Person environment fit and job stress among head nurses in acute care hospitals.

The purpose of this study was to apply the Person-Environment fit model to the role of the head nurse to: (1) discover if a significant relationship exists between P-E fit and job stress among head nurses on Nursing; units in acute care hospitals; (2) correlate selected objective demographic variables with P-E fit and job stress; (3) identify major job stressors of the head nurse role; and (4) determine the relationship of job stress to specific physiological and psychological strains. A significant linear relationship was not established between P-E fit and job stress. The results were, in fact curvilinear, and tended in the direction that as P-E misfit increased job stress increased. Pearson product moment correlation revealed that P-E fit/misfit was not significantly correlated with any control variables such as head nurse age, length of time in the position, length of time practicing Nursing;, size of hospital, size of unit and type of unit. Job stress, however, was significantly correlated with nurse's age, time in position, hospital size, and years practicing Nursing;. A significant relationship was not established between types of unit and either job stress of P-E fit. Regression analysis revealed that of the major study variables, age, hospital size, years practicing Nursing;, and length of time in position accounted for 25% of the variation in job stress. Job stressors for the head nurse were explored and evaluated, both singly and as they altered when modified by the variable of frequency. It was also discovered that psychological strains of depression, feeling burned out, and fatigue were significantly correlation with both P-E fit/misfit and job stress. Physiological symptoms of abdominal distress, headaches, indigestions, colds, and constipation were significantly related to job stress, while having headaches were significant with P-E fit/misfit. This study only initiated the investigation of the application of the person-environment fit model to the role of the head nurse. It leaves open many questions including: 1. How much job stress is distressful and how much is unstressful? 2. Are head nurse job stresses different depending upon clinical specialty? 3. What variables not examined in this study might also explain head nurse job stress or variance? 4. What are other measures of physiological strains which would help in the understanding of these symptoms? 5. What is needed to better understand psychological strains? 6, What are behavioral strains and their relationship to head nurse job stress and person-environment fit/misfit as seen in replication research?

PERSON ENVIRONMENT FIT AND JOB STRESS AMONG HEAD NURSES IN ACUTE CARE HOSPITALS by Patricia A. Hanson A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah June 1982 © Patricia A. Hanson 1982 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Patricia A. Hanson This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. ~02~-~/Y~ ~!i'7 J1f4J L~ ~ Chainnan: Ver 1 a B. Co 11 ins, R. N ., Ph.D. Ann P. Hutton, R.N., M.S. THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Utah: I have read the thesis of Patricia A. Hanson in its final form and have found that (I) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. Verla B. Collins, R.N., Ph.D. Member, Supervisory Committee Approved for the Major Department Linda K. Amos, Ed.D., F.A.A.N. Chairman, Dean Approved for the Graduate Council ABSTRACT The purpose of this study was to apply the Person-Environment fit model to the role of the head nurse to: (1) discover if a signi­ficant relationship exists between P-E fit and job stress among head nurses on nursing units in acute care hospitals; (2) correlate se­lected objective demographic variables with P-E fit and job stress; (3) identify major job stressors of the head nurse role; and (4) de­termine the relationship of job stress to specific physiological and psychological strains. A significant linear relationship was not established between P-E fit and job stress. The results were, in fact, curvilinear, and tended in the direction that as P-E misfit in­creased job stress increased. Pearson product moment correlation revealed that P-E fit/ misfit was not significantly correlated with any control variables such as head nurse age, length of time in the position, length of time practicing nursing, size of hospital, size of unit and type of unit. Job stress, however, was significantly correlated with nurse's age, time in position, hospital size, and years practicing nursing. A significant relationship was not established between type of unit and either job stress or P-E fit. Regression analysis revealed that of the major study variables, age, hospital size, years practicing nursing, and length of time in position accounted for 25% of the variance in job stress. Job stressors for the head nurse were explored and evaluated, both singly and as they altered when modified by the variable of frequency. It was also discovered that psychological strains of depression, feeling burned out, and fatigue were significantly cor­related with both P-E fit/misfit and job stress. Physiological symp­toms of abdomenal distress, headaches, indigestion, colds, and con­stipation were significantly related to job stress, while having headaches were significant with P-E fit/misfit. This study only initiated the investigation of the application of the person-environment fit model to the role of the head nurse. It leaves open many questions including: 1. How much job stress is distressful and how much is eustressful? 2. Are head nurse job stresses different depending upon clinical specialty? 3. What variables not examined in this study might also explain head nurse job stress variance? 4. What are other measures of physiological strains which would help in the understanding of these symptoms? 5. What is needed to better understand psychological strains? 6. What are behavioral strains and their relationship to head nurse job stress and person-environment fit? 7. What is the correlation between head nurse job stress and person-environment fit/misfit as seen in replication research? v I wish to dedicate this thesis to my parents, Lester and Isa­bell Hanson, whose love and support has made the completion of this work possible. TABLE OF CONTENTS ABSTRACT . . • LIST OF TABLES LIST OF FIGURES ACKNOWLEDGMENTS Chapter I. INTRODUCTION Problem Statement and Conceptual Definitions Rationale and Significance of the Research. Review of the Literature. Conceptual Framework •••••• Research Questions • II. METHODOLOGY Design .• Objectives . Setting . . • . . Sampling Criteria Measurement Tool • Reliability ••• Validity •.•.. III. ANALYSIS OF DATA AND DISCUSSION OF FINDINGS Characteristics of Head Nurses • Characteristics of Hospitals. Research Questions . • • • • . . Job Stress . . . • • • . . • • Strains • . . . • . . . • . . IV. SUMMARY, LIMITATIONS, AND NURSING IMPLICATIONS. Summary .•• . • • • • . . • . . • Limitations ••••.••.••. Implications for Nursing Practice Implications for Nursing Research Page iv ix x xi 1 1 3 5 22 26 28 28 28 28 30 30 31 32 33 33 33 36 48 52 55 55 56 58 59 Chapter Critique of the P-E Fit Model Conclusion .••••.•.. Page 61 61 APPENDIX, PERSON-ENVIRONMENT FIT AND JOB STRESS QUESTIONNAIRE . 63 REFERENCES . . • . 0 • • • • • • • • • • • • • • • • • • • •• 82 viii LIST OF FIGURES Figure 1. Focal Position of Middle Manager 2. Focal Position of the Head Nurse •. Page 6 7 3. Relationship of Context, Vulnerability, and Stressors 15 4. Application of P-E Fit to Managerial Job Stress 19 5. Relationship of Objective Environment, Objective Person, Objective P-E Fit and Subjective Environment Subjective Person, and Subjective P-E Fit • . • • . • • . . . . .. 24 6. Person-Environment Fit Model: Relationship of P-E Fit, Fit-Misfit, Adaptation/Maladaptation, Strain, Health/ Illness................. 25 7. Relationship of P-E Fit/Misfit to Job Stress • . . • • •. 38 Table 1 . 2. 3. 4. 5. 6. 7. 8. 9. 10. LIST OF TABLES Summary of Stress Models .... Characteristics of Head Nurses . Characteristics of Hospitals. Pearson Product Moment Correlations Among Major Study Variables .............. . Percentages and Frequencies Between Type of Hospital Nursing Unit and ,Degree of Total Job Stress Percentages and Frequencies Between Type of Hospital Nursing Unit and Degree of Total Person-Environ­ment Mi sfi t . . . . . . . . . . . . . . . . . . . Stepwise Multiple Regression Analysis of the Demo­graphic, P-E Misfit Variables with Job Stress Ten Most Frequently Reported Simple Job Stressors Ten Most Frequently Reported Job Stressors, Modi-fied Multiplicatively by Frequency ..... . Spearman Rank Order Correlation of Physiological and Psychological Symptoms with Job Stress and P-E Fit/Misfit ............... . Page 21 34 35 41 42 43 46 49 50 54 ACKNOWLEDGMENTS I wish to thank my supervisory committee, Dr. Verla Collins, Ann Hutton, and Dr. John Seybolt for their support, input and en­couragement throughout all phases of the completion of the thesis. The help of Dr. Dale Lund and Dr. John Sullivan was invaluable in the preparation and interpretation of the statistics. Dr. Beth Burdett and Sister Josephine gave valuable input as to the grammatical and structural flow of this work. All of this assistance was greatly appreciated and has helped make the culmination of this thesis possi­ble. CHAPTER I INTRODUCTION There is a new disease rampant in America today that is rapidly reaching epidemic proportions. The symptoms vary from headaches to heart attacks, from indigestion to massive gastrointestinal bleeding. It can be likened to a cancer, but rather than overproduction of any one organ cell or system, it is a runaway condition of normal body func­tion. It is the body's response to stress. Nursing, a care-giving profession, deals with people's lives 24 hours a day, 7 days a week. Those being cared for often have become ill because of the strains which resulted from stresses in their lives. They may also be stressed just because they are ill. The nurse is not immune, and while the nurse cares for a stress­ed patient, she may indeed be adding to her own stress. One person is usually responsible to see that the patient and the nurse are cared for. This person is the head nurse. Considering the dual nature of the responsibilities (to both patient and staff), and the dual foci of the role (both as clinical expert and manager), the head nurse is herself very vulnerable to job stress and resultant strain. Problem Statement and Conceptual Definitions Job stress can be examined from many different directions. The objective of this research was to explore the relationship between subjective person-environment fit, job stress, and job strain among head nurses on nursing units in acute care hospitals. Job Stress 2 Job stress, as used in this study, is synonymous with person­environment misfit. Job stress refers to any characteristic of the job environment which poses a threat to the individual. That threat may be either demands which the person is unable to meet, or insufficient sup­plies to meet the individual's needs. The measurement of job stress was correlated with measures of goodness of fit between environment and the properties of the person. Job Strain While job stress and job strain are often used synonymously, job strain, in this paper, refers to any physiological, psychological, or behavioral deviation from the normal response of the individual. Environment Environmental factors include such things as work relationship (with superior, subordinates, colleagues, inability to delegate, lack of social support, and politics); organizational structure and climate; extra-organiz~tional sources; job characteristics intrinsic to the set­ting (quantitative and qualitative overload, time pressures, working conditions, technological change); role in the organization (role ambi­guity, role conflict, responsibility for people and things, too little responsibility, authority, holding a middle management position); and career development. 3 Person Person-related factors include such factors as personality tendencies, emotional stability, conformity, innerdirectedness, rigidity, feasibility, achievement orientation, and type-A behavior. Person-Environment Fit/Misfit Perfect person-environment fit occurs when job demands and worker abilities to meet these demands are equal. Person-environment (P-E) misfit occurs when there is an inequality between these variables. Rationale and Significance of the Research In'a limited number of studies, job stress has been examined in relationship to critical care nursing (Mann, 1978; Oskins, 1977; Still­man & Strauser, 1980; Stehle, 1981); to nursing administration (Arndt & Leager, 1970a, 1970b; Kavern & Oliver, 1978; Clark, 1980); and to general staff nurses (Hartl, 1979; Ivancevich & Matteson, 1980; Rozell, 1978; Scully, 1980; Tierney & Strom, 1980). Little has been written about stress in nursing mid-management (Stevens, 1974; Leatt & Schneck, 1980). Recent research has addressed the issue of the alarmingly high turnover in nursing (Seybolt, Pavett & Walker, 1978; Briet, 1976). These investigators reported varying turnover rates ranging from 35 to 70% yearly (Seybo1t et al., 1978; McCloskey, 1974), and indicate that the turnover is accounted for by various issues including staffing, schedul­ing, wages, stress of the job, and excess responsibility (Ivancevich, 1980; Shukin, 1978). As yet, the percentage of head nurse turnover has not been documented. 4 The staff nurse's manager, the head nurse, is in the pivotal position, hoping to do something to minimize the staff's turnover rate by reducing stress, at the same time trying to meet the demands of nurs­ing administration. The problems of nursing are bigger than any group of head nurses. If, in fact, what head nurses want to do is incon­gruent with what they are able to do, it is not unlikely that they experience stress. In a positive sense, this stress can be a powerful motivating force to action and change. When the situations exceed the individual's ability to meet the demands, stress, followed by strain, occurs. In the pivotal position, the head nurse has the potential of influencing the staff. Friedler's (1966) review of the importance of middle management listed a series of investigations indicating that the first-line leader has considerable influence on the productivity of the group reporting to him. A similar conclusion was reached in studies of middle managers in public school settings (Bidwell, 1957). It is likely that a similar situation could exist with the nursing middle management-­the head nurse. When stress levels adversely influence the behavior of the head nurse, the staff is likely to be similarly affected. A cycle is established which must be broken if stress, as a contributing factor in high turnover and job dissatisfaction, is to be brought under control. In order to break this cycle, it is essential that the stresses of the head nurse job are identified, and their relationship to the goodness­of- fit between the head nurse and the environment be documented. Bridging the gap between the person and his environment has traditionally been the job of the manager (Harrison, 1978). It is the 5 manager's job to promote the efforts of the individual workers so that the workers can modify the demands of their jobs, enabling them to bring about a better fit in keeping with their own individual preferences. The directors of nursing who work with the head nurse have the responsi­bility of promoting a good P-E fit among that group. When they observe signs of strain (physiologically, psychologically, or behaviorally), the results of this study may serve as a guide in the examination of the job stresses which lead to the manifest strains. Such an examina­tion could serve as a basis for manipulation of the environment, nar­rowing the gap betw~en environmental demands and personal resources. Nursing administrators are in the position of influencing changes in the environment or serving as guidance counselors for head nurses fac­ing environmental no-change situations. Review of the Literature It is appropriate to examine the literature which augments understanding of stress, both in general and, particularly, as it applies to nursing middle management. The nursing mid-manager, more commonly known as the head nurse, is, for the purpose of this research, defined as the person in the hierarchical structure of nursing administration responsible for the day-to-day operation of a particular nursing unit. Head nurses are responsible to nursing administration for the nursing activities of that unit, ranging from organization and direction of the general staff to the non-nursing management functions required for the operation of the unit. In many ways, the nursing mid-manager is caught between the needs of the patients, the expectations of the nursing administration, and the 6 demands of the general nursing staff. The literature which has been cited supports the idea that both nursing administration and general staff nurses are experiencing stress and burnout. What, then, is happening to the nursing middle manager? Numerous authors have demonstrated the middle managers do indeed experi-ence stress. General Middle Management Kiev and Kohn (1979) found middle managers to have higher self­reports of stress than the top management. Morris (1975) explained the vulnerability of middle managers by a 'cross relationship' model. As seen in Figure 1, the middle manager is in a focal position in terms of Top Margement Coll eagues ----- Middle Manager I ------- Users Subordinates Figure 1. Focal position of middle manager. Note. Adapted from Managerial stress and 'the cross of relation­shipS'lby J. Morris. In D. Gowler, & K. Legge (Eds.), Managerial stress. Epping: Gower Press, 1975. organizational relationships. Morris claimed that the manager is forced to bring all four arms of the cross into 'dynamic balance' in order to deal with the relational stress of the position and to do the job well. Kay (1974) reported that today's middle manager is particularly hard-pressed in four different stressor areas. These areas include: 7 (1) pay compression as salaries of the new recruits increase, (2) job insecurity, (3) lack of real authority at the corresponding areas of high responsibility, and (4) feeling occupationally "boxed inll in terms of job mobility and career advancement. Kahn, Wolfe, Quinn, Snoek, and Rosenthal (1964) suggested that role conflict and ambiguity are likely to be greater at middle management levels than at either senior or junior levels. They postulated that this was so because of higher ego involvement on the middle management level which creates high aspiration for advancement. This high aspiration brings with it high pressure from co-workers. The discrepancy between the person and the environment, and the stress which accompani e's it, 1 eve 1 s off when the mi ddl e manager achieves the desired environment of top management. Head nurses are indeed middle managers and, as such, are placed in the pivotal position between hospital and nursing administration, professional colleagues, staff, patients, families, and other medical and paramedical personnel (see Figure 2). It seems reasonable to expect Professional Colleagues Hospital Administration Nursing Administration ----- Head Nurse ------ PPhaytsiiecniatns s General Nursing Staff Families Figure 2. Focal position of the head nurse. that the head nurse would face the same stressors as those found in middle management, in general. Stress 8 Historically, the concept of stress as we know it is not very old. Etymologically, the term stress is derived from the Latin "stingere" which means lito draw tight.1I In 1867 a French physiologist Bernard recognized the potential dysfunctional consequences of upsetting the balance or IIstr:essing" the organism (Ivancevich & Matteson, 1980). In 1920, Walter Cannon spoke of "critical stress levels" which could bring about a collapse of homeostatic mechanisms. It wasn't until the 1930s that Hans Selye introduced the term stress. He re­referred to outside forces acting on an organism and the general effects of normal wear and tear on the body. While there are as many definitions of stress as there are stress researchers, the majority of the definitions fall into one of three basic categories. First, from a stimulus perspective, stress is the force or stimulus acting upon the individual that results in a response of strain (Ivancevich, 1980). From the response standpoint, stress is the physiologi~al or psychological response an individual makes to an environmental stressor. Thirdly, there exists the possi­bility of a stimulus-response definition which says that stress ;s the consequence of the interaction between stimulus and the idiosyncratic response of the individual (Ivancevich, 1980). A fourth explanation of stress is also possible. Ivancevich and Matteson (1980) referred to it as a working definition and viewed stress as an adaptive response. 9 This means that stress is a response Ilmediated by individu~l character­istics and for psychological processes, which place a physical and/or psychological demand upon a person" (p. 89). In these definitions, stress is either a dependent (response, response-stimulus, or adaptive) variable, or an independent variable (stimulus). Some stress researchers differentiate stress from strain, while others talk of them synonymously. Cox (1978) categorized stress and stress effects in five different groups. Subjective effects included such th-ings as anxiety, depression, fatigue, frustration, low self­esteem, threat,tension, nervousness, and loneliness. Behavioral effects included accident proneness, drug use, excessive drinking and smoking, restlessness, excitability, and impulsive behavior. Inability to make decisions or concentrate, frequent forgetfulness and hypersensitivity to criticism are among the cognitive effects. Physiological effects were varied. They were interactive with behavioral components and in­cluded such things as asthma, hypertension, elevated heart rate, in­creased serum catecholamines, and cholesterol and coronary heart di­sease. Organizational effects were also interactive with behavioral effects and i·ncluded absenteeism, poor industrial relations, poor pro­ductivity, high accident and labor turnover rates, poor organizational climate, antagonism at work, and job dissatisfaction. Stress Models The Physiological Model. Selye (1956) developed a biochemical model of stress and described stress in terms of a general adaptation syndrome (GAS), and explained stress as the common denominator of all 10 physiological adaptive reactions in the body. Se1ye, borrowing from the medical-physical definition of stress, looked at the stress phe­nomenon as a physical state manifested by a syndrome consisting of all the specifically ind~ced changes within the biological system. Se1ye's explanation follows the stimulus-response definition previously men­tioned. -Accordingly, the stress syndrome manifests itself through specific changes in the ,action of the adrena1s, the thymus, the thyroid, the gastrointestinal tract, and the cardiovascular system which are in­duced by nonspecific stimu1us--the stressors. Strengths of Se1ye's model included his position that some stress is both necessary, valuable, and useful and, therefore, can be either positive or negative. "Eustress," a term coined by Se1ye, reflects the concept of positive stress. "Distress," on the other hand, becomes synonymous with the cOrmlon usage of the term stress; that is, unpleasant anxiety-provoking experiences. It seems that for Se1ye, stress is not a point but rather is a continuum--at one point along the continuum, the events are "eustressfu1," but if they increase or are prolonged, they have the potential of becoming "distressful." Whether a stressor is distressful or eustressfu1, depends upon the adaptation of the individ­ual. The adaptation is the nonspecific response to the specific threat and~ay be physiological, psychological, or both. Psychosomatic Hodel. A psychosomatic model for stress has been postulated and is based.on the premise that tensions.and strains in one system affect other bodily systems. It is an attempt to understand how physiological reactions are set in motion by psychological processes. 11 It is also an attempt to determine which physiological reactions and psychological processes are linked. To date, the psychological model has not been applied to managerial situations. Occupational Model. House (1974) developed an occupational model for stress which illustrates the relationships of -occupational stress to heart disease. It is proposed in this model that the relation­ship between social conditions and outcomes such as heart disease is mediated through the individual's perception of the situation, and that the perceived meaning of objective conditions depends on both the nature of the person and the nature of the social situation. House did not define specific organizational variables, but attempted to illustrate the role of organizational stress in the etiology of coronary heart di­sease and the possibility of other chronic disease as well. Psychological Model. While the previous models have emphasized physiological stress, Lazarus examined stress from a more psychological standpoint. According to Lazarus (1966), stress is a universal phe­nomenon which results in intense and distressing experience and has a tremendous influence on behavior. He took into consideration the char­acteristics of the individual and noted that, considering the important role of personality factors in contributing to stress reactions, stress is defined in terms of transactions between individuals and situations, rather than from either one in isolation. Leaving the physiological-psychological models of stress, we find another approach--that of the behavioral models. Such models have more relevance and applicability to the focus of this study, job stress. 12 Personality/Behavioral Model. Job stress and vulnerability cannot be discussed without citing the work done by Friedman and Rosen­man (1974). These cardiologists described a phenomenon they called the "Type All personality. While there is debate about whether Type A is really a personality characteristic or a behavioral characteristic, the symptoms are the same. Included are people with high degree and intense ambitions, a drive for·achievement and recognition; competitiveness and aggression. This person has a compulsion to overwork and is always struggling against time limitations. It is not uncommon that this in­dividual neglects other aspects of his life, including his family, social pursuits, and recreational activities. The "Type Bn personal ity or behavioral, characteristic is applic­able to the person who is more easy going and relaxed. Such an individ­ual does not feel a need to beat the clock. Since he has few pressing conflicts, he also has few hostilities (Kiev & Kohn, 1979). Process Models. Albrecht (1979) differentiated between physi­cal and emotional stress. He viewed organizational stress as being pri­marily emotional and subdivided it into: (1) time stress, (2) antici­patory stress, (3) situational stress, and (4) encounter stress. He clearly viewed stress as a management problem, which interestingly creates an additional stress for the manager. McGrath (1976) said: ..• there is a potential for stress when an environmen­tal situation is perceived as presenting a demand which threatens to exceed the person's capabilities and resources for meeting it, under conditions where he expects a substan­tial differential in the rewards and costs from meeting the demand versus not meeting it. (p. 1352) 13 For McGrath, three conditions must be present for a situation to be stressful. First, it must be perceived as stressful by the person ex­periencing it. Second, it must be interpreted by him in relation to his ability to meet the demand; and third, he must perceive the potential consequences of successfully coping with the demands as more desirable than the expected consequences of leaving the condition unaltered. In order for the above conditions to be present, there are four processes which take place and which are linked together. These include: (1) the cognitive appraisal process, (2) decision making, (3) performance, and (4) outcome. These processes link together the situation as per­ceived by the individual, his response selection, and resultant be­havior. r~argolis and Kroes (1974) discussed job stress as being a condi-tion at work which, when interacting with worker characteristics, dis-rupts the psychological and physiological homeostasis of the individual. For these researchers, the causal situation conditions are job stressors and the disrupted homeostasis is job-related strain. They suggested five dimensions of job-related strain: (1) short-term subjective states, (2) long-term more chronic psychological responses, (3) transient phy­siological changes, (4) physical health, and (5) work performance de-crement. Beehr and Newman (1978), adopted the following definition of job stress: Job stress refers to a situation wherein job-related fac­tors interact with a worker to change (disrupt or enhance) his or her psychological condition such that the person is forced to deviate from normal functioning. (p. 669) 14 It is interesting to note that with this definition the authors were including the possibility of beneficial effects of stress on health. McLean (1974) had a perception of job stress consistent with that of Margolis and Kroes. He considered occupational "stress" or "stressorsll to be work-related factors which produced a maladaptive response. McLean (1979) discussed three concepts which he indicated described job stress. These areas included individual vulnerability, context, and specific stressors. Individual vulnerability varies from person to person and may even vary within a given individual. Since long-term personality characteristics of a person contribute to the dimensions of vulnerability, it is important to recognize both the gene­tic and developmental aspects of the individual. Vulnerability alters with age, mood, experience, fatigue, and other individual variables. Even though one may be vulnerable, unless the context and stressor ele­ments are present, symptomatic stress response will not occur. Stres­sors, in McLean's model, are those psychological and social factors that arouse emotional and physical reactions in the individual. Exam­ples of stressors could be change, uncertainty, conflict, or pressure either on or off the job. Context, in McLean's model, refers to the external environment, organizational climate (competitive or collaborative), management style (authoritarian or participatory), morale (high or low), physical en­vironment (noisy or quiet), the economy (prosperity or recession), family life (loving or hostile), to mention a few. The relationship among context, vulnerability, and stressors is shown in the Venn diagram in Figure 3. JOB CONTEXT INDIVIDUAL ...._ __. ....._ ........V..' l. L NERABILITY PSYCHOLOGICAL AND SOCIAL STRESSORS Figure 3. Relationship of context, vulnerability, and stressors. 15 Note. Adapted from Work stress by A. McLean. Reading: Addison­Wesley Publishing Co., 1979. 16 The area of mutual overlap of the three boxes is representa­tive of the conditions in which stress symptoms appear. It is im­portant to think of these three areas as dynamic entities, in that they are constantly moving toward and away from each other depending upon relative intensity of each at anyone given time period. This helps explain why one situation can produce stress symptoms in an individual at one time and not at another. According to McLean, it is only when all three variables overlap that stress symptoms appear. Kiev and Kohn (1979) used McLean's context-vulnerability-stressors model in a study they conducted with 6,000 members of the American Management Association. Their intent was to describe what managers (both top and mid-management) define as stress, both on and off the job, how they coped with stress, and the extent to which they experienced stress. They discovered that the typical businessman was not the hur­ried executive. They also found out that the most stress-producing factors are work and time pressures, disparity between a manager's own goals and the expectations of the organization, the "political" climate of the organization, and lack of feedback on job performance. The parti­cipants indicated that their most effective coping techniques included: (1) analysis of the situation and deciding if it is worth worrying about or not, and (2) delegating work to a subordinate. Interestingly, the managers surveyed did not feel that their health had been adversely affected by their work. Person-Environment Fit Model. Another approach to job stress has been defined by a group of researchers. Caplan, Cobb, French, 17 Van Harrison, and Pinneau (1980) defined job stress as any character­istics of the job environment which posed a threat to the individual. Two types of job stress may threaten the person, either confronting de­mands which he may not be able to meet (person), or having insufficient supplies to meet his needs (environment). In essence, there is a per­ceived incongruity or IIlack of fitll between the person and the environ­ment. According to French, Rodgers, and Cobb (1974), the basic concepts of demands and supplies do not appear in isolation; each is important only in relationship to the other. Person-Environment fit (P-E fit) can be evaluated subjectively through self-evaluation or objectively by an outside observer. Caplan et al. (1980) contended that these evaluations will likely differ but not necessarily in one predictable direction. Within the framework of P-E fit, job stress and job strain are differentiated. Job stress is evaluated by: (1) measures of a potentially threatening dimension of the environment, and (2) measures of goodness of fit between the en­vironmental dimensions and the properties of the person. Strain, how­ever, refers to any deviation from a normal response in the person. Such strains may be: (1) psychological (job dissatisfaction, anxiety, low self-esteem); (2) physiological (hypertension, elevated serum cholesterol); and/or (3) behavioral (increased smok1ng, and/or drinking, visits to the physician). Harrison (1978), in his discussion of P-E fi~, equated job stress with poor P-E fit and suggested that such stress can lead to strain, that is; any deviation from the normal response of the person. He main­tained that the more stresses (areas of P-E misfit), the more pronounced 18 the strain will be. It is interesting to note that just as Selye indi­cated that "eustress" does exist, likewise good P-E fit enhances the individual's sense of competence and self-worth, ultimately resulting in the person's personal growth. P-E misfit necessitates action on the part of the individual. He or she copes through either an attempt to change the objective en­vironment (environmental mastery), change the objective person (adapta­tion), or put up defenses which distort the individual's perception of the objective environment or his objective self. Various strains ,occur in response to P-E misfit. The factors which determine the type of strain include: (1) motives which are not being met, (2) genetic and social background of the individual, (3) defense and coping predispositions of the individual, and (4) situa­tional constraints or particular responses (Harrison, 1978). Caplan et al. (1980) described four areas as being evaluative of P-E fit. These areas are job complexity, role ambiguity, work load, and responsibility for persons. These four areas of P-E fit were measured in a study of job demands and worker health conducted by this group. In their work, each of these four measures was correlated with both person, environment, and P-E fit measures. Although these correla­tions varied as to their ability to predict strain, on the whole, the P-E fit measures performed as well as or better than the environ­ment or person measures independently. Marshall and Cooper (1979) applied the P-E fit model to mana­gerial job stress utilizing the model in Figure 4. With this model, it is obvious that stress is not a characteristic of either the environment Environmental-related Person-related Personal Interactions Inherent to Job Neurotic/ -----------~=::::-:_:-::~.... Psycho 1o gi-cal Tenden- Role in the Organization cies Organizational Emotional Structure and Climate Instability Non-organizational Sources ___ Conformity/ Non-conform ity Self-motiva tion Rigidity Flexibility Achievement Orientation A-Type Manifestations of Stress ~ Poor Physical Health U1 ~ • Poor Mental Health ~ ~ U1 ~ Organizational Symptoms Figure 4. Application of P-E fit to managerial job stress. Note. Adapted from Executives under pressure by J. Marshall, & C. L. Cooper. New York: Praeger Publishers, 1979. --' 1..0 20 or the person in isolation, but is the outcome of the interaction of the two. It should also be noted that the factors of both environment and person are not 'cast in concrete' but are variable, which would ac­count for the fact that various situations are stressful at sometimes and not at others. Judging from the variety of stress models, stress is not only a popular topic, but can also be viewed from a number of different direc­tions. The various models add to our understanding of stress as it applies to the job situation. These models are summarized in Table. 1. Nursing Literature Since the focus of this research is head nurse job stress, it is appropriate to review the literature that deals specifically with this topic. As has been stated, while much work has been done to study stress in critical care areas, among general staff nurses and among nursing administrators, few investigators have focused on head nurses. Specifically, no investigators have utilized the person-environment fit model, and its application to nursing. The nursing literature only touches upon job stress for nursing mid-managers. Stevens (1974) discussed the concept of the head nurse as manager. She substantiated the idea that the head nurse is in a pivotal position which links nursing administration with nursing care. Head nurses have one foot in clinical nursing and the other in administra­tion, requiring that they have both clinical nursing and managerial ex­pertise. One study was found that addressed the problem of head nurse Model Physiological Psychosomatic Psychological Personal ity Process Person-Environment Fit Table 1 Summary of Stress Models Proponents Selye (1956) Basowitz et al. (1955), ~1echan ic (1962). Janis (1954); House (1974) lazurus (1966) Friedman and Rosenman (1974 ) Albrecht (1979), ~kgrath (1976), Margolis and Kroes (1974), Mclean (1974, 1979) Beehr and Newman (1978), Kiev and Kohn (1979) Caplan et al. (1980), French, Rodgers, and Cobb (1974), Harrison (1978), Marshal and Cooper. (1979) Basic Tenets Stress is the common denominator of a11 physiological adap­tive reactions in the body. It consists of all specifically induced biological changes. Eustress is positive stress, while distress is negative or unpleasant stress. Similar to physiological model but expands to examine the link between physiological and psychological processes. Emphasis is psychological. Stress, as a universal phenomenon, results in intense and distressing experience which has an effect on behavior. Emphasizes work done on Type A and Type B personalities. Type A personalities being more vulnerable to stress. Stress occurs when an environmental situation is perceived as presenting a demand which threatens to exceed the person1s capabilities and resources for meeting it. Stress occurs when the characteristics of the person and the environmental demands are not equal. N --I 22 stress. Head nurse stress was examined across specialties. Five types of stress were discussed: administrative role, types of patients, task ambiguity, staffing problems, and physician contact. Leatt and Schneck<--­( 1980) concluded that different specialty areas did experience different types of stress. Medical-surgical and ICU units were more frequently exposed to patient-based stress, while psychiatric specialties experi­enced more task ambiguity stress. Pediatric specialties experienced self-movement stress most frequently. The findings suggested that all types of nursing specialties are accompanied by some kind of stress, yet they differ in the frequency with which these stressors occur. Age and experience had no effect on perception of stress. Educational ef­fect was minimal. Leatt and Schneck concluded that since there are different stresses for different types of clinical units, senior management needs to have different work policies for head nurses in the various types of specialities. Essentially, they implied that senior management needs to manipulate the environment and match the person with the job. The authors did not say how this could be done. Conceptual Framework The conceptual framework upon which this study was based is that of Person-Environment fit. The Person Environment fit model was selected out ofa desire to determine the applicability of this model to the head nurse job setting. It was felt that this was suitable due to the high degree of interaction of head nurse with the environment. It was anticipated that the use of this model would augment our under­standing about head nurse job stress. 23 The degree of person-environment fit can be determined either objectively or subjectively. Objective P-E fit refers to the goodness of fit between the objective person and the objective environment; fit being independent of the person's perception of it. Subjective P-E fit refers to the fit between the subjective person and the subjective en­vironment, the individual's perception of his P-E fit. P-E fit repre­sents the interaction between the person and the environment (Harrison, 1978). Four relationships may exist between objective environment (Eo)' objective person (Po)' subjective environment (Es)' and subjective per­son (P s·). The fit between Eo and Es equals the individual's contact with reality. The relationship between Po and Ps results in accuracy of self-assessment. There also exists a subjective fit (Fs) which equals Ps - Es ' and an objective fit which equals Po - Eo' The relationships of these areas of fit are diagrammed in Figure 5. The relationship of Eo - Po and Es - Ps is an interactive one, represented in Figure 5 with dashes, while the relationship of Eo - Es and Po - Ps is directional, going from the objective to the subjective, as indicated with the directional arrows. The degree to which objec­tive job P-E fit and subjective job P-E fit are congruent or incongruent indicates the degree of job stress experienced by the person. It is this sense that P-E misfit can be used to define job stress. This stress is manifested by strains, be they physiological, psychological, or behavioral. If these strains are allowed to persist unchecked, they will be manifest in the individual in the form of illness. These rela-tionships are graphically illustrated in Figure 6. 24 Objective .. Subjective Environment Env1i ronment Objecli~ing / I I • Defense Subjective P-E Fit / P-E Fit ~ t I I I I Objective .. Subjective Person Person Figure 5. Relationship of objective environment, objective person, objective P-E fit and subjective environment subjective person, and subjective P-E fit. Note. Adapted from Person-environment fit and job stress by R. V. Harrison. In C. L. Cooper, & R. Payne (Eds.), Stress at work. New York: John Wiley and Sons, 1978. Es = Ps I ncongruence I /MiSfit = STRESS EIo ' ~ /s Objective g' e: /' I P-E Fi t 00. a1 Subjecti ve P~ /8 ~~E/it~ I J5 Es = Ps Congruence Fit __ Maladaptation Strain Illness Physiological Psychological Behavioral Challenge- Health Adaptation Figure 6. Person-environment fit model: Relationship of P-E fit, fit/misfit, adaptation/maladaptation, strain, health/illness. Note. Adapted from Job demands and worker health by R. D. Caplan; S. Cobb; J. R. P. French; R. Harrison; & S.~Pinneau. Michigan: Survey Research Center, Institute for Social Research, University of Mary-land, 1980 N (J1 26 When the objective and subjective P-E fit is one of congruence, the differences between Eo and Po and Es and Ps are modified either by active objective coping, utilizing environmental mastery or adaptation, or active subjective coping, utilizing defenses, in which case, Eo = Po or Es = Ps ' and the person experiences less stress and resultant strain. As noted in Figure 6, P-E fit (congruence) leads to challenge and positive adaptation, which promotes health. On the other hand, when P-E fit is one in which Eo ; Po or Es ; Ps ' the resultant incon­gnuence is a P-E misfit which produces stress. This stress leads to maladaptation, strain, and illness. When operationalizing environmental mastery and adaptation to change the objective environment and person, ;mplen~ntation of defenses to cope with subjective person and environ­ment may decrease the individual's ability to cope with reality or main­tain an ,accurate self-assessment. Research Questions 1. Is there a significant relationship between P-E fit and job stress among head nurses on nursing units in acute care hospitals? This question addresses the section of the model which deals with the subjective P-E fit (job congruence and job incongruence) and job stress. 2. Specific variables a. Are the objective variables of head nurse age, length of time the head nurse has held the position, the length of time the nurse has practiced nursing, the size of the hospital, size of unit, and type of unit, significantly correlated with both P-E fit and job 27 stress? b. Of the objective variables head nurse age, length of time the head nurse has held the position, the length of time the nurse has practiced nursing, size of hospital, size of unit, and P-E fit, which combination of variables accounts for most variance in the occurrence of head nurse job stress. This question is focused specifically at aspects of objec­tive persons (nurse's ag~, length of time in position, and 1ength of time practicing nursing); and objective environ­ment (size of hospital, size of uni~, type of unit); and how those specific entities are related to subjective P-E fit and job stress. 3. What are the major stressors of the head nurse role? This question examines the specific stressors of the head nurse role as perceived by the head nurse. These stressors exist as an outgrowth of job incongruence and are the pre­cursors to actual strains. 4. Is there a relationship between job stress and speci­fic physiological and/or psychological symptoms? This ques­tion addresses the nature of the resultant strains, strains being the physiological ,psychological, and behavioral mani­festations of the individual. CHAPTER II METHODOLOGY Design The research design employed was a descriptive survey. Data were obtained by means of a four-part questionnaire which identified person-environment fit and job stressors, as well as pertinent demo­graphic data. Objectives The objectives were to: 1. Determine the relationship between head ,nurse job stress and P-E fit. 2. Identify the major job stressors in the head nurse role. 3. Determine the relationship between P-E fit/misfit, job stress, and specific physiological and psychological strains. Setting The research was conducted in Salt Lake, Utah, and Davis Coun­ties in the State of Utah. The population included head nurses on nursing units in acute care hospitals in the State of Utah. An acci­dental or sampling by convenience method was used to obtain the sample 29 of nurses which participated. Of the 42 ,acute care hospitals in the State of Utah, nine hos­pitals in the three counties mentioned agreed to participate. Two of the hospitals were in Utah County, two in Davis County, and five in Salt Lake County. Using the three counties provided a base from which the sample would be obtained, utilizing head nurses in hospitals of various demographic configurations. From the nine hospitals participating, there was a possibility of 125 head nurse respondents. Of these possible respondents, 113 head nurses returned the questionnaires for a 90% re­turn rate. Only 108 questionnaires, (86%) were used in the analysis since the last five came in very late after statistical analysis had begun. Head nurses were given the questionnaires by the researcher and asked to complete and return them. Four of the hospitals allowed time for the head nurses to complete the questionnaire at the time they re­ceived it, one had them complete it during the day and return it to a designated secretary at the end of the day. The head nurses at the other four hospitals were given self-addressed stamped envelopes and were asked to return the questionnaire by mail. The first five hospitals mentioned had a 100% return rate. Of the four hospitals from which the questionna.ires were returned by mail, 73% of the head nurses returned the questionnaires. The question naturally arises as to the impact of the different types of data collection upon the results. Were the nurses who com­pleted the questionnaire in the presence of the researcher able to do so as candidly as those who answered the questionnaire privately? 30 Separate analyses were not conducted to compare the two groups. Such an investigation might prove instructive if further analysis were to be performed, and would be especially helpful with a larger sample size. Sampling Criteria The head nurse had to meet the following criteria in order to participate: 1. Have managerial responsibilities for a specific unit or units. 2. Be currently working in that capacity. Measurement Tool The tool used to measure P-E fit and job stress consisted of four parts, a COpy of which can be found in the Appendix. The first part of the questionnaire consisted of the P-E fit measurement. It was used by permission of Caplan et al. (1980). The second part of the questionnaire was a measurement of person­oriented job stress. It consisted of 21 items for which the participant was asked to rate various groups of people, both as to frequency and stressfulness of interaction. The third part of the questionnaire identified work situations which could be stressful. The items incorporated in this part of the questionnaire included areas addressed in a Job Related Tension Index developed by Robert Kahn (l966) as well as potentially stressful situa­tions previously experienced by this researcher. Each item was evalu­ated in terms of frequency and stressfulness, the interrelationship be­ing equivalent to situational job stress. Both the second and third parts were constructed by the investigator. The fourth part of the questionnaire collected demographic data as well as data related to frequency of physiological and psychological symptoms. Reliability 31 The reliability of the first three parts of the questionnaire was established quantitatively utilizing statistical analysis to deter­mine alpha coefficients. The reliability of the P-E fit portion of the questionnaire had been previously established by the Michigan researchers and examined four areas of P-E fit: work overload, role ambiguity, responsibility for persons, and job complexity. The cross-sectional estimate for reliability was as follows: Quantitative workload fit Responsibility for persons Job complexity poor fit Role ambiguity poor fit .71 .74 .72 .74 However, after collection of the data in this study, the P-E fit mea­sures were subjected to further reliability tests, and for this sample the alpha coefficient was only .34. It was decided that the reliability of the total P-E fit measurement was inadequate for the correlational studies that would follow. An item analysis was performed and a new subset produced. This was accomplished by evaluation of the Pearson Product Moment correlational coefficient and the frequency for each of the P-E fit measures. Person items which had both an r of .13464 or greater, as well as a variance of .778 or greater, and environmental items which had an r of .2707 and a frequency variance of .1383, were 32 considered to be the most reliable items and were used in the analysis. These values were selected because they represented the eight best items on each scale as well as the fact that with the additions of each item the reliability improved; with the additions of further items reli­ability decreased. Once the subsets (person and environmental) were established the total person scale of reliable items and the environmental 'scale of reliable items were subjected to alpha coefficient testing, the result­ing alpha coefficient then equaled .643. The difference between the person ,scale of reliable items and the environmental scale of reliable items represents P-E fit/misfit. The two job stressors sections of the questionnaire were also subjected to alpha-coefficient analysis. The persons job stressors tool had an alpha coefficient of .92. The situational job stressors too] had a computed alpha coefficient of .692. Both scales were con­sidered adequate to utilize in the further correlational analysis. Validity Neither construct nor criterion related validity of the total questionnaire have been established quantitatively. Such validity is very difficult to establish. The nature of the questions follows logi­cally from the basis of the nature of the research and establishes con­stant or face validity for the tool. CHAPTER III ANALYSIS OF DATA AND DISCUSSION OF FINDINGS Characteristics of Head Nurses Table 2 delineates the general characteristics of the head nurses participating in the sample, reflecting the objective person as­pect of the model. Of the head nurses participating, 96.3% (~ = 103) were female, while 3.7% (~ = 4) were male. The ages ranged from 23 to 62 with a mean age of 37.5. The nurses had been practicing nursing for an average of 14 years with a range from 2 to 41 years. Of the head nurses in this sampl~, 83% had been in the position for less than five years, the range being from 1 to 20 years with a mean of 3.7 years. Of the group sampled, 45.5% (~ = 49) had an Associate Degree, 49.1% (~ = 53) had a Baccalaureate Degree, 1 .9% (~ = 2) had a Master of Science Degree, and .9% (~= 1) had educational preparation beyond the M.S. level. Characteristics of Hospitals Table 3 depicts the general characteristics of the hospitals involved and represents the objective environment of the model. Of the nine participating hospitals, 44% (N = 4) had from 300 to 399 beds. There was one hospital in each of the other five categories, these specifically being 0 to 100 beds, laO to 199, 200 to 299, 400 to 499, and 500 to 599 beds. The sample represented participants from 52 34 Table 2 Characteristics of Head Nurses Sample N Percent· Mean Female 103 96.3 Male 4 3.7 Age: 37.5 20-29 32 32.0 30-39 26 25.0 40-49 31 30.0 Over to 14 14.0 Years Practicing Nursing: 14.0 1- 5 18 17.0 6-10 35 33.0 11-15 15 14.0 16-20 15 14.0 21-25 11 10.0 26-30 6 6.0 31-35 4 4.0 36-40 2 2.0 41-45 1 1 .0 Length of Time Held Position: 3.7 1- 2 Years 48 45.0 3- 5 40 37.0 6-10 13 12.0 11-15 4 4.0 16-20 2 2.0 Educational Background: AD 49 45.4 BS 53 49.1 MS 2 1 .9 Post MS 1 .9 35 Table 3 Characteristics of Hospitals Sample N Percent Mean Number of Beds: 0-100 1 11 100-199 1 11 200-299 1 11 300-399 4 44 400-499 1 11 500-599 1 11 Types of Units: Medical-Surgical 52 49 Specialty 21 20 Nu rsery 2 2 Pediatrics 6 7 Psychiatric 1 1 OR-Recovery 6 7 OB-Gyn 11 10 Other 7 7 Beds Per Unit: 27 1-10 14 15 11-19 17 17 20-29 19 20 30-39 31 32 40-49 11 11 50-59 2 2 60-69 0 0 70-79 2 2 36 medical-surgical units, 21 specialty units (ICUs, and ERs), 2 nurser­ies, 6 pediatric units, 1 psychiatric unit, 6 operating and recovery rooms, 11 obstetrical and gynecological units, and 7 nontraditional nursing units (float pools, IV teams). Beds per unit ranged from 3 to 80 with a mean of 27. Research Questions In attempting to answer the research questions it is important to bear in mind their relationship to the model upon which this study was built. Questions 1,2, and 3 address the areas of P-E fit/misfit and job stress, their interrelationships and their correlation with certain selected demographic variables. Question 4 deals directly with identification of job stressors, while Question 5 addresses the area of strain, focusing on physiological, and psychological manifestations of stress. Behavioral manifestations of stress were not addressed. Subjective P-E Fit and Job Stress The first research question examined the relationship of sub­jective P-E fit and job stress: Is there a significant relationship between P-E fit and situational job stress among head nurses on nursing units in acute care hospitals? The answer to this question was sought through Pearson Product Moment correlation of the total P-E fit scores (TPEF3) with total job stressor scores (TOCSS). The Pearson Product Moment correlation of TPEF3 with TOCSS was .09 with a significance of .165. The lack of 37 statistical significance indicates that there is no linear relation­ship between P-E fit and job stress. To determine if a curvilinear relationship existed between total P-E fit scores and total job stressors, a cross-tabulation graphic pre­sentation was made. Original P-E fit/misfit scores ranged in absolute value from 0 (perfect fit) to 20 (highest reported misfit). For the purposes of the graph, the scores were reduced to seven categories. Tabulations were made of the mean of all job stress scores in each of the ranges. These ranges were used to facilitate the examination of the general trend of the. relationship between P-E fit/misfit and job stress. This was done by establishing the mean stress scores of each of the seven ranges and graphing them accordingly. Figure 7 demon­strates that while the relationship certainly is not perfectly curvi­linear, there is a trend in that direction. While the li is not large, the moderate to high levels of P-E misfit are associated with the higher levels of stress, while the lower P-E misfit·scores are associ­ated with the lower levels of stress, though not to significant levels. Contrary to expectation, the very highest levels of P-E misfit are associated with the very lowest reported job stress. It is difficult to account for this result within the frame­work of the person-environment fit model. For this small number of head nurses, person-environment misfit does not equal job stress. Per­haps the answer lies in the fact that the greater the misfit, the more likely the individual is to be overwhelmed, and to not even be aware of what is causing the stress, therefore, the situations are not per­ceivedas stressful. Another possible explanation is that these VJ VJ 420 400 380 ~ 360 ....., (/) .a 340 o r-;) 320 300 280 0-2 3-5 6-8 9-11 12-24 P-E Fit/Misfit Figure 7. Relation of P-E fit/misfit to job stress. 15-17 18-20 w (X) 39 individuals have a high tolerance for incongruence between person and environment. P-E misfit is not stressful for them. Along this same line it is possible that some head nurses simply do not expect that the job will be stressful. No matter how great the P-E incongruence, the situation for them is not stressful. Looking at this result from another angle, makes one question the validity of the tools measuring P-E fit/misfit and job stress. Did the tool used really measure P-E fit/misfit and likewise, did the tool used measure job stress? Could this account for the unexpected results? The results for the remainder of the subjects were in the direc­tion expected. Thirty people with P-E fit/misfit scores from 9 to 17 have the higher job stress scores. Seventy-six head nurses having the lower P-E fit/misfit scores had the lower job stress scores. When P-E fit/misfit equaled 6 to 8, the job stressors' scores which had been rising, dropped off quite abruptly, only to rise quite sharply when P-E fit/misfit·scores equaled 9 to 11. The explanation for the drop and subsequent rise is not clear, though one might. postulate that with near perfect P-E fit, the job may not be as challenging, therefore, giving rise to job stress. A small amount of P-E misfit perhaps is to be expected, adds spice to the job, and does not necessarily equal job stress. The next question which sheds light on subjective P-E fit and job stress was: Are the objective variables of head nurse age, length of time the head nurse has held the position, the length of time the nurse has practiced nursing, size of hospital, size of unit, and type of unit significantly correlated with both subjective P-E fit and job stress? 40 Of the variables under consideration, the Pearson product mo­ment correlation coefficients revealed that P-E fit/misfit was not sig­nificantly correlated with any of the specific variables. On the other hand, job stress was significantly related to nurse age, time in posi-tion, hospital size, and years practicing nursing. Job stress was not significantly related to size of unit, type of unit, or P-E fit/misfit (see Table 4). The relationship between job stress and head nurse1s age indi­cated that the older the nurse, the lower the stress. Likewise, the longer the nurse has been in the position, the lower the stress. The correlation also indicated that the larger the hospital, the greater the stress. It also indicated that the greater the number of years practicing nursing, the lower the stress. The specialty units and the medical-surgical units and their relationship to P-E fit and job stress was evaluated through the use of Chi-square values resulting from cross-tabulations. The Chi-square values analysis indicated that there was no significant relationship between these units and either P-E fit/misfit or job stress. Such analysis of the other unit specialties was not done as a small N in each group precluded significant statistical analysis. The results of the evaluations are shown in Tables 5 and 6. Despite the lack of significance, there are some interesting observations to be made from the data. / I~""'" C .... ·:1,,t;; t"" t7,ii/ :J~~ ,,~ :f~j < 1 . 2. 3. 4. 5. 6. 7. Table 4 Pearson Product-Moment Correlations Among the Major Study Variables 1 2 3 4 5 6 7 Nurse I sAge Time in Position .54*** Hospital Size -.27** -.09 Years Practicing Nursing .83*** .54*** -.30*** Size of Unit -.02 -.01 -.06 .. 06 P-E Misfit .05 .06 .00 .08 .09 Job Stress -.41*** -.23** • 34 *** -. 38*** .10 .09 * Q = .05 ** Q = .01 *** Q = .001 .~..... Table 5 Percentages and Frequencies Between Type of Hospital, Nursing Unit, Type of Hospital Nursing Unit Medica l-Surgical Specialty x2 = 6.47 df = 4 N.S. and Degree of Total Job Stress Degree of Job Stress Low Stress Moderate Stress High Stress Percent N Percent N Percent N 36.5 (19 ) 23.1 ( 12) 40.4 (21 ) 23.8 ( 5) 47.6 (10) 28.6 ( 6) Totals Percent 100.0 100.0 N (52) (21) +::0 N Table 6 Percentages and Frequencies Between Type of Hospital Nursing Unit and Degree of Total Person-Environment Misfit Type of Hospital Nursing Unit Medical-Surgical Special ty x2 = 3.12 df = 4 N.S. Degree of Person Environment Misfit Low P-E Misfit Moderate P-E Misfit High P-E Misfit Totals Percent N Percent N Percent N Percent N 28.8 38.1 ( 15) ( 8) 42.3 33.3 (22) ( 7) 28.8 28.6 ( 1 5) 1 00 • 0 ( 52 ) ( 6) 1 00 . 0 ( 21 ) +::a w 44 Of the 52 head nurses on medical-surgical units, 33 (63.5%) indicated that they have either moderate to high stress, and 37 (71.1%) reported moderate to high misfit. A similar relationship existed for the nurses on specialty units (leUs, ERs). Of the 21 reporting spe­cialty head nurses, 16 (76.2%) reported moderate to high job stress, and 13 (61.9%) reported moderate to high P-E misfit. The data about specialty units would support the conclusions from the literature that these types of units are highly stressed, so finding that the head nurses on these units are highly stressed was not surprising. What is new is the documentation of the fact that head nurses on medical-surgical units also report experiencing high stress. This is probably not surprising since it has been noted that the general staff nurse has been reported as being highly stressed; it stands to reason that the head nurses would likely be experiencing high stress. It does raise the question as to whether the stresses are the same or whether head nurses in different clinical areas experience different stresses,. Leatt and Schneck (1980) waul d argue that differ­ent specialities experience different stresses. On the other hand, one could argue that supervisory tasks would have common characteris­tics regardless of clinical specialty and thus, the stresses would be similar. This research did not provide a large enough sample of head nurses from various speCialties to answer this speculation, but pro­vides instead a stepping stone for further studies. A second part of this question required additional information about subjective P-E fit and job stress: Of the objective variables head nurse age, length of time the head nurse has held the position, the length of time the nurse has practiced nursing, size of hospital, size of unit, type of unit, and the subjective P-E fit, which com­bination of variables accounts for most variance in the occur­rence of head nurse job stress? 45 A stepwise multiple regression analysis was performed on the demographic variables and subjective P-E fit to evaluate how much vari­ance they explained in job stress. From the analysis summarized in Table 7, age was the best predictor of job stress; the older the head nurse, the lower the stress (r = -.40). Age was significant and explained 16% of the variance in job stress. In addition to age, hospital size added the next most to the amount of explained variance in job stress. To­gether, age and hospital size explained 22% of the variance in job stress. The third most important variable in the regression analysis was unit size. Age, hospital size, and unit size account for 24% of the total variance. P-E fit/misfit is the fourth variable that adds information about job stress. Its contribution is minimal and does not add significantly to the explanation of job stress. Together with the first three variables 25% of variance in reported job stress is explained. Although the simple! is not significant for P-E mis-fit, it is in the expected direction, in that the greater the misfit, the greater the stress. The other variable, years head nurse has prac­ticed nursing, and the length of time the head nurse has held the position, added very little to the explanation of job stress. Their ranking in the regression analysis indicated that even though they 46 Table 7 Stepwise Multiple Regression Analysis of the Demographic, P.E. Misfit Variables with Job Stress Indepedent Simple r Explained Variables (Zero-Order) Multiple .!: Variance Age -.40*** .40 . 16 Hospital Size .36*** .47 .22 Unit Size .14 .49 .24 P.E. Misfit .10 .50 .25 Years Practicing Nursing -.32*** .51 .26 Length of Time in Position -.21** .51 .26 * .E. < .05 ** .E. < .01 *** £. < .001 47 were significant, the degree of explanation of job stress variance is already explained by the preceding variables. It stands to reason that older head nurses probably would have been practicing nursing longer and have had more time to become ac­customed to the stresses of nursing. Although stresses may still be present they may not be as bothered by them. The years may have taught them helpful coping skills. Hospital size also makes sense in its relationship to job stress. The larger the hospital the more complex the system, thus the more likely it is that possibilities for stress exist. Also, the larger the hospital, the greater the probability of high patient acuity levels. The more ill the patient, the more resources the hospital provides to improve patient care, adding again to the general complexity of the work environment. The relationship of unit size to job stress would follow the same rationale as is associated with hospital size. Increasing size means that the head nurse would supervise more people, who are caring for more patients, who are having more procedures, ordered by more phy­sicians, which added together increases the overall complexity of the individual unit. P-E fit/misfit contributes little to an explanation of job stress. The original premise of this research was based on the suppos­ition that the greater the discrepancy between the person and his/her job environment, the greater the job stress. While the results did not indicate that the relationship is significant, the trend is in that direction and as such it stands to reason that P-E fit/misfit would 48 add something to the explanation of job stress. Years practicing nursing and length of time in position all add minimally to our knowledge about job stress. It would appear that the age of the head nurse incorporates these variables. In summary, of the major variables examined the age of the head nurse, the hospi­tal size and the unit size explain the most about job stress. This conclusion applies to those aspects covered by this re­search. It still only addresses 25% of the variance in job stress. The logical question to follow is: What variables account for the other 75%? Such things might include hospital policies; physician-head nurse relationship; general physical environment and adequacy of facilities; perceives support/nonsupport of anciliary services; type and degree of illness of patients (cancer patients, dying patients, chronically ill patients, burn victims); perceived support/nonsupport of nursing ad­ministration; perceived adequacy/inadequacy of salary as compared to the work required, as well as all of the situational job stressors listed in Tables.8 and 9. Job Stress Having examined the research questions which dealt with the subjective P-E fit portion of the model, the next stage of the data analyses were to examine what the job stresses were for the head nurse. The research question was: What are the major job stressors of the head nurse role? In order to answer the research question, the data were evalu­ated in two ways. First, simple job stressors were ranked according to Percent 68 62 58 57 55 53 46 46 44 46 49 Table 8 Ten Most Frequently Reported Simple Job Stressors N (73) (67) (63) (62) (59) (57) (50) (50) (48 ) (50) Situation Job Stressors Having an inadequate number of nurses to staff the floor Having to take disciplinary action with one of your supervisees Feeling that you have too heavy a work-load, one that you can't pos­sibly finish during an ordinary work day Thinking that the amount of work you have to do may interfere with you well while it gets done Feeling of being caught in the mid­dle between your staff and top ad-ministration . Thinking that you will not be able to satisfy the conflicting demands of various people over you Having to decide things that affect the lives of individuals, people you know Feeling that you have little back-up or support from superiors Feeling that superiors don't know how ha rd you work Feeling that you have to do things on the job that are against your better judgment Table 9 Ten Most Frequently Reported Job Stressors, Modified r1ultipl icatively by Frequency 50 Percent N Situational Job Stressor 31 27 27 24 20 20 20 17 17 16 34 29 29 26 22 22 22 18 18 17 Feeling that you have too heavy a work­load, one that you can't possibly finish during an ordinary work day Having an inadequate number of nurses to staff the floor Not knowing what your superior thinks of you, how he/she evaluates your performance The fact that you can't get information needed to carry out your job Feeling that your job tends to inter­fere with your family life Staff scheduling Feeling of being caught in the middle between your staff and top administra­tion Feeling that you have little back-up or support from superiors Feeling that superiors don't know how hard you are working Having to decide things that affect the lives of individuals, people you know 51 frequency and second, job stressors modified multiplicatively by fre­quency of occurrence of the job stressor were ranked according to fre­quency. The ten most frequently occurring job stressors in both of these rankings are found in Tables 8 and 9. It is important to note that the tables are not the same. Four items were deleted from the simple job stressors list when the job stres­sors were modified by frequency. The four simple job stressors which moved down in rank order of stressfulness included: (1) having to take disciplinary action, (2) thinking that the amount of work interferes with how well it gets done, (3) thinking that you will not be able to satisfy the conflicting demands of various people ove~'you, and (4) feeling you have to do something against your better judgment. Ap­parently, these situations, though stressful, did not occur with great frequency. The four situational stressors which, when modified by frequency, moved up in rank order included: (1) not knowing what the supervisor thinks of you, (2) being unable to get the information needed to carry out your job, (3) feeling that your job tends to interfere with your family life, and (4) staff scheduling. While these items were some- . what less stressful individually, their overall stressfulness increases because of their frequency of occurrence. It is possible that repetitiveness of a stressful situation may condition the one being stressed such that the situation no longer is perceived as being stressful. On the other hand, a stressful situation which occurs with more frequency runs the risk of being seen as very stressful, especially if the repetition of the stressful situation wears 52 down one's ability to cope with that situation. Six items were part of both the simple stressors' list as well as that the grouping of job stressors, as modified by frequency. These items included: 1. Feeling that you have too heavy a work load, one that you cannot possibly finish during an ordinary day 2. Having an inadequate number of nurses to staff the floor 3. Feeling of being caught in the middle between the staff and top administration 4. Feeling little back-up or support from superiors 5. Feeling that supervisors do not know how hard you are working 6. Having to decide things that affect the lives of indi­viduals, people you know Of these six situations, the first five are essentially out of the control of head nurses. They are dependent upon the adequacy with which others do their jobs in order to feel any relief from the stressful ness of the situation. The sixth situation is more self­determined and is both stressful and frequent. Strains The last part of the model deals with physiological, psychologi­cal, and behavioral strains which were manifestations of maladaptation to the stressful situations. A small sample of physical and psychologi­cal strains and the relationship to job stress and P-E fit were examined. The strains examined were only representative of both physical and 53 psychological effects of stress and are, by no means, exhaustive. Be­havioral strains were not evaluated. The research question which examined this area of the model was: Is there a relationship between job stress, P-E fit, and specific physiological and psychological symptoms? A Spearman Rank Order correlational analysis was performed correlating the 13 physical/psychological symptoms being evaluated with both job stress and P-E fit/misfit. As can be seen in Table la, the symptoms of headaches, colds, abdominal distress, indigestion, constipation, fatigue, depression, and feeling burned out were significantly cor­related with job stress. When looking at P-E fit/misfit, the psycho­logical variables were again the most significant followed by head­aches as the only physiological symptom. It is interesting to note that of the physiological symptoms which correlated with job stress, the majority are gastrointestinal. This would follow the trend that is occurring in which more women tak­ing on managerial positions are developing the typically "male" di­sease of ulcers. There was a stronger relationship between the psychological variables of depression, feeling burned out and fatigue and head nurse job stress than between the physiological variables and head nurse job stress. Table 10 Spearman Rank Order Correlation of Physiological and Psychological Symptoms with Job Stress and P-E Fit/Misfit 54 Physiological/Psychological P-E Symptoms Job Stress Fit/Misfit 1 . Depression .54*** .20** 2. Feeling Burned Out .52*** .33** 3. Fatigue .49*** .28** 4. Abdominal Distress .40*** .02 5. Headaches .36*** .21* 6. Indigestion .25** .00 7. Colds .21* .03 8. Constipation .20* . 11 9. Fl u · 14 .01 10. Allergies · 13 .03 11 . Joint Pains · 11 .00 12. Diarrhea .09 -.01 13. Respiratory Distress .05 . 11 * £.< .05 ** £.< .01 *** £.< .001 CHAPTER IV SUr~MARY, LIMITATIONS, AND NURSING IMPLICATIONS Summary Few researchers have undertaken the investigation and descrip­tion of job stresses related to the position of the head nurse. The purpose of this study was to augment the knowledge in this area utiliz­ing the model of person-environment fit/misfit, stress, and strain. Results from this investigation have added to understanding of the phenomena and suggest areas for further research. Concentrating first on subjective P-E fit, it was found that with this sample, subjective P-E fit did not correlate significantly with job stress. The explanation for this lack of association was not clear, but some of the possibilities included: (1) small sample size (the ~ for this study was only. 108), which may reflect a problem of sampling procedures, (2) inadequacy of the subjective P-E fit tool utilized (will be discussed under· limitations), and (3) subjective P-E misfit is something different from job stress among the population of head nurses. It is interesting to postulate that P-E misfit is not the same thing as job stress, in that the results of this study did not support the assumption of the P-E fit model theory that job stress equals P-E misfit. Looking next at job stress, various issues were discussed. First, it was shown that the head nurse job is stressful, especially 56 for young, inexperienced head nurses in large hospitals, on larger nursing units, no matter what the clinical specialty. The situa­tional stressors which cause the most stress are those which are com­pounded by frequency of occurrence and are in large part external to or out of the control of the head nurse. This lack of control may reflect the characteristics of the head nurse in relationship to self­esteem, and learned helplessness. These responses may occur due to the overwhelming nature of the situational stressors, or may reflect the hierarchical position of the head nurse in the organizational structure of the hospital and a perceived powerlessness due to that position. Physiological and psychological strains are not uncommon and in this study have shown some significant correlations were demon­strated between job stress and P-E fit/misfit and these symptoms. (The correlations of physiological and psychological strains with job stress and P-E fit are not identical which raises further ques­tions regarding the equivalency of job stress and P-E fit/misfit.) The psychological strains manifested by depression, fatigue, and burn­out are the most highly related with both P-E fit and job stress (R = .001). Physiological symptoms, including headaches (R = .001), colds (£ = 0.05), and gastrointestinal distress (£ = .01 indigestion, £ = .05 constipation) are significantly correlated with job stress. Headaches was the only physiological symptom significantly correlated with P-E fit/misfit (R = .05). Limitations There are specific limitations associated with each part of 57 this study. Theoretically the study focuses only on P-E fit/misfit and does not address the issue that people can experience stress without feeling a misfit with their job, due to intervening variables such as coping skills, self-esteem, self-confidence, etc. The ,lack of correlation between subjective P-E fit and job stress raised the question of the reliability of the tools as well as the soundness of the theoretical assumption that P-E misfit equals job stress. The tool used to measure subjective P-E fit had been used successfully to differentiate' stressed from nonstressed men in a nonhealth care setting. It is possible that if a different type of tool, one speci­fically formulated to measure subjective P-E fit/misfit among head nurses were created, there would be a significant correlation between P-E fit/misfit and job stress. Re-evaluation of the job stressors' tools revealed that some items of potential head nurse job stress had not been included. The area of salary and its potential stress-producing properties was not addressed. Likewise, the tool was not focused on the problem of clinically proficient nurses being promoted to managerial positions without leadership preparation and training, and the stress that is produced by such a situation. The area of strains is an important topic and was only intro­duced. The researcher readily acknowledges that this work barely scratches the surface of psychological and physiological strains, and leaves the area of behavioral strains such as smoking behavior, drink­ing behavior, absenteeism, etc. totally untouched. 58 Implications for Nursing Practice The results of this study are valuable to nursing from an administrative standpoint. Both head nurses and nursing administra­tors need the information. The head nurse needs to understand the stresses of the job which would facilitate learning how to elicit support and feedback as well as promote increasing coping skills. Understanding the phenomenon of head nurse job stress would allow the nursing administrator the possibility of directly handling stress rather than letting it control the organization, perhaps by putting more control of the problems within the grasp of the individ­ual head nurses. It has been shown that the higher the stress, the higher the probability of physiological and psychological symptoms. When nursing administrators observe symptoms of depression burnout, fatigue or somatic complaints of frequent headaches, colds, or gastrointestinal upset, it would behoove them to look for stress­related causes such as too heavy workload, inadequate number of nurses, uncertainty of standing with supervisors, and the other situations as listed in Table 9. When a nursing administrator is looking for a new head nurse, many factors need to be taken into consideration, including leader­ship ability, clinical expertise, problem solving skills, and ability to successfully implement change. When considering the candidate's ability to handle the stress of the job, the nursing administrator might well consider the nurse's age and nursing experience as longevity is related to lower stress levels. When the administrator has no choice or in fact really wants a younger, less experienced 59 nurse in the head nurse position, it is important to remember that this new head nurse will probably experience significant job-related stress and as such the nursing administrator needs to be prepared to give added educational support and direction. Some of the stresses of the head nurse job are environmental in nature (supervisors, unit size, and number of nurses per unit), and as such tend more to be within the control of the nursing admin­istrator. Other sources of stress come from within the individual head nurse and as such are out of the control of the nursing admin­istrator's direct intervention. When faced with stressed head nurses, it is important for the nursing director to differentiate between the environmental and personal sources of that stress before determining the plan of action. Implications for Nursing Research If this study does nothing else, it raises issues which need further research. Again, going from the model upon which it was built, areas for research in each of the various phases of the model can be found. The entire area of objective P-E fit needs to be examined. When looking at subjective P-E fit, the most obvious need is for a tool which reliably and validly measures subjective P-E fit/misfit among head nurses in acute care hospitals. In the area of job stres­sors, rank is needed which might corroborate the reliabilities es­tablished. Investigations are needed to establish more than the face validity of these tools. Likewise, some items have been omitted which need to be included in future research. 60 The findings raise the question as to how much stress is distressful and how much is eustressful. These differences need to be delineated. They also present the question of whether stresses are the same for head nurses no matter what the clinical speciality of the unit supervised which would lend information as to how much head nursing is clinical and how much is managerial. Only a selected number of variables were examined in relationship to the explanation of job stress variance as measured by the regression equation. Further studies are needed which add to our understanding of the var­iance in job stress. The area of strain has hardly been touched upon. Investiga­tion needs to be done which would establish in greater detail sources of physiological and psychological job related strain. These strains need to be evaluated subjectively and objectively employing various measures of physiological strain, including blood pressure, heart rate, serum cortisol to name a few. Measures of psychological strain need also to be developed and utilized in future research. Behavioral manifestations of job stress have not even begun to be understood. This leaves a wide gap in knowledge of job-related strains, a gap which requires extensive nursing research. At the same time one investigates behavioral manifestations of job stress, ques­tions arise as to the relationship between job stress and strain and worker production turnover rates, etc. creating even another area for research. Once these areas have been adequately explored there is still much work to be done in the realm of intervention. Research is 61 needed on intervention strategies appropriate for each phase of the model, to determine what works, what does not work, why and why not. Such strategies might include both prehead nurse as well as post­head nurse intervention, utilizing leadership ladder preparation for nurses aspiring to administrative positions, the way clinical ladders are used in clinical advancement. Critique of the P-E Fit Model The P-E fit model is useful in understanding head nurse job stress as it lends itself to the differentiation between the person, the environment, and the interplay between them. While this study was focused on subjective P-E fit, the model encompasses both objective and subjective aspects of the person and the environment. Objective person and environment contribute to the subjective person and environment. In this model the difference between the person and environment equals person environment misfit which equates to job stress. Job stress leads to strain and ultimate illness. On the other hand equality of person and environment is person-environment fit which results in adaptation and challenge and promotes health. While the model is logical, there is some question as to the validity of the misfit equalling stress, theoretical framework. While this adds an element of question to the validity of the total model, it does not detract from the usefulness of the information obtained in the operationalization of the individual parts of the model. Conclusion Stress is an energy charged word in the vocabulary of today_ 62 It is most commonly thought of as being unpleasant and distressful, usually because it has gotten out of hand and is controlling the person rather than being used by the individual to strengthen and enhance his life. The head nurse role is thought to be stressful due to the dual role of the head nurse as both clinician and manager. This was a be­ginning exploration into the nature of stress for the head nurse, its relationship to person-environment fit, and the resultant strains which occur when stress becomes distressful. APPENDIX PERSON-ENVIRONMENT FIT AND JOB STRESS QUESTIONNAIRE Note. From Job demands and worker health by R. D. Caplan; S. Cobb; J. R~ French; R. Van Harrison; & S. R. Pinneau. Copyright 1980 by Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan. Reprinted by permission. August 1981 Dear Head Nurse, I am a graduate student at the University of Utah focusing my Masterts work on nursing administration. Having been a head nurse I remember the stresses that I faced and so for my thesis I have chosen to study head nurse stress. Recognizing that the job is a very difficult one I want to find out in more detail just what ~ feel are some of the major stresses of the job. Attached you will find a questionnaire which deals with head nurse job stress. I would appreciate it ff you would help me in this research by completing the questionnaire. It should take you 25-30 minutes to complete the form. Your completion and return of these forms will be considered your informed consent to participate in this study. I have chosen 64 to obtain your consent in this manner as it assures complete anonymity. I want you to feel secure that this information is strictly confidential and anonymous, so that you can feel free to be completely candid in your answers. The purpose of this study is to increase understanding of head nurse job stress and is a first step in helping to minimize that stress. I hope you will feel as I do, that your participation in this study is very important. I really want to know what stresses you. If you have any questions please feel free to ask them or to contact me. Thank you for your help. Sincerely, fbdf~ Ha-;1'&Jerl,1 Patricia Hanson 5064 South 3760 West Salt Lake City, Utah 84118 . 969-4812 Person-Environment Fit Please read what each of the following jobs are like. Then circle the number which describes the job you would prefer if you were looking for a new job. Next circle the number which best describes the job you have now. Follow this same procedure for each item in this section. Jane's job Anna's job Jane works on the same tasks every day. She uses the Almost each day things are different in Anna's job. Each same procedures or equipment all of the time. Each task is rarely the same as the previous one. She is likely task is like the one just finished. to use different procedures or equipment from case to case. Exactly 11 ke A lot like Jane's Jane's 1. I would prefer a job: 2 2. My job is: 2 Toni's job Toni's job requires her to be around people constantly. She works or talks with people DOst of the time. Somewhat Halfway Somewhat A lot like Exactly like 1 ike Jane's Between like Anna's Anna's Anna's 3 3 4 5 6 7 4 5 6 7 Bonnie's job Bonnie's job does not require her to work with anyone else. In her job Bonnie works alone. She rarely deals with other people. Exactly like A lot like Somewhat Halfway Somewhat A lot like Exactly like Toni's Toni1s like Toni's Between like Bon.ls Bonnie's Bonnie's 3. I would prefer a job: 4. My job is: Sarah's job 2 2 In Sarah's job she works with peorle from several different groups. She has to handle each group differently because they have different needs and want to get different things done. 3 3 4 4 5 5 Dawn's job 6 6 7 7 Dawn's contact at work is strictly with the people in her own work group or department. She does not need to deal with several different groups or departments or organiza­tions. Exactly like A lot like Somewhat Halfway Somewhat A lot like Exactly like 5. I would prefer a job: 6. My job is: Sa rah ' s Sa rah ' s 1 ike Sa rah 's Between li ke Dawn's Da\,/n ' s Dawn's 2 2 3 3 4 4 5 5 6 6 7 7 0'1 (J1 Tanna's job In Tanna's job she works on many different tasks which are all in different stages of completion. Some things are just being started while others are halfway finished, and others may be finished by someone else. Joan's job Joan's job requires her to work on one job at a time. When that work unit is completed, she starts to work on another unit or task. Two or more units are never worked on at the same time. She always finishes one unit before starting another. Exactly like A lot like Somewhat Halfway Somewhat A lot like Exactly like 7. I would prefer a job: 8. My job is: Tanna's Tanna's like Tanna's Between like Joan's Joan's Joan's 2 2 3 3 4 4 5 5 6 6 7 7 Vicki's job Diane's job Vicki's job has changes in work load. Every once in a while Vicki has to work to her absolute maximum. ~:hen that happens, she has to concentrate as hard as she can and be as careful as she can. Diane's job goes along evenly from hour to hour and from day to day_ The pace of the work stays about the same. She rarely, if ever, has to suddenly change the pace of her work and work even faster and harder. Exactly like A lot like Somewhat Halfway Somewhat A lot like Exactly like Vicki's Vicki's like Vicki 's Bet~leen 1 ike Diane's Diane's Diane'S 9. I would prefer a job: 2 3 4 5 6 7 10. My job is: 2 3 4 5 6 7 Val's job Ed's job Val's job is defined an~ described in almost every I On Ed's job, a person has some idea of the purpose of the detail. Nothing is left to change. There is a job, but no exact instructions are given on how to do the procedure for every type of task. work. There is often no set procedure. Exactly like A lot like SOIIe'/hat Halfway Somewhat A lot like Exactly like Val's Val's like Val's Between like Ed's Ed's Ed's 11. I would prefer a job: 2 3 4 5 6 7 12. My job is: 2 3 4 5 6 7 Q) 0'\ A great deal 13. How much slow down in the work load do you 5 experience? 14. How much time to do you have to think and contemplate? 5 15. How much work load do you have? 5 16. What quantity of work do others expect you to do? 5 17. How much time do you have to do all your work? 5 18. How many projects, assignments, or tasks do you have? 5 19. How many lulls between heavy work load periods do you have? 5 How much of each of the following types of responsibility do you have? Ver~ 1 ittle 20. How much responsibility do you have for the future of others? 21. How much responsibility do you have for the job security of others? 22. How much responsibility do you have for the morale of others? 23. How much responsibility do you have for the welfare and lives of others? A lot Some A little Hardly any 4 3 2 4 3 2 4 3 2 4 3 2 4 3 2 4 3 2 4 3 2 J\ little Some A lot A great deal 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 (J) ........ If you were designing a job for yourself, how much of each of the following ~IDuld you like to have in such a job? 24. How much work load would you like to have? 25. How much time would you like to have to do all your work? 26. How much slowdown in the work load would you prefer? 27. How much time to think and contemplate would you like? 28. What quantity of work would you prefer others to expect of you? 29. How many projects or assignments would you like to have? 30. How many lulls between heavy work periods would you like to have? Very' 1 ittle Hardly any A little Some A lot !.JIreat deal 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 Some A lot A great number 2 3 4 5 2 3 4 5 O"l 00 If you could have your own way about designing a job for yourself, how would you like each of the following to be? 31. Bow much responsibility would you like to have for the future of others? 32. How much responsibility would you like to have for the job security of others? 33. How much would you like for the morale of others? 34. How much would you like for the welfare and lives of others? If you could have your own way about designing a job for yourself, how would you like each of the following to be? 35. How much of the time would you like your work objectives to be well defined? 36. How often would you like to be clear on what others expect of you? 37. liow often would you like to be able to predict what others will expect of you on the job? 3R. How often would you like to be clear on what your job responsibilities are? Very littl e A 1 ittle Some A lot A great deal 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 Very often Fairly often Some- Occa- Rarely times sionally 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 0"1 1..0 These questions deal with different aspects of \-Iork. Please indicate how often these aspects appear in your job. Very often fairly often 39. How often are you clear on what your job responsibilities are? 2 40. How often can you predict what others will expect of you on the job? 2 41. How much of the time are your work objectives well defined? 2 42. How often are you clear about what others expect of you on the job? 2 Some- Occa-times sionally 3 4 3 4 3 4 3 4 Rarely 5 5 5 5 ......... o JOB STRESSORS How often during the day do you have something to do as part of your job with each of the following groups of people? Nearly all of Never Rarely Some of the time Often the time 1. Your direct supervisor or other staff over you 2 3 4 5 2. People you supervise. directly or indirectly 2 3 4 5 3. Others in the hospital but not in the same department. (i.e. lab, X-ray. pharmacy) 2 3 4 5 4. Outsiders who have business with your unit (patients, families. physicians) 2 3 4 5 5. Peers (other head nurses) 2 3 4 5 6. Significant others (please specify) 2 3 4 5 How stressful are your interactions with each of the following individuals or groups? Not Mildly Sometimes Very Stressful Stressful Stressful Stressful Stressful 7. Administrative superiors 2 '3 4 5 8. Colleagues 2 3 4 5 9. Supervisors 2 3 4 5 10. Supervisees (your staff) 2 3 4 5 11. Physicians 2 3 4 5 12. Patients 2 3 4 5 13. Families of patients 2 3 4 5 14. Physical therapists 2 3 4 5 Note. Adapted from Organizational stress: Studies in role conflict and ambiguity by R. Kahn, R. P. Wolfe, R. P. Quinn, J. D. Snoek, & R. A. Rosenthal. New York: John Wiley and Sons, Inc., 1964. ....... ~ Not Mildly Stressful Stressful 15. Respiratory therapists 2 16. laboratory personnel 2 17. Dieticians 2 18. Pharmacists 2 19. X-ray department 2 20. Housekeeping 2 21. Admitting personnel 2 Sometimes Stressful Stressful 3 4 3 4 3 4 3 4 3 4 3 4 3 4 Very Stressful 5 5 5 5 5 5 5 ....... N All of us are occasionally made to feel uncomfortable by certain kinds of situations. I would like you to tell me how stressful these situations are for you. Not Mildly Sometimes Very Stressful Stressful Stressful Stressful Stressful sl. Feeling that you have too little authority to carry out the responsibilities assigned to you 2 3 4 5 s2. Being unclear on just what opportunities for advancement or promotion exist for you 2 3 4 5 s3. Being unclear on just what the scope and responsibilities of your job are 2 3 4 5 s4. Feeling that you have too heavy a work-load, one that you can't possibly finish during an ordinary work day 2 3 4 5 s5. Thinking that you will not be able to satisfy the conflicting demands of various peoples over you 2 3 4 4 s6. Feeling that you are not fully qualified to handle your job 2 3 4 5 s7. Not knowing what your superior thinks of you, how he/she evaluates your performance 2 3 4 5 s8. The fact that you can't get information needed to carry out your job 2 3 4 5 s9. Having to decide things that affect the lives of individuals, people you know 2 3 4 5 s10. Feeling that you may not be liked and accepted by people you work with 2 3 4 5 s11. Feeling unable to influence your immediate superior's decisions and actions that affect you 2 3 4 5 ~ ~ Not Mildly Sometimes Very Stressful Stressful Stressful Stressful Stressful s12. Not knowing just what the people you work with expect of you 2 3 4 5 s13. Thinking that the amount of work you have to do may interfere with how well it gets done 2 3 4 5 s14. feeling that you have to do things on the job that are against your better judgement 2 3 4 5 s15. feeling that your job tends to interfere with your family life 2 3 4 4 s16. feeling that your progress on the job is not what it should or could be 2 3 4 5 s17. Thinking that someone else may get the job above you. one you are directly in line for 2 3 4 5 s18. feeling that you have too much responsibility and authority delegated to you by your superiors 2 3 4 5 s19. Interacting with other non-nursing departments 2 3 4 5 s20. Interacting with other nursing units 2 3 4 5 s21. Staff scheduling 2 3 4 5 s22. feeling of having too much responsibility without the accompanying authority 2 3 4 5 s23. feeling of being caught in the middle between your staff and top administration 2 3 4 5 s24. Interacting with patients 2 3 4 5 s25. Interacting with families 2 3 4 5 526. Interacting with physicians 2 3 4 5 ~ ~ Not Mildly Stressful Stressful s27. Having to take disciplinary action with one of your supervisees 2 s28. Having an inadequate number of nurses to staff the floor 2 s29. Feeling you have little back up or support from superiors 2 s30. Feeling that superiors don't know how hard you are working 2 s31. Feeling that supervisors lack confidence in you 2 s32. Feeling uncertain that your supervisors will back you up in difficult situations 2 s33. Uncertainty as to whether or not your super-visors appreciate your work 2 s34. Feeling unsure as to whether or not those over you are doing their jobs well 2 s35. Feeling that your job is challenging and exhilarating 2 Sometimes Stressful Stressful 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 Very Stressful 5 5 5 5 5 5 5 5 5 ......., <..n Now consider these same questions in relationship to how frequently do you encounter each of these situations. Never Rarely Sometimes fl. Feeling that you have too little authority to carry out the responsibilities assigned to you 2 3 f2. Being unclear on just what opportunities for advancement or promotion exist for you 2 3 f3. Being unclear on just what the scope and responsibilities of your job are 2 3 f4. Feeling that you have too heavy a work-load, one that you can't possibly finish during an ordinary work day 2 3 f5. Thinking that you will not be able to satisfy the conflicting demands of various people over you 2 3 f6. Feeling that you are not fully qualified to handle your job 2 3 f7. Not knowing what your superior thinks of you, how he/she evaluates your performance 2 3 fa. The fact that you can't get information needed to carry out your job 2 3 f9. Having to decide things that affect the lives of individuals, people you know 2 3 flO. Feeling that you may not be liked and accepted by people you work with 2 3 fll. Feeling unable to influence your immediate superior's decisions and actions that affect you 2 3 Rather Often 4 4 4 4 4 4 4 4 4 4 4 Nearly all the time 5 5 5 5 5 5 5 5 5 5 5 ........ 0\ f12. Not knowing just what the people you work with expect of you f13. Thinking that the amount of work you have to do may interfere with how well it gets done f14. Feeling that you have to do things on the job that are against your better judgement f15. Feeling that your job tends to interfere with your family life f16. Feeling that your progress on the job is not what it should or could be f17. Thinking that someone else may get the job above you. one you are directly 1n line for f18. Feeling that you have too much responsibility and authority delegated to you by your superiors f19. Interacting with other non-nursing departments f20. Interacting with other nursing units f21. Staff scheduling f22. Feeling of having too much responsibility without the accompanying authority f23. Feeling of being caught in the middle between your staff and top administration f24. Interacting with patients f25. Interacting with families f26. Interacting with physicians Never Rarely Sometimes 2 3 2 3 2 3 2 3 2 3 2 ,3 2 3 2 3 2 3 2 3 2 3 2 3 2 3 2 3 2 3 Rather j)ften 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Ne~r1y all the time 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 ....... ....... Never Ra re 1 y f21. Having to take disciplinary action with one of your supervlsees 2 f28. Having an inadequate number of nurses to staff the floor 2 f29. Feeling you have little back up or support from superi ors 2 f30. Feeling that superiors don't know how hard you are working 2 f3l. Feeling that supervisors lack confidence 1n you 2 f32. Feeling uncertain that your supervisors will back you up in difficult situations 2 f33. Uncertainty as to whether or not your super-visors appreciate your work 2 f34. Feeling unsure as to whether or not those over you are doing their jobs well 2 f35. Feeling that your job is challenging and exhilarating 2 Sometimes Rather Often 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 3 4 Nearly all the time 5 5 5 5 5 5 5 5 5 ...... 00 JOB STRESS QUESTIONNAIRE Demographic Information 1. How old are you? _______ _ 2. What is your sex? Male Female 3. How many years have you been practicing nursing? ______ _ 4. What is your educational background? (Highest degree completed) _____________ _ 5. What 1s the exact title of your present position? _______________________ _ How many beds does the hospital have? ________ _ 6. What type of unit do you work on? ______________ _ How many beds does it have? ________ _ 7. How long have you held your present position? _____________ _ 8. Do you have customarily students on your unit? No Yes 9. If so, check all that apply and indicate how many at one time: RN Nursing students A.D. Medical Interns ______ _ B.S. Medical Residents ______ _ LPN Nursing students Other Med i ca 1 s tuden ts ----r( p"""'l-e-a s-e-s-pe-c-.i-:fy-)....--- 10. How many people do you supervise? RN's male . LPN's male Aides male female female female Other ________ _ 11. Average nurse patient ratio: 7-3 3-11 shift -- shift 12. What is your preferred mode of nursing care? specify} 11-7 shift teams, 13. 00 you have an assistant head nurse? ______ _ 14. Are you married, single, divorced, widowed? ________ _ primary care, total care, other-- ......... 1..0 15. Do you have children? No ___ Yes Ages ____ _ 16. Do you have other outside activities? No ___ Yes ~Jhat kinds of activHies? _______ ___ 17. How would you rate your health? Excellent Good Fa i r Poor 18. Do you hve any chronic illnesses? No Yes Please indicate _______________ _ 19. Do you often miss work due to menstrual cramps? No Yes a. How often have you missed work for reasons other-l]an cramps~ver Rarely Sometimes Rather Often Often 20. Have you been through menopause? No Yes Specify av-e-ra-ge num-b-e-r of days -a-b-sent per year- ----- 21. How often do you have: headaches colds abdominal distress allergies joint pains indigestion respiratory distress constipation diarrhea "flu" fatigue depression feel "burned out" Just a few final questions: Never -1- 1 1 1 1 1 1 1 1 1 1 1 1 Rarely Sometimes Rather Often Nearly all the time 2 3 4 5 2 3 4 5 234 5 234 5 2 3 4 5 2 3 4 5 2 3 4 5 234 5 2 3 4 5 2 3 4 5 2 3 4 5 234 5 234 5 25. Do you now feel that: ___ Your job is easier than you thought it would be. ___ Your job is about what you expected. ___ Your job is harder than you thought it would be. 26. Compared to other supervisory jobs you held how would you rate this one? More fulfilling About the same less fulfilling Have never held another super­visory position OJ o 27. What is the single most stressful part of your job? 28. "'hat is the most rewarding part of your job? 29. Please comment on any aspect of your job that makes it stressful that may not have been covered in this questionnaire. Thank you very much for your cooperation in completing this form. l~hen all the data is in and analyzed a summary of the findings wi 11 be sent to your ~lurs i ng 01 rector. Thanks again, ex> ~ REFERENCES Albrecht, L. Stress and the manager. New Jersey: Prentice Hall, Inc., 1979. Arndt, C., & Laeger, E. Role strain in a diversified role set--the director of nursing service, part II, sources of stress. Nursing Research, 1970,}2, 495-501. Arndt, 0., & Laeger, E. Role strain in a diversified role set-­the director of nursing service, part I. Nursing Research, 1970, }2, 253-259. Basowitz, H.; Pershy, H.; Korchin, S. J.; & Grinker, R. R. Anxiety and stress. 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