Occupational stress of nurses in South Africa

Abstract

The objective of this study was to examine the construct validity and reliability of the Nursing Stress Indicator (NSI) and to identify differences between occupational stressors of professional and enrolled nurses. A cross-sectional survey design was used. A sample of professional nurses (N = 980) and enrolled and auxiliary nurses (N = 800) in South Africa was used. The NSI was developed as measuring instrument and administrated together with a biographical questionnaire. Five reliable stress factors, namely Patient Care, Job Demands, Lack of Support, Staff Issues, and Overtime were extracted. The most severe stressors for nurses included health risks posed by contact with patients, lack of recognition and insufficient staff. Watching patients suffer, demands of patients and staff issues were also severe stressors for professional nurses. The severity of stressors was higher for professional nurses (compared with enrolled and auxiliary nurses). Organisations that employ nurses should implement programmes to monitor and manage stress, specifically regarding staff issues and job demands.

Full text

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Curationis May 2006
Occupational stress of nurses in
South Africa
S. Rothmann
WorkWell: Research Unit for People, Policy and Performance, North-West University, Potchefstroom Campus
J.J. van der Colff
WorkWell: Research Unit for People, Policy and Performance, North-West University, Potchefstroom Campus
J.C. Rothmann
WorkWell: Research Unit for People, Policy and Performance, North-West University, Potchefstroom Campus
Keywords:
Abstract: Curationis 29(2): x-y
The objective of this study was to examine the construct validity and reliability of the
Nursing Stress Indicator (NSI) and to identify differences between occupational
stressors of professional and enrolled nurses. A cross-sectional survey design was
used. A sample of professional nurses (N = 980) and enrolled and auxiliary nurses (N
= 800) in South Africa was used. The NSI was developed as measuring instrument and
administrated together with a biographical questionnaire. Five reliable stress factors,
namely Patient Care, Job Demands, Lack of Support, Staff Issues, and Overtime were
extracted. The most severe stressors for nurses included health risks posed by contact
with patients, lack of recognition and insufficient staff. Watching patients suffer,
demands of patients and staff issues were also severe stressors for professional
nurses. The severity of stressors was higher for professional nurses (compared with
enrolled and auxiliary nurses). Organisations that employ nurses should implement
programmes to monitor and manage stress, specifically regarding staff issues and job
demands.
Opsomming
Die doelstelling van hierdie studie was om die konstrukgeldigheid en betroubaarheid
van die Nursing Stress Indicator (NSI) te bepaal en verskille tussen die werkstressore
vir professionele en ingeskrewe verpleegsters te bepaal. ‘n Dwarssnee opname-ontwerp
is gebruik. ‘n Steekproef van professionele verpleegsters (N = 980) en ingeskrewe
staf- en assistent verpleegsters (N = 800) in privaat en provinsiale hospitale in Suid-
Afrika is geneem. Die NSI is ontwikkel en saam met ‘n biografiese vraelys op deelnemers
toegepas. Vyf betroubare stresfaktore is onttrek, naamlik Pasiëntsorg, Werkeise, Gebrek
aan Ondersteuning, Personeelaangeleenthede en Oortyd. Die ernstigste stressore vir
verpleegsters was gesondheidsrisiko’s a.g.v. kontak met pasiënte, gebrek aan erkenning
en onvoldoende personeel. Om te sien hoe pasiënte ly, eise van pasiënte asook
personeelaangeleenthede was ook ernstige stressore vir professionele verpleegsters.
Die ernstigheid van stressore was hoër vir professionele verpleegsters (in vergelyking
met ingeskrewe staf en assistent-verpleegsters). Organisasies wat verpleegsters
indienneem moet programme implementeer on stres te monitor en bestuur, spesifiek
ten opsigte van personeelaangeleenthede en werkseise.
Correspondence address:
Prof S Rothmann
WorkWell: Research Unit for People, Policy
and Performance
North-West University Potchefstroom
Campus
Private Bag X6001
Potchefstroom
2520
Tel : (018) 299-1397
Fax : (018) 299-1360
E-mail : bpksr@puk.ac.za
Research Article

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Background and problem
statement
A stable and productive health service is
of vital importance to any country. This
includes the nursing profession which
comprises by far the greatest component
of this service section. The nursing
profession is seen as a stressful and
demanding profession (Carson, Bartlett
& Croucher, 1991; Coffey & Coleman,
2001; Fagin, Brown, Bartlett, Lear &
Carson, 1995). Stress as a phenomenon
gained recognition in the nursing
environment because of the data from
patients and empirical studies by
researchers that suggested that stress
and health are closely linked. Nurses are
seen to have more stress than most
people due to the nature of the job and
the system within which they work
(Bond, 1986).
It is important to determine the stressors
endemic to nursing in South Africa. In
South Africa, nurses face various
problems (Hartley, 2005). An inadequate
supply of protective equipment,
negligible waste disposal methods and
high patient loads are some of the issues
that threaten the well-being of health
workers already critically understaffed.
Nurses are routinely exposed to dangers
such as viruses, bacteria and needle-
prick injuries. Staff shortages often force
nursing staff to do work outside their job
definitions - often without appropriate
training or remuneration. Overworked
staff face the trauma and stress of
increasing numbers of HIV/AIDS
patients.
According to Spielberger and Vagg
(1999), the identification of major sources
of stress at work offers a twofold benefit
for both management and employees;
firstly by resulting in work environment
changes that reduce stress and increase
productivity, and secondly by facilitating
the development of effective
interventions that could reduce the
debilitating effects of occupational
stress. Meyerson (1994) and Handy
(1988, 1991) showed that stress occurs
in a particular context, since individuals
differ in the meaning they attribute to
stressful experiences.
Dewe (1989) adds another dimension to
the measurement of stress in
occupational settings by noting that the
specific meaning attributed to stressful
events and the perceived intensity should
also be extended to include the frequency
of the experienced stressor.
Consequently, severity of a stressor can
be obtained where an infrequently
experienced stressor is not overestimated
by only taking its perceived intensity into
account. A further useful taxonomy of
stressors in terms of their intensity and
frequency is the distinction between
acute and chronic stressors. Whereas an
acute stressor is derived from a rather
sudden event with relative short duration
in which an almost immediate
psychological reaction is evoked, chronic
stressors are experienced frequently and
intensely (Farmer, 1990; Newton, 1989).
Consequently, the study of stressors
specific to nursing in South Africa seems
important. However, it is also important
to establish the reliability and validity of
a measure of perceived stress of nurses.
The objectives of this study were to
determine the construct validity and
internal consistency of an occupational
stress measure and to identify job
stressors for nurses in South Africa.
Occupational stress
The Spielberger State-Trait (STP) model
of occupational stress (Spielberger, Vagg,
& Wasala, 2003) conceptualises stress
as a complex process that consists of
three major components, namely sources
of stress that are encountered in the work
environment, the perception and
appraisal of a particular stressor by an
employee, and the emotional reactions
that are evoked when a stressor is
appraised as threatening.
The STP model of occupational stress
focuses on the perceived severity and
frequency of occurrence of two major
categories of stressors, namely job
pressures and lack of support
(Spielberger et al., 2003). The STP model
recognizes the importance of individual
differences in personality traits in
determining how workplace stressors are
perceived and appraised. Occupational
stress is defined as the mind-body
arousal resulting from physical and/or
psychological job demands. The
appraisal of a stressor as threatening
leads to anxiety and anger and the
associated activation of the autonomic
nervous system. If severe and persistent,
the resulting physical and psychological
strain may cause adverse behavioural
consequences (Spielberger et al., 2003).
Employees evaluate their work
environment in terms of the severity and
frequency of occurrence of specific job
demands and pressure and the level of
support provided by other employees
(supervisors and co-workers), as well as
organisational features (policies and
procedures). Failing to take the
frequency of occurrence of a particular
stressor into account may contribute to
overestimating the effects of highly
stressful situations that rarely occur,
while underestimating the effects of
moderately stressful events that are
frequently experienced.
Lambert and Lambert (2001) found that
the following factors in South Africa
contribute to a stressful work
environment for nurses: impaired
communication with management, racism,
lack of fair competitive remuneration and
disregard for professional worth, non-
conducive physical and psychological
surroundings, a lack of support from
supervisors, high responsibility, long
working hours and task overload.
Nurses use the word stress to describe a
combination of unpleasant situations
and unpleasant inner personal
experiences (Bond, 1986). Vachon (1987)
found that much of the stress experienced
by caregivers was not related to
interaction with patients. She reported a
distribution of variables as follows: illness
- 15%, patient/family - 23%, occupational
role - 26% and work environment - 36%.
Cavanagh (1997) divides stressors within
the nursing profession in three
categories, namely personal,
interpersonal and work environment
stressors. Personal stressors include an
inability to manage home, work and study
responsibilities. Interpersonal stressors
reflect on relationships with doctors,
supervisors, other senior personnel and
colleagues (Basson & Van der Merwe,
1994). Work environment stressors
include a high work load and long
working hours (Basson & Van der
Merwe, 1994); caring and dealing with
pain, suffering and dying of patients; the
strain of being exposed to making
mistakes and managing demanding
responsibilities (Cavanagh, 1997); role
conflict and ambiguity (Levert, Lucas &
Ortlepp, 2000) and under-staffing
(Erasmus, Poggenpoel & Gmeiner, 1998;
Kilfedder, Power & Wells, 2001).
A lack of autonomy at work might
contribute to occupational stress of
nurses. For nurses that served in Vietnam,

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one of the hardest things was to give up
on their autonomy. They were used to
the mutual professional regard between
physician and nurse in Vietnam. Back in
the United States, nurses saw themselves
slip into the traditional role of a
“handmaiden”. One of the nurses said
this: “I questioned a doctor and got
reprimanded. It was like a slap in the face,
and I saw all my powers taken away from
me” (Norman, 1990). Interviews with
professional nurses whose roles were
changed from the hospital environment
to nursing roles in the community,
showed their experience of an acute fear
of their new professional autonomy.
Community nurses become aware of
their previously protected status as
professionals who were not expected to
think for themselves, or take any
initiatives while working in hospitals
(Roberts, 1994).
The emotional demands associated with
caring for patients also contribute to
occupational stress in nursing. Bond
(1986) concluded that emotions have a
bad name in nursing. The dangers of
emotional involvement for nurses are
often pointed out, but not the dangers of
emotional shallowness. Emotional
maturity is considered as the absence of
emotions rather than skill in being aware
of them and expressing them
appropriately. “Getting emotional” is
seen as failure, whereas being rational is
over-valued. In an effort not to show
emotions, nurses work harder. They do
not discuss it with their colleagues and
in the process they try killing off one of
the greatest resources they have to cope
with stress and for helping others do so.
However, in trying not to show emotions,
nurses might depersonalise their
patients.
Dartington (1994) had an experience that
sums up the emotional demands of
nursing: “What I, the students and the
tutors were all experiencing at first hand
were the unconscious assumptions of the
hospital system, which were that
attachment should be avoided for fear of
being overwhelmed by emotional
demands that may threaten competence
and that dependency on colleagues and
supervisors should be avoided.” Norman
(1990) found that nurses insulate
themselves, they avoid feeling sad or
angry or helpless. A common feeling
associated with death is the feeling of
inadequacy. There is the grief about the
death itself and also the feeling of having
failed to save a life (Mawson, 1994).
Obholzer and Roberts (1994) state that
staff working closely with people in great
pain and with dying people experience
much stress.
Roberts (1994) found in an old-age
hospital that the nurses in the continuing
care wards were low on morale, and
relationships were antagonistic towards
the nurses in the other wards. These
nurses worked in the wards where there
was no hope for the elderly to heal and
leave the hospital. The nurses receive
little positive feedback from colleagues,
patients or families of the patients. In fact,
many of their patients died soon after
being transferred to the ward. Nurses in
these wards were deprived of hope and
the satisfaction of seeing their patients
improve and moving back into the
community.
Lack of resources is another source of
stress for nurses. James (2002) found that
nurses often experience a lack or
inadequate amount of resources. This
lack of resources leaves the nurses with
a feeling of dissatisfaction because they
cannot do their nursing work as expected
of them. Resources include items such
as staff, linen, food and equipment.
Furthermore, support by nurse managers
seems to be very important to nurses and
the lack thereof is a source of stress.
James (2002) found that the nurses she
interviewed felt unsafe and insecure to
operate optimally as nurses, because of
the lack of support and favouritism
practised and displayed by the nurse
managers.
Tummers, Janssen, Landeweerd, and
Houkes (2001) found that workload was
high for nurses. They described workload
as “budget constraints with the
consequences of staff shortages, low
salary, low career opportunity, and less
time for direct patient care.” Their studies
indicate that workload is an important
predictor of emotional exhaustion.
Govender (1995) found in her research
that, in comparison with professional
nurses, nurses’ seniority correlates
positively and significantly with the total
sources of stress scores, especially with
issues related to workload and conflict
with doctors. Shift work places a lot of
stress on the nurse. Two out of the eight
most common problems of shift work are
the major communication problems
among shifts and informal clique forming
on any shift, which is viewed as negative
and intimidating (Schaffner &
Bermingham, 1993).
Relationships with colleagues, nurse
managers and doctors can cause stress
for the nurse. When nurses feel helpless
towards their patients, they tend to
experience a lot of anger and frustration,
but this is often denied. This causes their
negative feelings to erupt against one
another or to be directed at their
superiors. Sometimes doctors prescribe
pain-inflicting procedures and the nurses
unconsciously blame the doctors for
that. The structure of the relationship
between the doctors and nurses does not
allow the far more experienced nurses to
advise doctors on the best ways to do a
particular procedure (Cohn, 1994). In
interviewing urban and rural nurses,
Wilkes and Beale (2001) found that
nurses felt that conflict with doctors
causes stress for nurses. They had
different ideas on medication, and the
doctors were also unable to support
nurses when they needed it.
It seems that in order to protect
themselves, nurses would deny a
colleague support. Mawson (1994)
experienced in the Walsingham Child
Health Team that the team does not want
to become involved with the feelings of
guilt in a member, caused by the pain-
inflicting procedures unfortunately
necessary for her patient. The team does
not want “the pain in their work made
more acute”.
A vast number of stressors for nurses
were identified. Not all of them are
applicable to all nurses at all times. In
most of the research, the researchers
concentrated on the stress of nurses in a
specific health care unit, intensive care
(Le Blanc, De Jonge, De Rijk & Schaufeli,
2001; Couden, 2002), psychiatric or
mental wards (Erasmus et al., 1998;
Humpel & Caputi, 2001; Levert et al.,
2000), gynaecology (Orji, Fasubaa,
Onwudiegwu, Dare & Ogunniyi, 2002),
general nurses (Yip, 2001), conditions
such as HIV/AIDS and cancer (Lempp,
1995), and healthcare management
(Rodham, 2002). A few comparative
studies were identified: emergency
department and general ward nurses
(Yang et al., 2001), general and mental
health nurses (Tummers, Janssen,
Landeweerd & Houkes, 2001), and urban
and rural nurses (Wilkes & Beale, 2001).
No study could be found that compared
professional, enrolled and auxiliary
nurses.

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Method
Research design
A cross-sectional survey design was
used. The design can be used for the
description of the population at a specific
point in time (Shaughnessy &
Zechmeister, 1997). Considerations
regarding ethical issues were addressed
by means of active inclusion and
consultation with the relevant
stakeholders at the Department of Health,
hospital groups in South Africa, as well
as with the participants in the study. The
objectives of the study were explained
to, and written consent obtained from,
the participants at their place of work
where the data collection also took place.
Confidentiality and anonymity were
assured.
Participants
Random samples (N = 1780) were taken
from hospital wards, psychiatric wards,
community/occupational services and
nursing management. The sample was
stratified according to categories of
nurses and included professional nurses
(N = 980), as well as enrolled and auxiliary
nurses (N = 800). The characteristics of
the study population are reported in
Table 1.
Table 1 shows that more than half of the
sample was made up of Afrikaans-
speaking women (54,15%). Furthermore,
it seems that registered (professional)
nurses form the biggest part of the ranks
of the different nurse categories
(43,17%). Seven of the nine provinces of
South Africa participated in the study.
Women are by far the biggest part of the
sample (97,12%).
Measuring instrument
The Nursing Stress Indicator (NSI) was
developed based on the STP model of
occupational stress (Spielberger et al.,
2003). The NSI was developed for the job
stressors specific to the nursing
environment in two major categories,
namely job pressures and lack of support.
Items for the NSI were generated based
on a literature review of occupational
stress in nursing and by interviewing
professional, enrolled and auxiliary
nurses. The NSI consists of 124 items.
Firstly, participants rated each of the 62
statements in terms of perceived intensity
of the particular stressor on a 9-point
scale, ranging from 1 (low) to 9 (high). In
the second part of the questionnaire, the
participants were asked to respond in
terms of perceived frequency in
experiencing these stressors over a
period of the past 6 months on a 10 point
scale ranging from 0 (no days) to 9+ (more
than 9 days). The severity of a stressor
is expressed as the product of the
intensity and frequency thereof.
A biographical questionnaire was also
included. Participants were given the
option of providing their names and
contact details if they wanted feedback.
Other information included in the
questionnaire was rank, working full time
or part time, unit, time in unit, specialised
training needed for unit, time in
profession, shifts, province, education,
gender, marital status, language and
health.
Statistical analysis
The SAS program was used to carry out
statistical analyses regarding the
reliability and construct validity of the
NSI (SAS Institute, 2000). Principal
component extraction with a varimax
rotation was carried out through SAS
FACTOR on the 124 items of the NSI for
a sample of 1780 professional, enrolled
and auxiliary nurses. Cronbach alpha
coefficients and inter-item correlations
Item Category Percentage
Home Language Afrikaans 54,15
English 30,94
Sepedi 1,77
Sesotho 1,49
Setswana 3,41
SiSwati 0,14
Tshivenda 0,07
IsiNdebele 0,07
IsiXhosa 2,34
IsiZulu 5,18
Other 0,43
Rank Enrolled auxiliary nurse 21,29
Enrolled nurse (staff nurse) 19,71
Registered nurse 43,17
Unit manager 9,64
Process manager 1,29
Nursing manager 0,86
Nursing services specialist 0,22
Other position 3,81
Province Eastern Cape 6,91
Free State 5,20
Gauteng 45,12
KwaZulu-Natal 22,02
Mpumalanga 6,84
North West 6,99
Western Cape 6,91
Gender Male 2,88
Female 97,12
Table 1 Characteristics of the participants (n = 1780)

Item F
1
F
2
F
3
F
4
F
5
h
2
Death of a patient with whom you have developed a close relationship 0,79 0,00 0,00 0,00 0,00 0,66
Watching a patient suffer 0,76 0,00 0,00 0,00 0,00 0,64
Death of a patient 0,71 0,00 0,00 0,00 0,00 0,58
Making a mistake when treating a patient 0,71 0,00 0,00 0,00 0,00 0,63
Communicating with a patient about death 0,65 0,00 0,00 0,00 0,00 0,54
Disagreement with medical practitioner or colleague concerning the 0,64 0,00 0,00 0,00 0,00 0,58
treatment of a patient
Patients who fail to improve 0,64 0,00 0,00 0,00 0,00 0,53
Inadequate information from a medical practitioner regarding the 0,60 0,00 0,00 0,00 0,00 0,55
medical condition of the patient
Demands of clients/patients 0,00 0,74 0,00 0,00 0,00 0,61
Stock control in the ward/unit/institution 0,00 0,63 0,00 0,00 0,00 0,46
Language and communication barriers with clients/patients 0,00 0,58 0,00 0,00 0,00 0,43
Adhering to the budget of the hospital/institution 0,00 0,58 0,00 0,00 0,00 0,40
Dealing with other health care professionals.(e.g. dieticians, 0,00 0,56 0,00 0,00 0,00 0,37
social workers, pharmacists)
Management of staff 0,00 0,56 0,00 0,00 0,00 0,40
Dealing with difficult patients 0,00 0,54 0,00 0,00 0,00 0,46
Excessive involvement in committee meetings 0,00 0,53 0,00 0,00 0,00 0,39
Meeting deadlines 0,00 0,51 0,00 0,00 0,00 0,43
Frequent changes from boring to demanding activities 0,00 0,46 0,00 0,00 0,00 0,41
Security risk posed in area where your job is located 0,00 0,46 0,00 0,00 0,00 0,30
Health risk posed by contact with patients 0,00 0,46 0,00 0,00 0,00 0,32
Difficulty getting along with supervisor/manager 0,00 0,00 0,72 0,00 0,00 0,58
Poor or inadequate supervision/management 0,00 0,00 0,65 0,00 0,00 0,55
Inadequate support by supervisor/manager 0,00 0,00 0,62 0,00 0,00 0,52
Conflict with a supervisor/manager 0,00 0,00 0,61 0,00 0,00 0,58
Experiencing negative attitudes towards the organisation 0,00 0,00 0,51 0,00 0,00 0,44
Lack of support from colleagues 0,00 0,00 0,50 0,00 0,00 0,47
Inadequate or poor quality equipment 0,00 0,00 0,49 0,00 0,00 0,40
Lack of recognition for good work 0,00 0,00 0,46 0,00 0,00 0,39
Lack of participation in policy-making decisions 0,00 0,00 0,45 0,00 0,00 0,39
Lack of opportunity to talk openly with other staff members 0,00 0,00 0,45 0,00 0,00 0,40
Insufficient personnel to handle workload 0,00 0,00 0,00 0,59 0,00 0,52
Shortage of staff 0,00 0,00 0,00 0,55 0,00 0,50
Poorly motivated co-workers 0,00 0,00 0,00 0,50 0,00 0,54
Insufficient time to perform tasks 0,00 0,00 0,00 0,47 0,00 0,54
Fellow workers not doing their job 0,00 0,00 0,00 0,45 0,00 0,47
Covering work for another employee 0,00 0,00 0,00 0,45 0,00 0,46
Working overtime 0,00 0,00 0,00 0,00 0,67 0,53
Working emergency hours 0,00 0,00 0,00 0,00 0,61 0,43
Working overtime due to “Moonlighting” 0,00 0,00 0,00 0,00 0,49 0,31
Squared Multiple Correlations 0,89 0,86 0,81 0,76 0,71
Percentage variance 11,44 11,29 9,66 7,98 3,74
Percentage covariance 25,92 25,59 21,90 18,10 8,48
Factor labels: F
1
: Stress: Patient Care, F
2
: Stress: Job Demands, F
3
: Stress: Lack support, F
4
: Stress: Staff Issues, F
5
: Stress: Overtime.
Table 2 Factor loadings, communalities (h
2
), percentage variance and covariance for principal factor extraction
and varimax rotation on NSI items

Professional Nurses Enrolled Nurses
Item Intensity Frequency Severity Intensity Frequency Severity
Mean SD Mean SD Mean SD Mean SD
FACTOR 1: PATIENT CARE
Death of a patient with whom you have developed a close relationship 5,50 3,12 1,77 2,58 9,74 4,77 3,05 2,28 2,90 10,88
Watching a patient suffer 6,21 2,72 3,87 3,33 24,03 5,18 2,99 3,12 3,16 16,16
Death of a patient 5,28 2,76 2,97 3,14 15,68 4,47 2,83 2,87 3,12 12,83
Making a mistake when treating a patient 5,76 3,10 1,18 1,92 6,80 3,95 2,96 1,30 2,08 5,14
Communicating with a patient about death 4,68 2,71 2,57 2,87 12,03 3,90 2,73 2,05 2,62 8,00
Disagreement with medical practitioner or colleague concerning the 5,02 2,67 2,32 2,54 11,65 3,42 2,71 1,45 2,23 4,96
treatment of a patient
Patients who fail to improve 4,94 2,56 4,06 3,25 20,06 4,35 2,48 3,28 2,96 14,27
Inadequate information from a medical practitioner regarding the medical 5,31 2,63 3,32 3,05 17,63 4,22 2,79 2,48 2,87 10,47
condition of the patient
FACTOR 2: JOB DEMANDS
Demands of clients/patients 5,07 2,30 5,87 3,15 29,76 4,70 2,62 4,66 3,26 21,90
Stock control in the ward/unit/institution 4,98 2,41 5,54 3,30 27,59 4,40 2,70 4,40 3,37 19,36
Language and communication barriers with clients/patients 4,20 2,19 3,44 2,89 14,45 4,12 2,45 3,33 2,98 13,72
Adhering to the budget of the hospital/institution 4,75 2,40 4,96 3,36 23,56 3,92 2,69 3,38 3,27 13,25
Dealing with other health care professionals (e.g. dieticians, social workers, 3,33 2,00 4,21 3,44 14,02 3,00 2,18 2,95 3,19 8,85
pharmacists)
Management of staff 4,65 2,40 5,08 3,43 23,62 3,56 2,69 2,44 3,10 8,69
Dealing with difficult patients 5,25 2,36 4,61 3,13 24,2 4,89 2,59 4,42 3,16 21,61
Excessive involvement in committee meetings 4,13 2,40 3,34 3,09 13,79 3,37 2,45 2,24 2,68 7,55
Meeting deadlines 5,10 2,33 4,67 3,21 23,82 4,18 2,67 3,17 3,10 13,25
Frequent changes from boring to demanding activities 4,65 2,31 4,52 3,24 21,02 4,19 2,48 3,41 3,16 14,29
Security risk posed in area where your job is located 3,89 2,51 3,34 3,09 12,99 3,89 2,68 2,23 2,68 8,67
Health risk posed by contact with patients 5,42 2,66 5,49 3,34 29,76 5,54 2,73 5,14 3,33 28,48
Table 3 Descriptive statistics of stressor intensity and frequency items: professional and enrolled nurses
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Curationis May 2006

FACTOR 3: STRESS, LACK OF SUPPORT
Difficulty getting along with supervisor/manager 4,10 2,73 1,95 2,57 8,00 3,50 2,63 1,96 2,74 6,86
Poor or inadequate supervision/management 4,76 2,63 2,68 2,88 12,76 3,89 2,70 2,46 2,95 9,57
Inadequate support by supervisor/manager 5,33 2,61 3,10 3,06 16,52 4,59 2,66 2,81 3,01 12,90
Conflict with a supervisor/manager 4,58 2,77 2,10 2,64 9,62 3,52 2,69 1,81 2,51 6,37
Experiencing negative attitudes towards the organisation 4,84 2,47 3,77 3,17 18,25 4,06 2,64 3,07 3,10 12,46
Lack of support from colleagues 4,97 2,51 2,87 2,75 14,26 4,35 2,51 2,70 2,75 11,75
Inadequate or poor quality equipment 5,18 2,74 2,82 2,90 14,61 4,31 2,73 2,69 2,94 11,59
Lack of recognition for good work 5,63 2,35 4,20 3,29 23,65 5,33 2,70 4,04 3,37 21,53
Lack of participation in policy-making decisions 5,04 2,46 2,94 3,07 14,82 3,94 2,55 2,21 2,88 8,71
Lack of opportunity to talk openly with other staff members 4,28 2,41 2,57 2,72 11,00 4,01 2,40 2,74 2,85 10,99
FACTOR 4: STAFF ISSUES
Insufficient personnel to handle workload 6,30 2,27 5,67 3,08 35,72 5,45 2,75 4,69 3,34 25,56
Shortage of staff 6,74 2,32 5,93 3,20 39,97 6,17 2,73 5,44 3,28 33,56
Poorly motivated co-workers 5,90 2,37 4,90 3,07 28,91 4,97 2,64 4,41 3,27 21,92
Insufficient time to perform tasks 5,83 2,45 4,40 3,14 25,65 4,89 2,61 3,30 3,09 16,14
Fellow workers not doing their job 6,30 2,27 5,09 3,01 32,07 5,45 2,75 4,34 3,30 23,65
Covering work for another employee 4,97 2,60 4,15 3,23 20,63 4,79 2,77 4,04 3,23 19,35
FACTOR 5: OVERTIME
Working overtime 4,07 2,52 4,49 3,52 18,27 3,56 2,49 3,76 3,43 13,39
Working emergency hours 3,41 2,62 2,38 3,05 8,12 2,83 2,56 1,90 2,86 5,38
Working overtime due to “Moonlighting” 2,84 2,77 1,83 2,99 5,20 2,75 2,64 2,00 3,06 5,50
Professional Nurses Enrolled Nurses
Item Intensity Frequency Severity Intensity Frequency Severity
Mean SD Mean SD Mean SD Mean SD
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were used to assess the internal
consistency of the measuring instrument.
T-tests were used to determine
differences between professional nurses
on the one hand and enrolled and
auxiliary nurses on the other hand. A cut-
off point of d = 0,50 (medium effect,
Cohen, 1988) was set for the practical
significance of differences between
means.
Results
The results of the factor analysis are
shown in Table 2. Loadings of variance
on factors, communalities and
percentage of variance and covariance
are shown. Variables are ordered and
grouped by size of loading to facilitate
interpretation. Zeros represent loadings
that were < 0,45 (20% of variance). Labels
for each factor are suggested in the
footnote.
Principal of support. The fourth stress
factor dealt with staff issues such as
shortage of staff and insufficient time to
perform tasks. This factor was labelled
staff issues. The fifth stress factor dealt
with overtime with items such as working
overtime and working overtime due to
“Moonlighting”. This factor was labelled
overtime.
Descriptive statistics for the intensity,
frequency and severity of stressors for
nurses are given in Table 3. Severity is
expressed as the product of intensity and
frequency.
The results in Table 3 shows that
professional nurses (compared with
enrolled and auxiliary nurses) obtained
higher scores on stressors. The most
severe stressors for professional nurses
were the following: watching a patient
suffer, demands of patients, stock control
in the ward or unit, health risks posed by
contact with patients, lack of recognition
for good work, staff issues, such as
insufficient staff, poorly motivated
workers, insufficient time to perform tasks
and fellow workers not doing their jobs.
The most severe stressors for enrolled
and auxiliary nurses were the following:
health risks posed by contact with
patients, lack of recognition for good
work, and insufficient staff.
Descriptive statistics, alpha coefficients
and mean inter-item correlation
coefficients of the NSI factors are
reported in Table 4.
Table 4 shows that the alpha coefficients
of the five extracted factors of the NSI
are highly acceptable when compared to
the guideline of 0,70 (Nunnally &
Bernstein, 1994). The mean inter-item
correlation coefficients are in the
recommended range (0,15 < r <0,50) (Clark
& Watson, 1995).
The significance of differences between
intensity of stressors for professional
and enrolled and auxiliary nurses is
reported in Table 5.
Table 5 shows practically significant
differences (of medium effect) between
professional nurses on the one hand and
enrolled and auxiliary nurses only
regarding the following stressors: a)
Professional nurses (compared with
enrolled and auxiliary nurses) obtained a
higher score on stress because of the
possibility of making a mistake when
treating a patient. b) Professional nurses
(compared with enrolled and auxiliary
nurses) obtained a higher score on stress
because of disagreement with medical
practitioners or colleagues concerning
the treatment of a patient.
Discussion
It was the aim of this study to determine
the reliability and construct validity of
the NSI and to identify the occupational
stressors for nurses. Principal
component analysis resulted in five
factors, namely patient care, job
demands, lack of support, staff issues,
and overtime, describing the perceived
occupational stressors for nurses. The
reliabilities (coefficient alphas) of the five
factors were acceptable.
The first factor, patient care, emphasises
the physical help/care provided by
nurses to patients. These include death
of a patient with whom you have
developed a close relationship, watching
a patient suffer, death of a patient, making
a mistake when treating a patient,
communicating with a patient about
death and disagreement with a medical
practitioner or colleague concerning the
treatment of a patient. Mawson (1994)
and Obholzer and Roberts (1994) regard
these as severe stressors for nurses.
However, the results showed that
severity of stress because of patient care
was substantially lower than other
stressors. Only one stressor, namely
watching a patient suffer, had a higher
severity than other stressors. Studies in
other contexts (e.g. Kop & Euwema, 2001)
confirm that stressors related to the
specific occupation individuals find
themselves in, are often less severe than
organisational stressors. In comparing
professional and enrolled and auxiliary
nurses’ stress in respect of the first factor,
it becomes clear that the severity of
stressors for professional nurses is
higher than that of the enrolled and
auxiliary nurses.
The items loading on the second factor
refer to the demands associated with the
job of the nurse, including workload
(Tummers et al., 2001). Job demands
include stressors such as health risk
posed by contact with patients, meeting
deadlines, dealing with difficult patients,
demands of clients/patients. Health risks
posed by contact with patients was the
most severe stressor for professional
nurses as well as enrolled and auxiliary
Item Mean SD Skewness Kurtosis r-Mean a
Patient care 39,08 18,00 -0,31 -0,87 0,57 0,91
Job demands 52,99 19,42 -0,05 -0,42 0,38 0,88
Lack of support 45,61 18,41 -0,05 -0,63 0,44 0,89
Staff issues 34,27 11,68 -0,54 -0,40 0,49 0,85
Overtime 9,82 6,21 0,37 -0,66 0,44 0,70
Table 4 Descriptive statistics, alpha coefficients and mean inter-item correlation coefficients of the NSI factors
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1
Curationis May 2006
Item Professional Nurses Enrolled Nurses d
Mean SD Mean SD
Stress: Patient Care 42,71 17,59 34,27 17,41 0,48
Death of a patient with whom you have developed a close relationship 5,50 3,12 4,77 3,05 0,23
Watching a patient suffer 6,21 2,72 5,18 2,99 0,34
Death of a patient 5,28 2,76 4,47 2,83 0,29
Making a mistake when treating a patient 5,76 3,10 3,95 2,96 0,58
*
Communicating with a patient about death 4,68 2,71 3,90 2,73 0,29
Disagreement with medical practitioner or colleague concerning the 5,02 2,67 3,42 2,71 0,59
*
treatment of a patient
Patients who fail to improve 4,94 2,56 4,35 2,48 0,23
Inadequate information from a medical practitioner regarding the 5,31 2,63 4,22 2,79 0,39
medical condition of the patient
Stress: Job Demands 55,45 18,84 49,74 19,72 0,29
Demands of clients/patients 5,07 2,30 4,70 2,62 0,14
Stock control in the ward/unit/institution 4,98 2,41 4,40 2,70 0,21
Language and communication barriers with clients/patients 4,20 2,19 4,12 2,45 -
Adhering to the budget of the hospital/institution 4,75 2,40 3,92 2,69 0,31
Dealing with other health care professionals.(e.g. dieticians, social 3,33 2,00 3,00 2,18 0,15
workers, pharmacists)
Management of staff 4,65 2,40 3,56 2,69 0,41
Dealing with difficult patients 5,25 2,36 4,89 2,59 0,14
Excessive involvement in committee meetings 4,13 2,40 3,37 2,45 0,31
Meeting deadlines 5,10 2,33 4,18 2,67 0,34
Frequent changes from boring to demanding activities 4,65 2,31 4,19 2,48 0,19
Security risk posed in area where your job is located 3,89 2,51 3,89 2,68 -
Health risk posed by contact with patients 5,42 2,66 5,54 2,73 -
Stress: Lack of Support 48,71 18,38 41,50 17,63 0,39
Difficulty getting along with supervisor/manager 4,10 2,73 3,50 2,63 0,22
Poor or inadequate supervision/management 4,76 2,63 3,89 2,70 0,32
Inadequate support by supervisor/manager 5,33 2,61 4,59 2,66 0,28
Conflict with a supervisor/manager 4,58 2,77 3,52 2,69 0,38
Experiencing negative attitudes towards the organisation 4,84 2,47 4,06 2,64 0,30
Lack of support from colleagues 4,97 2,51 4,35 2,51 0,25
Inadequate or poor quality equipment 5,18 2,74 4,31 2,73 0,32
Lack of recognition for good work 5,63 2,35 5,33 2,70 -
Lack of participation in policy-making decisions 5,04 2,46 3,94 2,55 0,43
Lack of opportunity to talk openly with other staff members 4,28 2,41 4,01 2,40 -
Stress: Staff Issues 36,12 11,02 31,81 12,06 0,36
Insufficient personnel to handle workload 6,30 2,27 5,45 2,75 0,31
Shortage of staff 6,74 2,32 6,17 2,73 0,21
Poorly motivated co-workers 5,90 2,37 4,97 2,64 0,35
Insufficient time to perform tasks 5,83 2,45 4,89 2,61 0,36
Fellow workers not doing their job 6,30 2,27 5,45 2,75 0,31
Covering work for another employee 4,97 2,60 4,79 2,77 -
Stress: Overtime 10,32 6,28 9,14 6,07 0,19
Working overtime 4,07 2,52 3,56 2,49 0,20
Working emergency hours 3,41 2,62 2,83 2,56 0,22
Working overtime due to “Moonlighting” 2,84 2,77 2,75 2,64 -
* Practically significant difference: d > 0,50 (medium effect)
Table 5 The significance of differences between intensity of stressors for professional and enrolled nurses

1
Curationis May 2006
nurses. For professional nurses,
stressors such as demands of patients
and stock control were also relatively
severe. Administrative demands
associated with nursing were also more
stressful for professional nurses
(compared to enrolled and auxiliary
nurses).
The third factor indicates stress because
of a lack of support in the organisation
as well as from supervisors and
colleagues. The items loading on this
factor include the following: lack of
recognition for good work, inadequate
support by supervisor/manager,
inadequate or poor quality equipment,
lack of support from colleagues. Stressors
loading on this factor were also relatively
less severe, except for one stressor,
namely a lack of recognition for good
work. This was a relatively severe
stressor for all categories of nurses.
The fourth factor was about stress
because of staff issues and included
items such as shortage of staff, fellow
workers not doing their job, poorly
motivated co-workers, covering work for
another employee and insufficient
personnel to handle workload. This
factor is also related to workload of
nurses (Tummers et al., 2001). Stressors
related to staff issues were clearly the
most severe of all stressors measured by
the NSI for all categories of nurses.
Severe stressors include insufficient staff
to handle the workload, shortage of staff,
poorly motivated co-workers and fellow
workers not doing their jobs. While it
seems that the shortage of staff is a
problem, training and motivation of
current staff also seem to be problematic.
Therefore, in addition to a shortage of
staff, poor performance management
might be the most important problem
causing stress for nurses.
The fifth factor concerned stress
because of overtime and include items
such as working overtime, working
emergency hours and working overtime
due to “moonlighting”. Although
working overtime was a more severe
stressor for professional nurses
(compared with enrolled and auxiliary
nurses), the severity of stress because
of overtime was relatively low for all
categories of nurses.
In the total sample of professional nurses,
stressors that could be regarded as
serious include shortage of staff,
insufficient personnel to handle
workload, fellow workers not doing their
job, health risk posed by contact with
patients, demands of clients/patients and
poorly motivated co-workers. In the total
sample for the enrolled and auxiliary
nurses, stressors that could be regarded
as serious include a shortage of staff,
health risk posed by contact with
patients, insufficient personnel to handle
workload and fellow workers not doing
their job. Comparing the five factors, it
becomes clear that stress because of staff
issues were the most severe for
professional nurses as well as enrolled
and auxiliary nurses.
Stressors that showed a medium
intensity and frequency can typically be
placed under the description of chronic
stressors. For the professional nurses,
these items deal exclusively with events
that can be considered daily occurrences
in the nursing environment (except for
two items, dealing with difficult patients
and watching a patient suffer), for
example, insufficient time to perform
tasks, meeting deadlines, management of
staff, adhering to the budget of the
hospital/institution, lack of recognition
for good work. Items that showed
medium intensity and frequency for the
enrolled and auxiliary nurses include the
following: poorly motivated co-workers,
demands of clients/patients, dealing with
difficult patients, lack of recognition for
good work, stock control in the ward/unit/
institution, and covering work for other
employees. The stressors for the enrolled
and auxiliary nurses are a combination of
staff issues, job demands, and lack of
support.
The findings of this study indicate that
professional nurses (compared with
enrolled and auxiliary nurses) experienced
more stress regarding the possibility of
making a mistake when treating a patient.
Also professional nurses experience more
stress because of disagreement with
medical practitioners or colleagues
concerning the treatment of a patient.
Recommendations
Based on the findings of this study it is
recommended that organisations that
employ nurses should implement
programmes to reduce stress because of
staff issues and job demands. If these
stressors are allowed to continue
unattended, they can expect to find
negative costs such as burnout,
employee turnover and lowered levels of
service. Specifically, programmes should
be implemented that improve recruitment,
selection and performance management
(including performance appraisal,
training and creating a motivational
environment). Furthermore, support
systems, such as counselling services,
should be made available to nursing staff
of all categories.
In order to reduce the impact of stress on
service delivery and staff motivation, it
is recommended that stress management
programmes should include the proactive
identification of stress as well as the
evaluation of these stressors in terms of
severity and impact. Standarised and
validated measuring instruments should
be used and the exercise should be
performed at least once every two years.
Early identification of stress risks can
provide for the proactive management of
risk groups, customised interventions
(versus generic interventions), and more
effective stress risk control. Linking
stress to burnout, engagement, ill-health
and commitment could further stress
management towards proactive,
preventative and promotive health and
wellness care in the nursing environment.
In terms of perceived strain, this study is
a first step towards the development of a
perceived stressor profile for nurses in
South Africa. It is recommended that the
study be expanded to all the provinces
of South Africa. It is important for future
research in the nursing environment to
take into account the physiological,
psychological and behavioural strains.
Also, further refining and testing of the
NSI is needed in other nursing samples.
Future studies could focus on the staff
issue stressors and their link to the mass
exodus of South African nurses. It is
recommended that future studies
validate findings with regard to the equal
comparison of the perceived strain
construct across cultural groups. Cross-
cultural comparisons would greatly
enhance validity of findings in terms of
the multi-cultural South-African context.
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