A Study of Job Stress, Stress Coping Strategies, and Job Satisfaction for Nurses Working in Middle-Level Hospital Operating Rooms

Abstract

Background: 

Understanding the interactive relationships between demographics and work-related variables, job stress, job stress coping strategies, and job satisfaction for operating room (OR) nurses is important.

Purpose: 

The purpose of this study was to determine the stressors, the stress coping strategies, and the job satisfaction of nursing staff who worked in the OR and to evaluate influence of demographic characteristics on job stress, stress coping strategies, and job satisfaction.

Methods: 

A cross-sectional research design was used to collect data. Participants included 121 nurses with more than 6 months of work experience at seven hospitals in Yunlin and Chiayi Counties. Data were collected from March through May 2008. One hundred twelve questionnaires were returned, giving a response rate of 92.56%. The questionnaire included four parts designed to gather data on demographics and work-related information, job stress, stress coping strategies, and job satisfaction.

Results: 

Major findings of this study were as follows: (a) stress level and frequency perception of OR nurses were significantly related to the type of hospital; (b) the most intense stressor perceived by OR nurses was patient safety; (c) the stressor most frequently perceived by OR nurses was administrative feedback; (d) although all job stressors were positively related to destructive stress coping strategies, professional status, patient safety, and OR environment were also positively related to constructive stress coping strategies; (e) factors including work rewards, OR environment, and administrative management of job satisfaction were inversely related to destructive stress coping strategies; and (f) factors including work rewards, OR environment, and administrative management of job satisfaction were inversely related to all job stressors.

Conclusions/Implications for Practice: 

Major suggestions of this study include the following: (a) hospitals should ensure set standard operating procedures for the OR, strengthen the designed-in security of the OR working environment, and provide adequate safety protection equipment to safeguard OR staff and patients; (b) the OR department should increase the quantity and the quality of stress relief courses; (c) the OR department should improve the OR environment and the administrative management skills; and (d) the OR department should offer self-esteem-related training programs to assist OR nursing staff to adopt constructive stress coping strategies.

Introduction

Nurses are the backbone of the medical system and act as the first line of patient medical care. Therefore, nursing quality is one of the most important factors determining medical service performance. Nursing work is one of the most stressful and challenging vocations because of its need for specialization, complexity, and requirement to handle emergency situations (^{Benoliel, McCorkle, Georgiadou, Denton, & Spitzer, 1990; Su, 1993}). The negative influence of job stress on nurses and hospitals is manifested through absence, unhealthiness, staff conflict, depression, staff turnover, and inferior service (^{Foxall, Zimmerman, Standly, & Captain, 1990; Larson, 1987; Price & Murphy, 1984}).

Prior studies have identified sources of job stress for nurses (^{Gray-Toft & Anderson, 1981; Huang, Hwang, Lin & Sun, 2001; Lee & Wang, 2002}), tested the frequency of stressors (^{Foxall et al., 1990; Wu, 1993}), determined factors related to job satisfaction (^{Chung, Chen & Huang, 2004; Mueller & McCloskey, 1990}), and explored job stress coping strategies (^{Dewe, 1993; Gribbins & Marshall, 1982}).

A number of findings relevant to this area have been already made. Nurse demographics are correlated with job stress (^{Huang et al., 2001; Wu, 1993}), stress response (^{Su, 1993}), and job satisfaction (^{Chung et al., 2004}). Nurse job satisfaction correlates inversely to stress (^{Healy & Mckay, 2000; Leung, Spurgeon, & Cheung, 2007}), job stressors are positively related to stress response (^{Su, 1993}), nurses adopt positive stress coping behaviors more often than negative behaviors (^{Shih & Chou, 2002}), and job stress correlates positively to negative stress coping strategies (^{Su, 1993}).

The operating room (OR) is one of the most stimulating and challenging hospital units in which nurses work. Characteristics that lead nurses to experience pressure in the OR include the need to work quickly, to face higher medical dispute risks, to work uncertain shifts, to handle precision instruments, and to master complex techniques. According to previous studies, the OR is a unit of the hospital characterized by elevated stress and lower satisfaction (^{Chang & Hsu, 2000; Foxall et al., 1990; Su, 1993}).

Job satisfaction affects quality of life (^{Yu et al., 2008}). To promote OR nurse work performance and life quality, it is important to study the interactive relationships between demographics and such factors as work-related variables, job stress, job stress coping strategies, and job satisfaction.

Because of differences in patient conditions, workload, and instruments among different types of hospitals, OR nurses in different working environments may perceive job stress and job satisfaction differently and as a result adopt different stress coping strategies. Our review of the literature found that no single study has addressed the issues of job stress, job stress coping strategies, and job satisfaction for OR nurses working in different types of hospitals. Furthermore, no study focused on the relationship between job stress, stress coping strategies, and job satisfaction in OR nurses.

Therefore, the objective of this study was to investigate job stress, stress coping strategies, and job satisfaction in OR nurses working at different hospital types and relationships between these factors. The conceptual framework for this study is illustrated in Figure 1.

Figure 1: Operating room nurses' personal demographic data may affect stress level perception and stress frequency perception. Job stress correlates with job satisfaction, which, in turn, correlates with stress coping strategies.

Methods

Participants

The researcher first contacted the chiefs and the head nurses in the OR departments of hospitals in Yunlin and Chiayi counties and explained the purpose and the procedure of this research to determine willingness to participate. Five regional teaching hospitals (RTHs) and two community teaching hospitals (CTHs) agreed to participate. Among the 121 OR nurses agreeing to participate, 112 (92.56%) completed all questionnaires. All participants were basic-level nurses working in the OR who had been employed for more than 6 months.

Instruments

The questionnaire used in this study included four elements covering a demographic and work-related data, a stressor scale, a stress coping strategy scale, and a job satisfaction scale. All items in the questionnaire were designed in reference to former studies (^{Chang & Hsu, 2000; Chung et al., 2004; Dewe, 1987; Foxall et al., 1990; Gray-Toft & Anderson, 1981; Huang et al., 2001; Mueller & McCloskey, 1990; Su, 1993; Wu, 1993}) and were evaluated and modified by nine scholars and practitioners with relevant expertise.

Demographic and work-related data included age, marital status, number of children, religion, education level, years of nursing experience, professional career status (including experience at other hospitals, experience in other departments, years employed in the present hospital, and years employed in the OR), whether the position was voluntary or appointed, whether the respondent had attended courses for dealing with stress or not, shift arrangement, professional title, salary, and hospital type.

The stressor scale consists of two parts: stress level perception and stress frequency perception. It is a 57-item questionnaire. The stress level perception scale was measured with a 5-point Likert scale ranging from 1 (no pressure) to 5 (extreme pressure). The stress frequency perception scale was also measured with a 5-point Likert scale ranging from 1 (never) to 5 (always). Factor analysis was used to determine the factor structure of the stressor scale. According to the Kaiser-Eigen value criterion of 1 for determining the structure of factors (^{Kim & Mueller, 1978}), seven subscales were extracted from the 57 items. The alpha reliability coefficients of the seven subscales of the stressor scale were between .84 and .94. The subscales of the stressor scale are as follows: professional status (13 items), patient safety (4 items), OR environment (10 items), patient care (9 items), administrative management (9 items), interpersonal relationships (9 items), and administrative feedback (3 items).

The stress coping strategy scale covered a 25-item questionnaire. Stress coping strategy was measured with a 5-point Likert scale ranging from 1 (never) to 5 (always). Factor analysis was used to determine the factor structure of the stress coping strategy scale. According to the Kaiser-Eigen value criterion of 1 and the scholars' suggestions for determining the structure of factors, two subscales were organized from the 25 items. Alpha reliability coefficients for the two stress coping strategy subscales were between .80 and .84. These subscales covered the aspects of constructive strategy (11 items) and destructive strategy (14 items).

The job satisfaction scale was arranged as a 27-item questionnaire, with job satisfaction measured according to a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Factor analysis was used to extract the factor structure of the job satisfaction scale. Five subscales were extracted from the 26 items (the total satisfaction item was not included). Alpha reliability coefficients for the five subscales of job satisfaction fell between .61 and .89. Subscales covered the aspects of work rewards (5 items), OR environment (9 items), self-esteem (2 items), administrative management (8 items), and job ability (2 items).

Statistical Analysis

Data from completed questionnaires were processed and analyzed using SPSS version 10.0 (SPSS Inc., Chicago, IL). Descriptive statistics such as mean value and standard deviation were used to describe participant characteristics, stress level perception, stress frequency perception, stress coping strategies, and job satisfaction. Independent t test, analysis of variance (ANOVA), and Pearson's correlation were used to determine correlations between stress level perception, stress frequency perception, stress coping strategies, and job satisfaction based on variable characteristics. The level of significance for this study was set at .05.

Results

Demographic Data and Work-Related Variables

Demographic data and work-related variables for the 112 nurses in this study are shown in Table 1. All were women. The mean age of the participants was 32 years (SD = 5.80 years, range = 21-48). A slight majority were single (53.6%), professed no religious beliefs (55.4%), and received their basic education in junior college (57.1%). Most had 1 to 10 years of nursing experience. In terms of their career, 60.7% had nursing experience in another hospital, 78.6% had never worked in another department, 50.9% had nursing experience in their present hospital less than 5 years, and 68.7% had 1 to 10 years of OR nursing experience. Most (81.3%) voluntarily accepted service in OR. Only 25.9% had attended stress release training. Most (92.0%) needed to work variable shifts, 42.0% had salaries between NT$35,001 and NT$40,000. Most (88.4%) worked in RTHs, whereas the remainder (11.6%) worked in CTHs.

TABLE 1: OR Nurse Demographic Data and Work-Related Variables (N = 112)

TABLE 1: Continued

Job Stress Level Perception

The mean stress level perception score was 3.01. Among the seven stress scale subscales, patient safety was rated highest (M = 3.39, SD = 1.01), followed by administrative feedback (M = 3.18, SD = 0.95), OR environment (M = 3.10, SD = 0.83), administrative management (M = 3.01, SD = 0.71), professional status (M = 3.00, SD = 0.74), patient care (M = 2.91, SD = 0.67), and interpersonal relationships (M = 2.64, SD = 0.67).

According to a one-way ANOVA and a t test of stress level perception of the seven job stressors for each demographic data and work-related variables, the variable of type of hospital showed significant variance in terms of professional status (t = 2.51, p = .02), with nurses employed at RTHs perceiving greater professional status stress than those employed at CTHs. The professional title variable showed significant variance in terms of patient safety (t = −2.07, p = .04), with registered nurses perceiving greater stress attributable to patient safety rather than the licensed vocational nurse peers. The variable of whether the position was voluntary or appointed shows significant variance in terms of administrative management (t = −2.46, p = .02). Nurses who served voluntary in the OR perceived lower administrative management stress than those who had been appointed. Furthermore, variables including number of children (F = 2.78, p = .04), shift arrangement (t = −2.91, p = .01), and type of hospital (t = 2.86, p = .01) show significant variance in terms of administrative feedback, whereas nurses who worked in changing shifts or those employed at RTHs perceived greater administrative feedback stress (see Table 2). After a Scheff's test, we found that nurses with no children perceived greater administrative feedback stress than those who had more than two children.

TABLE 2: Summary of Analysis of Variations for Stress Level Perception (N = 112)

TABLE 2: Continued

Job Stress Frequency Perception

Mean score for stress frequency perception was 3.05. Among the seven subscales of the stressor scale, administrative feedback was rated highest (M = 3.28, SD = 0.92), followed by patient safety (M = 3.21, SD = 1.02), administrative management (M = 3.16, SD = 0.70), OR environment (M = 3.11, SD = 0.80), professional status (M = 3.08, SD = 0.72), patient care (M = 2.95, SD = 0.72), and interpersonal relationships (M = 2.76, SD = 0.66).

According to a one-way ANOVA and a t test of job stressor frequency for each demographic characteristic and work-related variable, the age variable shows significant variance in terms of professional status (F = 3.32, p = .02). Variables of age (F = 4.93, p = .00), years employed at their present hospital (F = 2.53, p = .04), years employed in the OR (F = 3.45, p = .01), and whether the position was voluntary or appointed (t = −2.03, p = .05) each show significant variance in terms of administrative management stress. Nurses who reported serving voluntarily in the OR perceived lower administrative management stress frequency than those reporting having been appointed. The variable of hospital type showed significant variance in terms of interpersonal relationships (t = 2.25, p = .04) and administrative feedback (t = 2.46, p = .02), with nurses employed at RTHs perceiving a higher frequency of interpersonal relationship and administrative feedback stress than those employed at CTHs.

After a Scheff's test, we found that participants older than 40 years and who had worked in the OR for more than 20 years perceived more frequent administrative management stress than others.

Stress Coping Strategy

The mean score for stress coping strategy with regard to constructive stress coping strategies was 3.63 (SD = 0.5). The destructive stress coping strategies score was 2.66 (SD = 0.52). The most frequently occurring 10 stress coping strategy behaviors all belong to the constructive strategy category.

According to a one-way ANOVA and a t test of job stress coping strategies for each demographic characteristic and work-related variable, the variables of marital status (F = 3.48, p = .03) and number of children (F = 3.73, p = .01) showed significant variance in terms of destructive coping strategies.

After a Scheff's test, we found that nurses who were single or had no children more frequently adopted destructive stress coping strategies than the others.

Job Satisfaction

The mean score for job satisfaction was 2.96. Among the five subscales of the job satisfaction scale, job ability scored highest (M = 3.26), followed by self-esteem (M = 3.07) and OR environment (M = 2.96). The subscale work rewards (M = 2.40) was the lowest scoring satisfaction subscale (see Table 3). The lowest three job satisfaction indexes included overtime pay (M = 2.20, SD = 0.88), on duty pay (M = 2.20, SD = 0.93), and night shift pay (M = 2.29, SD = 0.92).

TABLE 3: Summary of Analysis of Variations for Job Satisfaction (N = 112)

TABLE 3: Continued

According to a one-way ANOVA and a t test of job satisfaction for each demographic characteristic and work-related variable, variables of having attended courses for coping with stress (t = −2.15, p = .04), shift arrangement (t = 2.58, p = .02), and type of hospital (t = −2.45, p = .03) showed significant variance in terms of work rewards. Nurses who had participated in courses dealing with stress management, worked according to a varying shift schedule, or were employed at CTHs perceived higher work reward satisfaction. The variable of salary showed significant variance in terms of OR environment (F = 3.11, p = .01). The variables of years employed in nursing (F = 2.77, p = .03), years employed in their present hospital (F = 2.71, p = .03), salary (F = 3.55, p = .01), and type of hospital (t = −2.73, p = .02) showed significant variance in terms of self-esteem. Nurses employed at CTHs perceived higher self-esteem satisfaction than those employed at RTHs (see Table 3).

Using a Scheff's test, we found that nurses with monthly salaries less than NT$30,000 perceived lower OR environment satisfaction than others. Participants employed in nursing for more than 20 years perceived higher self-esteem satisfaction than those who had been employed in nursing for 1 to 5 years. Furthermore, those employed in their present hospital for more than 20 years perceived higher self-esteem satisfaction than those employed in their present hospital for less than 5 years. Finally, those with monthly salaries less than NT$30,000 perceived lower self-esteem satisfaction than others.

Relationships Between Job Stress, Stress Coping Strategies, and Job Satisfaction

After the Pearson's correlation coefficient test, we found that among the seven subscales of the stressor scale, professional status, patient safety, and OR environment correlated positively with constructive stress coping strategies. All subscales of the stressor scale correlated positively with destructive stress coping strategies (see Table 4).

TABLE 4: Pearson Correlation Between Stress Level Perception and Stress Coping Strategies

After the Pearson's correlation coefficient test, we found that among the seven subscales of stressors, the stress level perception of all subscales correlated positively with the frequency reception of all subscales.

After the Pearson's correlation coefficient test, we found that among the five subscales of job satisfaction, satisfaction with work rewards, OR environment, and administrative management correlated inversely with stress level perception. The self-esteem subscale correlated inversely with stress level perceptions of patient care, administrative management, interpersonal relationships, and administrative feedback subscales (see Table 5).

TABLE 5: Pearson Correlation Between Stress Level Perception and Job Satisfaction

After the Pearson's correlation coefficient test, we found that in the five job satisfaction subscales, satisfaction with work rewards, OR environment, and administrative management all correlated inversely with frequency of adopting destructive stress coping strategies. Self-esteem satisfaction correlated positively with frequency of adopting constructive stress coping strategies (see Table 6).

TABLE 6: Pearson Correlation Between Job Satisfaction and Stress Coping Strategies

Discussion

Demographic Data and Work-Related Variables

Data analysis in this study showed that OR nurses older than 40 years who had been working at their present hospital for more than 20 years or had been working in the OR for more than 20 years perceived higher frequency of all job stress factors compared with their younger counterparts. However, of all such, only differences on the administrative management subscale registered statistical significance. These findings are consistent with those of ^{Mao and Lee (1992)} but not of ^{Wu (1993)}. This is possibly due to the physical and mental condition of the elder OR nurses not being optimal for OR nursing work because OR nurses must work under situations that are fluid and rapidly changing, handle precision instruments, and learn advanced techniques. However, in this study, only eight nurses were older than 40 years, five had been working at their present hospital for more than 20 years and three had been working in the OR for more than 20 years. Therefore, the above conclusion should be applied only with appropriate care. It is suggested that future research may target this issue.

We found that nurses with more than two children perceived the lowest level of job stress across all factors and that those with no children experienced the highest job stress level. These findings are similar to those of ^{Su (1993)}, but not ^{Lee (1989)}. It may be that nurses who have more children place more value on their family and have more life experiences than those with no children. Because only eight nurses had more than two children in this study, the above conclusions should also only be applied with appropriate care.

This study found that nurses who voluntarily served in the OR perceived lower frequency of job stress across all factors than those who had been appointed, although only the administrative management subscale achieved statistical significance. This could be inferred by the possibility that nurses who volunteered for service in the OR were already aware of and prepared for the complex nature of OR work. It can therefore be recommended that volunteers be given priority consideration when superintendents of hospitals recruit nurses for the OR.

This study showed no significant difference in level or frequency perception of stress between nurses who had participated in courses dealing with stress management and those who had not. Only 25.89% of OR nurses in this study had participated in such courses. Stress management training hours for OR nurses may not be long enough and stress management courses may not be of sufficient quality. To assist OR nurses to deal more effectively with job stress, access to training and quality of stress reduction courses should be improved.

This study also showed that nurses employed at RTHs compared with those employed at CTHs perceived more stress and reported a higher frequency of job stress, resulting in lower job satisfaction. In Taiwan, OR nurse workload in higher level hospital practice has increased, with increasing multiple, complex, and critical patient care problems. It is suggested that the administrative department of hospitals design appropriate management and reward systems for OR nurses based on the type of hospital they operate.

Job Stress

Study analysis shows that patient safety accounted for the highest stress level perception among OR nurses. This is related to OR work being high risk and including many emergency situations as well as to keen public awareness of the patient safety issues and the high incidence of medical disputes, which are frequently reported in the media (^{Lin, Chen, & Hou, 2007}). It is strongly recommended that hospitals implement standard operating procedures in the OR, strengthen OR working environment security design, and provide safety protection equipment adequate to safeguard OR staff and patients.

Study findings show that administrative feedback was most frequently cited factor in job stress, followed by patient safety. These findings are similar to previous research findings (^{Huang et al., 2001; Su, 1993}). The high profile role of administrative feedback in stress frequency may be attributed to intense competition within the medical industry, competition that places great emphases on reducing costs and workforce and raising efficiency.

Job Satisfaction

Analysis shows that work rewards accounted for the lowest job satisfaction. Overtime pay, on duty pay, and night shift pay comprised the lowest job satisfaction indexes. These findings are consistent with those of previous studies (^{Chang & Hsu, 2000; Chung et al., 2004}). A suggestion is for the OR nurse reward system to take into account nonfixed shifts, workforce, and stress levels in the OR. The improvement of job satisfaction for OR nurses and the encouragement of constructive stress coping behaviors should be urgently considered.

Relationships Between Job Stress, Stress Coping Strategies, and Job Satisfaction

Analysis shows that job stressors all relate positively to destructive stress coping strategies. However, professional status, patient safety, and OR environment were also positively related to constructive stress coping strategies. These findings are also similar to those of previous studies (^{Cheng, Tsai, & Chen, 1999; Su, 1993}). It is possible that appropriate stress is helpful for OR nurses to adopt constructive stress coping strategies whereas excessive stress encourages OR nurses to adopt destructive stress coping strategies (^{Cheng et al, 1999; Lee, 1992}).

Analysis of this study shows that all job stressors were related inversely to work rewards, OR environment, self-esteem, and administrative management of job satisfaction. These findings are consistent to those of previous studies (^{Cimete, Gencalp, & Keskin, 2003}). It is suggested that the OR manager should measure the perception level of job stress of OR nurses and help nursing staffs adapt to job stress and promote job satisfaction and life quality.

Further, analysis of this study shows job satisfactions scores for work rewards, OR environment, and administrative management to be inversely related to destructive stress coping strategies. These findings are consistent with those of previous studies (^{Healy & Mckay, 2000}). It is suggested that the OR department should improve the OR environment, the administration management skills, and the rationalization of OR work rewards system to reduce the probability of destructive stress coping strategies adoption.

Results of this study show the perception of self-esteem job satisfaction to be positively related to constructive stress coping strategies and inversely related to the level of job stress perception of patient care, administrative management, interpersonal relationships, and administrative feedback factors. These findings are consistent with those of a previous study (^{Lee, 1989}). It is suggested that the OR department should offer self-esteem and assertiveness-related training program to assist the OR nursing staff adopt constructive stress coping strategies.

Conclusions

The foremost finding of this study is that perception of the level and frequency of stressors and job satisfaction for OR nurses is significantly related to different types of hospitals. OR nurses working at RTHs perceive more frequent and more intense job stress and lower job satisfaction than those working at CTHs.

Another finding of this study is that patient safety accounted for the highest stress level perception score of all OR nurse job stressors. Administrative feedback accounted for the most frequently perceived stress faced by OR nurse job stressors.

The third finding of this study is that the job stressors of professional status, patient safety, and OR environment are positively related to constructive stress coping strategies. All job stressors are positively related to destructive stress coping strategies. Job satisfaction factors including work rewards, OR environment, and administrative management were found to be related inversely to destructive stress coping strategies. The job satisfaction factors of work rewards, OR environment, and administrative management were found inversely related to all job stressors.

Previous researchers focused only on medical centers or on one type of hospital. Instead, this study contributes to filling the gaps in the research on OR staff. This study also provides further findings on the relationships between job stress, job stress coping strategies, and job satisfaction.

However, participants of this study were limited to those serving in middle-level hospitals in Yunlin and Chiayi counties in Taiwan. The conclusions of this research may not apply to OR nurses at hospitals of other levels or those working in other regions or countries.

Acknowledgments

The authors acknowledge the study participants and the chiefs and head nurses of the Changhua Christian Hospital Yunlin Branch, the China Medical University Beigang Hospital, the Chia Yi Hospital, the National Taiwan University Hospital Yunlin Branch, the St. Martin De Porres Hospital, the Buddhist Tzu Chi General Hospital Dalin Branch, and the St. Joseph's Hospital. Grateful appreciation also goes to the St. Joseph's Hospital for its grant (No. 9703).