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• To enhance your understanding of the relationships between workplace stressors and job performance
• To familiarise yourself with validated scales that can be used to measure stress, resilience and job performance
• To consider measures that could be implemented to mitigate stressors, increase resilience and foster effective coping mechanisms among nurses
Background Nurses are a crucial part of healthcare organisations, constituting around half of the global healthcare workforce. Therefore, it is important to examine the factors that may affect their job performance, which is central to the delivery of effective healthcare services.
Aim To examine the relationships between stress, resilience and job performance within the nursing context in Jordan.
Method A cross-sectional descriptive correlational design was used. A self-administered questionnaire comprising stress, resilience and job performance scales was completed by a convenience sample of 207 nurses working in five hospitals in the northern and middle regions of Jordan.
Results Overall, respondents self-reported moderate stress levels, normal resilience levels and moderate job performance. The study identified: a moderate positive correlation between stress and resilience; a weak negative correlation between stress and job performance; and a weak positive correlation between resilience and job performance.
Conclusion It is essential that nurse managers, leaders and policymakers implement measures to mitigate the stressors encountered by nurses, increase resilience and foster effective coping mechanisms. Such measures could enhance nurses’ resilience and job performance, ultimately improving patient care.
Nursing Management. doi: 10.7748/nm.2023.e2112
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Ta’an W, Hijazi D, Suliman M et al (2023) Exploring the relationships between stress, resilience and job performance among nurses in Jordan. Nursing Management. doi: 10.7748/nm.2023.e2112
Published online: 20 December 2023
Nurses are a fundamental part of healthcare systems, constituting almost 50% of the global healthcare workforce (World Health Organization 2022). Their role in providing high-quality healthcare is pivotal, therefore nurses’ job performance is crucial both for healthcare organisations and patients. Durmuş et al (2020) described job performance as the extent to which tasks are executed, or the alignment of an employee’s conduct with stipulated conditions, while Banibakr and Shafie (2018) stated that job performance encapsulates the assessment of executed tasks compared with established standards and benchmarks.
For nurses, job performance encompasses the aptitude and efficacy they demonstrate in meeting their professional obligations. This includes domains such as patient care, communication skills, collaborative working, cognitive flexibility and the ability to navigate ethical and legal responsibilities. Nurses’ job performance affects patient outcomes and satisfaction, while also shaping their professional development and career trajectory (Lu et al 2019). Therefore, it is essential to identify the factors that can potentially influence nurses’ job performance, so that healthcare organisations can address these areas and subsequently improve patient care.
Nurses operate in an environment replete with various stressors, including time constraints, interpersonal issues, lack of support, physical health issues and high workloads (Kannappan and Veigas 2022). Stress has been defined as a non-specific reaction to a range of stressors, affecting an individual’s physical and psychological well-being (Hashemi and Garshad 2012, Hazavehei et al 2012). The Mental Health Foundation (2021) described stress as the body’s response to pressure, with too much stress potentially resulting in people feeling overwhelmed or unable to cope.
While low and moderate levels of stress can elicit adaptive responses to challenging situations, excessive and persistent stress has detrimental physiological, psychological and behavioural effects, including compromised job performance (Williams et al 2020). Research has found there is a negative association between heightened stress levels and job performance, culminating in compromised task completion, suboptimal decision-making, diminished focus, apathy and medical errors (Jun et al 2020). Therefore, elevated stress levels can present a risk to patient safety.
In recent years, there has been an increased focus on the concept of resilience in nurses. Resilience is an adaptive modality for navigating and overcoming threats, adversity, and internal and external stressors, with the outcome of preserving psychological equilibrium and mental well-being (Gao et al 2017, Foster et al 2020). Resilience is further construed as an individual’s ability to recover from adverse events such as interpersonal conflicts, health issues and workplace demands (Villasana et al 2016, Cantero-García and Alonso-Tapia 2018). It should also be noted that healthcare organisations have a responsibility to provide the means and conditions that enable staff to develop their resilience.
Evidence has shown that, for healthcare professionals, resilience has the potential to mitigate the negative effects of workplace stress, including fatigue, anxiety, depression and burnout (Gito et al 2013, Hao et al 2015, Kaplan et al 2017). Resilience is also associated with benefits such as reduced absenteeism, increased work productivity and heightened job performance (Handini et al 2020). Therefore, resilience is important in providing high-quality patient care, ensuring patient safety, enhancing patient satisfaction and reducing hospital readmissions, thereby reducing healthcare costs (Henshall et al 2020).
Despite the crucial links between stress, resilience and job performance among nurses, these areas remain relatively underexplored in Jordan. The study detailed in this article was undertaken to explore the relationships between stress and resilience among nurses in Jordan and to explore how nurses’ resilience might mitigate the adverse effects of workplace stress, thereby leading to enhanced job performance.
• Nurse managers need to implement interventions that reduce nurses’ stress levels, strengthen their resilience and enhance their job performance
• Nursing curriculums and training programmes need to better prepare nursing students for stressful, challenging work situations, for example by using simulation-based training
• Nurse managers need to optimise staffing and workload planning to minimise stressors that affect nurses, thereby reducing sickness, burnout and turnover
To examine the relationships between stress, resilience and job performance within the nursing context in Jordan.
A cross-sectional, correlational design employing a self-administered questionnaire was used in this study.
The study encompassed five hospitals with a capacity of at least 100 beds in the northern and middle regions of Jordan. Four of these were four government hospitals and one was a university hospital. Convenience sampling was used to select respondents based on their availability during the data collection period.
Initially, the necessary sample size was determined using G*Power 3 software (Faul et al 2007), which showed that at least 136 respondents were required. To account for possible attrition and missing data, this figure was increased by 20%, meaning that the aim was to obtain a minimum of 163 respondents.
Respondents were required to have at least a bachelor’s degree or a three-year diploma in nursing, have at least one year of work experience and be working full-time. Nurses were considered ineligible to participate in the study if they worked in administrative, infection prevention and control, or quality assurance roles, if they were working part-time and if they had less than one year of work experience.
The questionnaire used in this study comprised four sections. The first section was a sociodemographic questionnaire designed by the lead researcher (DH), which encompassed variables such as age, gender, number of years of nursing experience, education level, hospital, hospital type, department, shift type and nurse-patient ratio.
The other three sections comprised:
• Six Dimension Scale of Nursing Performance (Six-D Scale) (Schwirian 1978).
• The Depression, Anxiety and Stress Scale – 21 Items (DASS-21) (Lovibond and Lovibond 1995).
• The Brief Resilience Scale (Smith et al 2008).
These tools were used after obtaining approval from their respective authors. They were translated into Arabic then translated back into English as a quality control measure to ensure their accuracy and cultural relevance. This process was overseen by a panel of researchers whose aim was to maintain the scales’ original intent and meaning.
The Six-D Scale, developed by Schwirian (1978), comprises 52 items organised into six subscales: leadership, critical care, teaching and collaboration, planning and evaluation, interpersonal relations and communication, and professional development. Respondents rate their job performance levels for each of these items on a four-point Likert scale from 1 (‘not very well’) to 4 (‘very well’). The original tool did not explain how to interpret the scores, so the authors of this article used the visual binning criteria on SPSS (Pallant 2020) to create the following cutoff points based on percentile: below 2.88 = low level of performance; between 2.89 and 3.33 = moderate level of performance; 3.34 and above = high level of performance.
The DASS-21 (Lovibond and Lovibond 1995) comprises 21 items, each of which is self-rated on a scale of 0 (‘did not apply to me at all’) to 3 (‘applied to me very much or most of the time’). The items are divided into three subscales: depression, anxiety and stress. Scores for the seven items in each subscale are added together and the total is multiplied by two to calculate the final score. This study used the stress subscale of the DASS-21, for which stress levels are categorised as: 0-14 = normal; 15-18 = mild; 19-25 = moderate; 26-33 = severe; 34+ = extremely severe (Lovibond and Lovibond 1995).
The Brief Resilience Scale (Smith et al 2008) assesses people’s ability to recover and ‘bounce back’ from stress. It consists of six items rated on a five-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. The scores for each item are added together to give a total out of 30. Total scores are classified as indicating low (6-18), normal (19-25) or high (>25) resilience.
Cronbach’s alpha coefficient was used to assess the reliability of the scales and subscales. All displayed alpha values ranged between 0.77 and 0.97, which are considered strong and reliable (Taber 2018).
Data collection took place between 1 July and 31 December 2022. A total of 225 questionnaires were distributed to nurses at the five hospitals and 207 nurses completed it, yielding a response rate of 92%.
SPSS version 26 facilitated data analysis. Descriptive statistics were used to summarise respondents’ demographic characteristics and the main variable results. Pearson’s correlation coefficient was used to examine the relationships between the main variables. According to Cohen (1988), the effect size is low if the r value is around 0.1 (weak correlation), medium if r is around 0.3 (moderate correlation) and large if r is more than 0.5 (strong correlation). A level of significance of 0.05 was adopted.
Ethical approval for the study was obtained from the Jordan University of Science and Technology institutional review board and the Ministry of Health institutional review board committee. Respondents were fully informed of the study’s purpose and their rights to voluntary participation, to confidentiality and to withdraw from the study at any time without facing adverse consequences. Informed consent was obtained from all respondents. The questionnaires were anonymous to protect their confidentiality.
Respondents’ ages ranged from 22 years to 46 years, with a mean of 31.35 years (standard deviation (SD) 4.9). Their mean number of years of nursing experience was 8.32 years (SD 4.59), ranging from 1 year to 22 years. Table 1 shows further demographic characteristics of respondents.
In terms of job performance, respondents’ mean total score on the Six-D Scale was 158.61 (SD 29.17). Scores were standardised, yielding a mean of 3.05 (SD 0.56), indicating a moderate job performance level. Table 2 shows the self-reported job performance of the respondents, with the mean scores for each subscale ordered from highest to lowest.
Respondents’ stress scores on the DASS-21 subscale translated to a mean total stress score of 22.86 (SD 4.539). This corresponds to a moderate stress level. Table 3 shows the stress levels among the respondents.
Respondents exhibited a normal level of resilience on the Brief Resilience Scale, with a mean score of 3.13 (SD 0.78). Table 4 shows the resilience levels among the respondents.
Pearson correlation coefficient analyses indicated:
• A moderate positive correlation (r=0.345, P<0.01) between stress and resilience.
• A weak positive correlation (r=0.258, P<0.01) between resilience and job performance.
• A weak negative correlation (r=-0.13, P<0.01) between stress and job performance.
Table 5 summarises the Pearson’s correlation coefficients between respondents’ stress, resilience and job performance.
To the authors’ knowledge, this is the first study to examine the relationship between stress, resilience and job performance among nurses in Jordan. One strength of the study is that it focused on nurses working in hospitals in the northern and middle regions of Jordan, areas which are underrepresented in previous research. Additionally, the study provided new insights into the relationship between stress, resilience and job performance among nurses in Jordan, thereby addressing a gap in the literature.
The results of this study indicated that nurses’ job performance in Jordan is at a moderate level. These findings are consistent with similar research conducted by Al-Hamdan et al (2017) in Jordanian hospitals, as well as an international study in China by Tong (2018). Nurses’ moderate level of job performance might be attributed to increased workload hindering their ability to deliver optimal patient care, particularly in public hospitals with suboptimal nurse-patient ratios (Mansour and Sharour 2021). Insufficient resources, such as staffing shortages, outdated equipment and limited technological access, could also adversely affect nurses’ job performance (Moyimane et al 2017, Mansour and Nogues 2022, Rashid et al 2022). Additionally, stress, lack of collaboration, and communication issues among healthcare professionals can hinder job performance (Irandoost et al 2022).
This study found that nurses’ mean stress levels were moderate. This finding is aligned with studies in Jordan showing moderate-to-severe stress levels among nurses (AbuRuz 2014) and in Saudi Arabia indicating that 30% of nurses had severe or very severe stress (Abdoh et al 2021). Similarly, a study by Tee et al (2020) observed moderate-to-severe stress among 13% of Filipino nurses.
Factors contributing to nurses’ stress levels could include high workloads, extended working hours, personal and relational issues and a lack of support systems (Happell et al 2013).
The nurses in this study tended to exhibit a normal level of resilience. Although specific studies on nurses’ resilience levels using the Brief Resilience Scale are limited in Jordan, similar research in other countries provides contextual insight. For example, a study in South Korea indicated moderate-to-high resilience levels among nurses (Park and Lee 2018), highlighting nurses’ capability to cope with job demands and stress. Resilience levels among nurses might be influenced by healthcare systems, cultural norms, social factors and work environments (Janzarik et al 2022).
This study identified a weak negative correlation between job performance and stress. This corroborates findings from studies by Ardıç et al (2022) and Bui et al (2021), both of which indicated negative correlations between perceived stress and job performance. Similarly, a Jordanian study by Al-Nuaimi et al (2021) emphasised the negative relationship between stress and nurses’ job performance. This finding is perhaps unsurprising given the demanding nature of the nursing role, including its prolonged working hours, substantial workloads, inadequate resources and challenging patient and family interactions. Management initiatives such as promoting work-life balance, offering training, fostering teamwork and establishing positive work environments could mitigate nurses’ stress and enhance their job performance (Irandoost et al 2022).
A moderate positive correlation between stress and resilience was found in this study, which is consistent with work by Alatawi et al (2022) and Talebian et al (2022). This contrasts with a study in Malaysia, which found a strong negative correlation between stress and resilience (Mulud et al 2022), as well as a Jordanian study indicating a negative correlation between resilience, perceived stress and quality of life (Alhawatmeh et al 2021). Nurses experiencing high stress levels may develop effective coping mechanisms that foster resilience over time, aided by supportive colleagues and resources (Klainin-Yobas et al 2021).
Finally, there was a weak positive correlation between nurses’ job performance and resilience in this study. This finding aligns with various studies which have indicated that higher resilience corresponds to improved job performance (Kašpárková et al 2018, Walpita and Arambepola 2020, Hosgör and Yaman 2022). Therefore, nurses with greater resilience may be better equipped to navigate job stressors, maintain their focus and practise effectively.
The findings of this study need to be considered in the Jordanian context. When comparing the nursing workforce in Jordan with the nursing workforce in other countries, for example the UK, Iran and South Korea, several differences become evident. In Jordan, there is a shortage of healthcare professionals, including nurses, leading to high workloads and a reliance on foreign nurses (Suliman et al 2023).
In Iran, the nursing workforce is larger than in Jordan but there are nonetheless challenges, such as uneven distribution, inadequate compensation and limited access to advanced training (Irandoost et al 2022). In South Korea, nursing is highly regarded, with a well-educated workforce, effective training programmes and strong government support (Park and Lee 2018). However, the country has an ageing population and high workloads for nurses (Shamsi and Peyravi 2020).
In the UK, the nursing profession has well-established training, continuous professional development and relatively good nurse-patient ratios (Vollam and Tume 2021). Overall, while each country has its unique healthcare challenges, the UK and South Korea appear to have more robust nursing workforces compared with Jordan and Iran, due to factors such as investment in education, training and workforce planning (Drennan and Ross 2019).
There are various implications and recommendations based on the findings of this study for a range of stakeholders in the nursing profession, extending to clinical practice, research, education, nurse management and administration.
Nurse managers, leaders and policymakers in healthcare and education sectors can use the insights from this study to strategise interventions that will reduce nurses’ stress levels, strengthen their resilience and enhance their job performance, thereby developing a nursing workforce with higher levels of satisfaction. The findings of this study could also encourage healthcare organisations to tailor patient care approaches to mitigate stressors and enhance healthcare delivery.
In terms of research, a longitudinal study could be conducted to examine the relationships between stress, resilience and job performance among nurses over an extended period. This would enhance understanding of how these factors evolve over time, thereby contributing to the identification of evidence-based interventions that could support nurses’ well-being.
In education, the development of nurse education curricula and training programmes could be enhanced to better prepare future nurses for the challenges they are likely to experience in practice. For example, simulation-based training involving healthcare scenarios could enable nursing students to practise critical thinking, decision-making and team working under pressure in complex and high-stress situations. This type of training can improve their ability to respond effectively in challenging situations (Tortorelli et al 2021).
Finally, nurse managers and administrators could optimise staffing and workload management, aligning these areas with identified stressors to reduce burnout and turnover rates.
One limitation of this study was that the generalisability of the results may have been adversely affected by the use of convenience sampling, by the exclusion of military and private hospitals due to difficulty in accessing participants in these settings, and by the fact that only nurses from the north and middle of Jordan were included. In addition, using a cross-sectional design may affect causal inference, and the variables were measured using self-reported tools, which may increase subjectivity.
This study explored the complex dynamics between stress, resilience and nurses’ job performance in five hospitals in Jordan. It found that the nurses in this study tended to experience moderate stress levels and a normal level of resilience. Additionally, they self-reported a moderate level of job performance overall, demonstrating that there is potential for improvement in this area. Therefore, the results of this study suggest that nurse managers, leaders and policymakers need to take action and develop policies aimed at reducing stress levels, fostering resilience and promoting coping mechanisms to optimise nurses’ job performance.
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