Work Stressors and Intention to Leave Among Jordanian Nurses During COVID-19: A Cross-sectional study

Abstract

Background: Nurses come across several stressors in the workplace, especially during COVID-19 outbreaks. Work stressors are associated with physical and psychological health problems among workers and thus increase their intentions to leave work. Aim: This study aimed to identify Jordanian nurses’ perceptions regarding work stressors and intention to leave levels, examine if nurses' perceptions regarding work stressors and intention to leave scores differ across nurses' demographic data, and investigate the relationship between work stressors and intention to leave.

Methods: A descriptive cross-sectional study was conducted. A convenient sample of 154 nurses who worked with COVID-19 patients participated in this study. Self-reported questionnaires were sent online via social media applications to participants. 

Results: Most of the participants (85.7%) had a positive level of work stressors regarding their perceptions. Concerning the intention to leave, 57.8% of participants had a slightly positive level, and 21.4% had a moderately positive level. There were significant differences in work stressors and the intention to leave scores according to nurses' age, marital status, educational level, and experience duration (p< 0.015). Also, work stressors significantly correlated with intention to leave (r = 0.52, p< 0.001). 

Conclusions: Health organizations must adopt strategies, programs, and policies to reduce work stressors and the intention to leave among nurses during these stressful events.

Background

Work stressors are factors within workplaces that have been shown to influence feelings of stress among employees in the workplace (Centers for Disease Control and Prevention [CDC], 2018); National Institute for Occupational Safety and Health [NIOSH], 2018). The mismatch between work demands and worker's capabilities leads to work-related stress which is associated with physical and psychological health problems among workers, increased absenteeism, and intention of workers to leave their work (CDC, 2018; NIOSH, 2018). Stress in the work environment will worsen if employees feel that they are unsupported by their colleagues and supervisors (World Health Organization [WHO], 2020).

Healthcare workers including nurses encounter several stressors in the workplace (American Psychological Association [APA], 2019; NIOSH, 2019). The sources of stress for nurses might be attributed to several factors such as work overload, time pressure, lack of social support at work, exposure to infectious diseases, needle stick injuries, exposure to work-related violence or threats, sleep deprivation related to rotating shift, role ambiguity and conflict especially for novice nurses, understaffing, career development issues, and dealing with seriously ill patients (CDC, 2008; NIOSH, 2008).

Stress in the workplace has several adverse consequences on healthcare providers which are classified as; psychological impacts including anxiety, depression, and job dissatisfaction; behavioral impacts such as sleep problems, absenteeism, and turnover; and physical impacts including headache, irritable bowel syndrome, and high blood pressure (CDC, 2016; NIOSH, 2016).Most of the previously mentioned consequences were considered as factors that impact the quality of care provided to patients, there is a relationship between these consequences, and burnout and poor patient safety  (Hall et al., 2016) 

In Jordan, studies have shown that stress in the nursing profession is related to several factors including patient demands, work overload, in-work conflicts, lack of staff, lack of organizational and supervisor support, and role ambiguity (Higazee,2015; Rayan et al., 2016). On the other hand, work stressors are one of the major factors that lead to the intention to leave and actually quit the nursing profession (Lo et al., 2018). Lo and colleagues (2018) asserted that job stressors negatively affect job satisfaction. Intention to leave was correlated positively with job stressors including violence and bullying at the workplace; workload; and work-family conflict (Al-Zamel et al., 2020).

COVID-19 puts the health sector and healthcare workers around the world as the first line of defense against this infectious disease especially nurses who are standing bravely against COVID-19 (Misra, 2020). Healthcare providers, including nurses, experienced several factors related to work stress during the COVID-19 outbreak such as; fear of death, high-risk infection, negative emotions, and loss of contact with their families (Kang et al., 2020& Xiang et al., 2019). Also, the increasing number of patients and the absence of healthcare workers due to sickness, and death contributed to raising both occupational and psychological stress (Chen et al., 2020). Such stressors may also impact negatively nurses in various aspects including absenteeism, turnover, and medical errors (CDC, 2008; CDC, 2020; NIOSH, 2008).

Turnover in the healthcare sector is a serious worldwide problem due to the increasing demand for health services (Shanafelt et al., 2017).In addition to the high turnover cost associated with recruiting and training new employees (Worku et al., 2019(. Jordan, like other countries, faces the problem of work stressors and intention to leave among healthcare workers, especially during the outbreaks of COVID-19 (Alghunmeen et al.,2020&Alnaeem et al., 2022). Yet, there are no studies conducted in Jordan to explore the perceptions of work stressors and intention to leave or to examine the relationship between these work stressors and intention to leave among nurses during COVID-19 outbreaks. 

Thus, this study addressed the gap in the literature and aimed to identify the nurse’s perceptions of work stressors and intention to leave and to investigate the relationship between the previously mentioned variables among Jordanian nurses during COVID-19 outbreaks.

In addition, the results of this study could guide policy-makers and managers in assessing work stressors and consequently developing a work stress prevention or management program that is tailored to Jordanian nurses when dealing with such crises. Prevention and management of work stressors among nurses will not only improve their health but also decrease their intention to leave, increase job satisfaction and productivity, enhance patients’ safety, and improve the quality of nursing care outcomes. 

Research Questions:

1. What are the perceptions of work stressors level, and intention to leave level among Jordanian nurses during the COVID-19 outbreak?

2. Are there significant differences in the work stressors scores according to demographic data of Jordanian nurses during the COVID-19 outbreak?

3. Are there significant differences in intention to leave scores according to demographic data of Jordanian nurses during the COVID-19 outbreak?

4. Is there a relationship between work stressors and intention to leave among Jordanian nurses during the COVID-19 outbreak?

Literature Review

Search Strategy: The literature was retrieved from the ELSEVIER database (Science Direct), Google Scholar, and PubMed. The database search was carried out through several phases with different combinations of keywords, such as: ‘nurses stress’, ‘nurses occupational stress’, ‘nurses' work stressors’, ‘work-related stress’, ‘intention to leave’, ‘turnover’, and ‘COVID-19 impact’. 

Plenty of studies have been globally conducted to explore work stressors and factors in the workplace which influence stress among nurses. Kokoroko and Sanda (2019) found that there was a significant positive correlation between workload and job stress. Rayan et al. (2019) considered workplace bullying and violence as major causes of stressors in nurses’ workplaces, and they found a positive relationship between variables. The stressors in the workplace that were resulted from bullying and violence could impact both productivity and quality of care (Al-Ghabeesh & Qatoom, 2019). Moreover, Work-family conflict (WFC) which occurred when demands of the work role, as opposed to family or personal life roles contributed to high-stress level among nurses, affected their job satisfaction, and led them to leave the job (Ekici et al., 2017). 

On the other hand, work environments including social (i.e., relationships in work) and physical environments in the workplace were reported as nurses' work stressors by several studies. Some of these studies were conducted to study coworker support, relationships, and the impact of workplace stress. For instance, working conditions, relationships between and among coworkers, and support from management were factors that affected job satisfaction or dissatisfaction. The lack of respect between the coworkers is associated positively with stress in the workplace (Guissiet al., 2019).

Similarly, Mosadeghrad’s (2013) results showed that 34.9 % of nurses had a high occupational stressors rate. These stressors were associated positively with the workload, understaffing (nurse shortage), insufficient break time, inadequate pay, unsupportive management, poor work environment (conflict with co-workers, uncooperative environment), and organizational issues.

The Chronic stress in the workplace might lead to burnout. Burnout was considered as a predictor for; (1) physical consequences such as hyperlipidemia, diabetes type two, coronary heart disease, muscular pain, fatigue, headaches, and gastrointestinal issues; (2) psychological problems including insomnia, depression symptoms, anxiety, and other psychological ill-health symptoms; (3) professional outcomes such as job dissatisfaction, absenteeism, performance imbalance, decrease productivity, and turnover (Salvagioni, et al. 2017; Nashwan, et al. 2021; Nashwan et al. 2020). Work stressors are one of the most factors that led to the intention to leave (Mosadeghrad, 2013). 

In Jordan, several studies were also conducted to explore factors that influence the intention to leave among Jordanian nurses. Alhamwan and colleagues (2015) asserted that organizational factors like leadership, career advancement, and pay level had an excessive impact on the intention to leave (Alhamwan, et al. 2015). The safety climate and team working at work had a positive effect on creating a healthy work environment and increasing the intent to stay among nurses (Abu Alrub, et al., 2016). Whereas the intention to leave was associated negatively with organizational commitment, high quality of work life, and job satisfaction. These variables were affected by support (friends, peer family, and supervision support), pay, coping mechanisms, leadership style, and work environment. (Al-Zamel, et al., 2020). It is also important to mention that, some studies linked both work stressors and intention to leave with nurse’s demographic data (Higazeeet et al., (2016), De Oliveira et al., (2017), Omar et al. (2015), Ali et al. (2020). and Sharififard et al. (2019), 

In conclusion job stressors were a path to the intention to leave whereby stressors led to job dissatisfaction, and in turn led to leaving the profession (Lo, et al., 2018).

Currently, many researchers investigated the impact of current outbreaks of (COVID-19) on workers, work stressors, and intention to leave. Shreffler and colleagues (2020) revealed that healthcare workers who dealt and compacted with COVID-19 reported high psychological effects including; stress, anxiety, and depressive symptoms. 71% of staff nurses were worried about getting COVID-19 patients and demonstrated a high level of workload-related stress resulting from providing care for infected patients (Ali et al. 2020). Also, they found that 82% of nurses have stress about the transmission of infection to their friends and family.  COVID-19 outbreak has put heavy pressure on nurses especially those in frontline defense (Huang et al.2020).  Healthcare providers, especially nurses, experienced significant problems associated with work stress during the COVID-19 global outbreak. These problems include fear of death, high-risk of infection, negative emotions, and loss of contact with family due to the infectious nature of the disease (Kang, et al. 2020 & Xiang, et al. 2019). Several factors that contributed to feelings of stress among healthcare workers. These factors include the followings: lack of personal protective equipment; inadequate guidance and training in dealing with COVID-19; time pressure and long work hours; the risk of catching infection; the risk of bringing the infection to family members; the uncertainty of information about COVID-19; and colleagues’ fear. High levels of stress led to an increase in sick leave requested and absenteeism among healthcare workers which in turn contributed to increased workload, increase burdens on their colleagues, and also affected the total patient care (Maraqa et al., 2020). Increasing fear levels from COVID–19 were associated with decreased job satisfaction, increased psychological distress, and increased organizational and professional intentions to leave (Labrague & De Los Santos, 2020). 

According to the literature, work stressors in nursing can be affected by three major factors; firstly, individual characteristics of nurses such as age, gender, qualification, and years of experience. Secondly, organizational conditions include workload, bullying environment, the hazard of the workplace and relationships at work. Thirdly, patients issue such as satisfaction and caring process. All work stressors can affect negatively the satisfaction of nurses, care quality including patient safety, and productivity if there is no response from the management lines to prevent them or to decrease the consequences of these stressors in the work environment. Lack of satisfaction among nurses may lead to workers thinking about quitting and decreasing the productivity of workers which will reflect on the quality of care, the organization productivity, and finally may lead to the expensive cost paid by the organization in terms of losing expertise, losing continuity of care process, recruiting new worker, and training cost of the new workers..

Methodology

Study design

This study employed a descriptive cross-sectional correlational design. The study was descriptive as it aimed to identify nurses' perceptions of work stressors level and intention to leave level, and correlational as it aimed to investigate the relationships between the study variables which are work stressors and intention to leave.

Settings of the study

This study was conducted in the COVID-19 isolation nursing units in two Jordanian public governmental hospitals. These hospitals are specialized in dealing with COVID-19 patients from the beginning of the outbreaks in Jordan. The total bed capacity for the first hospital is 166 beds, and the total number of nurses in isolation units is 150 nurses. The second hospital includes 65 beds for COVID-19 cases and the total number of nurses in isolation units is 100 nurses. 

Study Population

The target population was all nurses working in rotating shifts at Jordanian COVID-19 isolation units. The accessible population was nurses working in all isolation units at the selected hospitals. 

Sampling scheme and sample size

A convenience sampling scheme was used. The sample size was estimated by using a sample size online calculator (Creative Research Systems. Survey software) based on the study population, with a predetermined confidence level of 95%. Taking into consideration that the accessible population size is around 250 nurses, the sample of nurses required to have proper generalizability for the results was calculated to be 152 nurses. The invitations were sent to more than 200 nurses for a possible low response rate.

Inclusion/exclusion criteria:

The inclusion criteria were: (1) Jordanian nurses with at least a diplomas degree (practical associated nurses), (2) nurses who work in rotating shifts, (3) having at least 1 year of experience in the current workplace, (4) nurses who deal with COVID-19 patients, (5) having experience at least 6 months in COVID-19 unit.

The exclusion criteria were: (1) nurses who have less than 6 months of experience in COVID-19 isolation units, (2) nurses who have managerial positions and work on the 1^st shift only because managers had less contact with COVID-19 patients.

Study Instruments

Data collection instruments that used in this study included: (1) A socio-demographic and professional characteristic data sheet; (2) Nurses Occupational Stressors Scale (NOSS); (3) Turnover Intention Scale (TIS).

(1) Socio-demographic and professional characteristic data sheet. Participants were asked about their age, gender, marital status, education level, number of years in practicing nursing, number of years in practicing nursing in the current hospital, and number of months practicing nursing in the COVID-19 isolation unit.

(2) Nurses Occupational Stressors Scale (NOSS) -21 items developed by Chen et al.(2020). It contains 21items that are distributed into nine subscales as follows:(1) work demands subscale 3-items, (2) work-family conflict subscale 3-items, (3) insufficient support from coworkers or caregivers subscale 3-items, (4) workplace violence and bullying subscale 1-item, (5) organizational issues subscale 3-items, (6) occupational hazards subscale 2-items, (7) difficulty taking leave subscale 2-items, (8) powerlessness subscale 2-items, and (9) unmet basic physiological needs subscale 2-items. All items are scored on a 4-point Likert scale (1 to 4 representing the nurses response about work stressors "strongly disagree", "disagree", "agree", and "strongly agree" respectively). The mean of the 21 items was used to estimate the participants' occupational stressors levels. The mean of the NOSS is ranged from the lowest mean 1 to the highest mean 4 (Chen et al., 2020). Therefore, the mean was divided into 4 intervals reflected 4 levels of occupational stressors (strong negative level (1-1.49), negative level (1.5-2.49), positive level (2.5-3.49), strong positive level (3.5-4)) as suggested by (Chen et al., 2020). This scheme has more than 90% efficiency in avoiding the mean interpretation biases of a 4-point Likert scale (Pornel et al.,2011). The Cronbach's score of the 21-item NOSS as a whole was 0.91. The content validity index of the NOSS was 0.81. The NOSS was chosen in this study for some reasons including (1) a comprehensive assessment of nursing work stressors, (2) twenty-one items only, so relatively little time is required for its filling. 

(3) Turnover Intention Scale (TIS): was developed by Michaels and Spector (1982). It is used to predict the intention to leave of employees. It contains 3-Items. All items were scored on a 6-point Likert scale (1 to 6 representing the nursing response about the intention to leave "strongly disagree", "moderately disagree", "slightly disagree", "slightly agree", "moderately agree", and "strongly agree" respectively) (Michaels & Spector, 1982). This scale includes questions asking how often respondents seriously thought about quitting their job, whether they wanted to quit, and whether they were planning to quit by starting to look for another job ( Michaels & Spector, 1982).The turnover intention score was an average sum of scores of the three items, ranging from 1 to 6, reflecting the intention to leave levels respectively as (Strong Negative (1-1.83), Moderate Negative (1.84-2.67), Slight Negative(2.68-3.51), Slight Positive(3.52-4.35), Moderate Positive(4.36-5.19), and Strong Positive(5.2-6) as recommended by (Michales& Spector, 1982). The Cronbach’s alpha score for the scale is 0.80 (Michaels & Spector, 1982). The scale is a valid and reliable measurement to detect employee turnover intentions (Michaels & Spector, 1982).  

Ethical Considerations

Official approvals were obtained from the institutional review board (IRB) of Zarqa University, the Jordanian Ministry of Health, and the selected hospital administrative authorities.

A consent form, study objectives, and confidential assurance were sent with the questionnaires to avoid ethical concerns regarding enrolling participants in the study against their willingness. Participants were assured that their participation is completely voluntary without any coercion. All data which were collected for this study including the Online application properties of participants were in the safekeeping of the researcher (password-locked personal computer). The participants were assured that all obtained information was used for research purposes only. 

Pilot study

A pilot study was employed online. The pilot sample size is recommended to be equal to 10% of the estimated sample size (Connelly, 2008). Thus, the pilot study was conducted with 20 nurses chosen conveniently from Al-Basheer hospitals. The pilot study was conducted to test the clarity of the questionnaires, evaluate participants’ understanding of the questionnaires, and determine the estimated time required to fill the questionnaires. The participants completed the questionnaires within 10-15 minutes. They expressed their understanding and satisfaction with the clarity and simplicity of the items in the questionnaires.

Data collection Procedure: 

The researcher visited the director of nursing of each hospital to sign the ethical approval form and to explain the purposes of the study. The researcher then visited the data collection floors and introduced herself to the head nurses and targeted nurses, and informed them about the study’s purposes. The researcher also explained the study’s data collection methods. After getting approval from nurses to participate in this study, they suggested using their WhatsApp work groups to participate in the study. The number of managers was taken to facilitate communication with participants. Online software was used to design an electronic web-based questionnaire package. This package contains a consent form, the objective of the study, guidelines to fill out the questionnaires, and the instruments. An invitation was sent using WhatsApp to the manager. Then this invitation was sent to WhatsApp groups to the participants in the selected hospitals. Reminding message was sent after 1 week of the first invitation through WhatsApp to all participants through WhatsApp work groups by their manager. This method was used to reach as many nurses as possible in COVID-19 because of the quarantine circumstances, participants' preferences and to comply with social distancing guidelines. Data collection was started on (February 21, 2021) and was completed on (March 20, 2021).

Data analysis

Before conducting data analysis, the researcher checked all the questionnaires to assess if participants meet the inclusion criteria. All participants who did not meet the inclusion criteria were excluded from the study. Data were analyzed using the Statistical Package for Social Science (SPSS), Version 25. Frequencies and percentages, means, and standard deviation were included to describe study variables including demographic variables, work stressors items, and intent to leave items. Mann-Whitney U, Kruskal-Wallis, and Spearman’s rho correlation tests were used to investigate the relationships between samples' demographic data and both work stressors and intention to leave, the non-parametric tests were used because there were violated assumptions in the parametric test. Pearson’s r-coefficient correlation was used to determine the presence, and the direction of a relationship between the work stressors and intent to leave, and the assumptions of Pearson’s r-coefficient test were met. 

Results

One hundred and fifty-four nurses participated in the current study who ranged in age from 23 to 39 with an average age of 29.59 years. The majority of the sample age 45.5% fell below the mean. The nurses had an average of 5.75 years of practicing in nursing, an average of 3.91 in their current hospital. 55.2% of the sample had 5 years or lower in practicing nursing and 74.7% for the same interval for practicing nursing in the current hospital. Nurses had an average of 8.27 months in practicing nursing in COVID-19 isolation units and 61.1% of the sample had worked in the COVID-19 isolation unit for (6-8) months and 37% for (9-11) months. There is a convergence ratio for both gender male and female presentations. More than half of the sample was married. The majority of the sample (74.7%) had a bachelor’s degree in nursing. 18.2% of participants had a diploma degree in nursing and 7.1% had a master’s degree in nursing (Table 1).

Nurses' perceptions regarding work stressors level

The total work stressors score for the sample in this study ranged from 2.19 to 3.81. The mean score was 3.17. The work stressors levels for the sample started from the negative level which remains an absence of the strong negative level. The majority of the sample 85.7% had a positive work stressors level, 11% of the sample had a strong positive work stressors level, and 3.2% represented a negative work stressors level (Table 2).

In deeper, higher than 50% of the sample had a positive level for all work stressors except for work-family conflict (WFC). Where WFC was reported as a strong positive level for 61.7% of the sample. 

Nurses' perceptions regarding the intention to leave level

The score for the sample in this study ranged from 2 to 5.33. The mean score was 4.03. The intention to leave levels for the sample started from the moderate negative level which remains an absence of the strong negative level. The majority of the sample 57.8% had a slightly positive intention to leave level, 21.4% of the sample had a moderate positive level, and 6.5% had moderate negative intention to leave level (Table 3).

Differences in work stressors and intention to leave scores according to demographic data of nurses

Data analysis revealed no significant differences between males and females regarding their work stressors scores. The analysis of the Mann-Whitney U test revealed that male nurses work stressors scores were higher than female nurses scores (U = 2901.5, Z = - 0.22, p = 0.82) (Table 4). Again, the Mann-Whitney U test was used to test any significant difference between single and married nurses. Data analysis revealed that there was a significant difference between single and married nurses concerning their work stressors scores. The analysis of the Mann-Whitney U test revealed that work stressors scores for single nurses were higher than married nurses scores (U = 2112.5, Z = - 3.00, p = 0.003) (Table 4). 

Relationship between work stressors and intention to leave

Pearson correlation coefficient was run to detect and determine the relationship between work stressors and intention to leave. According to Kowang et al. (2015) Pearson correlation interpretation, there was a moderate, positive significant relationship between the two variables (r = 0.52, p<0.001) (Table 5).

Kruskal-Wallis test showed that there was a significant difference between education levels regarding the work stressors scores (Kruskal-Wallis H = 13.06, df = 2, p= 0.001) which revealed that the work stressors had been scored high to low respectively by diploma, bachelor, and master degree holder nurses (Table 6).

When the Mann-Whitney U test was enrolled to test any significant differences between males and females. Data analysis revealed no significant differences between males and females regarding their intention to leave scores. The run analysis of the Mann-Whitney U test revealed that female nurses’ intention to leave scores was higher than male nurses scores (U = 2805.5, Z = - 0.575, p= 0.56) (Table 7).

 Data analysis revealed that there were significant differences between single and married concerning their intention to leave scores. The run analysis of the Mann-Whitney U test revealed that intention to leave scores for single nurses were higher than married nurses scores (U = 2276.5, Z = - 2.43, p = 0.015). 

Discussion

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.

Conclusion

The current study shed the light on the work stressors and intention to leave among nurses who work at COVID-19 units in Jordanian hospitals. Furthermore, we explored the perception of work stressors and intention to leave among Jordanian nurses and their relationship with each other. Most nurses had a positive level of work stressors and more than half had a slightly positive level of intention to leave. There was a significant positive correlation between work stressors and the intention to leave. There was a significant negative relationship connects both of nurses' age and experiences durations with both work stressors and intention to leave. Also, there were significant differences in scoring both work stressors and intention to leave regarding education level and marital status.

We suggest that understanding the work stressors that face nurses at COVID-19 units is essential to generate strategies and policies that decrease such stressors. Consequently, increasing nurses' satisfaction, enhancing patients’ safety, improving nursing outcomes. and decreasing intention to leave.

Declarations

Ethics approval and consent to participate

The study was granted ethical approval to conduct the study by the Institutional Review Board (IRB) at Zarqa University, the Jordanian Ministry of Health, and the selected hospital administrative authorities. Informed consent was obtained from all participants. All research activities were performed in accordance with the Declaration of Helsinki and Belmont report. 

Consent for publication 

Not applicable. 

Availability of data and materials

All data and materials used in this study are available upon request from the corresponding author.

Competing interests

The authors have no conflicts of interest to disclose.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contribution

Conceptualization: OAO

Data Curation, Methodology, and Formal Analysis: OAO, GMA, IAO

Writing (draft), and Writing (final): OAO, GMA, IAO, AJN

All authors discussed the results and contributed to the final manuscript

Acknowledgments

The publication of this article was funded by Qatar National Library.

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Tables

Table 1. Socio-demographic and Professional Characteristic Data (n=154)

Table 2. Work Stressors Level

Table 3. Intention to Leave Level

Table 4. Mann-Whitney U test for Work Stressors Scores.
 

Table 5. Correlation between the Intention to Leave and Work Stressors

Table 6. Kruskal-Wallis test for work stressors scores

Table 7. Mann-Whitney U test for intention to leave scores