Work Stress & Job Satisfaction in Clinical Practice Article

Work Stress & Job Satisfaction in Clinical Practice Article

Work Stress & Job Satisfaction in Clinical Practice Article

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Article 1: Can work-related stress and job satisfaction affect job commitment among nurses? Work Stress & Job Satisfaction in Clinical Practice Article

Article 2: Nursing students’ stress and satisfaction in clinical practice along different stages

Article 3: Decreasing Stress and Burnout in Nurses: Efficacy of Blended Learning With Stress Management and Resilience Training Program

Article 4: The impact of occupational stress on nurses’ caring behaviors and their health related quality of life.

Article 5: Nurse Work Environment and Stress Biomarkers: Possible Implications for Patient Outcomes.

Article 6: The impact of professional identity on role stress in nursing students: A cross-sectional study.

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Nurse Education Today 68 (2018) 86–92 Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/locate/nedt Nursing students’ stress and satisfaction in clinical practice along different stages: A cross-sectional study☆ T ⁎ Hanna Admia, , Yael Moshe-Eilonb, Dganit Sharonc, Michal Mannd a Department of Nursing, Yezreele Valley College and Research Division, Rambam Health Care Campus, Haifa, Israel Rambam Health Care Campus, Haifa, Israel c Nursing Department, Ruppin Academic Center, Emek Hefer, Israel d Department of Nursing, Yezreele Valley College, Israel b A R T I C LE I N FO A B S T R A C T Keywords: Clinical practice Nursing education Nursing students Satisfaction Stress Background: Research in the field of nursing students’ stress shifted internationally in recent decades from Western to Eastern countries with an emphasis on Middle East and Far East countries. The clinical experience has always been at the heart of nursing education cross-culturally and is a major source of stress and attrition. Objectives: To investigate the perceptions of stress and satisfaction of undergraduate nursing students during three stages of clinical learning experiences: preclinical, clinical and advanced clinical. Design: A cross-sectional study. Settings: Three Bachelor’s in Nursing programs in three higher educational institutions in Israel. Participants: Nursing undergraduate students in their second, third and fourth year of study (n = 892). Methods: The Nursing Students Stress Scale and the Nursing Students Professional Satisfaction questionnaires were used for data collection. Descriptive statistics used to analyze the data included: Pearson correlation, Cronbach’s alpha, one way ANOVA, t-test, Kruskal Wallis and Mann Whitney U tests. Results: Overall mean level of stress was mild-moderate (2.67) and overall satisfaction moderate-high (3.57). Year of study and gender were the most significant predictors of nursing students’ stress. The level of stress and satisfaction of second year students in the preclinical stage was significantly higher compared to peers in their third and fourth year. Female students experienced significantly higher levels of stress and satisfaction. The top most stressful situations for second year students were related to inadequate preparation to cope with knowledge and skill demands, whereas for third and fourth year students they were conflicts between professional beliefs and the reality in hospital practice. Conclusions: Nurse Educators are challenged to tailor stress reduction interventions according to the students’ perceptions of stress. It is not only critical for their wellbeing and attrition, but also important in developing nursing professionals who will provide better care and caring for patients. 1. Introduction Research on nursing students’ experience of stress during their clinical experience has increased in recent years internationally, especially in the Far-East and Middle-East (Al-Gamal et al., 2017; Arieli, 2013; Bartlett et al., 2016; Cheung et al., 2016; Hamaideh et al., 2016; Jun and Lee, 2017; Shaban et al., 2012; L. Sun et al., 2016; Yildrim et al., 2017). Work Stress & Job Satisfaction in Clinical Practice Article

Nursing education in Israel has undergone changes over the past decades similar to what has occurred in many countries worldwide. This includes reform from diploma schools of nursing to academic university-based education; recruitment of larger numbers of students due to nursing shortage; lack of clinical settings and clinical ☆ ⁎ preceptors; growing cultural diversity within the students population and development of new simulation technologies (Ben Natan and Oren, 2011; Ehrenfeld et al., 2007; Oren and Ben Natan, 2011; Spitzer and Perrenoud, 2006). The importance of clinical education on knowledge, skills and attitudes of the future nursing workforce has long been acknowledged in the theoretical, empirical and policy literature. The clinical experience has always been at the heart of nursing education. Nursing students were found to experience significantly more stress and stress-related health outcomes compared to non-nursing students (Bartlett et al., 2016; Gibbons et al., 2011; Pryjmachuk and Richards, 2007). A major source of stress for nursing students, in addition to their academic This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Corresponding author. E-mail addresses: h_admi@RMC.gov.il, hannaa@yvc.ac.il (H. Admi). https://doi.org/10.1016/j.nedt.2018.05.027 Received 9 December 2017; Received in revised form 14 April 2018; Accepted 31 May 2018 0260-6917/ © 2018 Elsevier Ltd. All rights reserved. Nurse Education Today 68 (2018) 86–92 H. Admi et al. Fig. 1. Nursing students’ stress in the clinical learning experience and satisfaction: Schematic framework. 3. Literature Review requirements, is the clinical practice in different health care organizations. During the last decades there has been a growing awareness that caring for nursing students is not only critical to their well-being and academic achievements, but is also necessary in order to prepare them to become caring professionals for others (Drew et al., 2016). 3.1. Nursing Students Stress in Clinical Learning Settings In accordance with Lazarus’s stress theory, stress among nursing students in clinical settings can be viewed as the students’ perceived gap between the demands in a specific clinical situation and their resources or abilities to perform the tasks. Undergraduate nursing students reported significantly higher stress levels compared to undergraduate students from the general student population (Bartlett et al., 2016; Jun and Lee, 2017). Qualitative studies found that nursing students’ experiences in the clinical practice were influenced mainly by their relationships with patients, clinical preceptors and other nursing students in their group. Sense of inadequacy, being ignored, ineffective communication, ambivalence, disgust, frustration and conflict were themes that emerged (Arieli, 2013; Jamshidi et al., 2016; Rafati et al., 2017; F.K. Sun et al., 2016). Work Stress & Job Satisfaction in Clinical Practice Article

A vast number of quantitative research studies examined nursing students stress by using cross-sectional designs. A review of 23 quantitative articles identified the main clinical sources of stress in nursing students: fear of unknown situations, mistakes with patients and handling of technical equipment (Pulido-Martos et al., 2012). Many studies used Sheu et al.’s (1997) Perceived Stress Scale (PSS) to measure nursing students’ stress in clinical experience (Al-Gamal et al., 2017; Hamaideh et al., 2016; Liu et al., 2015; Shaban et al., 2012; Sheu et al., 2002). Senior nurses’ perceptions of stress in clinical settings are in many aspects different compared to the reported stress of unexperienced nursing students (Riahi, 2011). In summary, the literature review revealed a growing interest in the field of nursing students’ stress over the past decade, especially in Middle East and Far East countries. It is difficult to compare results because of differences in research design, methods and the use of different tools and scores. Although the majority of academic articles 2. Background: Conceptual Framework and Study Objective There is a lack of consensus among researchers regarding the concept of stress (Riahi, 2011).For the purpose of this study, Lazarus and Folkman’s (1984) relational “stress and coping” theory provides the conceptual framework. According to Lazarus and Folkman (1984, p.19), “Psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being”. Cognitive appraisals are subjective, not necessarily conscious and in reality can take place simultaneously. Based on Lazarus and Folkman’s (1984) theory and our literature review, we developed the theoretical framework of this study (Fig.1). The purpose of this study was to investigate the perceptions of stress and satisfaction of undergraduate nursing students during different stages of clinical learning experiences in three higher education institutions in Israel. The study objectives were to examine: 1. Type, level and ranking of stress, in different stages of the nursing program. 2. Association between nursing students’ demographic and professional characteristics and levels of stress experienced. 3. Relationships between students stress in the clinical practice and satisfaction 87 Nurse Education Today 68 (2018) 86–92 H. Admi et al. Table 1 Nursing Students’ Stress Scale (NSSS). Stress sub scale (Factors) The degree of stress you felt or might feel in the following situations: (Items) Inadequate knowledge and training Required to perform nursing tasks without adequate training Did not know the answers to questions asked by the clinical instructor Performed nursing tasks without having someone to consult with Performed nursing tasks you were not sure how to do Asked by a nurse on the floor to perform a task that was not suitable to your phase of study Asked to help perform a specific procedure without knowing how Work Stress & Job Satisfaction in Clinical Practice Article

Did not know how to respond when a patient refused to cooperate Did not know the answer to a physician’s question Did not know the answer to a patient’s question Exposed part of a patient’s body during a bath Had to make a bed with dirty linen Handled a bedpan with repulsive body secretions Helped a patient urinate Brushed a patient’s dentures Helped a vomiting patient Treated a patient with a physical deformity Supported an amputated limb during treatment The clinical instructor made embarrassing comments when you were taking care of a patient. Had difficulty treating patients under the close supervision of the clinical instructor. Received no verbal feedback after you completed a task for the first time Had difficulties establishing priorities when performing many tasks simultaneously Did not having sufficient time to provide the best required treatment Had to provide nursing care without appropriate available equipment Had difficulties in maintaining patient privacy Performed an action that you thought might cause pain to the patient Performed an action that you were afraid might harm the patient Treated a patient experiencing pain Difficulty in accepting a nurse’s behavior contrary to what was learned A staff nurse required you to perform a procedure that contradicted what you had learned Difficulty discovering a patient had not received the nursing care they needed Adverse or embarrassing experiences Clinical supervision Insufficient hospital resources Patient’s pain and suffering Education – reality conflict 4. Method emphasize theoretically the high level of clinical stress among nursing students, empirical studies do not completely support this assertion and report mild to moderate levels of stress. However, when the same tools are used in the same stage of learning, cultural similarities and differences are beginning to evolve that require further cross-cultural research. A cross-sectional study was used to investigate the perceptions of stress and satisfaction of undergraduate nursing students during three stages of clinical learning experiences: preclinical (second year first semester), clinical and advanced clinical (third and fourth year). The study was conducted in 2017. A convenience sample of nursing students from three academic institutions (A, B, C) in northern Israel completed an electronic questionnaire. Work Stress & Job Satisfaction in Clinical Practice Article

The Google Docs web-based application was used to collect research data. This way the researchers did not know from which e-mail address or computer the responses were sent. Although the native language of the nursing students population varied (i.e; Hebrew, Arabic, Russian and other), all students are proficient in Hebrew, including reading and writing. Filling in the questionnaire took approximately 15 min. The ethical committees of all three academic institutions granted approval for the study prior to the data collection. One of the researchers or a nurse instructor presented the purpose of the study at the beginning or end of a class meeting. It was made clear that participation was voluntary and confidential. After the class introduction, students were invited to join the study via a posted ad on an electronic bulletin board of their nursing program that contained a link to the electronic questionnaire. The ad described the purpose of the study, and emphasized anonymity. 3.2. Nursing Students’ Satisfaction with Clinical Learning Experience Nursing students’ satisfaction is strongly related to their clinical learning experience and was found to have the greatest impact on student retention (Crombie et al., 2013; Hamshire et al., 2012; Lee et al., 2009; Wu and Norman, 2006). Research findings revealed that the majority of nursing students are satisfied with their nursing education. Satisfaction in clinical practice is high and significantly related to satisfaction with the nurse’s role and their choice of the nursing profession. Students with longer periods of clinical practice and individualized constant supervision were more satisfied. Other variables that were associated with students’ satisfaction were: perception of nursing; the clinical nurse preceptor; the length of the clinical period; the frequency and consistency of individualized supervision; atmosphere and leadership in the ward; and the nursing care on the ward. In addition, first year students and younger students were found to be more satisfied compared to third year and older students. (Abouelfettoh and Al Mumtin, 2015; Dimitriadou et al., 2015; D’Souza et al., 2015; Löfmark et al., 2012; Milton-Wildey et al., 2014; Papastavrou et al., 2010; Saarikoski et al., 2013; Sundler et al., 2014; Warne et al., 2010). In the present study we explored students’ satisfaction focusing on three facets: choice of the nursing profession; nursing studies (i.e., the entire nursing program excluding the clinical learning experience); and the clinical learning experience. 5. Measurement Instruments Data were collected using a questionnaire composed of three parts: Nursing Students Stress Scale (NSSS); Nursing Students Professional Satisfaction (NSPS); and demographic characteristics. Admi (1997) developed the NSSS originally in Hebrew. Work Stress & Job Satisfaction in Clinical Practice Article

The questionnaire includes 30 items and six subscales: inadequate knowledge and training (9 items), close supervision (3 items), adverse and embarrassing experiences (8 items), patient’s pain and suffering (3 88 Nurse Education Today 68 (2018) 86–92 H. Admi et al. Linear Regression was used for prediction of total stress levels with several independent parameters. items), insufficient hospital resources (4 items), and education-reality conflict (3 items). The NSSS measures the degree of stress perceived by nursing students in specific encounters during their clinical experience. Guided by the relational view of stress, each item represents the gap between a specific demand and the student’s resources. For example, “you did not know the answer to questions asked by the clinical preceptor” or “you found it difficult to discover that a patient had not received the nursing care they needed”. A 5-point Likert scale was used to measure the level of stress (lowest-1, mild-2, moderate-3, high-4, highest-5). The internal consistency reliability of the NSSS was very good, with an overall internal Cronbach’s alpha coefficient of 0.920 for overall scale (30 items) and range of 0.703–0.921 for the six subscales. (Table 1). The nursing students’ professional satisfaction (NSPS) questionnaire consists of 21 items and is divided into 3 sections: satisfaction with nursing studies (9 items), with the clinical experience (5 items) and with the choice of nursing profession (7 items). A 5-point Likert scale (least satisfied-1, most satisfied-5) was used to measure satisfaction. The internal consistency reliability of the NSPS was very good, with an overall internal Cronbach’s alpha coefficient of 0.910 for overall scale. Cronbach’s alpha coefficients for the 3 subscales were 0.888, 0.880 and 0.861 respectively. Significant inter-correlations (Spearman’s rho) were found among the three satisfaction subscales (range 0.344 to 0.560; p < 0.01). (Table 2). The last part of the questionnaire consists of demographic and professional characteristics such as: gender, age, family status, native language, year of study, previous nursing experience and working as a nurse aid during studies. The statistical software package IBM SPSS for windows version 21 was used to perform all statistical analysis in this study. Descriptive statistics in terms of mean, standard deviation, percentiles and ranges were performed for all parameters. Pearson correlation was conducted to examine correlations between personal characteristics and satisfactory questions. One way ANOVA, t-test, Kruskal Wallis and Mann Whitney U tests were performed to explore differences between groups. Cronbach’s alpha was used to measure internal consistency and p values < 0.05 were considered statistically significant. Work Stress & Job Satisfaction in Clinical Practice Article

Multivariate 6. Results Demographic and Professional characteristics: Comparison among Academic Institutions. Out of 892 eligible students in the three academic centers, 339 nursing students completed the survey questionnaire (38% response rate). Most of the participants were female nursing students, aged 21–25 years old, single, and from B institute. Arabic was the native language most spoken, with most students lacking experience in nursing care and had never been employed as a nurse aid during their studies. No significant differences were found between the student sample in this study and the nursing student population in Israel. Yet, several significant dissimilarities were noted among the three institutions. The B institute students were significantly older, married with children and predominantly spoke Russian as their native language compared to students in the other two institutions. The A institute students were significantly younger and predominantly spoke Arabic as their native language. More C institute students were single compared to other institutes (Table 3). 6.1. Nursing Students’ Stress in Clinical Practice The overall mean stress level was mild to moderate (2.67).The criteria for mean stress level ranged from lowest to highest: 1 (lowest), 2 (mild), 3 (moderate), 4 (high) and 5 (highest). The most stressful factor was education-reality conflict (3.29) followed by patient’s pain and suffering (2.89), inadequate knowledge and training (2.79), insufficient hospital resources (2.57) and close supervision (2.55). The least stressful factor was adverse and embarrassing experiences during patient care (2.34). Significant differences were found in the level of the stress factors, in relation to all demographic characteristics (Table 4). Second year preclinical students scored significantly higher, compared to third and fourth year students, in four out of the six stress factors. Women showed higher stress levels compared to male students in three stress factors. Older students, aged 31 and more, reported significantly higher stress levels in two factors. Higher stress levels were also found in some factors among married students with children, native Hebrew speakers, and students with no prior experience in nursing care. No differences in stress levels were found among the nursing programs in the three different institutions. Six situations were identified as the most stressful for all students sampled. However, differences were found in the ranking order among the students depending on the year of study. In addition, the ranking of three stressful situations were found to be significantly higher among second year students compared to third year students. Among second year students, three out of the five most stressful situations were related to the factor inadequate knowledge and training – “you had to perform nursing tasks that you were not sure how to perform” (ranked no. 1), “you were required to perform nursing tasks without adequate training” (ranked no. 2) and “you had to provide care to a patient in pain” (ranked no. 3). The two most stressful situations ranked by third and fourth year students were related to the factor education-reality conflict. Work Stress & Job Satisfaction in Clinical Practice Article

The first most stressful situation was “you found it difficult to discover that a patient had not received the nursing care they needed” and the second “you found it difficult to accept a nurse’s behavior when they treated a patient contrary to a professional principle you had learned”. These two items pertain to clinical situations in which the students felt a gap between professional standards taught in the nursing program and the practical reality of a hospital.The item “you have to treat a patient while they were suffering pain” was ranked as the third most stressful situation by the second and third year students while fourth Table 2 Nursing Students’ Professional Satisfaction (NSPS). Satisfaction subscale (Factors) To what extent are you satisfied with: (list of items) Nursing profession Ability to help people Nursing status among the health care team Nursing profession level of independence Acquiring knowledge and developing in your role as a nurse Your responsibility for patients’ care Sharing problems with your co-workers Decision to be an academic RN Learning theoretical nursing studies Practicing technical nursing skills Learning basic social sciences courses Learning basic medical sciences courses Relationships with other students in your nursing class Relationship with lecturers in the nursing school The clinical experience coordination The nursing school’s consideration of student’s needs Practicing interpersonal skills. Environmental learning conditions on the ward The clinical instructor’s training program Your progress rate Relationship with other students in the group The clinical instructor’s ability to correctly assess your skills Nursing studies Clinical experience (current or last) 89 Nurse Education Today 68 (2018) 86–92 H. Admi et al. Table 3 Demographic and professional characteristics by academic institutions (N = 339).s Number (percent) Characteristics Age (years) < 25 26–30 31+ Missing Gender (Female) Family status Single Married Married with children Missing Native Language Hebrew Arabic Russian Other Missing Previous experience in nursing care (Yes) Year of study 2 3 4 1 2 3 Total p Academic Institutions Work Stress & Job Satisfaction in Clinical Practice Article

A B C 228 (67%) 85 (25%) 25 (7%) 1 (0.3%) 247 (73%) 96 (81%) 20 (17%) 2 (2%) 93 (55%) 56 (33%) 20 (12%) 39 (77%) 9 (18%) 3 (6%) p < 0.0011,3 p < 0.051,3 p = 0.0011 87 (74%) 124 (73%) 36 (72%) p = 0.97 273 (81%) 39 (12%) 21 (6%) 6 (2%) 102 (86%) 13 (11%) 3 (3%) 127 (76%) 25 (15%) 15 (9%) 44 (92%) 1 (2%) 3 (6%) p < 0.051,3 p = 0013s p = 0.031 102 (30%) 169 (50%) 52 (15%) 15 (4%) 1(0.3%) 110 (32%) 24 (21%) 84 (72%) 8 (7%) 60 (38.2%) 59 (38%) 38 (24%) 18 (36%) 26 (52%) 6 (12%) p < 0.051,2 p < 0.0011,2 p < 0.051 26 (22%) 69 (41%) 15 (30%) p = 0.0011 112 (33%) 123 (36%) 104 (31%) 42 (36%) 49 (42%) 27 (23%) 53 (31%) 52 (31%) 65 (38%) 17 (33.3%) 22 (43.1%) 12 (23.5%) n.s. n.s. p = 0.0071 A vs. B. A vs. C. B vs. C. year students did not rank it as one of the top five stressful situations. 7. Discussion 7.1. Nursing Students’ Stress in Clinical Practice 6.2. Nursing Students’ Satisfaction In this study, the overall level of stress of nursing students in clinical practice was found to be mild to moderate. This finding is in accordance with the results of a few studies (Hamaideh et al., 2016; Shaban et al., 2012) and opposed to high levels of stress reported in the majority of other research studies (Bartlett et al., 2016; Jun and Lee, 2017; L. Sun et al., 2016). The discrepancy in findings can be explained both from socio-cultural and methodological perspectives. Comparisons among research studies are difficult because of the great variability regarding cultures, the use of stress tools, relying on different theoretical frameworks, comparing students in different stages during their nursing program and different designs and scoring calculations (Pulido-Martos et al., 2012). Nursing students with varied demographic and professional characteristics perceived differently the stress in clinical situations. These findings support the subjective notion of the stress theory. Namely, the perceptions and interpretations of the same clinical situations by different nursing students depend on their personal characteristics. In addition, as students gained professional knowledge, skills and experience, their appraisal of the clinical demands in relation to their capabilities to meet those demands changed. Regardless of the differences among the students’ population in three institutions, the type and ranking order of stress remain similar. This finding can be generalized to reflect stress in clinical practice among nursing students in Israel. Gender and year of study are the most significant characteristics in predicting type and level of stress among Israeli nursing students. Female nurses and students in their second preclinical year reported significantly higher levels of stress. This finding supports our original longitudinal study, indicating that the preclinical expected levels of stress were significantly higher than the actual stress experienced by the same group of students (Admi, 1997). A review of 23 quantitative Students’ satisfaction was measured in three different areas (subscales): the choice of nursing as a profession; nursing studies and clinical experience. Overall satisfaction level was moderate to high (3.56 ± 0.70) on a 1–5 point Likert scale (5 = very much satisfied). The satisfaction with the choice of nursing as a profession was the highest (3.89 ± 0.76) while satisfaction with the nursing studies was the lowest (3.25 ± 0.86). Work Stress & Job Satisfaction in Clinical Practice Article

Second year students were significantly more satisfied overall with their choice of nursing and with nursing studies, compared to others. Female nursing students were significantly more satisfied with their choice of nursing profession compared to male students (3.95 ± 0.75 vs.3.72 ± 0.79, p = 0.014). No other significant differences were found between personal characteristics and students’ satisfaction. 6.3. Relationship of Nursing Students’ Stress and Satisfaction Satisfaction with clinical experience was negatively correlated with the following stress subscales: inadequate knowledge and training; insufficient resources; and close supervision (r = −0.295, −0.225, and r = −0.218, p = 0.001 respectively). This shows that students that are more stressed in the clinical practice are less satisfied. Exceptions to this finding were the significant positive correlations between stress from patients’ pain and suffering and the choice of nursing as a profession (r = 0.112, p = 0.040) and nursing studies (r = 0.146, p = 0.007). In other words, students who are more satisfied with nursing as a profession and their studies are more stressed by patients’ pain and suffer. 90 Nurse Education Today 68 (2018) 86–92 H. Admi et al. Table 4 Demographic characteristics by level of stress sub-scales (factors)s. Personal characteristics stress subscales Academic institution A B C P Study year 2nd 3rd 4th P Gender Men Woman P Age (years) ≤25 26–30 31+ P Family status a Single b Married no children c Married with children P Native language Hebrew Arabic Russian P Prior experience None With P Inadequate knowledge and training Adverse and embarrassing experiences Close supervision Insufficient hospital resources Patient’s pain and suffering Education-reality conflict Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD 2.70 ± 0.81 2.90 ± 1.02 2.64 ± 1.06 0. 12 2.35 ± 0.86 2.29 ± 0.94 2.50 ± 1.03 0.36 2.44 ± 0.91 2.65 ± 1.00 2.46 ± 1.01 0.14 2.41 ± 0.91 2.69 ± 1.00 2.55 ± 1.01 0.06 2.84 ± 0.91 2.94 ± 0.92 2.85 ± 0.73 0.59 3.18 ± 0.90 3.41 ± 0.93 3.19 ± 1.05 0.08 3.23 ± 0.90 2.49 ± 0.97 2.68 ± 0.85 0.001⁎⁎ 2nd vs. 3rd 2nd vs. 4th 2.48 ± 1.03 2.35 ± 0.87 2.19 ± 0.90 0.08 2.69 ± 0.93 2.34 ± 0.99 2.63 ± 0.97 0.024⁎ 2nd vs. 3rd 2.91 ± 0.86 2.30 ± 1.01 2.52 ± 0.96 0.001⁎⁎ 2nd vs. 3rd 2nd vs. 4th 3.19 ± 0.79 2.78 ± 0.84 2.70 ± 0.96 0.001⁎⁎ 2nd vs.3rd 2nd vs. 4th 3.38 ± 0.90 3.18 ± 0.91 3.32 ± 1.0 0.27 2.55 ± 0.95 2.88 ± 0.95 0.004⁎⁎ 2.37 ± 1.07 2.33 ± 0.87 0.72 2.48 ± 1.07 2.57 ± 0.93 0.49 2.44 ± 0.98 2.61 ± 0.96 0.14 2.64 ± 0.88 2.98 ± 0.87 0.002⁎⁎ 2.95 ± 0.97 3.42 ± 0.88 0.001⁎⁎ 2.74 ± 0.95 2.77 ± 0.97 3.27 ± 0.87 0.03⁎ ≤ 25 vs. 31+ 2.42 ± 0.90 2.16 ± 0.95 2.11 ± 0.98 0.06 2.54 ± 0.98 2.50 ± 0.91 2.68 ± 1.01 0.72 2.52 ± 0.99 2.58 ± 0.95 2.86 ± 0.77 0.26 2.87 ± 0.87 2.87 ± 0.93 3.04 ± 0.85 0.66 3.20 ± 0.93 3.38 ± 0.97 3.79 ± 0.78 0.05⁎ ≤ 25 vs. 31+ 2.78 ± 0.98 2.83 ± 0.88 3.05 ± 0.95 0.48 2.39 ± 0.96 1.99 ± 0.75 2.38 ± 0.87 0.047⁎ a vs. b 2.61 ± 1.0 2.28 ± 0.72 2.49 ± 1.00 0.14 2.60 ± 1.0 2.49 ± 0.90 2.61 ± 0.85 0.84 2.90 ± 0.90 2.77 ± 0.89 3.03 ± 0.76 0.53 3.26 ± 0.95 3.37 ± 0.82 3.87 ± 0.76 0.012⁎ a vs. c 2.99 ± 0.91 2.69 ± 0.96 2.96 ± 1.00 0.041⁎ Heb vs Arb 2.12 ± 0.86 2.56 ± 0.95 2.13 ± 0.93 0.001⁎⁎ Heb vs Arab 0.014⁎ Arab vs Rus 2.57 ± 0.83 2.61 ± 1.05 2.44 ± 0.92 0.54 2.67 ± 0.97 2.50 ± 1.01 2.68 ± 0.97 0.28 2.99 ± 0.85 2.86 ± 0.90 2.88 ± 0.93 0.51 3.53 ± 0.88 3.15 ± 0.96 3.38 ± 0.88 0.005⁎⁎ Heb vs Arab 2.82 ± 0.99 2.71 ± 0.88 0.31 2.39 ± 0.92 2.21 ± 0.94 0.095 2.57 ± 0.98 2.49 ± 0.95 0.50 2.58 ± 0.95 2.53 ± 1.01 0.61 2.97 ± 0.93 2.72 ± 0.74 0.014⁎ 3.28 ± 0.96 3.31 ± 0.89 0.78 Mean on 5 point Likert scale (lowest stress level -1, highest -5). ⁎ p < 0.05. ⁎⁎ p < 0.01. Work Stress & Job Satisfaction in Clinical Practice Article

expressed the highest satisfaction with the profession followed by satisfaction in the clinical experience and relatively lowest satisfaction with the nursing studies. Satisfaction with the choice of nursing as a profession varies among countries and might be explained by the status of the profession (Lee et al., 2009). The level of satisfaction, in the current study, was found to be higher among female students and highest among second year students in the preclinical stage. Satisfaction declined in the third and fourth year of study. This finding is consistent with findings of Australian students who explained their decrease in satisfaction with the difficulties and lack of support in the clinical setting (Milton-Wildey et al., 2014). Many other reasons were identified in the literature related to students’ dissatisfaction in the clinical setting such as: too short periods of practice; inadequate supervision from clinical preceptors, nurse teachers, ward managers and staff nurses; lack of individualized supervision; problematic evaluation processes; the quality of patient care on the ward; not being prepared for clinical practice; and the role of the nurse (Abouelfettoh and Al Mumtin, 2015; Dimitriadou et al., 2015; MiltonWildey et al., 2014; Saarikoski et al., 2012; Warne et al., 2010). articles that analyzed sources of stress in nursing students, found that no changes in clinical stress occurred during the different years of the program (Pulido-Martos et al., 2012). Students in the preclinical stage expected the highest stress to come from situations in which they will not have the knowledge or the necessary training to meet clinical practice demands. Previous studies among beginning nursing students supported these findings of inadequacy of knowledge and skills (Jamshidi et al., 2016; Rafati et al., 2017; Shaban et al., 2012; Sheu et al., 2002). Sources of stress in nursing students with no or little clinical experience seem to be focused on the students themselves and the threat of not being able to cope with demands of new clinical situations. Experienced students (third and fourth year) in this study, perceived the discrepancy between theory and reality as the most stressful situations. The sources of stress shifted from student centered to the reality test of professional dilemmas. 7.2. Nursing Students’ Satisfaction Nursing students’ satisfaction with the profession was found to be significantly related to the clinical experience and has the greatest impact on students’ retention (Crombie et al., 2013; Hamshire et al., 2012; Lee et al., 2009; Wu and Norman, 2006). The Israeli students 7.3. Relationship between Nursing Students’ Stress and Satisfaction Negative correlations were found in this study between stress and 91 Nurse Education Today 68 (2018) 86–92 H. Admi et al. students’ satisfaction in the clinical practice. Similar negative relationships were reported in a Chinese study between students’ satisfaction and stress from role conflict and ambiguity (Wu and Norman, 2006). Work Stress & Job Satisfaction in Clinical Practice Article

Because the majority of the studies in the field are correlational, it is difficult to determine if satisfaction with the profession influences satisfaction in clinical practice, or vice versa, if the relationship holds true in both directions. Interventions should be tailored to students’ educational needs and relevant to the stressful demands of the clinical environment. The quality of nursing care on the ward, role models and individualized supervision are key components of nursing students’ satisfaction in clinical experience. Drew, B.L., Motter, T., Ross, R., Goliat, L., Sharpnack, P., Govoni, A., Bozeman, M., Rababah, J., 2016. Care for the caregivers: evaluation of mind-body self-care for accelerated nursing students. Holist. Nurs. Pract. 30 (3), 148–154. D’Souza, M.S., Karkada, S.N., Parahoo, K., Venkatesaperumal, R., 2015. Perception of and satisfaction with the clinical learning environment among nursing students. Nurse Educ. Today 35 (6), 833–840. http://dx.doi.org/10.1016/j.nedt.2015.02.005. Ehrenfeld, M., Itzhaki, M., Baumann, S.L., 2007. Nursing in Israel. Nurs. Sci. Q. 20 (4), 372–375. http://dx.doi.org/10.1177/0894318407307165. Gibbons, C., Dempster, M., Moutray, M., 2011. Stress, coping and satisfaction in nursing students. J. Adv. Nurs. 67 (3), 621–632. http://dx.doi.org/10.1111/j.1365-2648. 2010.05495.x. Hamaideh, S.H., Al-Omari, H., Al-Modallal, H., 2016. Nursing students’ perceived stress and coping behaviors in clinical training in Saudi Arabia. J. Ment. Health 26 (3), 197–203. http://dx.doi.org/10.3109/09638237.2016.1139067. Hamshire, C., Willgoss, T.G., Wibberley, C., 2012. ‘The placement was probably the tipping point’–The narratives of recently discontinued students. Nurse Educ. Pract. 12 (4), 182–186. Jamshidi, N., Molazem, Z., Sharif, F., Torabizadeh, C., 2016. The challenges of nursing students in the clinical learning environment: a qualitative study. Sci. World J. 201, 1846178. http://dx.doi.org/10.1155/2016/1846178. Jun, W.H., Lee, G., 2017. Comparing anger, anger expression, life stress and social support between Korean female nursing and general university students. J. Adv. Nurs. (May), 1–9. http://dx.doi.org/10.1111/jan.13354. Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal and Coping. Springer, New York. Lee, J.H., Kim, S.S., Yeo, K.S., Cho, S.J., Kim, H.L., 2009. Experiences among undergraduate nursing students on high-fidelity simulation education: a focus group study. J. Korean Acad. Soc. Nurs. Education 15 (2), 183–193. Liu, M., Gu, K., Wong, T.K.S., Luo, M.Z., Chan, M.Y., 2015. Perceived stress among Macao nursing students in the clinical learning environment. Int. J. Nurs. Sci. 2, 128–133. Löfmark, A., Thorkildsen, K., Råholm, M.B., Natvig, G.K., 2012. Nursing students’ satisfaction with supervision from preceptors and teachers during clinical practice. Nurse Educ. Pract. 12 (3), 164–169. http://dx.doi.org/10.1016/j.nepr.2011.12.005. Milton-Wildey, K., Kenny, P., Parmenter, G., Hall, J., 2014. Educational preparation for clinical nursing: the satisfaction of students and new graduates from two Australian universities. Work Stress & Job Satisfaction in Clinical Practice Article

Nurse Educ. Today 34 (4), 648–654. http://dx.doi.org/10.1016/j.nedt. 2013.07.004. Oren, M., Ben Natan, M., 2011. The essence of nursing in the shifting reality of Israel today. Online J. Issues Nurs. 16 (2), 7. http://dx.doi.org/10.3912/OJIN. Vol16No02PPT04. Papastavrou, E., Lambrinou, E., Tsangari, H., Saarikoski, M., Leino-Kilpi, H., 2010. Student nurses experience of learning in the clinical environment. Nurse Educ. Pract. 10 (3), 176–182. http://dx.doi.org/10.1016/j.nepr.2009.07.003. Pryjmachuk, S., Richards, D.A., 2007. Predicting stress in preregistration nursing students. Br. J. Health Psychol. 12, 125–144. Pulido-Martos, M., Augusto-Landa, J.M., Lopez-Zafra, E., 2012. Sources of stress in nursing students: a systematic review of quantitative studies. Int. Nurs. Rev. 59 (1), 15–25. Rafati, F., Nouhi, E., Sabzehvari, S., Dehghan-Nayyeri, N., 2017. Iranian nursing students’ experience of stressors in their first clinical experience. J. Prof. Nurs. 33 (3), 250–257. Riahi, S., 2011. Role stress amongst nurses at the workplace: concept analysis. J. Nurs. Manag. 19 (6), 721–731. Saarikoski, M., Kaila, P., Lambrinou, E., Cañaveras, R.M.P., Tichelaar, E., Tomietto, M., Warne, T., 2013. Students’ experiences of cooperation with nurse teacher during their clinical placements: an empirical study in a Western European context. Nurse Educ. Pract. Shaban, I.A., Khater, W.A., Akhu-Zaheya, L.M., 2012. Undergraduate nursing students’ stress sources and coping behaviours during their initial period of clinical training: a Jordanian perspective. Nurse Educ. Pract. 12 (4), 204–209. http://dx.doi.org/10. 1016/j.nepr.2012.01.005. Sheu, S., Lin, H.S., Hwang, S.L., Yu, P.J., Hu, W.Y., Lou, M.F., 1997. The development and testing of perceived stress scale of clinical practice. Nurs. Res. 5 (4), 341–351 (in Chinese). Sheu, S., Lin, H.S., Hwang, S.L., 2002. Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: the effect of coping behaviors. Int. J. Nurs. Stud. 39, 165–175. http://dx.doi.org/10.1016/S00207489(01)00016-5. Spitzer, A., Perrenoud, B., 2006. Reforms in nursing education across Western Europe: implementation processes and status. J. Prof. Nurs. 22 (3), 162–171. Sun, F.K., Long, A., Tseng, Y.S., Huang, H.M., You, J.H., Chiang, C.Y., 2016. Undergraduate student nurses’ lived experiences of anxiety during their first clinical practicum: a phenomenological study. Nurse Educ. Today 37, 21–26. Sun, L., Gao, Y., Yang, J., Zang, X.Y., Wang, Y.G., 2016. The impact of professional identity on role stress in nursing students: a cross-sectional study. Int. J. Nurs. Stud. 63, 1–8. Sundler, A.J., Bjork, M., Bisholt, B., Ohlsson, U., Engstrom, A.K., Gustafsson, M., 2014. Student nurses’ experiences of the clinical learning environment in relation to the organization of supervision: a questionnaire survey. Nurse Educ. Today 34 (4), 661–666. http://dx.doi.org/10.1016/j.nedt.2013.06.023. Warne, T., Johansson, U.B., Papastavrou, E., Tichelaar, E., Tomietto, M., … den Bossche, Van, 2010. An exploration of the clinical learning experience of nursing students in nine European countries. Work Stress & Job Satisfaction in Clinical Practice Article

Nurse Educ. Today 30 (8), 809–815. Wu, L., Norman, I.J., 2006. An investigation of job satisfaction, organizational commitment and role conflict and ambiguity in a sample of Chinese undergraduate nursing students. Nurse Educ. Today 26 (4), 304–314. Yildrim, N., Karaca, A., Cangur, S., Acıkgoz, F., Akkus, D., 2017. The relationship between educational stress, stress coping, self-esteem, social support, and health status among nursing students in Turkey: a structural equation modeling approach. Nurse Educ. Today 33–39. http://dx.doi.org/10.1016/j.nedt.2016.09.014. 8. Limitations The study used a cross-sectional method of data collection and selfreported questionnaire with the potential risk of social desirability answers. Although the questionnaire is valid and reliable it needs to be revised and modified to better fit international students at different stages of the nursing program and in a rapidly changing health care system. 9. Conclusions and Implications The clinical learning experience has long been recognized as the major source of stress within the nursing educational program. Nurse educators should help students to bridge the gap between theory and reality and tailor stress reduction interventions according to the stage in the program. The findings of this study strengthen the importance of the quality of clinical supervision and quality of clinical practice. It is recommended to develop standardized tools to measure the quality and appropriateness of clinical fields to serve as learning environments for nursing students. Personal characteristics frequently serve as criteria for admission to nursing programs. Results of international studies in regard to associations between personal characteristics and stress are inconsistent. In this study, only gender was found to be related to stress and satisfaction among nursing students. Further international studies are needed with the use of standardized instruments. In addition, qualitative research would help to gain understandings of the experience of current generations of nursing students within the changing complex health care environment and diverse immigrant societies. Dealing with the stress and satisfaction of the future generation of nurses is not only critical for their wellbeing and academic achievements, it also means that they will become nursing professionals who provide better care and caring for the patients. References Abouelfettoh, A., Al Mumtin, S., 2015. Nursing students’ satisfaction with their clinical placement. Work Stress & Job Satisfaction in Clinical Practice Article

J. Sci. Res. Rep. 4 (6), 490–500. Admi, H., 1997. Nursing students’ stress during the initial clinical experience. J. Nurs. Educ. 36 (7), 323–327. http://dx.doi.org/10.3928/0148-4834-19970901-07. Al-Gamal, E., Alhosain, A., Alsunaye, K., 2017. Stress and coping strategies among Saudi nursing students during clinical education. Perspect. Psychiatr. Care 1–8 (preprint). Arieli, D., 2013. Emotional work and diversity in clinical placements of nursing students. J. Nurs. Scholarsh. 45 (2), 192–201. Bartlett, M.L., Taylor, H., Nelson, J.D., 2016. Comparison of mental health characteristics and stress between baccalaureate nursing students and non-nursing students. J. Nurs. Educ. 55 (2), 87–90. Ben Natan, M., Oren, M., 2011. The essence of nursing in the shifting reality of Israel today. Online J. Issues Nurs. 16 (2). Cheung, T., Wong, S.Y., Wong, K.Y., Law, L.Y., Ng, K., Tong, M.T., … Yip, P.S.F., 2016. Depression, anxiety and symptoms of stress among baccalaureate nursing students in Hong Kong: a cross-sectional study. Int. J. Environ. Res. Public Health 13 (8), 779. http://dx.doi.org/10.3390/ijerph13080779. Crombie, A., Brindley, J., Harris, D., Marks-Maran, D., Thompson, T.M., 2013. Factors that enhance rates of completion: what makes students stay? Nurse Educ. Today 33 (11), 1282–1287. http://dx.doi.org/10.1016/j.nedt.2013.03.02. Dimitriadou, M., Papastavrou, E., Efstathiou, G., Theodorou, M., 2015. Baccalaureate nursing students’ perceptions of learning and supervision in the clinical environment. Nurs. Health Sci. 17 (2), 236–242. http://dx.doi.org/10.1111/nhs.12174. 92 JONA Volume 47, Number 7/8, pp 391-395 Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved. THE JOURNAL OF NURSING ADMINISTRATION Decreasing Stress and Burnout in Nurses Efficacy of Blended Learning With Stress Management and Resilience Training Program Donna L. Magtibay, MSN, RN Sherry S. Chesak, PhD, RN Kevin Coughlin, FNT Amit Sood, MD OBJECTIVE: The study_s purpose was to assess efficacy of blended learning to decrease stress and burnout among nurses through use of the Stress Management and Resiliency Training (SMART) program. BACKGROUND: Job-related stress in nurses leads to high rates of burnout, compromises patient care, and costs US healthcare organizations billions of dollars annually. Many mindfulness and resiliency programs are taught in a format that limits nurses_ attendance. METHODS: Consistent with blended learning, participants chose the format that met their learning styles and goals; Web-based, independent reading, facilitated discussions. The end points of mindfulness, resilience, anxiety, stress, happiness, and burnout were measured at baseline, postintervention, and 3-month follow-up to examine within-group differences. RESULTS: Findings showed statistically significant, clinically meaningful decreases in anxiety, stress, and burnout and increases in resilience, happiness, and mindfulness. CONCLUSIONS: Results support blended learning using SMART as a strategy to increase access to resiliency training for nursing staff. Work Stress & Job Satisfaction in Clinical Practice Article

Author Affiliations: Assistant Professor (Ms Magtibay) and Assistant Professor (Dr Chesak), Department of Nursing, and Consultant in General Internal Medicine and Professor of Medicine General Internal Medicine Division (Dr Sood), Mayo Clinic, Rochester; and Independent Consultant, Excelsior (Mr Coughlin), Minnesota. Dr Sood developed the SMART program and has proprietary interest in it. Dr Sood was the lead interventionist but did not have any role in the data collection, analysis, or interpretation and did not have access to the original data at any time. The authors declare no conflict of interest. Correspondence: Ms Magtibay, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (magtibay.donna@ mayo.edu). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal_s Web site (www.jonajournal.com). DOI: 10.1097/NNA.0000000000000501 Stress and burnout in nursing have been topics of discussion for years. A 2011 survey sponsored by the American Nurses Association listed the acute and long-term effects of stress and overwork as 1 of their top 2 safety and health concerns.1 Burnout is defined as a prolonged response to physical or emotional stressors that result in feelings of exhaustion, being overwhelmed, self-doubt, anxiety, bitterness, cynicism, and ineffectiveness.2 Burnout negatively affects the physical and emotional health of nurses and contributes to rising organizational costs.3 It also has a negative impact on patient satisfaction, outcomes, and death rates.4 A study funded by the Robert Wood Johnson Foundation determined that the depression rate of nurses was 18%, twice that of the US general public.5 In addition to the personal suffering of dealing with depression, it is highly likely that hospital nurses with depression have an adverse effect on their coworkers and on the quality of patient care.5 Essential to providing high-quality patient care are the benefits of expert nurses who are healthy enough to offer such care. These benefits require that attention is paid to the health and well-being of nurses. Many of the stress-related disorders of nurses may improve with stress reduction techniques, as tested in multiple studies with various patient populations.6 Nurses who have used stress coping techniques have been found to have fewer mental health problems, such as anxiety, depression, and feelings of inadequacy. Coping with unavoidable stress may include changing communication techniques, choosing how JONA  Vol. 47, No. 7/8  July/August 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 391 to react to a situation, and managing personal expectations and attitudes.7 The latter change speaks directly to the benefits of mindfulness and resilience training. Mindfulness refers to the practice of learning to focus attention and awareness on the moment-bymoment experience with an attitude of curiosity, openness, and acceptance.8 Resiliency is the ability to overcome challenges and to bounce back stronger and wiser.Work Stress & Job Satisfaction in Clinical Practice Article

9 The development of resilience in persons and organizations is viewed by experts as a potential answer to the stress associated with contemporary lifestyles and workplaces.10 Psychological resilience is more pronounced in people who have mindful attention.10 Ponte and Koppel11 reported on research that lists the benefits of mindfulness on patient care, including improved provider-patient communication and enhancement of the clinician_s attentiveness and ability to identify conditions. Mindful presence could lead to decreased diagnostic and medication errors.11 Healthcare organizations that implement burnout interventions such as mindfulness and resilience training may have increased employee retention, reduced turnover and performance problems, and increased patient satisfaction.4 According to Phillips and Bayer,12 this training can kindle core capacities that support making healthy choices. A national survey of nurses listed convenience as the most important factor when choosing types of stress management training.13 A blended learning environment allows for this convenience by combining the positive aspects of classroom interaction with the convenience of online learning. In this environment, participants access the content as convenient for their schedules, enabling them to learn the concepts and practice the interventions at their own pace. In addition, participants have access to experts for questions and to reinforce learning. Blended learning better meets the needs of those who have conflicting priorities of work commitments and personal relaxation time.14 Mindfulness and resilience training programs taught in the classroom require skilled facilitation, limit participation to persons who are able to travel to the classroom location, and may be cost prohibitive.15 Investigators have attempted to make mindfulness training more convenient and accessible. Bazarko et al16 compared the use of telephonic sessions of a mindfulness-based stress reduction program versus in-person sessions for nurses. The participants reported improvement in general health, decreased stress, and decreased work burnout. Reports of online programs to improve stress, mindfulness, empathy, and resilience have also shown similar results.13,15,17 The current programs have modest effects, however, and 392 require considerable time for learning and practice. Newer programs are needed that are more pragmatic and provide flexibility for nurses. We believe the Stress Management and Resiliency Training (SMART) program better meets these criteria. Stress Management and Resiliency Training Stress Management and Resiliency Training is a structured design to retrain the brain by teaching concepts and skills to move from a reactive lower brain to an intentional higher brain. This retraining is conducted through intentionally paying attention to life experiences and reframing those experiences through the principles of gratitude, compassion, acceptance, higher meaning, and forgiveness.18 The program goal is to enhance peace, joy, resilience, and altruism, thereby reducing stress and improving well-being.19 Stress Management and Resiliency Training has been tested for physicians, radiologists, and patients with breast cancer, as well as other groups, and has shown efficacy for increasing resilience, well-being, and mindfulness and decreasing stress and anxiety.18,20-22 This study was designed to test the efficacy of SMART among transplant nurses and nurse leaders using blended learning as the delivery method for improving stress, resilience, happiness, anxiety, mindfulness, and burnout. Work Stress & Job Satisfaction in Clinical Practice Article

Methods Study Design This study was designed as a quasi-experimental, 1-group baseline to postintervention conducted at Mayo Clinic_s campus in Rochester, Minnesota, a large academic tertiary medical center. Approval was obtained from the Mayo Clinic Institutional Review Board. Sample A convenience sample of 50 nurses self-selected to participate. They consented and were enrolled in the study (female sex, 92%; age range, 24-63 years, which reflect the demographic characteristics of nurses at the study site). Participants included transplant nurses in direct patient care (n = 28), those in leadership roles (n = 18), and those who selected the Bother[ category (n = 8); 46 were employed full time, and 4 were employed part time. The number of years in practice was not collected. Procedure Congruent with blended learning principles, participants were offered various options for learning the content. As adult learners, they could select the options that best met their learning styles and interest: Web-based format, independent reading, or facilitated JONA  Vol. 47, No. 7/8  July/August 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. discussions or a combination. There was no timeline for content completion; however, participants were encouraged to complete the Web-based portion before the week 8 survey. No continuing education credits were offered, and participants were not paid for their study involvement. Outcome measures were assessed using an online survey assessment tool, Research Electronic Data Capture, at baseline (week 0) and weeks 8, 12, and 24. 24 was compared with baseline using the paired t test (or Wilcoxon signed rank test). Change from baseline was summarized using a point estimate and 95% confidence interval. All survey data were included in the statistical analysis. The missing data were compensated using the last-observation-carriedforward method. Intervention Stress Management and Resiliency Training was redesigned from a classroom setting to a Web-based format consisting of 12 modules. Each module contained premodule and postmodule self-assessment, brief videos to introduce the topic, and reading assignments from the complementing book, The Mayo Clinic Guide to Stress-Free Living23 (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A537). The modules also provided exercises designed to take the concepts from theory into practice. Participants received access to the online content plus a copy of the book23 without charge. In addition, participants were invited to attend 4 discussions facilitated by the book_s author (A.S.) and by the principal investigator (D.L.M.) at weeks 8, 12, 16, and 20. Week 8 and 12 sessions were conducted in-person; week 16 and 20 sessions were offered through telephone conversation. The facilitated sessions were conducted to problem solve and answer questions and were not structured around specific topics. The study enrolled 50 nurses. Participant attendance at each follow-up session included 20 at week 8, 15 at week 12, 2 at week 16, and 1 at week 20.Work Stress & Job Satisfaction in Clinical Practice Article

Participants who completed the surveys at each interval numbered 45 at week 8, 40 at week 12, and 33 at week 24. Outcomes were measured in the 6 categories. Table 1 summarizes the measurement results. At week 8, after suggested completion of Web-based learning, the results showed marked improvement in all categories. For this period, results showed significant decreases in anxiety (P G .001), personal burnout (P G .001), and work-related burnout (P G .001). Of note, the interval between weeks 8 and 12 showed greater improvement than the other time intervals. The final surveys at week 24 showed significant improvement in all categories. The largest decrease was in anxiety, with a reduction of 45.2% (P G .001). The other measures also were encouraging: reduction in stress of 29.8% (P G .001); personal burnout, 33.6% (P G .001); work-related burnout, 32.6% (P G .001); and client-related burnout, 38.5% (P G .001). In addition, increased measures were noted for happiness (P G .001) and mindful attention (P G .001). Measures The survey consisted of 6 measurement tools: Subjective Happiness Scale,24 Perceived Stress Scale,25 Generalized Anxiety Scale,26 Mindful Attention Awareness Scale,27 Connor-Davidson Resilience Scale, and Copenhagen Burnout Inventory.28 Descriptions of the scales and reliability data are provided in the Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A538. Each of these instruments is a validated measure of our study goals, which were to assess the program_s impact on stress, anxiety, mindfulness, happiness, resilience, and burnout. Furthermore, many of these tools have been responsive to our intervention, and the combined participant burden with these tools was approximately 10 minutes. Statistical Analysis The end points for the study, happiness, stress, anxiety, mindful attention, resilience, and burnout were continuous variables and were assessed at baseline and at weeks 8, 12, and 24 after the baseline. For the primary analysis, the value of each end point at week Results Discussion This study showed improvements in stress, anxiety, resilience, mindfulness, happiness, and burnout among nurses with a SMART program as early as week 8. The gains continued through week 24. These findings are similar to the published benefits of SMART, in which the participants include healthcare providers.18,20,29,30 The SMART has been the focus of several studies. Published results have supported improvements in stress, anxiety, resilience, mindfulness, self-regulation, happiness, and positive health behaviors.18,20-22,29,30 This study supports the effectiveness of SMART as an intervention to reduce stress, anxiety, and burnout while improving happiness, mindfulness, and resilience in nurses. Work Stress & Job Satisfaction in Clinical Practice Article

It also suggests that the flexibility of blended learning allows a viable option in teaching SMART with nurses. The strengths of this study were the results provided for the short-term (8 weeks) and long-term (24 weeks) outcomes. The sample size was statistically adequate to provide meaningful estimates JONA  Vol. 47, No. 7/8  July/August 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 393 Table 1. Baseline and Follow-up Assessments of Study End Points Observed Data,a Mean (SD) Assessment Tool Subjective Happiness Scale (range, 1-7) Baseline 8 wk 12 wk 24 wk Mindful Attention Awareness Scale (range, 1-6) Baseline 8 wk 12 wk 24 wk Generalized Anxiety Disorder (range, 0-21) Baseline 8 wk 12 wk 24 wk Perceived Stress Scale (range, 0-40) Baseline 8 wk 12 wk 24 wk Copenhagen Burnout Inventory Personal burnout (range, 0-100) Baseline 8 wk 12 wk 24 wk Work-related burnout (range, 0-100) Baseline 8 wk 12 wk 24 wk Client-related burnout (range, 0-100) Baseline 8 wk 12 wk 24 wk Connor-Davidson Resilience Scale (2 items) (range, 0-8) Baseline 8 wk 12 wk 24 wk Last Value Carried Forward (N = 50), Mean (SD) Pb 4.86 5.11 5.29 5.54 (0.91) (0.78) (0.74) (0.78) 4.86 5.06 5.24 5.38 (0.91) (0.79) (0.78) (0.79) .02 G.001 G.001 2.66 2.94 3.35 3.39 (0.78) (0.68) (0.63) (0.59) 2.66 2.87 3.20 3.26 (0.78) (0.74) (0.73) (0.71) .03 G.001 G.001 8.32 5.60 3.80 4.00 (4.95) (4.39) (2.77) (3.00) 8.32 5.96 4.72 4.56 (4.95) (4.48) (3.83) (3.64) G.001 G.001 G.001 17.56 15.47 11.55 10.79 (6.92) (6.60) (5.77) (6.43) 17.56 16.14 13.52 12.32 (6.92) (6.77) (7.11) (7.20) .10 G.001 G.001 52.58 42.22 33.23 32.05 (19.87) (19.80) (16.11) (19.12) 52.58 44.83 36.92 34.90 (19.87) (21.45) (18.52) (19.90) G.001 G.001 G.001 53.71 43.73 35.43 34.18 (19.44) (18.40) (15.72) (20.03) 53.71 46.29 39.20 36.20 (19.44) (20.87) (18.00) (20.54) G.001 G.001 G.001 33.92 29.00 18.88 19.29 (18.99) (18.39) (15.90) (19.14) 33.92 30.43 22.43 20.85 (18.99) (19.21) (17.83) (19.54) .13 G.001 G.001 6.2 6.3 6.8 6.9 (1.1) (1.2) (1.1) (1.0) 6.2 6.3 6.5 6.7 (1.1) (1.2) (1.2) (1.2) .31 .048 .004 a Data were available for N = 50, 45, 40, and 33 participants at baseline and 8, 12, and 24 weeks, respectively. In addition to summarizing the observed data, the data were also summarized after using the approach of last value carried forward to impute values for participants who had missing data at a given follow-up time point. After using the approach of last value carried forward, data were available for all participants (N = 50) at each time point. b The paired t test was used to compare the mean at each follow-up time point with the baseline after using the approach of last value carried forward to impute data for participants who had missing data at the given follow-up time point. for the potential magnitude of the effect of the blended learning strategy. Despite its potential positive findings, this study has limitations that must be addressed. Work Stress & Job Satisfaction in Clinical Practice Article

No control group was used for comparison with the relatively small convenience sample. Within 72 hours of opening the study for enrollment, these 50 nurses, from a potential pool of 125, were enrolled and consented to participate. The results of the study may have been influenced by this highly motivated group. Furthermore, no continuing education credits were 394 offered, and participants were not reimbursed for time spent in the study. One participant withdrew from the study. Others stayed enrolled, but 16 did not complete the surveys given their busy work schedules. The findings of this study are encouraging and warrant additional research. The convenience sample used was homogeneous in that it was from a single healthcare institution. Future research can expand enrolment to a more heterogeneous sample, including nurses from multiple locations. The limitations of having JONA  Vol. 47, No. 7/8  July/August 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. no control group can be strengthened using a wait-list control group or by offering an educational intervention matched in time of involvement and attention. for resiliency training such as SMART. It allows access for nurses who typically are unable to participate in traditional, on-site programs. Conclusions Acknowledgments Blended learning allows nurses to control their learning environment and seems to be a feasible strategy The authors thank Mr Darrell R. Schroeder for statistical support. References 1. American Nurses Association. 2011 ANA health and safety survey [Internet]. http://www.nursingworld.org/2011HealthSurvey Results.aspx. Accessed April 21, 2016. 2. Maslach C, Leiter MP. Reversing burnout: how to rekindle your passion for your work. Stanford Social Innovation Review: SSIR. 2005. http://ssir.org/articles/entry/reversing_ burnout. Accessed April 21, 2016. 3. Potter P, Deshields T, Berger JA, Clarke M, Olsen S, Chen L. Evaluation of a compassion fatigue resiliency program for oncology nurses. Oncol Nurs Forum. 2013;40(2):180-187. 4. Henry BJ. Nursing burnout interventions: what is being done? Clin J Oncol Nurs. 2014;18(2):211-214. 5. Robert Wood Johnson Foundation_s Interdisciplinary Nursing Quality Research Initiative (INQRI). INQRI study: nurses experience depression at twice the rate of general public: interdisciplinary research spotlights stressful environments that strain nurses_ mental health [Internet]. 2012. http://www.rwjf. org/en/library/articles-and-news/2012/07/inqri-study–nursesexperience-depression-at-twice-the-rate-of-g.html. Accessed April 21, 2016. 6. Milliken TF, Clements PT, Tillman HJ. The impact of stress management on nurse productivity and retention. Nurs Econ. 2007;25(4):203-210. 7. Smith M, Hambleton S. Workplace stress and career burnout among clinicians. Clinical Advisor. 2013. http://www. clinicaladvisor.com/cmece-features/workplace-stress-andcareer-burnout-among-clinicians/article/302216/. Accessed April 21, 2016. 8. Marchand WR. Mindfulness-based stress reduction, mindfulnessbased cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress. J Psychiatr Pract. 2012; 18(4):233-252. 9. Wieczorek T. Can resiliency be learned? Definitely, with collaboration, know-how, and hard work. Work Stress & Job Satisfaction in Clinical Practice Article

Public Manage. 2014; 96(3):6-10. 10. Foureur M, Besley K, Burton G, Yu N, Crisp J. Enhancing the resilience of nurses and midwives: pilot of a mindfulnessbased program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp Nurse. 2013; 45(1):114-125. 11. Ponte PR, Koppel P. Cultivating mindfulness to enhance nursing practice. Am J Nurs. 2015;115(6):48-55. 12. Phillips R, Bayer GA. Behavior change through brain health: managing stress and building resilience. Employee Benefit Plan Rev. 2012;66(11):5-7. 13. Kemper KJ, Khirallah M. Acute effects of online mind-body skills training on resilience, mindfulness, and empathy. J Evid Based Complementary Altern Med. 2015;20(4):247-253. 14. Woodhouse J. Strategies for Healthcare Education: How to Teach in the 21st Century. Oxford, England: Radcliffe Publishing; 2007. 15. Morledge TJ, Allexandre D, Fox E, et al. Feasibility of an online mindfulness program for stress management: a randomized, controlled trial. Ann Behav Med. 2013;46(2):137-148. 16. Bazarko D, Cate RA, Azocar F, Kreitzer MJ. The impact of an innovative mindfulness-based stress reduction program on the health and well-being of nurses employed in a corporate setting. J Workplace Behav Health. 2013;28(2):107-133. 17. Krusche A, Cyhlarova E, Williams JM. Mindfulness online: an evaluation of the feasibility of a web-based mindfulness course for stress, anxiety and depression. BMJ Open. 2013; 3(11):e003498. 18. Sood A, Prasad K, Schroeder D, Varkey P. Stress management and resilience training among Department of Medicine faculty: a pilot randomized clinical trial. J Gen Intern Med. 2011;26(8):858-861. 19. Sood A. Train Your Brain, Engage Your Heart, Transform Your Life: A Two-Step Program to Enhance Attention; Decrease Stress; Cultivate Peace, Joy and Resilience; and Practice Presence With Love: A Course in Attention & Interpretation Therapy. Rochester, MN: Morning Dew Publications; 2010. 20. Chesak SS, Bhagra A, Schroeder DR, Foy DA, Cutshall SM, Sood A. Enhancing resilience among new nurses: feasibility and efficacy of a pilot intervention. Ochsner J. 2015;15(1):38-44. 21. Loprinzi CE, Prasad K, Schroeder DR, Sood A. Stress Management and Resilience Training (SMART) program to decrease stress and enhance resilience among breast cancer survivors: a pilot randomized clinical trial. Clin Breast Cancer. 2011;11(6):364-368. 22. Sharma V, Sood A, Prasad K, Loehrer L, Schroeder D, Brent B. Bibliotherapy to decrease stress and anxiety and increase resilience and mindfulness: a pilot trial. Explore (NY). 2014; 10(4):248-252. 23. Sood A. The Mayo Clinic Guide to Stress-Free Living. Cambridge, MA: Da Capo/Life Long; 2013. 24. Lyubomirsky S, Lepper HS. A measure of subjective happiness: preliminary reliability and construct validation. Soc Indic Res. 1999;46(2):137-155. 25. Work Stress & Job Satisfaction in Clinical Practice Article

Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. 26. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. 27. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84(4):822-848. 28. Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen burnout inventory: a new tool for the assessment of burnout. Work Stress. 2005;19(3):192-207. 29. Prasad K, Wahner-Roedler DL, Cha SS, Sood A. Effect of a single-session meditation training to reduce stress and improve quality of life among health care professionals: a Bdose-ranging[ feasibility study. Altern Ther Health Med. 2011;17(3):46-49. 30. Sood A, Sharma V, Schroeder DR, Gorman B. Stress Management and Resiliency Training (SMART) program among Department of Radiology faculty: a pilot randomized clinical trial. Explore (NY). 2014;10(6):358-363. JONA  Vol. 47, No. 7/8  July/August 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 395 Sarafis et al. BMC Nursing (2016) 15:56 DOI 10.1186/s12912-016-0178-y RESEARCH ARTICLE Open Access The impact of occupational stress on nurses’ caring behaviors and their health related quality of life Pavlos Sarafis1,2*, Eirini Rousaki2, Andreas Tsounis2,3, Maria Malliarou2, Liana Lahana2, Panagiotis Bamidis2,4, Dimitris Niakas2 and Evridiki Papastavrou1 Abstract Background: Nursing is perceived as a strenuous job. Although past research has documented that stress influences nurses’ health in association with quality of life, the relation between stress and caring behaviors remains relatively unexamined, especially in the Greek working environment, where it is the first time that this specific issue is being studied. The aim was to investigate and explore the correlation amidst occupational stress, caring behaviors and their quality of life in association to health. Methods: A correlational study of nurses (N = 246) who worked at public and private units was conducted in 2013 in Greece. The variables were operationalized using three research instruments: (1) the Expanded Nursing Stress Scale (ENSS), (2) the Health Survey SF-12 and (3) the Caring Behaviors Inventory (CBI). Univariate and multivariate analyses were performed. Results: Contact with death, patients and their families, conflicts with supervisors and uncertainty about the therapeutic effect caused significantly higher stress among participants. A significant negative correlation was observed amidst total stress and the four dimensions of CBI. Certain stress factors were significant and independent predictors of each CBI dimension. Conflicts with co-workers was revealed as an independent predicting factor for affirmation of human presence, professional knowledge and skills and patient respectfulness dimensions, conflicts with doctors for respect for patient, while conflicts with supervisors and uncertainty concerning treatment dimensions were an independent predictor for positive connectedness. Work Stress & Job Satisfaction in Clinical Practice Article

Finally, discrimination stress factor was revealed as an independent predictor of quality of life related to physical health, while stress resulting from conflicts with supervisors was independently associated with mental health. Conclusion: Occupational stress affects nurses’ health-related quality of life negatively, while it can also be considered as an influence on patient outcomes. Keywords: Occupational stress, Nurses, Health-related quality of life, Caring behaviors Background Occupational stress can be defined as a situation wherein job-related factors interact with an employee, changing his/her psychological and physiological condition in a way that the person is forced to deviate from normal functioning [1]. * Correspondence: pavlos.sarafis@cut.ac.cy 1 Department of Nursing, Cyprus University of Technology, Limassol, Cyprus 2 Hellenic Open University, Faculty of Social Sciences, Patra 26335, Greece Full list of author information is available at the end of the article Work-related stress can be damaging to a person’s physical and mental health, while its’ high levels have been related/connected to high staff truancy and low levels of productivity. According to the American Institute of Stress, stress is a major factor in up to 80 % of all workrelated injuries and 40 % of workplace turnovers [2]. Nursing is perceived as a strenuous job with high and complicated demands. The high job demands and the combination of too much responsibility and too little authority have been identified as some of the primary sources of occupational stress amid nursing staff [3–7]. © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sarafis et al. BMC Nursing (2016) 15:56 Occupational stress may affect significantly nurse’s quality of life, and simultaneously reduce the quality of care. Caring is an interpersonal procedure defined by expert nursing, interpersonal sensitivity and intimate relationships, including positive communication and implementation of professional knowledge and skills [8]. Job related stress has as a result loss of compassion for patients and increased incidences of practice errors and therefore is unfavorably associated to quality of care [9]. Numerous studies show that it has a direct or indirect impact on the delivery of care and on patient results [10–12]. Purpose of the study The main purpose of this study is to investigate the relation between nurses’ working stress and the patient care behaviors as well as nurses’ health-related quality of life. According to the main hypotheses, occupational stress leads to the deterioration of nurse’s physical and mental health status, while it is negatively affecting the adoption of good practices concerning nurses’ caring behaviors. Method Study design-sample A correlational study was conducted. Work Stress & Job Satisfaction in Clinical Practice Article

In total, 300 questionnaires were distributed to nurses working in one public General Hospital and 3 private ones. The final sample consisted of 246 nurses (higher education graduates) and nursing assistants (high school or post-secondary education) (Response Rate 82 %). The composition of the sample reflects the Greek reality. Greece has the third lowest density of nurses (3.3 per 1. 000 population) in OECD countries after Turkey and Mexico, while many working positions in health-care units are covered by nursing assistants than Registered nurses [13]. Inclusion criteria for nurses were as follows: willingness to partake in, at least 1 year of work experience, with immediate association with patients. Research instruments Socio-demographics The first part of the questionnaire contained questions recording socio-demographic and work-related characteristics of the sample. Caring behaviors The Greek Version of the Caring Behaviors Inventory scale (CBI-GR) was used [14]. There are 4 correlated dimensions within its 24 items: (1) Assurance of Human Presence – items 16,17,18,20, 21, 22, 23 and 24 (2) Professional Knowledge and Skills – items 9,10,11,12 and 15 (3) Patient Respectfulness – items 1, 3, 5, 6, 13 and 19) Positive Connectedness – items 2, 4, 7, 8 and 14. Each item is ranked on a 6-point Likert scale from 1 = never to 6 = always. The higher the score, the more the nurse expresses the specific caring behavior. Total and subscale Page 2 of 9 scores can be derived from the instrument. Papastavrou et al., [14] translated, adapted and cross-validated the 24item English Version of CBI into Greek and evaluated its’ psychometric properties. The CBI-GR was proved to be comparable with the original 24-item English Version and suitable to measure nurse caring among Greek-speaking nurses [14]. Occupational stress The Expanded Nursing Stress Scale (ENSS) for the investigation of nurses’ work related stress is one of the most widely used scales which has already been adapted and validated in Greek and developed by Gray-Toft & Anderson [15]. It incorporates 59 items with 9 subscales. Each item requires respondents to rate on a five-point Likert scale ranging from “1 never stressful” to “4 extremely stressful” and “0 does not apply”. The higher the score, the more agreeable the replier is to the situation being stressful. Total and subscale scores can be derived from the instrument. The subscales include: 1. limisted knowledge in dealing with death and dying 2. Conflicts with other employers 3. feeling unqualified to aid with the patient and their family emotional needs 4. Peer –related problems 5. conflicts with supervisor and accepting the least possible support by the charge nurse, immediate supervisor and administrators 6. workload 7. uncertainty concerning treatment and receiving insufficient information of their medical condition from physicians 8. fear to fail nursing tasks due to patients’ and their families’ irrational demands 9. feeling discriminated and isolated by nursing colleagues and other professionals. Adding all the scores from the 59 items we get the total stress score. [16]. ENSS demonstrated improved reliability (α = .96) [16] over the original NSS (α = .89) [15]. Work Stress & Job Satisfaction in Clinical Practice Article

The translation and validation of the questionnaire was made by Moustaka et al., [17], who granted permission to use it. Quality of life SF-12, which measures physical and mental health status was used for the quality of life assessment. SF-12 includes 12 questions: 2 concerning physical functioning, 2 regarding role limitations caused by physical health problems, 1 question about bodily pain, 1 with reference to general health perceptions, 1 on vitality, 1 in regard to social functioning, 2 in relevance to role limitations because of emotional problems and 2 questions referring to general mental health [18]. It was constructed as a shorter alternative of the SF-36 Health Survey, which although it has proved to be useful for a variety of purposes, is too long for inclusion in some large-scale health measurement [18]. Translation and validation of the questionnaire was made by Kontodimopoulos et al. [18]. Sarafis et al. BMC Nursing (2016) 15:56 Ethical considerations The Ethics Committees of both the public General Hospital and the private ones granted permission for conducting the research. The questionnaires were anonymous and selfadministered. Nurses meeting the inclusion criteria were verbally requested to participate in the study. Each attendant was free to take part, refuse or withdraw at any time, without any consequences. Data analysis Demographic data were analysed using descriptive statistics. Mean values (SD) were used to describe quantitative variables, which were portrayed as absolute and relative frequencies. The associations of two continuous variables were analysed by Pearson correlations coefficients. In order to investigate the association of stress factors with SF-12 summary scores and the CBI subscales multiple linear regression analysis was conducted after adjusting for sex, age, family status, having children, educational level, working sector, working experience, shift and working position. All reported p values are two-tailed. Statistical significance was set at p < 0.05 and analyses were conducted using SPSS statistical software (version 18.0). Page 3 of 9 Table 1 Sample characteristics N (%) Sex Women 211 (85.8) Men 35 (14.2) Age (years), mean (SD) 39.7 (8.2) Family status Unmarried 77 (31.3) Married 156 (63.4) Divorced 10 (4.1) Widowed 3 (1.2) Children Yes 158 (64.2) No 88 (35.8) Degree University 11 (4.5) Technical university 97 (39.6) 2 year Technical School 78 (31.9) High school 57 (23.3) Other 2 (0.8) Post-graduate degree Results Respondent demographics The sample consisted of 246 nurses with mean age 39.7 years (SD = 8.2 years). Sample characteristics are presented in Table 1. Most participants were women (85.8 %) and 63.4 % of them were married, while 39.6 % were technological institutions’ graduates. Most of the participants (54.9 %) were nursing assistants, as Greece is in the 32nd place of out of 34 OECD countries rank at the number of nurses (per 1000 population). Work Stress & Job Satisfaction in Clinical Practice Article

No 236 (95.9) Yes 10 (4.1) PhD No 244 (99.2) Yes 2 (0.8) Working sector Public 218 (88.6) Private 28 (11.4) Total years in nursing, mean (SD) 15.3 (9.1) Mean values of the ENSS, SF-12 and CBI scales Years in nursing in current job, mean (SD) 8.0 (7.0) Mean values of study scales are provided in Table 2. More stressful factors were those that were related to death and dying (mean value m = 2.65; SD = 0.76) and those related with patient and family (m = 2.56; SD = 0.88) (Fig. 1). The least stressful factors were those that were related to discrimination (m = 0.79; SD = 1.01). Mean total stress was 2.22 (SD = 0.65). Also, mean value in physical component summary score was 45.02 (SD = 7.63) and in mental component summary score was 45.50 (SD = 11.18). Highest mean values in CBI scales were found in “Professional knowledge and skill” (m = 5.07; SD = 0.73) and in “Assurance of human presence” (m = 4.90; SD = 0.76). Shift Occupational stress and its correlation with quality of life and caring behaviors all ENSS scales except for “Discrimination Stressors”, indicating that more stressors are related with poorer mental health. Also, the physical component summary (PCS) score was significantly negatively correlated with stressors that had to do with discrimination, workload, Correlation between ENSS scales and SF-12 and CBI scales are provided in Table 3. Mental component summary (MCS) score was negatively correlated with almost Morning 58 (23.9) Rotated 185 (76.1) Working position Nursing assistant 135 (54.9) Nurse 88 (35.8) Supervisor of department 17 (6.9) Supervisor of sector 5 (2.0) Head of department 1 (0.4) Sarafis et al. BMC Nursing (2016) 15:56 Page 4 of 9 Table 2 Mean values of study parameters Mean (SD) ENSS Death and Dying Stressors 2.65 (0.76) Patient and Family Stressors 2.56 (0.88) Problems with Supervision Stressors 2.39 (0.86) Uncertainty Concerning Treatment Stressors 2.34 (0.86) Conflict with Physician Stressors 2.29 (0.88) Workload Stressors 2.20 (0.83) Inadequate Emotional Preparation Stressors 2.13 (0.94) Problems with Peers Stressors 1.71 (0.84) Discrimination Stressors 0.79 (1.01) Total stress score 2.22 (0.65) SF-12 Physical component summary score 45.02 (7.63) Mental component summary score 45.50 (11.18) CBI Assurance of human presence 4.90 (0.76) Professional knowledge and skill 5.07 (0.73) Respect for patient 4.60 (0.84) Positive connectedness 4.42 (0.89) problems with peers and supervision, indicating that more stressors in the afore-mentioned sectors are related with poorer physical health. Significantly negative correlations were found between almost all ENSS and CBI subscales. Thus, more stressful factors are related with worse behavior of the participants towards their patients. Multiple regression results with SF-12 scales as dependent variables and stress subscales as independent, adjusted for demographics and other sample characteristics are given in Table 4. The desire for resigning was independently associated with physical health, with those who wanted to abandon the nursing profession confronting more physical symptoms. Work Stress & Job Satisfaction in Clinical Practice Article

On the other hand, specialty, working sector and Fig. 1 Mean values of ENSS subscales in order of importance resignation desire, were independent predicting factors for quality of life related with mental health. Only discrimination stressors were found to be negatively related to PCS scores while all other stressors were found to be negatively related to MCS scores. Also, after adjusting for demographics it was found that stress in total was negatively related to all CBI subscales. Additionally, stress regarding Workload, Uncertainty Concerning Treatment, Problems with Peers and Supervision were negatively related to all CBI subscales. Stress caused by Conflict with Physician was negatively related to “Assurance of human presence”, “Respect for patient” and “Positive connectedness”. Stress caused by Discrimination Stressors was negatively related to “Professional knowledge and skill” and “Respect for patient”. Multiple regression results with CBI scales as dependent variables and stress subscales as independent, adjusted for demographics and other sample characteristics are given in Table 5. The resignation desire was an independently predicting factor for all the CBI dimensions, with nurses who did not want to leave their job having higher scores in the “Assurance of human presence” and those who wanted to retire having lower score in the rest of the three remaining dimensions. Conflicts with co-workers was independent predicting factor for the “Assurance of human presence”, “Professional knowledge and skills” and “Respect for patient” dimensions, conflicts with doctors predicted the “Respect for patient” dimension and conflicts with supervisors was an independent predicting factor for the “Positive connectedness”. In all the above cases, the higher the stress on behalf of the conflicts was, the lower the score in the CBI dimensions was. Finally, the working sector was an independently predicting factor for the “Assurance of human presence” with nurses who worked in the private sector having higher scores. Discussion The present study provided empirical support for the existence of stress experience in the nursing profession. Sarafis et al. BMC Nursing (2016) 15:56 Page 5 of 9 Table 3 Correlation between stress scales and SF-12 and CBI scales SF-12 CBI ENSS Physical component summary score Mental component summary score Assurance of human presence Professional knowledge and skill Respect for patient Positive connectedness Death and Dying Stressors −0.03 Inadequate Emotional Preparation Stressors −0.09 −0.26*** −0.17** −0.13* −0.19** −0.19** −0.25** −0.25*** −0.22** −0.21** −0.16* Discrimination Stressors Workload Stressors −0.13* −0.07 −0.12 −0.15* −0.17** −0.11 −0.13* −0.28*** −0.28*** −0.21** −0.28*** −0.27*** Uncertainty Concerning Treatment Stressors −0.07 −0.31*** −0.27*** −0.22** −0.31*** −0.31*** Conflict with Physician Stressors −0.08 −0.29*** −0.26*** −0.14* −0.31*** −0.31*** Problems with Peers Stressors −0.13* −0.26*** −0.31*** −0.33*** −0.30*** −0.27*** Problems with Supervision Stressors −0.14* −0.32*** −0.27*** −0.18** −0.31*** −0.34*** Patient and Family Stressors −0.05 −0.33*** −0.21** −0.04 −0.21** −0.20** Total stress score −0.12 −0.35*** −0.31*** −0.23*** −0.33*** −0.33*** *p < 0.050 **p < 0.010 ***p < 0.001 Work Stress & Job Satisfaction in Clinical Practice Article

The existence of anxiety symptoms among Greek nursing personnel complies with the findings from other researcher’s. In a study concerning the degree of anxiety and related symptoms in emergency nursing personnel in Greece, anxiety levels were found to be high among women and employees in public hospitals [19]. Moreover, the Nursing Stress Scale was used on 120 newly qualified nurses and 128 fourth-year student nurses in Ireland, to measure and compare the perceived levels of job-related stress and stressors. The perceived levels of stress were high in both groups. The topics that were concluded from the responses of both groups included extreem workload, strenuous working relationships and ill- provided clinical learning needs, while student nurses also reported the combination of academic demands with clinical placement [20]. All dimensions of CBI scales scored high, showing that participants tended to give answers to the positive part of the research tool, considering that high quality caring is the right of all patients and a responsibility of all nurses. The above trend highlights nurses’ perceptions about the importance of their acts and it is in agreement with literature review [21, 22]. The frequency of different caring behaviors reflects nurse’s perception about what caring is. The higher grade in caring behaviors was associated to the area of “Professional Knowledge and skills” which was followed by “Assurance of human presence” and “Patient respectfulness”. The Table 4 Multiple regression results with SF-12 scales as dependent variables and stress subscales as independent, adjusted for demographics and other sample characteristics Death and Dying Stressors Physical component summary score Mental component summary score β (SE)a β (SE)a P P 0.64 (0.70) 0.366 −2.45 (1.00) 0.015 Inadequate Emotional Preparation Stressors −0.32 (0.54) 0.560 −2.45 (0.76) 0.002 Discrimination Stressors −1.03 (0.49) 0.036 −0.75 (0.71) 0.294 Workload Stressors −0.86 (0.63) 0.171 −3.09 (0.88) 0.001 Uncertainty Concerning Treatment Stressors −0.33 (0.59) 0.577 −3.07 (0.82)

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