OCCUPATIONAL STRESS, JOB SATISFACTION, AND JOB PERFORMANCE

AMONG HOSPITAL NURSES IN KAMPALA UGANDA

by

ROSE CHALO NABIRYE

KATHLEEN C. BROWN, COMMITTEE CHAIR CONNIE L. KOHLER

ELIZABETH H. MAPLES NA-JIN PARK

ERICA R. PRYOR

A DISSERTATION

Submitted to the graduate faculty of the University of Alabama at Birmingham, in partial fulfillment of the requirements for the degree of

Doctor of Philosophy

BIRMINGHAM, ALABAMA

2010

ii

Copyright by Rose Chalo Nabirye

2010

iii

OCCUPATIONAL STRESS, JOB SATISFACTION, AND JOB PERFORMANCE AMONG HOSPITAL NURSES IN KAMPALA, UGANDA

ROSE CHALO NABIRYE

SCHOOL OF NURSING

ABSTRACT

Occupational stress, a common occurrence among various professions

worldwide, is regarded as a major occupational health problem for healthcare

professionals especially nurses. Occupational stress has been reported to affect job

satisfaction and job performance among nurses, thus compromising nursing care and

placing patients’ lives at risk. Stress is a complex phenomenon resulting from the

interaction between individuals and the environment. Therefore, significant

differences in occupational stress, job satisfaction and job performance among nurses

may exist due to different work settings.

The aims of the study were to: 1) examine the relationships between

occupational stress, job satisfaction and job performance among hospital nurses in

Kampala City, Uganda; 2) establish whether personal background characteristics

affect the relationships between occupational stress, job satisfaction and job

performance; and 3) examine whether there is a difference in levels of occupational

stress, job satisfaction and job performance by type of hospital.

A non-experimental correlational design was used in the study. A total of 333

nurses from four hospitals completed the Nurse Stress Index, the Job Satisfaction

Survey, and the Six-Dimensional Scale of Nurse Performance scales. Study findings

demonstrated that there were significant differences in levels of occupational stress,

job satisfaction and job performance between the public and private not-for- profit

iv

hospitals. Nurses in the public hospital reported higher levels of occupational stress

and lower levels of job satisfaction and performance. There were significant negative

relationships between occupational stress and job performance and between

occupational stress and job satisfaction. Nursing experience, type of hospital, and

number of children had a statistically significant relationship with occupational stress,

job satisfaction and job performance. Type of hospital (public versus private), ward

(obstetrics/gynecology versus other ward types), and job satisfaction were significant

predictors of self-rated quality of job performance. Job satisfaction was shown to

mediate the relationship between occupational stress and job performance.

Large scale studies were recommended to identify sources of occupational

stress and factors that enhance job satisfaction among hospital nurses in Uganda.

Future research is needed to examine best practices for human resource managers to

improve nurse motivation, job satisfaction and nurse performance in hospitals.

Key words: occupational stress, job satisfaction, job performance, personal

characteristics, work characteristics, public hospital, private not-for-profit hospitals,

best practices for human resource management.

v

DEDICATION

In loving memory of my late father Mr. Nathan Gusongoirye Waako who always

encouraged me to study hard and sacrificed the little resources he had in order to

provide for my education.

vi

ACKNOWLEDGEMENTS

First and foremost, I am most grateful to the Almighty God for giving me this

opportunity to advance in my studies. I am sincerely grateful for the

sponsorship/scholarship grants awarded to me for doctoral study, including the UAB-

ICER Training Grant through Dr. Eric Chamot for the initial grant which enabled me

to enroll in the program. I convey my heartfelt gratitude to all the staff in the Fogarty

office, especially Heather White and Alexis MacLean for the untiring patience and

support accorded to me while at UAB. My gratitude to Sigma Theta Tau, the Gladys

Farmer Colvin Memorial Scholarship, and to the Makerere University Staff

Development and Training Division for additional grants which enabled me complete

the program, and to Makerere University School of Graduate Studies for funding the

study. Sincere gratitude also goes to the Good Health Program of Birmingham and

Deep South Center for Occupational Health and Safety, UAB and Auburn University,

for providing the pens which were distributed to the participants during data

collection.

I am greatly indebted and sincerely grateful to Dr. Kathleen C. Brown, my

supervisor and Dissertation Committee Chair for the guidance, support and continuous

advice not only on academic matters but on social issues as well. I sincerely

appreciated her patience and commitment to see me through the PhD program.

My sincere gratitude also goes to Dr. Erica Pryor, for the continuous advice,

support and expertise in statistics and for always being there for me whenever I

needed her wise counsel. I am grateful to dissertation committee members Dr.

Elizabeth Maples, Dr. Connie Kohler and Dr. Na-Jin Park for their support,

vii

encouragement and guidance throughout the doctoral program and dissertation

writing.

I thank Dr. Isaac Okullo, my Ugandan supervisor, for his advice and

encouragement throughout the PhD program. In the same way, I am thankful to

Professor Wabwire-Mangen Fred of the School of Public Health, Makerere University

for the professional advice and guidance, despite his busy schedule. My sincere

gratitude also goes to Dr. D. K. Sekimpi for the support and encouragement

throughout the doctoral program.

I am so grateful to all UAB School of Nursing Faculty and other staff, whoever

I came in contact with, but most especially Drs. Lynda Wilson and Jacqueline Moss,

for giving me encouragement and advice which kept me “hanging in there.” To the

PhD nursing students in academic years 2006/2007-2008/2009, I say thank you all for

the support you gave me. Tracy, I thank you so much for providing the sisterly support

academically and socially throughout my stay in Birmingham. I thank Dr. Mantana

Damrongsak Brown for “showing me the ropes” and always being there for me.

I am sincerely grateful to my friends Pat Yeilding and family, Sandy and Bill

Myers, and family for always being there for me. The words of encouragement,

spiritual and other forms of support, the love you showed me and prayers surely kept

me going. I sincerely thank the Ugandan and ‘ZamUga’ communities in Birmingham

and beyond, most especially Dr. Kabagambe Edmond and family, Sarah, Vincy,

Jacqueline Makaaru, Jacqueline Mulundika and Margaret for the family atmosphere

which made me “feel at home away from home” throughout my stay in Birmingham.

I appreciate the Principal of Makerere University College of Health Sciences

Professor Nelson Sewankambo for the continuous support and advice especially on

funding opportunities. My sincere gratitude goes also to the Department of Nursing

viii

faculty and staff for the support and encouragement not only to me but to my family

during my absence.

I am grateful to Associate Professor Sara Groves from John Hopkins

University, for the support and advice especially for writing the literature review and

dissertation report. I thank Mr. Yovani Lubaale and Dr. Nazarius Mbona of Makerere

University Institute of Statistics and School of Public Health respectively for the

assistance in data analyses.

Many thanks go to the Assistant Commissioner Nursing Services of Mulago

Hospital, the Senior Nursing Officers and the Medical Directors of Mengo, Kibuli and

Rubaga Hospitals for the support during preparation and actual data collection. To the

dear nurses who participated in the study, I am so grateful for your precious time to

complete the questionnaires. Many thanks also go to the research assistants including

Godfrey, Scovia, Allen and Richard for the support, interest, and diligence they

accorded the study.

I thank my extended family members, my mum Gertrude Gusongoirye, and

brothers David, Robert, Charles, Peter, Dan, Edward and sister in-law Mrs. Joyce

Nankinga Gusongoirye. I thank you for your endless love, prayers and moral support.

And last but not least, my beloved children, Doreen, Ellen, Pauline, Solomon

and Derrick, thank you for being such wonderful children. In spite of missing

motherly love and care, you gave me unconditional love, support and encouragement

that actually motivated me to continue and complete my studies.

ix

TABLE OF CONTENTS

Page

COPYRIGHT ................................................................................................................. ii 

ABSTRACT .................................................................................................................. iii 

DEDICATION ............................................................................................................... v 

ACKNOWLEDGEMENTS .......................................................................................... vi 

LIST OF TABLES ....................................................................................................... xii 

LIST OF FIGURES .................................................................................................... xiv 

LIST OF ABBREVIATIONS ...................................................................................... xv 

CHAPTER 

1 INTRODUCTION  

Health Care System in Uganda ............................................................................ 3  Statement of the Problem ..................................................................................... 4  Significance of the Study ..................................................................................... 6  Specific Aims of the Study .................................................................................. 7  Research Questions .............................................................................................. 7  Operational Definitions ........................................................................................ 8  Conceptual Framework ........................................................................................ 9  Assumptions for the Study ................................................................................. 10 

2 LITERATURE REVIEW ..................................................................................... 11  Occupational Stress ............................................................................................ 11 

Sources of Occupational Stress among Nurses ......................................... 12  Workload .................................................................................................. 13  Organizational Pressure ............................................................................ 15  Interpersonal Relationships/Intrinsic Nature of the Work ........................ 16 

Professionalism ......................................................................................... 17  Effects of Occupational Stress ........................................................................... 18  Job Satisfaction among Nurses .......................................................................... 22  Job Performance among Nurses ........................................................................ 29  Summary of Literature ....................................................................................... 32 

x

3 METHODOLOGY ............................................................................................... 33  Study Design ...................................................................................................... 33  Ethical Considerations ....................................................................................... 33  Setting ................................................................................................................ 34  Study Sample ..................................................................................................... 35 

Inclusion Criteria ...................................................................................... 35  Exclusion Criteria ..................................................................................... 36 

Sample Size ........................................................................................................ 36  Instruments ......................................................................................................... 37 

The Nurse Stress Index (NSI) ................................................................... 37  The Job Satisfaction Survey (JSS) ............................................................ 38  The Six Dimension Scale of Nursing Performance (6-DSNP) ................. 39 

Pilot-testing of Instruments ................................................................................ 39  Data Collection Procedures ............................................................................... 40  Data Safety and Integrity ................................................................................... 41  Data Analysis ..................................................................................................... 42  Limitations of the Study .................................................................................... 43 

4 FINDINGS ............................................................................................................ 44  Demographic Characteristics ............................................................................. 44  Work Characteristics .......................................................................................... 45  Instrument Reliability ........................................................................................ 47  Descriptive Statistics for Instrument Sub-scales ............................................... 50 

Nurse Stress Index .................................................................................... 50  Job Satisfaction Survey ............................................................................. 51  Nurse Performance Scale .......................................................................... 52 

Occupational Stress and Demographic Characteristics ..................................... 54  Occupational Stress and Work Characteristics .................................................. 55  Job Satisfaction and Demographic Characteristics ............................................ 57  Job Satisfaction and Work Characteristics ........................................................ 58  Job Performance and Demographic Characteristics .......................................... 60  Job Performance and Work Characteristics ....................................................... 61  Findings Related to Research Questions ........................................................... 63 

Research Question 1 ................................................................................. 63  Research Question 2 ................................................................................. 64  Research Question 3 ................................................................................. 65  Research Question 4 ................................................................................. 67  Research Question 5 ................................................................................. 69 

5 DISCUSSION, CONCLUSIONS, IMPLICATIONS,   AND RECOMMENDATIONS ............................................................................. 73  Discussion .......................................................................................................... 73 

Occupational Stress ................................................................................... 73  Job Satisfaction ......................................................................................... 75  Occupational Stress and Job Performance ................................................ 77  Characteristics, Stress, Job Satisfaction and Job Performance ................. 78  Mediating Role of Job Satisfaction on Stress and Job Performance ........ 79  Stress, Job Satisfaction and Job Performance by Hospital Type .............. 80 

The Conceptual Framework ............................................................................... 81  Conclusions ........................................................................................................ 82 

xi

Implications ....................................................................................................... 83  Implications for Nursing Education .......................................................... 83  Implications for Nursing Practice ............................................................. 83 

Recommendations .............................................................................................. 84 

REFERENCES ............................................................................................................ 86 

APPENDICES ............................................................................................................. 92  Appendix A: Institutional Review Board for Human Use Approval ................. 93  Appendix B: Permission to Use Research Instruments ................................... 104  Appendix C: Instruments ................................................................................. 109  Appendix D: Instrument Sub-scales and Number of Items ............................. 120 

xii

LIST OF TABLES

Table Page 1 Socio-demographic Characteristics of the Sample ................................................. 45  2 Work Characteristics of the Sample ....................................................................... 46  3 Number of Items and Cronbach’s Alphas for the NSI Sub-scales ......................... 47  4 Number of Items and Cronbach’s Alphas for the JSS Sub-scales.......................... 48  5 Number of Items and Cronbach’s Alphas for the 6-DSNP Sub-scales .................. 49  6 Range of Possible Scores, Mean Scores and Standard Deviations for NSI ........... 50  7 Range of Possible Scores, Mean Scores and Standard Deviations for JSS ............ 51  8 Range of Possible Scores, Mean Scores and Standard Deviations for 6-DSNP .... 52  9 Descriptive Analyses for Job Satisfaction (JSS) .................................................... 53  10 Descriptive Analyses for Nurse Performance Scale .............................................. 54  11 Mean Scores for Occupational Stress by Demographic Characteristics ............... 55  12 Mean Scores for Occupational Stress by Work Characteristics ............................ 57  13 Mean Scores for Job Satisfaction by Demographic Characteristics ...................... 58  14 Mean Scores for Job Satisfaction by Work Characteristics .................................. 60  15 Mean Scores for Job Performance by Demographic Characteristics .................... 61  16 Mean Scores for Job Perofrmance by Work Characteristics ................................. 62  17 Correlations for Job Performance, Job Satisfaction with Occupational Stress ..... 64  18 Effect of Personal Background and Work Characteristics on the Relationships

of Occupational Stress, Job Satisfaction and Job Performance Quality ............... 66  19 The Final Predictive Model for Self-Rated Job Performance ............................... 67  20 The Mediating Role of Job Satisfaction between Occupational Stress and Job

Performance .......................................................................................................... 69  21 Means for Occupational Stress, Job Satisfaction and Job Performance for the

Different Hospitals ............................................................................................... 70 

xiii

22 Influence of Type of Hospital on Job Performance, Job Satisfaction and

Occupational Stress .............................................................................................. 71  23 Post Hoc Results of Differences in Means in Occupational Stress, Job

Satisfaction and Job Performance by Hospital ..................................................... 72 

xiv

LIST OF FIGURES

Figure Page

1 Diagram of Theoretical/Conceptual Model .............................................................. 10

 

xv

LIST OF ABBREVIATIONS

6-DSNP Six Dimensional Scale of Nurse Performance

AIDS Acquired Immuno-Deficiency Syndrome

BSN Bachelor of Science in Nursing

EM Enrolled Midwife

EN Enrolled Nurse

ENT Ear, Nose and Throat

GDP Gross Domestic Product

HIV Human Immunodeficiency Virus

ICU intensive care unit

ILO International Labor Organization

IPR interpersonal relations

JSS Job Satisfaction Survey

M Mean

MoH

NGO

Ministry of Health

Non-Governmental Organization

NHS National Health Service

NSI Nurse Stress Index

OSH Occupational Safety and Health

RM Registered Midwife

RMN Registered Mental-health Nurse

RN Registered Nurse

RN/M Registered Nurse/Midwife

xvi

RPN Registered Pediatric Nurse

SD standard deviation

SNO Senior Nursing Officer

SPSS Statistical Package for Social Sciences

UBOS Uganda Bureau of Statistics

UK United Kingdom

US United States

WHO World Health Organization

1

CHAPTER 1

INTRODUCTION

Occupational stress can be defined as the harmful physical and emotional

responses that occur when the requirements of the job do not match the resources,

capabilities and needs of the worker (Alves, 2005; Bianchi, 2004; Lindholm, 2006;

Nakasis & Ouzouni, 2008). The International Labor Organization (ILO) asserts that

all countries, professions and all categories of workers, families and societies are

affected by occupational stress (Ogon, 2001). According to Alves (2005), 40% of all

American workers perceive their jobs as being extremely stressful. Similar findings

are noted in the United Kingdom, where occupational stress is estimated to be the

largest occupational health problem (Edwards & Burnard, 2003). Additionally,

research has demonstrated that as workload and work-associated stress increase, turn-

over rates of workers are also noted to increase. Thus, occupational stress results in

considerable costs to organizations in terms of absenteeism, loss of productivity, and

health care resources (AbuAlRub, 2004; Cottrell, 2001; Gueritault-Chalvin,

Kalichman, Demi, & Peterson, 2000; Nakasis & Ouzouni, 2008).

Lack of productivity due to occupational stress and its related effects,

including staff conflicts, recruitment and retention problems, burnout, absenteeism,

litigation and rapid turn-over, and lack of job satisfaction, has been reported to cause

significant monetary costs to the National Health Service [NHS] Trusts in the UK

(Cottrell, 2001; Mackay, Cousins, Kelly, Lee, & McCaig, 2004). Alves (2005)

reported that organizations spend as much as $75 billion a year on stress-related

2

outcomes including physical injuries at work and absenteeism; while the World

Health Organization (WHO, 2002) estimates the cost of stress and stress-related

problems to organizations to be in excess of $150 billion annually.

Job stressors and low job control have also been shown to be risk factors for

patient safety and to lead to poor job performance including reduced quality of

nursing care (Sveinsdottir, Biering, & Ramel, 2006). Occupational stress has also

been associated with chronic health problems like cardiovascular disease,

musculoskeletal disorders, physical injuries and cancers (Alves, 2005; Bradly &

Cartwright, 2002). Mental illness and serious health compromising behaviors such as

increased risk for suicide, substance abuse (such as smoking and alcohol

consumption), poor diet and lack of exercise are also associated with occupational

stress (Adeb-Saeedi, 2002; Oginska-Bulik, 2006).

The common sources and effects of occupational stress identified in the

literature are from the perspective of American and European workers. Since

occupational stress has been reported to affect all societies and professions (Ogon,

2001), it can be assumed that nurses working in Ugandan hospitals experience

occupational stress. Research has further demonstrated that the sources of

occupational stress, its levels and effects vary greatly depending on local forces such

as nature of work, work setting and cultural orientation. Thus, significant differences

in occupational stress among nurses in different countries may exist due to different

work settings and levels of social support (Evans, 2002). At present, there are scant

data about sources of occupational stress and its relationship with job satisfaction and

job performance in African countries or in Uganda in particular. There is, therefore, a

need to understand the predictors of occupational stress and the levels and inter-

3

relationships of occupational stress, job satisfaction and job performance among

nurses working in Ugandan hospitals.

Health Care System in Uganda

Uganda, which is listed among the developing countries, is located in East

Africa. The country is bordered by Kenya in the east, Sudan in the north, Democratic

Republic of Congo in the west, Tanzania in the south and Rwanda in the southwest

(UBOS, 2005). Uganda is characterized by poor health and developmental statistics.

For example, life expectancy (in years) at birth for males and females is 48 and 51

respectively and the infant mortality rate is 136 per 1000 live births; with 7.6 % of

gross domestic product (GDP) expenditure on health (WHO, 2005). The health

infrastructure in Uganda is composed of hospitals, health centers and aid posts which

may belong to the government, non government organizations (NGOs) or to

individuals (private). The hospitals are categorized as national referral, regional

referral or district/rural hospitals. The health centers are graded as health center IV,

III, II according to level of service, which is at the county, sub-county, and parish

levels respectively. There are a number of training schools and universities which

offer certificate/diploma and degree courses for healthcare professionals. Two-thirds

of these belong to the government and a third to NGOs and individuals

(http://www.health.go.ug/health_units.htm). The training schools for nurses are

distributed in various regions/districts throughout the country.

Nursing education includes various programs leading to different cadres of

nurses depending on the educational level of entry to the program and the length of

the program. Enrolled Nurses or Midwives (EN or EM) training lasts two and a half

years and eligible students must have acquired a Uganda Certificate of Education or

4

its equivalent. This level of training has been phased out, but the cadre of nurses still

exists in the hospitals. The registered level training is a three year program and

eligible students must have a Uganda Advanced Level Certificate of Education or its

equivalent. Graduates at this level can be general nurses (RN), midwives (RM),

pediatric nurses (RPN) or mental health nurses (RMN).

In the past, registered level nurses could complete further education in any

other discipline of interest to get an equivalent certificate diploma after practicing for

a minimum of two years. For example, an RN could apply to complete RM

preparation and vice versa and train for one and a half years, creating another cadre of

nurses, the Registered Nurse/Midwives (RN/M) or double trained nurses. This type of

further education was referred to as horizontal training while that of an EN or EM

midwife to registered level was termed vertical training. Double training has been

phased out and nurses are encouraged to pursue further education in the same line,

which is, general nursing, midwifery, pediatrics, etc. The Public Health Nurse (PHN)

program is a two year program only offered to nurses who have done at least two

disciplines at the registered level. The BSN is a four year university level program

plus an additional one year internship. The BSN program prepares nurses to acquire

competencies in nursing, midwifery, primary health care (community nursing), and

research.

Statement of the Problem

A human resource crisis exists in resource-constrained countries like Uganda

due to the macroeconomic and governing factors. A shortage of nursing staff has

been reported with a ratio of one nurse (nurses and midwives combined) to a

population of 3,065. It has also been reported that despite employing 30,000 health

5

care workers in 2004, an extra 5,000 qualified staff were needed to address the serious

staff shortage (Dieleman, et al., 2007). The situation has been compounded by the

HIV/AIDS pandemic as the high number of HIV/AIDS patients leads to excessive

workload and increased tasks.

There are continuous complaints by Ugandan nurses about work overload, and

the demand for nurses continues to grow as many drop out of work with very little

intervention seen. It has been reported that there is lack of enough space in the

hospitals and they are overcrowded with very sick patients. The situation is worsened

by lack of facilities and shortage of nurses, which is likely to cause stress to the nurses

(Ojoatre, 2008). For example, according to the government newspaper (New Vision),

one of the senior staff in Mulago Hospital reported that there were only 8-12 staff

members including nurses, midwives and doctors for five wards in the department of

Obstetrics and Gynecology at any one time. The staff manages the patient load which

is three times the load that is expected for 24 staff members on one ward.

At the First Global Forum on Human Resources for Health that took place in

Uganda in 2008 it was observed that there was an imbalance between the number of

nurses trained in the country and those who register to practice. It was speculated that

nurses have migrated to other countries, have joined other fields, or sit at home due to

the poor work conditions. Nurses also complain of working all day long despite the

high numbers of very seriously ill patients who require more attention. They have

further complained that their work is very stressful citing the very high nurse-patient

ratio which is reported to be 1:1000. The nurse-patient ratio is reported to be above

the 1:2 or 1:5 recommended by the World Health Organization for fatal complications

and common illnesses respectively (Natukunda, 2008).

6

Nurses have also observed that working when tired results in mistakes for

which they are blamed; therefore, they would rather not go to work under the

circumstances. This is in addition to the public outcry about the deteriorating nursing

care in Ugandan hospitals. Since there are no established occupational health services

due to limited resources and lack of occupational health professionals, there is a risk

of continuous loss of nurses, either due to stress related diseases or attrition due to

lack of job satisfaction (OSH WORLD, 2008; UBOS, 2005).

Significance of the Study

Studies of potential sources and effects of occupational stress have been

conducted among nurses in the United States and Europe. However, stress is a

complex phenomenon which results from interaction between an individual and the

environment in which the person exists. Thus, significant differences in occupational

stress among nurses may exist due to different work settings and levels of social

support (Evans, 2002). It was further asserted that occupational stress is a function of

local forces, pressures and cultures that requires customized interventions (Muscroft

& Hicks, 1998). Therefore, this study examined associations between occupational

stress, job satisfaction and job performance among hospital nurses in Uganda.

The results of this study may be used to guide policy makers and nurse

managers to develop a stress prevention/management model specific to the Ugandan

situation. Prevention and management of occupational stress among nurses will not

only improve their health but may improve job satisfaction and nursing care, which

will in turn reduce costs for the healthcare organizations as well as individuals.

7

Specific Aims of the Study

The specific aims of the study were to:

1. Examine relationships between occupational stress, job satisfaction and job

performance among hospital nurses in Kampala, Uganda.

2. Establish whether personal background characteristics influence occupational

stress, job satisfaction and job performance among hospital nurses in

Kampala, Uganda.

3. Examine whether there is a difference in levels of occupational stress, job

satisfaction and job performance among hospital nurses in Kampala, Uganda

by type of hospital; that is, government versus private not-for-profit (faith-

based) hospitals.

Research Questions

The research questions in this study were as follows:

1. Is there a relationship between occupational stress and job performance among

hospital nurses in Kampala, Uganda?

2. Is there a relationship between occupational stress and job satisfaction among

hospital nurses in Kampala, Uganda?

3. Do personal background characteristics affect the relationships among

occupational stress, job satisfaction and job performance among hospital

nurses in Kampala, Uganda?

4. Does job satisfaction mediate the relationship between occupational stress and

job performance among hospital nurses in Kampala, Uganda?

5. Are there differences in levels of occupational stress, job satisfaction and job

performance among hospital nurses in Kampala, Uganda by type of hospital?

8

Operational Definitions

The following operational definitions were used in this study:

Hospital nurse refers to any individual who qualified as a nurse or midwife at

any level (degree, diploma, or certificate), is registered by the Uganda Nursing

Council to practice nursing or midwifery, and is working in a hospital setting in

Uganda.

Personal background characteristics include the following demographic and

work characteristics: age, gender, marital status, number of children, hospital, ward/

department, nursing education, years of nursing experience, responsibility, and hours

worked on a typical day. These were measured by an investigator developed

demographic questionnaire.

Occupational stress refers to the harmful physical and emotional responses

that occur when the requirements of the job do not match the resources, capabilities

and needs of the worker (Alves, 2005). Occupational stress was measured by the

Nurse Stress Index (NSI) developed by Harris (Harris, 1989).

Job satisfaction refers to the level or degree to which employees like their jobs

(Spector, 1997). Hospital nurses’ job satisfaction was measured by the Job

Satisfaction Survey (JSS) developed by Spector in 1985 (Spector, 1997).

Job performance refers to how effectively an individual carries out his/her

roles and responsibilities related to his/her job (AbuAlRub, 2004). The Six Dimension

Scale of Nursing Performance (Schwirian, 1978) was utilized to measure hospital

nurses’ job performance or effectiveness in carrying out their roles and frequencies of

responsibilities in relation to patient care.

9

Conceptual Framework

The conceptual models/frameworks identified in the literature that have been

used to guide the study of occupational stress and coping are Lazarus and Folkman’s

cognitive theory of stress and coping (Lazarus & Folkman, 1984) and Karasek’s

Demand-Control Model (Karasek, 1979). According to Lazarus and Folkman’s

(1984) cognitive theory of stress and coping, stress is defined by the interaction

between the individual and the environment. Demands from the environment

exceeding the available resources result in stress or coping, depending on the

individual’s appraisal of the environmental effects or stressors. The variables in the

theory that guided this research are personal and workplace characteristics. Workplace

and work characteristics act as environmental stressors while personal characteristics

may facilitate the individual nurse’s ability to carry out the process of appraisal of the

stressors. Occupational stress and coping will result accordingly, depending on the

level of appraisal. The individual’s perception of how much control he/she has is a

factor which leads to feelings of stress when the situation is perceived as

uncontrollable or to feelings of positive coping if the situation is perceived as

controllable.

According to the Demand-Control Model (Karasek, 1979), there is interaction

of objective work load demands in the environment and the employee’s decision

latitude to meet the demands. Decision latitude is defined as the authority which the

individual employee has to make job decisions and the opportunity to utilize and

develop skills on the job (Karasek, 1979). Long term exposure to situations with

increased demands but with low control leads to low productivity and health related

problems. The assumption in the model is that psychological strain results from joint

effects of work demands and the decision-making freedom available for the employee

10

facing the demands. In other words, jobs with high demands but with low control

increase the risk of stress-related illness. The variables in this model which guided the

study are job demands or job strain (workload pressures).

Work and Personal Factors Cognitive Factors Behavioral Outcome

 

 

 

JJ 

 

 

Figure 1 Diagram of Theoretical/Conceptual Model

Assumptions for the Study

The study was conducted under the following assumptions:

1. Occupational stress can be measured and self reported by nurses.

2. Stressors occur in life and work environments and individuals react to these

stressors.

3. Nurses work in stressful environments that each individual nurse appraises and

reacts to differently.

Environmental Stressors (Workplace factors) - Type of hospital - Ward/unit - Responsibility - Hours worked on a typical day

Personal Characteristics: - Age - Sex - Nursing Education - Nursing experience - Marital Status - Number of children

OCCUPATIONAL STRESS

JOB SATISFACTION

JOB PERFORMANCE

11

CHAPTER 2

LITERATURE REVIEW

This chapter provides a review of literature related to occupational stress, job

satisfaction, and job performance among nurses of all specialties in or outside the

hospital. The first section of the review is related to sources and effects of

occupational stress. The second section includes a review of factors that affect job

satisfaction and the third section reviews factors related to job performance.

An abundance of research has been reported on occupational stress, job

satisfaction and job performance among nurses in the United States (U.S.), Europe,

and Asia, but very little in Africa. It should be noted that even the limited research in

Africa was conducted only in South Africa and no research was reported on in east,

west, north or central African nurses. This phenomenon was observed by Adejumo

and Lekalakala-Mokgele (2009) in their study appraising African nursing scholarship

where 68.3% of the publications in the past two decades were from South Africa,

5.2% from West Africa, and 3.3% from East Africa. These findings may be due to the

fact that African nurses outside of South Africa have limited research skills and rarely

publish.

Occupational Stress

Many studies have investigated occupational stress occurrence among various

professions in the U.S, Europe and Asia. Researchers have examined effects of stress

on employee health, job satisfaction, job performance, and coping strategies. As a

12

result of their studies, these authors, have also suggested management and prevention

strategies (Bianchi, 2004; Bradley & Cartwright, 2002; Chen, Chen, Tsai, & Lo,

2007). Occupational stress is documented as a common occurrence in health

professions throughout the world. The National Health Services (NHS) in the United

Kingdom and in Australia reported that occupational stress occurred among health

professionals at higher levels than in any other comparable profession (Adeb-Saeedi,

2002; Cottrell, 2001). This higher level of stress in health service has been attributed

to the nature of the work of health professionals in which nurses, physicians and

hospital administrators are involved in providing help to people experiencing life

crises (Tyson & Pongruengphant, 2004). Nursing has been shown to be a strenuous

profession, with nurses more exposed to stress-provoking factors than other

healthcare workers. According to Evans (2002), a survey commissioned by the

Sunday Times in 1997 reported that nursing was the sixth most stressful profession.

This literature review will examine the sources of identified occupational stress and

then the effects of stress.

Sources of Occupational Stress among Nurses

Sources of stress for nurses can be divided into four areas: workload,

organizational pressures, interpersonal interactions, and professionalism. In reality it

is rare that only one source of stress is present. Sources of stress are frequently

interrelated and synergistic effects are observed due to a variety of sources of stress.

For example, interpersonal conflicts may be due to organizational and management

issues. Research has demonstrated that sources of occupational stress among nurses

vary between regions, countries, organizations, departments, nursing specialties and

individuals. This has been attributed to the different health systems, their culture,

13

availability of resources, nature of work, different educational levels, age,

employment contract, work experience and personality traits (Lee & Wang, 2002;

Lindholm, 2006; Peterson & Wilson, 2002).

Individual differences affect the perception of the stressful situations and the

use of coping strategies. For example, in a study comparing Guatemalan and U.S.

nurses’ attitudes towards nursing, Guatemalan nurses were discontent with the lack of

resources to treat patients while the U.S. nurses were discontent with the work

environment drawbacks (Coverston, Harmon, Keller, & Malner, 2004). Further,

researchers found that younger public health nurses in the U.S., those with shorter

length of current working experience, a higher level of education, and less pre-job or

job continuing education perceived more occupational stress (Kirkcaldy & Martin,

2000; Lee & Wang, 2002). It can be argued that these less experienced and younger

public health nurses may have lacked enough experience at their current job. This

may lead to lack of confidence and or competence in their work roles, thus the higher

perception of occupational stress. However, it is not clear why those with a higher

level of education perceive more occupational stress, but it may be due to role

ambiguity. In contrast, Kirkcaldy and Martin (2000), in their study of job stress and

job satisfaction among hospital nurses in Northern Ireland, found that older nurses

reported more stress while younger nurses experienced better psychological health.

This could be a result of more social responsibility for the older nurses which could

lead to work-home conflicts.

Workload

Workload has been demonstrated to be one of the most frequent stressors

(Callaghan, Shiu, & Wyatt, 2000; Khowaja, Merchant, & Hirani, 2005; Li & Lambert,

14

2008). In a study of 102 nurses in a Chinese intensive care unit, excessive workload

was the most frequently cited source of workplace stress. This was a result of the

nursing shortage with fewer nurses to care for more patients (Li & Lambert, 2008).

Work load, shift work, overtime, and covering for absent colleagues were the most

common identified stressors in other studies (Begat, Ellefsen, & Severinsson, 2005;

Cottrell, 2001; Xianyu & Lambert, 2006). Lee and Wang (2002) investigated

perceived occupational stress and related factors among public health nurses, and

reported that personal responsibility and workloads were the major sources of

occupational stress. Excessive work load was also included as a major contributor to

stress among hospital based Brazilian nurses (Stacciarini & Troccoli, 2004). Heavy

workload may be due to the physically arduous work of nursing jobs, as well as due to

organizational pressures when there is a nursing shortage. Lack of confidence and

competence in the nursing role can have a synergistic relationship with work load,

creating high stress scores (Kirkcaldy & Martin, 2000).

Differences in stress by work settings have been reported. For example, a

study of job stress, coping and health perceptions of Hong Kong primary care nurses

reported low-to-moderate frequencies of stress among primary care nurses compared

to higher stress reported by those working in acute care settings (Lee & Wang, 2002).

This is expected as nurses working in acute care settings deal with very sick patients,

thus increased workload and emotional exhaustion. Further, Lindholm (2006)

reported that nurse managers and clinical directors had a significant probability of a

high level of work stress because they were exposed to high job demands. In addition,

significantly greater job stress was reported among medical-surgical nurses than those

working in home care (Salmond & Ropis, 2005).

15

Organizational Pressure

Organizational pressure and management issues are common causes for stress

(McGrath, Reid, & Boore, 2003; Tyson, Pongruengphant, & Aggarwal, 2002). Stress

from a perceived lack of organizational support, lack of resources, lack of autonomy,

lack of competence and confidence, lack of communication and guidance, and low

salaries or absent reward systems are organizational and management issues. Lee and

Wang (2002) reported personal responsibility, inadequate guidance and support, lack

of consultation and communication, lack of materials or resources, inadequate

manpower, and having to take risks to complete tasks as sources of institutional stress.

Ongoing organizational pressure has been identified as another source of stress

(Begat, Ellefsen, & Severinsson, 2005; Cottrell, 2001; Xianyu & Lambert, 2006).

The work environment and institutional settings themselves have been

associated with occupational stress. Sveinsdottir and colleagues observed that, in

addition to stressful factors intrinsic to nursing, organizational and management

attributes influenced work-related stress among nurses (Sveinsdottir, et al., 2006).

Some of the organizational and management attributes identified include work

environment and institutional setting. For example, in a study of occupational duties,

it was reported that certified nurse anesthetists perceived that responsibilities related

to patient care and anesthesia were inherently stressful (Roberts, 2005). Nurse

anesthetists care for patients who are usually unconscious and who require critical

nursing care and often contribute to work anxiety. Other significant stressors for the

certified nurse anesthetist included lack of institutional support, lack of adequate

surgical preparation, and a negative operating room environment.

In a study of stress and coping among cardiovascular nurses in Brazil, Bianchi

(2004) identified institutional work conditions as the major source of stress for nurses.

16

Makinen and colleagues similarly reported that occupational stress due to work social

arrangements are partially determined by the organization of work (Makinen,

Kivimaki, Elovainio, & Virtanen, 2003). Makinen and colleagues further reported that

the patient-focused nursing modes reduced the interpersonal problems among the

staff, thus decreasing work stress (2003). Evans (2002) identified six major nurse

stressors, including leadership, organizational control, intrinsic job features, job

image, reward systems, and human resource systems and recommended that

organizations should develop policies that encourage smooth communication and

socialization in the workplace.

Interpersonal Relationships/Intrinsic Nature of the Work

Working with difficult patients, the nurses’ feelings about death and dying,

interpersonal conflicts, managing the patients’ pain and the presence of the family

also contribute to occupational stress (Adeb-Saeedi, 2002; McGrath, et al., 2003;

Tyson, et al., 2002). The HIV epidemic and high mortality rates have contributed to

stressful work conditions for nurses. In a study of occupational stress of nurses in

South Africa, health risks posed by contact with HIV/AIDS patients, lack of

recognition for the job they are doing, and insufficient staff were identified as the

most common stressors for nurses (Rothmann, van der Colf, & Rothmann, 2006).

These findings are consistent with literature about the effect of the HIV/AIDS

pandemic on the health care workforce, with reports of increased emotional burden

and stress among health workers due to anxiety and fears of occupational exposure

(Dieleman, et al., 2007; WHO, 2005). Dieleman and colleagues found specifically in

Uganda that 83% of the staff interviewed had increased fear of occupational exposure

as a health worker, 36% had had a potential exposure injury in the past year, and the

17

only resource available for nurses was to wash the area under running water

(Dieleman, et al., 2007). Eighty-six percent of the staff also reported that an increase

in the amount of work increases the likelihood of injuries, contributes to a large

emotional burden with burnout in caring for very sick patients who do not respond to

therapy, and increases concern about being stigmatized if they do contract HIV/AIDS.

The majority of the staff continued to report a significant fear of getting infected even

though there was adequate protection available in the hospital. It was found that

hospital administrators were haphazard in addressing this staff issue, with no written

policies to prevent or mitigate the impact of HIV/AIDS, and that this affected working

conditions and staff motivation (Dieleman et al, 2007).

Professionalism

Professional issues have also been reported to lead to stress among nurses. For

example, Evans (2002), in a Yorkshire, UK study exploring the district nurses’

perception of occupational stress, found that job image and reward systems were

among the six major stress factors for the nurses. In another study of perceived

occupational stress and related factors in public health nurses in Taipei City, Taiwan,

Lee and Wang (2002) found that lack of recognition in the workplace was a

significant stressor among nurses. Likewise, Stacciarini and Troccoli (2004) in their

study of occupational stress, job satisfaction and state of health in Brazilian nurses,

reported that lack of recognition, lack of status of the nursing profession, lack of

autonomy, low salaries, lack of resources, and assignments outside the individual’s

specialty were sources of stress for nurses.

Ethical conflicts have also been identified as sources of job related stress and

anxiety (Begat, et al., 2005). According to Begat and colleagues, ethical dilemmas

18

arise because of nurses’ values and desires to provide high-quality care. This is in

agreement with McGrath, Reid and Boore’s (2003) findings that too little time to

perform duties to one’s satisfaction and rationing of resources and services resulted in

moderate to high stress. In another study of occupational responsibilities, perceived

stressors and work relations of the certified nurse anesthetist, perceived occupational

stress were related to patient care and anesthesia work in general (Roberts, 2004).

These stressors included patient complications and unexpected patient outcomes such

as death of a patient on the operating table. Lack of competence and confidence in the

nursing role has also been identified as a stressor (Kirkcaldy & Martin, 2000). The

nurse who lacks confidence and who is not competent in the role may be concerned

about committing errors which may lead to punishment and or litigation.

Effects of Occupational Stress

Occupational stress has been reported to result in a significant monetary cost

for health care systems (Cottrell, 2001; Evans, 2002). This is due to lack of

productivity as a result of staff conflicts, health care consumption, recruitment and

retention problems, burnout, absenteeism, litigation, and rapid turnover. The World

Health Organization (WHO, 2002) estimates the cost of stress and stress related

problems to organizations to be in excess of $150 billion annually. According to the

Health Enhancement Research Organization, a depressed employee is estimated to

spend $3,189 annually on health care expenses as compared with $ 1,679 for a non-

depressed employee in the UK (Cottrell, 2001). In addition, depressed workers’

accumulated short-term disability days resulted in 20 million more lost work days per

year than non-depressed workers (Cottrell, 2001). Although litigation cases are not

common in the developing countries like Uganda, the population is becoming

19

increasingly aware of their rights and starting to sue health institutions for health

workers’ negligence of duty. Therefore, the cost of occupational stress is likely to

increase in health care ministries in these countries not only in terms of medications

and other supplies but also in litigation cases. It is also likely to increase individual

nurses’ stress as they will be working with anxiety and fear of litigation in the event

of errors as they execute their duties.

Occupational stress negatively affects individuals’ health and wellbeing.

Individual effort-reward imbalance has been associated with burnout, which results

from prolonged intense stress. In a study of burnout among nurses in Germany, the

nurses who experienced effort-reward imbalance reported higher levels on two of the

three core dimensions of burnout (Bakker, Killmer, Siegrist, & Schaufeli, 2000).

Bakker and colleagues found that the nurses who identified a negative imbalance

between efforts spent on their job and the reward they felt from the job reported

feeling more emotionally drained than those who did not. The feelings of personal

accomplishment were lowest among nurses who had a mismatch between demands

and rewards, and who had high intrinsic effort in their jobs.

Emotional exhaustion and burnout have been recognized as occupational

hazards for people-oriented professions such as nursing. Brown and colleagues

examined demanding work schedules and mental health in nursing assistants working

in nursing homes, and reported that working two or more double shifts per month was

associated with an increased risk for all negative mental health indicators (Brown,

Zijlstra, & Lyons, 2006). Furthermore, working 6-7 days per week was associated

with depression and somatization. In a study of stress, coping and managerial support

and work demand among nurses, consistent relationships between work stress and

depression, anxiety and job satisfaction were identified (Bennett, Lowe, Matthews,

20

Dourali, & Tattersall, 2001) They suggested that lack of management support, having

job overspill, making decisions under time pressure and lack of recognition by the

organization were key predictors of negative effect. Chronic health problems such as

cardiovascular disease, musculoskeletal disorders, physical injuries and cancers have

also been associated with occupational stress (Alves, 2005). Mental illness and

serious health compromising behaviors such as increased risk for suicide, substance

abuse (such as smoking and alcohol consumption), poor diet, and lack of exercise

weree also associated with occupational stress (Adeb-Saeedi, 2002; Oginska-Bulik,

2006).

Occupational stress also contributes to many nurses leaving their jobs

(Cottrell, 2001; Sveinsdottir, et al., 2006). The high turnover of nurses results in a

shortage of nurses, which leads to work overload for the remaining nurses and

becomes a vicious cycle. The high turnover of nurses is attributed to a lack of job

satisfaction which is associated with occupational stress. For example, Flanagan and

Flanagan (2002) in a study of job satisfaction and job stress reported that the NSI was

the strongest explanatory variable accounting for 30.3% of job satisfaction. Tyson and

colleagues, who also utilized the NSI to measure occupational stress in their study of

coping with organizational stress among hospital nurses in Southern Ontario, reported

a negative correlation between job stress and job satisfaction (Tyson, et al., 2002).

The shortage of nurses has also been reported to affect nursing care negatively.

In a study on hospital nurse staffing and patient mortality, nurse burnout and job

satisfaction in Pennsylvania, it was found that surgical patients experienced a high

risk-adjusted 30 day mortality and failure to rescue when the patient-to-nurse ratio

was high (Aiken, Clerke, & Sloane, 2002). Patients were more at risk of dying in a

30-day period because the nurses could not rescue them when hospital units were

21

understaffed. In the same study, nurses were more likely to experience burnout and

job dissatisfaction when the patient-to-nurse ratio was high. Lack of job satisfaction

can lead to employees’ resentment which may be manifested in chronic absenteeism,

lateness or reduced effort and increased error rate (Ackerman & Bezuidenhout, 2007).

This is a manifestation of poor nursing care which places patients’ lives at risk.

Sveinsdottir and others (2006) also reported that job stressors and low job control lead

to poor job performance, reduced quality of nursing care, and concerns for patient

safety.

Because of the great shortage of nurses in Ugandan hospitals, it is a common

phenomenon for nurses to work double shifts or to work for seven days or more

without “off duty.” Nurses stand in for colleagues who fail to report for duty due to

sick leave or other social problems. Due to poor remuneration in their primary job,

nurses prolong their work schedules when they want to accumulate vacation days in

order to work elsewhere to make additional money in a second job. According to

Kyadondo and Whyte (2003), public sector reforms and poor remuneration have

weakened workers’ positions as professionals and result in their seeking

supplementary sources of income outside the health care system. Kyadondo and

Whyte further observed that while other professionals in Uganda supplemented their

salaries by engaging in agriculture, beer brewing or trade, health workers were found

in small storefront clinics, drug shops and laboratories. This means that health

workers end up overworked if they continue to work in the public sector as well as in

private enterprises. Further research is needed to examine stress and related factors

among Ugandan nurses.

22

Job Satisfaction among Nurses

Job satisfaction is defined as the level or degree to which employees like their

jobs (Spector, 1997). Numerous components of job satisfaction have been identified

including including satisfaction with pay, potential for creativity, autonomy, task

identity, satisfaction with organizational promotion policy and their individual

promotions, satisfaction with co-workers, and available continuing education

opportunities. Previous researchers have reported an inverse or negative relationship

between perceived stress and job satisfaction, that is, as job satisfaction increases,

stress decreases (Flanagan & Flanagan, 2002; Sveinsdottir, et al., 2006; Zangaro &

Soeken, 2007).

Organizational support is reported to increase nurses’ job satisfaction. The

findings of Bradley and Cartwright’s study of social support, job stress, health and job

satisfaction among nurses in the United Kingdom indicated that perceived

organizational support was related to nurses’ health and job satisfaction (Bradley &

Cartwright, 2002). Organizational support may include provision of adequate

resources, good communication, training and development and adequate support

supervision. In a study of staff dissatisfaction in the surgical theatre complex of a

private hospital in South Africa, the results indicated that dissatisfaction was due to

poor working conditions, lack of management support, unequal distribution of work,

lack of resources, poor remuneration, an inflexible time system, and staff shortages

(Ackerman & Bezuidenhout, 2007).

Quality interprofessional collaboration between nurses and doctors and

positive leadership has also been reported as important factors for nurse job

satisfaction. A meta-analysis study of nurses’ job satisfaction by Zangaro and Soeken

(2007) reported that nurse-physician collaboration and autonomy were strongly

23

correlated with job satisfaction and job stress among nurses. This meta-analysis,

conducted in the U.S. included 31 studies published between 1991 and 2003.

However, although the meta-analysis was conducted in the U.S., it is not clear

whether all the reviewed research was conducted in the U.S. Therefore it is not

possible to assess whether the observations could be generalized only to nurses in the

U.S., or generalized more widely.

In a study of factors influencing stress and job satisfaction for nurses working

in psychiatric units in Greece, the findings indicated that job satisfaction was

primarily influenced by the quality of clinical leadership and psychological stress

(Nakasis & Ouzouni, 2008). In a study among Australian nurses, role discrepancy

especially task delegation practice contributed to nurses’ intention to quit their jobs

(Takase, Maude & Maniase, 2006). This report supports the above observation that

clinical leadership influences job satisfaction. This may be due to poor

communication and transparency which results in psychological stress and job

dissatisfaction.

Other researchers have reported job satisfaction among nurses in terms of

intrinsic and extrinsic factors. Intrinsic factors, also known as motivators are those

factors inherent to the nursing job itself, while extrinsic or hygienic factors refer to

conditions of work and work environment. While some research has reported that

nurses may be stressed due to the nature of their job (intrinsic factors), other studies

indicate that nurses are satisfied with the intrinsic factors. For example, Lephoko and

colleagues reported that nursing management and nursing staff in selected hospitals in

Mpumalanga province, South Africa were content with the intrinsic factors of their

jobs but were dissatisfied with the extrinsic factors of the organizational climate

(Lephoko, Bezuidenhout, & Roos, 2006). On the other hand, (Salebi & Minnaar,

24

2007) in a study of nurses in a public hospital in South Africa, reported that more

respondents (42%) experienced low satisfaction with motivational (intrinsic) aspects

of their job as compared to only 22% who experienced low satisfaction with hygiene

(extrinsic) aspects of the job. The intrinsic motivational components of this study

included responsibility, opportunity for creativity and innovation, independence, and

recognition while the extrinsic hygiene factors were relationships in the work place,

supervisors’ decision making skills, supervision, working conditions, policies, job

security and salaries. Extrinsic organizational climate in the Lephoko and colleagues

(2006) study referred to management, physical environment, career development,

performance management, motivation, empowerment and organizational alignment.

The results of the above two studies conducted in the same country of South

Africa are contradictory. This is an indication that like occupational stress, job

satisfaction is influenced by many factors including differences in regions,

organizations or hospitals. Furthermore, these researchers defined intrinsic and

extrinsic factors very differently making study comparison difficult. A universally

agreed upon definition of intrinsic and extrinsic factors is needed to better compare

regions in nurse satisfaction for different regions and countries.

In another study in selected hospitals in England, Lephalala and colleagues

reported that the most important extrinsic factor that caused job dissatisfaction among

nurses was their salary (Lephalala, Ehiers, & Oosthuizen, 2008). Salaries between

private hospitals and the National Health Service varied considerably and salaries

within one hospital were also not uniform. In the same study, nurses were satisfied

with other extrinsic factors such as organization and administration policies,

supervision and interpersonal relations. These findings are inconsistent with those of

Lephoko and colleagues (2006) in South Africa in which nurses were dissatisfied with

25

extrinsic factors related to organizational climate. This result is most likely is a

reflection of cultural and economic differences and the level of development of the

health care systems. In the same study, Lephoko et al., (2006) reported that lack of

promotion or advancement opportunities and lack of involvement in decision and

policy making were the most important intrinsic factors influencing nurses’ job

satisfaction among nurses in the private hospitals studied. This also contradicts other

studies emphasizing that each hospital or health care environment has its own milieu

that contributes to nurse satisfaction and dissatisfaction.

Organizational commitment is another factor reported to have an impact on

job satisfaction. In a study exploring nurses’ views and experience in mainland China,

it was reported that organizational commitment had the strongest positive impact on

job satisfaction (Lu, While, & Barriball, 2007). In the same study, organizational

commitment was positively related to professional commitment.

Although there is not much reported in the literature on spousal support, an

exploratory study confirmed the hypotheses that there was a negative correlation

between work-family conflict and job satisfaction and that spousal support was

positively correlated with job satisfaction (Patel, Beekhan, Paruk, & Ramgoon, 2008).

According to Patel and colleagues, these findings indicated that nurses who are more

satisfied with their jobs were less likely to allow work to encroach on their family

lives. This conclusion is in agreement with the available literature which reports that

an employee who perceives himself or herself to have job control has higher job

satisfaction (Chinweuba, 2007; Sveinsdottir, et al., 2006). Although this study did not

specifically investigate the contribution of spousal support to job satisfaction among

nurses, one of the sub-scales in the Nurse Stress Index contains items related to

work/home conflict that may allude to spousal support.

26

Job satisfaction among nurses has also been studied in relation to working

conditions, emotional climate, and social climate. In a study of job satisfaction of

registered nurses in a community hospital in the Limpopo Province in South Africa,

the majority of respondents were dissatisfied with working conditions and emotional

climate of the hospital, but fairly satisfied with the social climate (Kekana, Rand, &

Wya, 2007). Working conditions were defined by reflecting on the individual’s

perception of working conditions as influenced by workload, salary, fringe benefits,

availability of adequate resources, professional growth opportunities and the

challenges of the job. Emotional working climate referred to the level of autonomy

experienced by nurses, how they conceive themselves as nurses and their professional

commitment. The social work climate referred to the personal interactions at work,

group cohesiveness and team spirit. Under working conditions, 83% of the

participants rated workload and the degree of fair remuneration as highly dissatisfying

while 82% rated pressure under which they worked as the most highly dissatisfying

under the emotional climate (Kekana, et al., 2007).

These findings were consistent with previous reports that heavy workload is a

source of occupational stress which leads to low job satisfaction. However, the factors

which are related to job satisfaction may be influenced by the differences between

study populations, the design and conditions under which the studies are conducted.

For example, in a study of nurses in Southern Taiwan which examined the effects of

job rotation and role stress on job satisfaction and organizational commitment, nurses

reported that job rotation had an effect on job satisfaction (Ho, Chang, Shih, & Liang,

2009). This differs from the previous studies cited above. However, it is clear that

frequent rotation on the job may not allow nurses to develop the required individual

unit skills thus stress and job dissatisfaction result.

27

In a Taiwanese study of hospital nurses, the researchers found that work

characteristics such as routinization had the greatest negative impact on job

satisfaction followed by personality traits and job involvement (Chu, Hsu, Price, &

Lee, 2003). In another study of working conditions that contribute to absenteeism

among nurses in a provincial hospital in the Limpopo Province, South Africa,

constraining working conditions such as inadequate group cohesion, inadequate

delegation of autonomy, role ambiguity, ineffective routinization and excessive

workload resulted in absenteeism in the work place (Nyathi & Jooste, 2008). As such,

these findings are in agreement with Selebi and Minnar (2007) who report that

routinization, role ambiguity and lack of delegation autonomy do not give opportunity

for innovations and creativity by the employees, and may result in job dissatisfaction.

It has been reported in the literature that there is a negative link between job

satisfaction, intention to leave, and actual turnover (AbuAlRub & Al-Zaru, 2008).

Work related stress has been found to increase turnover rate of workers due to less job

satisfaction. Wilson and colleagues in their study of job satisfaction among a

multigenerational nursing workforce also acknowledged that job satisfaction is a

significant predictor for nurse retention (Wilson, Squires, Widger, Cranley, &

Tourangeau, 2008). Cottrell (2001) reported that over 30,000 nurses in the UK left

their profession in 1997 alone. Such a loss, coupled with the recruitment crisis, results

in increasing stress on those who remain on the job.

Job stress and job satisfaction have also been reported to be influenced by

personal characteristics such as age and experience of nurses. For example, significant

inverse correlations were reported between job satisfaction and age, and years of

nursing experience with job stress (Ernst, Franco, Messmer, & Gonzalez, 2004).

Other personal characteristics such as mental and physical health, marital status,

28

education level, rural/urban setting, and perceived HIV stigma were reported to have

significant influence on job satisfaction. In addition, there are significant differences

in job satisfaction scores among five countries in a study of HIV stigma and nurse job

satisfaction in five African countries (Chirwa, et al., 2008). These results reinforce

the fact that there are many factors which affect job satisfaction.

In another study of the relationship between job stress and job satisfaction

among nurse educators in Nigeria, educational qualification was reported to influence

the relationship between job stress and job satisfaction (Chinweuba, 2007). This result

was attributed to the fact that the nurse educators with a higher education had a higher

chance of securing a desired and satisfying job. The education qualification has also

been reported to affect the employees’ role perception, professional commitment and

role conflict, thus affecting job satisfaction indirectly (Lu, et al., 2007). Chinweuba

rightly observes that nurse educators with less qualifications have less chance of

securing satisfying jobs, have more role conflicts role ambiguity and work overload or

under load. This means that they have less control of their work days, poor promotion

opportunities and low levels of salaries. The two reports highlight the importance of

higher education not only to nurse educators but all nurses.

It has been reported in the literature that employees who have job

dissatisfaction react differently (Ackerman & Bezuidenhout, 2007). In their study of

staff dissatisfaction in the theatre complex of a private hospital in South Africa,

Ackerman and Bezuidenhout observed that while some employees may react by

leaving the organization, others may actively and constructively attempt to improve

the conditions by voicing their concerns. Further, others may wait passively for

conditions to improve or worsen. Therefore, considering the nursing shortage, the

need to understand job satisfaction warrants the attention of organizational leaders as

29

well as researchers. It is not known what proportion of the reported shortage of nurses

in Uganda is due to lack of job satisfaction, occupational stress, or any other cause. It

is therefore important to explore levels of job satisfaction among nurses in Uganda to

improve the quality of nursing care in these hospitals. It is noted that studies of job

satisfaction among nurses have utilized various instruments. The JSS developed by

Spector (1997) was used to measure job satisfaction in the current study because its

sub-scales and items include factors that may be related to the work environment for

Ugandan nurses.

Job Performance among Nurses

Occupational stress and low job control have been shown to be risk factors for

patient safety and to lead to poor job performance (AbuAlRub, 2004). Using the Six-

Dimensional Scale of Nurse Performance (6-DSNP) developed by Schwirian (1978),

Taskase and colleagues found that the quality of job performance was reduced when

job dissatisfaction was present (Takase, Maude, & Manias, 2005). A high level of

occupational stress has been found to reduce nursing quality. A shortage of nursing

staff due to turnover as a result of occupational stress was associated with increased

patient mortality rates in an intensive-care unit (Sveinsdottir, et al., 2006). However,

in a study on job stress, recognition, job performance and intention to stay at work

among Jordanian hospital nurses, it was reported that recognition of nurses’

performance had a direct and buffering effect on job stress and the level of intention

to stay at work (AbuAlRub & Al-Zaru, 2008). This is consistent with available

literature which has reported that recognition leads to job satisfaction and nurses

seeing no reason to leave their jobs (Cartledge, 2001). Higher occupational stress

levels have also been significantly associated with poorer self-rated and supervisor-

30

rated job performance, more sick days, and more reported absences for mental health

reasons.

Supervisor support is another factor which is reported to affect nurses’

performance. In a study of primary nurses’ performance and the role of supportive

management, it was found that performance increased where supervisor support was

higher (Drach-Zahavy, 2004). Furthermore, nurses’ perception of the costs of seeking

support had a negative impact on nurses’ performance. This means that supervisor

support needs to be readily available to improve nurses’ job performance. In another

study, Abu Al Rub (2004) reported that perceived social support from co-workers

enhanced the level of reported job performance, and lowered the level of job stress

among the nurses.

In a longitudinal survey of nurses’ self-reported performance during an entry

to practice program, participants reported significant increases in frequency and

quality of nursing behaviors over time (Roud, Giddings, & Koziol-McLain, 2005).

The researchers concluded that new graduate nurses can successfully integrate

knowledge gained during training into clinical practice when provided with time and

support. This is probably true for all employees because the longer one stays on the

job, the more confident and competent one becomes in the skills required for the job.

With confidence and competence in the job skills, performance is improved.

Morale is another factor which affects nurses’ performance. Nurses’ morale

can be boosted by creating a conducive environment characterized by support

supervision, positive feedback, and good communication. Perceptions that they are

valued, job satisfaction and organization commitment may lead to improved work

place efficiency and output (Stapleton, et al., 2007). Career commitment has also been

reported to have a significant positive relationship on job performance. According to

31

some researchers, career commitment is mostly attitudinal when employees become

emotionally attached to the organizations and accept their goals and values (Mrayyan

& Al-Faouri, 2008). With the acceptance of organizational goals and values,

employees may remain in the organizations. This not only improves job performance

but also reduces organizational costs due to high turnover.

Many researchers have studied occupational stress, job satisfaction and job

performance among nurses. However, the studies have been either in individual

private or public hospitals and very few compared these variables across both public

and private hospitals. In a five year follow-up study of stress among nurses in public

and private hospitals in Thailand, nurses in public hospitals reported more stress than

those in private hospitals. However, job satisfaction did increase over time,

particularly in public hospitals (Tyson & Pongruengphant, 2004). The researchers

attributed the increase in job satisfaction to maturity/age, improvement in monetary

compensation, and organizational support.

Religious beliefs have also been reported to affect performance and service

delivery. In a study to evaluate the service delivery given by religious health care

providers in Uganda, it was reported that religious not-for-profit facilities hire medical

staff below the market wage but the workers provide better quality care than their

government counterparts (Reinikka & Svensson, 2003). The researchers concluded

that altruistic concerns of religious not-for-profit hospitals motivate the healthcare

providers to provide quality care to the poor. This finding is similar to the findings of

(Mrayyan & Al-Faouri, 2008) who observed that employees who are emotionally

attached to the organizations and accept their goals and values are satisfied with their

jobs.

32

There are indications that nursing care in hospitals in Uganda has deteriorated.

This is reflected in various newspaper complaints about neglect of patients and poor

nursing care in the Ugandan hospitals. It is therefore assumed that nurses’ job

performance does not meet public and administrative expectations. No study has been

conducted to assess hospital nurses’ job performance in Uganda. It is therefore

important to conduct this study to document nurses’ perceptions of their job

performance and the factors which are associated with it. This will guide policy

makers and nurse managers in developing strategies for improving job performance in

Ugandan hospitals.

Summary of Literature

Based on the review of the literature, occupational stress, job satisfaction, and

job performance are the major factors associated with retention of nurses and quality

of care. Additionally, occupational stress has been found to differ among professions

and work settings. The majority of the research studies regarding sources of

occupational stress and job satisfaction have been conducted on American and

European nurses and their work settings. The conceptual model guiding this study

indicated that cultural templates influence the appraisal of job demands, job

satisfaction, and job performance (Lazarus & Folkman, 1984). Therefore, given the

diversity of reported stressors for nurses, there is a need to identify the relationships

among occupational stress, job satisfaction and job performance of nurses in the

Ugandan hospitals.

33

CHAPTER 3

METHODOLOGY

This chapter provides a description of the methods utilized in implementation

of the study. The study design, data collection instruments, subjects, procedure for

collection of data, and methods of data analysis are presented.

Study Design

A correlational, cross-sectional study design was utilized to investigate the

research questions. The relationships among occupational stress, job satisfaction, and

job performance were explored. The effects of personal characteristics such as age,

marital status, nursing education, nursing experience and type of unit on occupational

stress, job satisfaction and job performance were also explored. Further, differences

by hospital setting (government or private not-for-profit) in regard to perception of

occupational stress, job satisfaction and job performance were also examined.

Ethical Considerations

Protection of human subjects was evaluated by the Institutional Review

Boards of the University of Alabama at Birmingham and Makerere University.

Permission was sought from the hospitals’ administrators to conduct research in a

large public hospital and three private not-for-profit faith-based hospitals, all situated

in Kampala, Uganda. Consent was also sought from the nurses and nurses who

volunteered to fill the questionnaires were assumed to have given consent. A form

explaining the purpose of the study and the rights of the participants to withdraw from

34

the study anytime without penalty was attached to the questionnaires to ensure

voluntary consent. Further, the questionnaires had no identifiers to ensure anonymity

and confidentiality. Only aggregate data were reported, individual data were kept in

strict confidence and used only for research purposes.

Setting

The study was conducted on a sample of nurses working in Mulago National

Referral and Teaching hospital, and three private not-for-profit (faith-based) hospitals

situated in Kampala, Uganda. Mulago National Referral and Teaching Hospital is

utilized for clinical and practical teaching/experience for Makerere University

medical, nursing, pharmacy and other health professional students. The Directorate of

Nursing in the hospital is headed by the Assistant Commissioner, Nursing Services

who is assisted in her managerial duties by several Area Managers or Senior Nursing

Officers (SNOs). Each Area Manager is responsible for an area which is composed of

several units/wards. These areas include: Accident and Emergency, Medical, Surgical,

Pediatrics, Obstetrics and Gynecology, Outpatient Clinics (Assessment Center,

Private Wing), Community Health Services, Operating Theatres and Special Clinics

(Ear, Nose and Throat [ENT] and Ophthalmology).

Several cadres of nurses including graduate nurses (BSN), Registered Nurses

(RN), Registered Midwives (RM), Registered Nurse/Midwives (RN/M), Public

Health Nurses (PHN), Enrolled Nurses (EN) and Enrolled Midwives (EM) work in

Ugandan hospitals. The nurses are allocated to the various units according to their

availability and consideration of the expected workload on the unit. The hospital

nursing staff includes 1000 nurses and the hospital has a bed capacity of 1,500

35

patients. Nursing staff on the units/wards are also assisted by nursing

assistants/nursing aides and nursing students from the various nursing schools.

The three non-governmental not-for-profit hospitals situated in Kampala also

have different departments including Medical, Surgical, Pediatrics, Obstetrics and

Gynecology, Outpatient Clinics, but no specialized clinics are available. The total

number of nurses in each hospital varies between 150-200 nurses and includes

Enrolled Nurses (EN), Enrolled Midwives (EM), Registered Nurses and Midwives

(RN/M), Tutors, Public Health Nurses (PHN) and Diploma Trained nurses. These

hospitals have bed capacity from 300 to 360 and have training schools for nurses and

midwives at enrolled and registered levels.

Study Sample

The target population in this study was all nurses working in the four selected

hospitals namely; the national public referral and teaching hospital and three private

not-for-profit faith-based hospitals at the time of the study.

Inclusion Criteria

Subjects in this study had to fulfill the following conditions: (a) must have

been a qualified nurse (BSN, RN, RM, RN/M, PHN, EN or EM), (b) a fulltime

employee of the hospital included in the study for at least six months by the time of

the study, (c) between 20 and 60 years of age, (d) willing to participate in the study,

and (e) working in the general surgical, medical, pediatrics, or obstetrics and

gynecology wards.

36

Exclusion Criteria

The following categories of nurses were excluded from the study: (a) those

nurses who were currently enrolled in advanced educational study, (b) nurses who

were working on contractual terms (above the retirement age of 60 years), and (c)

tutors and nurses working in Operating Theatres, specialized ward/units like intensive

care units (ICU), Heart Institute or burn units. The nurses working on these units were

assumed to be extremely busy and that other factors may influence nurses’ working

conditions. For example, while functional or task-oriented nursing is the major mode

for nursing care in the hospitals, some of the specialized wards/units have acquired

different modes of nursing care. In addition, some of the specialized units operate

under different projects whose working conditions are totally different from the

general wards/units.

Sample Size

The required sample size was calculated based on a power analysis for partial

correlation and regression analyses (Cohen & Cohen, 1983). The conventional

standard level of significance (.05) and power (.80) was utilized to calculate sample

size (Polit & Beck, 2004). According to Polit and Beck (2004) nursing studies usually

have modest effects; therefore a relatively modest effect size of .20 was utilized and

the adequate sample size calculated for the study was 321. However, the

questionnaires were distributed to a total of 400 nurses who met the inclusion criteria

and volunteered to participate in the study in order to account for non-responses and

incomplete questionnaires. A total of 333 nurses submitted completed questionnaires.

37

Instruments

Three instruments were utilized to examine the relationships between

occupational stress, job satisfaction and job performance. The instruments utilized

included the Nurse Stress Index [NSI] (Harris, 1989), Job Satisfaction Survey [JSS]

(Spector, 1997), and the Six Dimension Scale of Nursing Performance [6-DSNP]

(Schwirian, 1978). The three instruments were part of a questionnaire with sections,

each consisting of an instrument. The questionnaire also included a section to identify

and assess personal characteristics such as age, gender, nursing education (registered,

diploma, BScN, masters), nursing experience, and the department where the nurse

works. This was because personal characteristics have been reported to have an

influence on the perception of stress, job satisfaction and job performance

(Chinweuba, 2007; Ernst, et al., 2004).

The Nurse Stress Index (NSI)

The NSI (Harris, 1989) aims at identifying sources of stress among nurses in

hospital and community settings. The 30 item instrument consists of six subscales

which each include five items. The sub-scales include: workload pressures related to

insufficient time (Managing Workload 1), items 1-5; workload pressures due to

resources and conflicting priorities (Managing Workload 2), items 6-10;

Organizational Support and Involvement, items 11-15; Dealing with Patients and

Relatives, items 16-20; Home and Work Conflicts, items 21-25; and Confidence and

Competence in Role items 26-30 (see appendix D). Respondents are asked to rate

their potential stressors on a 5-point Likert scale ranging from 1= no pressure to 5=

extreme pressure. The NSI is self-reported and the respondents read and circle the

selected score from 1 = no pressure, 2 = very little pressure, 3 = moderate pressure, 4

38

= high pressure, and 5 = extreme pressure for each item. A total score can be

computed ranging from 30-150 and means of subscales can be calculated to assess

relative importance of sources of stress. The scores can also be derived from each sub-

scale and compared directly to obtain information on perceived sources of stress

(Harris, 1989). Acceptable levels of reliability and validity of the NSI were

established with overall Cronbach’s alpha of 0.90 (Harris, 1989).

The Job Satisfaction Survey (JSS)

The JSS aims at assessing the degree to which people like their jobs (Spector,

1997). The JSS is a self-report instrument which provides an overall job satisfaction

score after assessing nine facets or sub-scales, namely; pay, promotion, supervision,

fringe benefits, contingent rewards, operating conditions, coworkers, nature of work

and communication. The respondents agree or disagree on a 6-point continuum for

each item, with 1 representing much disagreement, 2 disagree moderately, 3 disagree

slightly, 4 agree slightly, 5 agree moderately, and 6 agree very much. Each sub-scale

has four items resulting in a total of 36 items; however, some items are worded

positively while others are worded negatively (see appendix D). This implies

therefore that agreement for a positively worded item and disagreement with a

negatively worded item indicates job satisfaction and vice versa. Reverse scoring

therefore is necessary for the negatively worded items making 1 represent much

agreement and 6 represent very much disagreement. The numbered responses are

summed after reversing the negative items to get the total satisfaction score of the 36

items ranging from 36-216. Reliability and validity of the instrument was established

with an overall Cronbach’s alpha score of .91 (Spector, 1997).

39

The Six Dimension Scale of Nursing Performance (6-DSNP)

The Six Dimension Scale of Nursing Performance (Schwirian, 1978) assesses

nurses’ job performance. This is the person’s effectiveness in carrying out his/her

roles and responsibilities in relation to patient care. The instrument is self-reported

consisting of six sub-scales and 52 items. The sub-scales include: Leadership, Critical

Care, Teaching/Collaboration, Planning/Evaluation, Interpersonal Relations/

Communication and Professional Development. Respondents are asked to rate the

items as to how often (column A) and how well (column B) they perform the

behavior/item to assess frequency and quality of performance respectively. The nurses

rate the items on a 4-point scale with 1 = not expected in this job; 2 = never or

seldom; 3 = occasionally and 4 = frequently for column A, while column B is rated

with 1 = not very well; 2 = satisfactorily; 3 = well and 4 = very well. However, the

items on the professional development sub-scale are assessed for quality only. Since

the sub-scales are of different lengths ranging from 5 to 12 items, their scores are

calculated according to the average of ratings on behaviors/items per sub-scale. The

numbers of items in each sub-scale are as follows: Leadership = 5, Critical Care = 7,

Teaching/Collaboration = 11, Planning/Evaluation = 7, Interpersonal Relations/

Communication = 12 and Professional Development = 10 (see appendix D). It is

assumed that higher scores indicate better performance (Schwirian, 1978). Reliability

and validity of the 6-DSNP was established and Cronbach’s alpha coefficients for

each sub-scale ranged from .90 to .97 (Schwirian, 1978).

Pilot-testing of Instruments

Since the data collection instruments were based on American and European

cultures in previous studies, instruments for this study were pilot-tested to validate

40

their appropriateness to the Ugandan situation before actual data collection. The

researcher and a small group (n=4) of nurses at the level of Senior Nursing Officers

reviewed and assessed whether the questions were clear and appropriate to the

Ugandan situation. It was agreed that all items were clear and understandable by the

Ugandan nurses and the tools were adapted and adopted for use in the study.

Data Collection Procedures

The study was conducted after getting approval from the Institutional Review

Boards (IRBs) at the University of Alabama at Birmingham and Makerere University.

Permission to conduct the study was also sought from the administrators of the four

hospitals. Four meetings, one per hospital, were organized with the nurses through the

Directors of the hospitals and the Directors of Nursing Services. The purpose of the

study, the methods of data collection and time frame for the study were explained to

the nurses at the meetings. It was explained to the nurses that they were free to

withdraw from the study at any time without penalty. It was also made clear that there

was no financial or any other form of gain from the nurses’ participation. The nurses

were then invited to participate in the study and the questionnaires were distributed to

those who volunteered to participate in the study.

In order to maximize participation of nurses and response rate, the researcher

recruited and trained four BSN prepared research assistants. The research assistants

were responsible for distributing and collecting the completed questionnaires from the

nurses in the various wards/units who did not attend the meetings but volunteered to

participate in the study. A sealed wooden box was placed at each ward/unit in which

nurses dropped the completed questionnaires. The research assistants collected the

completed questionnaires from their assigned wards/units on a daily basis.

41

In order to observe confidentiality, the nurses were not required to sign a

consent form. It was explained that any nurse who volunteered to complete the data

collection instruments was assumed to have given informed consent. Each

questionnaire had an information sheet attached to it explaining the purpose of the

study, the time frame for the study and assurance that the information given was to be

utilized for study purposes only and strict confidentiality was to be observed. The

information sheet also included instructions to the participants not to write their

names or any identifiers on the questionnaires. Further, the information sheet had

instructions for the participants to place the completed questionnaires in the boxes

provided on the wards/units.

Data Safety and Integrity

The investigator developed and maintained a codebook for each item on the

questionnaires and all questionnaires were assigned a serial number. Four research

assistants were recruited and trained to distribute and collect the already completed

questionnaires. The training included a review of the items in the questionnaires to

ensure a common understanding of the questions and appropriate data collection

techniques. These included clarifying instructions and responding to participants’

questions and ensuring confidentiality while collecting the completed questionnaires.

The questionnaires were kept under lock and key in the principal investigator’s office.

The principal investigator double-checked the questionnaires for completeness before

data were entered in the computer programs for analysis.

42

Data Analysis

Data analysis was conducted using Windows SPSS version 16.0. The data

were entered in the Windows SPSS data base by two data entry clerks (double entry)

to enhance the quality of data entry process and for quality control in the data entry

process. The data were assessed for completeness, consistency, and missing values. A

questionnaire was required to have 80% of the questions completed before it could be

accepted to be entered in the computer program for analysis. No questionnaires were

disqualified due to incompleteness. The few missing values of some questionnaires

were imputed using the multiple imputation method. The internal consistency of the

study instruments and instrument subscales was evaluated using Cronbach’s alpha.

The study variables were analyzed using descriptive statistics appropriate for

the scale of measurement. Bivariate relationships were evaluated with Pearson

correlation coefficients for continuous variables and with analysis of variance

(ANOVA) or independent t-tests to examine differences in group means for

categorical variables. Multiple regression analysis was used to investigate

relationships among occupational stress, job satisfaction, and job performance,

controlling for personal and work characteristics. The following assumptions were

evaluated for the multiple regression analyses: that the expected value of the

dependent variable is a linear function of the independent variables (linearity), that the

variance is the same for any fixed combination of independent variables

(homoscedasticity), and that it follows a normal distribution for any fixed

combinations of independent variables (normality) (Munro, 2001). The regression

models were also assessed for potential problems with multicollinearity using

variance inflation factor (VIF) values. The potential mediating effect of job

satisfaction on the relationship between occupational stress and job performance was

43

assessed using the approach of Baron and Kenny (1986). The level of significance

was set at alpha=.05 for all analyses.

Limitations of the Study

1. The study was conducted in hospitals situated in Kampala, Uganda where

nurses’ work environment and organization of work may be different from

other hospitals and health centers in the rural areas. Therefore, the results from

this study may not be generalizable to all nurses in Ugandan hospitals.

2. The participants were volunteers; therefore the results may be biased.

3. Occupational stress measurement was based on self-report rather than by

physiological biochemical analyses of blood or by physical and mental status

assessments.

4. The instruments utilized in this study were based on American and European

populations and may not have been culturally appropriate for the Ugandan

nurses.

44

CHAPTER 4

FINDINGS

This chapter presents the findings of the study. The first section presents the

demographic and work characteristics including age, gender, marital status, number of

children, hospital and ward/unit where participants work, nursing education, nursing

experience, responsibility on the ward/unit, and hours worked on a typical day. The

second section includes reliabilities of instruments used in the study. The third section

presents descriptive analyses related to the study variables while section four includes

the statistical analyses of data related to the study questions.

Demographic Characteristics

A total of 400 eligible nurses attended the meetings and were invited to

participate in the study. Although all eligible nurses agreed to participate in the study,

a total of 333 nurses (response rate 83%) returned completed valid questionnaires that

were included in the analyses. The age range was 20 to 60 years with a mean age of

36 years (SD = 9.1). A majority of the participants were female (95%), 61% were

married while 25% had never married. More than a third (41%) had between 1-2

children and 29% had between 3-4 children. The average number of children per

participant was 2.2 (SD = 1.8).

45

Table 1 Socio-demographic Characteristics of the Sample Characteristic Frequency % Agea 20-29 91 27.33 30-39 135 40.54 40-49 71 21.32 50-60 36 10.81 Gender Female 317 95.20 Male 16 4.80 Marital status Married 206 61.86 Divorced/Separated 32 9.61 Widow/Widower 11 3.30 Never married 84 25.23 Number of childrenb 0 68 20.42 1-2 138 41.44 3-4 98 29.43 > 5 29 8.71 a M = 36.02; SD = + 9.11 b M = 2.19; SD = + 1.84

Work Characteristics

Two-thirds of the participants (59%) were from the public hospital and the

remaining participants were from the three private, faith-based hospitals (21%, 12%,

and 8% respectively). The majority of participants (60%) were at the Registered level

(RN, RM or RN/M), followed by the Enrolled level (36%), with only 4.5% at the

Graduate level (BSN and above). Almost two-thirds of the participants were nurses

with less than 14 years of nursing experience. Twenty percent of the participants

reported 20 years or more of nursing experience. Many participants reported working

longer hours than a standard shift on a typical day, with 43% working more than eight

46

hours. Two-thirds of the participants (63%) had no extra responsibility on the

wards/units and 37% were ward/unit in-charges or deputies.

Table 2 Work Characteristics of the Sample Characteristic Frequency % Hospital Private 1 25 7.51 Private 2 71 21.32 Private 3 41 12.31 Public 196 58.86 Nursing Education Enrolled Nurse (EN) 77 23.12 Enrolled Midwife (EM) 42 12.61 Registered Nurse (RN) 100 30.03 Registered Midwife (RM) 49 14.71 Double Trained (RN/M) 50 15.02 BSN and above 15 4.50 Ward/Unit Medical 117 35.14 Surgical 57 17.12 Obstetrics/Gynecology 102 30.63 Pediatrics 57 17.12 Nursing Experience (Years)c < 4 70 21.02 5-9 68 20.42 10-14 74 21.32 15-19 53 15.92 20-24 26 7.81 25-29 21 6.31 >30 24 7.20 Responsibility Ward/Unit In-charge 123 36.94 None 210 63.06 Hours worked on a typical dayd <8 189 56.76 9-11 125 37.53 >12 19 5.71 c M = 12.59; SD = + 9.08 d M = 8.76; SD = + 8.62

47

Instrument Reliability

The internal consistencies of the Nurse Stress Index (NSI), Job Satisfaction

Survey (JSS) and the Six-Dimension Scale of Nursing Performance (6-DSNP) were

assessed using Cronbach’s alpha coefficients. The reliability estimates for all the three

instruments were acceptable, ranging from .81 for the Job Satisfaction Survey to .93

for the Six-Dimension Scale of Nursing Performance, as shown in tables 3, 4 and 5.

The Cronbach’s alphas for the six sub-scales of the NSI ranged from .54 for the Home

and Work Conflicts scale to .80 for the Organizational Support and Involvement

scale.

Table 3 Number of Items and Cronbach’s Alphas for the NSI Sub-scales Instrument Sub-scale Number of

items Cronbach’s alpha

1. Managing Workload 1 (Pressures due to insufficient time)

5 .78

2. Managing Workload 2 (Pressures due to resources and conflicting priorities)

5 .78

3. Organizational Support and Involvement

5 .80

4. Dealing with Patients and Relatives

5 .77

5. Home and Work Conflicts

5 .54

6. Confidence and Competence in Role

5 .74

Total Score

30 .92

48

The JSS sub-scales Cronbach’s alphas ranged from -.02 for the Promotion

sub-scale to .59 for the Supervision sub-scale. The Cronbach’s alpha for the total scale

was acceptable at .81 as shown in table 4.

Table 4 Number of Items and Cronbach’s Alphas for the JSS Sub-scales Instrument Sub-scale Number of

items Cronbach’s alpha

1. Pay

4 .46

2. Promotion

4 -.02

3. Supervision

4 .59

4. Fringe Benefits

4 .37

5. Contingent Rewards

4 .33

6. Operating Conditions

4

.42

7. Co-workers

4 .49

8. Nature of Work

4 .54

9. Communication

4 .53

Total Score

36 .81

49

The 6-DSNP scale examines both the self-rated frequency (Column A) and

quality (Column B) of performance. The Cronbach’s alphas of the 6-DSNP Column B

sub-scales ranged from .61 to .79 for the Leadership and Teaching/Collaboration sub-

scales respectively. The total scale overall Cronbach’s alpha was .93.

Table 5 Number of Items and Cronbach’s Alphas for the 6-DSNP Sub-scales Instrument Sub-scale Number of

items Cronbach’s alpha

1. Leadership

5 .61

2. Critical Care

7 .75

3. Teaching/Collaboration

11 .79

4. Planning/Evaluation

7 .74

5. Interpersonal Relations/ Communication

12 .77

6. Professional Development

10 .76

Total Score

52 .93

50

Descriptive Statistics for Instrument Sub-scales

Nurse Stress Index

The observed means for the NSI sub-scales ranged from 12.69 for the

Leadership sub-scale to 14.42 for the Managing Workload 1 sub-scale. The overall

mean score for the NSI was 82.18 with an SD of 21.63 as shown in table 6.

Table 6 Range of Possible Scores, Mean Scores and Standard Deviations for NSI Sub-scale Range of

Possible Scores Mean Scores for Sample

SD

1. Managing Workload 1

5-25 12.69 4.55

2. Managing Workload 2

5-25 14.42 4.72

3. Organizational Support and Involvement

5-25 14.14 5.21

4. Dealing with Patients and Relatives

5-25 14.23 4.34

5. Home and Work Conflicts

5-25 13.36 3.82

6. Confidence and Competence in Role

5-25 13.54 4.48

Total Score

30-150 82.18 21.63

51

Job Satisfaction Survey

The means for the JSS sub-scales ranged from 9.17 for the Fringe Benefits

sub-scale to 18.80 for the Co-workers sub-scale. The overall mean score for the JSS

was 127.65 with an SD of 19.22 as shown in table 7.

Table 7 Range of Possible Scores, Mean Scores and Standard Deviations for the JSS Sub-scale Range of

Possible Scores Mean Scores for

Sample SD

1. Pay

4-24 10.79 4.47

2. Promotion

4-24 13.43 3.55

3. Supervision

4-24 18.15 4.22

4. Fringe Benefits

4-24 9.17 3.9

5. Contingent rewards

4-24 11.25 4.11

6. Operating Conditions

4-24 12.21 3.12

7. Co-workers

4-24 18.80 3.85

8. Nature of Work

4-24 18.79 4.20

9. Communication 4-24 15.06 4.64

Total Score

36-216 127.65 19.22

According to Spector (1997), participants can be assigned to satisfaction,

ambivalent or dissatisfaction categories. For the 36-item total, where possible scores

range from 36-216, the ranges 36-108 represent dissatisfaction, 108-144 ambivalence

and 144-216 represent satisfaction. As shown in table 8, the majority of respondents

were ambivalent (undecided) as to whether they were satisfied with their jobs or not

52

(68%) while 17.42% reported satisfaction with their job. Almost 15% reported

dissatisfaction with their jobs.

Table 8 Level of Satisfaction for Job Satisfaction Survey (JSS) Level of Satisfaction

Frequency Percentage

Dissatisfied 47 14.11

Ambivalent 228 68.47

Satisfied

58 17.42

Note: Score ranges 36-107 = Dissatisfaction, 108-143 = Ambivalent, and 144-216 = Satisfaction (Spector, 1997).

Nurse Performance Scale

Two separate measures from the 6-DSNP were calculated for each subject: the

total 52 item scale score for Column B (performance quality) and a mean of the six-

subscale mean scores for Column B. The measures were highly correlated (r=.997, p

<.001). Descriptive analyses were run on both outcome measures.

The observed mean total scores for the 6-DSNP (for Column B) ranged from

15.23-38.05 for the Leadership and Interpersonal Relations/Communication sub-

scales respectively. The total score mean was 158.66 with a standard deviation of

22.11 as shown in table 9.

53

Table 9 Range of Possible Scores, Mean Total Scores and Standard Deviations for the 6-DSNP Sub-scales (Column B) Sub-scale Range of

possible scores Mean Total Sub-scale

Scores

SD

1. Leadership 5-20 15.23 2.59

2. Critical Care 7-28 22.20 3.97

3. Teaching/Collaboration 11-44 30.35 6.22

4. Planning/Evaluation 7-28 20.88 4.00

5. Interpersonal Relations/Communication

12-48 38.05 5.35

6. Professional Development 10-40 32.30 4.68

Total Score 52-208 158.66 22.11

Table 10 presents the mean sub-scale ratings (as opposed to mean total scores)

for the Six-Dimensional Scale of Nursing Performance. As shown in table 10, the

sub-scales for frequency (Column A) had similar mean scores. The IPR/

Communication, Critical Care and Planning/ Evaluation sub-scales for the frequency

of performance measure had the highest mean scores of 3.52, 3.51 and 3.50

respectively, while the Teaching/Collaboration sub-scale had the lowest mean

frequency score of 3.17. The total mean score for Column A was 3.42. The

Professional Development scale is not measured for frequency (Column A).

The mean scores for the quality or how well the nurses performed their

nursing activities ranged from 2.76 for the Teaching/Collaboration scale to 3.23 for

the Professional Development sub-scale respectively. The Critical Care and

IPR/Communication sub-scales had an equal mean of 3.17, while the Planning and

54

Evaluation sub-scale had a mean score of 2.98. The overall mean score for the total

scale was 3.05.

Table 10 Sub-scale Means and Standard Deviations for the Nurse Performance Scale (6-DSNP) Activity How Frequent

(Column A) How Well

(Column B) Mean SD Mean SD

Critical Care 3.51 .38 3.17 .56

Teaching/Collaboration 3.17 .42 2.76 .57

IPR/Communication 3.50 .40 2.98 .57

Planning/Evaluation 3.52 .28 3.17 .44

Professional Development*

-- -- 3.23 .43

Total 3.42 .37 3.05 .43

*Professional Development scale is not measured for frequency (Column A)

Occupational Stress and Demographic Characteristics

Descriptive statistics of levels of occupational stress (as measured by the

NSI) by age, gender, marital status and number of children are presented in Table 11.

Overall, all age groups reported high stress with mean scores ranging from 75.51 to

90.34. The older age group of 50 to 60 years reported the highest mean score of

90.34 followed by the 40-49 years age group with a mean score of 84.97. There was

a significant difference in occupational stress mean scores among the age groups (F =

4.99, p = .002). Post hoc tests revealed that the youngest age group (20-29 years) was

significantly less stressed than the 30-39 or the 40-49 year old age groups (all p <

.05). The categories for number of children also had a significant differences in mean

55

scores for occupational stress (F = 3.56, p = .015), with post hoc results indicating

that nurses with no children had significantly lower occupational stress than those

who had 1-2 or 3-4 children (all p <.05). There were no significant differences in

occupational stress mean scores for gender (F = 1.53, p = .217) or marital status

groups (F = 2.03, p = .110).

Table 11 Mean Scores for Occupational Stress by Demographic Characteristics Characteristic Mean SD ANOVA (p value) Age F = 4.99, p =.002 20-29 (n = 86) 75.51 19.84 30-39 (n = 133) 82.86 20.06 40-49 (n = 70) 84.97 23.43 50-60 (n = 35 90.34 24.13 Gender F = 1.53, p = .217 Female (n = 308) 81.83 21.56 Male (n = 16) 88.68 22.60 Marital status F = 2.03, p =.110 Married (n = 201) 81.34 20.83 Divorced/Separated (n = 30) 85.30 18.94 Widow/Widower (n =11) 96.63 17.12 Never married (n = 82) 81.12 24.36 Number of children F = 3.56, p = .015 0 (n =67) 74.65 22.82 1-2 (n = 132) 83.60 20.16 3-4 (n = 97) 84.97 22.46 >5 (n = 28) 83.71 19.34

Occupational Stress and Work Characteristics

Occupational stress was also examined by work characteristics (hospital,

nursing education, ward/unit, nursing experience, responsibility, and hours worked on

a typical day) and is presented in Table 12. The public hospital had the highest mean

56

score of occupational stress (M = 88.27, SD 20.87) while the three private hospitals

had almost similar mean scores (73.35 to 76.09). There was a significant difference in

mean scores of stress among the different hospitals (F = 14.46, p < .001).

The mean stress levels for nurses with higher educational level (RN, RM,

RNM, and BSN and above) reported the highest stress levels with the means ranging

from 82.42 to 91.61 for the BSN and above group and the Double Trained group

respectively. As seen in Table 12, there were significant differences in stress levels

among the different education level groups (F = 4.16, p = .001). There was no

significant difference in levels of stress among the different wards/units with means

ranging from 79.09 to 87.29 (F = 1.94, p = .124).

The nurses who had worked for more than 20 years reported the highest levels

of occupational stress (M = 90.50, SD = 25.55). Nurses with five or less years of

experience reported the lowest levels of stress (M = 73.54, SD = 18.42). The

differences in stress levels between working experience groups was statistically

significant (F = 6.663, p < 001). Post hoc results revealed that occupational stress

levels for nurses with 1-5 years of experience were significantly lower than for nurses

with 6-10, 11-15 or 21 or more years of experience (all p <.05). The mean stress

levels for those without extra responsibilities (not ward/unit in-charges) and those

who had extra responsibility (ward/unit in-charges) ranged from 81.60 to 83.16 with

SD of 21.82 and 21.34 respectively. The results indicated that there was no significant

difference in mean stress levels between the two groups (F = 0.394, p = .530).

The occupational stress means by different groups of hours worked on a

typical day ranged from 78.21 (SD = 21.61) to 88.48 (SD = 19.65). The relationship

between hours worked on a typical day and occupational stress was statistically

significant (F = 8.588, p < .001).

57

Table 12 Mean Scores for Occupational Stress by Work Characteristics Characteristic Mean SD ANOVA (p value) Hospital F = 14.46, p < .0001 Public (n = 193) 88.27 20.87 Private 1 (n = 22) 76.09 23.48 Private 2 (n = 69) 72.15 20.03 Private 3 (n = 40) 73.35 16.40 Nursing Education F = 4.16, p = .001 Enrolled Nurse (n = 75) 75.41 21.58 Enrolled Midwife (n = 42) 79.16 16.98 Registered Nurse (n = 96) 85.00 20.93 Registered Midwife (n = 48) 80.02 20.13 Double Trained (n = 49) 91.61 25.68 BSN and above (n = 14) 82.42 15.88 Ward/Unit F = 1.94, p = .124 Medical (n = 112) 83.28 21.78 Surgical (n = 55) 87.29 22.12 Obs./Gyn. (n = 101) 79.09 19.52 Pediatrics (n = 56) 80.48 23.81 Nursing Experience (Years) F = 6.66, p < .001 1-5 (n = 79) 73.54 18.42 6-10 (n = 90) 83.21 21.96 11-15 (n = 55) 87.34 18.14 16-20 (n = 46) 79.02 19.80 21+ (n = 54) 90.50 25.55 Responsibility F = .39, p = .530 Ward/Unit In-charge (n = 119) 83.16 21.34 None (n = 205) 81.60 21.82 Hours worked on a typical day F = 8.59, p < .001 <8 78.21 21.61 9-11 88.48 19.65 >12 81.55 25.36

Job Satisfaction and Demographic Characteristics

The results of job satisfaction in relation to personal characteristics are

presented in table 13. The mean scores for job satisfaction among the age groups were

58

statistically different (F = 5.623, p = .001). Post hoc results revealed that nurses in the

20-29 year s age group had statistically higher job satisfaction than the 30-39 or 40-49

years age groups (all p < .05). There were no significant relationships between gender

(F = 1.456, p = .228), marital status (F = .229, p = .876) and number of children to

levels of job satisfaction (F = 2.487, p = .060).

Table 13 Mean Scores for Job Satisfaction by Demographic Characteristics Characteristic

Mean

SD

ANOVA (p value)

Age F = 5.62, p = .001 20-29 (n = 91) 134.02 19.13 30-39 (n = 135) 124.64 17.90 40-49 (n= 71) 124.11 18.69 50-60 (n = 36) 129.86 21.62 Gender F = 1.46, p = .228 Female (n = 317) 127.94 18.68 Male (n = 16) 122.00 28.126 Marital status F = .23, p = .876 Married (n = 206) 127.24 18.89 Divorced/Separated (n = 32) 126.81 17.40 Widow/Widower (n= 11) 131.09 17.85 Never married (n = 84) 128.55 21.03 Number of children F = 2.49, p = .060 0 (n = 68) 132.46 20.51 1-2 (n = 138) 127.88 18.48 3-4 (n = 98) 125.42 19.76 >5 (n = 29) 122.90 15.90

Job Satisfaction and Work Characteristics

The job satisfaction mean scores ranged from 123.00 (SD = 18.79) for the

public hospital to 136.95 (SD = 16.46) for private hospital 2. As presented in table 14,

there was a significant difference in levels of job satisfaction among the hospitals (F =

59

11.30, p < 001). The Registered Nurses reported the least job satisfaction with a mean

score of 123.14 (SD = 16.34)) followed by the double trained nurses and BSN and

above with job satisfaction mean scores of 123.84 (SD = 23.34) and 126.27 (SD =

19.23) respectively. The Enrolled Nurses and Midwives reported the highest levels of

job satisfaction with mean scores of 134.27 (SD = 20.18) and 132.07 (SD = 17.26)

respectively. The results indicated that there is a significant difference in job

satisfaction levels by level of nursing education (F = 3.961, p = .002). Nurses with 1-5

years of experience reported the highest level of job satisfaction (Mean = 135.53, SD

= 19.58), while those with 11-15 years of experience reported the least job satisfaction

(Mean = 119, SD = 17.36). A significant difference in job satisfaction was indicated

among the years of nursing experience groups (F = 6.597; p < .001). Post hoc results

revealed that nurses with 1-5 years of nursing experience had more job satisfaction

than nurses with 6-10 or 11-15 years of experience (all p < .05).

Nurses without extra responsibility (not ward or unit in-charges or deputies)

reported a slightly higher level of job satisfaction than those with this responsibility.

However, the difference in mean levels of satisfaction between the two groups was

not significant (F = 0.311, p = .577). Nurses working in the surgical and pediatric

wards/units reported lower levels of satisfaction with mean scores of 123.95 (SD =

16.75) and 126.75 (SD = 21.20.4358) respectively. Those working in the

obstetrics/gynecology wards reported a higher level of job satisfaction (Mean =

130.44, SD = 18.91). These results indicated no significant difference between the

groups (F = 1.472, p= 0.222).

60

Table 14 Mean Scores for Job Satisfaction by Work Characteristics Characteristic Mean SD ANOVA (P value) Hospital F = 11.30, p < .0001 Public (n = 196) 123.00 18.79 Private 1 (n = 25) 129.84 14.71 Private 2 (n = 71) 136.95 16.46 Private 3(n = 41) 132.46 21.32 Nursing Education F = 3.96, p = .002 Enrolled Nurse (n = 77) 134.27 20.18 Enrolled Midwife (n = 42) 132.07 17.26 Registered Nurse (n = 100) 123.14 16.34 Registered Midwife (n = 49) 127.00 17.19 Double Trained (n = 50) 123.84 23.34 BSN and above (n = 15) 126.27 19.23 Ward/Unit F = 1.47, p = .222 Medical (n = 117) 127.47 19.87 Surgical (n = 57) 123.95 16.75 Obs./Gyn. (n = 102) 130.44 18.91 Pediatrics (n = 57) 126.75 20.43 Nursing Experience (Years) F = 6.60, p < .001 1-5 (n = 83) 135.53 19.58 6-10 (n =92) 125.71 17.27 11-15 (n = 56) 119.70 17.36 16-20 (n = 46) 126.37 18.00 21+ (n = 56) 128.20 20.80 Responsibility F = 0.31, p = .577 Ward/Unit In-charge (n = 123) 126.89 17.70 None (n = 210)

128.10 20.08

Job Performance and Demographic Characteristics

Job performance was assessed using column B scores of the 6-DSNP. The

mean of the sub-scale scores between the age groups ranged from 2.95 (SD = .51) for

the 40-49 years age group to 3.13 for the 20-29 years age group (SD = .39). The

results indicated no significant differences in the mean scores for job performance

61

among the different age groups. Further, as shown in Table 15, there were no

significant differences in mean scores for the gender (F = 0.04, p = .842) and marital

status (F = 2.073, p = .104)). Number of children mean scores ranged from 2.97 (SD =

.36) for those having 5 or more children to 3.21 (SD = .39) for those without children.

These results indicated a significant difference in job performance means among the

number of children groups.

Table 15 Mean Scores for Job Performance by Demographic Characteristics Characteristic Mean* SD ANOVA (p value) Age F = 2.46, p = .063 20-29 (n = 91) 3.13 .39 30-39 (n = 135) 3.05 .40 40-49 (n= 71) 2.95 .51 50-60 (n = 36) 3.05 .42 Gender F = 0.04, p = .842 Female (n = 317) 3.05 .44 Male (n = 16) 3.03 .43 Marital status F = 2.07, p = .104 Married (n = 206) 3.03 .43 Divorced/Separated (n = 32) 2.95 .43 Widow/Widower (n= 11) 3.01 .29 Never married (n = 84) 3.14 .43 Number of children F = 3.86, p = .010 0 (n = 68) 3.21 .39 1-2 (n = 138) 3.02 .43 3-4 (n = 98) 3.01 .45 >5 (n = 29) 2.97 .36 *Mean for six sub-scales of the 6-DSNP

Job Performance and Work Characteristics

As shown in Table 16, the public hospital had the lowest mean score for job

performance (Mean = 2.9, SD = .45) and private hospital 1 has the highest (M = 3.32,

62

SD .40). There was a significant difference in means for the different hospitals (F =

7.95, p < .001). The means for nursing education ranged from 2.84 (SD = .49) for the

Registered Midwives to 3.19 (SD = .44).

Table 16 Mean Scores for Job Performance by Work Characteristics Characteristic Mean* SD ANOVA (p value Hospital F = 7.95, p < .0001 Public (n = 196) 2.96 .45 Private 1 (n = 25) 3.32 .40 Private 2 (n = 71) 3.15 .34 Private 3(n = 41) 3.12 .38 Nursing Education F = 3.60, p = .004 Enrolled Nurse (n = 77) 3.12 .36 Enrolled Midwife (n = 42) 3.02 .37 Registered Nurse (n = 100) 3.11 .422 Registered Midwife (n = 49) 2.84 .49 Double Trained (n = 50) 3.00 .47 BSN and above (n = 15) 3.19 .44 Ward/Unit F = 4.34, p = .005 Medical (n = 117) 3.11 .42 Surgical (n = 57) 2.98 .43 Obs./Gyn. (n = 102) 2.95 .45 Pediatrics (n = 57) 3.17 .37 Nursing Experience (Years) F = 1.46, p = .214 1-5 (n = 83) 3.13 .40 6-10 (n =92) 3.02 .45 11-15 (n = 56) 3.06 .35 16-20 (n = 46) 2.95 .47 21+ (n = 56) 3.03 .47 Responsibility F = 0.0006, p = .980 Ward/Unit In-charge (n = 123) 3.05 .44 None (n = 210)

3.05 .43

*Mean for six sub-scales of the 6-DSNP

63

The results indicated that there were significant differences in means for nurse

performance among the nursing education groups (F = 3.60, p = .004) and type of

ward/unit (F = 4.34, p = .005). There were no differences in means for nurse

performance between nurses who had extra responsibility (Ward/Unit in-charges or

Charge nurses) and those without extra responsibility (F = .0006, p .980) or for

nursing experience (F = 1.460, p = .214).

The analyses presented above were on the mean subscale score for the 6-

DSNP. The same descriptive analyses by demographic and work characteristics were

repeated on the 52-item total score. The results were congruent regarding statistically

significant group differences. (Results are not shown).

Findings Related to Research Questions

This section presents results of the study in relation to the research questions.

Pearson correlation was utilized to answer question one, while multiple regression

analyses were utilized to answer questions two and three. The fourth and fifth

questions were answered using one-way Analysis of Variance (ANOVA).

Research Question 1

What is the relationship between occupational stress and job performance

among hospital nurses in Kampala, Uganda?

The relationship between occupational stress and job performance of the

nurses was investigated using Pearson correlation coefficient. As indicated in Table

17, the results demonstrated a significant negative relationship between occupational

stress (as measured by the NSI) and job performance, measured as how well the

participants performed their activities (r = -.131, p = .018). This indicated that higher

64

stress levels were associated with lower levels of self-rated job performance quality.

However, no significant relationship was found (r = -.018, p = .746) between

occupational stress and job performance as measured by the self-rated frequency of

activities (how often the participants performed the nursing activities).

Research Question 2

Is there a relationship between occupational stress and job satisfaction among

hospital nurses in Kampala, Uganda?

The relationship between occupational stress and job satisfaction (JSS) of the

nurses was also investigated using Pearson correlation coefficient, as shown in table

17. A significant inverse relationship was found between occupational stress and job

satisfaction (r = -.501, p = .000). This indicated that high stress levels resulted in low

job satisfaction.

Table 17 Correlations for Job Performance, Job Satisfaction with Occupational Stress r p value Job Performance

Column A (How frequent) -.018 .746

Column B (How well) -.131 .018

Job Satisfaction

-.501 .000

65

Research Question 3

Do personal background characteristics affect the relationships between

occupational stress, job satisfaction and job performance among hospital nurses in

Kampala, Uganda?

Regression analyses were performed to investigate whether personal and work

characteristics (nursing education, nursing experience, type of hospital, ward/unit, and

number of children) affect the relationships between occupational stress, job

satisfaction and job performance. Number of children was used a proxy indicator for

family responsibility. The response variable was job performance, measured using the

mean of the six sub-scale means of the 6-DSNP (Column B).

The primary predictor variables were occupational stress (as measured by the

NSI) and job satisfaction (as measured by the JSS). Both predictors were significant

in separate simple linear regression models (R2 = .021, F = 6.87, p = .009; R2 = .033, F

= 11.42, p = .001, respectively).

The covariates included in the initial multiple regression model were selected

based on significant bivariate relationships with job performance. Based on these

analyses (see tables 15 and 16), the only personal characteristic included was number

of children. The work characteristics included as covariates were type of hospital and

ward and nursing education. Based on the ANOVA results, hospitals were grouped

into public and private for analysis. Reference-cell coded indicator variables (Unit 1,

Unit 2 and Unit 3) were created to represent the different type of wards, with the

medical ward as the reference group. Nursing education was recorded into four

groups: enrolled nurses/enrolled midwives, registered nurses/registered midwives,

double trained, and BSN and above.

66

Preliminary examination of the data for normality, linearity, and homogeneity

of variances were conducted using standard techniques and no serious violations were

noted. Initial models were also evaluated for problems with multicollinearity using

variance inflation factor (VIF) values, and again no problems were noted (Munro,

2001; Pallant, 2001).

The set of covariates was entered in the first block, followed by occupational

stress at the second step, then job satisfaction at the third step. Individual predictors

and the changes in adjusted R-squared values for each step were evaluated for

statistical significance (see table 18).

Table 18 Effect of Personal Background and Work Characteristics on the Relationships of Occupational Stress, Job Satisfaction and Job Performance Model Beta t P value Constant

10.856 .000

Number of children

-.094 -1.688 .092

Type of hospital

-.187 -2.911 .004

Unit 1(Surgical)*

-.057 -.956 .340

Unit 2 (Obs/Gyn)*

-.142 -2.322 .o21

Unit 3(Pediatrics)*

.084 1.415 .158

Nursing Educational Level

.092 1.565 .119

Occupational stress

-.019 -.302 .763

Job satisfaction

.141 2.278 .023

* Reference group – medical ward

67

Several smaller models were evaluated. As shown in Table 19, the best

predictive model for job performance included type of hospital (public/private), type

of ward/unit, and job satisfaction. The model including type of ward/unit and type of

hospital contributed approximately 8% of the variance in job performance. When job

satisfaction was added to the model with type of unit and type of hospital, the model

accounted for approximately 10% of the variance in job performance.

Table 19 The Final Predictive Model for Self-Rated Job Performance Quality Model

Beta t P value

Constant 16.439 .000

Type of hospital -.190 -3.425 .001

Unit 1 (Surgical) -.060 -1.020 .308

Unit 2 (Obs/gyn) -.155 -2.578 .010

Unit 3 (Pediatric) .076 1.302 .194

Job satisfaction

.139 2.526 .012

All models were re-run with the job performance 52-item total score as the

outcome. The predictors selected for the initial model based on bivariate analyses

were the same. No differences in significant predictors in the initial and final models

were noted. (Results are not shown.)

Research Question 4

Does job satisfaction mediate the relationship between occupational stress and

job performance among hospital nurses in Kampala, Uganda?

68

The potential mediating role of job satisfaction between occupational stress

and job performance was examined by conducting step-wise multiple regressions

(Baron & Kenny, 1986) with occupational stress as the independent variable, job

satisfaction as the potential mediator and job performance as the dependent variable.

For this analysis, the 52 item total score for the 6-DSNP (Column B) was used. In

step 1, a simple regression analysis with occupational stress (X) predicting job

performance (Y) was conducted (Y = B0 + B1X + e) and it indicated a significant

relationship (beta = -.124, t = -2.250, p =.025). In step 2, a simple regression analysis

conducted with occupational stress predicting job satisfaction (Z) represented by Z =

B0 + B1X + e also showed a significant relationship (beta = -.501, t = -10.39, p <.001).

In the third step, a simple regression analysis of job satisfaction predicting job

performance also indicated a significant relationship (beta = .177, t = 3.279, p =.001).

Based on the significant results of step 1 to 3, a fourth step was conducted with

occupational stress and job satisfaction predicting job performance (Baron & Kenny,

1986). As showed in table 20, occupational stress was not significant after controlling

for job satisfaction (beta = -.047, t = -.748, p =.455) indicating full mediation by job

satisfaction (beta = .154, t = 2.422, p =.016).

69

Table 20 The Mediating Role of Job Satisfaction between Occupational Stress and Job Performance Model Beta t p value 1 Occupational Stress -.124 -2.25 .025

2 Occupational Stress -.501 -10.39 .000

3 Job Satisfaction .177 3.28 .001

4 Occupational Stress -.047 -.75 .455

Job Satisfaction .154 2.42 .016 1. Dependent Variable: Job Performance 2. Dependent Variable: Job satisfaction 3. Dependent Variable: Job Performance 4. Dependent Variable: Job Performance

Research Question 5

Are there differences in levels of occupational stress, job satisfaction and job

performance among hospital nurses in Kampala, Uganda by type of hospital?

As shown in table 21, the public hospital had the highest mean score for

occupational stress (M = 88.28, SD = 20.88), followed by private hospital 1 (M =

76.09, SD = 23.49). However, private hospital 1 had the highest mean score for job

performance (M = 172.56, SD = 20.70) followed by private hospital 2 (M = 163.32,

SD = 17.12). The job satisfaction mean score for the public hospital was the lowest

(M = 123.00, SD = 18.80) while private hospital 2 had the highest mean score (M =

136.96, SD = 16.46 followed by private hospital 3 (M = 132.46, SD = 21.32).

70

Table 21 Means for Occupational Stress, Job Satisfaction and Job Performance for the different hospitals Variable Hospital Mean Std. Deviation Std. Error Occupational Stress Private 1 76.09 23.49 5.01

Private 2 72.16 20.04 2.41

Private 3 73.35 16.41 2.59

Public 88.28 20.87 1.50

Job Satisfaction Private 1 129.84 14.71 2.94

Private 2 136.96 16.46 1.95

Private 3 132.46 21.32 3.33

Public 123.00 18.79 1.34

Job Performance Private 1 172.56 20.69 4.14

Private 2 163.32 17.12 2.03

Private 3 161.66 19.41 3.03

Public 154.52 23.35 1.67

A one-way between groups analysis of variance was conducted to explore the

influence of type of hospital on job performance. Job performance was measured

using the mean 52-item total score (for Column B). Assumptions of normality and

homoscedasticity were evaluated as a preliminary step and there were no serious

violations. There were statistically significant differences at the p value < .05 level in

occupational stress (F = 14.465, p = .000); job satisfaction (F = 11.297, p = .000); and

job performance (F = 7.234, p-value = .000) for the different hospitals as shown in

71

Table 22 Influence of Type of Hospital on Job Performance, Job Satisfaction and Occupational Stress Mean difference between hospitals F p-value Job Satisfaction 11.297 < .001

Job performance 7.324 < .001

Occupational Stress 14.465 < .001

Post Hoc comparisons using the Tukey HSD test indicated that the mean score

for occupational stress for the public hospital was significantly and positively

different from all three private not-for-profit hospitals. Mean differences were as

follows: public and private 1 = 12.19, S.E = 4.58, p = .041; public and private 2 =

16.12, S.E = 2.86, p < .001 and public and private 3 = 14.93, S.E = 3.5, p = .000. As

seen in table 19, the differences in job satisfaction scores for public hospital from

those of private 2 and private 3 hospitals were statistically significant. Furthermore,

the mean score for job performance for public hospital was significantly different

from those of private 1 and private 2 hospitals at p <.005. However, no mean

differences for occupational stress, job satisfaction and job performance between the

three private not-for-profit hospitals were observed.

72

Table 23 Post Hoc Results of Differences in Means in Occupational Stress, Job Satisfaction and Job Performance by Hospital Dependent variable Hospital (I) Hospital (J) Mean Difference (I-J) p-value Occupational Stress

Public Private 1 12.19* .041

Private 2 16.12* .000

Private 3 14.93* .000

Job Satisfaction Public Private 1 -6.84 .299

Private 2 -13.96* .000

Private 3 -9.46* .015

Job Performance Public Private 1 -18.04* .001

Private 2 -8.80* .018

Private 3 1.42 .191

73

CHAPTER 5

DISCUSSION, CONCLUSIONS, IMPLICATIONS,

AND RECOMMENDATIONS

A correlational study was conducted to explore relationships among

occupational stress, job satisfaction and job performance among hospital nurses in

Kampala, Uganda. This chapter presents the discussion, conclusions, implications and

recommendations based on the results of the study. The interpretation of key findings

is discussed in section one. The second section includes an outline of the conclusions.

The third section presents the implications for nursing practice, nursing education and

research, while recommendations are presented in the fourth section.

Discussion

Occupational Stress

More than half of the nurses (54%) reported moderate to extreme stress on the

job while almost half (45%) reported high stress in the past one month. This is

consistent with previous research which indicated that occupational stress occurs at

high levels among health professionals. The results indicated that these Ugandan

nurses worked under pressure and were experiencing occupational stress.

In this study, the older age groups, 40-49 and 50 years and above, and nurses

with more than 20 years of experience reported the highest stress scores. These results

contradict previous studies in the United States in which young public health nurses

and those with less experience perceived more occupational stress than older nurses

(Kirkcaldy & Martin, 2000). This discrepancy could be due to differences in

74

responsibilities in Uganda. However, these results indicate a pattern which may be

unique to the Ugandan situation. For example, nurses with no children also had

significantly lower levels of occupational stress than those who had 1-2 or 3-5

children. This may indicate that older nurses in Uganda may report more job stress

due to social responsibilities such as caring for family members. In the US, on the

other hand, the younger nurses could be stressed due to lack of experience on the job.

In Uganda, as nurses gain more experience in the profession, they also have

increasing financial responsibilities to provide for their immediate families as well as

their extended families as is the case for many Ugandans. In Uganda, an adult who is

earning a living is culturally and socially expected to provide for immediate and

extended family members. The financial burden experienced by older Ugandan nurses

may explain the increased stress reported by this age group. In addition, it was

observed by Kyadondo and Whyte that public sector reforms and poor remuneration

have weakened workers’ positions and therefore experienced professionals establish

supplementary sources of income outside the health care system (Kyaddondo &

White, 2003). Fulfilling responsibilities of multiple jobs may contribute to perceived

stress.

Furthermore, those who had the highest educational level (BScN and above)

reported the highest perceived stress levels. This is in agreement with previous

research (Kirkcaldy & Martin, 2000; Lee & Wang, 2002). It is not clear why nurses

with higher education perceived more stress but one possible explanation could be

role ambiguity. It has been reported that organizational and management attributes of

work environments and institutional settings influence work-related stress among

nurses (Sveinsdottir et al., 2005). Takase and colleagues also observed that role

discrepancy contributed to nurses’ intention to quit their jobs in Australia (Takase,

75

Maude & Manias, 2006). This could be the case for the Ugandan nurses because

BScN and above prepared nurses have no clear roles even in the public hospitals. Role

conflict and role ambiguity may contribute to stress for these nurses. However, since

the current study did not explore organizational factors related to occupational stress,

there is a need for further research to identify sources of stress for nurses with highest

educational qualifications in Uganda.

Significant differences in stress levels were found among nurses working in

different units. Nurses who worked in pediatric units reported the highest levels of

stress. This finding may be due to the nature of the work in pediatric units and

interaction with parents or guardians. Usually these units have many children who are

very ill creating situations which may lead to emotional attachment and unrealistic

desires to provide high quality care in adverse situations (Begat, et al., 2005).

Job Satisfaction

Results of the current study indicated a strong negative relationship between

occupational stress and job satisfaction (r = -.501, p-value = .000). These results are in

agreement with previous studies which similarly reported a negative relationship

between perceived occupational stress and job satisfaction (Flanagan & Flanagan,

2002; Sveinsdottir, Bierring et al., 2006; Zangaro & Soeken, 2007). Many factors

influence the perceptions of occupational stress and job satisfaction. For example, in a

study of satisfaction and intent to stay among current health workers in Uganda,

respondents reported health care for dependants as a more important satisfying factor

than their salaries (Ministry of Health, The Republic of Uganda, 2007). However, as

mentioned earlier, identification of the sources of occupational stress for the nurses in

76

Ugandan hospitals was not an aim of this study. Therefore, a need exists to conduct

investigations which explore these factors in Ugandan hospitals.

Interestingly, nurses with lower educational qualifications (EN and EM)

reported the highest levels of job satisfaction (53%) while those with higher education

qualifications (RN, BScN and above) reported the lowest levels of job satisfaction.

These findings contradict Chinweuba’s report where higher educational qualifications

resulted in more job satisfaction (Chinweuba, 2007). In Chinweuba’s study, this

phenomenon was attributed to the fact that nurses with higher educational

qualifications have chances of securing desired satisfying jobs. It is not clear why

nurses with higher educational qualifications in Ugandan hospitals perceive their jobs

as highly stressed and less satisfying. However, it could be due to role conflict and

ambiguity or lack of recognition as explained above. It has also been reported in the

literature that routine jobs with limited challenges results in less job satisfaction

(Selebi & Minnar, 2007). This could be the case for nurses with higher education in

Uganda. However, this phenomenon also calls for further research to understand the

factors influencing the nurses’ perceptions of occupational stress and job satisfaction.

Regarding nursing experience, results of this study indicated that nurses with

little experience of 1-5 years had the highest level of job satisfaction (30%) while

those with 11-15 years reported the least job satisfaction (7%). These findings

contradict a Uganda health workforce study in which older respondents were more

satisfied than younger ones (MoH, 2007). In this Uganda Ministry of Health study,

the older respondents reported strong attachment to the facilities and communities

where they worked, had better relationships with their supervisors, and reported

receiving more recognition for good work. It is not clear why the more experienced

nurses in the current study reported less satisfaction on their jobs. It should be noted

77

that the Uganda health workforce study involved all professionals in healthcare, while

the current study involved only nurses. It is therefore difficult to compare the two

studies. However, it can be argued that nurses with less experience are usually

younger and have less responsibility especially in the social context of Uganda. More

experienced nurses are older and may have larger families to care for with associated

stress and the possible perception that work could be interfering with their family

lives (Patel et al., 2008). It could also be due to the fact that nurses who have worked

for more than 10 years would be seeking promotion or advanced opportunities. They

could also be interested in becoming involved in decision and policy making at their

workplace. Previous literature has demonstrated that nurses are likely to report low

job satisfaction if they do not receive promotion and advancement opportunities

(Laphalala et al., 2006). This explanation was also alluded to in the Uganda health

workforce study (MoH, 2007) in which respondents complained of working for many

years without pay or position upgrades.

Occupational Stress and Job Performance

The findings of the current study indicated that there was a small negative

relationship between occupational stress as indicated by the NSI and job performance

(r = -.124, p value = .025). These findings concur with previous studies, including an

investigation conducted by AbuAlRub (2004) who reported that occupational stress

and low job control lead to poor job performance and were risk factors for patient

safety. However, in the same study, a U-shaped relationship between stress and job

performance was found. Nurses with low or higher stress performed better on their

jobs than nurses with moderate stress (AbuAlRub, 2004). It has been argued that

some employees are motivated to perform when there is a lot of pressure. However,

78

stress in the best work environment may need to be controlled since excessive

pressure is known to result in negative effects for the patients, nurses or organizations.

Because more than half of the participants (54%) reported moderate to extreme

pressure, the performance of nurses may be compromised due to occupational stress.

Therefore, there is a need to investigate the factors which lead to the moderate to

extreme pressures for the nurses and address them, so that performance is improved.

Demographic Characteristics, Occupational Stress, Job Satisfaction and Job Performance

Multivariate regression analyses demonstrated statistically significant

differences in occupational stress, job satisfaction and job performance among nurses

by age, nursing experience, and nursing education. These results are consistent with

Enst, Franco et al. (2004) who reported an inverse relationship between job

satisfaction, age and nursing education level and are consistent with Roud and

colleagues (2005) who reported a positive relationship between nursing experience

and job performance.

Although the effect of personal characteristics on occupational stress, job

satisfaction and job performance were investigated in this study, other factors such as

organizational commitment and work environment need to be examined (Bradley, et

al., 2002). Further, the variables age and nursing experience are interrelated, and it is

difficult to isolate their individual influences. It is therefore necessary to further

investigate the interrelations of these factors and how they influence the relationships

of occupational stress, job satisfaction and job performance. Research has

demonstrated that the factors leading to occupational stress and job satisfaction are

many and interrelated and that that employees react differently to job dissatisfaction

79

(Ackerman & Bezuidenhout, 2007). Therefore, more investigations are recommended

to identify employee characteristics and other motivations which influence job

satisfaction.

A regression model with occupational stress and job satisfaction as

independent variables explained only 3% of the variance in job performance.

However, the variance in job performance increased to 8% after controlling for

personal background characteristics such as nursing education and experience, type of

hospital, ward/unit, and number of children. The number of children had the most

significant contribution to the variance in job performance followed by job

satisfaction and hospital respectively. The number of children or the size of the family

has financial implications for the nurse in the Ugandan context. This again reflects

the importance of the family in relation to job satisfaction and job performance.

Mediating Role of Job Satisfaction on Occupational Stress and Job Performance

The study findings suggested full mediation of job satisfaction on the

relationship between occupational stress and job performance (beta = .154, t – 2.422,

p-value = .016). Occupational stress was not a significant predictor of job

performance after controlling for job satisfaction. Very little has been reported about

the mediating effect of job satisfaction on the relationship between occupational stress

and job performance. Factors which influence job satisfaction may influence job

performance. It is important to note that retention of health workers on their jobs has

been linked to job satisfaction. Further, job satisfaction is known to be influenced by

various factors. Some of the factors reported to influence job satisfaction include pay,

promotion, potential for creativity, autonomy, recognition, leadership, fringe benefits

80

and working conditions. Nurses’ perceptions and experiences are influenced by the

specific hospital context (Dieleman, et al., 2007).

In this study, job satisfaction was found to have a full mediation effect on the

relationship between occupational stress and job performance, indicating that job

satisfaction had an indirect effect on the relationship between occupational stress and

job performance. These results emphasize the importance of nurses’ job satisfaction in

improving nursing care and nurse retention in Ugandan hospitals. Therefore, there is

need for further research to identify factors that would enhance job satisfaction among

nurses in the different hospitals in Kampala, Uganda.

Stress, Job Satisfaction and Job Performance by Hospital Type

Results of a one-way ANOVA indicated statistically significant differences in

occupational stress, job satisfaction, and job performance in the different hospitals. A

post-hoc comparison using the Tukey HSD test indicated that the public hospital was

significantly different from the other hospitals in all three variables under study. The

mean score for occupational stress for the public hospital (M = 88.28, SD = 20.88)

was higher and this was statistically different from mean stress scores of the private 1,

private 2 and private 3 hospital nurses. The results also indicated that the mean score

for job satisfaction for the public hospital (M = 123.00, SD = 18.00) was significantly

lower than those of private 2 and private 3 hospitals. In addition, the mean score for

job performance for the public hospital (M = 154.00, SD = 23.35) was significantly

lower than the mean job performance scores of nurses in private hospitals 2 and 3.

However, no difference was observed for the three variables between the three private

not-for-profit hospitals.

81

It can be concluded that differences were found in occupational stress, job

satisfaction and job performance between public and private not-for-profit hospitals.

According to Reinikka and Svensson (2003), religious hospitals provide better quality

service although they tend to employ nurses of lower educational qualification.

Reinika and Svensson attributed this to the religious beliefs and values of the

employees of these hospitals. While this could be true, other factors may also

contribute to the differences in stress, job satisfaction and job performance levels

between the public and the private hospitals. Most services in the public hospital are

expected to be rendered free of charge while small reasonable fees are paid for

services in the other three hospitals. This payment structure could contribute to

overcrowding and work overload for nurses in the public hospital. Further, the nurses

may face the challenge of utilizing limited resources for many patients resulting in

occupational stress, low job satisfaction and subsequent poor job performance. It can

also be argued that Mulago Hospital, as a national referral hospital, may care for the

patients with the most serious conditions and nurses employed at a referral hospital

may experience emotional stress because of inability to give the necessary care

because of difficulties in setting priorities due to large numbers of critically ill

patients.

The Conceptual Framework

Based on the findings of this study, there is support for the use of Lazarus and

Folkman’s cognitive theory of stress and coping (Lazarus & Folkman, 1984) and

Karasek’s Demand-Control Model (Karasek, 1979). The study was able to

demonstrate that the workplace acts as the environment in which nurses’ experience

different levels of stress and job satisfaction. The hospital where nurses worked also

82

influenced the level of occupational stress, job satisfaction, and job performance.

Further, the findings demonstrated that the reaction or appraisal of stress is related to

personal background characteristics including nursing education, nursing experience

and the number of children. This suggested that the social cultural context affects the

appraisal of the working environment.

Stress and job satisfaction were found to influence job performance. Both the

Lazarus and Folkman and Karasek conceptual frameworks depict the individual

nurses as appraising the situation and behaving accordingly, whether they are satisfied

with their jobs or not. In the appraisal, nurses decide whether they have control or not,

become stressed, get no satisfaction with their jobs and perform well or poorly on

their jobs.

Conclusions

The following conclusions about relationships between occupational stress,

job satisfaction and job performance among hospital nurses in Kampala Uganda were

drawn:

1. Hospital nurses in Kampala, Uganda experienced moderate to extreme stress

at work.

2. The younger hospital nurses in Kampala were more satisfied with their jobs

than the older nurses.

3. Hospital nurses in Kampala with more nursing experience were more stressed

and less satisfied with their jobs than nurses with fewer years of experience.

4. There was a negative relationship between occupational stress and job

performance among hospital nurses in Kampala.

83

5. Job satisfaction had a mediating effect on the relationship between

occupational stress and job performance among hospital nurses in Kampala.

6. The nurses in the public hospital experienced more occupational stress than

nurses in the other three private not-for-profit hospitals.

7. Nurses in the public hospital reported less job satisfaction than nurses in the

private not-for-profit hospitals.

8. The nurses in the public hospital had lower perceptions of their job

performance than nurses in the private not-for- profit hospitals.

Implications

Implications for Nursing Education

The findings of this study indicate that nursing students need to understand

that occupational stress is a common occurrence in the nursing profession and it

affects job satisfaction and performance. Therefore, Ugandan nursing school curricula

at undergraduate and graduate programs should include content related to

occupational stress identification, prevention and management. Nursing students

should be taught that it is important to use culturally appropriate/sensitive measures in

research and practice. In addition, nursing students should have clinical experiences in

both public and not-for-profit hospitals to expose them to differences in the work

culture and environment in different types of hospitals.

Implications for Nursing Practice

Since work environment and personal characteristics contributed to

occupational stress and job satisfaction, nurses should be able to assess these factors

and give each other support in order to improve performance and nursing care to their

84

patients. The Ministry of Health and nurses in managerial roles should try to improve

those factors, such as good communication and recognition for excellent work, which

may reduce occupational stress and increase job satisfaction among their nurses.

Nurse leaders should also advocate for better working conditions which would

improve nurse satisfaction with their jobs such as better pay, fringe benefits, provision

of adequate resources, hiring more nurses to reduce on the work overload, or better

promotion policies. Appointed nurse managers and other managers in health care

settings should be trained in management in general and in human resource

management in order for them to be able to address the above issues.

Recommendations

Based on the findings, conclusions, and implications which arose from the

study, the following are recommended:

1. The study assessed the relationships between occupational stress, job

satisfaction and job performance based on self reports by the respondents; therefore,

other methods of assessment should be utilized to obtain objective data. For example,

occupational stress should be assessed using physiological measures and job

performance should be assessed using a pre-determined checklist and observations.

2. More studies should be conducted on a larger scale to identify sources of

occupational stress and factors that enhance job satisfaction for the hospital nurses in

Uganda.

3. As job satisfaction was found to fully mediate the relationship between

occupational stress and job performance, studies to identify factors which influence

job satisfaction among the hospital nurses in Uganda should be conducted in order to

improve nurse performance.

85

4. Since there were significant differences between the public and private not-

for-profit hospitals for all the three major variables, more studies should be conducted

to identify the factors which lead to these differences.

5. Future research is needed to examine differences in best practices for human

resource management between the public hospitals and private not-for-profit

hospitals.

86

REFERENCES

AbuAlRub, R. F. (2004). Job stress, job performance, and social support among hospital nurses. Journal of Nursing Scholarship, 36(1), 73-78.

AbuAlRub, R. F., & Al-Zaru, I., M. (2008). Job stress, recognition, job performance

and intention to stay at work among Jordanian hospital nurses. Journal of Nursing Management, 16, 227-236.

Ackerman, E. R., & Bezuidenhout, M. C. (2007). Staff dissatisfaction in the theatre

complex of a private hospital. Curationis, 30(3), 68-73. Adeb-Saeedi, J. (2002). Stress amongst emergency nurses. Australian Emergency

Nursing Journal, 5(2), 19-24. Aiken, L. H., Clerke, S. P., & Sloane, D. M. (2002). Hospital nurse staffing and

patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993.

Alves, S. L. (2005). A study of occupational stress, scope of practice, and

collaboration in nurse anesthetists practicing in anesthesia care team settings. AANA Journal, 73(6), 443-452.

Bakker, A. B., Killmer, C. H., Siegrist, J., & Schaufeli, W. B. (2000). Effort-reward

imbalance and burnout among nurses. Journal of Advanced Nursing, 31(4), 884.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in

social psychological research: Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.

Begat, I., Ellefsen, B., & Severinsson, E. (2005). Nurses' satisfaction with their work

environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being -- a Norwegian study. Journal of Nursing Management, 13(3), 221-230.

Bennett, P., Lowe, R., Matthews, V., Dourali, M., & Tattersall, A. (2001). Stress in

nurses: coping, managerial support and work demand. Stress & Health: Journal of the International Society for the Investigation of Stress, 17(1), 55-63.

Bianchi, E. R. F. (2004). Stress and coping among cardiovascular nurses: a survey in

Brazil. Issues in Mental Health Nursing, 25(7), 737-745.

87

Bradley, J. R., & Cartwright, S. (2002). Social support, job stress, health, and job satisfaction among nurses in the United Kingdom. International Journal of Stress Management, 9(3), 163-182.

Brown, H., Zijlstra, F., & Lyons, E. (2006). The psychological effects of

organizational restructuring on nurses. Journal of Advanced Nursing, 53(3), 344-357.

Callaghan, P., Shiu, A., & Wyatt, P. (2000). Factors related to stress and coping

among Chinese nurses in Hong Kong. Journal of Advanced Nursing, 31, 1518–1527.

Chen, Y. M., Chen, S. H., Tsai, C. Y., & Lo, L. Y. (2007). Role stress and job

satisfaction for nurse specialists. Journal of Advanced Nursing, 59, 497-509. Chinweuba, U. A. (2007). Relationship between job-stress and job satisfaction among

Nurse educators in Nigeria. West African Journal of Nursing, 18(2), 82-88. Chirwa, M. L., Greeff, M., Kohi, T., Naidoo, J., Makoae, L. N., Dlamini, P. S., et al.

(2008). HIV Stigma and Nurse Job satisfaction in five African Countries. Journal of the Association of Nurses in Aids care 20(1), 14-21.

Chu, C.-I., Hsu, H.-M., Price, J. L., & Lee, J.-Y. (2003). Job satisfaction of hospital

nurses: an empirical test of a causal model in Taiwan. International Council of Nurses, International Nursing Review, 50, 176-182.

Cohen, J., & Cohen, P. (1983). Applied Multiple Regression/Correlation Analysis for

the Behavioral Sciences, Second Edition (Electronic version). Hillsdale, NJ: Lawrence Erlbaum Associates.

Cottrell, S. (2001). Occupational stress and job satisfaction in mental health nursing:

focused interventions through evidence-based assessment. Journal of Psychiatric and Mental Health Nursing, 8, 157-164.

Coverston, C. R., Harmon, K. R., Keller, E. R., & Malner, A. A. (2004). A

Comparison of Guatemalan and USA nurses' attitudes towards nursing. International Council of Nurses, International Nursing Review, 51, 93-103. Dieleman, M., Bwete, V., Maniple, E., Kakker, M., Namaganda, G., Odaga, J., et al.

(2007). I believe that the staff have reduced their closeness to patients: an exploratory study on the impact of HIV/AIDS on staff in four rural hospitals in Uganda. . BMJ Health services Research, 7(205).

Drach-Zahavy, A. (2004). NURSING AND HEALTHCARE MANAGEMENT AND

POLICY Primary nurses’ performance: role of supportive management. Journal of Advanced Nursing, 45(1), 7-16.

Edwards, D., & Burnard, P. (2003). A systematic review of stress and stress

management interventions for mental health nurses. Journal of Advanced Nursing, 42(2), 169-200.

88

Ernst, M. E., Franco, M., Messmer, P. R., & Gonzalez, J. L. (2004). Practice applications of research. Nurses' job satisfaction, stress, and recognition in a pediatric setting [corrected] [published erratum appears in PEDIATR NURS 2005 Jan-Feb;31(1):20]. Pediatric Nursing, 30(3), 219-227.

Evans, L. (2002). An exploration of distict nurses' perception of occupational stress.

British Journal of Nursing, 11(8), 576-585. Flanagan, N. A., & Flanagan, T. J. (2002). An analysis of the relationship between job

satisfaction and job stress in correctional nurses. Research in Nursing & Health, 25(4), 282-294.

Gueritault-Chalvin, V., Kalichman, S. C., Demi, A., & Peterson, J. L. (2000). Work-

related stress and occupational burnout in AIDS caregivers: test of a coping model with nurses providing AIDS care. AIDS Care, 12(2), 149-161.

Harris, P. E. (1989). The Nurse Stress Index. Work and Stress, 3(4), 335-346. Ho, W., Chang, C. S., Shih, Y., & Liang, R. (2009). Effects of job rotation and role

stress among nurses on job satisfaction and organizational commitment. BMC Health Services Research, 9(8). doi:10 1186/1472-6963-9-8

Karasek, R. A. (1979). Job demands, job decision latitude, and mental strain:

Implications for job re-design. Administrative Science Quarterly., 24(2), 285-308.

Kekana, H. P., Rand, E. A., & Wya. (2007). Job satisfacton of registered nurses in a

community hospital in Limpomp Province in South Africa. Curationis, 30(2), 2435.

Khowaja, K., Merchant, R. J., & Hirani, D. (2005). Registered nurses perception of

work satisfaction at a tertiary care University hospital. Journal of Nursing Management, 13, 32-39.

Kirkcaldy, B. D., & Martin, T. (2000). Job stress and satisfaction among nurses:

individual differences. Stress Medicine, 16(2), 77-89. Kyaddondo, D., & White, R. S. (2003). Working in a decentralized system: A threat

to health workers' respect and survival in Uganda. International Journal of Health Planning and Management, 18, 329-342.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping. New York:

Springer. Lee, I., & Wang, H. (2002). Perceived Occupational Stress and Related factors in

Public Health Nurses. Journal of Nursing Research, 10(4), 253-259. Lephalala, R. P., Ehiers, V. J., & Oosthuizen, M. J. (2008). Factors influencing nurses'

job satisfaction in selected private hospitals in England. Curationis, 31(3), 60-69.

89

Lephoko, C. S. P., Bezuidenhout, M. C., & Roos, J. H. (2006). Organisational climate as a cause of job dissatisfaction among nursing staff in selected hospitals within the Mpulanga Province. Curationis, 29(4), 28-36.

Li, J., & Lambert, V. A. (2008). Workplace stressors, coping, demographics and job

satisfaction in Chinese intensive care nurses. Nursing in Critical Care, 13(1), 12-24.

Lindholm, M. (2006). Working conditions, psychosocial resources and work stress in

nurses and physicians in chief managers’ positions. Journal of Nursing Management, 14(4), 300-309.

Lu, H., While, A. E., & Barriball, K. L. (2007). A model of job satisfaction of nurses:

a reflection of nurses' working lives in Mainland China. Journal of Advanced Nursing, 58(5), 468-479.

Makinen, A., Kivimaki, M., Elovainio, M., & Virtanen, M. (2003). Organization of

nursing care and stressful work characteristics. Journal of Advanced Nursing, 43(2), 197-205.

McGrath, A., Reid, N., & Boore, J. (2003). Occupational stress in nursing.

International Journal of Nursing Studies, 40(5), 555. MoH. (2007). Uganda Health Workforce Study: Satisfaction and Intent to Stay

Among Current Health Workers: The Republic of Uganda. Mrayyan, M. T., & Al-Faouri, I. (2008). Predictors of career commitment and job

performance of Jordanian nurses. Journal of Nursing Management, 16(3), 246-256.

Munro, H., Barbara (2001). Stastical Methods for Health Care Research (4th ed.).

Philadelphia: Lippincott Williams & Wilkins. Muscroft, J., & Hicks, C. (1998). A comparison of psychiatric nurses' and general

nurses' reported stress and counselling needs: a case study approach. Journal of Advanced Nursing, 27, 1317-1325.

Nakasis, K., & Ouzouni, C. (2008). Factors influencing stress and job satisfaction of

nurses working in psychiatric units: A research review. Health science Journal, 2(4), 183-195.

Natukunda, C. (2008, 3/16/2008). Where did all the nurses go? New Vision. Retrieved

from http://www.newvision.co.ug Nyathi, M., & Jooste, K. (2008). Working conditions that contribute to absenteeism

among nurses in a provincial hospital in the Limpopo Province. Curationis, 31(1), 28-37.

90

Oginska-Bulik, N. (2006). Occupational stress and its consequences in healthcare professionals: the role of Type D Personality. International Journal of Occupational Medicine & Environmental Health, 19(2), 113-122.

Ogon, D. A. (2001). InFocus program on safety and health at work and the

environment: International Labour Organization. Ojoatre, K. (2008, 6/19/2008). Nurses are overworked. New Vision. Retrieved from

http://www.newvision.co.ug Pallant, J. (2001). SPSS Survival Manual A step by step guide to data analysis using

SPSS. Buckingham Open University Press. Patel, C. J., Beekhan, A., Paruk, Z., & Ramgoon, S. (2008). Work-family conflict, job

satisfaction and spousal support: An exploratory study of nurses' experience. Curationis, 38-44.

Peterson, M., & Wilson, J. F. (2002). The culture-work-health model and work stress.

American Journal of Health Behavior, 26(1), 16-24. Polit, D. F., & Beck, C. T. (2004). Nursing Research: Principles and Methods, 7th

Edition. Philadelphia: Lippincott Williams & Wilkins. Reinikka, R., & Svensson, J. (2003). Working for God? Evaluating Service Delivery

of religious Not-For-Profit health Care Providers in Uganda. Washington DC: World Bank Development Research Group

Roberts, T. (2005). The Certified Registered Nurse Anesthetist: Occupational

responsibilities, perceived stressors, coping strategies, and work relationships. AANA Journal, 73(5), 351-356.

Rothmann, S., van der Colf, J. J., & Rothmann, J. C. (2006). Occupational stress of

nurses in South Africa. Curationis, 29(2), 22-33. Roud, D., Giddings, L. S., & Koziol-McLain, J. (2005). A longitudinal survey of

nurses' self reported performance during an entry to practice programme. Nursing Praxis in New Zealand, 21(2), 37-46.

Salebi, C., & Minnaar, A. (2007). Job satisfaction among nurses in a public hospital in

Gauteng. Curationis, 30(3), 53-61. Salmond, S., & Ropis, P. E. (2005). Research for practice. Job stress and general well-

being: a comparative study of medical-surgical and home care nurses. MEDSURG Nursing, 14(5), 301-309.

Schwirian, P., M. (1978). Evaluating the Performance of Nurses: A multidimensional

Approach. Nursing Research, 27(6), 347-351. Spector, P., E. (1997). Job Satisfaction Application, Assessment, Cause, and

Consequences. California: Thousand Oaks: Sage Publications.

91

Stacciarini, J.-M. R., & Troccoli, B. T. (2004). Occupational stress and constructive thinking: health and job satisfaction. Journal of Advanced Nursing, 46(5), 480-487.

Stapleton, P., Henderson, A., Creedy, D. K., Cookie, M., Patterson, E., Alexander, H.,

et al. (2007). Boosting morale and improving performance in the nursing setting. Journal of Nursing Management, 15, 811-816.

Sveinsdottir, H., Biering, P., & Ramel, A. (2006). Occupational stress, job

satisfaction, and working environment Icelandic nurses: A cross-sectional questionnaire survey. International Journal of Nursing Studies, 43(7), 875-889.

Takase, M., Maude, P., & Manias, E. (2005). The impact of role discrepancy on

nurses' intention to quit their jobs. Journal of Clinical Nursing, 15, 1071-1080. Tyson, P. D., & Pongruengphant, R. (2004). Five-year follow-up study of stress

among nurses in public and private hospitals in Thailand. International Journal of Nursing Studies, 41(3), 247-254.

Tyson, P. D., Pongruengphant, R., & Aggarwal, B. (2002). Coping with

organizational stress among hospital nurses in Southern Ontario. International Journal of Nursing Studies, 39(4), 453-459.

UBOS. (2005). The 2002 Uganda Population and Housing Census - Main report.

Entebbe, Uganda: UBOS. WHO. (2002). The Global Occupational Health Network (COHNET) Newsletter,

Issue No. 2 WHO. (2005). Uganda. Summary Country Profile for HIV/AIDS treatment scaleup.

Retrieved March 1, 2007 Wilson, B., Squires, M., Widger, K., Cranley, L., & Tourangeau, A. (2008). Job

satisfaction among a multigenerational nursing workforce. Journal of Nursing Management, 16, 716-723.

Xianyu, Y., & Lambert, V. A. (2006). Investigation of the relationships among

workplace stressors, ways of coping, and the mental health of Chinese head nurses. Nursing and Health Sciences, 8, 147-155.

Zangaro, G. A., & Soeken, K. L. (2007). A Meta-Analysis of studies of Nurses' job

satisfaction. Research in Nursing and Health, 30, 445-458.

   

92

APPENDICES

93

Appendix A: Institutional Review Board for Human Use Approval

 

94

95

96

97

98

99

100

101

102

103

104

Appendix B: Permission to use Research Instruments

105

106

107

108

----- Original Message ---- From: Pat Schwirian <schwirian.1@osu.edu> To: nabirye rose <rnabiryechalo@yahoo.co.uk> Sent: Tuesday, 26 February, 2008 2:15:35 PM Subject: RE: Permission to use the Six Dimension scale of Nursing Performance for dissertation work Dear Rose: I am very pleased that you find the 6-D Scale useful for your Dissertation research. You certainly have my permission to use it in your work. Do you have (1) the article that describes the scoring strategy and (2) the Scales themselves. Since the instrument is pretty old, it is sometimes hard to find. I will be glad to e-mail you the 6-D forms as attachments and FAX you the Nursing Research article if you give me your FAX number. Best of luck in your research work. pms -----Original Message----- From: nabirye rose [mailto:rnabiryechalo@yahoo.co.uk] Sent: Tuesday, February 26, 2008 2:07 PM To: schwirian.1@osu.edu Subject: Permission to use the Six Dimension scale of Nursing Performance for dissertation work Dear Prof Schwirian, I am a Ugandan PhD student at the School of Nursing, University of Alabama at Birmingham. Currently, I am in the process of developing my disseration proposal. My area of interest is occupational stress among nurses and my topic is "Predictors of occupational Stress, among Hospital Nurses in Uganda". I have decided to use the Schwirian Six Dimension Scale of Nursing Performance (Schwirian, 1978) as one of my tools for the study. I am therefore writing to ask for permission to use your instrument for my study. Thank you very much in advance. Yours Sincerely, Rose Nabirye PhD student School of Nursing University of Alabama at Birmingham

109

Appendix C: Instruments

110

111

The Nurse Stress Index (NSI)

Reference: Harris, P. (1989) The Nurse Stress Index. Work and Stress. Vol. 3, No. 4, 335-346 Permission to reproduce the NSI from the original article was sought and obtained from Michelle Whittaker, Permissions Administrator, Taylor & Francis (UK) Journals

Instructions: Please rate by circling the number that corresponds to the amount of pressure you feel from each item. 1. - No pressure 2. - Very little pressure 3. - Moderate pressure 4. - High pressure 5. - Extreme pressure

ITEMS

RATE

1.

Time pressures and deadlines

1 2 3 4 5

2.

I have too little time in which to do what is expected of me

1 2 3 4 5

3. The demands of others for my time at work are in conflict

1 2 3 4 5

4. I spend my time ‘fighting fires’ rather than working to a plan

1 2 3 4 5

5. Trivial tasks interfere with my professional role 1 2 3 4 5

6. Fluctuations in workload 1 2 3 4 5

7. Management expects me to interrupt my work for new priorities

1 2 3 4 5

8. Deciding priorities 1 2 3 4 5

9. My nursing and administrative roles conflict 1 2 3 4 5

10. Shortage of essential resources 1 2 3 4 5

11. Decisions or changes which affect me are made ‘above’, without my knowledge or involvement

1 2 3 4 5

12. Management misunderstands the real needs of my department

1 2 3 4 5

13. Lack of support from senior staff 1 2 3 4 5

14.

I only get feedback when my performance is unsatisfactory

1

2

3

4

5

15.

Relationships with superiors

1 2 3 4 5

112

Instructions: Please rate by circling the number that corresponds to the amount of pressure you feel from each item. 1. - No pressure 2. - Very little pressure 3. - Moderate pressure 4. - High pressure 5. - Extreme pressure

16. Difficulty in dealing with aggressive people 1 2 3 4 5

17. Difficult patients 1 2 3 4 5

18. Involvement with life and death situations 1 2 3 4 5

19. Bereavement counseling 1 2 3 4 5

20. Dealing with relatives 1 2 3 4 5

21. Over-emotional involvement 1 2 3 4 5

22. Job versus home demands 1 2 3 4 5

23. My supervisors do not appreciate my home pressures 1 2 3 4 524. Domestic/family demands inhibit promotion 1 2 3 4 5

25. I need to absent myself from work to cope with

domestic problems 1 2 3 4 5

26. Bringing about change in staff/organization 1 2 3 4 5

27. Tasks outside of my competence 1 2 3 4 5

28. Coping with new technology 1 2 3 4 5

29. Lack of specialized training for present task 1 2 3 4 5

30. Uncertainty about the degree or area of my responsibility

1 2 3 4 5

113

JOB SATISFACTION SURVEY (JSS)

Permission to utilize the JSS was sought and obtained from Paul E. Spector, Department of Psychology University of South Florida.

Copyright Paul E. Spector 1994, All rights reserved.

PLEASE CIRCLE THE ONE NUMBER FOR EACH

QUESTION THAT COMES CLOSEST TO REFLECTING YOUR OPINION

ABOUT IT.

Dis

agre

e ve

ry m

uch

Dis

agre

e m

oder

atel

y

Dis

agre

e sl

ight

ly

Agr

ee s

light

ly

Agr

ee m

oder

atel

y

Agr

ee v

ery

muc

h

1 I feel I am being paid a fair amount for the work I do. 1 2 3 4 5 6

2 There is really too little chance for promotion on my job. 1 2 3 4 5 6

3 My supervisor is quite competent in doing his/her job. 1 2 3 4 5 6

4 I am not satisfied with the benefits I receive. 1 2 3 4 5 6

5 When I do a good job, I receive the recognition for it that I should receive. 1 2 3 4 5 6

6 Many of our rules and procedures make doing a good job difficult. 1 2 3 4 5 6

7 I like the people I work with. 1 2 3 4 5 6

8 I sometimes feel my job is meaningless. 1 2 3 4 5 6

9 Communications seem good within this organization. 1 2 3 4 5 6

10 Raises are too few and far between. 1 2 3 4 5 6

11 Those who do well on the job stand a fair chance of being promoted. 1 2 3 4 5 6

12 My supervisor is unfair to me. 1 2 3 4 5 6

13 The benefits we receive are as good as most other organizations offer. 1 2 3 4 5 6

14 I do not feel that the work I do is appreciated. 1 2 3 4 5 6

15 My efforts to do a good job are seldom blocked by red tape. 1 2 3 4 5 6

16 I find I have to work harder at my job because of the incompetence of people I work with.

1 2 3 4 5 6

17 I like doing the things I do at work. 1 2 3 4 5 6

18 The goals of this organization are not clear to me. 1 2 3 4 5 6

114

PLEASE CIRCLE THE ONE NUMBER FOR EACH

QUESTION THAT COMES CLOSEST TO REFLECTING YOUR OPINION

ABOUT IT. Copyright Paul E. Spector 1994, All rights reserved. D

isag

ree

very

mcu

h

Dis

agre

e m

oder

atel

y

Dis

agre

e sl

ight

ly

Agr

ee s

light

ly

Agr

ee m

oder

atel

y

Agr

ee v

ery

muc

h

19 I feel unappreciated by the organization when I think about what they pay me.

1 2 3 4 5 6

20 People get ahead as fast here as they do in other places. 1 2 3 4 5 6

21 My supervisor shows too little interest in the feelings of subordinates. 1 2 3 4 5 6

22 The benefit package we have is equitable. 1 2 3 4 5 6

23 There are few rewards for those who work here. 1 2 3 4 5 6

24 I have too much to do at work. 1 2 3 4 5 6

25 I enjoy my coworkers. 1 2 3 4 5 6

26 I often feel that I do not know what is going on with the organization. 1 2 3 4 5 6

27 I feel a sense of pride in doing my job. 1 2 3 4 5 6

28 I feel satisfied with my chances for salary increases. 1 2 3 4 5 6

29 There are benefits we do not have which we should have. 1 2 3 4 5 6

30 I like my supervisor. 1 2 3 4 5 6

31 I have too much paperwork. 1 2 3 4 5 6

32 I don't feel my efforts are rewarded the way they should be. 1 2 3 4 5 6

33 I am satisfied with my chances for promotion. 1 2 3 4 5 6

34 There is too much bickering and fighting at work. 1 2 3 4 5 6

35 My job is enjoyable. 1 2 3 4 5 6

36 Work assignments are not fully explained. 1 2 3 4 5 6

115

SIX DIMENSION SCALE OF NURSING PERFORMANCE (6-DSNP)

Permission to utilize the 6-DSNP was sought and obtained from Schwirian, P., M.

Reference: Schwirian, P.M. (1978). Evaluating the performance of nurses: A multidimensional approach. Nursing Research 27, 347 – 351.

Instructions: The following is a list of activities in which nurses engage with varying degrees of frequency and skill.

1. IN COLUMN A: please enter the number that best describes how often you perform the activities in the performance of your current job.

2. IN COLUMN B: for those activities that you perform please enter the number that best describes how well you perform them.

PLEASE USE THE KEY AT THE TOP OF EACH COLUMN

COLUMN A COLUMN B How often do you perform these activities in your current job?

How well do you perform these activities in your current job?

1- Not expected in this job

2- Never or seldom

3- Occasionally

4- Frequently

1- Not very well

2- Satisfactorily

3- Well

4- Very Well

Column A Column B

1. Teach a patient's family members about the patient's needs.

2. Coordinate the plan of nursing care with the medical plan of care.

3. Give praise and recognition for achievement to those under his/her direction

4. Teach preventive health measure to patients and their families.

5. Identity and use community resources in developing a plan of care for a patient and his/her family.

6. Identify and include in nursing care plans anticipated changes in patient's conditions.

116

COLUMN A COLUMN B

How often do you perform these activities in your current job?

How well do you perform these activities in your current job?

1- Not expected in this job

2- Never or seldom

3- Occasionally

4- Frequently

1- Not very well

2- Satisfactorily

3- Well

4- Very Well

Column A Column B

7. Evaluate results of nursing care.

8. Promote the inclusion of patients decision and desires concerning his/her care

9. Develop a plan of nursing care for a patient.

10. Initiate planning and evaluation of nursing care with others.

11. Perform technical procedures: e.g. oral suctioning, tracheostomy care, IV therapy, catheter care, dressing changes.

12. Adapt teaching methods and materials to the understanding of the particular audience: e.g., age of patient, educational background and sensory deprivation.

13. Identify and include immediate patient needs in the plan of nursing care.

14. Develop innovative methods and materials for teaching patients.

15. Communicate a feeling of acceptance of each patient and a concern for the patient's welfare.

16. Seek assistance when necessary.

17. Help a patient communicate with others.

18. Use mechanical devices: e.g., suction machine, Gomco, cardiac monitor, respirator

19. Give emotional support to family of dying patient.

20. Verbally communicate facts, ideas, and feelings to other health care team members.

117

COLUMN A How often do you perform these activities in your current job?

1- Not expected in this job

2- Never or seldom

3- Occasionally

4- Frequently

COLUMN B

How well do you perform these activities in your current job?

1- Not very well

2- Satisfactorily

3- Well

4- Very Well

Column A Column B

21. Promote the patients' rights to privacy.

22. Contribute to an atmosphere of mutual trust, acceptance, and respect among other health team members.

23. Delegate responsibility for care based on assessment of priorities of nursing care needs and the abilities and limitations of available health care personnel.

24. Explain nursing procedures to a patient prior to performing them.

25. Guide other health team members in planning for nursing care.

26. Accept responsibility for the level of care under his/her direction.

27. Perform appropriate measures in emergency situations.

28. Promote the use of interdisciplinary resource persons.

29. Use teaching aids and resource materials in teaching patients and their families.

30. Perform nursing care required by critically ill patients.

31. Encourage the family to participant in the care of the patient.

32. Identify and use resources within the health care agency in developing a plan of care for a patient and his/her family.

33. Use nursing procedures as opportunities for interaction with patients.

34. Contribute to productive working relationships with other health team members.

118

Column A Column B

How often do you perform these activities in your current job?

How well do you perform these activities in your current job?

1- Not expected in this job

2- Never or seldom

3- Occasionally

4- Frequently

1- Not very well

2- Satisfactorily

3- Well

4- Very Well

Column A Column B

35. Help a patient meet his/her emotional needs.

36. Contribute to the plan of nursing care for a patient.

37. Recognize and meet the emotional needs of a dying patient.

38. Communicate facts, ideas, and professional opinions in writing to patients and their families.

39. Plan for the integration of patient needs with family needs.

40. Function calmly and competently in emergency situations.

41. Remain open to the suggestions of those under his/her direction and use them when appropriate.

42. Use opportunities for patient teaching when they arise.

119

The following PROFESSIONAL DEVELOPMENT behaviors should be evaluated in

terms of quality only--i.e. COLUMN B.

Column B

How well do you perform these activities in your current job?

1- Not very well

2- Satisfactorily

3- Well

4- Very Well

Column B

43. Use learning opportunities for ongoing personal and professional growth.

44. Display self-direction.

45. Accept responsibility for own actions.

46. Assume new responsibilities within the limits of capabilities.

47. Maintain high standards of performance.

48. Demonstrate self-confidence.

49. Display a generally positive attitude.

50. Demonstrate a knowledge of the legal boundaries of nursing.

51. Demonstrate knowledge in the ethics of nursing.

52. Accept and use constructive criticism.

******************************************************************

Reference: Schwirian, P.M. (1978). Evaluating the performance of nurses: A multi-dimensional approach. Nursing Research, 27, 347- 351.

120

Appendix D: Instrument Sub-scales and Number of Items

121

Nurse Stress Index (NSI) Sub-scales Item Numbers 1 Workload pressures related to insufficient time

(Managing Workload 1) Q1NSI – Q5NSI

2 Workload pressures due to resources and conflicting priorities (Managing Workload 2)

Q6NSI – Q10NSI

3 Organizational Support and Involvement Q11NSI – Q15NSI 4 Dealing with Patients and Relatives Q16NSI – Q20NSI 5 Home and Work Conflicts Q21NSI – Q25NSI 6 Confidence and Competence in Role Q26NSI – Q30NSI Job Satisfaction Survey ( JSS) Sub-scales Item Numbers 1 Pay 1 10r 19r 28 2 Promotion 2r 11 20 33 3 Supervision 3 12r 21r 30 4 Fringe benefits 4r 13 22 29r5 Contingent rewards 5 14r 23r 32r6 Operating conditions 6r 15 24r 31r7 Coworkers 7 16r 25 34r8 Nature of work 8r 17 27 35 9 Communication 9 18r 26r 36r NB r = reverse scoring (i.e. negatively worded

responses) are renumbered from 6-1 instead of 1-6 Thus: 1: Disagree very much = 6 2: Disagree moderately = 5 3: Disagree slightly = 4 4: Agree slightly = 3 5: Agree moderately = 2 6: Agree very much = 1

Six-Dimensional Scale of Nursing

Performance (6-DSNP) Sub-scales Item Numbers

1 Leadership 2, 23, 25, 26, 41 2 Critical Care 11, 18, 19, 27, 30,, 37,40 3 Teaching/Collaboration 1, 4, 5, 12, 14, 28, 29, 31,

32, 38, 39 4 Planning/Evaluation 2, 6, 7, 9, 10, 13, 36 5 Interpersonal Relations/Communication 8, 15, 16, 17, 20, 21, 22,

24, 33, 34, 35, 42 6 Professional Development 43, 44, 45, 46, 47, 48, 49,

50, 51, 52