predisposing factors for stress among nurses working in ... · among nurses working in critical...

بسم الله الرحمن الرحيم

An-Najah National University

Faculty Of Nursing

Predisposing Factors For Stress Among Nurses Working In Critical Care Units In Nablus Public

Hospitals

Submitted By 4th Year Students

Name Of Students:

Abdulaziz Masre Ahmed Adnan Isra' Al-sheikh Ayat Samara

Teacher Of The Subject: Mariam Altell

Supervisor Name: Fatima Herzallah

1st Semester 2008-2009

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OUTLINES:

Acknowledgement………………………………………………. 4

Introduction……………………………………………………… 5

CH 1: literature review……………………………………………7

CH 2: methodology:………………………………………………15

Aim of study………………………………………………15

Study design………. …………………………………….15

Study questions ……………………………………………15

Problem statement …………………………………………15

Hypothesis…………………………………………………..15

Setting ………………………………………………………16

Population…………………………………………………...16

Sample………………………………………………………16

Inclusion criteria ……………………………………………16

Tool of data collection………………………………………16

Field work…………………………………………………...17

CH 3: data analysis and results………………………………………… 18

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Results collecting and analysis…………………………………21

CH 4: Discussion and conclusions……………………………………… ...26

Discussion………………………………………………………26

Conclusions……………………………………………………..30

Recommendations ……………………………………………..32

References ………………………………………………………34

Annexes …………………………………………………………37

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Acknowledgement

To our fathers and mothers who were the kind embrace for their sons, who

supported their sons financially and emotionally to the last day of their study. To the

university to which we belong “An-Najah National University” represented by Dr.

Rami Hemdallah who always support us and our faculty. To the dean of our faculty

which we appreciate for its support Dr. Adnan Sarhan the person who was the

kindhearted father for all of his students. To the person who taught us the principles of

research Dr. Aida Al-Qaisi. To the person who taught us this material Miss. Mariam

Al-Tell from whose experience we were benefited. To the kind smile, to the

affectionate woman who supervised our work and was the best supervisor, to Miss.

Fatima Herzallah who supported us by her kindness and experience to finish this

work perfectly. To the ministry of health which accepted us in its hospitals .to all

nurses who help us to accomplish this research project . To all of these people we

present this work.

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Introduction

Stress is a well-known and identified problem within the nursing profession. It

is important to understand that the very nature of nursing is stressful, increasing the

vulnerability of all nurses to the hazards of occupational stress.

Identification of job related stressors and strategies that can be employed to

manage occupational stress for the nursing profession have been receiving increased

consideration by researchers, nursing organizations, and employers over the last two

decades.

The environment of critical care units has been recognized as stressful since their

inception in the 1960’s. The high-tech, fast paced, emotionally charged atmosphere is

noisy and filled with the sounds of intricate machinery, which can often be heard in

unison to the moaning of patients. Critical care nurses confront death and dying, end

of life decisions, and ethical dilemmas regularly. In addition to providing vigilant

care to their patients, critical care unit nurses interact frequently with distraught

families. The physical work demands in critical care units can be grueling, requiring

heavy lifting, long hours and shift work. Conflicting values between nurses,

physicians, and coworkers create additional tensions in the units. However, the acute

shortages of nurses especially in critical care units has prompted considerable

research related to the identification of stressors for this group of nurses.

Research has indicated that increased stress can lead to job dissatisfaction,

burnout, and precipitate attrition from critical care units, thereby increasing

employment costs. Prolonged exposure to stress may lead to a variety of physical and

psychological disorders.

The aim of study , is to identify the predisposing factors for stress (stressors)

among nurses working in critical care units in Nablus public hospitals, and to suggest

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recommendations or strategies to minimize some of the known stressors of the critical

care unit nurses.

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Chapter one: literature review

Stress has been identified as a 20th century disease and has been viewed as a

complex and dynamic transaction between individuals and their environments (Evans

& Kelly, 2004).Stress can be regarded as a psychological threat, in which the

individual perceives a situation as a potential threat (Canadian Journal of Behavioral

Science, 2004). Stress occurs when one is faced with events or encounters that they

perceive as an endangerment to their physical or psychological well being

(McGowan, 2001). The cause of stress for critical care nurses has found to be related

to the nature of the nursing profession . Included in these stressors are death and

dying , conflict, and Staffing/ working conditions.

Critical care unit stressors: Death and dying. Nurses’ attitudes about death and dying are extremely complex, and can be related

to their own fears, anxieties, and personal attitudes towards death (Cox et al., 1996).

Research by Foxall and associates indicated that critical care unit nurses experienced

significantly more stress related to death and dying than did medical surgical nurses

(Foxall et.al.1990). In fact nurses in all clinical practice areas of the hospital

consistently rank death and dying issues as problematic, especially issues concerning

unexpected deaths, removal of life support equipment, and moral dilemmas related to

do-not resuscitate (DNR) orders. This could be explained by their professional

orientation that emphasizes cure (Yang & Mcilfatrick, 2001).

This is certainly true of critical care units that are geared towards aggressive life

saving interventions versus providing palliative care. Technological advances have

made it possible to prolong life with aggressive interventions when it is no longer

appropriate, creating an environment of suffering for patients who may be

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experiencing painful procedures, or invasive treatments. At the same time family

members may be isolated from their loved ones, or witness personal indignities

imposed on them by the impersonal atmosphere of the unit (Shotton, 2000).

Medical futility has become an issue of increasing importance in the critical care units

environment due to increasing numbers of people dying there, often in undesirable

situations (Kirchhoff et al. 2000). In general nurses are concerned that many of their

patients are suffering needlessly from meaningless and painful treatments. While

nurses believe they should participate in ethical decision-making, research has shown

that their actual participation is limited (Erlen & Sereika, 1997). A study by Solomon

et al. (1993) revealed that almost half of the doctors and nurses surveyed indicated

that they had acted against their beliefs in providing care to patients at the end of life.

Patients or family members acting in their behalf may choose to forgo or

discontinue life support systems, resulting in a DNR order from the physician. The

many ambiguities surrounding DNR orders results in uncertainties about continued

treatment and procedures among staff and families. Families may need guidance to

initiate DNR orders for their loved ones, and although nurses believe they should

explain the implications related to DNR orders to families, they experience

significant stress when doing so (Yang & Mcilfatrick, 2001). When a DNR decision

has been made that conflict with the nurses’ own personal moral beliefs, moral

conflict occurs. Jezuit ( 2000) found that critical care nurses felt responsible for

patients' deaths when they withdrew life support equipment, and hung narcotic

infusions especially when the dosage of the drip was left up to their discretion.

Many critical care patients linger in the unit for weeks before they die affording

nurses who care for them time to bond with them and their families. For some nurses,

emotional involvement with their patients and their families can create intense

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feelings of grief and loss when the patient dies (Yang & Mcilfatrick, 2001).

Compassion and empathy for patients and their families drains energy from nurses

leaving them physically, emotionally, and spiritually exhausted increasing their risk of

developing compassion fatigue. Prolonged exposure to deaths may result in

unresolved loss (Couden, 2001).

The appearance of grotesque, disfigured survivors of catastrophic events may be

shocking for nurses that rush to stabilize them. Or nurses may become overwhelmed

by the death of a child that reminds them of their own. Traumatic events of these

types are referred to as critical incidents, and may result in acute or chronic stress

disorders. While critical incident debriefing sessions are held for healthcare

professionals that provide care to mass victims of tragedy, there was little information

to support this intervention being utilized for other critical care nurses. Nurses

suffering from critical incident stress may lose their capacity to perform well on the

job resulting in negative outcomes for their patients (Caine & Ter-Bagdasarian, 2003).

Conflict.

Conflict is inevitable in stressful settings such as intensive care. It exists at many

different levels between doctors, nurses, families, and ancillary staff. Research has

shown that nurses find disagreements with physicians to be the most distressing

(Greenfield, 1999). Unfortunately many nurses experience so much anxiety at the

thought of confrontation with a doctor, they choose not to challenge any treatment

decisions, and provide little input into care decisions. Conflict and lack of

collaboration between nurses and physicians are detrimental to patient outcomes, and

create feelings of resentment, and powerlessness for nurses (Forte, 1997).

Rosenstein (2002) found his research on nurse-physician relationships to be

consistent with previous research that indicated that doctors were very disruptive in

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the workplace. Over 90% of participating nurses in his study reported that they had

either experienced or witnessed doctors’ verbal abuse, condescension, berating

colleagues and patients, and abusive language. Reports were also given of doctors

having tantrums, and throwing things. Rosenstein believes that only a small percent

of physicians actually contribute to this type of disruptive behavior, but tolerance of it

perpetuates dissonance among staff members, thereby inhibiting collaboration and

outcomes of care.

Nurses also stated that reports of doctors’ rude behaviors went unheeded by

administrators; while a majority of them cited fear of retribution as the main barrier

to reporting abusive behavior of doctors (Rosenstein, 2002). Why is this type of

unruly behavior tolerated in the workplace? Greenfield (1999) explains that the

tension between doctors and nurses can be related to the historical dominant role of

the physician and the subservient role of the nurse. In other words the nursing

profession that is predominately female is undervalued by the patriarchal and

hierarchical healthcare culture. Rosenstein believes that lack of professional respect

and feeling that their contributions are not significant is demoralizing to nurses.

Authoritative workplaces are a mismatch for contemporary nursing professionals

that value autonomy, patient advocacy and holistic practice. This is particularly true

in critical care areas, where nurses must be able to think critically, and respond

emergently to life threatening situations. Nurses attempting advocating for their

patients in non-supportive environments become discouraged and may choose to

leave (Sundin-Huard, 2001). Nurses advocate to provide what they deem the best care

for their patients, and if unsuccessful they have feelings of frustration, anger, or

intense moral distress. Moral distress has been linked to burnout in nurses (Sundin-

Huard & Fahy, 1999).

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Disparities in treatment goals may be another reason that nurses and doctors are

conflicted concerning treatment practices. The nursing profession values are centered

on “care” versus the medical focus of “cure” (Greenfield, Sundin-Huard &

Fahy, 1999). This type of opposition becomes very apparent with end-of life issues.

Nurses trying to care for their patients, and alleviate suffering become upset that

doctors continue to provide painful treatments. Some nurses may fear lack of support

from colleagues, or medical backlash at expressing their opinion about patient care

issues. Sundin-Huard & Fahy ( 1999 ), found that less experienced nurses feared

criticism by their peers if their input related to ethical dilemmas was deemed

inadequate.

Advocating for patients can create tension between nurses and families as well.

Pediatric intensive care nurses felt exasperated, and helpless in their inability to keep

a baby born with anencephaly from suffering. Instead, the baby’s mother obtained a

court order that forced them to comply with her wishes to keep the baby intubated.

Nurses that provided care to the baby were distressed at watching the baby suffer for

2 ½ years before she died (Perkin et al., 1997). Nurses receive little education to

prepare them to support and guide families in crisis situations. Maybe that is why so

many nurses may feel that they are not adequately prepared to deal with the emotional

needs of patients and families (Cox & Griffiths, 1996). However, Erlen and

Sereika (1997) found that “nurses felt it was important to establish a good relationship

with families in order to fulfill their nursing responsibilities.” Nevertheless families

that require so much time and communication can be very taxing to busy critical care

unit nurses (Couden, 2001).

Staffing/ working conditions. Staffing issues are the number one concern of nurses nationwide according to a

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survey conducted by the American Nurses Association (Nursing World, September,

2001). Despite the lure of attractive sign on bonuses, hospitals have reported 20%

vacancy rates for critical care nurses. In addition it takes longer to fill these positions

Pierce (2001) believes that (American Association of Critical Care Nurses, 2002).

working short-staffed in the unit increases the pressure enormously for ICU nurses.

Amid the technological chaos of ventilator alarms, vasoactive drug administration,

and cardiac monitoring, intensive care nurses are interrupted frequently by doctors,

families, and patients that require their immediate attention. Codes, accidental

extubations, etc., are frequent occurrences in the unit demanding their immediate

expertise (Smith et al., 2001). Due to lack of ancillary support nurses are performing

secretarial duties, making beds, and picking up meal trays (Greenfield, 1999). Many

nurses are skipping breaks, and staying beyond there 12 hour shifts just to complete

their work. Mandatory overtime and increased staffing ratios have increased the

stress.

The risk of errors is increased significantly for critical care nurses as they struggle

to stay abreast of the newest medications, and use of high tech equipment. Floating to

unfamiliar units where nurses are unfamiliar with equipment, procedures and

medication protocols further increases the likelihood of error. Unable to provide

professional standards of quality of care that nurses believe their patients deserve,

results in guilt and feelings of incompetence (Pierce, 2001). It is no wonder that 70%

of nurses surveyed by the American Nursing Association cited acute and chronic

stress, and overwork as one of their top three health and safety concerns (Nursing

World, September, 2001).

According to Ruggiero (2003), a factor of the intense emotional support that is

needed for the patient and family is yet another burden of stress placed on nurse. In

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addition, exposures to pain, suffering and traumatic life events that the nurse

experience on a daily basis can contribute to stress (Cohen-Katz, Capuano, Baker, &

Shapiro, 2005). The lack of organizational support and involvement, which are

outside of the control of nurses, can greatly affect job satisfaction (McGowan, 2001).

There were comparative studies between different nursing backgrounds and

environment. For example medical-surgical nursing verses home-health nursing

(Salmond & Ropis, 2005), which examined and compared the differences in both

backgrounds. Ultimately it found both areas of practice had their own version of stress

and it identified common stressors. Unfortunately no concrete measures were utilized

to combat the problem.

Some research suggests that men and women differ in their perceptions of

stressors (Misra, McKean, West, & Russo, 2000). Misra et al. (2000) found that

women reported that they experienced a greater number of stressors than did men. In

particular, women had higher scores on reported self-imposed stressors than did men.

Misra et al. (2000) concluded that men tend to perceive life events as being less

stressful and react more positively to stressors. McDonough and Walters (2001) found

that women tended to report a greater number of Stressors related to their social life,

relationships, child, family health, and job stress than did men. They also found that

men tended to report a greater number of stressors related to their finances than did

women.

The ICU is a highly stressful environment and may therefore be associated with a

high rate of Burnout Syndrome (BOS) in staff members (Donchin Y, Seagull FJ,

2002). The cost of BOS includes decreased quality of care (Thomas NK. Resident

burnout. JAMA 2004).

Decreasing stress for nurses in the workplace is multifaceted (Rosenstein, 2002).

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The first step is for organizations to recognize, and accept that the work environment

is responsible for much of the stress experienced by nurses, and not just something

that nurses have to deal with of their own (Corr, 2000). Administrators must be

committed to implementing changes that will help to minimize some of the

known stressors of ICU nurses. Nurses need to feel that they are involved in decision

making especially related to patient care issues. Therefore a more decentralized

democratic management approach would be beneficial (Harris, 2001). It is imperative

to increase nurses’ visibility in the workplace by establishing programs that

recognizes their contributions (Rosenstein, 2002).

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chapter two : methodology

:Aim of the study 2.1

1)-To identify the major predisposing factors for stress ( stressors) among nurses working in

critical care units in Nablus public hospitals.

2)- To explore the relationship between predisposing factors of stress (stressors) and presented

variables ( age, gender, work experience, and work place).

:tudy designS 2.2

A descriptive, non experimental study.

:tudy questionS 2.3

1)-what is the major predisposing factors for stress (stressors) among nurses working

in critical care units in Nablus public hospitals ?

2)-what is the relationship between predisposing factors of stress (stressors) and presented

variables ( age, gender, work experience, and work place) ?

:roblem statement P2.4 Is there any relationship between working in critical care unit and developing stress

among nurses working in this area?

:ypothesisH2.5

1)- There is no significant statistical differences at α=0.05 between predisposing

factors of stress among critical care nurses in Nablus public hospitals and age

variable.

2)- There is no significant statistical differences at α=0.05 between the predisposing

factors of stress among critical care nurses in Nablus public hospitals and gender

variable.

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3)- There is no significant statistical differences at α=0.05 between the predisposing

factors of stress among critical care nurses in Nablus public hospitals and work

experience variable.

4)- There is no significant statistical differences at α =0.05 between the predisposing

factors of stress among critical care nurses in Nablus public hospitals and work place

variable {ICU, CCU, ER, hemodialysis).

:ettingS .62

public hospitals in Nablus city.

:opulationP2.7

Population of this study involves both male and female nurses who are working in the

critical care units in Nablus public hospitals.

2.8 Sample:

A convenience sample of 50 nurses who are working in critical care units in Nablus

public hospitals.

2.9 Inclusion criteria:

* Nurse's age >= 21 years old .

* Nurses with at least 1 year of critical care experience

:ool of data collection T2.10

An adopted questionnaire (Hussein H (2003). Jordan magazine for applied sciences)

was distributed for nurses who are working in critical care units in Nablus public

hospitals, to identify the major sources of stress among them.

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Questionnaire consist of two parts :

qualification Demographic variables ( age, gender, marital status, scientific :Part one

, years of service, work place{ICU, CCU, ER, hemodialysis} ).

criteria that represent the major sources of stress among consist of 6 : Part two

critical care nurses, include the following :

1)- Workload.( points 1-12)

2)- Unfair policy of the hospital.(points 13-17) 3)- Conflict with physicians, nurses and supervisors.( points 18-23)

4)- Inadequate preparation to deal with the emotional needs of patients and their

families.(points 24-32)

5)- Dealing with death and dying, and appropriate decision making.(points 33-37)

6)- Lack of staff support.( points 38-40)

The answers depend on Likert Scale which consist of 4 scales : (strongly disagree (1), disagree (2), agree (3), strongly agree (4) ) .

:Field work2.11

Questionnaire were distributed for nurses who working in critical care units in Nablus

public hospitals, and distributed on two shifts (A&B). Questionnaires were filled by

the participants and returned to the researcher, then the researcher put questionnaires

in a closed file and sent it to the statistical analyzer to analyze data.

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Chapter three : Data analysis and results

This chapter includes a show for procedure, population, sample, reliability and

validity of the study. It includes also the statistical analysis for the results as the

following:

The procedure: the researchers used the procedure of field description

which is considered to be appropriate for this study ( descriptive inquiry )

Population: Both male and female nurses who are working in critical care

units in Nablus public hospitals .

Sample: a convenience sample of 50 nurses who are working in critical care

units in Nablus public hospitals .

These tables show the distribution of the study sample according to

its variables.

Table No (1): The sample distribution according to age

Age Frequency Percentage

21-25 13 26.0 26-30 18 36.0 31-35 8 16.0 36-40 7 14.0 46 and above 4 8.0

Total 50 100.0

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Table No (2): The sample distribution according to gender

Gender Frequency Percentage

Male 35 70.0

Female 15 30.0

Total 50 100.0

Table No (3): The sample distribution according to marital status

Marital status Frequency Percentage

single 20 40.0 married 23 46.0 separate from his wife/her husband

7 14.0

Total 50 100.0

Table No (4): The sample distribution according to Scientific Qualifications

Scientific Qualifications Frequency Percentage

diploma two years 16 32.0 diploma three years 12 24.0 bachelor 22 44.0

Total 50 100.0

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Table No (5): The sample distribution according to years of service

years of service Frequency Percentage

1-5 years 12 24.0 6-10 years 10 20.0 11-15 years 15 30.0 16-20 years 8 16.0 20 years and above 5 10.0

Total 50 100.0

Table No (6): The sample distribution according to work place

work place

Frequency Percentage

ICU 28 56.0 ER 15 30.0 hemodialysis 7 14.0

Total 50 100.0

Methodology: the researchers adopted the method of their research after

review related literatures.

Reliability: the researchers made sure that the study is reliable by presenting

it to many experts who represented that it is reliable and valid.

Study procedure: the study procedures were done according to the

following steps:

Final preparation of the study parts.

Determination of the study sample.

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Distribution of the study questionnaire.

Collecting the questionnaire from the sample, computerizing the results

and analyzing them using SPSS program.

Documenting the sample results.

Results collecting, and analysis3.1

1. Statistical processing

For processing of data the researchers used SPSS program using the following

statistical ways:

Frequencies and percentages.

Means and standard deviations.

T. test for 2 independent groups

One way ANOVA

Krounpakh α test for test stability which was (0.76) which is considered to be

acceptable for this test.

2. Study questionnaire results

This study aimed to identify the predisposing factors for stress (stressors)

among nurses working in critical care units in Nablus public hospitals.

For achieving the study goals the researchers adopted a questionnaire consists of

40 points according to 6 criteria that represent the major sources of stress among

critical care nurses and then they exposed it to many experts to make sure that it is

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reliable, next they distributed it to the sample and then collected, computerized, and

processed the results using SPSS program.

Here are the results according to its questions’ arrangement and its hypothesis:

The results related to study questionnaire: for answering the study questions and then collecting the percentages, means and standard deviations. The following table shows these results:

Table No (7):The questionnaire results, means, standard deviations, and

percentages

QN 1)- Workload.( points 1-12) Mean SD percentage

1. Having to accomplish a lot of work in a specific

time .

2.7600 .59109 55.20 %

2. Find difficulty to accomplish work in a specific

time .

2.8200 .66055 56.40 %

3. Having to work additional hours without taking

rest .

2.8800 .62727 57.60 %

4. Working additional hours to accomplish my work

on time.

2.6800 .81916 53.60 %

5. Working quickly to accomplish my work . 3.6000 .49487 72.00 %

6. My work is almost repeated and the same . 3.3600 .48487 67.20 %

7. Working under high pressure . 3.5800 .49857 71.60 %

8. Not enough staff to adequately cover the unit. 3.7000 .46291 74.00 %

9. presence of many patients make me stressful. 3.2400 .71600 64.80 %

10. Inadequate equipments and devices inside the

ward .

3.0800 .82906 61.60%

11. occupational safety and security unavailable 3.1400 .75620 62.80 %

12. not enough salads to achieve your accountability 3.0800 .75160 61.60 %

Total 3.1600 .30945 63.20 %

QN 2)- Unfair policy of the hospital.(points 13-17)

Mean SD percentage

13. the policies and instructions of hospitalization

unpredictable

3.4200 .64175 68.40 %

14. the rules and instructions inflexible 3.5200 .64650 70.40 %

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15. the task measuring system unsuitable 3.4000 .83299 68.00 %

16. the shifts system unsuitable 2.3200 1.13281 46.40 %

17. floating to other units/services that are short

staffed

3.0600 .73983 61.20 %

Total 3.1440 .55113 62.88 %

QN 3)- Conflict with physicians, nurses and supervisors.( points 18-23)

Mean SD percentage

18. difficulty in working with particular nurse (or

nurses) in my immediate work setting

2.8600 .96911 57.20 %

19. having to deal with abuse from physician. 2.3600 .94242 47.20 %

20. criticism by a physician 2.7400 1.02639 54.80 %

21. Inadequate information from a Dr. about health

status of pt.

2.8400 .95533 56.80 %

22. The supervisor use inappropriate pattern of

interaction with nurses and in managing his

department

2.4400 1.14571 48.80 %

23. Lack of support by nursing administrators 3.1400 .96911 62.80 %

Total 2.7300 .70862 54.60 %

QN 4)- The emotional needs of patients and their families.(points 24-32)

Mean SD percentage

24. Patients making unreasonable demands 3.4600 .64555 69.20 %

25. The clients are not cooperative to execute their therapeutic plan (like taking medications, nutritiontypes, Etc…)

3.3800 .85452 67.60 %

26. The client's family and visitors are not discipline (number, time of visit, keeping quiet, Etc…)

3.2800 1.03095 65.60 %

27. Difficulty in working with patients of the oppositesex

2.1400 .75620 42.80 %

28. Fear of making a mistake in treating a patient 2.8600 1.16075 57.20 %

29. I feel suffering when I perform procedure or testwhich cause pain to the client

3.1600 .68094 63.20 %

30. the client's suffering affects me physically and psychologically

2.7200 .80913 54.40 %

31. I have stress if I give care to patient in emergency case

3.3000 .46291 66.00 %

32. Not enough time to provide emotional support to the patient

3.5200 .50467 70.40 %

Total 3.0911 .30835 61.82

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QN 5)- Dealing with death and dying.(points 33-37)

Mean SD percentage

33. I feel un happy while listening and talking to a patient about his/her approaching death .

3.2400 .79693 64.80 %

34. I have stress if any patient died during my shift 3.0400 .85619 60.80 %

35. I have stress if physician(s) not being present when a patient dies

3.6200 .49031 72.40 %

36. My job confirm me to make a serious decision concerning a patient

3.3600 .63116 67.20 %

37. Having to make decisions under pressure 3.4800 .50467 69.60 %

Total 3.3480 .40569 66.96 %

QN 6)- Lack of staff support.( points 38-40)

Mean SD percentage

38. Lack of privet emotional support from other administrators

2.8000 .78246 56.00 %

39. head nurse support me if I have critical issue .

2.5800 .73095 51.60 %

40. Lack of emotional support from other health care provider due to nature of nursing as a job.

2.7800 .78999 55.60 %

Total 2.7200 .28856 54.40 %

Table No (8): this table show the predisposing factors for stress (stressors) with

its mean, SD, and percentages.

QN Predisposing factors for stress (stressors)

Mean SD percentage

1. Workload.( points 1-12) 3.1600 .30945 63.20 %

2. Unfair policy of the hospital.(points 13-17)

3.1440 .55113 62.88 %

3. Conflict with physicians, nurses and supervisors.( points 18-23)

2.7300 .70862 54.60 %

4. The emotional needs of patients and their families.(points 24-32)

3.0911 .30835 61.82

5. Dealing with death and dying.(points 33-37)

3.3480 .40569 66.96 %

6. Lack of staff support.( points 38-40)

2.7200 .28856 54.40 %

Total 3.0322 .32331 60.64 %

25

The previous table shows the following conclusion:

The major predisposing factor for stress (stressor) among critical care nurses in

Nablus public hospitals is dealing with death and dying with percentage (66.96%),

followed by workload with percentage (63.20%), followed by unfair policy of

hospital with percentage (62.88 %), followed by the emotional needs of the patients

and their families with percentage(61.82 %), followed by Conflict with physicians,

nurses and supervisors with percentage (54.60 %), and finally lack of staff support

with percentage (54.40 %) .

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Chapter four : Discussion and conclusion 4.1 Discussion First hypothesis:

“There is no significant statistical differences at α=0.05 between the

predisposing factors of stress among critical care nurses in Nablus public

hospitals and age variable. “ANOVA was made for the sample and the results

were as the following:

Table No (9): ANOVA test for age variable

Sum of Squares df Mean Square F Sig.

Between Groups 4.341 4 1.085 19.390 2.400

Within Groups 2.519 45 .056

Total 6.860 49

The previous table shows that Sig. level is 2.400 which is greater than level

assumed in hypothesis (0.05). So we accept the hypothesis and say that “there

is no significant statistical differences at α=0.05 between the predisposing


variable.

27

Second hypothesis:

“There is no significant statistical differences at α=0.05 between the


hospitals and gender variable. “T-Test was made for the sample and the results

were as the following:

Table No (10) : Group statistics

gender N Mean Std. Deviation Std. Error Mean

male 35 3.1821 .30406 .05140

female 15 3.3338 .49818 .12863

Table No (11) : Independent samples test

The previous table shows that Sig.level is 0.061 which is greater than

assumed grade in hypothesis (0.05). So we accept the hypothesis and say

“there is no significant statistical differences at α=0.05 between the


hospitals and gender variable.

T-Test for equality of means

f

Sig. t Df Sig. (2-tailed)

Mean

Difference

Std. Error

Difference

Equal variances assumed

11.486

.061

-1.324 48 .192 -.15174 .11459

Equal variances not

assumed

-1.095 18.631 .287 -.15174 .13852

28

Third hypothesis:

“There is no significant statistical differences at α=0.05 between the predisposing


experience variable. “ANOVA was made for the sample and the results were as the

following:

Table No (13): ANOVA test for work experience variable


Between Groups 2.714 4 .678 7.363 1.100


Total 6.860 49

The previous table shows that Sig. level is 1.100 which is greater than level

assumed in hypothesis (0.05). So we accept the hypothesis and say that “there

is no significant statistical differences at α=0.05 between the predisposing

factors of stress among critical care nurses in Nablus public hospitals and

work experience variable.

29

Fourth hypothesis :

“There is no significant statistical differences at α=0.05 between the predisposing

factors of stress among critical care nurses in Nablus public hospitals and work place

variable. “ANOVA was made for the sample and the results were as the following:

Table No (14): ANOVA test for work place variable


Between Groups 1.303 2 .651 5.510 .007


Total 6.860 49

The previous table shows that Sig. level is .007 which is less than level assumed

in hypothesis (0.05). So we reject the hypothesis and say that “there is

significant statistical differences at α=0.05 between the predisposing factors of

stress among critical care nurses in Nablus public hospitals and work place

variable.

30

Conclusions:

After data statistical analysis using SPSS program the study has the following

results :

results related to the questionnaire questions : :First

The major predisposing factor for stress (stressor) among critical care nurses in

Nablus public hospitals is dealing with death and dying with percentage (66.96%),

followed by workload with percentage (63.20%), followed by unfair policy of

hospital with percentage (62.88 %), followed by the emotional needs of the patients

and their families with percentage(61.82 %), followed by Conflict with physicians,

nurses and supervisors with percentage (54.60 %), and finally lack of staff support

with percentage (54.40 %) .

the results related to hypothesis: :Second

First hypothesis:

There is no significant statistical differences at α=0.05 between the predisposing


variable.

Second hypothesis:

There is no statistical differences at α=0.05 between the predisposing factors of stress

among critical care nurses in Nablus public hospitals and gender variable.

Third hypothesis:

There is no significant statistical differences at α=0.05 between the predisposing


experience variable.

31

Forth hypothesis:

there are statistical differences near α=0.05 about the predisposing factors of stress

among critical care nurses in Nablus public hospitals according to work place

variable.

32

Recommendations

1)- Nurses need to feel that they are involved in decision making especially

related to patient care issues. Therefore a more decentralized, democratic

management approach would be beneficial (Harris, 2001). It is imperative to

increase nurses’ visibility in the workplace by establishing programs that

recognize their contributions (Rosenstein, 2002).

2)- Break down barriers of communication between physicians and nurses,

and promote collaboration between nursing and medical services. This can be

accomplished by creating open forums, group discussions, and collaborative

workshops. Organizations must develop and strictly enforce policies for

disruptive behavior in the workplace (Rosenstein, 2002).

3)- Provide access to educational programs, not only in clinical areas, but in

teamwork, communication, family interactions, and stress management

(Rosenstein, 2002). Critical incident debriefing should be available, and

encouraged for ICU nurses (Caine & Ter-Bagdasarian, 2003).

4)- The development of an ethics forum would give nurses a place to express

their concerns. about end-of communication, family -life issues and other

ethical concerns. Membership would be for ICU bedside nurses. The forum

could also be used to educate nurses about ethical issues, and familiarize them

with relevant hospital policies (Perkin et al., 1997).

5)- Stress management programs are a quick fix for some of the real problems

in the work place, but may be beneficial when implemented along with other

interventions. Even the development of a simple program will promote good

faith that the organization is trying to alleviate the problem.

6)- Despite budget constraints nursing units must be staffed sufficiently. The

provision of ancillary support will at least take some strain off nurses that are

being underutilized by performing non nursing tasks (Harris, 2001).

Increasing flexibility of scheduling and shifts will enhance the workplace. The

addition of an on-site child care facility will facilitate work-life balance.

33

7)- Along the same lines as ethics forum is a peer support group led by an

independent facilitator. Skills and knowledge can be shared, enhancing team-

building. Other concerns and issues can be discussed as well. Just realizing

that someone else is feeling the same way that you do is significant in

reducing stress (Corr, 2000).

34

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.http://www.aacn.org/aacn/pubpolcy.nsf 2)- Caine, R. M., & Ter-Bagdasarian, L. (2003). Early identification and management of critical incident stress. Critical Care Nurse, 23(1), 59-65.

3)- Canadian Journal of Behavioral Science. 2004;35:73–83. Day, AL; Livingstone, HA. Gender differences in perceptions of stressors and utilization of social support among university students. 4)- Cohen-Katz, J., Capuano, T., Baker, D. M., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout, part II. Holistic Nursing Practice, , 26-35. Retrieved September 27, 2006, from Ovid data base.

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12)- Foxall, M. J., Zimmerman, L., Standley, R., & Captain, B. B. (1990). A comparison of frequency and sources of nursing job stress perceived by intensive care, hospice, and medical surgical nurses Journal of Advanced Nursing, 15, 577-584. Retrieved January 14, 2003 from EBSCO host.

13)- Greenfield , L. J. (1999). Doctors and nurses: a troubled partnership. Annals of Surgery, 230(3), Retrieved March 12, 2003 from Infotrac.

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15)- Hussein H (2003). Jordan magazine for applied sciences. 6(1), 96-123. 16)- Jezuit, D. L., (2000). Suffering of critical care nurses with end-of-life decisions. MEDSURG Nursing. 9(3), 145-153.

17)- Kirchhoff, K. T., Spuhler, V., Walker, L., Hutt, A., Cole, B. V., & Clemmer, T. (2000). End-of-life care: intensive care nurses’ experiences with end-of-life care. American Journal of Critical Care, 9 (1), 36. Retrieved 3-01-2003 from: http://www.aacn.org/AACN/jrnlajcc.nsf/GetArticle/ArticleSix91?OpenDocument

18)- McDonough, P. & Walters, V. (2001). Gender and health: Reassessing patterns and explanations. Social Science and Medicine, 52, 547-559.

19)- McGowan, B. (2001). Self-reported stress and it's effects on nurses. Nursing Standard, 15(42), 33-38. Retrieved September 28, 2006, from Ovid data base.

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Retrieved November 24, 2002 , from f603a5.pdhttp://www.mayo.edu/proceedings/2001/mar/7

29)- Solomon, M. Z., O’Donnell, L., Guilfoy, V., Wolf, S. M., Nolan, K., Jackson, R., et al. (1993).Decisions near the end of life: professional views on life sustaining treatments. American Journal of Public Health, 83(1), 14-22

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37

بسم الله الرحمن الرحيم

أخي الممرض / أختي الممرضة

السلام عليكم ورحمة الله وبركاته

بعد ، ،وتحية طيبة

ى استبانهبين أيديكم ى " التعرف عل ببات تھدف إل ا مصادر/مس ي يشعر بھ ضغوط العمل الت . الطاقم التمريضي في المستشفيات الحكومية في مدينة نابلس

ن فاھتمام عملي ومھني إن الباعث الرئيس ھو ابتكم ستعامل بمنتھى السرية ول حسب ، و إن إج

، وستستخدم لأغراض البحث العلمي فقط . الاسميطلب منكم ذكر

ة والموضوعية ، نكما مل منك الإجابة على تساؤلاتھا نأ وخي الدق ا وت رجو تعاونكم في تعبئتھ .موضوعية قدر الإمكان جمن أجل الوصول إلى نتائ

مرة أخرى نشكر لك حسن تعاونك .

الباحثون : أحمد عدنان إسراء الشيخ سمارهآيات عبد العزيز مصري كلية التمريضد عمي المشرفة :

سرحان د.عدنان حرز اللهأ . فاطمة

38

: : معلومات عامة الجزء الأول ا يرجى وضع إشارة ( ة ، كم ق xيرجى تعبئة البيانات المطلوب ارة التي تنطب رة/ العب ام الفق ) أم

عليك . : ) العمر ( بالسنوات - 1

[]21- 25 []26- 30 ] [31- 35

فوقفما -46[] 41-45[] 40 -36[]

[] أنثى [] ذكر الجنس : - 2 [] متزوج / ة [] أعزب/ عزباء : الاجتماعيةة الحال - 3

[] أرمل / ة [] مطلق / ة سنوات 3دبلوم [] [] دبلوم (سنتين) : المؤھل العلمي – 4[] ماجستير س[] بكالوريو

-------------------------------(أخرى ( حدد/ي )) سنوات الخدمة : - 5

[]5 - 1 []10 - 6 فأكثر 20[] 16- 20[] 11 - 15 []

مكان العمل : -6 [] ICU [] Hemodialysis[] ER

39

: الجزء الثاني

ببة لضغوط العمل 40يشتمل ھذا الجزء على ( ) عبارة تتعلق بالمؤشرات التنظيمية المختلفة المسة ( ع علام تبانة ووض ي الإس ارة واردة ف ل عب راءة ك ى ق ام ، يرج ل الأقس رقم ) أxداخ فل ال س

المناسب وفقا للمقياس التالي ، وبما أمكن من الدقة والموضوعية.

1 2 3 4 أوافق بشدة أوافق أعارض أعارض بشدة

: طبيعة العمل وظروفه. أولا

4 3 2 1 العبارةالرقم

يطلب مني إنجاز أعمال كثيرة في وقت محدد 1 المحدد أجد صعوبة في إنجاز مھام عملي في الوقت 2

3 رة ذ فت ة دون اخ اعات طويل ل س ل مواصلة العم از العم ب إنج يتطل

راحة أجد نفسي أعمل ساعات إضافية لانجاز مھام عملي في وقتھا 4 أثناء عملي يجب علي العمل بسرعة لإنجاز مھامي 5 العمل الذي أقوم به يغلب عليه التكرار والروتين 6 أجد نفسي أعمل تحت ضغط عال 7

8 ي ضغط دة يسبب ل عدم كفاية الكادر التمريضي على الوردية الواح

نفسي وجود عدد كبير من المرضى مما يسبب لي ضغطا في العمل 9 لا تتوافر كامل الأجھزة و المعدات والمواد اللازمة داخل القسم 10 ات الأمان والوقاية والسلامة المھنية غير متوفرةوسائل وإجراء 11 لا أتمتع بالسلطات الكافية لإنجاز مسؤولياتي 12

. وتعليمات المستشفى : سياساتثانيا

4 3 2 1 العبارةالرقم سياسات وتعليمات المستشفى غير محددة 13 التعليمات والقواعد المتبعة جامدة وغير مرنة 14 نظم قياس الأداء غير مناسبة 15 نظام الورديات / النوبات غير مناسب 16

ام 17 ى الأقس ن / إل ات م ين / الممرض ل الممرض ى نق ل الإدارة عل تعم باستمرار

( أطباء، ممرضين/ممرضات، مشرفين ) زملاء العمل والتعامل مع العلاقات طبيعة : ثالثا


18 م لا ي/ تعاملني الممرضين / الممرضات (الذين /اللواتي أعمل معھ

/ معھن) معاملة جيدة

40

لا يعاملني الأطباء (الذين أعمل معھم) معاملة جيدة 19 ينتقد الأطباء عملي 20 لا يمدني الطبيب بالمعلومات الصحية الكافية عن حالة المريض 21

22 ه م وتوجي ي إدارة القس با ف لوبا مناس رف أس ارس المش لا يم

الممرضين / الممرضات

23 ين ؤازرة للممرض اندة و الم دعم والمس رف ال دم المش /لا يق

الممرضات

والتعامل معھم العلاقات مع المرضى والزائرين طبيعة :رابعا

4 3 2 1 العبارةالرقم طلبات المرضى وشكواھم واستفساراتھملا تنقطع 24

25 ذ خطط ي تنفي وع لا يتعاون المرضى ف ة ون اول الأدوي م ( تن علاجھ

الغذاء ... الخ)

26 دد ، موعد ر منضبطين ( من حيث الع ذوو المرضى والزائرون غي

الزيارة ، والھدوء ، ... الخ ) مع مريض من الجنس الآخر أشعر بالإحراج عندما أتعامل 27 أثناء معالجة المريض أشعر بالخوف من ارتكاب أي خطأ 28 أتألم عندما أقوم بإجراء فحص أو تقييم لمريض ينتج عنه الألم 29 أتأثر نفسيا / جسديا عندما أرى المريض يتألم 30 ا نفسياتواجد المريض في حالة طوارئ يسبب لي ضغط 31 عدم توفر الوقت الكافي لتوفير الدعم العاطفي للمريض 32

خامسا : التعامل مع حالات الموت والاحتضار والقدرة على اتخاذ القرارات الحازمة


33 الحديث والاستماع للمريض عن إحساسه حول قرب وفاته يشعرني

بالضيق نفسيا بموت مريض داخل القسم الذي أعمل فيهأتأثر 34

35 ود دم وج احبة لع اة مص ة وف دوث حال د ح ي عن غط نفس عر بض أش

طبيب القسم يتطلب العمل اتخاذ إجراءات وقرارات حاسمة ذات مسؤولية كبيرة 36 الصائبة تفي اتخاذ القراراأن أكون مبتكرا ييتوجب عل 37

الدعم النفسي من زملاء العمل : ادسا س

4 3 2 1 العبارةالرقم أجد الدعم النفسي في أموري الخاصة من زملائي 38 رؤسائي في العمل يقدرون إذا مررت بظروف شخصية صعبة 39

40 ي ع زملائ ل م ي فرصة التعام وفر ل ي لا ت ة عمل دعم طبيع ي ال وتلق

النفسي منھم

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