resp. 41 41 41 41 41 41 41 41
Average Score 3.976 4.39 2.756 3.976 4.341 4.073 3.63 4.24 31.3 3.92
8 3
 Appendix 10
Table 40

ORGANIZA- Item # 5 Item# 12 Item # 18 Item# 25 Item# 33 Item# 40 Item# 42

TIONAL
POLICIES

Score 7 1 1 7 1 7 7
Strongly

# of resp 2 8 4 2 6 1 1
Agree

subtotal 14 8 4 14 6 7 7

Score 6 2 2 6 2 6 6
Agree

# of resp 8 9 7 3 2 4 3

Subtotal 48 18 14 18 4 24 18

Score 5 3 3 5 3 5 5
Moderately
Agree

# of resp 9 10 14 7 9 6 7

subtotal 45 30 42 35 27 30 35

Score 4 4 4 4 4 4 4
Undecided

# of resp 11 8 8 21 19 18 13

Component Mean Score (component score / number of items)

subtotal 44 32 32 84 76 72 52

Score 3 5 5 3 5 3 3
Moderately
Disagree

# of resp 6 4 7 5 2 4 6
18 20
subtotal 35 15 10 12 18

Component Score (Sum of average score)

Score 2 6 6 2 6 2 2
Disagree

# of resp 2 2 0 2 2 5 6

subtotal 4 12 0 4 12 10 12

Score 1 7 7 1 7 1 1
Disagree
Strongly

# of resp 3 0 1 1 1 3 5

subtotal 3 0 7 1 7 3 5

Total of Item 176 120 134 171 142 158 147

Total # of Resp. 41 41 41 41 41 41 41
Average Score 4.29 2.927 3.27 4.171 3.463 3.85 3.59 25.5 3.65
6
 Appendix 10
Table 41

TASK Item # 4 Item# 15 Item # 22 Item# 24 Item# 29 Item# 36

REQUIRE-
MENT

Score 1 1 7 7 7 1
Strongly

# of resp 7 12 6 0 2 14
Agree

subtotal 7 12 42 0 14 14

Score 2 2 6 6 6 2
Agree

# of resp 5 7 9 2 3 15

Subtotal 10 14 54 12 18 30

Score 3 3 5 5 5 3
Moderately
Agree

# of resp 9 9 16 8 8 7

subtotal 27 27 80 40 40 21

Score 4 4 4 4 4 4
Undecided

# of resp 12 7 5 11 10 2

Component Mean Score (component score / number of items)

subtotal 48 28 20 44 40 8

Score 5 5 3 3 3 5
Moderately
Disagree

# of resp 5 2 5 15 12 2

subtotal 25 10 15 45 36 10

Component Score (Sum of average score)

Score 6 6 2 2 2 6
Disagree

# of resp 2 2 0 2 3 0

subtotal 12 12 0 4 6 0

Score 7 7 1 1 1 7
Disagree
Strongly

# of resp 1 2 0 3 3 1

subtotal 7 14 0 3 3 7

Total of Item 136 117 211 148 157 90

Total # of Resp. 41 41 41 41 41 41
Average Score 3.317 2.854 5.146 3.61 3.829 2.195 20.95 3.492
 Appendix 10
Table 42

Interaction Item # Item# Item # Item# Item# Item# 6 Item # Item# Item# Item#
3 10 16 23 28 19 35 37 39
Score 7 1 7 1 1 7 7 1 7 1
Strongly Agree

# of 9 8 7 1 3 4 7 18 3 7
resp
63 8 49 1 3 28 49 18 21 7
subtotal

Score 6 2 6 2 2 6 6 2 6 2

# of 13 7 11 2 5 12 11 12 5 8
Agree

resp
78 14 66 4 10 72 66 24 30 16
Subtotal

Score 5 3 5 3 3 5 5 3 5 3
Moderately

# of 8 12 13 6 5 10 8 4 9 10
Agree

resp 36 50 40 12
40 65 18 15 45 30
subtotal

Score 4 4 4 4 4 4 4 4 4 4
Undecided

# of 9 6 7 15 16 12 6 6 10 10
resp
36 24 28 60 64 48 24 24 40 40
subtotal

Score 3 5 3 5 5 3 3 5 3 5
Moderately
Disagree

# of 2 3 2 6 6 2 6 0 7 3
resp 15
6 6 30 30 6 18 0 21 15
subtotal

Component Mean Score (component score / number of items)

Score 2 6 2 6 6 2 2 6 2 6

# of 0 2 0 7 2 2 2 0 5 3
Disagree

resp
0 12 0 42 12 4 4 0 10 18
Component Score (Sum of average score)

subtotal

Score 1 7 1 7 7 1 1 7 1 7

# of 0 3 1 4 4 0 1 1 2 0
Disagree
Strongly

resp
0 21 1 28 28 0 1 7 2 0
subtotal

Total of Item 223 130 215 183 162 208 202 85 169 126

Total # of 41 41 41 41 41 41 41 41 41 41
Resp.

Average 5.439 3.171 5.244 4.463 3.95 5.073 4.927 2.073 4.122 3.073 41.54 4.154
Score
Appendix 10
Table 43

Nurse-Nurse Item # 3 Item# 10 Item # 16 Item# 23 Item# 28

Score 7 1 7 1 1

Strongly # of resp 9 8 7 1 3
Agree
subtotal 63 8 49 1 3

Score 6 2 6 2 2
Agree

# of resp 13 7 11 2 5

Subtotal 78 14 66 4 10

Score 5 3 5 3 3
Moderately
Agree

# of resp 8 12 13 6 5

subtotal 40 36 65 18 15

Score 4 4 4 4 4
Undecided

# of resp 9 6 7 15 16

Component Mean Score (component score / number of items)

subtotal 36 24 28 60 64

Score 3 5 3 5 5
Moderately
Disagree

# of resp 2 3 2 6 6

subtotal 6 15 6 30 30

Component Score (Sum of average score)

Score 2 6 2 6 6
Disagree

# of resp 0 2 0 7 2

subtotal 0 12 0 42 12

Score 1 7 1 7 7
Disagree
Strongly

# of resp 0 3 1 4 4

subtotal 0 21 1 28 28

Total of Item 223 130 215 183 162

Total # of Resp. 41 41 41 41 41
Average Score 5.439 3.171 5.244 4.463 3.95 22.2 4.45
7
Appendix 10
Table 44

Nurse-Physician Item # 6 Item# 19 Item # 35 Item# 37 Item# 39

Strongly Score 7 7 1 7 1

# of resp 4 7 18 3 7
Agree

subtotal 28 49 18 21 7

Score 6 6 2 6 2
Agree

# of resp 12 11 12 5 8

Subtotal 72 66 24 30 16

Score 5 5 3 5 3
Moderately
Agree

# of resp 10 8 4 9 10

subtotal 50 40 12 45 30

Score 4 4 4 4 4
Undecided

# of resp 12 6 6 10 10

Component Mean Score (component score / number of items)

subtotal
48 24 24 40 40

Score 3 3 5 3 5
Moderately
Disagree

# of resp 2 6 0 7 3

subtotal 6 18 0 21 15

Component Score (Sum of average score)

Score 2 2 6 2 6
Disagree

# of resp 2 2 0 5 3

subtotal 4 4 0 10 18

Score 1 1 7 1 7
Disagree
Strongly

# of resp 0 1 1 2 0

subtotal 0 1 7 2 0

Total of Item 208 202 85 169 126

Total # of Resp. 41 41 41 41 41
Average Score 5.073 4.927 2.073 4.122 3..073 19.2 3.85
7
 Appendix 10
Table 45

PAY Item # 1 Item# 8 Item # 14 Item # 21 Item # 32 Item # 44

Score 7 1 7 1 7 1
Strongly
Agree

# of resp 4 12 3 9 5 21

subtotal
28 12 21 9 35 21
Score 6 2 6 2 6 2
Agree

# of resp 9 11 6 12 5 10

Subtotal 54 24
22 36 30 20
Score 5 3 5 3 5 3
Moderately
Agree

# of resp 5 8 5 13 5 15

subtotal 25 24 25 39 25 45

Score 4 4 4 4 4 4
Undecided

# of resp 9 12 12 10 17 3

subtotal
36 48 48 40 68 12

Component Mean Score (component score / number of items)

Score 3 5 3 5 3 5
Moderately
Disagree

# of resp 13 5 10 4 14 2

subtotal
39 25 30 20 42 10
Score 2 6 2 6 2 6

Component Score (Sum of average score)

Disagree

# of resp 4 1 11 3 3 0

subtotal
8 6 22 18 6 0
Score 1 7 1 7 1 7
Disagree
Strongly

# of resp 9 4 6 2 4 2

subtotal
9 28 6 14 4 14
Total of Item 199 165 188 164 210 122

Total # of Resp. 53 53 53 53 53 53

Average Score 3.75 3.11 3.55 3.09 3.96 2.30 19. 3.2
76 9
 Appendix 10
Table 46

PROFESS- Item # 2 Item# 9 Item # 11 Item# 27 Item# 34 Item# 38 Item# 41

IONAL
STATUS

Score 1 7 7 1 7 7 1
Strongly

# of resp 13 7 15 2 8 6 2
Agree

subtotal
13 49 105 2 56 42 2
Score 2 6 6 2 6 6 2
Agree

# of resp 9 12 7 7 7 6 2

Subtotal
18 72 42 14 42 36 4
Score 3 5 5 3 5 5 3
Moderately
Agree

# of resp 11 17 20 9 14 13 5

subtotal
33 85 100 27 70 65 15
Score 4 4 4 4 4 4 4
Undecided

# of resp 3 6 7 17 12 10 5

Component Mean Score (component score / number of items)

subtotal
12 24 28 68 48 40 20
Score 5 3 3 5 3 3 5
Moderately
Disagree

# of resp 8 6 1 10 6 8 13

subtotal

Component Score (Sum of average score)

40 18 3 50 18 24 65

Score 6 2 2 6 2 2 6
Disagree

# of resp 2 2 1 7 2 2 6

subtotal
12 4 2 42 4 4 36

Score 7 1 1 7 1 1 7
Disagree
Strongly

# of resp 7 3 2 1 4 8 20

subtotal
49 3 2 7 4 8 140

Total of Item 177 255 282 210 242 219 282

Total # of Resp. 53 53 53 53 53 53 53

Average Score 3.34 4.81 5..32 3.96 4.57 4.13 5..32 31.4 4.49
5
Appendix 10
Table 47

AUTONOMY Item # 7 Item# 13 Item # Item# 20 Item# Item# Item # Item #

17 26 30 31 43
Score 1 7 1 1 7 1 1 7
Strongly Agree

# of 4 6 9 4 2 5 6 4
resp
4 42 9 4 14 5 6 28
subtotal

Score 2 6 2 2 6 2 2 6

# of 5 6 13 8 4 4 8 7
Agree

resp
10 36 26 16 24 8 16 42
Subtotal

Score 3 5 3 3 5 3 3 5
Moderately

# of 10 12 10 12 14 15 14 14
Agree

resp
30 60 30 36 70 45 42 70
subtotal

Score 4 4 4 4 4 4 4 4
Undecided

# of 9 15 11 8 21 7 11 10
resp
36 44 32 84 28 44 40
subtotal 60

Component Mean Score (component score / number of items)

Score 5 3 5 5 3 5 5 3
Moderately
Disagree

# of 11 7 4 16 8 14 7 8
resp
55 21 20 80 24 70 35 24
subtotal

Score 6 2 6 6 2 6 6 2

Component Score (Sum of average score)

Disagree

# of 8 3 1 5 2 3 5 6
resp
48 6 30 4 18 30 12
subtotal 6

Score 7 1 7 7 1 7 7 1

# of 6 4 5 0 2 5 2 4
Disagree
Strongly

resp
42 4 35 0 2 35 14 4
subtotal

Total of Item 225 229 170 198 222 209 187 220

Total # of 53 53 53 53 53 53 53 53
Resp.

Average 4.25 4.32 3.20 3.74 4.19 3.94 3.53 4.15 31.32 3.92
Score
 Appendix 10
Table 48

ORGANIZA- Item # 5 Item# 12 Item # 18 Item# 25 Item# 33 Item# 40 Item# 42

TIONAL
POLICIES

Score 7 1 1 7 1 7 7
Strongly

# of resp 3 16 10 0 5 2 7
Agree

subtotal 21 16 10 0 5 14 49

Score 6 2 2 6 2 6 6
Agree

# of resp 10 10 9 6 7 1 2
12
Subtotal 60 20 18 36 14 6

Score 5 3 3 5 3 5 5
Moderately
Agree

# of resp 15 9 16 13 14 5 12

subtotal 75 27 48 65 42 25 60

Score 4 4 4 4 4 4 4
Undecided

# of resp 5 12 10 17 17 20 11

Component Mean Score (component score / number of items)

subtotal 20 48 40 68 68 80 44

Score 3 5 5 3 5 3 3
Moderately
Disagree

# of resp 8 1 7 9 6 10 12
24 5
subtotal 35 27 30 30 36

Component Score (Sum of average score)

Score 2 6 6 2 6 2 2
Disagree

# of resp 7 3 1 4 3 6 4

subtotal 14 18 6 8 18 12 8

Score 1 7 7 1 7 1 1
Disagree
Strongly

# of resp 5 2 0 4 1 9 5

subtotal 5 14 0 4 7 9 5

Total of Item 219 148 157 208 184 176 214

Total # of Resp. 53 53 53 53 53 53 53

Average Score 4.13 2.79 2.96 3.92 3.47 3.32 4.038 24.5 3.50
2 2
 Appendix 10
Table 49

TASK Item # 4 Item# 15 Item # 22 Item# 24 Item# 29 Item# 36

REQUIRE-
MENT

Score 1 1 7 7 7 1
Strongly

# of resp 10 12 5 2 2 22
Agree

subtotal 10 12 35 14 14 22

Score 2 2 6 6 6 2
Agree

# of resp 10 16 10 4 7 10

Subtotal 20 32 60 24 42 20

Score 3 3 5 5 5 3
Moderately
Agree

# of resp 15 6 14 8 12 15

subtotal 45 18 70 40 60 45

Score 4 4 4 4 4 4
Undecided

# of resp 10 8 14 7 7 4

Component Mean Score (component score / number of items)

subtotal 40 32 56 28 28 16

Score 5 5 3 3 3 5
Moderately
Disagree

# of resp 5 6 5 19 18 1

subtotal 25 30 15 57 54 5

Component Score (Sum of average score)

Score 6 6 2 2 2 6
Disagree

# of resp 1 2 3 6 4 0

subtotal 6 12 6 12 8 0

Score 7 7 1 1 1 7
Disagree
Strongly

# of resp 2 3 2 7 3 1

subtotal 14 21 2 7 3 7

Total of Item 160 157 244 182 209 115

Total # of Resp. 53 53 53 53 53 53

Average Score 3.02 2.96 4.60 3.43 3.94 2.17 20.12 3.35
 Appendix 10
Table 50

Interaction Item # Item# Item # Item# Item# Item# 6 Item # Item# Item# Item#
3 10 16 23 28 19 35 37 39
Score 7 1 7 1 1 7 7 1 7 1
Strongly Agree

# of 10 13 9 8 10 5 7 25 3 10
resp
70 13 63 8 10 35 49 25 21 10
subtotal

Score 6 2 6 2 2 6 6 2 6 2

# of 11 18 15 7 6 5 17 8 5 9
Agree

resp
66 36 90 14 12 30 102 16 30 18
Subtotal

Score 5 3 5 3 3 5 5 3 5 3
Moderately

# of 16 9 7 6 9 21 10 15 14 14
Agree

resp 27 105 50 45
80 35 18 27 70 42
subtotal

Score 4 4 4 4 4 4 4 4 4 4
Undecided

# of 10 7 4 11 7 12 6 3 10 7
resp
40 28 16 44 28 48 24 12 40 28
subtotal

Score 3 5 3 5 5 3 3 5 3 5
Moderately
Disagree

# of 4 3 9 10 13 4 10 0 12 8
resp 15
12 27 50 65 12 30 0 36 40
subtotal

Component Mean Score (component score / number of items)

Score 2 6 2 6 6 2 2 6 2 6

# of 2 1 4 7 5 4 2 1 6 2
Disagree

resp
4 6 8 42 30 8 4 6 12 12 Component Score (Sum of average score)
subtotal

Score 1 7 1 7 7 1 1 7 1 7

# of 0 2 5 4 3 2 1 1 3 3
Disagree
Strongly

resp
0 14 5 28 21 2 1 7 3 21
subtotal

Total of Item 272 139 244 204 193 240 260 111 212 171

Total # of 53 53 53 53 53 53 53 53 53 53
Resp.

Average 5.13 2.62 4.60 3.85 3.64 4.53 4.91 2.09 4 3.23 38.6 3.86
Score
Appendix 10
Table 51

Nurse-Nurse Item # 3 Item# 10 Item # 16 Item# 23 Item# 28

Score 7 1 7 1 1
Strongly

# of resp 10 13 9 8 10
Agree

subtotal 70 13 63 8 10

Score 6 2 6 2 2
Agree

# of resp 11 18 15 7 6

Subtotal 66 36 90 14 12

Score 5 3 5 3 3
Moderately
Agree

# of resp 16 9 7 6 9

subtotal 80 27 35 18 27

Score 4 4 4 4 4
Undecided

# of resp 10 7 4 11 7

Component Mean Score (component score / number of items)

subtotal 40 28 16 44 28

Score 3 5 3 5 5
Moderately
Disagree

# of resp 4 3 9 10 13

subtotal 12 15 27 50 65

Component Score (Sum of average score)

Score 2 6 2 6 6
Disagree

# of resp 2 1 4 7 5

subtotal 4 6 8 42 30

Score 1 7 1 7 7
Disagree
Strongly

# of resp 0 2 5 4 3

subtotal 0 14 5 28 21

Total of Item 272 139 244 204 193

Total # of Resp. 53 53 53 53 53

Average Score 5.13 2.62 4.60 3.85 3.64 19.8 3.97

4
Appendix 10
Table 52

Nurse-Physician Item # 6 Item# 19 Item # 35 Item# 37 Item# 39

Score 7 7 1 7 1
Strongly

# of resp 5 7 25 3 10
Agree

subtotal 35 49 25 21 10

Score 6 6 2 6 2
Agree

# of resp 5 17 8 5 9

Subtotal 30 102 16 30 18

Score 5 5 3 5 3
Moderately
Agree

# of resp 21 10 15 14 14

subtotal 105 50 45 70 42

Score 4 4 4 4 4
Undecided

# of resp 12 6 3 10 7

Component Mean Score (component score / number of items)

subtotal
48 24 12 40 28

Score 3 3 5 3 5
Moderately
Disagree

# of resp 4 10 0 12 8

subtotal 12 30 0 36 40

Component Score (Sum of average score)

Score 2 2 6 2 6
Disagree

# of resp 4 2 1 6 2

subtotal 8 4 6 12 12

Score 1 1 7 1 7
Disagree
Strongly

# of resp 2 1 1 3 3

subtotal 2 1 7 3 21

Total of Item 240 260 111 212 171

Total # of Resp. 53 53 53 53 53

Average Score 4.53 4.91 2.09 4 3.23 18.7 3.75

6
 Appendix 10
Table 53

PAY Item # 1 Item# 8 Item # 14 Item # 21 Item # 32 Item # 44

Score 7 1 7 1 7 1
Strongly
Agree

# of resp 5 19 4 19 6 37

subtotal
35 9 28 19 42 37
Score 6 2 6 2 6 2
Agree

# of resp 13 19 9 15 9 20

Subtotal 78 30
38 54 54 40
Score 5 3 5 3 5 3
Moderately
Agree

# of resp 10 19 8 27 9 23

subtotal 50 57 40 81 45 69

Score 4 4 4 4 4 4
Undecided

# of resp 17 20 24 22 30 8

subtotal
68 80 96 88 120 32

Component Mean Score (component score / number of items)

Score 3 5 3 5 3 5
Moderately
Disagree

# of resp 21 8 19 6 22 2

subtotal
63 40 57 30 66 10
Score 2 6 2 6 2 6

Component Score (Sum of average score)

Disagree

# of resp 6 3 17 3 8 1

subtotal
12 18 34 18 16 6
Score 1 7 1 7 1 7
Disagree
Strongly

# of resp 22 6 13 2 10 3

subtotal
22 42 13 14 10 21
Total of Item 328 284 322 280 353 215

Total # of Resp. 94 94 94 94 94 94

Average Score 3.49 3.02 3.43 2.98 3.76 2.29 18. 3.1
97 62
 Appendix 10
Table 54

PROFESS- Item # 2 Item# 9 Item # 11 Item# 27 Item# 34 Item# 38 Item# 41

IONAL
STATUS

Score 1 7 7 1 7 7 1
Strongly

# of resp 20 14 27 4 14 12 3
Agree

subtotal
20 98 189 4 98 84 3
Score 2 6 6 2 6 6 2
Agree

# of resp 19 21 15 9 10 12 3

Subtotal
38 126 90 18 60 72 6
Score 3 5 5 3 5 5 3
Moderately
Agree

# of resp 17 25 29 13 29 24 7

subtotal
51 125 145 39 145 120 21
Score 4 4 4 4 4 4 4
Undecided

# of resp 5 16 17 30 22 19 12

Component Mean Score (component score / number of items)

subtotal
20 64 68 120 88 76 48
Score 5 3 3 5 3 3 5
Moderately
Disagree

# of resp 15 8 2 24 8 12 17

subtotal

Component Score (Sum of average score)

75 24 6 70 24 36 85

Score 6 2 2 6 2 2 6
Disagree

# of resp 5 4 1 9 5 3 19

subtotal
30 8 2 54 10 6 114

Score 7 1 1 7 1 1 7
Disagree
Strongly

# of resp 13 6 3 5 6 12 33

subtotal
91 6 3 35 6 12 231

Total of Item 325 451 503 340 431 406 508

Total # of Resp. 94 94 94 94 94 94 94

Average Score 3.46 4.8 5.35 3.62 4.59 4.32 5.4 31.5 4.51
4
Appendix 10
Table 55

AUTONOMY Item # 7 Item# 13 Item # Item# 20 Item# 26 Item# Item # Item #

17 30 31 43
Score 1 7 1 1 7 1 1 7
Strongly Agree

# of 5 8 18 7 4 5 8 7
resp
5 56 18 7 28 5 8 49
subtotal

Score 2 6 2 2 6 2 2 6

# of 7 8 20 9 6 9 12 9
Agree

resp
14 48 40 18 36 18 24 54
Subtotal

Score 3 5 3 3 5 3 3 5
Moderately

# of 16 28 21 20 21 25 30 28
Agree

resp
48 140 63 60 105 75 90 140
subtotal

Score 4 4 4 4 4 4 4 4
Undecided

# of 35 27 24 24 48 22 20 23
resp
140 96 96 192 88 80 92
subtotal 108

Component Mean Score (component score / number of items)

Score 5 3 5 5 3 5 5 3
Moderately
Disagree

# of 14 15 5 24 11 17 13 11
resp
70 45 25 120 33 85 65 33
subtotal

Score 6 2 6 6 2 6 6 2

Component Score (Sum of average score)

Disagree

# of 8 4 1 10 2 7 8 10
resp
48 6 60 4 42 48 20
subtotal 8

Score 7 1 7 7 1 7 7 1

# of 9 4 5 0 2 9 3 6
Disagree
Strongly

resp
63 4 35 0 2 63 21 6
subtotal

Total of Item 388 409 283 361 400 376 336 394

Total # of 94 94 94 94 94 94 94 94
Resp.

Average 4.13 4.35 3.01 3.84 4.26 4 3.57 4.19 31.35 3.92
Score
 Appendix 10
Table 56

ORGANIZA- Item # 5 Item# 12 Item # 18 Item# 25 Item# 33 Item# 40 Item# 42

TIONAL
POLICIES

Score 7 1 1 7 1 7 7
Strongly

# of resp 5 24 14 2 11 3 8
Agree

subtotal 35 24 14 14 11 21 56

Score 6 2 2 6 2 6 6
Agree

# of resp 18 19 16 9 9 5 5
30
Subtotal 108 38 32 54 18 30

Score 5 3 3 5 3 5 5
Moderately
Agree

# of resp 24 19 30 20 23 11 19

subtotal 120 57 90 100 69 55 95

Score 4 4 4 4 4 4 4
Undecided

# of resp 16 20 18 38 36 38 24

Component Mean Score (component score / number of items)

subtotal 64 80 72 152 144 152 96

Score 3 5 5 3 5 3 3
Moderately
Disagree

# of resp 14 5 14 14 8 14 18
42 25
subtotal 70 42 40 42 54

Component Score (Sum of average score)

Score 2 6 6 2 6 2 2
Disagree

# of resp 9 5 1 6 5 11 10

subtotal 18 30 6 12 30 22 20

Score 1 7 7 1 7 1 1
Disagree
Strongly

# of resp 8 2 1 5 2 12 10

subtotal 8 14 7 5 14 12 10

Total of Item 395 268 291 379 326 334 361

Total # of Resp. 94 94 94 94 94 94 94

Average Score 4.2 2.85 3.1 4.03 3.47 3.55 3.8 25 3.57
Appendix 10
Table 57

TASK Item # 4 Item# 15 Item # 22 Item# 24 Item# 29 Item# 36

REQUIRE-
MENT

Score 1 1 7 7 7 1
Strongly

# of resp 17 24 11 2 4 36
Agree

subtotal 17 22 77 14 28 36

Score 2 2 6 6 6 2
Agree

# of resp 15 23 19 6 10 25

Subtotal 30 46 114 36 60 50

Score 3 3 5 5 5 3
Moderately
Agree

# of resp 24 15 30 16 20 22

subtotal 72 45 150 80 100 66

Score 4 4 4 4 4 4
Undecided

# of resp 22 15 19 18 17 6

Component Mean Score (component score / number of items)

subtotal 88 60 76 72 68 24

Score 5 5 3 3 3 5
Moderately
Disagree

# of resp 10 8 10 34 30 3

subtotal 50 40 30 102 90 15

Component Score (Sum of average score)

Score 6 6 2 2 2 6
Disagree

# of resp 3 4 3 8 7 0

subtotal 18 24 6 16 14 0

Score 7 7 1 1 1 7
Disagree
Strongly

# of resp 3 5 2 10 6 2

subtotal 21 35 2 10 6 14

Total of Item 296 272 455 330 366 205

Total # of Resp. 94 94 94 94 94 94

Average Score 3.15 2.89 4.84 3.51 3.89 2.18 20.46 3.41
 Appendix 10
Table 58

Interaction Item # 3 Item# Item # Item# 23 Item# Item# 6 Item # Item# Item# 37 Item#
10 16 28 19 35 39
Score 7 1 7 1 1 7 7 1 7 1
Strongly Agree

# of 19 21 16 9 13 9 14 43 6 17
resp 112
133 21 9 13 63 98 43 42 17
subtotal

Score 6 2 6 2 2 6 6 2 6 2

# of 24 25 26 9 11 16 28 20 10 17
Agree

resp 156 96
144 50 18 22 168 40 60 34
Subtotal

Score 5 3 5 3 3 5 5 3 5 3
Moderately

# of 24 21 20 12 14 31 18 19 23 24
Agree

resp 63 100 36 155 90 57

120 42 115 72
subtotal

Score 4 4 4 4 4 4 4 4 4 4
Undecided

# of 19 13 11 26 23 24 12 9 20 17
resp 104
76 52 44 92 96 48 36 80 68
subtotal

Score 3 5 3 5 5 3 3 5 3 5
Moderately
Disagree

# of 6 6 11 16 19 6 16 0 19 11
resp 30
18 33 80 95 18 48 0 57 55
subtotal

Component Mean Score (component score / number of items)

Score 2 6 2 6 6 2 2 6 2 6

# of 2 3 4 14 7 6 4 1 11 5
Disagree

resp
4 18 8 84 42 12 8 6 22 30
subtotal Component Score (Sum of average score)

Score 1 7 1 7 7 1 1 7 1 7

# of 0 5 6 8 7 2 2 2 5 3
Disagree
Strongly

resp
0 35 6 56 49 2 2 14 5 21
subtotal

Total of Item 495 269 459 387 355 442 462 196 381 297

Total # of 94 94 94 94 94 94 94 94 94 94
Resp.

Average 5.27 2.86 4.88 4.12 3.78 4.7 4.91 2.09 4.05 3.16 39.82 3.98
Score
Appendix 10
Table 59

Nurse-Nurse Item # 3 Item# 10 Item # 16 Item# 23 Item# 28

Score 7 1 7 1 1
Strongly

# of resp 19 21 16 9 13
Agree

112
subtotal 133 21 9 13

Score 6 2 6 2 2
Agree

# of resp 24 25 26 9 11
156
Subtotal 144 50 18 22

Score 5 3 5 3 3
Moderately
Agree

# of resp 24 21 20 12 14
63 100 36
subtotal 120 42

Score 4 4 4 4 4
Undecided

# of resp 19 13 11 26 23
104
subtotal 76 52 44 92

Score 3 5 3 5 5
Moderately
Disagree

Component Mean Score (component score / number of items)

# of resp 6 6 11 16 19
30
subtotal 18 33 80 95

Score 2 6 2 6 6
Disagree

# of resp 2 3 4 14 7 Component Score (Sum of average score)

subtotal 4 18 8 84 42

Score 1 7 1 7 7
Disagree
Strongly

# of resp 0 5 6 8 7

subtotal 0 35 6 56 49

Total of Item 495 269 459 387 355

Total # of Resp. 94 94 94 94 94

Average Score 5.27 2.86 4.88 4.12 3.78 20.91 4.1

8
Appendix 10
Table 60

Nurse-Physician Item# 6 Item # 19 Item# 35 Item# 37 Item# 39

Score 7 7 1 7 1
Strongly

# of resp 9 14 43 6 17
Agree

subtotal 63 98 43 42 17

Score 6 6 2 6 2
Agree

# of resp 16 28 20 10 17
96
Subtotal 168 40 60 34

Score 5 5 3 5 3
Moderately
Agree

# of resp 31 18 19 23 24
155 90 57
subtotal 115 72

Score 4 4 4 4 4
Undecided

# of resp 24 12 9 20 17

subtotal 96 48 36 80 68

Score 3 3 5 3 5
Moderately
Disagree

Component Mean Score (component score / number of items)

# of resp 6 16 0 19 11

subtotal 18 48 0 57 55

Score 2 2 6 2 6
Disagree

Component Score (Sum of average score)

# of resp 6 4 1 11 5

subtotal 12 8 6 22 30

Score 1 1 7 1 7
Disagree
Strongly

# of resp 2 2 2 5 3

subtotal 2 2 14 5 21

Total of Item 442 462 196 381 297

Total # of Resp. 94 94 94 94 94

Average Score 4.7 4.91 2.09 4.05 3.16 18.91 3.78