- Email: [email protected]
Stressors of dual-qualification nursing teachers in the ChengDu–ChongQing economic zone of China—A qualitative study
Nurse Education Today 33 (2013) 1496–1500
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Stressors of dual-qualification nursing teachers in the ChengDu–ChongQing economic zone of China—A qualitative study Youfeng Wu a, Hui Liu b, Hongyan He c,⁎ a b c
The First Affiliated Hospital of Chongqing Medical University, ChongQing 400016, China The second affiliated hospital of Shantou University Medical College, Shantou, Guangdong 515041, China The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515041, China
a r t i c l e Article history: Accepted 2 May 2013 Keywords: Stress Nursing teacher Qualitative study
i n f o
s u m m a r y Nursing and teaching are considered risk professions with high levels of stress and burnout. Dualqualification nursing teachers (DQNT) are nurses who both teach and practise. These nurses face additional stress. This study explored the stressors of DQNT in the Chengdu–Chongqing Economic Zone of China. This qualitative study used in-depth, open-ended interviews. The interview responses were analysed using a grounded theory approach. The participants in this study included 21 DQNT from 5 teaching hospitals in the Chengdu–Chongqing Economic Zone of China. The results indicated that heavy workload, personal safety, inadequate pay, role overload, and poor working environment are stressors of DQNT. Furthermore, Chinese DQNT face violence from patients and students. The study provides a theoretical basis to help DQNT to cope with stress. © 2013 Elsevier Ltd. All rights reserved.
Introduction A stressor is defined as “a chemical or biological agent, environmental condition, external stimulus or an event that causes stress to an organism” (Lazarus and Folkman, 1984). When a person encounters stressors, the body's stress response is triggered, and a series of physiological changes occur to allow the person to fight or flee. When people talk about “stress” in their life, they are often talking about stressors. Stressors produce the body's stress response and the experience of stress. When a person consistently works under tremendous stress, this situation may cause a great deal of damage to the body and may result in feelings such as worry, fear and depression (Margolis et al., 1974), leading to tardiness, absenteeism at work and decreased performance (Schafer, 1996). Working under stress also results in professional burnout (Dunham, 1992) and a lack of job satisfaction (Van Dick et al., 2001). Individuals in the caring professions, particularly nurses and teachers, are particularly at risk of experiencing job-related stress (Maslach et al., 2001). Recent studies have explored work stressors among nurses in many countries. Staceyr's (2011) cross-sectional study to explore the stressors of nurses collected data from a convenience sample of 1300 staff nurses from multiple patient care areas of a large teaching hospital in the southeastern United States. The (Their) study found that age, patient workload and days of the week worked were important factors in nurses' stress. A cross-sectional ⁎ Corresponding author. E-mail addresses: [email protected] (Y. Wu), [email protected] (H. Liu), [email protected] (H. He). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.05.003
survey of 5956 staff nurses in 19 acute hospitals in Japan explored the work stressors of nurses and found that poor work environments and nurses' inexperience are associated with stress (Kanai-Pak et al., 2008). A Chinese study in 2008 found that workload was the most frequent stressor among intensive care nurses (Li and Lambert, 2008). Tsai (1993) and her colleagues conducted a study to examine Chinese nurses' work stressors in Taiwan. Their findings showed that stressors for Taiwan nurses in work situations included five categories: patient care, workload, interpersonal relationships, opportunities for promotion and work as educators. According to the Health and Safety Executive of Britain, of all of the professions in the UK, teachers are under the most pressure, followed by nurses. Farber (2000) estimated that approximately 30%–35% of American teachers are strongly dissatisfied with their profession, and 5%–20% are truly burned out. A study in Hong Kong identified guidance work, school management, student behaviour management, workload, time pressures and work relationships as stressors for teachers in Hong Kong (Pearson and Moomaw, 2005). Eres and Atanasoska (2011) investigated the stressors of 416 Turkish teachers and 213 Macedonian teachers and found that personal and social characteristics and working conditions affected teachers' stress. Other studies have found that teachers' stressors include low motivation among students, workload, assessments by others, colleague relationships, conflict of roles, poor working conditions, and inadequate support of colleagues, family and friends (Detert et al., 2006). The literature review suggests that nurses and teachers are under significant stress. The stressors they experience primarily include high workload, low salary, poor working environment, and interpersonal relationships. Because DQNT are both nurses and teachers,
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
they are responsible not only for patients but also for students. Compared with nurses and teachers, DQNT are facing more (additional) stress. Over the last three decades, nursing education has developed rapidly alongside world economic expansion. Many countries have experienced considerable reform within nursing education systems (Spitzer and Perrenoud, 2006). In Britain, for example, the transition into higher education occurred with the introduction of Project 2000, with full integration of nursing colleges into universities occurring in 1996 (Pope et al., 2000). In the United States, there are not enough faculty members to educate the nurses needed to meet the rising care needs of the population (AACN, 2003). In China, the expansion of nursing education has been accelerated by the rapid development of the economy. However, there is an insufficient number of nursing teachers with adequate qualifications (Xu et al., 2000) due to a 30-year abolition of nursing from academia, a policy that was reversed only in 1983, with the establishment of the first five-year baccalaureate programme. To alleviate the shortage of nursing teachers, many experienced Registered Nurses have entered nursing schools to teach, becoming the first “dual-qualification nursing teachers”. In 2005, Chen and Zhang (2005) first defined DQNT as nurses who teach in the classroom and practise in clinical areas. DQNT perform a critical function in helping students to bridge the gap between theory and practice. In many countries, the term DQNT refers to part-time clinical affiliate nursing faculty (PTCANF), who often provide the bulk of clinical instruction for students in baccalaureate nursing programmes (Duffy et al., 2008; Kathleen and Whalen, 2009). They are expected to assist students in developing their professional stance, reflective processes, problem-solving processes, and practical skills (Jerlock et al., 2003). DQNT work closely with course faculty, who are generally full-time faculty who offer clinical oversight to ensure that course outcomes are met in clinical agencies. In our study, DQNT refers only to nurses who both practise in the clinical area and teach in the classroom. The stressors of DQNT, especially PTCANF, have been described for some western countries. Oermann (1998) examined work-related stress experienced by clinical nursing faculty (n = 226) and found that the major stressors experienced by clinical nursing faculty include coping with job expectations, feeling physically and emotionally drained, job demands that interfere with personal activities, heavy workload and teaching inadequately prepared students. Kathleen and Whalen (2009) conducted a descriptive and multivariate correlational study to identify work-related stressors in a sample of part-time clinical affiliate nursing faculty (n = 91) from a western state who teach in baccalaureate programmes. The most important stressors include being physically and emotionally drained, working outside of regular hours, dealing with multiple role expectations, and receiving inadequate monetary compensation. Although DQNT face many stressors, much of the researches in this area are limited to clinical nursing faculty. Few studies have focused on nurses who both teach in the classroom and practise in clinical areas. Better understanding of the stressors experienced by these DQNT may be helpful in relieving their stress, addressing the nursing faculty shortage and improving the quality of patient care. This paper attempts to explore the stressors of DQNT from their perspectives. We hope that the results of this study will help provide a theoretical basis to reduce the stress of DQNT. Methods Design To better understand and explore the stressors experienced by DQNT, this study used a qualitative approach. Data collection and analysis were inspired by the grounded theory approach (Corbin and
1497
Strauss, 2008), which allowed us to identify and describe various patterns in the data. Procedure and Sampling All teaching hospitals in the Chengdu–Chongqing Economic Zone (n = 8) of China were contacted by e-mail through their nursing directors. After two reminders were sent, 7 teaching hospitals gave us permission to conduct our research and agreed to participate in our study. The 7 teaching hospitals completed a questionnaire about hospital characteristics and selected a contact person who served as a liaison between the researchers and the nursing teachers. The contact persons identified nurses who met the following inclusion criteria: (1) DQNT with more than five years of teaching experience and nursing experience; (2) understand and speak Mandarin Chinese; and (3) willing to participate in an interview. The contact persons informed the nurses who met these criteria about the research and gave them written information and a questionnaire. The questionnaire comprised closed-ended questions about the nurses' personal characteristics, such as age, gender, work experience, ward, diploma and the question, “Have you experienced any stressors recently?” We purposefully selected hospitals from the initial sample of 7 hospitals with the aim of sampling a wide variety of hospital characteristics. This sampling resulted in the inclusion of 1 military medical university hospital, 3 general university hospitals, and 1 traditional Chinese medicine university hospital. These 5 teaching hospitals were geographically spread over the Chengdu–Chongqing Economic Zone of China. None of the 5 hospitals had a religious affiliation. We received 186 completed questionnaires from DQNT in these hospitals. Based on the answers of these 186 respondents, we purposefully selected 21 nursing teachers for interviews. Data Collection Signed consent was obtained prior to beginning the interviews, and all participants consented to the digital recorder pen recordings of their interviews. The data collection began on February 11, 2011 and ended on September 7, 2011, when data saturation was considered to be achieved. Seventeen interviews were conducted in the interview room of the university, and the remaining 4 were conducted in the participants' homes. The interviews lasted from 35 min to 1.5 h, with the majority lasting between 45 min and 1 h. No persons except for the interviewer were present during the face-to-face interviews. The participants received 50 yuan for participating in this qualitative study. All interviews were conducted by one researcher. To assist the interviewer, an interview guide with open-ended questions was used. The guide was based on a literature review and was reviewed by four experts to determine its face validity. During the interview, the interviewer repeated and summarised the statements of the informants and asked them whether these statements were correct. Data Analysis The analyses of the interviews followed the first steps in the analytical process described for a modified model of grounded theory (Corbin and Strauss, 2008). Text passages related to stressors were identified and coded on the basis of content (open coding). The content of the interviews was constantly compared during the data collection period to identify relations between the themes. Related themes were combined and assigned a category (categorising). The analysis began immediately after the first interview. We read all interviews repeatedly to gain a global overview of their content and to become familiar with the data. Transcriptions of the interviews were analysed via thematic content analysis (Burnard, 1991), which involved organisation of the data into categories and sub-categories during a search for emerging themes. The aim of this process was to
1498
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
account for most of the data in this category system. The category system was checked and validated by an independent adjudicator. The interviews and analyses continued until saturation was reached and no new information was identified. Ethical Considerations The Ethics Committee of Chongqing Municipal Health Bureau approved the detailed research protocol for this study. All participants received verbal and written information about the research. Participation was voluntary, and the informed consent procedure was respected.
offended by patients”.“Some of the patients, like devils, want to eat me”. “I am a paediatric nurse. Nowadays, each family has only one child. Parents are over-protective of their children. Some parents will beat us when we hurt their children unintentionally in the transfusion process”. “Students are difficult to supervise! One of my students got a score of 55 on the exam and needed a supplementary examination. He called me to threaten me. He said that if I did not let him pass the exam, he would get back at me”. “I was being trapped in the office by a student who was angry that I had confiscated his MP4, which he played in the classroom”.
Rigour Role Overload In this study, rigour was considered in relation to trustworthiness, auditability, and transferability (Guba and Lincoln, 1994). All members of the research team were involved in the data analysis to establish trustworthiness. Preliminary findings were returned to the participants for clarification and confirmation, contributing to the study's trustworthiness. Memos connecting codes to pieces of verbatim information supported the emergent categories. Findings All of the 21 interviewees believed that work as a DQNT is stressful. Heavy workload, personal safety, inadequate monetary compensation, role overload and poor working environment were the stressors they faced. Heavy Workload All of the interviewees stated that work overload was their main source of stress. They experienced higher workloads than ever before due to four main reasons: (1) inadequate supply of nurses, (2) reduced staffing and increased overtime, (3) reduction in patients' length of stay, and (4) significant amounts of time required to prepare for teaching. “Increasing cost pressures forced our hospital to reduce the patients' length of stay. As a result, we take care of patients who are sicker than in the past. Our work is more intensive than before”. “ High quality care policies formulated by China's Ministry of Health force us to perform a lot of nonprofessional tasks, such as delivering and retrieving food trays, housekeeping duties, transporting patients, and ordering, coordinating, or performing ancillary services”. “In our hospital, the nurse-patient ratio is only 0.33:1, which does not meet the required ratio of 4:1. All of us are undergoing overloaded work”. “I eagerly look forward to increasing the number of nurses in my unit”. “In my unit, nurses are in very short supply, so we have only one day to rest every week. However, the head nurse always ask me to teach on my rest day. I had no time to rest”. “I take care of patients in the daytime and teach in the evening. When I get home, it is close to 22:00. I feel exhausted every day.”
Personal Safety Personal safety is a topic of concern. During the interview process, 16 interviewees mentioned personal safety. The interviewees seemed very upset about this topic. Some interviewees worried about being attacked by patients and their family members, whereas others worried about being intimidated by the students they taught. “One of my nurse friends was tracked by a family member of one patient during her pregnancy, and it led to a miscarriage. Now, I am very afraid of going to work by myself. I am worried about being
Role overload refers to a lack of balance or reasonableness in the number or extent of expectations for a job or the number of different roles that an individual must fulfil. Role overload may lead to excessive demands on an individual's time and may create uncertainty about the individual's ability to adequately perform these roles (Driscoll and Cooper, 2002). Because the majority of DQNT are women, the potential for role overload is increased because it is often difficult to combine career aspirations and family commitments. They are responsible for multiple types of roles: they are nurses, teachers, mothers, wives, daughters and daughters-in law. These diverse responsibilities place them at particular risk of developing role strain. “Life is fine. I am getting frequent mild headaches, and I think it's because I have too much to do every day with no breaks. There is clinical work, teaching work, kids, husband, school activities…”. “My husband died in a car accident two years ago. My daughter is only four years old, and I need to pick up my daughter from kindergarten every day. If I have a teaching task, my daughter has to wait for me at kindergarten by herself”. “Chinese people believe in the Confucian culture, and this culture holds the value of filial piety. My mother-in-law wants me to do some housework, like preparing meals, washing, and cleaning the house. In my mother-in-law's eyes, this is something a daughter-in-law must do”. “In addition to the task of teaching, I also have to participate in a lot of annoying meetings, which occupy a lot of my time”. “I am the only child of my parents, and now they are getting older. I must take care of my aging parents”.
Inadequate Monetary Compensation A salary is not just remuneration for labour; salary level also reflects the value of the work. Janine (2005) notes that the major contributing factors to teacher stress arise from a lack of rewards and recognition. Olivier and Venter (2003) found that salaries cause a great deal of stress for teachers. During the interviews, some interviewees felt that they had to “eat grass but squeeze out milk”, the famous Chinese proverb that implies a heavy workload but low income. “We are like cheap labour. We only get 25 yuan ($4) for 45 minutes of classroom teaching”. “In our college, we get 30 yuan each lesson in the baccalaureate nursing programme, which is lower than any other programmes”.“Working in a hospital, the average daily wage is 200 yuan, but we only get 30 yuan for classroom teaching. It is too low to reflect our value”. “Salaries in the educational setting are significantly lower than those in the clinical setting, so I would like to be a nurse, and I don't want to be a teacher”.
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
Poor Working Environment A working environment is the place where one works. Poor working environments, including large class sizes, a lack of facilities, classrooms or nursing stations without air conditioning systems and noisy environments are stressful for DQNT. “Many students chat in class, paying no respect to me”. “Classroom space is too large, and the students sitting in the back cannot see the blackboard and cannot hear me”. “Chongqing is one of China's four big stove cities. It is very hot in the summer, but some of the classrooms have not installed air conditioning. I always wiped the sweat when I was teaching”. “In some classrooms without multimedia equipment, I had to write with chalk, which wasted a lot of time”.
Discussion This paper reports on a qualitative, descriptive study using a modified grounded theory approach to examine the research stressors of DQNT. Based on the analysis of the qualitative data, we identified five themes for the stressors of DQNT: heavy workload, personal safety, role overload, inadequate monetary compensation, and poor working environment. According to Hans Seyle, a certain level of stress is needed for optimal performance, but when the stress exceeds people's ability to meet the demands placed on them, they may experience feelings of burnout. Excessive work often results in the need to work extended hours, which is often associated with increased feelings of stress. During the interviews, all DQNT said that they were experiencing heavy workloads for two reasons: clinical work and teaching work. The demand for nurses is increasing, but the supply of nurses is not adequate to meet the current demand. This shortage is projected to become increasingly severe as demand increases and nursing schools are unable to keep up with the increasing educational demand (Kuehn, 2007). When a nursing shortage occurs, the workload increases for those who remain on the job (Baumann et al., 2001). Research shows that a heavy nursing workload not only produces physiological and psychological damage to nurses but also adversely affects patient safety and may lead to reduced patient satisfaction (Lang et al., 2004). Furthermore, a heavy workload negatively affects nursing job satisfaction and contributes to high turnover and nursing shortages. Numerous attacks on medical staff on the Chinese mainland have made headlines in recent years. In 2011 alone, China witnessed ten serious attacks on doctors and nurses that killed five medical staff members. Nurses' life safety cannot be guaranteed, which is also an important stressor. Because of the Chinese “one child per family” policy, couples often only have one child. Many parents dote on their children, and the children develop a defiant, imperious character. They often do not listen to teachers during class time, and if the teacher interferes with them, some of them will abuse and even beat the teacher. In our study, most of the DQNT are afraid of suffering violence from patients and students. Teachers who are under stress from violence cannot provide vigilant monitoring, empathetic patient care and good teaching. In the United States, major difficulties related to nurses' personal safety include musculoskeletal injuries and disorders because many nursing tasks require heavy lifting, bending and twisting. Violence often occurs in emergency departments, and violence prevention programmes have been established to protect medical staff. In China, violence is the greatest threat to nurses' personal safety, and the inability to guarantee personal safety is an important stressor. Measures should be taken to protect nurses' safety. There are significant benefits related to the improvements in nurses' safety, both for retaining nurses and for attracting new nurses into the profession. In the long run, these improvements will also benefit patients
1499
because measures to improve nurses' safety lead to a healthier and more effective workforce. Teaching, nursing practice, household upkeep, caring for ageing parents and children and other activities place DQNT in multiple and often time-consuming roles. This situation may leave little or no time for adequate rest for the mind, body, and spirit, and it may lead to physical ailments, such as chronic headaches, fatigue, malaise, depression, and poor productivity (Murray et al., 2001). When role obligations conflict and are difficult to meet, role stress may result (Hardy and Conway, 1988). DQNT should monitor their time and attempt to balance the multiple demands of their roles. They should develop support networks that include colleagues, family, friends, neighbours, child care providers, and professionals who can be accessed when role demands become unusually high. Competitive salaries are a fundamental aspect of the recognition of contributions and accomplishments. A major challenge in the recruitment and retention of teachers is that salaries in educational settings are often lower, sometimes significantly lower, than salaries in clinical settings (Kaufman, 2007). This discrepancy may make it difficult to recruit and retain faculty members. In our study, many nurses were not willing to teach in the classroom due to lower salaries. Kaufman (2007) reported that salary was the factor “with which nurse faculty were least satisfied at their current jobs”. To address these salary concerns, nursing education administrators are encouraged to work to improve faculty salaries by collecting salary data from regional and state peer institutions and from clinical settings. Administrators can then use this data as a basis for adjusting entry-level salaries and for requesting salary adjustments for current faculty members. Disch (2002) defined a healthy work environment as “a work setting in which policies, procedures and systems are designed so that employees are able to meet organisational objectives and achieve personal satisfaction in their work”. A positive work environment is important not only for physical, mental and emotional health but also for the results that it produces. The American Association of Critical-Care Nurses has noted that ‘unhealthy’ work environments in the clinical setting contribute to “medical errors, ineffective delivery of care, and conflict and stress among health professionals”; a ‘healthy’ work environment is necessary to “ensure patient safety, enhance staff recruitment and retention, and maintain an organisation's financial viability”. In our study, some DQNT believed that poor working environments produce stress. Hence, it is important for administrators to pay attention to the negative effects of unhealthy environments on DQNT and to establish measures to create a positive working environment, which may benefit both patients and DQNT. Limitations and Future Research 1) Teaching environments may differ in different places. The results of our study represent only one region (southwest) of China. 2) Although our study explored the stressors of DQNT, we did not explore strategies to help them relieve stress. Therefore, future research is needed. Conclusion Nursing and teaching are considered risk professions with high levels of stress and burnout. DQNT are nurses who both teach and practise in clinical areas, and these individuals face significant stress. Our study used in-depth, open-ended interviews to explore the stressors of DQNT in the Chengdu–Chongqing Economic Zone of China. The results indicated that heavy workload, personal safety, inadequate monetary compensation, role overload, and poor working environments are the main stressors of DQNT. Chinese DQNT experience more violence from patients and students than DQNT in other countries. Our study results provide a theoretical basis for helping DQNT cope with stress, which may benefit patients, students and DQNT.
1500
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
Funding Statement This study was supported by grants from Chongqing Municipal Health Bureau (NO2009-12-18). Ethical Approval Ethical approval was obtained from the Ethics Committee of Chongqing Municipal Health Bureau. Acknowledgements The authors wish to thank all the Dual-Qualification Nursing Teachers who willingly shared their stories. References American Association of Colleges of Nursing, 2003. Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the Supply. AACN, Washington, DC. Baumann, A., Giovannetti, P., O'Brien-Pallas, L., 2001. Healthcare restructuring: the impact of job change. Canadian Journal of Nursing Leadership 14, 14–20. Burnard, P., 1991. A method of analysing interview transcripts in qualitative research. Nurse Education Today 11 (6), 461–466. Chen, Lihong, Zhang, Haiyan, 2005. To explore the advantages of dual-qualification teachers in nursing higher vocational education. China Nursing Management 5 (1), 60–61. Corbin, J., Strauss, A., 2008. Basics of Qualitative Research. Techniques and Procedures for Developing Grounded Theory, 3rd ed. Sage Publications, Thousand Oaks, CA. Detert, Derosia, Caravella, Duquette, 2006. Reducing stress and enhancing the general well-being of teachers using Tai Chi Chih movements: a pilot study. Californian Journal of Health Promotion 4 (1), 162–173. Disch, L.J., 2002. The Tyranny of the Two-party System. Columbia University Press, New York. Driscoll, M.P., Cooper, C.L., 2002. Job-related stress and burnout. In: Warr, P. (Ed.), Psychology at Work. Penguin Group, London, England, pp. 203–228. Duffy, N., Stuart, G., Smith, S., 2008. Assuring the success of part-time faculty. Nurse Educator 33 (2), 53–54. Dunham, J., 1992. Stress in Teaching. Routledge Publishing, New York. Eres, Figen, Atanasoska, Tatjana, 2011. Occupational stress of teachers: a comparative study between Turkey and Macedonia. International Journal of Humanities and Social Science 1 (7), 59–65. Farber, B.A., 2000. Introduction: understanding and treating burnout in a changing culture. Journal of Clinical Psychology 56 (5), 589–594. Guba, E.G., Lincoln, Y.S., 1994. Competing paradigms in qualitative research. In: Denzin, N.K., Lincoln, Y.S. (Eds.), Handbook of Qualitative Research. Sage, Thousand Oaks, CA, pp. 105–107. Hardy, M.E., Conway, M.E., 1988. Role Theory: Perspectives for Health Professionals, 2nd ed. Appleton-Century-Crofts, Norwalk, CT.
Janine, 2005. Sources of Occupational Stress for Teachers, With Specific Reference to the Inclusive Education Model in the Western Cape. University of the Western Cape. Jerlock, M., Falk, K., Severinsson, E., 2003. Academic nursing education guidelines: tool for bridging the gap between theory, research and practice. Nursing and Health Sciences 5, 219–228. Kanai-Pak, Masako, Aiken, Linda H., Sloane, Douglas M., Poghosyan, Lusine, 2008. Poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in Japanese hospitals. Journal of Clinical Nursing 17 (24), 3324–3329. Kathleen, S., Whalen, 2009. Work-related stressors experienced by part-time clinical affiliate nursing faculty in baccalaureate education. International Journal of Nursing Education Scholarship 6 (1), 1–18. Kaufman, 2007. Beyond big and little: the four C model of creativity. Review of General Psychology 13 (1), 1–12. Kuehn, B.M., 2007. No end in sight to nursing shortage: bottleneck at nursing schools a key factor. JAMA: The Journal of the American Medical Association 10 (298), 1623–1625. Lang, T.A., Hodge, M., Olson, V., 2004. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration 34 (7–8), 326–327. Lazarus, R., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer, New York. Li, J., Lambert, V.A., 2008. Job satisfaction among intensive care nurses from People's Republic of China. International Nursing Review 55 (1), 34–39. Margolis, B., Kroes, W.H., Quinn, R.P., 1974. Job stress: an unlisted occupational hazard. Journal of Occupational Medicine 16, 659–661. Maslach, C., Schaufeli, W.B., Leiter, M.P., 2001. Job burnout. Annual Review of Psychology 52, 397–422. Murray, S.l, Holmes, J.G., Griffin, D.W., Bellavia, G., Rose, p, 2001. The mis-measure of love: how self-doubt contaminates relationship beliefs. Personality and Social Psychology Bulletin 27, 423–436. Oermann, M.H., 1998. Work-related stress of clinical nursing faculty. Journal of Nursing Education 37 (7), 302–304. Olivier, M.A.J., Venter, D.J.L., 2003. The extent and causes of stress in teachers in the George region. South African Journal of Education 23 (3), 186–192. Pearson, L.C., Moomaw, W., 2005. The relationship between teacher autonomy and stress, work satisfaction, empowerment and professionalism. Educational Research Quarterly 29, 37–53. Pope, R., Garrett, Graham, L., 2000. Quality assurance for nursing and midwifery education. Nurse Education Today 20, 341–349. Schafer, W., 1996. Stress Management for Wellness. Harcourt Brace College Publishers, Fort Worth. Spitzer, A., Perrenoud, S., 2006. Reforms in nursing education across Western Europe: from agenda to practice. Journal of Professional Nursing 22, 150–161. Stacey, R.P., 2011. The relationship between nurses' stress and nurse staffing factors in a hospital setting. Journal of Nursing Management 19 (6), 714–720. Tsai, Sing-ling, 1993. Chinese nurse stress in Taiwan, Republic of China. Issues in Mental Health Nursing 14 (3), 275–285. Van Dick, R., Phillips, U., Marburg, M., Wagner, U., 2001. Stress and strain in teaching: a structural equation approach. British Journal of Educational Psychology 71 (2), 243–259. Xu, Y., Xu, Z., Zhang, J., 2000. The nursing education system in the People's Republic of China: evolution, structure and reform. International Nursing Review 47, 207–217.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Stressors of dual-qualification nursing teachers in the ChengDu–ChongQing economic zone of China—A qualitative study Youfeng Wu a, Hui Liu b, Hongyan He c,⁎ a b c
The First Affiliated Hospital of Chongqing Medical University, ChongQing 400016, China The second affiliated hospital of Shantou University Medical College, Shantou, Guangdong 515041, China The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515041, China
a r t i c l e Article history: Accepted 2 May 2013 Keywords: Stress Nursing teacher Qualitative study
i n f o
s u m m a r y Nursing and teaching are considered risk professions with high levels of stress and burnout. Dualqualification nursing teachers (DQNT) are nurses who both teach and practise. These nurses face additional stress. This study explored the stressors of DQNT in the Chengdu–Chongqing Economic Zone of China. This qualitative study used in-depth, open-ended interviews. The interview responses were analysed using a grounded theory approach. The participants in this study included 21 DQNT from 5 teaching hospitals in the Chengdu–Chongqing Economic Zone of China. The results indicated that heavy workload, personal safety, inadequate pay, role overload, and poor working environment are stressors of DQNT. Furthermore, Chinese DQNT face violence from patients and students. The study provides a theoretical basis to help DQNT to cope with stress. © 2013 Elsevier Ltd. All rights reserved.
Introduction A stressor is defined as “a chemical or biological agent, environmental condition, external stimulus or an event that causes stress to an organism” (Lazarus and Folkman, 1984). When a person encounters stressors, the body's stress response is triggered, and a series of physiological changes occur to allow the person to fight or flee. When people talk about “stress” in their life, they are often talking about stressors. Stressors produce the body's stress response and the experience of stress. When a person consistently works under tremendous stress, this situation may cause a great deal of damage to the body and may result in feelings such as worry, fear and depression (Margolis et al., 1974), leading to tardiness, absenteeism at work and decreased performance (Schafer, 1996). Working under stress also results in professional burnout (Dunham, 1992) and a lack of job satisfaction (Van Dick et al., 2001). Individuals in the caring professions, particularly nurses and teachers, are particularly at risk of experiencing job-related stress (Maslach et al., 2001). Recent studies have explored work stressors among nurses in many countries. Staceyr's (2011) cross-sectional study to explore the stressors of nurses collected data from a convenience sample of 1300 staff nurses from multiple patient care areas of a large teaching hospital in the southeastern United States. The (Their) study found that age, patient workload and days of the week worked were important factors in nurses' stress. A cross-sectional ⁎ Corresponding author. E-mail addresses: [email protected] (Y. Wu), [email protected] (H. Liu), [email protected] (H. He). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.05.003
survey of 5956 staff nurses in 19 acute hospitals in Japan explored the work stressors of nurses and found that poor work environments and nurses' inexperience are associated with stress (Kanai-Pak et al., 2008). A Chinese study in 2008 found that workload was the most frequent stressor among intensive care nurses (Li and Lambert, 2008). Tsai (1993) and her colleagues conducted a study to examine Chinese nurses' work stressors in Taiwan. Their findings showed that stressors for Taiwan nurses in work situations included five categories: patient care, workload, interpersonal relationships, opportunities for promotion and work as educators. According to the Health and Safety Executive of Britain, of all of the professions in the UK, teachers are under the most pressure, followed by nurses. Farber (2000) estimated that approximately 30%–35% of American teachers are strongly dissatisfied with their profession, and 5%–20% are truly burned out. A study in Hong Kong identified guidance work, school management, student behaviour management, workload, time pressures and work relationships as stressors for teachers in Hong Kong (Pearson and Moomaw, 2005). Eres and Atanasoska (2011) investigated the stressors of 416 Turkish teachers and 213 Macedonian teachers and found that personal and social characteristics and working conditions affected teachers' stress. Other studies have found that teachers' stressors include low motivation among students, workload, assessments by others, colleague relationships, conflict of roles, poor working conditions, and inadequate support of colleagues, family and friends (Detert et al., 2006). The literature review suggests that nurses and teachers are under significant stress. The stressors they experience primarily include high workload, low salary, poor working environment, and interpersonal relationships. Because DQNT are both nurses and teachers,
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
they are responsible not only for patients but also for students. Compared with nurses and teachers, DQNT are facing more (additional) stress. Over the last three decades, nursing education has developed rapidly alongside world economic expansion. Many countries have experienced considerable reform within nursing education systems (Spitzer and Perrenoud, 2006). In Britain, for example, the transition into higher education occurred with the introduction of Project 2000, with full integration of nursing colleges into universities occurring in 1996 (Pope et al., 2000). In the United States, there are not enough faculty members to educate the nurses needed to meet the rising care needs of the population (AACN, 2003). In China, the expansion of nursing education has been accelerated by the rapid development of the economy. However, there is an insufficient number of nursing teachers with adequate qualifications (Xu et al., 2000) due to a 30-year abolition of nursing from academia, a policy that was reversed only in 1983, with the establishment of the first five-year baccalaureate programme. To alleviate the shortage of nursing teachers, many experienced Registered Nurses have entered nursing schools to teach, becoming the first “dual-qualification nursing teachers”. In 2005, Chen and Zhang (2005) first defined DQNT as nurses who teach in the classroom and practise in clinical areas. DQNT perform a critical function in helping students to bridge the gap between theory and practice. In many countries, the term DQNT refers to part-time clinical affiliate nursing faculty (PTCANF), who often provide the bulk of clinical instruction for students in baccalaureate nursing programmes (Duffy et al., 2008; Kathleen and Whalen, 2009). They are expected to assist students in developing their professional stance, reflective processes, problem-solving processes, and practical skills (Jerlock et al., 2003). DQNT work closely with course faculty, who are generally full-time faculty who offer clinical oversight to ensure that course outcomes are met in clinical agencies. In our study, DQNT refers only to nurses who both practise in the clinical area and teach in the classroom. The stressors of DQNT, especially PTCANF, have been described for some western countries. Oermann (1998) examined work-related stress experienced by clinical nursing faculty (n = 226) and found that the major stressors experienced by clinical nursing faculty include coping with job expectations, feeling physically and emotionally drained, job demands that interfere with personal activities, heavy workload and teaching inadequately prepared students. Kathleen and Whalen (2009) conducted a descriptive and multivariate correlational study to identify work-related stressors in a sample of part-time clinical affiliate nursing faculty (n = 91) from a western state who teach in baccalaureate programmes. The most important stressors include being physically and emotionally drained, working outside of regular hours, dealing with multiple role expectations, and receiving inadequate monetary compensation. Although DQNT face many stressors, much of the researches in this area are limited to clinical nursing faculty. Few studies have focused on nurses who both teach in the classroom and practise in clinical areas. Better understanding of the stressors experienced by these DQNT may be helpful in relieving their stress, addressing the nursing faculty shortage and improving the quality of patient care. This paper attempts to explore the stressors of DQNT from their perspectives. We hope that the results of this study will help provide a theoretical basis to reduce the stress of DQNT. Methods Design To better understand and explore the stressors experienced by DQNT, this study used a qualitative approach. Data collection and analysis were inspired by the grounded theory approach (Corbin and
1497
Strauss, 2008), which allowed us to identify and describe various patterns in the data. Procedure and Sampling All teaching hospitals in the Chengdu–Chongqing Economic Zone (n = 8) of China were contacted by e-mail through their nursing directors. After two reminders were sent, 7 teaching hospitals gave us permission to conduct our research and agreed to participate in our study. The 7 teaching hospitals completed a questionnaire about hospital characteristics and selected a contact person who served as a liaison between the researchers and the nursing teachers. The contact persons identified nurses who met the following inclusion criteria: (1) DQNT with more than five years of teaching experience and nursing experience; (2) understand and speak Mandarin Chinese; and (3) willing to participate in an interview. The contact persons informed the nurses who met these criteria about the research and gave them written information and a questionnaire. The questionnaire comprised closed-ended questions about the nurses' personal characteristics, such as age, gender, work experience, ward, diploma and the question, “Have you experienced any stressors recently?” We purposefully selected hospitals from the initial sample of 7 hospitals with the aim of sampling a wide variety of hospital characteristics. This sampling resulted in the inclusion of 1 military medical university hospital, 3 general university hospitals, and 1 traditional Chinese medicine university hospital. These 5 teaching hospitals were geographically spread over the Chengdu–Chongqing Economic Zone of China. None of the 5 hospitals had a religious affiliation. We received 186 completed questionnaires from DQNT in these hospitals. Based on the answers of these 186 respondents, we purposefully selected 21 nursing teachers for interviews. Data Collection Signed consent was obtained prior to beginning the interviews, and all participants consented to the digital recorder pen recordings of their interviews. The data collection began on February 11, 2011 and ended on September 7, 2011, when data saturation was considered to be achieved. Seventeen interviews were conducted in the interview room of the university, and the remaining 4 were conducted in the participants' homes. The interviews lasted from 35 min to 1.5 h, with the majority lasting between 45 min and 1 h. No persons except for the interviewer were present during the face-to-face interviews. The participants received 50 yuan for participating in this qualitative study. All interviews were conducted by one researcher. To assist the interviewer, an interview guide with open-ended questions was used. The guide was based on a literature review and was reviewed by four experts to determine its face validity. During the interview, the interviewer repeated and summarised the statements of the informants and asked them whether these statements were correct. Data Analysis The analyses of the interviews followed the first steps in the analytical process described for a modified model of grounded theory (Corbin and Strauss, 2008). Text passages related to stressors were identified and coded on the basis of content (open coding). The content of the interviews was constantly compared during the data collection period to identify relations between the themes. Related themes were combined and assigned a category (categorising). The analysis began immediately after the first interview. We read all interviews repeatedly to gain a global overview of their content and to become familiar with the data. Transcriptions of the interviews were analysed via thematic content analysis (Burnard, 1991), which involved organisation of the data into categories and sub-categories during a search for emerging themes. The aim of this process was to
1498
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
account for most of the data in this category system. The category system was checked and validated by an independent adjudicator. The interviews and analyses continued until saturation was reached and no new information was identified. Ethical Considerations The Ethics Committee of Chongqing Municipal Health Bureau approved the detailed research protocol for this study. All participants received verbal and written information about the research. Participation was voluntary, and the informed consent procedure was respected.
offended by patients”.“Some of the patients, like devils, want to eat me”. “I am a paediatric nurse. Nowadays, each family has only one child. Parents are over-protective of their children. Some parents will beat us when we hurt their children unintentionally in the transfusion process”. “Students are difficult to supervise! One of my students got a score of 55 on the exam and needed a supplementary examination. He called me to threaten me. He said that if I did not let him pass the exam, he would get back at me”. “I was being trapped in the office by a student who was angry that I had confiscated his MP4, which he played in the classroom”.
Rigour Role Overload In this study, rigour was considered in relation to trustworthiness, auditability, and transferability (Guba and Lincoln, 1994). All members of the research team were involved in the data analysis to establish trustworthiness. Preliminary findings were returned to the participants for clarification and confirmation, contributing to the study's trustworthiness. Memos connecting codes to pieces of verbatim information supported the emergent categories. Findings All of the 21 interviewees believed that work as a DQNT is stressful. Heavy workload, personal safety, inadequate monetary compensation, role overload and poor working environment were the stressors they faced. Heavy Workload All of the interviewees stated that work overload was their main source of stress. They experienced higher workloads than ever before due to four main reasons: (1) inadequate supply of nurses, (2) reduced staffing and increased overtime, (3) reduction in patients' length of stay, and (4) significant amounts of time required to prepare for teaching. “Increasing cost pressures forced our hospital to reduce the patients' length of stay. As a result, we take care of patients who are sicker than in the past. Our work is more intensive than before”. “ High quality care policies formulated by China's Ministry of Health force us to perform a lot of nonprofessional tasks, such as delivering and retrieving food trays, housekeeping duties, transporting patients, and ordering, coordinating, or performing ancillary services”. “In our hospital, the nurse-patient ratio is only 0.33:1, which does not meet the required ratio of 4:1. All of us are undergoing overloaded work”. “I eagerly look forward to increasing the number of nurses in my unit”. “In my unit, nurses are in very short supply, so we have only one day to rest every week. However, the head nurse always ask me to teach on my rest day. I had no time to rest”. “I take care of patients in the daytime and teach in the evening. When I get home, it is close to 22:00. I feel exhausted every day.”
Personal Safety Personal safety is a topic of concern. During the interview process, 16 interviewees mentioned personal safety. The interviewees seemed very upset about this topic. Some interviewees worried about being attacked by patients and their family members, whereas others worried about being intimidated by the students they taught. “One of my nurse friends was tracked by a family member of one patient during her pregnancy, and it led to a miscarriage. Now, I am very afraid of going to work by myself. I am worried about being
Role overload refers to a lack of balance or reasonableness in the number or extent of expectations for a job or the number of different roles that an individual must fulfil. Role overload may lead to excessive demands on an individual's time and may create uncertainty about the individual's ability to adequately perform these roles (Driscoll and Cooper, 2002). Because the majority of DQNT are women, the potential for role overload is increased because it is often difficult to combine career aspirations and family commitments. They are responsible for multiple types of roles: they are nurses, teachers, mothers, wives, daughters and daughters-in law. These diverse responsibilities place them at particular risk of developing role strain. “Life is fine. I am getting frequent mild headaches, and I think it's because I have too much to do every day with no breaks. There is clinical work, teaching work, kids, husband, school activities…”. “My husband died in a car accident two years ago. My daughter is only four years old, and I need to pick up my daughter from kindergarten every day. If I have a teaching task, my daughter has to wait for me at kindergarten by herself”. “Chinese people believe in the Confucian culture, and this culture holds the value of filial piety. My mother-in-law wants me to do some housework, like preparing meals, washing, and cleaning the house. In my mother-in-law's eyes, this is something a daughter-in-law must do”. “In addition to the task of teaching, I also have to participate in a lot of annoying meetings, which occupy a lot of my time”. “I am the only child of my parents, and now they are getting older. I must take care of my aging parents”.
Inadequate Monetary Compensation A salary is not just remuneration for labour; salary level also reflects the value of the work. Janine (2005) notes that the major contributing factors to teacher stress arise from a lack of rewards and recognition. Olivier and Venter (2003) found that salaries cause a great deal of stress for teachers. During the interviews, some interviewees felt that they had to “eat grass but squeeze out milk”, the famous Chinese proverb that implies a heavy workload but low income. “We are like cheap labour. We only get 25 yuan ($4) for 45 minutes of classroom teaching”. “In our college, we get 30 yuan each lesson in the baccalaureate nursing programme, which is lower than any other programmes”.“Working in a hospital, the average daily wage is 200 yuan, but we only get 30 yuan for classroom teaching. It is too low to reflect our value”. “Salaries in the educational setting are significantly lower than those in the clinical setting, so I would like to be a nurse, and I don't want to be a teacher”.
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
Poor Working Environment A working environment is the place where one works. Poor working environments, including large class sizes, a lack of facilities, classrooms or nursing stations without air conditioning systems and noisy environments are stressful for DQNT. “Many students chat in class, paying no respect to me”. “Classroom space is too large, and the students sitting in the back cannot see the blackboard and cannot hear me”. “Chongqing is one of China's four big stove cities. It is very hot in the summer, but some of the classrooms have not installed air conditioning. I always wiped the sweat when I was teaching”. “In some classrooms without multimedia equipment, I had to write with chalk, which wasted a lot of time”.
Discussion This paper reports on a qualitative, descriptive study using a modified grounded theory approach to examine the research stressors of DQNT. Based on the analysis of the qualitative data, we identified five themes for the stressors of DQNT: heavy workload, personal safety, role overload, inadequate monetary compensation, and poor working environment. According to Hans Seyle, a certain level of stress is needed for optimal performance, but when the stress exceeds people's ability to meet the demands placed on them, they may experience feelings of burnout. Excessive work often results in the need to work extended hours, which is often associated with increased feelings of stress. During the interviews, all DQNT said that they were experiencing heavy workloads for two reasons: clinical work and teaching work. The demand for nurses is increasing, but the supply of nurses is not adequate to meet the current demand. This shortage is projected to become increasingly severe as demand increases and nursing schools are unable to keep up with the increasing educational demand (Kuehn, 2007). When a nursing shortage occurs, the workload increases for those who remain on the job (Baumann et al., 2001). Research shows that a heavy nursing workload not only produces physiological and psychological damage to nurses but also adversely affects patient safety and may lead to reduced patient satisfaction (Lang et al., 2004). Furthermore, a heavy workload negatively affects nursing job satisfaction and contributes to high turnover and nursing shortages. Numerous attacks on medical staff on the Chinese mainland have made headlines in recent years. In 2011 alone, China witnessed ten serious attacks on doctors and nurses that killed five medical staff members. Nurses' life safety cannot be guaranteed, which is also an important stressor. Because of the Chinese “one child per family” policy, couples often only have one child. Many parents dote on their children, and the children develop a defiant, imperious character. They often do not listen to teachers during class time, and if the teacher interferes with them, some of them will abuse and even beat the teacher. In our study, most of the DQNT are afraid of suffering violence from patients and students. Teachers who are under stress from violence cannot provide vigilant monitoring, empathetic patient care and good teaching. In the United States, major difficulties related to nurses' personal safety include musculoskeletal injuries and disorders because many nursing tasks require heavy lifting, bending and twisting. Violence often occurs in emergency departments, and violence prevention programmes have been established to protect medical staff. In China, violence is the greatest threat to nurses' personal safety, and the inability to guarantee personal safety is an important stressor. Measures should be taken to protect nurses' safety. There are significant benefits related to the improvements in nurses' safety, both for retaining nurses and for attracting new nurses into the profession. In the long run, these improvements will also benefit patients
1499
because measures to improve nurses' safety lead to a healthier and more effective workforce. Teaching, nursing practice, household upkeep, caring for ageing parents and children and other activities place DQNT in multiple and often time-consuming roles. This situation may leave little or no time for adequate rest for the mind, body, and spirit, and it may lead to physical ailments, such as chronic headaches, fatigue, malaise, depression, and poor productivity (Murray et al., 2001). When role obligations conflict and are difficult to meet, role stress may result (Hardy and Conway, 1988). DQNT should monitor their time and attempt to balance the multiple demands of their roles. They should develop support networks that include colleagues, family, friends, neighbours, child care providers, and professionals who can be accessed when role demands become unusually high. Competitive salaries are a fundamental aspect of the recognition of contributions and accomplishments. A major challenge in the recruitment and retention of teachers is that salaries in educational settings are often lower, sometimes significantly lower, than salaries in clinical settings (Kaufman, 2007). This discrepancy may make it difficult to recruit and retain faculty members. In our study, many nurses were not willing to teach in the classroom due to lower salaries. Kaufman (2007) reported that salary was the factor “with which nurse faculty were least satisfied at their current jobs”. To address these salary concerns, nursing education administrators are encouraged to work to improve faculty salaries by collecting salary data from regional and state peer institutions and from clinical settings. Administrators can then use this data as a basis for adjusting entry-level salaries and for requesting salary adjustments for current faculty members. Disch (2002) defined a healthy work environment as “a work setting in which policies, procedures and systems are designed so that employees are able to meet organisational objectives and achieve personal satisfaction in their work”. A positive work environment is important not only for physical, mental and emotional health but also for the results that it produces. The American Association of Critical-Care Nurses has noted that ‘unhealthy’ work environments in the clinical setting contribute to “medical errors, ineffective delivery of care, and conflict and stress among health professionals”; a ‘healthy’ work environment is necessary to “ensure patient safety, enhance staff recruitment and retention, and maintain an organisation's financial viability”. In our study, some DQNT believed that poor working environments produce stress. Hence, it is important for administrators to pay attention to the negative effects of unhealthy environments on DQNT and to establish measures to create a positive working environment, which may benefit both patients and DQNT. Limitations and Future Research 1) Teaching environments may differ in different places. The results of our study represent only one region (southwest) of China. 2) Although our study explored the stressors of DQNT, we did not explore strategies to help them relieve stress. Therefore, future research is needed. Conclusion Nursing and teaching are considered risk professions with high levels of stress and burnout. DQNT are nurses who both teach and practise in clinical areas, and these individuals face significant stress. Our study used in-depth, open-ended interviews to explore the stressors of DQNT in the Chengdu–Chongqing Economic Zone of China. The results indicated that heavy workload, personal safety, inadequate monetary compensation, role overload, and poor working environments are the main stressors of DQNT. Chinese DQNT experience more violence from patients and students than DQNT in other countries. Our study results provide a theoretical basis for helping DQNT cope with stress, which may benefit patients, students and DQNT.
1500
Y. Wu et al. / Nurse Education Today 33 (2013) 1496–1500
Funding Statement This study was supported by grants from Chongqing Municipal Health Bureau (NO2009-12-18). Ethical Approval Ethical approval was obtained from the Ethics Committee of Chongqing Municipal Health Bureau. Acknowledgements The authors wish to thank all the Dual-Qualification Nursing Teachers who willingly shared their stories. References American Association of Colleges of Nursing, 2003. Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the Supply. AACN, Washington, DC. Baumann, A., Giovannetti, P., O'Brien-Pallas, L., 2001. Healthcare restructuring: the impact of job change. Canadian Journal of Nursing Leadership 14, 14–20. Burnard, P., 1991. A method of analysing interview transcripts in qualitative research. Nurse Education Today 11 (6), 461–466. Chen, Lihong, Zhang, Haiyan, 2005. To explore the advantages of dual-qualification teachers in nursing higher vocational education. China Nursing Management 5 (1), 60–61. Corbin, J., Strauss, A., 2008. Basics of Qualitative Research. Techniques and Procedures for Developing Grounded Theory, 3rd ed. Sage Publications, Thousand Oaks, CA. Detert, Derosia, Caravella, Duquette, 2006. Reducing stress and enhancing the general well-being of teachers using Tai Chi Chih movements: a pilot study. Californian Journal of Health Promotion 4 (1), 162–173. Disch, L.J., 2002. The Tyranny of the Two-party System. Columbia University Press, New York. Driscoll, M.P., Cooper, C.L., 2002. Job-related stress and burnout. In: Warr, P. (Ed.), Psychology at Work. Penguin Group, London, England, pp. 203–228. Duffy, N., Stuart, G., Smith, S., 2008. Assuring the success of part-time faculty. Nurse Educator 33 (2), 53–54. Dunham, J., 1992. Stress in Teaching. Routledge Publishing, New York. Eres, Figen, Atanasoska, Tatjana, 2011. Occupational stress of teachers: a comparative study between Turkey and Macedonia. International Journal of Humanities and Social Science 1 (7), 59–65. Farber, B.A., 2000. Introduction: understanding and treating burnout in a changing culture. Journal of Clinical Psychology 56 (5), 589–594. Guba, E.G., Lincoln, Y.S., 1994. Competing paradigms in qualitative research. In: Denzin, N.K., Lincoln, Y.S. (Eds.), Handbook of Qualitative Research. Sage, Thousand Oaks, CA, pp. 105–107. Hardy, M.E., Conway, M.E., 1988. Role Theory: Perspectives for Health Professionals, 2nd ed. Appleton-Century-Crofts, Norwalk, CT.
Janine, 2005. Sources of Occupational Stress for Teachers, With Specific Reference to the Inclusive Education Model in the Western Cape. University of the Western Cape. Jerlock, M., Falk, K., Severinsson, E., 2003. Academic nursing education guidelines: tool for bridging the gap between theory, research and practice. Nursing and Health Sciences 5, 219–228. Kanai-Pak, Masako, Aiken, Linda H., Sloane, Douglas M., Poghosyan, Lusine, 2008. Poor work environments and nurse inexperience are associated with burnout, job dissatisfaction and quality deficits in Japanese hospitals. Journal of Clinical Nursing 17 (24), 3324–3329. Kathleen, S., Whalen, 2009. Work-related stressors experienced by part-time clinical affiliate nursing faculty in baccalaureate education. International Journal of Nursing Education Scholarship 6 (1), 1–18. Kaufman, 2007. Beyond big and little: the four C model of creativity. Review of General Psychology 13 (1), 1–12. Kuehn, B.M., 2007. No end in sight to nursing shortage: bottleneck at nursing schools a key factor. JAMA: The Journal of the American Medical Association 10 (298), 1623–1625. Lang, T.A., Hodge, M., Olson, V., 2004. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration 34 (7–8), 326–327. Lazarus, R., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer, New York. Li, J., Lambert, V.A., 2008. Job satisfaction among intensive care nurses from People's Republic of China. International Nursing Review 55 (1), 34–39. Margolis, B., Kroes, W.H., Quinn, R.P., 1974. Job stress: an unlisted occupational hazard. Journal of Occupational Medicine 16, 659–661. Maslach, C., Schaufeli, W.B., Leiter, M.P., 2001. Job burnout. Annual Review of Psychology 52, 397–422. Murray, S.l, Holmes, J.G., Griffin, D.W., Bellavia, G., Rose, p, 2001. The mis-measure of love: how self-doubt contaminates relationship beliefs. Personality and Social Psychology Bulletin 27, 423–436. Oermann, M.H., 1998. Work-related stress of clinical nursing faculty. Journal of Nursing Education 37 (7), 302–304. Olivier, M.A.J., Venter, D.J.L., 2003. The extent and causes of stress in teachers in the George region. South African Journal of Education 23 (3), 186–192. Pearson, L.C., Moomaw, W., 2005. The relationship between teacher autonomy and stress, work satisfaction, empowerment and professionalism. Educational Research Quarterly 29, 37–53. Pope, R., Garrett, Graham, L., 2000. Quality assurance for nursing and midwifery education. Nurse Education Today 20, 341–349. Schafer, W., 1996. Stress Management for Wellness. Harcourt Brace College Publishers, Fort Worth. Spitzer, A., Perrenoud, S., 2006. Reforms in nursing education across Western Europe: from agenda to practice. Journal of Professional Nursing 22, 150–161. Stacey, R.P., 2011. The relationship between nurses' stress and nurse staffing factors in a hospital setting. Journal of Nursing Management 19 (6), 714–720. Tsai, Sing-ling, 1993. Chinese nurse stress in Taiwan, Republic of China. Issues in Mental Health Nursing 14 (3), 275–285. Van Dick, R., Phillips, U., Marburg, M., Wagner, U., 2001. Stress and strain in teaching: a structural equation approach. British Journal of Educational Psychology 71 (2), 243–259. Xu, Y., Xu, Z., Zhang, J., 2000. The nursing education system in the People's Republic of China: evolution, structure and reform. International Nursing Review 47, 207–217.