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
137
Embed
OCCUPATIONAL STRESS, JOB SATISFACTION, AND JOB PERFORMANCE AMONG ... · occupational stress, job satisfaction, and job performance among hospital nurses in kampala uganda by rose
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
OCCUPATIONAL STRESS, JOB SATISFACTION, AND JOB PERFORMANCE
AMONG HOSPITAL NURSES IN KAMPALA UGANDA
by
ROSE CHALO NABIRYE
KATHLEEN C. BROWN, COMMITTEE CHAIR CONNIE L. KOHLER
ELIZABETH H. MAPLES NA-JIN PARK
ERICA R. PRYOR
A DISSERTATION
Submitted to the graduate faculty of the University of Alabama at Birmingham, in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
BIRMINGHAM, ALABAMA
2010
ii
Copyright by Rose Chalo Nabirye
2010
iii
OCCUPATIONAL STRESS, JOB SATISFACTION, AND JOB PERFORMANCE AMONG HOSPITAL NURSES IN KAMPALA, UGANDA
ROSE CHALO NABIRYE
SCHOOL OF NURSING
ABSTRACT
Occupational stress, a common occurrence among various professions
worldwide, is regarded as a major occupational health problem for healthcare
professionals especially nurses. Occupational stress has been reported to affect job
satisfaction and job performance among nurses, thus compromising nursing care and
placing patients’ lives at risk. Stress is a complex phenomenon resulting from the
interaction between individuals and the environment. Therefore, significant
differences in occupational stress, job satisfaction and job performance among nurses
may exist due to different work settings.
The aims of the study were to: 1) examine the relationships between
occupational stress, job satisfaction and job performance among hospital nurses in
Kampala City, Uganda; 2) establish whether personal background characteristics
affect the relationships between occupational stress, job satisfaction and job
performance; and 3) examine whether there is a difference in levels of occupational
stress, job satisfaction and job performance by type of hospital.
A non-experimental correlational design was used in the study. A total of 333
nurses from four hospitals completed the Nurse Stress Index, the Job Satisfaction
Survey, and the Six-Dimensional Scale of Nurse Performance scales. Study findings
demonstrated that there were significant differences in levels of occupational stress,
job satisfaction and job performance between the public and private not-for- profit
iv
hospitals. Nurses in the public hospital reported higher levels of occupational stress
and lower levels of job satisfaction and performance. There were significant negative
relationships between occupational stress and job performance and between
occupational stress and job satisfaction. Nursing experience, type of hospital, and
number of children had a statistically significant relationship with occupational stress,
job satisfaction and job performance. Type of hospital (public versus private), ward
(obstetrics/gynecology versus other ward types), and job satisfaction were significant
predictors of self-rated quality of job performance. Job satisfaction was shown to
mediate the relationship between occupational stress and job performance.
Large scale studies were recommended to identify sources of occupational
stress and factors that enhance job satisfaction among hospital nurses in Uganda.
Future research is needed to examine best practices for human resource managers to
improve nurse motivation, job satisfaction and nurse performance in hospitals.
Key words: occupational stress, job satisfaction, job performance, personal
characteristics, work characteristics, public hospital, private not-for-profit hospitals,
best practices for human resource management.
v
DEDICATION
In loving memory of my late father Mr. Nathan Gusongoirye Waako who always
encouraged me to study hard and sacrificed the little resources he had in order to
provide for my education.
vi
ACKNOWLEDGEMENTS
First and foremost, I am most grateful to the Almighty God for giving me this
opportunity to advance in my studies. I am sincerely grateful for the
sponsorship/scholarship grants awarded to me for doctoral study, including the UAB-
ICER Training Grant through Dr. Eric Chamot for the initial grant which enabled me
to enroll in the program. I convey my heartfelt gratitude to all the staff in the Fogarty
office, especially Heather White and Alexis MacLean for the untiring patience and
support accorded to me while at UAB. My gratitude to Sigma Theta Tau, the Gladys
Farmer Colvin Memorial Scholarship, and to the Makerere University Staff
Development and Training Division for additional grants which enabled me complete
the program, and to Makerere University School of Graduate Studies for funding the
study. Sincere gratitude also goes to the Good Health Program of Birmingham and
Deep South Center for Occupational Health and Safety, UAB and Auburn University,
for providing the pens which were distributed to the participants during data
collection.
I am greatly indebted and sincerely grateful to Dr. Kathleen C. Brown, my
supervisor and Dissertation Committee Chair for the guidance, support and continuous
advice not only on academic matters but on social issues as well. I sincerely
appreciated her patience and commitment to see me through the PhD program.
My sincere gratitude also goes to Dr. Erica Pryor, for the continuous advice,
support and expertise in statistics and for always being there for me whenever I
needed her wise counsel. I am grateful to dissertation committee members Dr.
Elizabeth Maples, Dr. Connie Kohler and Dr. Na-Jin Park for their support,
vii
encouragement and guidance throughout the doctoral program and dissertation
writing.
I thank Dr. Isaac Okullo, my Ugandan supervisor, for his advice and
encouragement throughout the PhD program. In the same way, I am thankful to
Professor Wabwire-Mangen Fred of the School of Public Health, Makerere University
for the professional advice and guidance, despite his busy schedule. My sincere
gratitude also goes to Dr. D. K. Sekimpi for the support and encouragement
throughout the doctoral program.
I am so grateful to all UAB School of Nursing Faculty and other staff, whoever
I came in contact with, but most especially Drs. Lynda Wilson and Jacqueline Moss,
for giving me encouragement and advice which kept me “hanging in there.” To the
PhD nursing students in academic years 2006/2007-2008/2009, I say thank you all for
the support you gave me. Tracy, I thank you so much for providing the sisterly support
academically and socially throughout my stay in Birmingham. I thank Dr. Mantana
Damrongsak Brown for “showing me the ropes” and always being there for me.
I am sincerely grateful to my friends Pat Yeilding and family, Sandy and Bill
Myers, and family for always being there for me. The words of encouragement,
spiritual and other forms of support, the love you showed me and prayers surely kept
me going. I sincerely thank the Ugandan and ‘ZamUga’ communities in Birmingham
and beyond, most especially Dr. Kabagambe Edmond and family, Sarah, Vincy,
Jacqueline Makaaru, Jacqueline Mulundika and Margaret for the family atmosphere
which made me “feel at home away from home” throughout my stay in Birmingham.
I appreciate the Principal of Makerere University College of Health Sciences
Professor Nelson Sewankambo for the continuous support and advice especially on
funding opportunities. My sincere gratitude goes also to the Department of Nursing
viii
faculty and staff for the support and encouragement not only to me but to my family
during my absence.
I am grateful to Associate Professor Sara Groves from John Hopkins
University, for the support and advice especially for writing the literature review and
dissertation report. I thank Mr. Yovani Lubaale and Dr. Nazarius Mbona of Makerere
University Institute of Statistics and School of Public Health respectively for the
assistance in data analyses.
Many thanks go to the Assistant Commissioner Nursing Services of Mulago
Hospital, the Senior Nursing Officers and the Medical Directors of Mengo, Kibuli and
Rubaga Hospitals for the support during preparation and actual data collection. To the
dear nurses who participated in the study, I am so grateful for your precious time to
complete the questionnaires. Many thanks also go to the research assistants including
Godfrey, Scovia, Allen and Richard for the support, interest, and diligence they
accorded the study.
I thank my extended family members, my mum Gertrude Gusongoirye, and
brothers David, Robert, Charles, Peter, Dan, Edward and sister in-law Mrs. Joyce
Nankinga Gusongoirye. I thank you for your endless love, prayers and moral support.
And last but not least, my beloved children, Doreen, Ellen, Pauline, Solomon
and Derrick, thank you for being such wonderful children. In spite of missing
motherly love and care, you gave me unconditional love, support and encouragement
that actually motivated me to continue and complete my studies.
ix
TABLE OF CONTENTS
Page
COPYRIGHT ................................................................................................................. ii
ABSTRACT .................................................................................................................. iii
DEDICATION ............................................................................................................... v
ACKNOWLEDGEMENTS .......................................................................................... vi
LIST OF TABLES ....................................................................................................... xii
LIST OF FIGURES .................................................................................................... xiv
LIST OF ABBREVIATIONS ...................................................................................... xv
CHAPTER
1 INTRODUCTION
Health Care System in Uganda ............................................................................ 3 Statement of the Problem ..................................................................................... 4 Significance of the Study ..................................................................................... 6 Specific Aims of the Study .................................................................................. 7 Research Questions .............................................................................................. 7 Operational Definitions ........................................................................................ 8 Conceptual Framework ........................................................................................ 9 Assumptions for the Study ................................................................................. 10
2 LITERATURE REVIEW ..................................................................................... 11 Occupational Stress ............................................................................................ 11
Sources of Occupational Stress among Nurses ......................................... 12 Workload .................................................................................................. 13 Organizational Pressure ............................................................................ 15 Interpersonal Relationships/Intrinsic Nature of the Work ........................ 16
Professionalism ......................................................................................... 17 Effects of Occupational Stress ........................................................................... 18 Job Satisfaction among Nurses .......................................................................... 22 Job Performance among Nurses ........................................................................ 29 Summary of Literature ....................................................................................... 32
x
3 METHODOLOGY ............................................................................................... 33 Study Design ...................................................................................................... 33 Ethical Considerations ....................................................................................... 33 Setting ................................................................................................................ 34 Study Sample ..................................................................................................... 35
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
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
Occupational Stress ................................................................................... 73 Job Satisfaction ......................................................................................... 75 Occupational Stress and Job Performance ................................................ 77 Characteristics, Stress, Job Satisfaction and Job Performance ................. 78 Mediating Role of Job Satisfaction on Stress and Job Performance ........ 79 Stress, Job Satisfaction and Job Performance by Hospital Type .............. 80
The Conceptual Framework ............................................................................... 81 Conclusions ........................................................................................................ 82
xi
Implications ....................................................................................................... 83 Implications for Nursing Education .......................................................... 83 Implications for Nursing Practice ............................................................. 83
APPENDICES ............................................................................................................. 92 Appendix A: Institutional Review Board for Human Use Approval ................. 93 Appendix B: Permission to Use Research Instruments ................................... 104 Appendix C: Instruments ................................................................................. 109 Appendix D: Instrument Sub-scales and Number of Items ............................. 120
xii
LIST OF TABLES
Table Page 1 Socio-demographic Characteristics of the Sample ................................................. 45 2 Work Characteristics of the Sample ....................................................................... 46 3 Number of Items and Cronbach’s Alphas for the NSI Sub-scales ......................... 47 4 Number of Items and Cronbach’s Alphas for the JSS Sub-scales.......................... 48 5 Number of Items and Cronbach’s Alphas for the 6-DSNP Sub-scales .................. 49 6 Range of Possible Scores, Mean Scores and Standard Deviations for NSI ........... 50 7 Range of Possible Scores, Mean Scores and Standard Deviations for JSS ............ 51 8 Range of Possible Scores, Mean Scores and Standard Deviations for 6-DSNP .... 52 9 Descriptive Analyses for Job Satisfaction (JSS) .................................................... 53 10 Descriptive Analyses for Nurse Performance Scale .............................................. 54 11 Mean Scores for Occupational Stress by Demographic Characteristics ............... 55 12 Mean Scores for Occupational Stress by Work Characteristics ............................ 57 13 Mean Scores for Job Satisfaction by Demographic Characteristics ...................... 58 14 Mean Scores for Job Satisfaction by Work Characteristics .................................. 60 15 Mean Scores for Job Performance by Demographic Characteristics .................... 61 16 Mean Scores for Job Perofrmance by Work Characteristics ................................. 62 17 Correlations for Job Performance, Job Satisfaction with Occupational Stress ..... 64 18 Effect of Personal Background and Work Characteristics on the Relationships
of Occupational Stress, Job Satisfaction and Job Performance Quality ............... 66 19 The Final Predictive Model for Self-Rated Job Performance ............................... 67 20 The Mediating Role of Job Satisfaction between Occupational Stress and Job
Performance .......................................................................................................... 69 21 Means for Occupational Stress, Job Satisfaction and Job Performance for the
Different Hospitals ............................................................................................... 70
xiii
22 Influence of Type of Hospital on Job Performance, Job Satisfaction and
Occupational Stress .............................................................................................. 71 23 Post Hoc Results of Differences in Means in Occupational Stress, Job
Satisfaction and Job Performance by Hospital ..................................................... 72
xiv
LIST OF FIGURES
Figure Page
1 Diagram of Theoretical/Conceptual Model .............................................................. 10
xv
LIST OF ABBREVIATIONS
6-DSNP Six Dimensional Scale of Nurse Performance
AIDS Acquired Immuno-Deficiency Syndrome
BSN Bachelor of Science in Nursing
EM Enrolled Midwife
EN Enrolled Nurse
ENT Ear, Nose and Throat
GDP Gross Domestic Product
HIV Human Immunodeficiency Virus
ICU intensive care unit
ILO International Labor Organization
IPR interpersonal relations
JSS Job Satisfaction Survey
M Mean
MoH
NGO
Ministry of Health
Non-Governmental Organization
NHS National Health Service
NSI Nurse Stress Index
OSH Occupational Safety and Health
RM Registered Midwife
RMN Registered Mental-health Nurse
RN Registered Nurse
RN/M Registered Nurse/Midwife
xvi
RPN Registered Pediatric Nurse
SD standard deviation
SNO Senior Nursing Officer
SPSS Statistical Package for Social Sciences
UBOS Uganda Bureau of Statistics
UK United Kingdom
US United States
WHO World Health Organization
1
CHAPTER 1
INTRODUCTION
Occupational stress can be defined as the harmful physical and emotional
responses that occur when the requirements of the job do not match the resources,
capabilities and needs of the worker (Alves, 2005; Bianchi, 2004; Lindholm, 2006;
Nakasis & Ouzouni, 2008). The International Labor Organization (ILO) asserts that
all countries, professions and all categories of workers, families and societies are
affected by occupational stress (Ogon, 2001). According to Alves (2005), 40% of all
American workers perceive their jobs as being extremely stressful. Similar findings
are noted in the United Kingdom, where occupational stress is estimated to be the
largest occupational health problem (Edwards & Burnard, 2003). Additionally,
research has demonstrated that as workload and work-associated stress increase, turn-
over rates of workers are also noted to increase. Thus, occupational stress results in
considerable costs to organizations in terms of absenteeism, loss of productivity, and
health care resources (AbuAlRub, 2004; Cottrell, 2001; Gueritault-Chalvin,
Preliminary examination of the data for normality, linearity, and homogeneity
of variances were conducted using standard techniques and no serious violations were
noted. Initial models were also evaluated for problems with multicollinearity using
variance inflation factor (VIF) values, and again no problems were noted (Munro,
2001; Pallant, 2001).
The set of covariates was entered in the first block, followed by occupational
stress at the second step, then job satisfaction at the third step. Individual predictors
and the changes in adjusted R-squared values for each step were evaluated for
statistical significance (see table 18).
Table 18 Effect of Personal Background and Work Characteristics on the Relationships of Occupational Stress, Job Satisfaction and Job Performance Model Beta t P value Constant
10.856 .000
Number of children
-.094 -1.688 .092
Type of hospital
-.187 -2.911 .004
Unit 1(Surgical)*
-.057 -.956 .340
Unit 2 (Obs/Gyn)*
-.142 -2.322 .o21
Unit 3(Pediatrics)*
.084 1.415 .158
Nursing Educational Level
.092 1.565 .119
Occupational stress
-.019 -.302 .763
Job satisfaction
.141 2.278 .023
* Reference group – medical ward
67
Several smaller models were evaluated. As shown in Table 19, the best
predictive model for job performance included type of hospital (public/private), type
of ward/unit, and job satisfaction. The model including type of ward/unit and type of
hospital contributed approximately 8% of the variance in job performance. When job
satisfaction was added to the model with type of unit and type of hospital, the model
accounted for approximately 10% of the variance in job performance.
Table 19 The Final Predictive Model for Self-Rated Job Performance Quality Model
Beta t P value
Constant 16.439 .000
Type of hospital -.190 -3.425 .001
Unit 1 (Surgical) -.060 -1.020 .308
Unit 2 (Obs/gyn) -.155 -2.578 .010
Unit 3 (Pediatric) .076 1.302 .194
Job satisfaction
.139 2.526 .012
All models were re-run with the job performance 52-item total score as the
outcome. The predictors selected for the initial model based on bivariate analyses
were the same. No differences in significant predictors in the initial and final models
were noted. (Results are not shown.)
Research Question 4
Does job satisfaction mediate the relationship between occupational stress and
job performance among hospital nurses in Kampala, Uganda?
68
The potential mediating role of job satisfaction between occupational stress
and job performance was examined by conducting step-wise multiple regressions
(Baron & Kenny, 1986) with occupational stress as the independent variable, job
satisfaction as the potential mediator and job performance as the dependent variable.
For this analysis, the 52 item total score for the 6-DSNP (Column B) was used. In
step 1, a simple regression analysis with occupational stress (X) predicting job
performance (Y) was conducted (Y = B0 + B1X + e) and it indicated a significant
relationship (beta = -.124, t = -2.250, p =.025). In step 2, a simple regression analysis
conducted with occupational stress predicting job satisfaction (Z) represented by Z =
B0 + B1X + e also showed a significant relationship (beta = -.501, t = -10.39, p <.001).
In the third step, a simple regression analysis of job satisfaction predicting job
performance also indicated a significant relationship (beta = .177, t = 3.279, p =.001).
Based on the significant results of step 1 to 3, a fourth step was conducted with
1986). As showed in table 20, occupational stress was not significant after controlling
for job satisfaction (beta = -.047, t = -.748, p =.455) indicating full mediation by job
satisfaction (beta = .154, t = 2.422, p =.016).
69
Table 20 The Mediating Role of Job Satisfaction between Occupational Stress and Job Performance Model Beta t p value 1 Occupational Stress -.124 -2.25 .025
Are there differences in levels of occupational stress, job satisfaction and job
performance among hospital nurses in Kampala, Uganda by type of hospital?
As shown in table 21, the public hospital had the highest mean score for
occupational stress (M = 88.28, SD = 20.88), followed by private hospital 1 (M =
76.09, SD = 23.49). However, private hospital 1 had the highest mean score for job
performance (M = 172.56, SD = 20.70) followed by private hospital 2 (M = 163.32,
SD = 17.12). The job satisfaction mean score for the public hospital was the lowest
(M = 123.00, SD = 18.80) while private hospital 2 had the highest mean score (M =
136.96, SD = 16.46 followed by private hospital 3 (M = 132.46, SD = 21.32).
70
Table 21 Means for Occupational Stress, Job Satisfaction and Job Performance for the different hospitals Variable Hospital Mean Std. Deviation Std. Error Occupational Stress Private 1 76.09 23.49 5.01
Private 2 72.16 20.04 2.41
Private 3 73.35 16.41 2.59
Public 88.28 20.87 1.50
Job Satisfaction Private 1 129.84 14.71 2.94
Private 2 136.96 16.46 1.95
Private 3 132.46 21.32 3.33
Public 123.00 18.79 1.34
Job Performance Private 1 172.56 20.69 4.14
Private 2 163.32 17.12 2.03
Private 3 161.66 19.41 3.03
Public 154.52 23.35 1.67
A one-way between groups analysis of variance was conducted to explore the
influence of type of hospital on job performance. Job performance was measured
using the mean 52-item total score (for Column B). Assumptions of normality and
homoscedasticity were evaluated as a preliminary step and there were no serious
violations. There were statistically significant differences at the p value < .05 level in
occupational stress (F = 14.465, p = .000); job satisfaction (F = 11.297, p = .000); and
job performance (F = 7.234, p-value = .000) for the different hospitals as shown in
71
Table 22 Influence of Type of Hospital on Job Performance, Job Satisfaction and Occupational Stress Mean difference between hospitals F p-value Job Satisfaction 11.297 < .001
Job performance 7.324 < .001
Occupational Stress 14.465 < .001
Post Hoc comparisons using the Tukey HSD test indicated that the mean score
for occupational stress for the public hospital was significantly and positively
different from all three private not-for-profit hospitals. Mean differences were as
follows: public and private 1 = 12.19, S.E = 4.58, p = .041; public and private 2 =
16.12, S.E = 2.86, p < .001 and public and private 3 = 14.93, S.E = 3.5, p = .000. As
seen in table 19, the differences in job satisfaction scores for public hospital from
those of private 2 and private 3 hospitals were statistically significant. Furthermore,
the mean score for job performance for public hospital was significantly different
from those of private 1 and private 2 hospitals at p <.005. However, no mean
differences for occupational stress, job satisfaction and job performance between the
three private not-for-profit hospitals were observed.
72
Table 23 Post Hoc Results of Differences in Means in Occupational Stress, Job Satisfaction and Job Performance by Hospital Dependent variable Hospital (I) Hospital (J) Mean Difference (I-J) p-value Occupational Stress
Public Private 1 12.19* .041
Private 2 16.12* .000
Private 3 14.93* .000
Job Satisfaction Public Private 1 -6.84 .299
Private 2 -13.96* .000
Private 3 -9.46* .015
Job Performance Public Private 1 -18.04* .001
Private 2 -8.80* .018
Private 3 1.42 .191
73
CHAPTER 5
DISCUSSION, CONCLUSIONS, IMPLICATIONS,
AND RECOMMENDATIONS
A correlational study was conducted to explore relationships among
occupational stress, job satisfaction and job performance among hospital nurses in
Kampala, Uganda. This chapter presents the discussion, conclusions, implications and
recommendations based on the results of the study. The interpretation of key findings
is discussed in section one. The second section includes an outline of the conclusions.
The third section presents the implications for nursing practice, nursing education and
research, while recommendations are presented in the fourth section.
Discussion
Occupational Stress
More than half of the nurses (54%) reported moderate to extreme stress on the
job while almost half (45%) reported high stress in the past one month. This is
consistent with previous research which indicated that occupational stress occurs at
high levels among health professionals. The results indicated that these Ugandan
nurses worked under pressure and were experiencing occupational stress.
In this study, the older age groups, 40-49 and 50 years and above, and nurses
with more than 20 years of experience reported the highest stress scores. These results
contradict previous studies in the United States in which young public health nurses
and those with less experience perceived more occupational stress than older nurses
(Kirkcaldy & Martin, 2000). This discrepancy could be due to differences in
74
responsibilities in Uganda. However, these results indicate a pattern which may be
unique to the Ugandan situation. For example, nurses with no children also had
significantly lower levels of occupational stress than those who had 1-2 or 3-5
children. This may indicate that older nurses in Uganda may report more job stress
due to social responsibilities such as caring for family members. In the US, on the
other hand, the younger nurses could be stressed due to lack of experience on the job.
In Uganda, as nurses gain more experience in the profession, they also have
increasing financial responsibilities to provide for their immediate families as well as
their extended families as is the case for many Ugandans. In Uganda, an adult who is
earning a living is culturally and socially expected to provide for immediate and
extended family members. The financial burden experienced by older Ugandan nurses
may explain the increased stress reported by this age group. In addition, it was
observed by Kyadondo and Whyte that public sector reforms and poor remuneration
have weakened workers’ positions and therefore experienced professionals establish
supplementary sources of income outside the health care system (Kyaddondo &
White, 2003). Fulfilling responsibilities of multiple jobs may contribute to perceived
stress.
Furthermore, those who had the highest educational level (BScN and above)
reported the highest perceived stress levels. This is in agreement with previous
research (Kirkcaldy & Martin, 2000; Lee & Wang, 2002). It is not clear why nurses
with higher education perceived more stress but one possible explanation could be
role ambiguity. It has been reported that organizational and management attributes of
work environments and institutional settings influence work-related stress among
nurses (Sveinsdottir et al., 2005). Takase and colleagues also observed that role
discrepancy contributed to nurses’ intention to quit their jobs in Australia (Takase,
75
Maude & Manias, 2006). This could be the case for the Ugandan nurses because
BScN and above prepared nurses have no clear roles even in the public hospitals. Role
conflict and role ambiguity may contribute to stress for these nurses. However, since
the current study did not explore organizational factors related to occupational stress,
there is a need for further research to identify sources of stress for nurses with highest
educational qualifications in Uganda.
Significant differences in stress levels were found among nurses working in
different units. Nurses who worked in pediatric units reported the highest levels of
stress. This finding may be due to the nature of the work in pediatric units and
interaction with parents or guardians. Usually these units have many children who are
very ill creating situations which may lead to emotional attachment and unrealistic
desires to provide high quality care in adverse situations (Begat, et al., 2005).
Job Satisfaction
Results of the current study indicated a strong negative relationship between
occupational stress and job satisfaction (r = -.501, p-value = .000). These results are in
agreement with previous studies which similarly reported a negative relationship
between perceived occupational stress and job satisfaction (Flanagan & Flanagan,
2002; Sveinsdottir, Bierring et al., 2006; Zangaro & Soeken, 2007). Many factors
influence the perceptions of occupational stress and job satisfaction. For example, in a
study of satisfaction and intent to stay among current health workers in Uganda,
respondents reported health care for dependants as a more important satisfying factor
than their salaries (Ministry of Health, The Republic of Uganda, 2007). However, as
mentioned earlier, identification of the sources of occupational stress for the nurses in
76
Ugandan hospitals was not an aim of this study. Therefore, a need exists to conduct
investigations which explore these factors in Ugandan hospitals.
Interestingly, nurses with lower educational qualifications (EN and EM)
reported the highest levels of job satisfaction (53%) while those with higher education
qualifications (RN, BScN and above) reported the lowest levels of job satisfaction.
These findings contradict Chinweuba’s report where higher educational qualifications
resulted in more job satisfaction (Chinweuba, 2007). In Chinweuba’s study, this
phenomenon was attributed to the fact that nurses with higher educational
qualifications have chances of securing desired satisfying jobs. It is not clear why
nurses with higher educational qualifications in Ugandan hospitals perceive their jobs
as highly stressed and less satisfying. However, it could be due to role conflict and
ambiguity or lack of recognition as explained above. It has also been reported in the
literature that routine jobs with limited challenges results in less job satisfaction
(Selebi & Minnar, 2007). This could be the case for nurses with higher education in
Uganda. However, this phenomenon also calls for further research to understand the
factors influencing the nurses’ perceptions of occupational stress and job satisfaction.
Regarding nursing experience, results of this study indicated that nurses with
little experience of 1-5 years had the highest level of job satisfaction (30%) while
those with 11-15 years reported the least job satisfaction (7%). These findings
contradict a Uganda health workforce study in which older respondents were more
satisfied than younger ones (MoH, 2007). In this Uganda Ministry of Health study,
the older respondents reported strong attachment to the facilities and communities
where they worked, had better relationships with their supervisors, and reported
receiving more recognition for good work. It is not clear why the more experienced
nurses in the current study reported less satisfaction on their jobs. It should be noted
77
that the Uganda health workforce study involved all professionals in healthcare, while
the current study involved only nurses. It is therefore difficult to compare the two
studies. However, it can be argued that nurses with less experience are usually
younger and have less responsibility especially in the social context of Uganda. More
experienced nurses are older and may have larger families to care for with associated
stress and the possible perception that work could be interfering with their family
lives (Patel et al., 2008). It could also be due to the fact that nurses who have worked
for more than 10 years would be seeking promotion or advanced opportunities. They
could also be interested in becoming involved in decision and policy making at their
workplace. Previous literature has demonstrated that nurses are likely to report low
job satisfaction if they do not receive promotion and advancement opportunities
(Laphalala et al., 2006). This explanation was also alluded to in the Uganda health
workforce study (MoH, 2007) in which respondents complained of working for many
years without pay or position upgrades.
Occupational Stress and Job Performance
The findings of the current study indicated that there was a small negative
relationship between occupational stress as indicated by the NSI and job performance
(r = -.124, p value = .025). These findings concur with previous studies, including an
investigation conducted by AbuAlRub (2004) who reported that occupational stress
and low job control lead to poor job performance and were risk factors for patient
safety. However, in the same study, a U-shaped relationship between stress and job
performance was found. Nurses with low or higher stress performed better on their
jobs than nurses with moderate stress (AbuAlRub, 2004). It has been argued that
some employees are motivated to perform when there is a lot of pressure. However,
78
stress in the best work environment may need to be controlled since excessive
pressure is known to result in negative effects for the patients, nurses or organizations.
Because more than half of the participants (54%) reported moderate to extreme
pressure, the performance of nurses may be compromised due to occupational stress.
Therefore, there is a need to investigate the factors which lead to the moderate to
extreme pressures for the nurses and address them, so that performance is improved.
Demographic Characteristics, Occupational Stress, Job Satisfaction and Job Performance
differences in occupational stress, job satisfaction and job performance among nurses
by age, nursing experience, and nursing education. These results are consistent with
Enst, Franco et al. (2004) who reported an inverse relationship between job
satisfaction, age and nursing education level and are consistent with Roud and
colleagues (2005) who reported a positive relationship between nursing experience
and job performance.
Although the effect of personal characteristics on occupational stress, job
satisfaction and job performance were investigated in this study, other factors such as
organizational commitment and work environment need to be examined (Bradley, et
al., 2002). Further, the variables age and nursing experience are interrelated, and it is
difficult to isolate their individual influences. It is therefore necessary to further
investigate the interrelations of these factors and how they influence the relationships
of occupational stress, job satisfaction and job performance. Research has
demonstrated that the factors leading to occupational stress and job satisfaction are
many and interrelated and that that employees react differently to job dissatisfaction
79
(Ackerman & Bezuidenhout, 2007). Therefore, more investigations are recommended
to identify employee characteristics and other motivations which influence job
satisfaction.
A regression model with occupational stress and job satisfaction as
independent variables explained only 3% of the variance in job performance.
However, the variance in job performance increased to 8% after controlling for
personal background characteristics such as nursing education and experience, type of
hospital, ward/unit, and number of children. The number of children had the most
significant contribution to the variance in job performance followed by job
satisfaction and hospital respectively. The number of children or the size of the family
has financial implications for the nurse in the Ugandan context. This again reflects
the importance of the family in relation to job satisfaction and job performance.
Mediating Role of Job Satisfaction on Occupational Stress and Job Performance
The study findings suggested full mediation of job satisfaction on the
relationship between occupational stress and job performance (beta = .154, t – 2.422,
p-value = .016). Occupational stress was not a significant predictor of job
performance after controlling for job satisfaction. Very little has been reported about
the mediating effect of job satisfaction on the relationship between occupational stress
and job performance. Factors which influence job satisfaction may influence job
performance. It is important to note that retention of health workers on their jobs has
been linked to job satisfaction. Further, job satisfaction is known to be influenced by
various factors. Some of the factors reported to influence job satisfaction include pay,
promotion, potential for creativity, autonomy, recognition, leadership, fringe benefits
80
and working conditions. Nurses’ perceptions and experiences are influenced by the
specific hospital context (Dieleman, et al., 2007).
In this study, job satisfaction was found to have a full mediation effect on the
relationship between occupational stress and job performance, indicating that job
satisfaction had an indirect effect on the relationship between occupational stress and
job performance. These results emphasize the importance of nurses’ job satisfaction in
improving nursing care and nurse retention in Ugandan hospitals. Therefore, there is
need for further research to identify factors that would enhance job satisfaction among
nurses in the different hospitals in Kampala, Uganda.
Stress, Job Satisfaction and Job Performance by Hospital Type
Results of a one-way ANOVA indicated statistically significant differences in
occupational stress, job satisfaction, and job performance in the different hospitals. A
post-hoc comparison using the Tukey HSD test indicated that the public hospital was
significantly different from the other hospitals in all three variables under study. The
mean score for occupational stress for the public hospital (M = 88.28, SD = 20.88)
was higher and this was statistically different from mean stress scores of the private 1,
private 2 and private 3 hospital nurses. The results also indicated that the mean score
for job satisfaction for the public hospital (M = 123.00, SD = 18.00) was significantly
lower than those of private 2 and private 3 hospitals. In addition, the mean score for
job performance for the public hospital (M = 154.00, SD = 23.35) was significantly
lower than the mean job performance scores of nurses in private hospitals 2 and 3.
However, no difference was observed for the three variables between the three private
not-for-profit hospitals.
81
It can be concluded that differences were found in occupational stress, job
satisfaction and job performance between public and private not-for-profit hospitals.
According to Reinikka and Svensson (2003), religious hospitals provide better quality
service although they tend to employ nurses of lower educational qualification.
Reinika and Svensson attributed this to the religious beliefs and values of the
employees of these hospitals. While this could be true, other factors may also
contribute to the differences in stress, job satisfaction and job performance levels
between the public and the private hospitals. Most services in the public hospital are
expected to be rendered free of charge while small reasonable fees are paid for
services in the other three hospitals. This payment structure could contribute to
overcrowding and work overload for nurses in the public hospital. Further, the nurses
may face the challenge of utilizing limited resources for many patients resulting in
occupational stress, low job satisfaction and subsequent poor job performance. It can
also be argued that Mulago Hospital, as a national referral hospital, may care for the
patients with the most serious conditions and nurses employed at a referral hospital
may experience emotional stress because of inability to give the necessary care
because of difficulties in setting priorities due to large numbers of critically ill
patients.
The Conceptual Framework
Based on the findings of this study, there is support for the use of Lazarus and
Folkman’s cognitive theory of stress and coping (Lazarus & Folkman, 1984) and
Karasek’s Demand-Control Model (Karasek, 1979). The study was able to
demonstrate that the workplace acts as the environment in which nurses’ experience
different levels of stress and job satisfaction. The hospital where nurses worked also
82
influenced the level of occupational stress, job satisfaction, and job performance.
Further, the findings demonstrated that the reaction or appraisal of stress is related to
personal background characteristics including nursing education, nursing experience
and the number of children. This suggested that the social cultural context affects the
appraisal of the working environment.
Stress and job satisfaction were found to influence job performance. Both the
Lazarus and Folkman and Karasek conceptual frameworks depict the individual
nurses as appraising the situation and behaving accordingly, whether they are satisfied
with their jobs or not. In the appraisal, nurses decide whether they have control or not,
become stressed, get no satisfaction with their jobs and perform well or poorly on
their jobs.
Conclusions
The following conclusions about relationships between occupational stress,
job satisfaction and job performance among hospital nurses in Kampala Uganda were
drawn:
1. Hospital nurses in Kampala, Uganda experienced moderate to extreme stress
at work.
2. The younger hospital nurses in Kampala were more satisfied with their jobs
than the older nurses.
3. Hospital nurses in Kampala with more nursing experience were more stressed
and less satisfied with their jobs than nurses with fewer years of experience.
4. There was a negative relationship between occupational stress and job
performance among hospital nurses in Kampala.
83
5. Job satisfaction had a mediating effect on the relationship between
occupational stress and job performance among hospital nurses in Kampala.
6. The nurses in the public hospital experienced more occupational stress than
nurses in the other three private not-for-profit hospitals.
7. Nurses in the public hospital reported less job satisfaction than nurses in the
private not-for-profit hospitals.
8. The nurses in the public hospital had lower perceptions of their job
performance than nurses in the private not-for- profit hospitals.
Implications
Implications for Nursing Education
The findings of this study indicate that nursing students need to understand
that occupational stress is a common occurrence in the nursing profession and it
affects job satisfaction and performance. Therefore, Ugandan nursing school curricula
at undergraduate and graduate programs should include content related to
occupational stress identification, prevention and management. Nursing students
should be taught that it is important to use culturally appropriate/sensitive measures in
research and practice. In addition, nursing students should have clinical experiences in
both public and not-for-profit hospitals to expose them to differences in the work
culture and environment in different types of hospitals.
Implications for Nursing Practice
Since work environment and personal characteristics contributed to
occupational stress and job satisfaction, nurses should be able to assess these factors
and give each other support in order to improve performance and nursing care to their
84
patients. The Ministry of Health and nurses in managerial roles should try to improve
those factors, such as good communication and recognition for excellent work, which
may reduce occupational stress and increase job satisfaction among their nurses.
Nurse leaders should also advocate for better working conditions which would
improve nurse satisfaction with their jobs such as better pay, fringe benefits, provision
of adequate resources, hiring more nurses to reduce on the work overload, or better
promotion policies. Appointed nurse managers and other managers in health care
settings should be trained in management in general and in human resource
management in order for them to be able to address the above issues.
Recommendations
Based on the findings, conclusions, and implications which arose from the
study, the following are recommended:
1. The study assessed the relationships between occupational stress, job
satisfaction and job performance based on self reports by the respondents; therefore,
other methods of assessment should be utilized to obtain objective data. For example,
occupational stress should be assessed using physiological measures and job
performance should be assessed using a pre-determined checklist and observations.
2. More studies should be conducted on a larger scale to identify sources of
occupational stress and factors that enhance job satisfaction for the hospital nurses in
Uganda.
3. As job satisfaction was found to fully mediate the relationship between
occupational stress and job performance, studies to identify factors which influence
job satisfaction among the hospital nurses in Uganda should be conducted in order to
improve nurse performance.
85
4. Since there were significant differences between the public and private not-
for-profit hospitals for all the three major variables, more studies should be conducted
to identify the factors which lead to these differences.
5. Future research is needed to examine differences in best practices for human
resource management between the public hospitals and private not-for-profit
hospitals.
86
REFERENCES
AbuAlRub, R. F. (2004). Job stress, job performance, and social support among hospital nurses. Journal of Nursing Scholarship, 36(1), 73-78.
AbuAlRub, R. F., & Al-Zaru, I., M. (2008). Job stress, recognition, job performance
and intention to stay at work among Jordanian hospital nurses. Journal of Nursing Management, 16, 227-236.
Ackerman, E. R., & Bezuidenhout, M. C. (2007). Staff dissatisfaction in the theatre
complex of a private hospital. Curationis, 30(3), 68-73. Adeb-Saeedi, J. (2002). Stress amongst emergency nurses. Australian Emergency
Nursing Journal, 5(2), 19-24. Aiken, L. H., Clerke, S. P., & Sloane, D. M. (2002). Hospital nurse staffing and
patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993.
Alves, S. L. (2005). A study of occupational stress, scope of practice, and
collaboration in nurse anesthetists practicing in anesthesia care team settings. AANA Journal, 73(6), 443-452.
Bakker, A. B., Killmer, C. H., Siegrist, J., & Schaufeli, W. B. (2000). Effort-reward
imbalance and burnout among nurses. Journal of Advanced Nursing, 31(4), 884.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in
social psychological research: Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.
Begat, I., Ellefsen, B., & Severinsson, E. (2005). Nurses' satisfaction with their work
environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being -- a Norwegian study. Journal of Nursing Management, 13(3), 221-230.
Bennett, P., Lowe, R., Matthews, V., Dourali, M., & Tattersall, A. (2001). Stress in
nurses: coping, managerial support and work demand. Stress & Health: Journal of the International Society for the Investigation of Stress, 17(1), 55-63.
Bianchi, E. R. F. (2004). Stress and coping among cardiovascular nurses: a survey in
Brazil. Issues in Mental Health Nursing, 25(7), 737-745.
87
Bradley, J. R., & Cartwright, S. (2002). Social support, job stress, health, and job satisfaction among nurses in the United Kingdom. International Journal of Stress Management, 9(3), 163-182.
Brown, H., Zijlstra, F., & Lyons, E. (2006). The psychological effects of
organizational restructuring on nurses. Journal of Advanced Nursing, 53(3), 344-357.
Callaghan, P., Shiu, A., & Wyatt, P. (2000). Factors related to stress and coping
among Chinese nurses in Hong Kong. Journal of Advanced Nursing, 31, 1518–1527.
Chen, Y. M., Chen, S. H., Tsai, C. Y., & Lo, L. Y. (2007). Role stress and job
satisfaction for nurse specialists. Journal of Advanced Nursing, 59, 497-509. Chinweuba, U. A. (2007). Relationship between job-stress and job satisfaction among
Nurse educators in Nigeria. West African Journal of Nursing, 18(2), 82-88. Chirwa, M. L., Greeff, M., Kohi, T., Naidoo, J., Makoae, L. N., Dlamini, P. S., et al.
(2008). HIV Stigma and Nurse Job satisfaction in five African Countries. Journal of the Association of Nurses in Aids care 20(1), 14-21.
Chu, C.-I., Hsu, H.-M., Price, J. L., & Lee, J.-Y. (2003). Job satisfaction of hospital
nurses: an empirical test of a causal model in Taiwan. International Council of Nurses, International Nursing Review, 50, 176-182.
Cohen, J., & Cohen, P. (1983). Applied Multiple Regression/Correlation Analysis for
the Behavioral Sciences, Second Edition (Electronic version). Hillsdale, NJ: Lawrence Erlbaum Associates.
Cottrell, S. (2001). Occupational stress and job satisfaction in mental health nursing:
focused interventions through evidence-based assessment. Journal of Psychiatric and Mental Health Nursing, 8, 157-164.
Coverston, C. R., Harmon, K. R., Keller, E. R., & Malner, A. A. (2004). A
Comparison of Guatemalan and USA nurses' attitudes towards nursing. International Council of Nurses, International Nursing Review, 51, 93-103. Dieleman, M., Bwete, V., Maniple, E., Kakker, M., Namaganda, G., Odaga, J., et al.
(2007). I believe that the staff have reduced their closeness to patients: an exploratory study on the impact of HIV/AIDS on staff in four rural hospitals in Uganda. . BMJ Health services Research, 7(205).
Drach-Zahavy, A. (2004). NURSING AND HEALTHCARE MANAGEMENT AND
POLICY Primary nurses’ performance: role of supportive management. Journal of Advanced Nursing, 45(1), 7-16.
Edwards, D., & Burnard, P. (2003). A systematic review of stress and stress
management interventions for mental health nurses. Journal of Advanced Nursing, 42(2), 169-200.
88
Ernst, M. E., Franco, M., Messmer, P. R., & Gonzalez, J. L. (2004). Practice applications of research. Nurses' job satisfaction, stress, and recognition in a pediatric setting [corrected] [published erratum appears in PEDIATR NURS 2005 Jan-Feb;31(1):20]. Pediatric Nursing, 30(3), 219-227.
Evans, L. (2002). An exploration of distict nurses' perception of occupational stress.
British Journal of Nursing, 11(8), 576-585. Flanagan, N. A., & Flanagan, T. J. (2002). An analysis of the relationship between job
satisfaction and job stress in correctional nurses. Research in Nursing & Health, 25(4), 282-294.
Gueritault-Chalvin, V., Kalichman, S. C., Demi, A., & Peterson, J. L. (2000). Work-
related stress and occupational burnout in AIDS caregivers: test of a coping model with nurses providing AIDS care. AIDS Care, 12(2), 149-161.
Harris, P. E. (1989). The Nurse Stress Index. Work and Stress, 3(4), 335-346. Ho, W., Chang, C. S., Shih, Y., & Liang, R. (2009). Effects of job rotation and role
stress among nurses on job satisfaction and organizational commitment. BMC Health Services Research, 9(8). doi:10 1186/1472-6963-9-8
Karasek, R. A. (1979). Job demands, job decision latitude, and mental strain:
Implications for job re-design. Administrative Science Quarterly., 24(2), 285-308.
Kekana, H. P., Rand, E. A., & Wya. (2007). Job satisfacton of registered nurses in a
community hospital in Limpomp Province in South Africa. Curationis, 30(2), 2435.
Khowaja, K., Merchant, R. J., & Hirani, D. (2005). Registered nurses perception of
work satisfaction at a tertiary care University hospital. Journal of Nursing Management, 13, 32-39.
Kirkcaldy, B. D., & Martin, T. (2000). Job stress and satisfaction among nurses:
individual differences. Stress Medicine, 16(2), 77-89. Kyaddondo, D., & White, R. S. (2003). Working in a decentralized system: A threat
to health workers' respect and survival in Uganda. International Journal of Health Planning and Management, 18, 329-342.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping. New York:
Springer. Lee, I., & Wang, H. (2002). Perceived Occupational Stress and Related factors in
Public Health Nurses. Journal of Nursing Research, 10(4), 253-259. Lephalala, R. P., Ehiers, V. J., & Oosthuizen, M. J. (2008). Factors influencing nurses'
job satisfaction in selected private hospitals in England. Curationis, 31(3), 60-69.
89
Lephoko, C. S. P., Bezuidenhout, M. C., & Roos, J. H. (2006). Organisational climate as a cause of job dissatisfaction among nursing staff in selected hospitals within the Mpulanga Province. Curationis, 29(4), 28-36.
Li, J., & Lambert, V. A. (2008). Workplace stressors, coping, demographics and job
satisfaction in Chinese intensive care nurses. Nursing in Critical Care, 13(1), 12-24.
Lindholm, M. (2006). Working conditions, psychosocial resources and work stress in
nurses and physicians in chief managers’ positions. Journal of Nursing Management, 14(4), 300-309.
Lu, H., While, A. E., & Barriball, K. L. (2007). A model of job satisfaction of nurses:
a reflection of nurses' working lives in Mainland China. Journal of Advanced Nursing, 58(5), 468-479.
Makinen, A., Kivimaki, M., Elovainio, M., & Virtanen, M. (2003). Organization of
nursing care and stressful work characteristics. Journal of Advanced Nursing, 43(2), 197-205.
McGrath, A., Reid, N., & Boore, J. (2003). Occupational stress in nursing.
International Journal of Nursing Studies, 40(5), 555. MoH. (2007). Uganda Health Workforce Study: Satisfaction and Intent to Stay
Among Current Health Workers: The Republic of Uganda. Mrayyan, M. T., & Al-Faouri, I. (2008). Predictors of career commitment and job
performance of Jordanian nurses. Journal of Nursing Management, 16(3), 246-256.
Munro, H., Barbara (2001). Stastical Methods for Health Care Research (4th ed.).
Philadelphia: Lippincott Williams & Wilkins. Muscroft, J., & Hicks, C. (1998). A comparison of psychiatric nurses' and general
nurses' reported stress and counselling needs: a case study approach. Journal of Advanced Nursing, 27, 1317-1325.
Nakasis, K., & Ouzouni, C. (2008). Factors influencing stress and job satisfaction of
nurses working in psychiatric units: A research review. Health science Journal, 2(4), 183-195.
Natukunda, C. (2008, 3/16/2008). Where did all the nurses go? New Vision. Retrieved
from http://www.newvision.co.ug Nyathi, M., & Jooste, K. (2008). Working conditions that contribute to absenteeism
among nurses in a provincial hospital in the Limpopo Province. Curationis, 31(1), 28-37.
90
Oginska-Bulik, N. (2006). Occupational stress and its consequences in healthcare professionals: the role of Type D Personality. International Journal of Occupational Medicine & Environmental Health, 19(2), 113-122.
Ogon, D. A. (2001). InFocus program on safety and health at work and the
environment: International Labour Organization. Ojoatre, K. (2008, 6/19/2008). Nurses are overworked. New Vision. Retrieved from
http://www.newvision.co.ug Pallant, J. (2001). SPSS Survival Manual A step by step guide to data analysis using
SPSS. Buckingham Open University Press. Patel, C. J., Beekhan, A., Paruk, Z., & Ramgoon, S. (2008). Work-family conflict, job
satisfaction and spousal support: An exploratory study of nurses' experience. Curationis, 38-44.
Peterson, M., & Wilson, J. F. (2002). The culture-work-health model and work stress.
American Journal of Health Behavior, 26(1), 16-24. Polit, D. F., & Beck, C. T. (2004). Nursing Research: Principles and Methods, 7th
Edition. Philadelphia: Lippincott Williams & Wilkins. Reinikka, R., & Svensson, J. (2003). Working for God? Evaluating Service Delivery
of religious Not-For-Profit health Care Providers in Uganda. Washington DC: World Bank Development Research Group
Roberts, T. (2005). The Certified Registered Nurse Anesthetist: Occupational
responsibilities, perceived stressors, coping strategies, and work relationships. AANA Journal, 73(5), 351-356.
Rothmann, S., van der Colf, J. J., & Rothmann, J. C. (2006). Occupational stress of
nurses in South Africa. Curationis, 29(2), 22-33. Roud, D., Giddings, L. S., & Koziol-McLain, J. (2005). A longitudinal survey of
nurses' self reported performance during an entry to practice programme. Nursing Praxis in New Zealand, 21(2), 37-46.
Salebi, C., & Minnaar, A. (2007). Job satisfaction among nurses in a public hospital in
Gauteng. Curationis, 30(3), 53-61. Salmond, S., & Ropis, P. E. (2005). Research for practice. Job stress and general well-
being: a comparative study of medical-surgical and home care nurses. MEDSURG Nursing, 14(5), 301-309.
Schwirian, P., M. (1978). Evaluating the Performance of Nurses: A multidimensional
Approach. Nursing Research, 27(6), 347-351. Spector, P., E. (1997). Job Satisfaction Application, Assessment, Cause, and
Stacciarini, J.-M. R., & Troccoli, B. T. (2004). Occupational stress and constructive thinking: health and job satisfaction. Journal of Advanced Nursing, 46(5), 480-487.
Stapleton, P., Henderson, A., Creedy, D. K., Cookie, M., Patterson, E., Alexander, H.,
et al. (2007). Boosting morale and improving performance in the nursing setting. Journal of Nursing Management, 15, 811-816.
satisfaction, and working environment Icelandic nurses: A cross-sectional questionnaire survey. International Journal of Nursing Studies, 43(7), 875-889.
Takase, M., Maude, P., & Manias, E. (2005). The impact of role discrepancy on
nurses' intention to quit their jobs. Journal of Clinical Nursing, 15, 1071-1080. Tyson, P. D., & Pongruengphant, R. (2004). Five-year follow-up study of stress
among nurses in public and private hospitals in Thailand. International Journal of Nursing Studies, 41(3), 247-254.
Tyson, P. D., Pongruengphant, R., & Aggarwal, B. (2002). Coping with
organizational stress among hospital nurses in Southern Ontario. International Journal of Nursing Studies, 39(4), 453-459.
UBOS. (2005). The 2002 Uganda Population and Housing Census - Main report.
Entebbe, Uganda: UBOS. WHO. (2002). The Global Occupational Health Network (COHNET) Newsletter,
Issue No. 2 WHO. (2005). Uganda. Summary Country Profile for HIV/AIDS treatment scaleup.
Retrieved March 1, 2007 Wilson, B., Squires, M., Widger, K., Cranley, L., & Tourangeau, A. (2008). Job
satisfaction among a multigenerational nursing workforce. Journal of Nursing Management, 16, 716-723.
Xianyu, Y., & Lambert, V. A. (2006). Investigation of the relationships among
workplace stressors, ways of coping, and the mental health of Chinese head nurses. Nursing and Health Sciences, 8, 147-155.
Zangaro, G. A., & Soeken, K. L. (2007). A Meta-Analysis of studies of Nurses' job
satisfaction. Research in Nursing and Health, 30, 445-458.
92
APPENDICES
93
Appendix A: Institutional Review Board for Human Use Approval
94
95
96
97
98
99
100
101
102
103
104
Appendix B: Permission to use Research Instruments
105
106
107
108
----- Original Message ---- From: Pat Schwirian <[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
ITEMS
RATE
1.
Time pressures and deadlines
1 2 3 4 5
2.
I have too little time in which to do what is expected of me
1 2 3 4 5
3. The demands of others for my time at work are in conflict
1 2 3 4 5
4. I spend my time ‘fighting fires’ rather than working to a plan
1 2 3 4 5
5. Trivial tasks interfere with my professional role 1 2 3 4 5
6. Fluctuations in workload 1 2 3 4 5
7. Management expects me to interrupt my work for new priorities
1 2 3 4 5
8. Deciding priorities 1 2 3 4 5
9. My nursing and administrative roles conflict 1 2 3 4 5
10. Shortage of essential resources 1 2 3 4 5
11. Decisions or changes which affect me are made ‘above’, without my knowledge or involvement
1 2 3 4 5
12. Management misunderstands the real needs of my department
1 2 3 4 5
13. Lack of support from senior staff 1 2 3 4 5
14.
I only get feedback when my performance is unsatisfactory
1
2
3
4
5
15.
Relationships with superiors
1 2 3 4 5
112
Instructions: Please rate by circling the number that corresponds to the amount of pressure you feel from each item. 1. - No pressure 2. - Very little pressure 3. - Moderate pressure 4. - High pressure 5. - Extreme pressure
16. Difficulty in dealing with aggressive people 1 2 3 4 5
17. Difficult patients 1 2 3 4 5
18. Involvement with life and death situations 1 2 3 4 5
19. Bereavement counseling 1 2 3 4 5
20. Dealing with relatives 1 2 3 4 5
21. Over-emotional involvement 1 2 3 4 5
22. Job versus home demands 1 2 3 4 5
23. My supervisors do not appreciate my home pressures 1 2 3 4 524. Domestic/family demands inhibit promotion 1 2 3 4 5
25. I need to absent myself from work to cope with
domestic problems 1 2 3 4 5
26. Bringing about change in staff/organization 1 2 3 4 5
27. Tasks outside of my competence 1 2 3 4 5
28. Coping with new technology 1 2 3 4 5
29. Lack of specialized training for present task 1 2 3 4 5
30. Uncertainty about the degree or area of my responsibility
1 2 3 4 5
113
JOB SATISFACTION SURVEY (JSS)
Permission to utilize the JSS was sought and obtained from Paul E. Spector, Department of Psychology University of South Florida.
Copyright Paul E. Spector 1994, All rights reserved.
PLEASE CIRCLE THE ONE NUMBER FOR EACH
QUESTION THAT COMES CLOSEST TO REFLECTING YOUR OPINION
ABOUT IT.
Dis
agre
e ve
ry m
uch
Dis
agre
e m
oder
atel
y
Dis
agre
e sl
ight
ly
Agr
ee s
light
ly
Agr
ee m
oder
atel
y
Agr
ee v
ery
muc
h
1 I feel I am being paid a fair amount for the work I do. 1 2 3 4 5 6
2 There is really too little chance for promotion on my job. 1 2 3 4 5 6
3 My supervisor is quite competent in doing his/her job. 1 2 3 4 5 6
4 I am not satisfied with the benefits I receive. 1 2 3 4 5 6
5 When I do a good job, I receive the recognition for it that I should receive. 1 2 3 4 5 6
6 Many of our rules and procedures make doing a good job difficult. 1 2 3 4 5 6
7 I like the people I work with. 1 2 3 4 5 6
8 I sometimes feel my job is meaningless. 1 2 3 4 5 6
9 Communications seem good within this organization. 1 2 3 4 5 6
10 Raises are too few and far between. 1 2 3 4 5 6
11 Those who do well on the job stand a fair chance of being promoted. 1 2 3 4 5 6
12 My supervisor is unfair to me. 1 2 3 4 5 6
13 The benefits we receive are as good as most other organizations offer. 1 2 3 4 5 6
14 I do not feel that the work I do is appreciated. 1 2 3 4 5 6
15 My efforts to do a good job are seldom blocked by red tape. 1 2 3 4 5 6
16 I find I have to work harder at my job because of the incompetence of people I work with.
1 2 3 4 5 6
17 I like doing the things I do at work. 1 2 3 4 5 6
18 The goals of this organization are not clear to me. 1 2 3 4 5 6
114
PLEASE CIRCLE THE ONE NUMBER FOR EACH
QUESTION THAT COMES CLOSEST TO REFLECTING YOUR OPINION
ABOUT IT. Copyright Paul E. Spector 1994, All rights reserved. D
isag
ree
very
mcu
h
Dis
agre
e m
oder
atel
y
Dis
agre
e sl
ight
ly
Agr
ee s
light
ly
Agr
ee m
oder
atel
y
Agr
ee v
ery
muc
h
19 I feel unappreciated by the organization when I think about what they pay me.
1 2 3 4 5 6
20 People get ahead as fast here as they do in other places. 1 2 3 4 5 6
21 My supervisor shows too little interest in the feelings of subordinates. 1 2 3 4 5 6
22 The benefit package we have is equitable. 1 2 3 4 5 6
23 There are few rewards for those who work here. 1 2 3 4 5 6
24 I have too much to do at work. 1 2 3 4 5 6
25 I enjoy my coworkers. 1 2 3 4 5 6
26 I often feel that I do not know what is going on with the organization. 1 2 3 4 5 6
27 I feel a sense of pride in doing my job. 1 2 3 4 5 6
28 I feel satisfied with my chances for salary increases. 1 2 3 4 5 6
29 There are benefits we do not have which we should have. 1 2 3 4 5 6
30 I like my supervisor. 1 2 3 4 5 6
31 I have too much paperwork. 1 2 3 4 5 6
32 I don't feel my efforts are rewarded the way they should be. 1 2 3 4 5 6
33 I am satisfied with my chances for promotion. 1 2 3 4 5 6
34 There is too much bickering and fighting at work. 1 2 3 4 5 6
35 My job is enjoyable. 1 2 3 4 5 6
36 Work assignments are not fully explained. 1 2 3 4 5 6
115
SIX DIMENSION SCALE OF NURSING PERFORMANCE (6-DSNP)
Permission to utilize the 6-DSNP was sought and obtained from Schwirian, P., M.
Reference: Schwirian, P.M. (1978). Evaluating the performance of nurses: A multidimensional approach. Nursing Research 27, 347 – 351.
Instructions: The following is a list of activities in which nurses engage with varying degrees of frequency and skill.
1. IN COLUMN A: please enter the number that best describes how often you perform the activities in the performance of your current job.
2. IN COLUMN B: for those activities that you perform please enter the number that best describes how well you perform them.
PLEASE USE THE KEY AT THE TOP OF EACH COLUMN
COLUMN A COLUMN B How often do you perform these activities in your current job?
How well do you perform these activities in your current job?
1- Not expected in this job
2- Never or seldom
3- Occasionally
4- Frequently
1- Not very well
2- Satisfactorily
3- Well
4- Very Well
Column A Column B
1. Teach a patient's family members about the patient's needs.
2. Coordinate the plan of nursing care with the medical plan of care.
3. Give praise and recognition for achievement to those under his/her direction
4. Teach preventive health measure to patients and their families.
5. Identity and use community resources in developing a plan of care for a patient and his/her family.
6. Identify and include in nursing care plans anticipated changes in patient's conditions.
116
COLUMN A COLUMN B
How often do you perform these activities in your current job?
How well do you perform these activities in your current job?
1- Not expected in this job
2- Never or seldom
3- Occasionally
4- Frequently
1- Not very well
2- Satisfactorily
3- Well
4- Very Well
Column A Column B
7. Evaluate results of nursing care.
8. Promote the inclusion of patients decision and desires concerning his/her care
9. Develop a plan of nursing care for a patient.
10. Initiate planning and evaluation of nursing care with others.
11. Perform technical procedures: e.g. oral suctioning, tracheostomy care, IV therapy, catheter care, dressing changes.
12. Adapt teaching methods and materials to the understanding of the particular audience: e.g., age of patient, educational background and sensory deprivation.
13. Identify and include immediate patient needs in the plan of nursing care.
14. Develop innovative methods and materials for teaching patients.
15. Communicate a feeling of acceptance of each patient and a concern for the patient's welfare.
19. Give emotional support to family of dying patient.
20. Verbally communicate facts, ideas, and feelings to other health care team members.
117
COLUMN A How often do you perform these activities in your current job?
1- Not expected in this job
2- Never or seldom
3- Occasionally
4- Frequently
COLUMN B
How well do you perform these activities in your current job?
1- Not very well
2- Satisfactorily
3- Well
4- Very Well
Column A Column B
21. Promote the patients' rights to privacy.
22. Contribute to an atmosphere of mutual trust, acceptance, and respect among other health team members.
23. Delegate responsibility for care based on assessment of priorities of nursing care needs and the abilities and limitations of available health care personnel.
24. Explain nursing procedures to a patient prior to performing them.
25. Guide other health team members in planning for nursing care.
26. Accept responsibility for the level of care under his/her direction.
27. Perform appropriate measures in emergency situations.
28. Promote the use of interdisciplinary resource persons.
29. Use teaching aids and resource materials in teaching patients and their families.
30. Perform nursing care required by critically ill patients.
31. Encourage the family to participant in the care of the patient.
32. Identify and use resources within the health care agency in developing a plan of care for a patient and his/her family.
33. Use nursing procedures as opportunities for interaction with patients.
34. Contribute to productive working relationships with other health team members.
118
Column A Column B
How often do you perform these activities in your current job?
How well do you perform these activities in your current job?
1- Not expected in this job
2- Never or seldom
3- Occasionally
4- Frequently
1- Not very well
2- Satisfactorily
3- Well
4- Very Well
Column A Column B
35. Help a patient meet his/her emotional needs.
36. Contribute to the plan of nursing care for a patient.
37. Recognize and meet the emotional needs of a dying patient.
38. Communicate facts, ideas, and professional opinions in writing to patients and their families.
39. Plan for the integration of patient needs with family needs.
40. Function calmly and competently in emergency situations.
41. Remain open to the suggestions of those under his/her direction and use them when appropriate.
42. Use opportunities for patient teaching when they arise.
119
The following PROFESSIONAL DEVELOPMENT behaviors should be evaluated in
terms of quality only--i.e. COLUMN B.
Column B
How well do you perform these activities in your current job?
1- Not very well
2- Satisfactorily
3- Well
4- Very Well
Column B
43. Use learning opportunities for ongoing personal and professional growth.
44. Display self-direction.
45. Accept responsibility for own actions.
46. Assume new responsibilities within the limits of capabilities.
47. Maintain high standards of performance.
48. Demonstrate self-confidence.
49. Display a generally positive attitude.
50. Demonstrate a knowledge of the legal boundaries of nursing.
51. Demonstrate knowledge in the ethics of nursing.