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
Copyright by
Rose Chalo Nabirye
2010
ii
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
iii
hospitals. Nurses in the public hospital reported higher levels of occupational stress
and lower levels of job satisfaction and performance. There were significant negative
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.
iv
DEDICATION
In loving memory of my late father Mr. Nathan Gusongoirye Waako who always
encouraged me to study hard and sacrificed the little resources he had in order to
provide for my education.
v
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 UABICER 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,
vi
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
vii
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.
viii
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 ix
3
METHODOLOGY ............................................................................................... 33 Study Design ...................................................................................................... 33 Ethical Considerations ....................................................................................... 33 Setting ................................................................................................................ 34 Study Sample ..................................................................................................... 35 Inclusion Criteria ...................................................................................... 35 Exclusion Criteria ..................................................................................... 36 Sample Size........................................................................................................ 36 Instruments......................................................................................................... 37 The Nurse Stress Index (NSI) ................................................................... 37 The Job Satisfaction Survey (JSS) ............................................................ 38 The Six Dimension Scale of Nursing Performance (6-DSNP) ................. 39 Pilot-testing of Instruments ................................................................................ 39 Data Collection Procedures ............................................................................... 40 Data Safety and Integrity ................................................................................... 41 Data Analysis ..................................................................................................... 42 Limitations of the Study .................................................................................... 43 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 x
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 xi
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 xii
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 xiii
LIST OF FIGURES
Figure
Page
1 Diagram of Theoretical/Conceptual Model .............................................................. 10
xiv
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
Ministry of Health
NGO
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
xv
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
xvi
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, turnover 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 (faithbased) 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
Environmental
Stressors (Workplace
factors)
- Type of hospital
- Ward/unit
- Responsibility
- Hours worked on a
typical day
Cognitive Factors
Behavioral Outcome
OCCUPATIONAL
STRESS
JOB
PERFORMANCE
Personal
Characteristics:
- Age
- Sex
- Nursing Education
- Nursing experience
- Marital Status
- Number of children
JJ JOB
SATISFACTION
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.
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 nondepressed 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 SixDimensional 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 subscale 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
Agea
20-29
30-39
40-49
50-60
91
135
71
36
27.33
40.54
21.32
10.81
Gender
Female
Male
317
16
95.20
4.80
Marital status
Married
Divorced/Separated
Widow/Widower
Never married
206
32
11
84
61.86
9.61
3.30
25.23
68
138
98
29
20.42
41.44
29.43
8.71
Number of childrenb
0
1-2
3-4
>5
a M = 36.02; SD = + 9.11
b M = 2.19; SD = + 1.84
Frequency
%
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
Hospital
Private 1
Private 2
Private 3
Public
25
71
41
196
7.51
21.32
12.31
58.86
Nursing Education
Enrolled Nurse (EN)
Enrolled Midwife (EM)
Registered Nurse (RN)
Registered Midwife (RM)
Double Trained (RN/M)
BSN and above
77
42
100
49
50
15
23.12
12.61
30.03
14.71
15.02
4.50
Ward/Unit
Medical
Surgical
Obstetrics/Gynecology
Pediatrics
117
57
102
57
35.14
17.12
30.63
17.12
70
68
74
53
26
21
24
21.02
20.42
21.32
15.92
7.81
6.31
7.20
123
210
36.94
63.06
189
125
19
56.76
37.53
5.71
Nursing Experience (Years)c
<4
5-9
10-14
15-19
20-24
25-29
>30
Responsibility
Ward/Unit In-charge
None
Hours worked on a typical dayd
<8
9-11
>12
c M = 12.59; SD = + 9.08
d M = 8.76; SD = + 8.62
Frequency
%
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
5
Cronbach’s alpha
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
30
.92
1. Managing Workload 1
(Pressures due to insufficient time)
Total Score
.78
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
4
Cronbach’s alpha
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
36
.81
1. Pay
Total Score
.46
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 subscales 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
5
Cronbach’s alpha
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
52
.93
1. Leadership
Total Score
.61
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
1. Managing Workload 1
Range of
Possible Scores
5-25
Mean Scores
for Sample
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
30-150
82.18
21.63
Total Score
SD
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
4-24
Mean Scores for
Sample
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
36-216
127.65
19.22
1. Pay
Total Score
SD
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 sixsubscale 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 subscales 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 6DSNP Sub-scales (Column B)
Sub-scale
SD
1. Leadership
5-20
Mean Total
Sub-scale
Scores
15.23
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
52-208
158.66
22.11
Total Score
Range of
possible scores
2.59
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 (6DSNP)
Activity
How Frequent
(Column A)
Mean
SD
How Well
(Column B)
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
--
--
3.23
.43
3.42
.37
3.05
.43
Professional Development*
Total
*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
Age
20-29 (n = 86)
30-39 (n = 133)
40-49 (n = 70)
50-60 (n = 35
Mean
SD
75.51
82.86
84.97
90.34
19.84
20.06
23.43
24.13
Gender
Female (n = 308)
Male (n = 16)
81.83
88.68
21.56
22.60
Marital status
Married (n = 201)
Divorced/Separated (n = 30)
Widow/Widower (n =11)
Never married (n = 82)
81.34
85.30
96.63
81.12
20.83
18.94
17.12
24.36
Number of children
0 (n =67)
1-2 (n = 132)
3-4 (n = 97)
>5 (n = 28)
ANOVA (p value)
F = 4.99, p =.002
F = 1.53, p = .217
F = 2.03, p =.110
F = 3.56, p = .015
74.65
83.60
84.97
83.71
22.82
20.16
22.46
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
Hospital
Public (n = 193)
Private 1 (n = 22)
Private 2 (n = 69)
Private 3 (n = 40)
88.27
76.09
72.15
73.35
20.87
23.48
20.03
16.40
Nursing Education
Enrolled Nurse (n = 75)
Enrolled Midwife (n = 42)
Registered Nurse (n = 96)
Registered Midwife (n = 48)
Double Trained (n = 49)
BSN and above (n = 14)
75.41
79.16
85.00
80.02
91.61
82.42
21.58
16.98
20.93
20.13
25.68
15.88
Ward/Unit
Medical (n = 112)
Surgical (n = 55)
Obs./Gyn. (n = 101)
Pediatrics (n = 56)
83.28
87.29
79.09
80.48
21.78
22.12
19.52
23.81
Nursing Experience (Years)
1-5 (n = 79)
6-10 (n = 90)
11-15 (n = 55)
16-20 (n = 46)
21+ (n = 54)
73.54
83.21
87.34
79.02
90.50
18.42
21.96
18.14
19.80
25.55
Responsibility
Ward/Unit In-charge (n = 119)
None (n = 205)
83.16
81.60
21.34
21.82
Hours worked on a typical day
<8
9-11
>12
78.21
88.48
81.55
21.61
19.65
25.36
ANOVA (p value)
F = 14.46, p < .0001
F = 4.16, p = .001
F = 1.94, p = .124
F = 6.66, p < .001
F = .39, p = .530
F = 8.59, p < .001
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
Age
20-29 (n = 91)
30-39 (n = 135)
40-49 (n= 71)
50-60 (n = 36)
Mean
SD
134.02
124.64
124.11
129.86
19.13
17.90
18.69
21.62
Gender
Female (n = 317)
Male (n = 16)
127.94
122.00
18.68
28.126
Marital status
Married (n = 206)
Divorced/Separated (n = 32)
Widow/Widower (n= 11)
Never married (n = 84)
127.24
126.81
131.09
128.55
18.89
17.40
17.85
21.03
Number of children
0 (n = 68)
1-2 (n = 138)
3-4 (n = 98)
>5 (n = 29)
132.46
127.88
125.42
122.90
20.51
18.48
19.76
15.90
ANOVA (p value)
F = 5.62, p = .001
F = 1.46, p = .228
F = .23, p = .876
F = 2.49, p = .060
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
Hospital
Public (n = 196)
Private 1 (n = 25)
Private 2 (n = 71)
Private 3(n = 41)
Mean
SD
123.00
129.84
136.95
132.46
18.79
14.71
16.46
21.32
Nursing Education
Enrolled Nurse (n = 77)
Enrolled Midwife (n = 42)
Registered Nurse (n = 100)
Registered Midwife (n = 49)
Double Trained (n = 50)
BSN and above (n = 15)
134.27
132.07
123.14
127.00
123.84
126.27
20.18
17.26
16.34
17.19
23.34
19.23
Ward/Unit
Medical (n = 117)
Surgical (n = 57)
Obs./Gyn. (n = 102)
Pediatrics (n = 57)
127.47
123.95
130.44
126.75
19.87
16.75
18.91
20.43
ANOVA (P value)
F = 11.30, p < .0001
F = 3.96, p = .002
F = 1.47, p = .222
Nursing Experience (Years)
1-5 (n = 83)
6-10 (n =92)
11-15 (n = 56)
16-20 (n = 46)
21+ (n = 56)
F = 6.60, p < .001
135.53
125.71
119.70
126.37
128.20
19.58
17.27
17.36
18.00
20.80
Responsibility
Ward/Unit In-charge (n = 123)
None (n = 210)
126.89
128.10
17.70
20.08
F = 0.31, p = .577
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
Age
20-29 (n = 91)
30-39 (n = 135)
40-49 (n= 71)
50-60 (n = 36)
Gender
Female (n = 317)
Male (n = 16)
Mean*
SD
3.13
3.05
2.95
3.05
.39
.40
.51
.42
ANOVA (p value)
F = 2.46, p = .063
F = 0.04, p = .842
3.05
3.03
Marital status
Married (n = 206)
Divorced/Separated (n = 32)
Widow/Widower (n= 11)
Never married (n = 84)
.44
.43
F = 2.07, p = .104
3.03
2.95
3.01
3.14
.43
.43
.29
.43
Number of children
0 (n = 68)
3.21
1-2 (n = 138)
3.02
3-4 (n = 98)
3.01
>5 (n = 29)
2.97
*Mean for six sub-scales of the 6-DSNP
.39
.43
.45
.36
F = 3.86, p = .010
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
Hospital
Public (n = 196)
Private 1 (n = 25)
Private 2 (n = 71)
Private 3(n = 41)
Mean*
SD
2.96
3.32
3.15
3.12
.45
.40
.34
.38
Nursing Education
Enrolled Nurse (n = 77)
Enrolled Midwife (n = 42)
Registered Nurse (n = 100)
Registered Midwife (n = 49)
Double Trained (n = 50)
BSN and above (n = 15)
3.12
3.02
3.11
2.84
3.00
3.19
.36
.37
.422
.49
.47
.44
Ward/Unit
Medical (n = 117)
Surgical (n = 57)
Obs./Gyn. (n = 102)
Pediatrics (n = 57)
3.11
2.98
2.95
3.17
.42
.43
.45
.37
ANOVA (p value
F = 7.95, p < .0001
F = 3.60, p = .004
F = 4.34, p = .005
Nursing Experience (Years)
1-5 (n = 83)
6-10 (n =92)
11-15 (n = 56)
16-20 (n = 46)
21+ (n = 56)
F = 1.46, p = .214
3.13
3.02
3.06
2.95
3.03
.40
.45
.35
.47
.47
Responsibility
Ward/Unit In-charge (n = 123)
None (n = 210)
3.05
3.05
.44
.43
F = 0.0006, p = .980
*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 6DSNP. 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
Column A (How frequent)
-.018
.746
Column B (How well)
-.131
.018
-.501
.000
Job Performance
Job Satisfaction
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
Constant
Beta
t
10.856
P value
.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
Constant
t
P value
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
1 Occupational Stress
Beta
-.124
t
-2.25
p value
.025
2 Occupational Stress
-.501
-10.39
.000
3 Job Satisfaction
.177
3.28
.001
4 Occupational Stress
-.047
-.75
.455
Job Satisfaction
1. Dependent Variable: Job Performance
2. Dependent Variable: Job satisfaction
3. Dependent Variable: Job Performance
4. Dependent Variable: Job Performance
.154
2.42
.016
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
Occupational Stress
Job Satisfaction
Job Performance
Hospital
Private 1
Mean
76.09
Std. Deviation
23.49
Std. Error
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
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
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
Job Satisfaction
F
11.297
p-value
< .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)
Occupational
Public
Stress
Job Satisfaction
Job Performance
Public
Public
Hospital (J)
Private 1
Mean Difference (I-J)
12.19*
p-value
.041
Private 2
16.12*
.000
Private 3
14.93*
.000
Private 1
-6.84
.299
Private 2
-13.96*
.000
Private 3
-9.46*
.015
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 notfor-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
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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 <[email protected]>
To: nabirye rose <[email protected]>
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:[email protected]]
Sent: Tuesday, February 26, 2008 2:07 PM
To: [email protected]
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
1.
2.
ITEMS
Time pressures and deadlines
RATE
3
4
1
2
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
5.
I have too little time in which to do what is expected of
me
The demands of others for my time at work are in
conflict
I spend my time ‘fighting fires’ rather than working to a
plan
Trivial tasks interfere with my professional role
1
2
3
4
5
6.
Fluctuations in workload
1
2
3
4
5
7.
1
2
3
4
5
8.
Management expects me to interrupt my work for new
priorities
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
Management misunderstands the real needs of my
department
Lack of support from senior staff
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
3.
4.
12.
13.
5
14.
I only get feedback when my performance is
unsatisfactory
15.
Relationships with superiors
1
2
3
4
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.
24.
My supervisors do not appreciate my home pressures
Domestic/family demands inhibit promotion
1
1
2
2
3
3
4
4
5
5
25.
1
2
3
4
5
26.
I need to absent myself from work to cope with
domestic problems
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.
Agree very much
Agree moderately
Agree slightly
Disagree slightly
Disagree moderately
PLEASE CIRCLE THE ONE NUMBER FOR EACH
QUESTION THAT COMES CLOSEST TO
REFLECTING YOUR OPINION
ABOUT IT.
Disagree very much
Copyright Paul E. Spector 1994, All rights reserved.
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
When I do a good job, I receive the recognition for it that I should receive.
1
2
3
6
Many of our rules and procedures make doing a good job difficult.
1
2
3 4
7
I like the people I work with.
1
2
3
8
I sometimes feel my job is meaningless.
1
2
3 4
9
Communications seem good within this organization.
1
2
3
10
Raises are too few and far between.
1
2
3 4
11
Those who do well on the job stand a fair chance of being promoted.
1
2
3
12
My supervisor is unfair to me.
1
2
3 4
13
The benefits we receive are as good as most other organizations offer.
1
2
3
14
I do not feel that the work I do is appreciated.
1
2
3 4
15
My efforts to do a good job are seldom blocked by red tape.
1
2
3
16
I find I have to work harder at my job because of the incompetence of
people I work with.
1
2
3 4
17
I like doing the things I do at work.
1
2
3
The goals of this organization are not clear to me.
1
2
3 4
18
5
6
4 5
6
5
4 5
6
6
5
6
4 5
6
5
6
4 5
6
5
6
4 5
6
5
6
4 5
6
5
4 5
5
6
6
6
Agree very much
Agree moderately
Agree slightly
Disagree slightly
Copyright Paul E. Spector 1994, All rights reserved.
Disagree moderately
PLEASE CIRCLE THE ONE NUMBER FOR EACH
QUESTION THAT COMES CLOSEST TO
REFLECTING YOUR OPINION
ABOUT IT.
Disagree very mcuh
114
19
I feel unappreciated by the organization when I think about what they pay
me.
1
2
3 4
20
People get ahead as fast here as they do in other places.
1
2
3
21
My supervisor shows too little interest in the feelings of subordinates.
1
2
3 4
22
The benefit package we have is equitable.
1
2
3
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
27
I feel a sense of pride in doing my job.
1
2
28
I feel satisfied with my chances for salary increases.
1
29
There are benefits we do not have which we should have.
1
30
I like my supervisor.
1
2
3
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
35
My job is enjoyable.
1
2
3
Work assignments are not fully explained.
1
2
3 4
36
5
6
4 5
6
5
4 5
6
6
5
6
3
4 5
6
2
3
4 5
6
2
3 4
5
4 5
5
4 5
5
6
6
6
6
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
How often do you perform these
activities in your current job?
COLUMN B
How well do you perform these activities
in your current job?
1- Not expected in this job
1- Not very well
2- Never or seldom
2- Satisfactorily
3- Occasionally
3- Well
4- Frequently
4- Very Well
Column A
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.
Column B
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
1- Not very well
2- Never or seldom
2- Satisfactorily
3- Occasionally
3- Well
4- Frequently
4- Very Well
Column A
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.
Column B
117
COLUMN A
How often do you perform these
activities in your current job?
COLUMN B
How well do you perform these activities
in your current job?
1- Not expected in this job
1- Not very well
2- Never or seldom
2- Satisfactorily
3- Occasionally
3- Well
4- Frequently
4- Very Well
Column A
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.
Column B
118
Column A
How often do you perform these activities in
your current job?
Column B
How well do you perform these
activities in your current job?
1- Not expected in this job
1- Not very well
2- Never or seldom
2- Satisfactorily
3- Occasionally
3- Well
4- Frequently
4- Very Well
Column A
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.
Column B
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 multidimensional approach. Nursing Research, 27, 347- 351.
120
Appendix D: Instrument Sub-scales and Number of Items
121
3
4
5
6
Nurse Stress Index (NSI) Sub-scales
Workload pressures related to insufficient time
(Managing Workload 1)
Workload pressures due to resources and
conflicting priorities (Managing Workload 2)
Organizational Support and Involvement
Dealing with Patients and Relatives
Home and Work Conflicts
Confidence and Competence in Role
Q11NSI – Q15NSI
Q16NSI – Q20NSI
Q21NSI – Q25NSI
Q26NSI – Q30NSI
1
2
3
4
5
6
7
8
9
Job Satisfaction Survey ( JSS) Sub-scales
Pay
Promotion
Supervision
Fringe benefits
Contingent rewards
Operating conditions
Coworkers
Nature of work
Communication
Item Numbers
1
10r
19r
11
20
2r
3
21r
12r
13
22
4r
5
14r
23r
15
6r
24r
7
25
16r
17
27
8r
9
18r
26r
1
2
Item Numbers
Q1NSI – Q5NSI
Q6NSI – Q10NSI
28
33
30
29r
32r
31r
34r
35
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
1
2
3
Six-Dimensional Scale of Nursing
Performance (6-DSNP) Sub-scales
Leadership
Critical Care
Teaching/Collaboration
4
5
Planning/Evaluation
Interpersonal Relations/Communication
6
Professional Development
Item Numbers
2, 23, 25, 26, 41
11, 18, 19, 27, 30,, 37,40
1, 4, 5, 12, 14, 28, 29, 31,
32, 38, 39
2, 6, 7, 9, 10, 13, 36
8, 15, 16, 17, 20, 21, 22,
24, 33, 34, 35, 42
43, 44, 45, 46, 47, 48, 49,
50, 51, 52