Background and Aim
Several researchers have described the nurses’ work as stressful and that the incidence of the occupational stress-related burnout in the profession was high. The aim of this study was to establish the relationship between the nurses’ satisfaction, their psychosocial work environment, the levels of their reported moral sensitivities and their well - being in Iran.
Material and Methods
This descriptive-correlation study was performed at the ILAM general hospitals, IR, during the year 2011. The research instruments which were used were the Psychosocial Work Environment (PWE), the Moral Sensitivity (MS) and the well-being profile of the nurses. A sample of 120 Registered Nurses (RN) were enrolled in the study by using a simple random sampling method. The descriptive statistics and the Pearson’s correlation test were performed by using SPSS.
Result
The relationship of the nurses’ satisfaction and their psychosocial work environment was moderate (M=106.5, SD= 7.2) . The nurses’ moral sensitivity was moderate (M=112.3, SD= 11.2).This study found that there were significant correlations between the PWE factors score and the MS subscale (P< 0.05, p<0.01). In addition, significant correlations were found between the nurses’ well-being and the PWE factors (P< 0.05, p<0.01).
Discussion and Conclusion
These findings proved that the nurses perceived their PWE as stressful. The supporting nurses may have a positive effect on their perceptions of well-being. The attending nurses reported less physical symptoms, reduced anxiety and fewer feelings of not being in control.
Introduction
The hospital practice environment has a significant effect on the nursing and the patient outcomes [1,2]. Several researchers have described the nurses’ work as stressful. A review of the employee stress in healthcare settings across 17 countries found that the nurses in a majority of the countries experienced high levels of stress and strain [3].
Butterworth et al’s (1999) research on stress, coping, burnout and job satisfaction among British nurses showed that the occupational stress levels were rising in the profession [4]. It has been reported that 40% of the hospital nurses suffered from burnout and that one in five hospital nurses considered leaving work within the next year. Nurses experience considerable stress in their job because they have long working hours, a wide range of tasks, and implicated relationships with the patients, their families, doctors and other co-workers [5].
Also, nurses are considered to be particularly susceptible to burnout. According to two European epidemiological studies, burnout affects approximately 25% of all the nurses [6]. Working under pressure, stress and dissatisfaction with the working hours, a high workload, lack of autonomy, conflicts with physicians and non supportive work conditions are some of the negative factors which are seen among nurses [7-11]. The issues of job stress, coping, and burnout among nurses are of universal concern to all the managers and administrators in the area of health care [12].
The estimated cost of stress related illnesses in the U.S. industry was reported in 1995 as approximately $ 13,000 per employee in an profession per year [10]. The percentage of absenteeism which is due to illnesses among the health care workers is quit high [13]. It has been suggested that the nature of work , the organizational change and the pressure at work, all contribute to the high levels of ill health. The poor psychological health and the high levels of sickness absence within the healthcare professions are likely to lead to a poorer quality of patient care [3].
Borrill et al (1996) surveyed over 11000 NHS staff and found more than 28% of the nurses suffered at least minor mental health problems [14]. Wall et al., (1997) found that 27% of the health care staff suffered serious psychological disturbances as compared to 18% of the general working population [12].
The nurses’ dissatisfaction, burnout, exhaustion and stress have also been associated with a lower quality of care and negative patient outcomes. Dugan et al. (1996) found a relationship between the nurses’ stress and the patient falls and medication errors. Koivula et al. (1998) reported that the nurses’ exhaustion prevented them from having necessary prerequisites for a quality improvement, while Laschinger and Leiter (2006) found that their emotional exhaustion was related to greater patient adverse events [15].
When the nurses feel dissatisfied with their work, they have a tendency to distance themselves from the patients, from the nursing tasks [16], and from their inner selves. Furthermore, the nurses who feel that their efforts are not fully appreciated, tend to leave the profession [17].
During their education, nurses learn the importance of the ethical practice, of being the patients’ advocates and of caring. Their ability to provide a high-quality care influences their perception of the job satisfaction. In addition, the nurses’ collaboration with other health care personnel can influence their job satisfaction. Collaboration with other professionals as well as with colleagues is important for their professional development and quality of care, and it is an important issue for the clinical nurse leadership [18].
In a study, Ellefsen (2002) found that the nurses in both Scotland and Norway experienced stress with respect to their public relationships, as well as tension in their collaboration with other professionals. The findings from research studies which investigated what the staff perceived as creating job satisfaction in their psychosocial work environment, as well as the ethical dilemmas which were experienced within the acute psychiatric care, showed that the factors which contributed to the job satisfaction or dissatisfaction could be related to the nurses’ value system [19]. The ethical dilemmas were specifically concerned with how to care for and handle the work in relation to the patient autonomy and how to approach the patient [20].
In nursing, the satisfaction with the psychosocial work environment is especially important because of the intrinsic aspect of the work and its potential to improve the patient care. When intrinsic conditions are present, the motivation levels increase, and, thus, the retention increases.
The aim of this study was to establish the relationship between the nurses’ satisfaction, their psychosocial work environment, the levels of the reported moral sensitivity and the well - being among nurses in Iran. It was hypothesized that the higher scores of the satisfaction with the psychosocial work environment may be associated with higher levels of the measured moral sensitivity and well-being.
Material and methods
This was a descriptive - correlation study that was performed at the ILAM hospitals, IR, Iran, during the year 2011. This study was approved by the institutional review board. The research instruments which were used were three questionnaires on the subjects of the nurses’ satisfaction with their psychosocial work environment ( PWE), their moral sensitivity (MS) and their well-being profile. A demographic questionnaire was also distributed and the items which were included were age, gender, state marriage and work experience.
The Work Environment Questionnaire (WEQ), contained the areas of job satisfaction and PWE: commitment to their career, influence on their duties, routines, communication, meaningful work, organizational changes, workload, job stress, job motivation, job expectations and security at work [21]. The instrument consisted of 29-items which were answered on a 6-point Likert scale which was anchored by the terms, ‘strongly disagree’ (1) and ‘strongly agree’ (6). The content validity, construct validity and the reliability of the WEQ had been previously established (the overall α-coefficient was 0.91) [20]. In this study, the reliability of the WEQ was 0.73. The Moral Sensitivity Questionnaire (MSQ) consisted of 27-items which were answered on a 7-point Likert scale. This questionnaire was designed to investigate: benevolence or a moral motivation to do good, focusing on an interpersonal orientation, such as building a trusting relationship with the patient and finding ways of responding to his/her individual needs; a structural moral meaning, which concerned ways of deriving a moral meaning from the decisions which were made and actions which were taken; modifying the autonomy, which referred to a strategy which was taken when a nurse perceived the need to limit a patient’s autonomy, while at the same time recognizing the principle of self-choice; and experiencing both a moral conflict and confidence in the medical and nursing knowledge. The content validity, construct validity and the reliability of the MSQ had been previously established (α-coefficient 0.73) [18]. In this study, the reliability of the MSQ was 0.78. The nurses were asked to rate their level of agreement with the statements. Higher scores indicated a more positive attitude towards the nurses’ moral sensitivity [18]. The well-being scale consisted of physical symptoms and anxiety, feelings of being nor being in control, engagement and motivation and eye- and sleep problems [18].
The target population comprised all the nurses who were working within 3 general hospitals within ILAM. By using a simple random method, a sample of 120 registered nurses (RNs) was selected. The entrance criteria included the nurses who were in service for more that 1 year and the exclusion criteria included the nurses who were not interested in the study. The research instruments, along with a demographic questionnaire, were distributed to the nurses. Descriptive and inferential statistical analyses were performed by using the Statistical Package for Social Sciences Program, Version 11.5 (SPSS). The Pearson’s correlation analysis was used to test the study hypotheses. A p-value of <0.05 was regarded as significant.
Results
The mean age of the nurses was 34(5.2) years and 80(66.6%) were women. The mean work experience of the nurses was 8.6(5.4) years, and 90(75%) were married.
The outcome of the items which concerned the nurses’ view of their PWE resulted in six factors, as has been presented in Table 1. The nurses’ satisfaction with their psychosocial work environment was moderate (M=106.5, SD= 7.2) [see Table/Fig-1].
The nurses’ moral sensitivity was moderate (M=112.3, SD= 11.2). A 7-factor analysis was chosen for the responses which were related to the MS in nursing care. These factors reflected the nurses’ grounds for the actions, ethical conflicts, values in the care independence, the patient-oriented care, the desire to provide high-quality care and the desire to provide high -quality care creates ethical dilemmas [see Table/Fig-1].
Mean value and SD for scale and subscale
| Scale | n | Mean | SD | score range |
|---|
| PWE |
| Total score | 120 | 106.5 | ±7.2 | 29-174 |
| Job stress and anxiety | 120 | 24.4 | ± 2.3 | 6-36 |
| Relationship with colleagues | 120 | 27.6 | ±3.2 | 7-42 |
| Collaboration and good communication | 120 | 15.4 | ±2.8 | 4-24 |
| Job motivation | 120 | 16.8 | ±5.3 | 5-30 |
| Work demands | 120 | 6.7 | ±1.2 | 2-12 |
| Professional development | 120 | 2.8 | ±1.1 | 1-6 |
| MS |
| Total score | 120 | 112.3 | ±11.2 | 27-189 |
| Ground for actions | 120 | 14.3 | ±2.1 | 4-28 |
| Ethical conflicts | 120 | 19.5 | ±3.4 | 5-35 |
| Values in care | 120 | 13.3 | ±2.8 | 4-28 |
| Independence | 120 | 10.6 | ± 1.8 | 3-21 |
| Patient-oriented | 120 | 13.4 | ±4.1 | 4-28 |
| The desire to provide quality care | 120 | 13.8 | ±2.1 | 4-28 |
| The desire to provide quality care creates ethical dilemmas | 120 | 11.4 | ±2.8 | 3-21 |
Correlations between PWE and MS factors for nurses
| PWE | Job stress and anxiety | Relationship with colleagues | Collaboration and good communication | Job motivation | Work demands | Professional development | Total score |
|---|
| MS |
| Grounds for Actions | 0.26* | -0.32** | 0.38** | 0.28* | -0.31* | 0.24* | 0.41** |
| Ethical conflicts | -0.44** | 0.31* | -0.29* | -0.40** | 0.22* | -0.40** | 0.52** |
| Care values | -0.19 | 0.22* | 0.27* | -0.17 | 0.19 | 0.21* | -0.31* |
| Independence | -0.14 | 0.38** | 0.33* | 0.28* | 0.29* | -0.33** | 0.25* |
| Patient-oriented Care | 0.18 | -0.18 | -0.20* | -0.34** | -0.26* | -0.18 | -0.27* |
| The desire to provide high quality care | -0.29* | 0.25* | 0.35** | 0.31* | -0.23* | -0.24* 0.38* | |
| The desire to provide high quality care creates ethical dilemmas | - 0.41** | -0.39** | 0.29* | 0.28* | -0.21* | -0.20* | -0.24* |
| Total score | 0.25* | 0.22* | 0.53** | -0.26* | -0.42** | -0.34** | 0.39 ** |
p< 0.05
p< 0.01 PWE, psychosocial work environment- MS, moral sensitivity
correlation between the factors of nurses well-being and PWE
| Nurses well-being | Physical symptom and anxiety | Feelings of not being in control | Engagement and motivation | Eye strain, sleep disturbance |
|---|
| PWE |
| Job stress and anxiety | 0.34** | 0.33** | 0.41** | 0.29* |
| Relationship with colleagues | -0.24* | -0.21* | 0.38** | -0.23* |
| Collaboration and communication | -0.29* | -0.25* | 0.33** | -0.21* |
| Job motivation | -0.27* | -0.24* | 0.29* | -0.22* |
| Work demands | -0.24* | 0.18 | -0.23* | 0.24 * |
| Professional development | -0.27* | -0.22* | 0.32 | -0.22* |
p< 0.05
p< 0.01 PWE, psychosocial work environment.
This study found that there were direction significant correlations between the PWE factors score and the MS subscale (P< 0.05, p<0.01) [see Table/Fig-2]. In addition, significant correlations were found between the nurses’ well-being and their PWE factors (P< 0.05, p<0.01) [see Table/Fig-3]. The correlations between the PWE and the MS subscales have been presented in [see Table/Fig-2].
Discussion and conclusion
The aim of this study was to establish the relationship between the PWE and the levels of reported MS in the nurses, as well as their well - being. The main factors, job stress and anxiety, showed a significant correlation with the ethical conflicts. This finding corresponded with the findings of a previous research study [22]. In addition to the job stress and the reported feelings of anxiety, it is not surprising that ethical conflicts emerge as well. In stressful situations, it is important not only for the nurses to control their anxiety, but it is also equally important for the patients. High levels of anxiety may reduce the nurses’ ability of adequately caring for the patients.
A previous research on anxiety which was done by Benner et al. (1999) suggests that anxiety contributes to a lack of understanding and perception about the caring situation. Anxiety is described as a feeling of fear which is related to some uncertain or future event or mental distress which is caused by a threat to a person or his/ her values [18].
Nurses wish to and want to be involved in the ethical decision-making, together with other professionals, for example, doctors, and they would like their opinions to be listened to and respected. The nurses’ own values and norms influence their actions. The organization’s set of values is a part of the nurses’ PWE. However, there may be a conflict between the values of the nurses and the organizations in which they work, as has been reflected in policies and regulations. These situations create ethical conflicts for the nurses and force them to compromise their moral integrity for the sake of the institution in which they practice [23]. It is the nurses’ values that give them the courage to review other possibilities rather than conforming to the existing conditions [18].
In the humanistic part of nursing, where nurses seek to sustain and preserve the caring, wholeness and humanity, nurses are viewed as the human environment which creates the caring field, in which their awareness and basic values serve as the human environmental field [18]. The human environment, the ,desire to provide high-quality care in morally sensitive situations and respect for the patient’s autonomy are important for nurses, in addition to being truthful to the patient and trusting their own experience of what is ethically right in difficult situations.
The PWE also has a direct correlation with the nurses’ well-being. Their job satisfaction is likely to have a positive influence on the number of sick-days, which was confirmed by Petterson’s (1997) research, where the group which reported lesser satisfaction had twice the number of sick-days than the more satisfied group. A similar finding was made by Johansson (1994), who established a correlation between a poor PWE and musculoskeletal symptoms.
The better the PWE, the happier the nurse is. The direct connection between the morale of the nurse and the quality of the care that she/he provides was indicated by the comparison with the findings of the study which was performed by Callaghan (2003). Callaghan (2003) found that the low morale among the nurses was due to, among other things, their poor PWE [18].
Inadequate work scheduling and long working hours have been identified as a major threat to the employees’ health and well being. A report which was made by the European Commission (1998) indicated that up to 72% of the workforce which was studied, reported that working long hours had impaired their home life and relationships. The relationship between the working hours and a range of health outcomes has been well documented. For example, long working hours have been associated with a rise in the stress levels and an increase in the reported anxiety; insomnia and somatic symptoms and the mental health . Similarly, shift work has also been found to bring about serious threats to the health and productivity . The employees who work shifts have been found to suffer from fatigue; sleep disruptions; impaired concentration; irritability and somatic symptoms such as digestive problems . However, studies have suggested that the effects of shift work can be reduced, not only through adopting appropriate shift rotations but also through increasing the predictability of the work schedules and the choice over the shift pattern [24].
Conclusions
We conclude that nurses perceive their PWE as stressful, which has a negative effect on their job satisfaction. The supporting nurses may have a positive effect on their perceptions of well-being. The attending nurses reported less physical symptoms, reduced anxiety and fewer feelings of not being in control.
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