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A comparison of stressors for nurses and technicians working on kidney dialysis units Strang, Janet M. 1992

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A COMPARISON OF STRESSORS FOR NURSES ANDTECHNICIANS WORKING ON KIDNEY DIALYSIS UNITSByJANET MARIE STRANGB.A., Simon Fraser University, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENT FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIES(Department of Counselling Psychology)We accept this thesis as conformingTHE UNIVERSITY OF BRITISH COLUMBIADecember, 1992©Janet Marie Strang, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(SignatureDepartment of  COLiluSE.2Li///^,S7c/167./Z2,:YThe University of British ColumbiaVancouver, CanadaDate^D.Etrer-47 / /77.,DE-6 (2/88)iiAbstractThere is a prolific number of research articlespostulating the origins of stress experienced by nursesemployed on kidney dialysis units; yet there is littleconsensus as to these etiologies. Alternatively, there arevery few research articles focusing on the origins of stressexperienced by dialysis technicians, despite their role in theteam approach to patient care. Both of these situations areexacerbated by the apparent absence of an evaluativeinstrument suitable for such studies.The purpose of this study was to develop an instrumentappropriate for stress related research involving dialysisnurses and technicians. In addition, the study attempted todevelop a clearer understanding as to which stressors impacton nurses and technicians, and in particular, to determinewhether these stressors were different for the two groups.Specifically, the study examined whether there was anysignificant group interaction, and whether there were anygroup differences in the performance of the nurses andtechnicians on the Sources of Stress Inventory (the measuredeveloped for this study).The sample consisted of 20 registered nurses and 12technicians who were employed on kidney dialysis units in twodifferent medical centers/hospitals in Los Angeles. Theseparticipants were administered the Sources of StressInventory. Statistical procedures used to analyze the dataiiiincluded Profile Analysis and Hotelling's test (T 2 ).Profile analysis indicated that overall, there was nosignificant group interaction and there were no significantgroup differences between the performance of the nurses andtechnicians on the Sources of Stress Inventory. The majorstressors were identified and found to be similar for bothgroups.Psychometric analysis on the Sources of Stress Inventoryindicated that with internal consistency based on Hoyt'sestimate of reliability of .93, the measure may become aviable tool for those researchers studying the origins ofstress experienced by kidney dialysis nurses and technicians.ivTable of ContentsAbstract^ iiTable of Contents^ ivList of Tables viiList of Figures^ viiiAcknowledgements ixChapter 1: INTRODUCTION^ 1Nature of the Problem^ 1Purpose of the Study 2Significance of the Study^ 3Chapter 2:Aspects of study related to research^ 3Aspects of study related tocounselling^ 4Definition of Terms 5Research Questions^ 6LITERATURE REVIEW 7Introduction^ 7Nurses:^Their Evolving Role andand Concomitant Stressors^ 8The Role of the Nurse 8Historical Views of Stressors andTheir Impact on Nurses; aPsychoanalytic Approach^ 9Researchers' Evaluations ofHistorically Based Studies^ 17Alternate View of Stressors andTheir Impact of Nurses^ 19VTechnicians: Their Evolving Roleand Concomitant Stressors^ 21The role of the Technician/Technologist^ 21Research on Stressors EffectingTechnicians^ 23Chapter 3:Structured Interview and QuestionnaireBased Studies: Nurses and Technicians ^ 23Summary^ 29METHOD 31Design^ 31Population 31Sample^ 31Variables 31Instrument^ 32Data Collection^ 32Research Hypotheses^ 32Research Hypothesis 1 32Research Hypotheses 2 33Rationale for ResearchHypotheses 1 and 2 33Statistical Hypotheses 33Statistical Hypothesis ^1 33Statistical Hypotheses 2 33Analysis of the Data^ 34Chapter 4: RESULTS^ 36Psychometric Analysis^ 36viProfile Analysis ofHypotheses 1 and 2^ 36Results: Hypothesis 1 39Results: Hypothesis 2^ 39Summary of Results 39Chapter 5: DISCUSSION^ 43Interpretation of research hypotheses ^ 43Interpretation of Major Sources ofStress for Nurses and Technicians^ 45Limitations of the Study^ 47Sample limitations 47Measurement limitations^ 48Design limitations 48Conclusions^ 48Recommendations 49References^ 51APPENDIX A: Sources of Stress Inventory^ 57APPENDIX B: Sources of Stress Inventory TestItem Analysis^ 58viiList of TablesTable 1: Group Means on the Items of theSources of Stress Inventory^ 37Table 2: Within Group Means on the Items ofthe Sources of Stress Inventory^ 41viiiList of FiguresFigure 1: Profile of the Mean Responses ofNurses and Technicians on the Items of theSources of Stress Inventory^ 40ixAcknowledgementsI wish to express my appreciation to my advisor, Dr. D.Der, for his encouragement and guidance throughout thisproject, and to Dr. W. Boldt, for his valuable assistancewith the statistical analysis of the data. In addition, Iwish to thank Dr. J. Allan and Dr. J. Paredes for theirparticipation on the Committee.1Chapter 1IntroductionHealth care professionals employed in hospital settingshave received considerable attention from stress researchers,due in part to the apparent relationship of stress to burnout.These researchers have focused on the following areas: (a)theoretical models of stress, (b) definitions of stress, (c)origins of stress, (d) effects of stress on staff, and (e)amelioration of such stress (Cronin-Stubbs, 1982; Maslach &Jackson, 1982; Vachon, 1987).As a result of complexities inherent in stress research,and in medical and technological advances that are changingthe work environment for staff, researchers have isolatedspecific units for study. Frequently, these units have twofactors in common: (a) staff care for critically ill patientsand (b) staff roles reflect medical/technical advances(Jacobson & McGrath, 1983). The kidney dialysis unit is onesuch unit that has received considerable attention from stressresearchers, and is the subject of this thesis.Nature of the ProblemPrevious stress research on nurses and techniciansworking on kidney dialysis units is beset with numerousmethodological problems. The following synopsis highlightsfour such problems: (a) Despite the team approach to patientcare, of which technicians play an integral role, researchershave focused mainly on nurses to the near exclusion oftechnicians; (b) Many of the studies suffer from2inadequate conceptualization and operationalization of stress;(c) Principle methods favoured for gathering data haveincluded the use of informal and unstructured interviews,informal observations of staff (a method favoured by earlyresearchers whose interpretations relected psychóanalytictheory), modified questionnaires from other speciality unitsor general questionnaires that do not address the stressorsspecific to a kidney dialysis unit and, (d) Analyses ofresults have frequently been subjective, anecdotal, andinterpretative beyond the scope of the research.Unfortunately, these problems are not just confined to earlierresearch, but are also prevalent in more recent publications(see Chapter 2 for relevant research analyses and references).Purpose of the StudyThis exploratory study attempts to address three of theaforementioned shortcomings of previous research: (a) theapparent absence of a viable instrument applicable to bothnurses and technicians employed on kidney dialysis units, (b)the repeated absence of advanced statistical analyses and (c)the general omission of technicians'as subjects.Addressing the first two related shortcomings invoked athree stage process. Initially, an instrument was designedspecifically for stress related research involving kidneydialysis nurses and technicians (see Chapter 3). Theinstrument was then administered to participants of thisstudy. Finally, statistical analysis of the data andpsychometric analysis of the instrument were conducted.3The third shortcoming was addressed by including in thisstudy both technicians and nurses employed on kidney dialysisunits. The inclusion of technicians provided both anopportunity to obtain information on their group meanresponses to items on the instrument, and to compare theseresponses to the group mean responses of the nurses.Significance of the StudyThere are several aspects to this study which may haveimplications for research and counselling practice. Someaspects are particularly relevant to the methodologicalproblems associated with previous stress related research onkidney dialysis units, while other aspects are more relevantto stress management counselling strategies on these units.Aspects of study related to research. Information regarding technician job related stressorshas been commonly obtained from nursing focused research,informal staff interviews and/or commentaries (articles)written by technicians. Thus, the impact of these stressorson technicians is not fully established. However, the abovelisted sources of information do suggest that exposure to andsubsequent impact of job related stressors may be similar fortechnicians as those purported by nurses. The team approachto patient care which prevails on kidney dialysis unitsfurther lends support to this suggestion. This study's use ofan instrument appropriate for both technicians and nurses mayprovide further insight on this issue.The use of unstructured interviews and informal4observations as a means of identifying nurse/technicianstressors has made replication of studies difficult. Thetrial administration in this study of an instrument specificto kidney dialysis units and which is amenable to advancedstatistical analysis, may be the first step in establishingand providing a reliable instrument which could facilitatereplication of these stress related studies.Aspects of study related to counselling. From a counselling perspective, information elicited fromthe study may impact on stress management strategies. Forexample, the forming of staff support groups has been onestrategy adopted by many units. However, the compositions ofthese support groups varies, and in many cases are composedof nursing staff only (Richmond, 1986; Schaefer & Peterson,1992). One potential outcome of this study is the acquisitionof information that may help determine the feasibility ofincluding technicians in such groups. Considering these twogroups for common counselling modalities may depend on whetheror not their performance differs on the aforementionedinstrument.In addition, identifying the stressors and theirperceived impact is often the first step in stress management(Guillory & Riggin, 1991; Wakefield, 1992). Such informationis particularly useful for supervisors and group facilitatorswho plan and implement strategies related to stressmanagement. This knowledge may also help both staff andsupervisors distinguish between those stressors that could5feasibly be eliminated or their impact reduced, versus thosestressors which by the very nature of the unit are notamenable to the above manipulations. The distinct nature ofthese stressors will necessitate different counsellinginterventions (Dewe, 1987; Lewis & Robinson, 1992).Definition of Terms "Stress" and derivatives of the word stress are used inthe literature as generic terms which can encompass one or allof the following components: (a) stressful situations, (b)physiological and emotional responses, (c) subjects'subjective interpretations of stress, (d) adaptive andmaladaptive coping responses, and (e) stress managementstrategies, etc. For the purpose of this study, and for theconvenience of the reader, stress terminology has beenarticulated accordingly:Stressors. - the stimuli/situation which produces astress response.Stress/stressful. - an individual's global and personal,subjective perception of the stressor(s).Stress response. - an individual's adaptive and/ormaladaptive response(s) to the stressor(s).Stress management techniques. - strategies aimed ateither eliminating or changing the stressor itself and/or itsimpact through individual or group interventions.Stress related research. - studies written by stresstheorists or researchers which include any of the followingcomponents: (a) definitions of stress; (b) identification of6stressors; (c) stress responses and (d) stress managementtechniques.Research Questions This exploratory study addresses the following twospecific research questions:1. Is there any significant group interaction in themean responses of the nurses and technicians on the instrumentdesigned for this study.2. Are there any significant group differences in themean responses of the nurses and technicians on the instrumentdesigned for this study.7Chapter 2Literature ReviewIntroductionThe stressors to which kidney dialysis staff are exposedreflect the two types of patient care provided on the unit;chronic care and intensive care. Whereas other specializedhospital units can be generally classified as either chroniccare or intensive care, components of both types of care co-exist on a kidney dialysis unit. Leonard (1981) stated, "Anephrology service provides a peculiar cross between intensivecare and chronic care. Patients who are medically stable formonths suddenly enter a crisis period with some lifethreatening complication" (p. 37). Based on their researchconducted at the Veterans Administration Medical Center, LongBeach, California, Gerber and Nehemkis (1980) described theunit as follows: "The renal dialysis unit is a unique medicalsetting: it is identified as an intensive care type unit yetit is also a chronic care setting" (p. 249). During dialysispatient cardiac complications can occur requiring staff toimplement split-second emergency procedures (Gerber &Nehemkis), illustrating the former care type. However, unlikeother intensive care units, these same patients will typicallyutilize the services of the unit for approximately three timesper week for treatment lasting three to four hours over aperiod of months or years (Barnes, 1980; Highland; 1987),illustrating the latter care type. The literature reviewed inthis chapter describing potential stressors on a kidney8dialysis unit reflect these two components.Nurses: Their Evolving Role and Concomitant Stressors The role of the nurse Nurses have played a major role in the planning andimplementation of dialysis services since regular maintenancedialysis for chronic patients commenced in the early sixties.The exact nature of this role is often determined by thelocation, size and type of facility as these factors affectstaffing complements (Fortner-Frazier, 1981).Although there may be some variation in nursing rolesfrom unit to unit, commonalties exist. According to Feiner(1991), "The registered nurse assumes the responsibility forall the professional issues related to patient's care. Theseduties include patient assessments, care planning,administering intravenous medications and supervising all thetechnical aspects of direct patient care" (p. 190). Nursesmay also be responsible for providing education and supportservices to patients (Butera, 1988; Kosier, 1988). Related tothe above duties is the added responsibility of keepingabreast of technological changes (Carroll, 1991; Tindira,Hong, & McKevitt, 1985). Other duties may involve schedulingstaff and supervising staff nurses and technicians.As the nurse's role continues to evolve, Jordon (1988)speculates that this role will broaden, resulting in a rolewhich encompasses more than the clinical aspects of nursing.She states, "We're going to see nephrology nurses who are notonly clinically experienced, but also experienced in9administration, regulatory agencies, and the politicalsystem" (p. 217). The latter, in part, reflects governmentconcerns regarding health care costs. Although nurses have inthe past been responsible for providing statistics on basicpatient usage and staffing costs, initiatives such as qualityassurance programs and increased financial accountability togovernment will result in additional administrative functions.As more institutions rely on computer programs to facilitatethese tasks, nurses will have to become experienced incomputer technology. Jordan (1988) predicts that in thefuture, "More nephrology nurses will fill key combinedadministrative and clinical decision-making positions (p.217).Historical views of stressors and their impact on nurses;a psychoanalytic approach Research on the stressors to which kidney dialysis staffare exposed commenced in the 1960's. The majority of theseearly researchers were psychiatrists who were assigned to theunit, and who adhered to a psychoanalytic theoreticalframework by which to explain the impact of these stressorsand the resulting patient and staff behaviours. The readershould note that when these authors refer to "staff", detailedexamination of their studies indicate that they are usuallyreferring to nurses only.A pioneer in this area of research, Kaplan De-Nour,co-published in 1968 one of the first articles which was basedon a two year period of informal observations, detailing the10emotional problems and reactions of the medical team emanatingfrom, "long-term and intensive contact with a comparativelysmall number of patients, as well as the new responsibilitiesthat must be assumed by various members of the team" (KaplanDe-Nour & Czaczkes, 1968, p. 987). They noted that thefollowing reactions were particularly prevalent among thenursing staff: (a) possessiveness towards patients, (b) over-protectiveness of patients, and (c) withdrawal from patients.Evidence for possessiveness towards patients was based ontheir observations that the nurses resented the psychiatristwho had joined the team, resented new residents assigned tothe unit, and argued with the technicians as to who was moreimportant to the patients. The following description wasviewed by Kaplan De-Nour and Czaczkes (1968) as evidence ofthe nursing team's possessiveness towards the patient, "thereis a constant latent struggle between the nurses andtechnicians, occasionally developing into overt fights, aboutwho is more important to the patients, whose recommendationsor orders the patients should obey, and in whom the patientsconfide more" (p. 988). They also described the team as afamily, with "the nurses taking up the role of the over-protective mother" (Kaplan De-Nour & Czaczkes, 1968, p. 989).The authors admit that the possessiveness and protectivenessof the nurses is difficult to substantiate based only on theirobservations, but argue that these reactions can be explainedby the underlying hostility and unconscious aggressionmanifested by the nurses in their arguments with patients11and other members of the medical team.Although Kaplan De-Nour and Czaczkes (1968) reportedemotional involvement of the nurses with their patients (i.e,possessiveness and over-protectiveness), they also observedwithdrawal reactions evidenced by the frequent changes ofnurses in the unit. The authors noted that the dialysis unitexperienced the highest drop-out rate of any unit in thehospital, yet they further stated that many of the nurses hadreasons for resigning supposedly unrelated to the stress oftheir work.Kaplan De-Nour, Czaczkes, and Lilos (1972) examined theexpectations that hemodialysis teams (nurses and physicians)have of their patients, and whether there was intra-teamagreement. Although their primary purpose was to determinewhat influence the team had on patient behaviour andadjustment to dialysis, the authors also hypothesized thatdiscrepancies in these expectations and subsequent lack ofteam agreement regarding such patients would be anotherstressor which could result in decreased job satisfaction,thereby contributing to the emotional problems of the staff.Three dialysis teams, each including about 10 members,completed a 12-item inventory relating to both the physicaland emotional aspects to dialysis treatment. Members of theseteams were required to choose descriptions which bestdescribed their idea of a "good" patient's behaviour orcondition from a list of 12 items, with each item consistingof three or four descriptions. The authors found that12discrepancies in expectations of patients existed within teamsand suggested that these discrepancies indicated personalbias, of which the latter was based on staff denial and whichcontributed to team dissatisfaction (Kaplan De-Nour, Czaczkes& Lilos, 1972).Unfortunately, there are several methodological problemsidentified by this writer associated with this study. Theinventory consisted of both three-point and four-point scales,yet for the purpose of evaluating agreement in expectations ofmembers of each team, only a three-point scale was used in thestatistical analysis. As well, no break down of the number ofphysicians versus nurses was given. The questionnaire alsocontained an additional possible answer that the item wasirrelevant for assessing a patient. No value was assigned tothis option. However, the one team that utilized this optionin over 25 per cent of their responses, was viewed as being,"uncooperative in a passive way" (Kaplan De-Nour, Czaczkes, &Lilos, 1972, p. 443). Moreover, the authors claimed that theteams use of this category made statistical analysesdifficult. No alternative explanation for the use of thiscategory was examined. In addition, the authors neitherdefined nor measured team satisfaction. The authors stated,"As we know these teams fairly well from frequent visits andinformal talks, we have not used 'scientific' methods formeasuring the satisfaction of the teams" (Kaplan De-Nour etal., p. 442). In view of the previously discussedmethodological problems, this author finds it difficult to13accept the writers' suggestion that diversity of team opinionreflects personal bias resulting in dissatisfaction of teammembers, thereby creating a stressor which could contribute tothe emotional problems of the staff.Moore (1972) and Wertzel, Vollrath, Ritz, and Ferner(1977) also identified patient contact as a major stressor fornursing personnel. Moore (1972) argued that such stress stemsfrom close contact with patients who as a result of unresolveddependency issues, often manifest transitory psychiatricsymptoms. This observation, as well as his assessment ofnurse dependency issues, were based on formal and informaldiscussions with dialysis nurses over a six-year period.Rather than attempting to verify the existence and/ormagnitude of this purported stressor, Moore (1972) speculatedon why women chose dialysis nursing and/or nursing in generalas a profession:I think we must ask how a group of nice girls, as thesenurses are, got themselves in this position. I supposeit might be useful to ask why these women want to benurses in the first place. I think it is fair to saythat there are probably many significant underlyingissues in the decision to become a nurse. Perhaps it isthe need to be needed that directs some girls towardnursing. Others may respond to prestige, drama,association with doctors (attractive paternal figures)and special status. Others may take care of others asthey wished to be taken care of. I think each nurse must14ask herself what some of her 'real reasons were'. (p.195)Unfortunately, his attempts to draw an analogy betweenthe dependency needs of the patients and the possibledependency needs of the nurses, neither addresses the extentto which the dialysis patient is a stressor compared to otherpotential stressors on the unit, nor do they render themselvesto practical solutions.Wertzel, Vollrath, Ritz, and Ferner (1977) in their studywhich examined nurse-patient social interactions, suggestedthat stress resulting from exposure to prolonged intensivecontact with chronically ill patients may explain both thehigh turn-over of nurses and the characterized depression ofthe nurses as indicated on the Giessen test, a personalityinventory based on psychoanalytical principles. Theycontended that according to psychoanalytic theory, depressionis closely related to self-insecurity which stems from theweakness of the ego-self system, and in an effort tocompensate for this weakness, the ego seeks other objects forhelp. The authors suggested that the patients themselvesbecome this object for the nurses which contributed topatient-contact related stress.Czaczkes and Kaplan De-Nour (1978), Kaplan De-Nour (1980)and Kaplan De-Nour (1983a) again identified patient contact asa stressor and further examined what components of thispatient contact were peculiar to a kidney dialysis unit. Allthree studies cited close contact with patients over a period15of months or years, patient behaviour, patient anxiety,patient adjustment to dialysis and patient death as suchcomponents. However, the authors argued these componentsbecome sources of stress as the result of staff's emotionalneeds which are reflected in the staff's reactions to thesestressors. For example, Czaczkes and Kaplan De-Nour (1978)reported that staff responded to less grateful and adjustedpatients with aggression and that this high level ofaggression in the medical staff was in itself the problem.They also noted the following reactions of the staff: (a)withdrawal, indicated by the high dropout rate of nurses; (b)denial, evidenced by staff minimizing the hopelessness oftheir patient's condition; (c) displacement of anger asindicated by intra-team tensions; and (d) overcompensation,reflecting staff doubts regarding the rightness of dialysis.Kaplan De-Nour (1980) also suggested that the characterizeddepression of nurses reported by Wertzel, Vollrath, Ritz, andFerner (1977) represented an introjection reaction.Therefore, the defense reactions exhibited by staff, and inparticular the nurses, were viewed as being the issue ratherthan the patient contact itself. These authors also foundthat any attempts on their part to increase staff insight withrespect to such reactions was met with resistance, increasedacting out of aggression, and increased intra-team aggression.Kaplan De-Nour (1983a) concluded:It is difficult to suggest what should be done todecrease the psychological distress of the staff and16whether anything should be done. I would be inclined toadopt the attitude that the medical staff are 'normal'people who should be able to handle and cope with thestresses of life, including that of working in dialysisunits. If some staff members do show symptoms ofpsychological distress they should get help outside theunit like any other patient in distress...Let us not turnstaff members into 'psychiatric patients,' butconcentrate all efforts on reactions/attitudes thatinfluence patients' welfare. (p. 403)Klingenstein (1986) a renal social worker, also observedstaff denial and aggression and their negative effect onpatients and insists that staff, "have to use other avenuesfor their own ventilation and support" (p. 402). However, shedid not elaborate on what avenues would be appropriate norwhether such avenues existed.In summary, the earlier studies which attempted toidentify stressors peculiar to dialysis units tended to focuson the uniqueness of the dialysis patient and the effect thatthis uniqueness had on dialysis staff. The studies emphasizeda psychoanalytic interpretation of staff behaviours with suchbehaviours and/or reactions being viewed as sources of stress.The first few published articles on this subject appeared tohave set the parameters for some of later studies which havealso been included in the above review. However, publicationof these studies also resulted in criticism of theirtheoretical interpretation of staff behaviour and of their17methodology, thereby encouraging further research.Researchers' evaluations of historically based studies The attempts by early researchers to interpret staffbehaviour has been criticized by several authors (Blodgett,1981; Gerber & Nehemkis, 1980; Manley, 1983). Manley (1983)warned, "however compelling may seem the evident truth ofone's insightful observations about staff behavior, lackingthe kind of associative data that is available only in thecourse of an extended exploratory psychotherapy, one is veryoften wrong" (p. 365). Also, Manley noted that the staffs'resentments to such interpretations were understandable, giventhat they viewed the liaison psychiatrist as a colleague andcertainly did not view themselves as patients. Gerber andNehemkis (1980) questioned the appropriateness of suchinterpretations as psychiatrists were originally assigned todialysis units to work with disruptive patients, and seldomworked directly with the nursing staff. As well, theyquestioned the usefulness of psychoanalytic interpretations ofstaff behaviour when no concrete solutions or interventionscould be derived from them. Blodgett (1981) focused hiscriticism on their methodology, and listed the followingconcerns: (a) imprecise and limited definitions, (b) the useof informal observation which does not lend itself toreplication and (c) the tendency of the researchers to focuson psychoanalytic interpretations of staff reactions tostressors to such a degree that the original sources of stresswere not adequately studied and that alternative explanations18were not considered.That alternative explanations for staff behaviour werenot considered led researchers to find "pathology" in staffresponses where in fact it may not have existed. For example,Kaplan De-Nour, Czaczkes, and Lilos (1972) suggested thatdiscrepancies in staff evaluations of patients were due toprofessional bias originating from denial of patients'conditions. Alternately, Blodgett (1981) argued that suchdiscrepancies were understandable if the two components of theevaluation, medical (objective) and personal (subjective) wereconsidered separately. The discrepancies occurred only in thesubjective aspects of the patient's evaluation which requiredassessment of the patient's emotional status, tolerance oftreatment, etc., for which no objective measures wereavailable. Therefore, he suggested that any discrepancieswere due to this subjective aspect and not to staff denial ofthe patient's condition. His position is substantiated byAbram (1968), Fielding, Grounds, and Mellsop (1974), andManley (1983) who found that nursing assessments of patientswere insightful and reliable and argued for their validity.The above studies have primarily focused on only onepotential stressor, the uniqueness of the kidney dialysispatient and how this uniqueness impacted on staff, and thestaff-patient relationship. As a result of this narrow focushowever, rather than attempting to substantiate the hypothesisthat the kidney dialysis patient and/or staff sand patientrelationship is indeed a stressor, these studies appear to19place more emphasis in determining who is at fault for theapparent less than "ideal" relationship which requires"concerned" staff and "appreciative" patient. According toMaslach and Jackson (1982):Whether the brunt of the blame is carried by staff or bypatients, blaming allows the contribution made by theproperties of the situation to be either minimized orignored. Such dispositional explanations limit, andeven misguide, attempts toward solutions to burnout.(p.231)They also hypothesized that characteristics of patients may beless stressful than the staff's perceived lack of control overtheir immediate environment, which included such factors asbehaviour of physicians, and hours and conditions of theirwork. While not discounting the role of personality variablesor the impact of the kidney dialysis patient upon staff,researchers have broadened their studies to investigate otherpotential situational stressors.Alternate views of stressors and their impact on nurses Several authors have reiterated that the first step inplanning any stress management intervention is theidentification of the stressors to which staff are exposed(Campbell, 1981; Dickerson, 1980; Guillory & Riggin, 1991;Lawrence & Lawrence, 1987). Jackson (1980) found that weeklystaff meetings were not an effective stress managementintervention until the staff became aware of the sources ofstress, which they were then able to examine objectively.20Pines and Kanner (1982) also argued that by identifyingsituational stressors, the emphasis is placed on thoseconditions in the environment that appear to effect all staff,regardless of individual traits, characteristics anddispositions.Several authors have identified staff shortages as onesuch stressor (Guillory & Riggin, 1991; Leonard, 1981;Richmond, 1986; Wakefield, 1992). Staff shortages have arippling effect that creates other stressors such as a heavypatient workload which in turn leads to unplanned overtime(Aguilar, 1991; Lane & Hawkins, 1981) resulting in fatigue(McMinn, 1979). As Pines & Kanner (1982) pointed out, a heavypatient workload results in time constraints preventing nursesfrom having the opportunity to discuss professional issues,clarify goals, spend more time with patients, and socialize orreceive positive feedback. They contend that the absence ofthese positive environmental conditions may have as muchimpact on nursing staff as the presence of negative stressors.Related to such absences, Houlihan (1982) noted that there isa conflict for nurses between expectations inherent in theirposition and what they can realistically accomplish. Aguilar(1991) states that, "Increasing resource constraints, on onehand...demand for quality services on the other;" and"Continuing changes and/or shortages in the number of health-care personnel;" (p. 160) are two of the major stressors thatimpact on nurses, along with rapid technological changesrelated to kidney dialysis. This highly technical21environment has also been identified as a potential stressorby Campbell (1981) and Rabin (1982).Unfortunately, some of the methodological concernsregarding the research presented in the previous sections arerelevant to these studies. The principle methods used foridentifying the stressors were informal and unstructuredinterviews and informal observations of staff, albeit some ofthe articles were written by kidney dialysis staff and thusthe stressors listed were based upon their experience.However, as no specific data were objectively gathered inthese studies, support for the existence and magnitude ofthese stressors could not be verified by any statisticalanalyses.Technicians: Their Evolving Role and Concomitant Stressors The role of the technician/technologist The role of technicians evolved in the early 1960's inpart as a result of hospital staff combining their knowledgeand expertise in order to understand the complexities of newhemodialysis procedures (Atkins, 1991). The continuingincrease in the demand for dialysis services, the shortage ofregistered nurses, and the increasing sophistication ofdialysis equipment have all contributed to the diversity ofduties and responsibilities of the technician (Hudson, 1988;Messana, 1991). Depending on the size and locality of theunit, technicians may be involved in one or more of thefollowing aspects of dialysis: (a) direct patient care, (b)water treatment, (c) disease control, (d) monitoring and22maintenance of complex dialysis equipment, (e) teachingtechnical information to staff or clients, and (f) managerialor administrative activities (Arslanian, 1991; Sharpe, 1985).This diversity of duties resulted in attempts toestablish two distinct positions; technician and technologist,with each position focusing on different components ofdialysis (Hover, 1991; Hudson, 1991). The term "technologist"began to refer to technicians responsible, "for theperformance of medical devices that are utilized in thedelivery of renal-replacement therapies" (Hover, 1991, p.109), whereas the term "technician" began to refer to thosetechnicians responsible for the clinical and technical aspectsof patient care. However, according to Arslanian (1991) andScrivner (1988), in practice these two positions frequentlyoverlap from unit to unit, with respective duties beingshared.In the United States, technicians became involved inpatient care in the early 1970's. The California NephrologyManpower Study which was completed in 1973, found that mosttechnicians were involved in some level of patient care. Thisinvolvement ranged from conducting dialysis procedures undersupervision to starting, monitoring and ending treatment andrecognizing complications and taking corrective action withoutsupervision (Fortner-Frazier, 1981; Scollard, 1991). Thus,not only do the technician's and the technologist's rolesoverlap, but also to some extent do those of the techniciansand the nurse's.23Research on stressors effecting technicians A comprehensive literature review revealed that very fewarticles focus specifically on stressors effectingtechnicians, but rather on issues relating to licensing andeducation standards and on defining the roles of thetechnician and technologist. When such stressors areaddressed by authors, they tend to be mentioned within thecontext of an "opinion paper" or within the confines of a"psychiatric observation study".Several authors have listed relationships with patientsas a major stressor for technicians due to the long hours theyspend with such patients and their families (e.g., Bocchino,1978; Fortner-Frazier, 1981; Halper, 1971). Other authorshave identified the technical and educational responsibilitiesassociated with the increasing sophistication of dialysisequipment (e.g., Feiner, 1991; Fortner-Frazier, 1981; White,1980). However, as in the previous articles reviewed, supportfor the existence and/or magnitude of these stressors was notverified by any statistical analyses derived from researchstudies.Structured Interview and Questionnaire Based Studies: Nurses and TechniciansIn an attempt to overcome some of the aforementionedmethodological problems associated with observation studies,some researchers have utilized structured interviews and/orquestionnaires, albeit with varying degrees of success.Mabry, Acchiardo, and, Trapp (1977) compared the feelings24and attitudes of staff in 1972 to those found in 1976 withregards to their personal relationships with patients andcolleagues. They stated that, "Some responses indicated thatnursing staff felt some stress associated with their role.They expressed frustration in caring for the chronically ill"(p. 39). Unfortunately, Mabry et al. do not attempt toquantify "some responses" or "some stress". The format of thequestionnaire is also not clear, with the combined number of"yes"/no" responses versus open-ended answers differingbetween the two samples. In addition, although sixtechnicians participated in the study, they are not mentionedin either the result or discussion sections of the paper.A longitudinal study based on structured interviewsconducted by O'Brien (1983) indicated that lack of adequatestaff resulting in technicians and nurses being overworked wasa major stressor. Whether or not death was considered a majorstressor depended on the age of the patient, the cause ofdeath, and whether or not the death was expected. However,interpretations of the results are mainly anecdotal and appearto stem from unit observation as well as the interviews.Balck, Dvorak, Speidel, and Aronow (1983) described theresults of a study in which the staff (35 nurses and 18physicians) of eight dialysis units were interviewed by meansof a questionnaire. The staff were asked to identify the mainstressors that created tension on a dialysis ward. Nursesreported intra-team tensions, death of a patient,deterioration of patient's health, and time pressure as being25major stressors. Balck, Dvorak, Speidel, and Aronow (1983)suggested that, "Time pressure constitutes a link between thepatient-originated and team-originated stressors because itresults from dealing with acute and critical dialysissituations within the typical constraints of understaffedfacilities" (p. 18). This study is atypical in that the staffwere asked which stressors they thought created tension on thedialysis ward, and in that the researchers rank ordered theresponses. The authors also noted limitations of the study;in particular, that the questionnaire return rate was only 32per cent which they suggested indicated a selection effectmaking interpretation of the results difficult. Althoughthese three features are elementary, they have beensurprisingly absent in many of the studies reviewed.Kaplan De-Nour & Czaczkes (1977) theorized that twosources of stress are the high emotional involvement of staffand high levels of aggression which characterizes staff-patient relationships. The researchers administered theMorgan and Cheadler Questionnaire to 9 nurses employed on thesame dialysis unit. The questionnaire designed by Morgan andCheadler in 1972 for use in psychiatric units is composed of20 items; 10 questions elicit patient preference and 10questions elicit patient rejection. The nurses were given analphabetical list of their patients and from this listselected patients they felt were relevant to each of the 20items. Kaplan De-Nour and Czaczkes found that the number ofresponses given by dialysis nurses were at least twice that26given by psychiatric nurses. They contended that theseresults indicated over involvement of nurses with theirpatients. The authors also stated that due to the fact thatthe dialysis nurses rejected 37% of their patients whilepsychiatric nurses rejected only 18% of their patients, theirclinical impressions of high levels of hostility andaggression among nurses was supported.However, the results may be more indicative of'methodological problems rather than the authors' clinicalobservations. Aside from the small sample size, thequestionnaire was administered to the nurses in individualinterviews, precluding the possibility of anonymity. In orderto compare their results to Morgan and Cheadler's whose sampleincluded 54 psychiatric patients, versus 16 kidney dialysispatients, Kaplan De-Nour and Czaczkes multiplied the number ofnurses' responses by 3.4. They did not take into account thatthis mathematical procedure does not necessarily produce datacomparable to Morgan and Cheadler's as a smaller list ofpatients may possibly result in more patients being includedunder each item due to memory and familiarity factors. Aswell, the authors mention that some of the items were notapplicable to a dialysis unit, yet the appropriateness ofusing a questionnaire designed for another specialty unit isnot discussed. Finally, alternative interpretations for thedifferences in results between the two studies are notconsidered. For example, the roles and duties of the nursesmay differ greatly between the two different types of units.27In another effort to identify stressors associated withpatients, researchers have focused on comparing how patientsand staff perceive the social climate on their unit (e.g.,Kaplan De-Nour, 1983b; Kroemeke & Nassar, 1980; Rhodes, 1981).These researchers hypothesized that differences in scoresbetween staff and patients on the Ward Atmosphere Scale (WAS)would reflect a source of stress.The Ward Atmosphere Scale, developed by R. Moos and P.Houts in 1972, measures attitudes and perceptions of patient-staff relationships and ward conditions. The questionnairecontains 100 true or false items which are categorized bythree subscales: (a) relationship, (b) treatment, and (c)systems (Rhodes, 1981).Kroemeke and Nassar's (1980) sample included 32 patients,7 registered nurses (RNs), 10 licensed practical nurses (LPNs)and 4 technicians. They found two discrepancies: (a) patientsperceived less emphasis being placed on dealing with theirpast and on their expression of anger than did the RNs, and(b) patients perceived less spontaneity on the unit than didthe LPNs. According to the authors, the former discrepancymay reflect different stages of patient grieving oradaptation. Although technicians were included in the study,their scores were not given. As the authors did not carry outsignificance testing for the mean scores of the staff andpatients, or provide the return rate for the questionnaires,interpretation of the data is difficult.Kaplan De-Nour (1983b) administered the WAS28Questionnaire, modified for dialysis units by Rhodes (1981),to 108 physicians and nurses from 8 different units and foundthat staff believed patients to be more involved in the unitthan the patients perceived themselves to be. Kaplan De-Nourinterpreted this finding as providing direct evidence forstaff denial (Kaplan De-Nour, 1983b, 1984). Unfortunately,the number of nurses in the sample versus physicians was notgiven.Rhodes (1981) administered his revised WAS Questionnaireto 18 nurses and 59 patients and found that there was astatistically significant difference in the perception ofthe social climate of the unit, with patients perceiving theenvironment more negatively than the staff. However, Rhodesalso administered the Beck Depression Inventory and found thatdepressed patients viewed the dialysis ward atmosphere morenegatively than nondepressed patients. Rhodes (1981)suggested the following explanation for this occurrence:The significant correlation of depression with low wardatmosphere implies that depression does act as a type offilter for interpreting the environment. The depressedpatient focusing on the dysfunctional apsects (sic) ofhis environment filters out positive factors to maintainhis negative perceptual set of the dialysis unit. (p.174)Although Rhodes stated that the WAS Questionnaire had acredible reputation for reliability and validity, having aretest reliability of .73 for patients and .96 for staff29established up to three years, he does not mention thereliability or validity of his revised WAS Questionnaire, orgive any other details regarding his adaptation of the WASQuestionnaire for use on kidney dialysis units.Devins, Anthony, Mandin and Taylor, (1983) alsoinvestigated the impact of depressed patients on nurses. Theyhypothesized that depressed patients would be more negativelyevaluated by the nurses versus nondepressed patients. Thesample included 18 nurses employed on their unit. Theysummarized their findings as follows:Contrary to prediction, dialysis nurses did not evaluatedepressed patients any more negatively than theyevaluated nondepressed patients nor did we observe anysignificant intercorrelations among nurses' expressionsof job dissatisfaction, emotional distress, and theirevaluations of the patients under their care. (p. 722)The findings of Devins et al., lend support to Rhode'sconclusion that discrepancies in the perceptions of wardatmosphere between nurses and patients may be attributable todepression in some patients, rather than any nursing bias ordenial.SummaryAs a result of an aging population, more patients withchronic and degenerative diseases will be utilizing kidneydialysis services (Aguilar, 1991). Increases in user demandfor such services will only exacerbate the impact of stressorsto which nurses and technicians are exposed.30The studies reviewed in this chapter unfortunately do notprovide conclusive evidence as to which stressors, as assessedby technicians and nurses, impact the most on their physical,mental and emotional well-being. Therefore, furtherinvestigation is crucial, for without this knowledgeappropriate remedial actions to either alleviate or amelioratesuch stressors is not feasible.31Chapter 3MethodDesignThe purpose of this exploratory study was twofold: (a)to determine whether the profiles of the nurses andtechnicians differed on the Sources of Stress Inventory and(b) to conduct psychometric analysis on the Sources of StressInventory, an instrument devised specifically for this study(Der, 1986).The study was a nonexperimental group comparisoninvestigation.PopulationThe target population for this study was all registerednurses and technicians who were qualified to work on kidneydialysis units within a hospital setting.SampleThe sample was obtained from two different medicalcenters/hospitals located in the Los Angeles area: (a) 14registered nurses and 2 registered technicians employed at theLong Beach Veteran's Administration Medical Center and, (b) 6registered nurses and 10 registered technicians employed atthe Harbor-University of California Los Angeles (UCLA) MedicalCenter. Twenty registered nurses (85% female and 15% male),and 12 technicians (67% female and 33% male), for a totalof 32 subjects participated in the study.Variables The two independent variables were registered nurses and32registered technicians. The dependent variables were theitems on the Sources of Stress inventory.InstrumentThe Sources of Stress Inventory was devised specificallyfor this study. Nurses and technicians voluntarily submittedsituations pertaining to their jobs which they foundstressful. These situations were than catagorized into threesubscales: Subscale A, Patients, included 13 items (1-13);subscale B, Staff, included 6 items (14-19); and subscale C,Working conditions, included 9 items (20-28).A self-report 28-item measure with 6-point reponsescales anchored by "low stress" and "high stress" wasdesigned. The minimum score was 28, and the maximum score was168 (see Appendix A).Data CollectionEach participant received a sealed envelope whichcontained the Sources of Stress Inventory and an envelope inwhich to return the completed document within a two weekperiod. All participants completed the document at home andreturned them within the allotted time, resulting in a 100%return rate.Research Hypotheses Parallel to the research questions in Chapter 1, thefollowing research hypotheses were investigated. Therationale for the research hypotheses concludes this section.Research Hypothesis 1. The profiles of the nurses andtechnicians on the Sources of Stress Inventory are parallel.33Research Hypothesis 2 The profiles of the nurses andtechnicians on the Sources of Stress Inventory are coincident.Rationale for Research Hypotheses 1 and 2The two hypotheses concerning the profiles of the nursesand technicians are exploratory. The basis for theseconjectures is that the team approach to patient care onkidney dialysis units exposes these two groups to comparablestressors, which may result in similar ratings on the Sourcesof Stress Inventory. A comprehensive review of the literatureelicted numerous journal articles on dialysis nurses andstress, compared to relatively few articles on dialysistechnicians and stress. Moreover, to this researcher'sknowledge, no research has been conducted in which the samemeasure was administered to both groups, and in which themeasure was specific to the stressors on a kidney dialysisunit. From a counselling perspective, obtaining informationon the profiles of the nurses and technicians will enlightencounsellors as to the feasibility of combining these twogroups in counselling interventions.Statistical Hypotheses The following statistical hypotheses corresponding tothe research hypotheses were tested at the .05 level.Statistical Hypothesis 1.*Ho : Cul = Cu2 , vs. H 1 : Cu l = Cu2This is a test of whether or not the profiles are parallel.Statistical Hypotheses 2.**Ho : l'u2 = 1'u2, vs. H1: l'ul = l'u234Given the profiles are parallel, this is a test of whether ornot the profiles are coincident.Key* Cul^Bold face letters are used as matrix orvector notations. C denotes a transformationmatrix and u refers to a mean vector on pvariables for Group One. Subsript denotesgroup.**1' 1,1 1^1' denotes the transpose of a unit vector.Bold face is used as a matrix notation.Subscript denotes group (Boldt, 1991).Analysis of the Data Profile analysis was undertaken to answer the generalquestion as to whether or not the performance of the nursesand technicians differed on the Sources of Stress Inventoryand more specifically, to test statistical hypotheses 1 and 2.The data for the profile analysis was generated from thesubjects' ratings of the 28 items on the Sources of StressInventory. The scores or responses to these 28 items can beassumed to be observations on continuous variables (Boldt,1991). One way to analyze multivariate data of this kind isto compare the two groups (nurses and technicians) throughprofile analysis. Profile analysis is appropriate insituations where a battery of questions is administered to35different groups of subjects, and one wishes to know if thegroups differ in some way on their mean response (Stevens,1986).Two assumptions of profile analysis are that theresponses be commensurate, and that the groups be derived fromsome criteria other than the profiles themselves (Tabachnick &Fidell, 1989). Both of these assumptions were met.In a stepwise fashion, profile analysis addresses andtests the following questions: (a) Are the profiles parallel?or, is there any interaction between group times test? and;(b) Are the profiles coincident? or, are there any significantgroup differences? Although these test items arestatistically independent, if the test of parallelism isrejected, the test of coincidence is usually consideredirrelevant. Only if the above two questions are not rejectedis the third question; (c) Are the profiles level? or, are theresponses to each question the same? addressed (Harris, 1985).As profile analysis is an application of multivariateanalysis of variance, the SPSSX Manova (profile analysis) waschosen to analyze the data (Lai, 1986). This programgenerates tests of significance pertinent to the tests ofparallism and coincidence. These tests will be discussed andreported in Chapter 4.36Chapter 4Results Psychometric Analysis Psychometric analysis was conducted on the Sources ofStress Inventory using the Laboratory of Educational ResearchTest Analysis Package (LERTAP). Reliability co-efficients anddiscimination indices were obtained.Internal consistency based on Hoyt's estimate ofreliability was .93. Reliability co-efficients for thesubscales were: Patient .90, Staff .80, and Working conditions.78. Item analysis was performed. Appendix B contains thediscrimination indices for each of the items on the scale.Except in one instance, the discimination indices werereasonably high. The mean scores and standard deviations aredisplayed in Table 1.As the nurses and technicians were asked to identifysituations they considered stressful, the instrumentpresumably has high face validity.Profile Analysis of Hypotheses 1 and 2Profile analysis (SPPSX) was carried out to compare theresponses of the nurses and technicians on the Sources ofStress Inventory.As was discussed in Chapter 3, profile analysis tests twohypotheses relating to the equality of mean vectors; thehypothesis of parallism and the hypothesis of coincidence(Tabachnick & Fidell, 1989). If the hypothesis of parallism istenable, then the second hypothesis of coincidence is tested.37Table 1Group Means on the Items of the Sources of Stress InventoryItem^MSubscale A Patients1^2.47^(1.70)2 2.00^(1.16)3^3.09^(1.17)4 4.38^(1.52)5^3.81^(1.40)6 2.00^(1.08)7^2.69^(1.47)8 3.81^(1.31)9^2.72^(1.25)10 3.03^(1.33)11^2.44^(1.50)12 3.34^(1.58)13^3.91^(1.75)Subscale B Staff14^2.59^(1.52)15 3.53^(1.67)16^2.72^(1.37)17 2.50^(1.34)18^2.38^(1.34)19 2.22^(1.41)(table continues)38Item^MSubscale C Working conditions20^2.50^(1.24)21 2.22^(1.16)22^2.97^(1.64)23 3.53^(1.57)24^2.16^(1.25)25 1.88^(1.01)26^2.91^(1.53)27 2.88^(1.79)28^3.00^(1.34)Note. Standard deviations are in parentheses.N = 3239The Hotelling's T2 (equivalent F-test) procedures were used totest both hypotheses (Harris, 1985). Profiles were generated(see Figure 1) as well as within group means for the 28 items(see Table 2). An alpha level of .05 was set.The results of the profile analysis of statisticalhypotheses one and two are as follows:Results: Hypothesis 1The result of Hotelling's T 2 analysis indicated thehypothesis of parallel profiles was tenable since, F = 3.73,27,4, p = .104. The F-ratio was not large enough to rejectthe null hypothesis of parallism at the .05 alpha level.Results: Hypothesis 2The result of Hotelling's T 2 analysis indicated thehypothesis of coincident profiles was tenable, since,F = 2.21, 1,30, p = .147. The F-ratio was not large enough toreject the null hypothesis of coincidence at the .05 level.Summary of Results The results of the profile analysis of the mean responsesof the nurses and technicians on the Sources of StressInventory indicate there was no significant group interactionand there were no significant group differences.40Figure 1. Profile of the mean responses of nurses andtechnicians on the items of the Sources of Stress Inventory.41Table 2Within Group Means on the Items of the Sources of StressInventoryNurses^TechniciansItem MSubscale A Patientsm1 2.55 2.422 2.10 2.003 3.00 3.344 4.75 4.005 3.70 4.086 2.15 1.927 3.10 2.428 3.95 3.759 3.00 2.4210 3.20 2.8311 2.65 2.5012 3.60 3.0813 4.10 3.83Subscale B Staff14 3.45 1.5815 4.15 2.8316 2.70 2.8317 2.60 2.33(table continues)42Nurses^TechniciansItem18^ 2.40^ 2.4119 2.40 2.08Subscale C Working conditions20^ 2.55^ 2.5821 2.40 2.0022^ 3.20^ 2.9223 3.75 3.5024^ 2.50^ 1.8325 2.00 1.8326^ 3.10^ 3.0027 3.90 1.5828^ 3.15^ 3.08Note. Nurses n = 20Technicians n = 1243Chapter 5DiscussionInterpretation of Research Hypotheses The results of profile analysis of the mean responses ofthe nurses and technicians on the Sources of Stress Inventoryindicated that the hypotheses of parallism and coincidencewere supported. Therefore, there appeared to be no overallsignificant group interaction or group differences. However,the profiles generated from the responses on the Sources ofStress Inventory suggested deviations from these results onspecific items. In order to investigate these observationsfurther, profile analysis was carried out on each subscale.The results of such analysis on Subscale A: Patients,supported the overall findings of parallism and coincidence.On the other hand, the results of profile analyses on SubscaleB: Staff, and Subscale C: Working Conditions, did not supportthe findings of parallism, indicating significant groupinteraction in the mean responses of the nurses andtechnicians. In other words, responses to a few of the itemsdepended on whether the individual was a nurse or atechnician. As the test of parallism was rejected forSubscale B and C, the test for coincidence was not applicable(Johnson & Wichern, 1982).The two items on Subscale B: Staff, which most stronglyindicated group interaction were relationship with physicians,and relationship with administration. The one item onSubscale C: Working Conditions, which most strongly indicated44group interaction, was professional development time available(inservice, resource persons). In addition, nurses reportedall three items as being more stressful than technicians (seeFigure 1 & Table 2, items 14, 15, and 27). The responses ofthe technicians and nurses to these three items were the maindeviations from the overall findings of parallism andcoincidence on the Sources of Stress Inventory's 28 items.Although relationships with physicians and administrationhave been noted as sources of stress for nurses, (e.g., DePalma, 1991; Eubanks, 1991), these have not been highlightedin the few studies on technicians and stress. The lack ofprofessional time available for nurses has been mentioned inthe literature, usually within the context of staff shortages(e.g., Aguilar, 1991; Wakefield, 1992). Again, this has notbeen the case for technicians. Thus it appears on the surfacethat these results are consistent with the literature.However, as the number of stress related studies which includetechnicians is extremely limited, interpretation of thesedeviations from either a theoretical or research base isdifficult. One can only speculate that the role of the nursemay necessitate more direct contact with physicians andadministration. This contact could increase the likelihood ofnurses emphasizing this stressor more than technicians as theimpact of the interpersonal relationships themselves, andperhaps the impact of physician/administration directives orpolicies, would be greater.In summary, although there were deviations on a few45items, the overall results suggested that exposure to andsubsequent impact of job related stressors were similar forboth nurses and technicians. These findings are consistentwith the team approach to patient care which is prevalenton most dialysis units.Interpretation of Major Sources of Stress for Nurses andTechnicians Upon examination of the within group means of nurses andtechnicians for each item, and of their profiles, it was foundthat with the exception of the previously noted deviations,similar stressors were salient for both groups.In order of severity, technicians placed greatestemphasis on (a) death of a patient, (b) dealing with angry/aggressive patients, (c) time pressure, (d) complicationsduring dialysis, and, (e) salary; whereas the nurses placedgreatest emphasis on (a) dealing with angry/aggressivepatients, (b) time pressure, (c) complications duringdialysis, (d) salary, and (e) death of a patient (see Table 2,items 4, 5, 8, 13, and 23). Thus, both groups identified thesame items as major stressors, albeit with a slightlydifferent emphasis on each of the five items (see Figure 1).Three of the major stressors reported in this study havealso been noted by other researchers. In particular, timepressure and death of a patient were identified by nurses inthe study by Balck, Dvorak, Speidel and Aronow (1983). Balcket al., linked time pressure to understaffing, an associationdescribed by other researchers with regards to nurses (e.g.,46Aguilar, 1991, Guillory & Riggin, 1991; Pines and Kanner,1982; and Wakefield, 1992). O'Brien (1983) noted that bothtechnicians and nurses regarded being overworked as a majorstressor. Further, O'Brien's (1983) study also found thatwhether the death of a patient was viewed as a major stressordepended on the circumstances surrounding the patient's death.Another factor which could alter the impact of such a stressoris the degree to which the issue of patient death is addressedin formal training. One could speculate that perhaps nursesplaced slightly less emphasis on this stressor compared totechnicians due to their training.Interestingly, two major sources of stress for bothnurses and technicians, complications during dialysis, andsalary, have not been typically reported in the literature.With regards to complications during dialysis, this could beattributable to the various techniques used for gatheringdata. For example, it is doubtful whether this item would beon stress questionnaires which are, (a) adapted from otherspecialty units, (b) related to attitudes and perceptions ofpatient-staff relationships, and (c) related to work stress ingeneral. Further, this item would unlikely be mentioned instructured interviews. Finally, the emphasis of observationstudies on patient-staff relationships could preclude therecording of complications during dialysis as a stressor.The same factors may account for the lack of reporting inthe literature with respect to salary; however, additionalfactors may have contributed to its conspicuous absence. For47example, staff may fear that such a response could beinterpreted as not being "dedicated", or not having the"right" attitude towards their work. Therefore, suchinformation would tend not to be elicited from participants inpersonal interviews, or on questionnaires in which theiranonymity was not guaranteed. Despite such a guarantee, eventhose studies which utilized questionnaires with open-endedquestions could have been similarly affected by such fears orperceived stigmas. Unless salary was listed as just one ofmany other items on a questionnaire, it is doubtful whetherthis source of stress would have been identified byresearchers. As previously stated, although salary was notspecifically referred to as a major source of stress in theliterature, Pines & Kanner (1982) noted that the absence ofpositive conditions of work may have as much impact on nursingstaff as the presence of negative stressors.In brief, although there were slight differences in themean responses on to these particular items, profile analysisof the data suggested that the same stressors were salient forboth the group of technicians and the group of nurses.Moreover, there appeared to be no overall significant groupdifferences on the other 23 items of the Sources ofStress Inventory.Limitations of the StudySample limitations From a statistical point of view, the generalizability ofthis study to a larger population is limited due to the48absence of randomization, and is only possible to the extentthe nurses and technicians who participated in this study arerepresentative of the larger population of nurses andtechnicians. Therefore, such generalizations should be madewith caution. The small sample size of this study (N=32)further limits the generalizability of this study.Measurement limitations Psychometric analysis indicates that the Sources ofStress Inventory has high internal consistency. However, theinstrument is limited to face validity only.Design limitations This study, a nonexperimental group comparison design,is exploratory and descriptive in nature.Conclusions The results of this study have confirmed the feasibilityof including technicians as well as nurses in counsellinginterventions, for example, staff support groups. As therewas no significant group interaction or group differences inthe mean responses of the nurses and technicians, it appearedthat both groups shared similarities with respect to theidentification and rating of the sources of stress found on akidney dialysis unit.Psychometric analysis on the initial trial of the Sourcesof Stress Inventory suggested that the instrument had highinternal consistency and face validity. These resultsindicated that the measure identified sources of stress andthe magnitude of their impact as perceived by nurses and49technicians employed on the kidney dialysis units representedin this study.In addition to these main conclusions, the inclusion oftechnicians as well as nurses in this study (in which malesand females were represented in both groups), may havetheoretical implications. The premise of earlier researcherssuch as Kaplan De-Nour and Czaczkes (1968), and Moore (1972),that female dependency needs contributed to stressful staff-patient relationships may have resulted from erroneousinterpretations of the behaviour of their all female nursingsample.Recommendations A review of the literature indicates that demand forkidney dialysis services will continue to increase.Consequently, the identification of sources of stress for bothtechnicians and nurses is imperative, for without thisinformation counselling interventions cannot be appropriatelyselected and initiated. Therefore, the following stepstowards achieving this goal are recommended:1. The Sources of Stress Inventory could bereadministered to the nurses and technicians of Long BeachVeteran's Administration Medical Center and Harbor-Universityof California, Los Angeles (UCLA) Medical Center; and ifpossible, administered to nurses and technicians of adifferent hospital within the Los Angeles area.2. 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Patient and Technicians: A Dual Role.Nephroloqy Nurse, 2(3), 4-46.57Appendix ASources of Stress InventoryPlease indicate the amount of stress you experience in the following areas by circling one of 6 numbersin each item (#1 indicating Low stress to #6 indicating High stress).How much stress do you experience as a result of:A) PATIENTSLow HighStress Stress(1) Putting patients on dialysis treatment ^ 1 2 3 4 5 6 3__(2) Taking patients off dialysis treatment 1 2 3 4 5 6 4(3) Dealing with depressive patients ^ 1 2 3 4 5 6 5__(4) Dealing with angry/aggressive patients ^ 1 2 3 4 5 6 6(5) Death of a patient ^ 1 2 3 4 5 6 7__(6) Transfer of patients 1 2 3 4 5 6 8(7) Having long-term relationships with patients ^ 1 2 3 4 5 6 9__(8) Complications during dialysis (ie. seizures, drop inblood pressure, etc.) ^ 1 2 3 4 5 6 10__(9) Non-compliance (diet) 1 2 3 4 5 6 11__(10) Non-compliance (fluid) 1 2 3 4 5 6 12(11) Dealing with patients'^families ^ 1 2 3 4 5 6 13__(12) Deterioration of patients' condition 1 2 3 4 5 6 14(13) Time pressure ^ 1 2 3 4 5 6 15__B) STAFF1 2 3 4 5 6 16__(14) Relationship with physicians ^(15) Relationship with administration 1 2 3 4 5 6 17(16) Relationship with nurses 1 2 3 4 5 6 18__(17) Relationship with technologists ^ 1 2 3 4 5 6 19(18) Workload assignment ^ 1 2 3 4 5 6 20__(19) Staff turnover 1 2 3 4 5 6 21C) WORKING CONDITIONS1 2 3 4 5 6 22_(20) Patient-staff ratio ^(21) Number of hours of work 1 2 3 4 5 6 1 23_(22) Working conditions 1 2 3 4 5 6 24(23) Salary ^ 1 2 3 4 5 6 25__(24) Vacation and holiday time ^ 1 2 3 4 5 6 126(25) Sick leave time available 1 2 3 4 5 6 27__(26) Machine problems ^ 1 2 3 4 5 6 28_(27) Professional development time available 1(inservice,^resource persons) ^ 1 2 3 4 5 6 29_(28) Your job in general ^ 1 2 3 4 5 6 13058Appendix BSources of Stress Inventory Test Item Analysis (N = 32) Item^ Discrimination IndexSubscale A Patients1^ .682 .533^ .704 .745^ .456 .697^ .398 .689^ .5610 .5711^ .6712 .7213^ .58Subscale B Staff141516171819.36.60.74.51.66.49(appendix continues)59Item Discrimination IndexSubscale C Working conditions20 .6021 .5122 .5123 .6424 .6625 .4426 .2727 .1528 .64Note. With the exception of one,were reasonably high.discrimination indices

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