BACKGROUND: “Everyday day, the nurse confronts stark suffering, grief and death as few people do. Many nursing tasks are mundane and unrewarding. Many are, by normal standards, distasteful. Others are often degrading; some are frightening (Hingley, 1984)”. Stress in the nursing profession is evident as many researchers continue to be intrigued by this topic. The issue of work-related stress has being explored and discussed in many profession but, the nursing profession has being widely researched. Stress does not only impact Nurses but for both patient’s and the organisation. This study sought to measure which components in the nursing profession contributes to stress. A quantitative approach has been used as its’ components of measurement and objectively relate to the aim of this study.
METHODS: This study will measure which factors contribute to stress in the nursing profession. The data collection methods for this study will be self-administered questionnaire. Data were obtained from the Registered General Nursing Division on a medical and surgical ward (n=40).
RESULTS AND RECOMMENDATIONS:
OUTLINE OF CHAPTERS
Chapter 1 Examine the term “stress” and how it is relevant to the nursing profession.
Chapter 2 Literature review on relevant material to supports the study.
Chapter 3 outlines the methodology of the research
Chapter 4 findings of the study composing of (n=40) Nurses
Chapter 5 Conclusion and recommendations
HYPOTHESIS 1: Stress is caused in the nursing environment by shift work, workload, and working environment.
CHAPTER ONE: INTRODUCTION
The term “stress” was first used by the endocrinologists Hans Selye in 1930 who proposed that the perceptions and responses of humans trying to adapt to challenges of everyday life. In recent times, stress is defined as when one is faced with events or encounters that they perceive as endangerment to their physical well-being (as cited by McGowan, 2001). In relation to the nursing profession many researchers have attempted to define stress. Chang (2005) proposes that stress is intrinsic to nursing and a highly demanding job with poor support, and rapidly changing circumstances. Whereas, Mann & Cowburn (2005) identified nursing as emotionally demanding and this interactive stress contribute to daily stress as a nurse. Malone (2004) asserts that the nursing profession more than any other profession has being singled out as a particular stressful profession. Death, grief, increased work load, conflict, attending to patients’ needs, dealing with emergencies are just a few of the daily tasks a nurse deals with on a daily basis the list is endless. There is a wealth of information on stress in any profession but, there is relevant material that supports that stress in the nursing profession is more evident due the nature of the job (Charney, 1995). Ireland has very little research on this topic there is a wealth of international material and these will be used for this research. There is apparent gap in research pertaining to stress on a typical medical-surgical ward and this has prompted this research. A quantitative approach was used to conduct this study and a self-administered questionnaire will be given to General Nurses on a medical-surgical ward. Findings could help in identifying certain elements of the nursing job that could be changed such as, shift work by offering more flexibility, and offering permanent positions. In addition, this research will hope to raise awareness with managers in the health service that stress is evident, and that more emphasis on stress reduction programmes and support as current strategies may not be working effectively as this phenomenon continues. Reducing stress in the nursing profession is important in retention, in addition, to the safety of nurse’s health and the people they care for.
CHAPTER TWO: LITERATURE REVIEW
SHIFT WORK AND THE IMPLICATIONS ON STRESS
Work stress continues to intrigue researchers and their main focus is mainly on occupations in the health care service in particular, the nursing profession. Charney, (1995) contends that nursing profession is a particularly stressful profession. There has been a wealth of research carried out on work-related stress (McVicar, 2003, Vahey, 2004). One researcher, Needleman (2002) in particular, focused on the impact of stress in the nursing profession and linked it to poor patient outcomes and medical complication. Research suggests that Nurses’ working rotating shifts experience stress at work which tends to lead to a high level of absenteeism (Colligan et al, 1979; as cited by nursing informatics, 2008). Several articles related to 12 hour shifts highlighting the negative aspects of these shifts (Gold, 1992; Yokoyama& Uchiyema, 2005). Some studies linked shift work to sleep disturbances (Adami & Lavie, 2007; Drake, 2004; Chan, 2008). While further studies support that workload and management styles all contributed stress (McVicar, 2003). And lastly, nursing shortage was directly linked to increase workload and stress among nurses’ (Buchan & Calman, 2004; Buerhaus, 2005).
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Gold (1992) contends that shift work contributed to medical errors by nursing staff. While, Yokoyama & Uchiyama (2005) agrees that shift work contributed to sleepiness causing medication errors. Roger (2004) also found the risk of error were significantly increased if nurses’ worked more than a 12 hour shift; also concluding that this lead to a higher level of absenteeism. Jennings (2005) conducted a study in which two groups to determine if shift length contributed to stress. One group worked an 8 hour shift and the second a 12 hour shift; the study concluded that both groups experienced the same levels of stress regardless of the length of the shift. Whereas, Hoffman (2003) carried out a similar study in 8 hour shift versus 12 hours and contends that both groups experience high levels of fatigue and exhaustion. However, the study did not indicate what type of nursing staff participated in the study. One might conclude that it is the working environment that contributes to the stress, and not the length of shift. Further studies show that stress is related to types of shifts work; a study carried out by Ruggiero (2003) found that Nurses’ experienced mild-severe depression was related to these shift patterns.
Recent studies have highlighted shift work and sleep disturbances (Adami & Lavie, 2007; Drake, 2004; Chan, 2008). Adami & Lavie (2007) identified sleep performance with performance indicating that shift work had a direct impact on performance. Similarly, Drake (2004) identified morbidity associated with sleep disturbances among shift workers and that there were a greater sleep-related accidents, stress and depression. Chang (2008) agrees concluding in a study that working rotating shifts reported higher levels of occupational accidents. Dorrian (2006) conducted a study on nurses’ working night duty which reported higher levels of stress, and physical and mental exhaustion.
Two studies concur that working 12 hour shifts had positive results for patients and staff. Bloodworth (2001) that 12 hour shifts provided better continuity of care for patients and overall better communications between patients and staff. While Slota &Balas-Stevens (1996) agrees that it does have more positive than negative as work could be spread over a longer period. Some studies indicate that shift work contributed to medications error as well as misuse of hospital equipment (Gold, 1992; Youkoyama & Uchiyama, 2005).
Further studies, support that workload contributed to stress (Aiken, 2002; Needleman, 2002). McNeese-Smith (1999) determined that heavy patient assignment contributed to stress among nurses’. Bratt et al. (2000) agrees heavy patient assignment and work pressure all impacted on stress experienced by Nurses’. “The hospital nurse workforce is experiencing high levels of workload, rising average patient acuity, few support resources, and workload which has been all identified as a source of stress for Nurses” (Vahey, 2004).
Gardulf (2005) carried out a large quantative study of (N=833) Swedish Nurses’ to investigate why nurses’ intend to quit their present job using two questionnaire and found that 54% intended to quit within a year with 32% citing psychologically, strenuous and stress was a reason for leaving. Whereas, Gillepsie & Melby (2003) using a triangulation design, reported that nurses working in an acute medicine experienced greater levels of emotionally exhaustion than Nurses’ working in emergency care. These findings suggest apart from workload, other stressors may be ranked indifferently from nurses’ working in different areas. However, with Gillespie & Melby (2003) cited lack of experience as a variant in dealing with workload. Similarly, one study examined a comparative study on a medical and surgical ward versus a community based nursing it concluded that there were different stress levels between the two groups however; the same types of stressors were experienced by the two groups.
Mc Vicar (2003) conducted a literature re review on workplace stress in nursing which looked at workload, management styles, and conflict as contributing factors in stress. Nurse work in an environment with constant stressors often caught between doctors, management, patients, and families. One of those stressors identified was the nurse-doctor relationship. Conflict Identified by Rosenstein (2002) in his research on the doctor-nurse relationship as a major conflict for Nurses’. A study of 90% participating nurses’ all witnessed verbal abuse by doctors to other colleagues and other staff personnel. However, only a small number of doctors displayed these behaviours it did contribute to conflict and stress in the workplace. In contrast, Timmons & Tanner (2005) highlighted that Nurses do try to keep doctors “happy” and try not to make “upset” even in when poor surgical practices are witnessed by Nurses’.
Buchan & Calman (2004) indicated that there is a global shortage of Nurses’ which is contributing to stress, and indicating that by 2014 the U.K would need as many Nurses’ to keep up with the current workforce. Buerhaus (2005) has indicating after conducting a national survey on the negative outcomes of nursing shortages and implications to patients. The survey indicated that nursing shortage had negative outcomes for patients’, such as; the ability for a nurse to respond was poor, which led to an increased wait in the time for tests and survey for patients. Aiken (2001) conducted a study and, revealed that nursing shortage, undesirable working hours and stress contributed to the decision to leave the nursing profession. In contrast, Buerhaus (2005) conducted 3 random surveys to determine the impact of the nursing shortage; the participants of the study were nurses’, doctors and, hospital management. The results showed that the nursing shortage had a negative on communication between nurse-patient relationship and, over efficiency.
CONCLUSION
Stress has being defined by many researchers but there a general consensus that stress is intrinsic to nursing (Chang, 2005). The nursing profession is one of the most stressful professions (Malone, 2004). Mann & Cowburn (2005) identified that the nursing profession was an emotionally demanding job. Shift work was identified as a source of stress for nurses’ regardless of shift length (Jennings, 2005). Sleep performance was directly associated to shift work (Admi & Lavie, 2007). There was considerable attention paid to shift work patterns, shift length, night duty, and its impact on stress.
CHAPTER THREE: METHODOLOGY
INTRODUCTION
This chapter outlines the aims and objectives of the study and the hypotheses. Cormack (2000) suggests the research approach must reflect that which is best suited to the research question asked. The aim will be to examine if workload, shift work contribute to stress in the nursing profession and what factors contribute to it. A descriptive quantitative approach will be employed. A letter requesting permission to gain access to participants of this study was sought and approved by the Director of Nursing. Approval was not required for ethical approval as patients were not the participants in the study. The voluntary nature of participation for the study will be explained to the participants in a letter of introduction to the study. A series of self-administered questionnaire will be given to the participants with clear instruction on how to fill out the survey. Consent will be obtained from the participants prior to the study. The author has chosen a research area based on personal experience. To understand quantitative research the author has examined some of the key philosophical assumptions.
METHODOLOGY
Both qualitative and quantitative approaches were examined and a descriptive quantitative approach was chosen for many reasons for the purpose of this study. First, a quantitative approach has been used as its components of measurement and objectivity relate to the aim of the proposed study. This is to measure what trigger stress for nurses in three chosen surgical-medical wards within a chosen hospital. Also in the literature review conducted for this proposal the vast majority of studies used a quantitative approach. Burns and Grove (2005) suggest that employing a quantitative approach is preferred, mainly for the function of obtaining information about the attitudes of people. The study will be examining the nurses’ perception on what they perceive as the causes of stress within their work environment. Cormack (2000) asserts that quantitative approach will concentrate on the collection of more numerical and measureable information. A descriptive survey described by Parahoo (1997) will be utilised, as the survey is appropriate for descriptive studies. By using a quantitative approach, objectivity can be achieved, thus helping to protect against biasing the study (Cormack 2000). In addition, Quantitative research utilises tools such as questionnaires, observation schedules and other measuring tools (Parahoo, 1997). For the proposed study a questionnaire will be used as a data collection tool as it corresponds with the criteria of quantitative research. The descriptive survey will be used for the proposed study as it involves obtaining data about peoples’ beliefs, preferences, attitudes and activities through direct questioning thus appearing suitable for this study (Pilot and Hungler, 1999).
POPULATION/SAMPLE
According to Burns and Grove (2005) sampling is a key feature of research methodology. The term population refers to all those whom the researcher wishes to make statement. The term sample applies to the group of people that the researcher selects from the defined population and these are all individuals about which information will be collected (Cormack, 2000). According to Burns and Grove (2005) it is appropriate to use probability sampling when carrying out quantitative research. Probability sampling involves a form of random selection in choosing elements, whereas non-probability sampling involves selecting the element by non random methods (Polit and Hungler, 1999). Simple random sampling will be employed for this research. It was highlighted by Burns and Grove (2005) that random sampling leaves the researcher the selection to chance and thus increases the validity of the study. This also decreases researcher bias (Polit and Beck, 2001). The target population for the proposed study will be all general staff nurses working on medical-surgical wards within the three medical-surgical wards chosen hospital. A sample will be selected as a subset of the target population (Parahoo, 1997). When all units of the target population cannot be studied a sample of the population is studied. The accessible population comprises of forty staff nurses working in the area specified. The target population will be based on inclusion and exclusion criteria.
INCLUSION CRITERIA
All registered staff nurses working in a full time, part time or job sharing capacity on a medical-surgical ward in the acute setting in the general hospital.
EXCLUSION CRITERIA
All registered nurses on maternity leave.
Relief staff or agency nurses
The sampling criteria are those characteristics necessary for the inclusion in the study (Polit and Hungler, 1999). For the purpose of this study it has been decided that a sample of general nurses who work on the medical-surgical ward chosen, and who will be on duty during data collection and will be representative of the whole wards studied.
DATA COLLECTION
Data collection is a crucial part of the research process. According to Burns and grove (2005) it is the precise systematic gathering of information relevant to the research purpose of the study. Questionnaires are the mean s by which the majority of nursing research is carried (Treacey and Hyde, 1999). They allow large amounts of information to be gathered quickly and cheaply, while remaining relatively confidential (Parahoo, 1997).
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Questionnaires
The study will undertake in two stages. First, a pilot study to conduct for the purpose of developing, testing and refining various aspects of the survey, methodology and questionnaire design, in preparation for the larger study to follow (Holershow, Gendall and wright, 2003). The data collection method for this study will be self administered questionnaires. This involves the participants writing their response without the help of the researcher (Parahoo, 1997). Questionnaires have the ability to reach large numbers of subjects and collect data at lower costs than other methods, for example, interviews costs the researcher while taking time applies to both the researcher and the participants. It was chosen to utilise a questionnaire for the purpose of this study as they are designed to collect data about beliefs, attitudes and knowledge from people (Polit and Hungler, 1999) it has been highlighted by Parahoo (1997) that the popularity of questionnaires suggest the advantages outweigh the disadvantages. The main disadvantage being that there may be a low response rate, as often, questionnaires can be time consuming.
To overcome this it will be highlighted to the participants in the study that it should only take twenty minutes. A cover page will be included giving clear instructions about how to fill out the questionnaires, the importance of the study and a guarantee of confidentiality (Cormack, 2000). The questionnaire will be posted individually to via the internal post service to each nurse in the sample.
DESIGN OF THE QUESTIONNAIRE
The author decided that a self-devised questionnaire will be used for this study as no appropriate questionnaire could be found from reviewing the literature. The researcher has been guided by the principle that the questions chosen will be related to one another as the author would want to prevent lack of focus on the research (Bryman and Bell, 2007). The questionnaire is designed to obtain information from a sample of (n=40) nurses in a general surgical ward pertaining to types of stress in the nurse profession. It consists of 10 questions. The types of questions used for questionnaire was dichotomous, multiple choice, ranking, and scale questions. This was used to prevent classifying many individuals, in addition, to prevent capturing only a portion of the underlying concept. Section three pertains to factors that have been identified in the literature review. A coding system will be initiated to every item in the question as coding is a crucial stage in the process of doing a content analysis (Brymam and Bell, 2007). The author will also include a demographic questionnaire and will include data regarding gender, age and number of years qualified; this data will be used for statistical purposes.
VALIDITY AND RELIABILITY
Validity and reliability are the criteria upon which veracity and credibility of the research findings are judged. They are a necessary requirement of all research though achievements will vary according to the type of research design or instrument used to collect data (Cormack, 2000).
For the purpose of this research the reliability of the instrument will be determined using the test-retest method. The tool will be administered to a number of Nurses who adhere to the inclusion criteria. It will then be re-administered to the same Nurses two weeks later and both questionnaires will be compared. If all the questions are answered the same, the tool will be deemed reliable. A method is valid when it measures what it sets out to measure (Parahoo, 1997). The questionnaire will be submitted to a panel of experts to evaluate has it measured what it is intended to do. The panel will make remarks about the questions relevance using a grading system known as the counter validity index (C.V.I) A.C.V.I. score of .80 or greater is considered to have good validity (Polit and Hungler, 1999).
DESIGN OF THE QUESTIONNAIRE
The author decided that a self-devised questionnaire will be used for this study as no appropriate questionnaire could be found from reviewing the literature. The researcher has been guided by the principle that the questions chosen will be related to one another as the author would want to prevent lack of focus on the research (Bryman and Bell, 2007). The questionnaire is designed to obtain information from a sample of 100 nurses in a general surgical ward pertaining to types of stress in the nurse profession. It consists of 10 questions. The types of questions used for questionnaire was dichotomous, multiple choice, ranking, and scale questions. This was used to prevent classifying many individuals, in addition, to prevent capturing only a portion of the underlying concept. Question 8 pertains to factors that have been identified in the literature review. A coding system will be initiated to every item in the question as coding is a crucial stage in the process of doing a content analysis (Brymam and Bell, 2007). The author will also include a demographic questionnaire and will include data regarding gender, age and number of years qualified; this data will be used for statistical purposes.
VALIDITY AND RELIABILITY
Validity and reliability are the criteria upon which veracity and credibility of the research findings are judged. They are a necessary requirement of all research though achievements will vary according to the type of research design or instrument used to collect data (Cormack, 2000).
For the purpose of this research the reliability of the instrument will be determined using the test-retest method. The tool will be administered to a number of Nurses who adhere to the inclusion criteria. It will then be re-administered to the same Nurses two weeks later and both questionnaires will be compared. If all the questions are answered the same, the tool will be deemed reliable. A method is valid when it measures what it sets out to measure (Parahoo, 1997). The questionnaire will be submitted to a panel of experts to evaluate has it measured what it is intended to do. The panel will make remarks about the questions relevance using a grading system known as the counter validity index (C.V.I) A.C.V.I. score of .80 or greater is considered to have good validity (Polit and Hungler, 1999).
DATA ANALYSIS
The goal of data analysis is to summarise the data so that it provides answers to the research question (Brink and Wood, 1994). Quantitative analysis will resume after all potential data is collected. Today statistics are simplified with the use of computer packages specially formulated for the purpose of data analysis. Statistical analysis will be carried out by means of a statistical software program called SPSS (Statistical package for social sciences). For the purpose of this study descriptive analysis is proposed, as the study is a descriptive study. Frequency, central tendency and dispersions are the main features of descriptive statistics/analysis (Parahoo, 1997). Frequency refers to how often a variable occurs, which will be presented using tables and bar charts-central tendency refers to mean, mode and median. The mean refers to the arithmetic average of a set of values and is reached by adding all the scores and dividing the number by the number of responses. The mode refers to the most frequent value and the median refers to the midpoint value when scores are arranged in ascending order (Parahoo, 1997).
Dispersion is the variance of the scores and is measured by range, the lowest and the highest values and standard deviation (SD). The S.D is a kind of average deviation of the observation from their mean (Parahoo, 1997). If the scores are homogenous, there is little or no deviation from the mean and therefore the S.D is zero or close to zero (Parahoo, 1997). The larger the S.D., the more scores deviated from the mean, this deviation can be either positive or negative.
They have been chosen for this quantitative study’s data analysis process. This analysis method is suitable for the proposed study as Parahoo (1997) suggest it conveys the main feature of the data. Frequency distributions will be used to describe the data in relation to stress in the Nursing profession and attitude scores. When presented in terms of percentages rather than absolute numbers, frequencies are easier to understand. According to Polit and Hungler (1999) when data is represented by means of diagrams they make the data more appealing. Data protection is vital; in the UK the legislation that covers data protection is the 1998 data protection act, which came into effect on March 1st 2000. The data must be protected and processed fairly and lawfully. In addition, the data must be relevant and not be kept longer than necessary (Bryman and Bell, 2007). Data will be saved on the hard drive of the computer and on a floppy disc. In view of these regulations the disc will be stored in a locked away cabinet. Only the researcher will have access to the hard drive by means of a password this will ensure data protection and confidentiality.
PILOT STUDY
A pilot study is a small-scale version or trail run, which is carried out in preparation for the main study (Polit, Beck and Hungler, 2001). A pilot study is conducted as a preliminary to the actual study (Porter and Carter, 2000). A pilot study serves a number of purposes; it aids testing of the research design and logistics of the study. It gives the researcher experience of engaging in the data collection; it helps determine the effectiveness of the data collection instrument and provides an opportunity for analysis research data (Porter and Carter, 2000). It is proposed that the pilot study will be conducted over two months to ascertain the workability of the questionnaire.
The questionnaire will be administered to 20 general nurses who fit the criteria from a similar environment within the same hospital. Ethical will be sought and consent obtained from the participants. By testing the tool for data collection, the researcher will be able to practice and develop her own questionnaire thus adding to a more efficient tool, which ultimately increases reliability and validity of the study.
ETHICAL CONSIDERATIONS
Ethics is the study of moral judgements based on values, beliefs and attitudes, which individuals or groups of people possess (Polit and Hungler, 1999). Ethical implications are imperative to safeguard the rights of individuals partaking in a research study (Parahoo, 1997). Parahoo (1997) describe a framework of six ethical principles that nurses can use to guard their patients from harm. These principles are: beneficence, non-munificence, fidelity, justice, veracity and confidentiality and will be defined separately later. Ethics approval for the proposed study will be sought from the ethics committee of the hospital the study is being carried out. Once approval is granted and access has been gained to potential participants, those who fit the inclusion criteria will be notified, inviting them to partake in the study. Informed consent will be obtained. The rights of the person as an individual should always remain at the fore-front of the research proposal (Polit and Hingler, 1999). The principle of self-determination will be used. This refers to potential participants have the right to decide voluntarily whether or not to participate in the study and can opt out at any time. Anonymity will be maintained as will confidentiality.
CONCLUSION
The methodological approach and rationale has been outlined for the proposed descriptive study exploring what stressors contribute to stress in nursing. Sampling was discussed as the key feature of research methodology. A sample of the population will be selected for this research with the use of random sampling to increase the validity of the study. In addition, inclusion and exclusion were discussed as part of the sampling criteria. Questionnaires will be the means of collecting data as the majority of nursing research has been carried out this way. As previously identified questionnaires have the ability to reach large numbers of subjects and costs less than any other method. Two important criteria were discussed as how research findings are judged. Validity and reliability are these criteria that are necessary for all research. A Questionnaire can be relative without being valid but it cannot be valid if it is not reliable (Parahoo, 1997). The next stage discussed was the data analysis which summarises the data so that it provides answers to the research questions. Statistical analysis will be carried out using a software program known as SPSS (Statistical Package for the Social Science). Another important part of the research is a pilot study which is carried out in preparation for the main body of the study. This entails a preliminary to the actual study. This is important as it gives the researcher experience of engaging in data collection, also, helps determine the effectiveness o the data collection instrument and provides an opportunity for analysing research data. Lastly, the important part of the research is ethical considerations and this is to safeguard the rights of individuals partaking in the research study.
OUTCOME OF THE STUDY
From reviewing all the relevant literature, it is proposed to identify the stressors that contribute to stress in the nursing profession. The primary function of this study is to help change the Nurses work practice to limit the stress in this rewarding profession. Shift work, long hours and work load have been identified many times as the stressors that contribute to stress. Once successful in the research the author will communicate its findings to relevant personnel as Burns and Grove (2005) states that research is not completed until the findings are communicated. Hopefully this will engage communication between the director of nursing and nursing staff in implementing probable change to current practice. It is also intended to submit the study for publication to relevant nursing journals, so they can be received by a wider audience and may initiate change in other hospitals to change current practices.
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