STRESS IN NURSES UNDERTAKING TERTIARY STUDIES by Sybe B Jongeling Department of Education Studies Western Australian College of Advanced Education A paper presented at the 1990 Annual Conference of the Australian Association for Research in Education The University of Sydney, Nov 27- Dec 1, 1990. STRESS IN NURSES UNDERTAKING TERTIARY STUDIES Introduction Stress is particularly prevalent in the human service professions. It appears that responsibility for people causes more stress than responsibility for material objects (Cherniss, 1980; Truch, 1980; Farber, 1983). Therefore, people involved in teaching, counselling and all of the major health professions are particularly susceptible to occupational stress and burnout. The factors which contribute to stress may be classified in terms of individual stressors, societal stressors and organisational stressors. To some extent workers have control over the individual, personal stressors. However, they have less influence on work-related and societal stressors. The work-related stressors have been identified as "long hours, isolation, lack of autonomy, client 'neediness', public mis-understanding of the nature of their work, insufficient resources, lack of criteria to measure accomplishments, excessive demands for productivity, inadequate job training and administrative indifference to or interference with their work" (Farber, 1983, p. 5). In addition to these general work-related stressors, people working in institutional settings often experience specific stresses relating to "organisational structures, most notably role ambiguity, role conflict and role overload" (Farber, 1983, p. 5). Essentially unrealistic worker expectations, bureaucratic constraints and public misperceptions of the role of human service professionals combine to produce stressful conditions, which Pines and Maslach (in Eisenstat & Felner, 1983, p. 143) describe as a syndrome of physical and emotional exhaustion", causing workers to develop a "negative self concept, negative job attitudes and loss of concern and feelings for clients".
Organisational changes and new requirements for promotional advancement in the human service professions, together with the greater emphasis on tertiary qualifications, rapid advances in technology, ethical and moral concerns and problems in client care have placed greater stress on members of the caring professions. In particular changes in the promotional structure of the nursing profession and an expanded role for the nurse which includes the use of high technology in the workplace appear to have placed considerable stress on the nursing profession. Therefore, this study sought to establish the incidence of stress among registered nurses pursuing tertiary studies, the factors contributing to stress and the extent specific workrelated stressors were of concern to practising nurses. Method The Sample The research was conducted among registered nurses undertaking tertiary studies in Western Australia. A sample of 66 nurses completed a Nursing Stress Inquiry Survey. Their ages ranged from 21 to 55 years, with an average age range of 36-40 years and a modal range of 31-35 years. Fifty-six of respondents were female (84.8%) and there were ten males (15.2%). All have had extended experience in nursing, the range was 5-29 years, with an average length of 15.6 years and a modal length of 14 years of service. One-third of the respondents were in their first year of a new position, while the average number of years in the present position was 3.5 years. Approximately half the respondents (55.9%) were employed full-time, while the remainder were part-time (40.7%) or casual (3.4%). Onethird (34.5%) indicated that their predominant work shift was during the daytime, 10.3 percent indicated afternoon and evening shift, 24.1 percent had mainly night shift, while 31 percent indicated that they did not have a predominant shift pattern. Measures of Stress. The General Health Questionnaire (GHQ), devised by Goldberg (1978), provided a measure of psychological distress. The 30-item version of the GHQ has been used extensively in recent studies on stress in the teaching profession, and comparative data for Western Australian teachers and for the general population of Perth is readily available (Finlay- Jones, 1986; Finlay-Jones & Murphy, 1979; Van Schoubroeck & Tuettemann, 1986). The GHQ can be used as a measure of minor psychiatric disturbance in the community. Respondents are to consider how their "health has been in general, over the past few weeks", and to answer such questions as: Have you recently been able to concentrate on whatever you're doing? (Better than usual/ Same as usual/ Less
than usual/ Much less than usual). Have you recently been satisfied with the way you've carried out your tasks? (More satisfied/ About same as usual/ Less satisfied than usual/ Much less satisfied). Have you recently felt that life isn't worth living? (Not at all/ No more than usual/ Rather more than usual/ Much more than usual) The recommended scoring method as outlined by Goldberg (1978, p. 8) requires that each item be treated as a bi-modal scale. A score of zero is allocated to the first two alternatives and a score of one is awarded to the second two alternative choices. This according to Goldberg (1978, p. 8) "eliminates any errors due to 'end-users' and 'middle-users' since they will score the same irrespective of whether they tend to prefer Columns 1 and 4 or Columns 2 and 3 to indicate possession or non-possession of the item in question". On the basis of the total score across all 30 items, respondents are classified as 'cases' (if they score 5 or more) or as 'non-cases' (score less than 5). Respondents identified as 'cases' are, according to Tuettemann and Punch (1990, p. 27), "very likely to be suffering from levels of tension, anxiety and depression high enough to have an adverse effect on their physical and mental well-being". Validity and reliability studies reported by Goldberg (1978) and Tennant (1977) indicate that in a clinical interview a respondent with a score of 5 on the 30-item GHQ has a 50 percent chance of being diagnosed as psychiatric case. This probability increases to 95 percent for respondents with a score of 10 or more. Internal consistency measures indicate a reliability of 0.95, while a test-retest reliability on a population whose clinical status had not altered over a period of months (using standardised psychiatric interviews) gave a value of 0.90. Although the GHQ was designed primarily as a measure of minor psychiatric disturbance, the instrument has been used in several studies to measure psychological stress. Therefore, the GHQ was used in this study to make meaningful comparison with existing data on stress in the teaching profession and in the general population. However, it was felt desirable to include two other measures of stress for comparison purposes. The Felt Effects Scale. This scale was developed by Baldock (1984) and used in a study on stress among staff in a tertiary institution. The 10-item scale requires the respondent to answer such questions as: I feel disinclined to go to work. (Rarely/ Sometimes/ Often) I am easily irritated by small things. (Rarely/ Sometimes/ Often)
I feel depressed, down in the dumps. (Rarely/ Sometimes/ Often) The Felt Effects Scale is scored according to the following recommendation: Rarely=0, Sometimes=1 and Often=2. A total score from 6-12 indicates serious levels of stress, while a score from 13-20 indicates very serious stress levels. A correlation between the Felt Effects Scale and the GHQ gave a value of 0.62. Global Item. This item requires the respondent to "place a tick in the box which most represents how stressed you have been feeling during the last six months. (a) A normal amount, nothing to worry about. (b) Rather more than usual for me - I'm somewhat concerned about it. (c) I've been feeling a lot more stress than usualquite worried. (d) I've been feeling severely stressed and anxious. It's a worry to me and my family. (e) I'm so anxious I'm having real difficulties coping at work and/or at home." The item is scored from 1-5. A score of 1 indicates normal levels of stress, while a score of 5 indicates severe stress. Other Variables Assessing work-related factors in stress. Sixteen items covering a number of dimensions of work-related factors in stress were included in the questionnaire. These factors, identified in the research literature in Australia and elsewhere, covered issues relating to job security, quality of work environment, relationship with others and work loads. Two items dealing with AIDS were also included. Respondents were asked to "indicate whether or not any of the following dimensions are relevant to you" by selecting the appropriate choice: Not at all/ Some/ A great deal. Typical items included: I FEEL STRESSED FOR REASONS HAVING TO DO WITH: Job security (Not at all/ Some/ A great deal). Relationship with senior staff of the Hospital administration (Not at all/ Some/ A great deal). Quality of leadership in the Hospital (Not at all/ Some/ A great deal).
Nursing patients who may have AIDS (Not at all/ Some/ A great deal). Scores were allocated on the basis of: Not at all=1, Some=2 and A great deal=3. Work-related stressors. This section of the survey included a list of statements referring to specific aspects of nursing. Respondents were asked to indicate their level of agreement with each statement in terms of Strongly Agree, Agree, Undecided, Disagree and Strongly Disagree. The statements represent some typical informal remarks about nursing and nursing conditions. Typical items include: Planning goes on with no real consultation with affected staff (SA A U D SD). Staff meetings are held in a threatening atmosphere (SA A U D SD). My immediate superior cares about his/her staff (SA A U D SD). Results and Discussion. In order make meaningful comparisons with other available research the terminology 'case/non-case' has been rejected in this study in favour of the three levels of stress: Low (GHQ score 0-4), Medium (GHQ score 5-9) and High (GHQ score 10-30). Table 1 gives a comparison of GHQ scores obtained in the present study and those reported by Louden (1987) and Van Schoubroeck and Tuettemann (1986). Table 1 Proportion of nurses and teachers in each of the GHQ stress categories GHQ score Nurses Teachers Low (GHQ < 5) 62% 60% Medium (GHQ 5-9) 16% 21% High (GHQ > 9) 22% 19% GHQ > 4 38% 40% The results appear to indicate that registered nurses engaged in tertiary studies experience levels of psychological stress similar to those reported by teachers in Western Australian schools. Approximately 40 percent of nurses and teachers
suffer from moderate to severe levels of psychological distress. The comparison figure for a professional, middle class Australian community is approximately 9% while some 10-20% of the general Perth population between 20-60 years of age can expect an incidence of moderate to severe psychological distress (Tuettemann & Punch, 1990, p. 27). Thus, nurses and teachers are twice as likely to suffer from psychological distress than the general population and four times the reported incidence of the general professional middle class. Of greater significance is the incidence of severe psychological distress. Table 1 shows that some 22% of nurses undertaking tertiary studies score 10 or more on the GHQ scale, and more than half of these score 16 and above. This means that in the study population approximately 1 in 4 practising nurses may need help in coping. If the levels of stress in the nursing profession as a whole are of similar dimension to those observed in this study, then nursing administrators and health authorities should carefully consider the implications of this for the quality of nursing care and the provision of services. Indeed, the presence of such a significant number of staff experiencing considerable levels of stress should be of National concern. To what extent the levels of stress in this study may be attributed to the extra burden of further study is not known. However, changing conditions in the nursing profession requiring registered nurses to upgrade their qualifications may be a significant factor in increasing nurses stress levels to critical proportions. This is an area for further study. A comparison of the scores obtained on the GHQ, the Felt Effect Scale and the Global Item seems to confirm the seriousness of the situation. Table 2 shows the proportion of respondents in each of the Felt Effect categories, while Table 3 indicates the distribution for the Global Item. Table 2 Proportion of nurses in each of the Felt Effect categories. Normal (Score 0-5) 62% Serious (Score 6-12) 35% Very Serious (Score 13-20) 3% Score 6-20 38% Table 3 Proportion of nurses responding to each of the
categories on the global item. A normal amount, nothing to worry about. 53% Rather more than usual for me - I'm somewhat concerned about it. 20% I've been feeling a lot more stress than usual - quite worried. 15% I've been feeling severely stressed and anxious. It's a worry to me and my family. 10% I'm so anxious I'm having real difficulties coping at work and/or at home. 2% Thus, the proportion of practising nurses enrolled in tertiary studies experiencing serious to very serious levels of stress as measured by the Felt Effect Scale is of the same magnitude (38%) as that obtained from the GHQ. While the one item Global response indicates that 47% of respondents are under mild to severe stress. Of these some 27% indicated that they are worried, under severe stress or have difficulty coping. Thus again the global item shows stress levels of similar magnitude the GHQ and Felt Effects Scales. An examination of the frequency of responses obtained for each of the 16 items, in the scale assessing the work-related factors in stress, reveals some interesting results. The "Quality of leadership in the hospital" is rated as the major reason contributing to stress, this is followed by the "Quality of working atmosphere in the hospital as a whole", "My level of control over my workload", the "Organisational structure of the hospital" and "level of input in decision making". See Table 4. Of least concern are "Relationship with patients", "Nursing patients who may have AIDS", "Job security" and "Relationship with colleagues". Most of the factors of concern are managerial in nature and can be rectified by modified work practices and greater staff involvement. This appears to be small price to pay for a less stressed staff. In general these results appear to reinforce the factors identified by Farber (1983). Thus, despite the knowledge of the general factors contributing to stress, very little appears to have been done to eliminate the stressors. When respondents were asked to agree or disagree with statements expressing specific work-related stressors, only a "too distant" administration and "lack of consultation in planning" were regarded as the major areas of concern. To a lesser extent "too much secrecy", "shift rosters affecting personal life" and "the adequacy of support services" were
identified as possible stressors. An examination of table 5 reveals that generally the nurses in this study were fairly positive in their responses to the specific work-related stressors. This study identified several general factors which appear to have an effect on the psychological distress of practising nurses engaged in tertiary study in Western Australia. However, the specific work-related factors used in this study appear not to be of concern. Thus, further research is necessary to identify the specific causes of stress among nurses engaged in tertiary study. These may well be personal stressors resulting from the increased demands of further study or they may be related to other pressures at work which were not identified in the present survey. There is, however, a need for further research in order to identify the specific factors contributing to such high levels of stress among these practising nurses. Table 4 Frequency of responses to the items assessing workrelated factors in stress. Reasons Not at Some Great All Deal Quality of leadership in hospital. 10 35 21 Quality of working atmosphere in the hospital as a whole. 19 27 20 My level of control over my work load. 21 27 18 Organisational structure of the hospital. 11 38 17 Level of input in decision making process. 15 35 16 Level of workload. 12 39 15 Level of respect and prestige nursing has in the outside community. 22 29 15 Relationship with staff immediately senior to me. 28 26 12 Relationship with senior staff of the hospital administration. 30 24 12
Relationship with medical staff. 28 28 9 Prospects of promotion. 33 24 9 Not knowing if a patient has AIDS. 35 24 7 Relationship with colleagues. 18 42 6 Job security. 42 18 6 Nursing of patients who may have AIDS. 43 18 5 Relationship with patients. 53 12 1 Table 5 Frequency of responses to specific work-related stressors Item SA+A U D+SD Staff meetings are helpful and informative 54 7 5 My superior cares about his/her staff 50 5 11 At staff meetings my contributions are welcomed 49 14 3 The administration is too distant from the staff 49 0 17 My immediate superior is competent to properly handle his/her job 44 11 11 Planning goes on with no real consultation with affected staff 39 10 17 I find the physical environment of my work place has improved markedly in the past few years 36 8 22 Decisions at staff meetings follow democratic processes 34 13 18 There is too much secrecy 33 6 26 Shift roster times adversely affect my personal life 31 5 30 I find the support services adequate 28 12 26
I usually have far too much work to do.24 9 33 There are far too many meetings which I must attend 24 4 37 I have very little faith in the leadership of the institution where I work 22 7 37 I'm often apprehensive about what's going to happen next 22 4 40 I see myself as unfairly disadvantaged by present promotion criteria and procedures 19 6 41 I would apply for another equivalent position if I could find one 17 10 39 Table 5 (cont) I'm too often forced to do jobs for which I am not properly trained 17 3 46 Staff meetings are held in a threatening atmosphere 11 2 52 My work is too low level and boring 7 6 53 REFERENCES Baldock, D. (1984). Staff Stress Enquiry. Mimeograph, Western Australian College of Advanced Education. Cherniss, C. (1980). Professional burnout in human service organisations. New York: Praeger. Eisenstat, R.A. & Felner, R.D. (1983). Organisational mediators of the quality of care: Job stressors and motivators in the human service settings. In B.A. Farber (ed), Stress and burnout in the human service professions. New York: Pergamon Press. Farber, B.A. (1983). Introduction: A critical perspective on burnout. In B.A. Farber (ed), Stress and burnout in the human service professions. New York: Pergamon Press. Finlay-Jones, R. (1986). Factors in the teaching environment associated with severe psychological distress among school teachers. Australian and New Zealand Journal of Psychiatry,20, 304-313
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