Nurses' perceptions regarding work stressors level
The majority of the sample (85.7%) had a positive level of work stressors which means that nurses who were working at COVID-19 units were exposed to workplace stressors. This outcome is expected since the nursing profession is considered a stressful profession, especially with Covid-19 outbreaks. Dealing with COVID-19 patients raises the stress level among nurses; this might be due to several factors such as fear of contagion, the dramatic increase in the number of patients, deficient knowledge about the virus, and fear to catch the infection and deliver it to family members. These results are in line with CDC (2008) and NIOSH (2008) which considered nursing as a highly stressful profession. Kang et al. (2020), Xiang et al. (2019), and Huang et al. (2020) emphasized that the COVID-19 outbreak was a stressful event for nurses who deal with confirmed cases of COVID-19.
In the current study, the most stressor mentioned by participants was firstly work demand (WD). This might be related to the dramatically increasing number of COVID-19 patients. The nurse-patient ratio was higher than the usual ratio during the COVID-19 crisis, and the responsibilities of staff nurses were extended to cover other non-nursing responsibilities, these results agreed with Maraqa et al. (2020).
The second stressor reported in the study was a work-family conflict (WFC). This might be related to the rotating shifts which were opposed to the social life for nurses, and most nurses are required to work additional hours to compensate for staff shortages resulting from the absence of infected nurses, this result goes along with Ekici et al. (2017).
The third stressor mentioned in the study was powerlessness (PL) which symbolizes contact with suffering and sick patients. This result may be attributed to the increase in the death rate among COVID-19 patients in Jordan. This result agreed with Blanco-Donoso et al. (2020) who asserted that nurses, where COVID-19 had been detected, had a high level of secondary traumatic stress contact with suffering and death issues.
The fourth stressor was work violence and bullying (WVB). Nurses complained of violence and bullying in the workplace. Guissi et al. (2019) reported that the lack of respect between coworkers was associated positively with stress in the workplace. Furthermore, Al-Ghabeesh and Qatoom (2019) reported that 90% of emergency department nurses reported that they have experienced bullying.
Nurses' perceptions regarding the intention to leave level
In our analysis, more than half of the participants had a slightly positive level of intention to leave, which means nurses who work at the COVID-19 unit had the intent to quit their job and are more likely they will in the future. 21.4% of the sample had a moderately positive intention to leave level. These outcomes are expected because the clinical practice of nursing at COVID-19 units is stressful. High work demands, a high number of COVID-19 patients, and fear of COVID-19. Additionally, quarantine conditions might influence nurses to be more overworked, stressed, and had low job satisfaction. This might push nurses to think about leaving their jobs. Our finding agreed with Labrague and De Los Santos (2020), who revealed that an increased level of fear of COVID–19 was associated with decreased job satisfaction, increased psychological distress, and increased organizational and professional intentions to leave.
Differences in work stressors scores according to demographic data of nurses
This study found a significant negative relationship connected the work stressors scores with nurses' ages, and the experience duration in each nursing, current hospital, and in COVID-19 isolation units. The finding might be explained as that younger and less experienced nurses do not yet acquire effective coping mechanisms with such stressors as older and more experienced nurses. Furthermore, nurses who hold high education levels had more psychological and cognitive development in interpretation and coping with stressors than nurses who hold less level of education. For marital status, single nurses had a high level of stressors than married nurses because single nurses during the COVID-19 outbreaks were forced to cover the work schedule in longer shifts than married nurses. These results were supported by Ali et al. (2020), and Mosadeghrad (2013). Our results are opposed to Higazeeet al. (2016) who reported that being married with high education level scored relatively high levels of job-related stress.
Differences in intention to leave scores according to demographic data of nurses
This study found a significant negative relationship connected the intention to leave with nurses' ages, and experience duration in each of the nursing, current hospital, and COVID-19 isolation units. This might be explained by that younger and less experienced nurses are more likely ready to take the risk of quitting their occupational position because there is a strong perception that they can easily find another job. Further, a significant difference in scoring for marital status where single nurses recorded high scores of intentions to leave than married nurses because married nurses had more responsibilities toward their families. Education levels had also a significant difference in the scoring of intention to leave, whereas participants who hold higher education degrees had a lower intention to leave score. Furthermore, nurses who hold higher education degrees had other administrative roles besides working with patients in the workplace, and thus their contact with patients is less than nurses who hold less degree of education. These results are consistent with De Oliveira et al.(2017) who reported that being young was one of the major factors that contributed to the intention to leave among nurses. Yáñez et al. in (2020) asserted that older healthcare providers had lower levels of intention to leave compared to their younger colleagues. These results are not going in line with Omar et al. (2015) who found that age, marital status, and educational level had no significant differences in intention to leave.
Relationship between work stressors and intention to leave
Our findings showed that work stressors have a significant positive relationship with the intention to leave. This could be explained as nurses who have more work stressors may not satisfy with their job which led them to leave their work. On the other hand, working in COVID-19 units may contribute to psychological distress and dissatisfaction that lead to nurses' intention to leave. A previous study asserted that work stressors were a path for the intention to leave whereby stressors led to job dissatisfaction and leaving the profession (Loet al., 2018). In general, these findings are consistent with Labrague and De Los Santos (2020), Khattaket al. (2020), (Nantsupawat et al., 2017), and Mosadeghrad(2013).
Regarding the relationship between each work stressor and intention to leave, there were significant positive correlations between all work stressors and intention to leave with differences in the strength of the correlation. These findings are consistent with a previous literature review of 37 articles done by Al-Zamel et al. (2020) who reported that intention to leave was associated positively with many factors including bullying at the workplace, workload, and family reasons. Previous research has also shown that organizational factors like leadership and career advancement had an excessive impact on the intention to leave (Alhamwan et al., 2015).
Limitations
The generalizability of the findings is limited because a convenience sampling scheme was adopted, secondly, the study represents governmental hospitals only, and there was no representation of the private and military hospitals. In addition, because the study is specific to the COVID-19 isolation units, the findings cannot be generalized to other nurses working in other settings. The study used a self-report questionnaire which means that results might include response bias. This would be because of the possibility that the respondents completed the questionnaires to only fill them out.
Implications and Recommendations
The current study addressed the perceptions of work stressors and intention to leave among Jordanian nurses who worked at isolation units and dealt with COVID-19 patients. Thus, this study might be considered the base for further studies that will be conducted to investigate work stressors and their effects on nurses. It is recommended to conduct qualitative studies to explore in depth the stressors faced by Jordanian nurses at COVID-19 units and to understand the organizational factors and personal characteristics that may help nurses to cope with such stressors. In addition, comparative studies between working in isolated units and non-isolated units are recommended to determine the effect of isolation on work stressors and intention to leave.
Unfortunately, the level of stressors in the workplace can affect the physical and psychosocial aspects of nurses. The findings of this study indicate the importance of adopting nurses stress management techniques like meditation, breathing exercises, music listening, sport, and expression of feelings.
The findings of this study indicate the importance of articulating policies and strategies that prevent and manage work stressors in the workplace. This will decrease the intention to leave, increase job satisfaction and productivity, and improve the quality of nursing care outcomes.
Nursing students should be well prepared for working under pressure, dealing with work stressors, and working during crisis such as COVID-19. Therefore, stress management and crises courses should be integrated with the nursing curricula of undergraduate students to help them in dealing with such crises.
Nursing Administration
The findings of this study indicate the importance of articulating policies and strategies that prevent and manage work stressors in the workplace. This will decrease the intention to leave, increase job satisfaction and productivity, and improve the quality of nursing care outcomes. Jordanian nurse leaders and policy-makers should be encouraged to create a healthy work environment by submitting an organizational change. Organizational change might include the following: reducing workload; encouraging healthy relationships between workers; avoiding violence and bullying; and providing sufficient support from managers.
Nursing administrators need to use effective policies to reduce these stressors at work. Because work stressors are associated with intention to leave of the workers, it is very important to minimize stressors by applying and implementing the correct interventions.
Reducing workload is recommended by supplementing the nurses units with additional nurses and adjusting the roles and tasks between nurses in the organization. Creating a respectful and cooperative working environment can reduce bullying and improve the relationship among workers.
The results of this study invite nursing leaders and managers to be more conscious of workplace stressors. They should be more supportive to their team member. Moreover, conducting educational programs for nurses concerning dealing with COVID-19 patients is vital to reduce stress and fear associated with COVID-19 outbreaks among nurses. Nurses are in need to get updated information and training to learn more about how to deal with COVID-19 in order to cope with work stressors. The information which should be presented to nurses should include: the nature of the COVID-19 virus, proper precautions to avoid transmission, and the recent trends in managing COVID-19 patients.