:
00207489~91 $3.00* 0.00 I991 Pcrgamon Press plc
Stress and well-being in nurses: a comparison of the public and private sectors PATRICK A. TYLER* DOUGLAS CARROLL and SHIRLEY E. CUNNINGHAM
Abstmc+Nurses in the public and private sectors were compared with regard to occupational stress and its sources and self-reported health and well-being. While both groups reported similar high levels of stress experience, most noticeably arising from high work loads and the experience of death and dying, group differences did emerge from an examination of the sources of stress. Whereas N.H.S. nurses were more troubled by high work loads, private sector nurses reported uncertainty over treatment as a more frequent source of stress than did their N.H.S. counterparts. Levels of self-reported mental and physical health symptomatology did not differ between groups. Nevertheless, overall nursing stress scores and symptomatology were significantly correlated, and workload was the best independent predictor of health and well-being status.
Introduction
Nursing is widely acknowledged to be a stressful occupation. Gray-Toft and Anderson (1981) have identified seven major sources of stress within nursing: death and dying, conflict with doctors, lack of support, inadequate preparation, conflict with other nurses, work load and uncertainty over treatment. Recently, Hipwell et al. (1989) investigated the prevalence of these sources of stress among nurses in four different hospital environments; a coronary care unit, a renal unit, a general medical ward and an acute geriatric ward. Earlier researchers argued that specialized nurses, most notably those in coronary and intensive care units, were most at risk (Vreeland and Ellis, 1969; Hay and Oken, 1972), *Author
to whom correspondence
should be addressed.
125
P. A. TYLER
126
et ul.
although more recent research has failed to reveal clear-cut distinctions between intensive care nurses and others on a range of stress-related measures (Johnson, 1979; Nichols et al., 1981; Keane et al., 1985). Hipwell et al. found that similarities among nurses working in different environments were far more striking than variations among them. The average profile for the four different wards for the seven sources of stress were close to identical; death and dying and work overload were major sources of stress for all nurses. While there has been at least preliminary exploration of stress and its sources among nurses working in different hospital wards, there has been, as yet, no comparison of private and public sector nurses. This is despite strong grounds for suspecting general problems of increased pressure and reduced morale within the public sector. As recently as 1989, Clay argued that “the experience for many of those working in the health service has continued to be one of bitterness and disillusionment”. Accordingly, the present study sought to compare the experience of stress of nurses working in the National Health Service (N.H.S.) with those working in the private sector. Further, whereas numerous studies attest to high levels of reported stress among nurses, few have investigated the possible consequences of such stress for mental and physical wellbeing. There is substantial general evidence that high levels of occupational stress are strongly associated with low levels of self-reported health and well-being (see, e.g. Kasl and Cooper, 1987). Further, what evidence there is for nursing certainly suggests that the stress experienced by nurses exacts a toll in terms of health. For example, Colligan er al. (1977) reported very high levels of psychiatric out-patient consultation among nurses. More recently, Revicki and May (1989) found that occupational stress among nurses was positively correlated with levels of depression. The present study sought to explore further the relationship between nursing stress and various aspects of self-reported health and well-being. Methods Subjects
Subjects were recruited from four N.H.S. and three private hospitals in the Midlands. The Director of Nursing for each of the hospitals was approached in person, and with their help a representative sample of nurses from each of the grades and ward types was drawn up. Questionnaires were distributed and collected by the nursing administration of each hospital, with anonymity being assured for each respondent. In all, 273 nurses were contacted. One hundred and fifty-six actually completed the questionnaires: 86 in the N.H.S. (a 53% participation rate) and 70 in the private sector (a 63% participation rate). Participation rates were not reliably different between the two sectors Ix ‘( 1) = 3. IO, n.s.1. The two samples were similar with regard to length of experience in the nursing profession (mean number of years was 12.85 and 12.54 for N.H.S. and private sector nurses respectively), and showed a comparable spread of wards (see Table 1) Ix’(S)= 8.74, n.s.j. Table
I. Frequency
of nurses across wards in the two sectors N.H.S.
General medical Surgical lntenrivc care Theat re Ourpatients Other5
26 16 IO 7 13 I-l
Private 33 IO II 6 ‘I 6
STRESS .-I.VD U’ELL-BElh’G
In both samples the highest percentage The breakdown
of nursing
were not reliably
of respondents
worked
on general
grades for the two samples is presented
different
[x’(2)= Table
medical
wards.
in Table 2. The profiles
3.35, n.s.1.
2. Frequency
of nurses
within
each grade N.H.S.
X E-F G-l
127
1.V .VL’RSES
Private
29 33 2-l
D
33 21 13
Questionnaires Nurses completed Toft
and
Goldberg nursing
two questionnaires:
Anderson
(1981)
and Hillier
(1979).
situations
portraying
as stressful
stressful circumstance;
scale how frequently
Stress Scale (NSS) constructed
Health
The NSS is designed
are experienced
a potentially
the Nursing
and the General
they found
a particular
Questionnaire
to measure
and poses respondents respondents
circumstance
symptoms,
anxiety,
on a four point
was preferred.
social dysfunction
stressful.
scale whether
As recommended,
they have experienced
an overall
GHQ
subscalc
values were obtained
Nursing
Stress Scale
The average overall for the N.H.S.
by adopting
scores (plus standard
and the private
and private
sector nurses ‘death
analyses of variance
(ANOVAs).
Significant
between
‘uncertainty
treatment’
IF( 1,154) = 8.96,
(F(l,l54)=4.38,
p < 0.051. and ‘work
frequent
sources
experience criterion Over
‘uncertainty
of stress than
of ‘work
load’ related
for statistical all
nurses
N.H.S.
O-O-l-1,
again
recently.
whereas the
system.
these values were not reliably component profiles
sources of stress
for the two samples: load’ were reported
was by means of a series of one-way group
differences
p < O.Ol/,
load’ IF(1,154)=6.41,
over treatment’ did
symptoms
and dying’ and ‘work
analysis
sector nurses reported
have to indicate
were 38.42 (12.89) and 40.27 (15.37)
of which reveals fairly similar
sources of stress. Initial
over
scoring
scores for the various
as the most frequent
34 items each on a four point
into four sub-scales: somatic
by summing
sector nurses respectively;
are presented in Fig. I, inspection for both N.H.S.
deviations)
by
which
NSS items are summed
any of the GHQ
the O-l-2-3
with
listed in the Introduction.
Respondents
value was obtained
IF( I, 154) = 0.67, n.s.1. Average
different
This is subdivided
and depression.
with
have to indicate
by Gray-
devised
the frequency
to yield a score for each of the seven areas of stressful encounter The 2%item version of CHQ
(GHQ)
the latter
stress. No other group
with
for
doctors’
p < 0.051; whereas
and ‘conflict
nurses,
were observed
‘conflict
private
with doctors’ to be more reported
differences
more
frequent
even approached
the
significance.
in this
study,
the seven dimensions
of the NSS were
significantly
intercorrelated (all at p < 0.001). Thus, those nurses who experienced stress more frequently tended to report more stress in all areas of their work. In order to separate the contributions of the seven NSS dimensions sectors, a discriminant load’ and ‘uncertainty
to the differences
analysis was carried over treatment’
in stress experienced
in the public and private
out. This showed that the two dimensions
jointly
and independently
differentiated
‘work between
P. .-I. TYLER
0.6
et al.
- NHS -+-Private sector
! T
Death and dying
Conflict ulth doctors
Lack Of support
Inadequate Conflict
preparatvzl
n1tn
other ""rses
Work load
Uncertainty over treatment
Nursing stress subsca!es Fig. I. Profiles of N.H.S. and private sector nurses on the subscales of the Nursing Stress Scale. The average stress scores represent the mean frequencies with which each stress source is experienced, averaged across all items on each subscale.
the groups, while the independent contribution of the other dimensions, including ‘conflict with doctors’ was not significant. General
Health
Questionnaire
Average overall scores on the GHQ were 3.15 (4.09) and 2.87 (4.18) for the N.H.S. and private sector nurses. There were no significant differences between the two sectors, either for the overall score IF( I, 154) = 0.18 n.s.1 or for any of the four subscale scores. Further, when the two sectors were examined in terms of the proportion of nurses achieving the GHQ ‘caseness’ criterion, 33% from each of the sectors scored four or more. A discriminant analysis was also unhelpful in separating the groups on the GHQ subscales. Thus the lack of difference between the two sectors in general work stress, as measured by the overall NSS score, is reflected in a lack of difference in general health and well-being as measured by the GHQ. Indeed GHQ scores did correlate significantly with NSS scores when all nurses were combined (I( 154) = 0.29, p < 0.0011. A stepwise multiple regression of the GHQ score on NSS dimension scores showed that scores on only one of NSS dimensions significantly predicted the GHQ scores independently; that one was ‘work load’ I?= 0.12. 0 = 0.34, ptresse> of’ intensive care unit nursing. f’.syc/~o.~~trur. Mrcl. 34. 109-l 18. Hipwell. A. E.. Tyler. P. A. and Wilson, C. \I. (IY8Y). Sources of %trcs\ and dissatisfaction among nur\cs in four hospital environments. Br. J. Med. Psykl. 62, 71-71). Johnson, Xl. (IY7Y). An.xicty/stre\s and the et’fec~s of disclosure between nurses and paticntb. .-i(/v. rl’ltrs. SC?. I, I-20. Kasl. S. and Cooper, C. L. (1987). (cds) S/re.ss anrf Healrh: /.s.we.r it1 Reseurch rrrc~r/roc/r,/o,~.~. !Vilcy. Chichester. Krane, A.. Ducette, J. and Adler, 0. C. (1985). Stress in ICU and non-ICU nurxs. Nurs. Res. 3-l. 231-236. Nichols, K. A., Springford. V. and Searl, J. (1981). An invc\tigation distressand discontent in various types of nursing. J. Adv. Nlrrs. 6, 31 l-338. Revicki, D. A. and May. H. J. (1989). Organi.!ational characteristics. occupational stress, and mental health in nurses. Behaviorul .Wed. IS, 30-36. Vreeland. R. and Ellis, G. L. (1969). Stresses on the nurse in an intcnzive-care unit. J. Aw. .Lled. ,-ls.~c. 20X. 332-334. \Veiner. .M. F. and Caldwell. T. (1981). Stresses and coping in ICU nur>ing: 2. Nurse support groups on ICUj. Gen. Hospitul P.pvhiat. 3. 12Y.
of
(Received
I2 Ju1.v 1990: acrepled jar puhl~urrort
12 ,\‘awr~rhrr IYYO)
00207489~91 $3.00* 0.00 I991 Pcrgamon Press plc
Stress and well-being in nurses: a comparison of the public and private sectors PATRICK A. TYLER* DOUGLAS CARROLL and SHIRLEY E. CUNNINGHAM
Abstmc+Nurses in the public and private sectors were compared with regard to occupational stress and its sources and self-reported health and well-being. While both groups reported similar high levels of stress experience, most noticeably arising from high work loads and the experience of death and dying, group differences did emerge from an examination of the sources of stress. Whereas N.H.S. nurses were more troubled by high work loads, private sector nurses reported uncertainty over treatment as a more frequent source of stress than did their N.H.S. counterparts. Levels of self-reported mental and physical health symptomatology did not differ between groups. Nevertheless, overall nursing stress scores and symptomatology were significantly correlated, and workload was the best independent predictor of health and well-being status.
Introduction
Nursing is widely acknowledged to be a stressful occupation. Gray-Toft and Anderson (1981) have identified seven major sources of stress within nursing: death and dying, conflict with doctors, lack of support, inadequate preparation, conflict with other nurses, work load and uncertainty over treatment. Recently, Hipwell et al. (1989) investigated the prevalence of these sources of stress among nurses in four different hospital environments; a coronary care unit, a renal unit, a general medical ward and an acute geriatric ward. Earlier researchers argued that specialized nurses, most notably those in coronary and intensive care units, were most at risk (Vreeland and Ellis, 1969; Hay and Oken, 1972), *Author
to whom correspondence
should be addressed.
125
P. A. TYLER
126
et ul.
although more recent research has failed to reveal clear-cut distinctions between intensive care nurses and others on a range of stress-related measures (Johnson, 1979; Nichols et al., 1981; Keane et al., 1985). Hipwell et al. found that similarities among nurses working in different environments were far more striking than variations among them. The average profile for the four different wards for the seven sources of stress were close to identical; death and dying and work overload were major sources of stress for all nurses. While there has been at least preliminary exploration of stress and its sources among nurses working in different hospital wards, there has been, as yet, no comparison of private and public sector nurses. This is despite strong grounds for suspecting general problems of increased pressure and reduced morale within the public sector. As recently as 1989, Clay argued that “the experience for many of those working in the health service has continued to be one of bitterness and disillusionment”. Accordingly, the present study sought to compare the experience of stress of nurses working in the National Health Service (N.H.S.) with those working in the private sector. Further, whereas numerous studies attest to high levels of reported stress among nurses, few have investigated the possible consequences of such stress for mental and physical wellbeing. There is substantial general evidence that high levels of occupational stress are strongly associated with low levels of self-reported health and well-being (see, e.g. Kasl and Cooper, 1987). Further, what evidence there is for nursing certainly suggests that the stress experienced by nurses exacts a toll in terms of health. For example, Colligan er al. (1977) reported very high levels of psychiatric out-patient consultation among nurses. More recently, Revicki and May (1989) found that occupational stress among nurses was positively correlated with levels of depression. The present study sought to explore further the relationship between nursing stress and various aspects of self-reported health and well-being. Methods Subjects
Subjects were recruited from four N.H.S. and three private hospitals in the Midlands. The Director of Nursing for each of the hospitals was approached in person, and with their help a representative sample of nurses from each of the grades and ward types was drawn up. Questionnaires were distributed and collected by the nursing administration of each hospital, with anonymity being assured for each respondent. In all, 273 nurses were contacted. One hundred and fifty-six actually completed the questionnaires: 86 in the N.H.S. (a 53% participation rate) and 70 in the private sector (a 63% participation rate). Participation rates were not reliably different between the two sectors Ix ‘( 1) = 3. IO, n.s.1. The two samples were similar with regard to length of experience in the nursing profession (mean number of years was 12.85 and 12.54 for N.H.S. and private sector nurses respectively), and showed a comparable spread of wards (see Table 1) Ix’(S)= 8.74, n.s.j. Table
I. Frequency
of nurses across wards in the two sectors N.H.S.
General medical Surgical lntenrivc care Theat re Ourpatients Other5
26 16 IO 7 13 I-l
Private 33 IO II 6 ‘I 6
STRESS .-I.VD U’ELL-BElh’G
In both samples the highest percentage The breakdown
of nursing
were not reliably
of respondents
worked
on general
grades for the two samples is presented
different
[x’(2)= Table
medical
wards.
in Table 2. The profiles
3.35, n.s.1.
2. Frequency
of nurses
within
each grade N.H.S.
X E-F G-l
127
1.V .VL’RSES
Private
29 33 2-l
D
33 21 13
Questionnaires Nurses completed Toft
and
Goldberg nursing
two questionnaires:
Anderson
(1981)
and Hillier
(1979).
situations
portraying
as stressful
stressful circumstance;
scale how frequently
Stress Scale (NSS) constructed
Health
The NSS is designed
are experienced
a potentially
the Nursing
and the General
they found
a particular
Questionnaire
to measure
and poses respondents respondents
circumstance
symptoms,
anxiety,
on a four point
was preferred.
social dysfunction
stressful.
scale whether
As recommended,
they have experienced
an overall
GHQ
subscalc
values were obtained
Nursing
Stress Scale
The average overall for the N.H.S.
by adopting
scores (plus standard
and the private
and private
sector nurses ‘death
analyses of variance
(ANOVAs).
Significant
between
‘uncertainty
treatment’
IF( 1,154) = 8.96,
(F(l,l54)=4.38,
p < 0.051. and ‘work
frequent
sources
experience criterion Over
‘uncertainty
of stress than
of ‘work
load’ related
for statistical all
nurses
N.H.S.
O-O-l-1,
again
recently.
whereas the
system.
these values were not reliably component profiles
sources of stress
for the two samples: load’ were reported
was by means of a series of one-way group
differences
p < O.Ol/,
load’ IF(1,154)=6.41,
over treatment’ did
symptoms
and dying’ and ‘work
analysis
sector nurses reported
have to indicate
were 38.42 (12.89) and 40.27 (15.37)
of which reveals fairly similar
sources of stress. Initial
over
scoring
scores for the various
as the most frequent
34 items each on a four point
into four sub-scales: somatic
by summing
sector nurses respectively;
are presented in Fig. I, inspection for both N.H.S.
deviations)
by
which
NSS items are summed
any of the GHQ
the O-l-2-3
with
listed in the Introduction.
Respondents
value was obtained
IF( I, 154) = 0.67, n.s.1. Average
different
This is subdivided
and depression.
with
have to indicate
by Gray-
devised
the frequency
to yield a score for each of the seven areas of stressful encounter The 2%item version of CHQ
(GHQ)
the latter
stress. No other group
with
for
doctors’
p < 0.051; whereas
and ‘conflict
nurses,
were observed
‘conflict
private
with doctors’ to be more reported
differences
more
frequent
even approached
the
significance.
in this
study,
the seven dimensions
of the NSS were
significantly
intercorrelated (all at p < 0.001). Thus, those nurses who experienced stress more frequently tended to report more stress in all areas of their work. In order to separate the contributions of the seven NSS dimensions sectors, a discriminant load’ and ‘uncertainty
to the differences
analysis was carried over treatment’
in stress experienced
in the public and private
out. This showed that the two dimensions
jointly
and independently
differentiated
‘work between
P. .-I. TYLER
0.6
et al.
- NHS -+-Private sector
! T
Death and dying
Conflict ulth doctors
Lack Of support
Inadequate Conflict
preparatvzl
n1tn
other ""rses
Work load
Uncertainty over treatment
Nursing stress subsca!es Fig. I. Profiles of N.H.S. and private sector nurses on the subscales of the Nursing Stress Scale. The average stress scores represent the mean frequencies with which each stress source is experienced, averaged across all items on each subscale.
the groups, while the independent contribution of the other dimensions, including ‘conflict with doctors’ was not significant. General
Health
Questionnaire
Average overall scores on the GHQ were 3.15 (4.09) and 2.87 (4.18) for the N.H.S. and private sector nurses. There were no significant differences between the two sectors, either for the overall score IF( I, 154) = 0.18 n.s.1 or for any of the four subscale scores. Further, when the two sectors were examined in terms of the proportion of nurses achieving the GHQ ‘caseness’ criterion, 33% from each of the sectors scored four or more. A discriminant analysis was also unhelpful in separating the groups on the GHQ subscales. Thus the lack of difference between the two sectors in general work stress, as measured by the overall NSS score, is reflected in a lack of difference in general health and well-being as measured by the GHQ. Indeed GHQ scores did correlate significantly with NSS scores when all nurses were combined (I( 154) = 0.29, p < 0.0011. A stepwise multiple regression of the GHQ score on NSS dimension scores showed that scores on only one of NSS dimensions significantly predicted the GHQ scores independently; that one was ‘work load’ I?= 0.12. 0 = 0.34, ptresse> of’ intensive care unit nursing. f’.syc/~o.~~trur. Mrcl. 34. 109-l 18. Hipwell. A. E.. Tyler. P. A. and Wilson, C. \I. (IY8Y). Sources of %trcs\ and dissatisfaction among nur\cs in four hospital environments. Br. J. Med. Psykl. 62, 71-71). Johnson, Xl. (IY7Y). An.xicty/stre\s and the et’fec~s of disclosure between nurses and paticntb. .-i(/v. rl’ltrs. SC?. I, I-20. Kasl. S. and Cooper, C. L. (1987). (cds) S/re.ss anrf Healrh: /.s.we.r it1 Reseurch rrrc~r/roc/r,/o,~.~. !Vilcy. Chichester. Krane, A.. Ducette, J. and Adler, 0. C. (1985). Stress in ICU and non-ICU nurxs. Nurs. Res. 3-l. 231-236. Nichols, K. A., Springford. V. and Searl, J. (1981). An invc\tigation distressand discontent in various types of nursing. J. Adv. Nlrrs. 6, 31 l-338. Revicki, D. A. and May. H. J. (1989). Organi.!ational characteristics. occupational stress, and mental health in nurses. Behaviorul .Wed. IS, 30-36. Vreeland. R. and Ellis, G. L. (1969). Stresses on the nurse in an intcnzive-care unit. J. Aw. .Lled. ,-ls.~c. 20X. 332-334. \Veiner. .M. F. and Caldwell. T. (1981). Stresses and coping in ICU nur>ing: 2. Nurse support groups on ICUj. Gen. Hospitul P.pvhiat. 3. 12Y.
of
(Received
I2 Ju1.v 1990: acrepled jar puhl~urrort
12 ,\‘awr~rhrr IYYO)
