Monika

INTRODUCTION

The manner in which nurses contend with thestress/strain of the professional role has been of interest both to researchers and to health care ad-ministrators over the past 30 years. A great deal ofinformation has been obtained and disseminated.However, due to the massive changes that haveoccurred and that continue to occur in health caresystems throughout the world, this area of researchremains of interest to members of the health careindustry. This article addresses, from an internationalperspective, the state of scientific research on rolestress/strain on nurses. A review and assessment ofresearch studies conducted by investigators fromaround the world are the foci of this presentation. Nopublished article could be located that discusses rolestress and strain on nurses from a global perspective.

In preparation for reviewing the literature on rolestress/strain on nurses, a MEDLINE search was con-ducted. In addition, the reference lists of all articlesreviewed were examined. While this method is by nomeans exhaustive for retrieving all pertinent articles

on role stress/strain on nurses, over 100 articles pub-lished since 1990 about nurses from 17 countries werelocated and reviewed (see Table 1). The major limita-tion of this review is that only articles written inEnglish (the native language of the authors) will bepresented. The wealth of publications on role stress/strain on nurses identified for this review attests tothe fact that this topic remains of extreme interest toresearchers, nurses and health care administratorsworldwide. Given the large number of articlesassessed, the authors have confidence that the readerwill be presented with a thorough literature review of role stress/strain on nurses from an internationalperspective. In the interest of maintaining an inter-national perspective, this article will present theresearch studies reviewed by country.

DEFINITION OF ROLE STRESS/STRAIN

Role stress/strain has been conceptualized as the con-sequence of disparity between an individual’s percep-tion of the characteristics of a specific role and what is actually being achieved by the individual currentlycarrying out the specific role. In other words, rolestress/strain occurs when divergence exists betweenwhat are perceived to be the role expectations andwhat is actually being accomplished within the role.This definition, regardless of country, appears to becompatible with all research reviewed.

Nursing and Health Sciences (2001), 3, 161–172

Research Article

Literature review of role stress/strain on nurses:An international perspective

Vickie A. Lambert, dnsc, faan and Clinton E. Lambert, phd, csFaculty of Health Sciences,Yamaguchi University School of Medicine, Ube, Japan

Abstract The presence of role stress/strain among nurses has been of concern throughout the world.However, to date, no one has conducted, from an international perspective, a literature review ofresearch on the topic. This article assesses research from 17 countries, identifies the major areasof focus in the studies, compares and contrasts the findings, summarizes the state of the scienceon role stress/strain on nurses and makes recommendations for future research.

Key words international perspective, literature review, nurses, role stress/strain.

Correspondence address: Vickie A. Lambert, Faculty of Health Sciences,Yamaguchi University School of Medicine, Ube 755-8554, Japan. Email:[email protected] 5 July 2001; accepted 19 July 2001.

162 V. A. Lambert and C. E. Lambert

RESEARCH BY COUNTRY

United States of America

The bulk of research on role stress/strain on nurses,over 40 studies, has been conducted within the USA.Although researchers have taken a variety of ap-proaches to examining aspects of role stress andstrain, the foci of the studies have tended to be in theareas of environmental factors, influencing and pre-dictive factors, physiological and attitudinal outcomes,conceptual model application and testing, and issuesof instrumentation. Some of the articles fit into morethan one of these categories. However, the strongesttheme that emerged from the research was the decid-ing factor regarding categorical placement.

Work environment factors

The largest number of studies conducted was in thearea of work environment factors. Work environmentfactors shown to contribute to or be correlated withrole stress/strain included:

• Low job control, high job demands and low sup-portive work relationships (Chapman, 1993; Fong,1993; Webster & Hackett, 1999; Cheng et al., 2000).

• Dealing with death and dying, being movedamong different patient care units within the organi-zation, being short of essential resources and work

overload (Foxall et al., 1990; Snape & Cavanagh, 1993;Murray, 1998).

• Uncooperative family members and clients,inability to reach physicians and unfamiliarity withsituations (Walcott-McQuigg & Ervin, 1992).

• Concern for the poor quality of the nursingstaff, medical staff, and patient care (Scalzi, 1990).

• The inability to deliver quality nursing care(Boswell, 1992).

• Perceived lack of job control (Glass et al., 1993).• Shift rotation (Robinson & Lewis, 1990).• Time demands and state laws restricting

the ability to carry out the advanced practise role(Manderino et al., 1994).

• Poor relationships with supervisors, co-workersand physicians and a longer period of time working inone specific clinical unit (Decker, 1997).

• Low organizational commitment and limitedopportunity to meet regularly with other nursing col-leagues (Lee & Henderson, 1996).

The measurement of these role stress/strain workenvironment factors was assessed in populations ofnurses who worked in administration, communitymental health, medical–surgical care, intensive care,hospice care, neurosurgical care, community healthand education. Several studies were conducted onlarge numbers of hospital nurses who were not identi-fied by clinical specialty. In a few studies, nurses fromvarious work settings were compared (Bene & Foxall,

Table 1. Number of published studies on role stress/strain in nurses by category and country, 1990–2001 (n = 105)

Work environment factors Influencing/predicting factors Model testing Outcomes Instr.(n = 63) (n = 29) (n = 4) (n = 4) (n = 5)

USA 18 16 3 2 3UK 20 4 0 2 2Canada 5 3 0 0 0Taiwan 2 0 0 0 0China 3 1 0 0 0Thailand 1 1 0 0 0Caribbean 0 1 0 0 0Australia 3 0 1 0 0New Zealand 1 0 0 0 0Netherlands 1 1 0 0 0Switzerland 1 0 0 0 0Germany 1 1 0 0 0Ireland 2 0 0 0 0Italy 0 1 0 0 0Israel 2 0 0 0 0Greece 1 0 0 0 0South Africa 2 0 0 0 0

Instr., Instrumentation.

1991), as well as educators who did or did not engagein clinical practise (Steel, 1991).

Influencing and predicting factors

The second largest number of studies conducted onrole stress/strain on nurses was in the category ofinfluencing and/or predicting factors. Influencing andpredicting factors found included: commitment ofcareer and dealing with others at work (Stechmiller &Yarandi, 1993).

• Capacity to dissipate job-induced tension andintentions to quit one’s job (Daily, 1990).

• Autonomy, control over practise group cohe-sion, substantive exchange and manager consideration(Brooks et al., 1993).

• Social support (Ogus, 1990; Bourbonnais et al.,1999).

• Psychological hardiness (Lambert & Lambert,1993; Collins, 1996; Sortet & Banks, 1996; Toscano &Ponterdolph, 1998).

• Ways of coping (Boyle et al., 1991).• Fun at work (DesCamp & Thomas, 1993).• Inter-domain conflict between work stressors

and family stressors (Fox & Dwyer, 1999).• Lack of empathic concern and poor commu-

nicative responsiveness (Omdahl & O’Donnell, 1999).• Caring for patients with immunodeficiency syn-

drome or AIDS (George et al., 1993).• Self-esteem and social intimacy (Moore et al.,

1997).• Neuroticism, lack of energy, rebelliousness, dis-

engagement, egocentrism, distrust, keeping up withnew developments, being female, re-evaluation ofone’s career, getting established in one’s career, intro-version and being married (Lengacher, 1993).

The measurement of these influencing and/or pre-dicting factors was assessed in populations of nursesreturning to school or working in education, criticalcare, AIDS care, home health, acute care, emergencycare, neurology, orthopedics, outpatient care, hemo-dialysis, rehabilitation and medical–surgical care. Inaddition, a number of the studies did not specify thetype of nurses investigated in the study sample. Onewould assume the nurses comprising the study samplecame from a variety of clinical disciplines within thehealth care agencies used for data gathering.

Model testing

Model testing was the third category of research onrole stress/strain on nurses within the USA. Onlythree studies were located that fit this category. Themodels tested consisted of an anticipated turnover

model (Lucas et al., 1993), a predictor of substanceabuse in nurses model (Trinkoff et al., 2000) and astress–response sequence model (Hinds et al., 1998).Variables measured included:

• Access to controlled substances in the workplace.

• Frequency of substance abuse.• Job demands.• Symptoms of depression.• Group cohesion.• Job stress.• Demographics.• Job satisfaction.• Intent to leave one’s current place of

employment.The subjects were nurses who worked in a pediatric

cancer center and in large urban hospitals in a varietyof clinical units and selected regions throughout theUSA.

Physiological and attitudinal factors

The fourth category of research on role stress/strainon nurses within the USA was on physiological andattitudinal factors. Only two studies could be locatedthat fit this category. The factors measured included:

• Blood pressure (systolic and diastolic readings).• Epinephrine levels.• Heart rate.• Perceived control at work (Fox et al., 1993;

Goldstein et al., 1999).The subjects consisted of nurses employed within

a hospital setting who worked rotating shifts on avariety of clinical units.

Instrumentation

The final group of studies conducted was in the areaof instrumentation. Only three studies could belocated that fit this category. These studies examinedthe reliability and validity of:

• The ‘Work-Related Strain Inventory’ (Revicki et al., 1991).

• The ‘Nurse Stress Checklist’ (Benoliel et al.,1990).

• The ‘Women’s Role Strain Inventory’(Lengacher, 1997).

The instruments were found to be valid and reli-able measurements for assessing role strain on nurses.

The major method of obtaining data by the USresearchers was by survey. A variety of questionnaireswere used to assess such variables as demographics,social support, depression, death anxiety, burnout, lifeexperiences, workload, somatic and psychological

Role stress/strain in nurses 163


symptoms, job satisfaction, sources of work stress, psy-chological hardiness, daily hassles, job involvement,family stressors, family–work conflict, role ambiguity,role conflict, intentions to quit one’s job, humor andjob motivation. The large majority of the study ques-tionnaires appeared to be reliable and valid. Manyresearchers tended to use widely accepted measure-ment instruments, such as the ‘Personal Views Survey’(Kobasa, 1979), the ‘Nurses’ Stress Scale’ (Gray-Toft& Anderson, 1981), the ‘Maslach Burnout Inventory’(Maslach & Jackson, 1986) and the ‘Job Demands andWorker Health Scale’ (Caplan et al., 1975).

Several studies used questionnaires and interviewsor just interviews to obtain data. However, the major-ity of the studies utilized questionnaires. Sample sizesvaried from 30 to over 36 000 subjects. The number of variables examined, whether the study was qualita-tive and whether a national data base was used de-termined the number of subjects in the sample. Themajority of the subjects were obtained from a con-venience sample. However, a limited number ofstudies used stratified sampling techniques. No ex-perimental designs could be found and only a limitednumber of studies using a qualitative design (Peter-mann et al., 1995; Murray, 1998) and physiologicalmeasures could be located. Very few studies presentedthe limitations of the study’s design and/or findings.

United Kingdom

The second largest number of contributions (n = 28)made in research on role stress/strain on nurses wasfrom the UK. The focus of the research was similar tothat of the research in the USA. The categories of theresearch were in the areas of work environmentfactors, influencing and predicting factors, attitudinaloutcomes and issues of instrumentation.


The largest percentage of studies focused on workenvironment factors. Similar to the findings in theUSA, researchers from the UK identified the follow-ing factors as contributing to or being correlated withrole stress/strain in nurses:

• Differences in role responsibilities (Carlisle etal., 1994).

• Differences in workplace setting (Avallone &Gibbon, 1998; Chung & Corbett, 1998).

• Lack of job security, limited resources, usingnew technology, perceived lowering of standards ofpatient care, increased paperwork, a constantly chang-ing environment and a lack of support in the clinicalarea (Lally & Pearce, 1996; Tovey & Adams, 1999).

• Managerial control if working in a hospital andlack of a fixed time schedule if working in a commu-nity mental health setting (Fielding & Weaver, 1994).

• Addition of many new work responsibilities(McGibbon, 1997).

• Close involvement with clients and feelings ofisolation and discrimination as a result of caring forAIDS patients (Hayter, 1999).

• Unpredictable staffing levels, understaffing,dealing with death and dying, working with poorlymotivated staff, constantly dealing with crises, conflictwith others in the workplace, low morale and dis-agreements concerning care of the patient (Lees &Ellis, 1990; Sullivan, 1993; Carson et al., 1997).

• Working with the severely mentally ill(McLeod, 1997).

• Not having facilities in the community to whichnurses can refer patients and interruptions within theoffice (Coffey, 1999).

• Pressure resulting from problems concerningconfidence and competence in the role (Michie et al.,1996).

• Increased case loads (Carson et al., 1996).• Emotional involvement, unpredictable events at

work, change and instability at work and work con-tent (Snelgrove, 1998).

• Being a newly qualified staff nurse (Charnley,1999).

Given all of the aforementioned work environmentstressors, it is of interest to note that Baillon et al.(1999) found no significant changes in the stress pat-terns when the staff members were moved from a tra-ditional psychiatric hospital to a ‘new purpose-built’unit. These findings are similar to those found byThomas (1992) who compared perceived stressorsamong nurses and auxiliary workers who deliveredpatient care to wards that had an organizational struc-ture of primary nursing, team nursing or functionalcare. No differences were found between the nursesand the auxiliary workers regarding perceptions ofstress. However, the sample size was very small (n = 12in each group). The measurement of the role of stress/strain work environment factors previously listed wasassessed in populations of nurses who worked in mid-wifery, AIDS care, acute care, intensive care, generalhospital care, psychiatry, forensic community mentalhealth and community mental health.


Several studies were located that fit within the cate-gory of influencing or predicting factors. Researchersfound that even after the effects of personal vulner-ability and ongoing social stress outside of work were

taken into account, stressful situations at work con-tributed to both anxiety and depression (Weinberg &Creed, 2000). Other predicting or influencing factorsfor role stress were found to include working withAIDS and cancer patients (Catalan et al., 1996) andworkload (Tyler et al., 1991). Tyler and Cushway(1992) found that nurses’ perceptions of excessiveworkload and use of avoidance coping strategiesappeared to be the best predictors of role stress/strainon nurses.

Attitudinal factors

Two studies were located that fit the category of atti-tudinal factors. Absenteeism, as an outcome, wasmeasured by Matrunola (1996) in nurses working inan elderly care unit. Absenteeism was not found to bea significant predictor of job satisfaction. Fagin et al.(1995) found higher absence rates, lower self-esteemand lack of personal fulfillment in psychiatric nursesin a community setting to be predictors of poorgeneral health.

Instrumentation

In the category of instrumentation two studies werelocated. Brown et al. (1995) developed the Commu-nity Psychiatric Nursing Questionnaire to assess whatnurses found stressful about their jobs. Nolan et al.(1995) assessed the efficacy of the Mental Health Pro-fessional Stress Scale (MHPSS) as an instrument formeasuring stress in mental health nurses.

The major means of gathering data in the UK wasby questionnaire using a convenience sample. A fewstudies utilized structured and semi-structured in-terviews. Only two studies (Hopkinson et al., 1998;Charnley, 1999) that used a qualitative method werelocated. No experimental designs or studies measur-ing physiological variables could be found. Samplesizes in the studies varied from 12 to 573. Sample sizewas determined by the number of variables examinedand by the study design. Some studies, however, had avery marginal number of subjects, which may haveinfluenced the statistical findings and conclusivenessof the results. As with the studies conducted in theUSA, the UK researchers often used widely acceptedvalid and reliable measurement instruments. How-ever, they also utilized measurements that were adap-tations of widely accepted questionnaires, such as the Folkman and Lazarus Coping Questionnaire(Folkman & Lazarus, 1984), or self-developed tools,such as the Psychiatric Nursing Stress Inventory (Sullivan, 1993). Many of the variables assessed in theUSA also were assessed by the UK researchers. Like

the USA researchers, few of the UK researchersreported the limitations of their research designs andfindings.

Canada

A limited number of studies, only eight, on role stress/strain on nurses were located from Canada. Thesestudies were in the area of work environment factorsand influencing or predicting factors.


The studies in the area of work environment factorsidentified the major sources of stress as:

• Lack of resources, workload, lack of adequatenursing staff and a sense of powerlessness (Frisch et al., 1991; Hatcher & Laschinger, 1996).

• Relating to other members of the health team,time pressures, patient and family expectations, per-sonal expectations and lack of knowledge or skills(Hartrick & Hills, 1993).

Significant correlations were found by Leiter et al.(1998) between patients’ satisfaction with nursingcare and nurses’ perceptions of the meaningfulness oftheir work. In one study, nurses’ perceptions of stress,job satisfaction and job design were analyzed bothbefore and after a major organizational change. Nosignificant differences were found in any of the vari-ables measured throughout the four time-periods(Woodcox et al., 1994).


In the area of influencing or predicting factors, Cana-dian researchers found that men had marginally lowerlevels of stress (Jamal & Baba, 2000). Family support,perceived organizational support for family life, per-ceived workload size and involvement in childcarewere found to be responsible for the work–familyconflict that nurses experienced (Gottlieb et al., 1996).The kind of work, amount of work and career futurewere found to be contributors to burnout in bothCanadian and Jordanian nurses (Armstrong-Stassenet al., 1994). This study was the only cross-culturalstudy located by the authors on role stress/strain onnurses.

The majority of the data gathered by the Canadianresearchers was by questionnaire using conveniencesamples. One study used a qualitative method fordata gathering and another used structured inter-views. The sample sizes ranged from 21 to 849 sub-jects. Sample size, as for the USA and UK studies, wasdetermined by study design and the number of vari-



ables examined. No experimental design studies werelocated. As was the case in studies done in the USAand the UK, few researchers addressed the limitationsof the design and findings of their studies.

Taiwan


Only two studies were located from Taiwan. Onestudy focused on work environment factors, withnursing care related to patient condition, interper-sonal relationships, workload and opportunities forpromotion being key role stressors (Tsai, 1993). Thesefindings are very similar to those found in countriesgenerally considered to have ‘western’-type cultures.The method of data gathering was through a writtenresponse to two open-ended questions, by nurses whowere working in three large teaching hospitals.

Instrumentation

The other study, which had a sample size of 138 andwas also conducted by Tsai (1997), was on instrumen-tation and focused on the development of a Chineseversion of the Nurse Stress Checklist by Benoliel et al.(1990). The majority of the instrument items showedsignificant Pearson’s correlation coefficients betweenthe Chinese and English versions. The items that werenot significant require further examination.

China

The four studies located on role stress/strain onnurses working in China focused on work environ-ment factors and influencing/predictive factors.


The three studies on work environment factorsfocused on:

• Adding the part-time student role to the workrole of public health nurses (Shiu, 1999).

• Identifying stressful factors in the workplace(Callaghan et al., 2000).

• Managing both work and family responsibilities(Shiu, 1998).

With the exception of Shiu (1998), who found thatpublic health nurses with children had minimal inter-role stress while juggling work and family responsibil-ities, the findings were similar to those of othercountries.


The one study on influencing and predicting factorsfound that nurses who adopted approach style copingmethods (problem orientation, ability enhancementand change of perspective) were better able to adaptto work stress than nurses who did not adopt suchcoping styles (Boey, 1998). In addition, the stress-resistant nurses were found to have greater supportfrom family relationships.

The studies conducted in China had sample sizesranging from 20 to 1335. As for studies conducted inother countries, sample size was determined by thestudy design. All but one study used conveniencesampling. The major means of data gathering was byquestionnaire. One study was qualitative and usedwritten recordings in a diary as the data source.

Thailand

The two studies located from Thailand focused onwork environment factors and influencing/predictingfactors. Both studies used questionnaires for gather-ing data and random sampling techniques.


The study that dealt with work environment factorsfound that in 354 hospital nurses the overall level ofconflict was moderate and the majority of subjectsused accommodation most frequently to manage conflict (Kunaviktikul et al., 2000). These findings aredifferent from similar studies conducted in othercountries. As the researchers point out, maintainingharmony within the Thai culture is very importantand had an influence on how the Thai nurses dealtwith stress in the work setting.


The study on influencing and predicting factors foundthat in 200 hospital nurses the use of avoidancecoping was the best predictor of stress (Tyson & Pongruengphant, 1996). Although avoidance copingwas the best predictor, it did not have an interactivebuffering effect on occupational stress.

Caribbean


Only one study could be located from the Caribbean.It focused on influencing and predicting factors, wasconducted on 119 hospital nurses located in StVincent and Trinidad and Tobago and used a survey

design (Baba et al., 1999). The findings suggested thatrole conflict, role overload and social support predictstress. Burnout was found to be the sole predictor ofdepression, which, in turn, predicted both absenteeismand turnover intentions. These findings are consistentwith role stress/strain findings from other countries.

Australia


Three of the four studies located from Australiafocused on work environment factors. Sources ofstress were found to be:

• A sense of marginality brought on by workingin very remote areas on Aboriginal settlements(Willis, 1990).

• Workload in terms of frequency of occurrenceand its perceived effect on the nurses (Healy &McKay, 1999).

• Legal implications of the role of an intensivecare nurse (White & Tonkin, 1991).

Model testing

The fourth study was in the category of model testing.The investigators examined the ‘Job Strain Model’ forits ability to predict employee well-being in terms ofjob satisfaction and mental health. The findings sug-gested that the model could be used to predict jobsatisfaction and mental health in Australian psychi-atric nurses.

In the Australian studies the major means of datagathering was by questionnaire; however, one studywas qualitative in design. The sample sizes rangedfrom 18 to 129 and were determined by study design.

New Zealand


The only study found from New Zealand fit into the category of work environment factors. Fourteenpediatric nurses responded to several questionnairesabout their role stress/strain. Sources of stress iden-tified included: conflict with physicians (the majorstressor), workload, inadequate preparation for deal-ing with the emotional needs of patients and theirfamilies and death/dying (Watson & Feld, 1996). Allof these findings are consistent with those from othercountries.

Netherlands

Two studies from the Netherlands were reviewed.


The study by Melchior et al. (1997) found, using meta-analysis, that the work environment factors of job satisfaction, staff support and involvement with theorganization were negatively associated with burnout.These findings are consistent with prior research con-ducted in other countries.


The second study fit into the category of influencingand predicting factors. In 402 community nurses, jobsatisfaction was affected to a greater extent by jobcharacteristics, whereas burnout was more a result of individual characteristics (Jansen et al., 1996). Thisstudy used questionnaires, some of which were Dutchtranslations of ‘classical’ measurement instrumentsused in other countries.

Switzerland


The only article located from Switzerland was a survey of 1248 nurses and physicians in which ethicalconflicts about appropriate patient care, team con-flicts, role ambiguity, workload and organizational de-ficits were identified as the major work environmentfactors contributing to stress/strain. These findings aresimilar to those from other countries. In addition, theSwiss researchers indicated that little is known aboutspecific health hazards related to nurses’ work envi-ronments other than the presence of burnout.

Germany

The two studies located from Germany were in thecategory of work environment factors and influenc-ing/predicting factors.


In the area of work environment factors, 91 nursesworking on cancer wards were assessed. As suggestedin research from other countries, interpersonal diffi-culties, on or off the job, were associated with physicaldistress in nurses. In addition, age, the presence oftrainees and the size of the institution were linkedwith stress levels.


A convenience sample of 361 staff nurses working in a variety of clinical settings was surveyed to de-



termine influencing/predicting factors related to rolestress/strain. Causal modeling analysis suggested thatincreased work stress and burnout were associatedwith a poorer locus of control. Thus, nurses perceivedtheir degree of control as instrumental in enablingthem to cope with stress and burnout.

Ireland


Ireland produced only two studies that focused onwork environment factors. In one study psychiatricnurses were surveyed regarding work stress. The find-ings suggested that stress was related to organiza-tional rather than work-related matters (Ryan &Quayle, 1999). The second study surveyed 40 nurses’attitudes about the extensions and expansion of theirclinical roles. The findings suggested that role ex-pansion led to enhanced quality of nursing care, lesstime for basic nursing care and increased job satisfac-tion. However, role extension led to physicians ‘off-loading’ mundane tasks onto nurses, improvedcontinuity of care, the use of nurses as a work forcefor saving money and an increase in nurses’ vulnera-bility to litigation (Magennis et al., 1999).

Italy


The only study located in Italy focused on influenc-ing/predicting factors related to role stress/strain.Four hundred and ten nurses from a variety of clinicalareas, who were working with AIDS patients, weresurveyed using questionnaires. The findings suggestedthat an empathic relationship seems to protect againstburnout when compared to a frustrating relationship.Nurses who received supportive social rewardstended to tolerate stress better than nurses whoreceived few or no supportive social rewards. Theimpact of working with HIV-infected patients causedpsychological stress, but it was a weak predictor ofburnout (Visintini et al., 1996). Such findings are con-sistent with those from other countries.

Israel


Both studies located from Israel focused on workenvironment factors. One hundred and thirty-onefemale nurses were administered questionnaires toassess the relationships among role stress and health

behavior practices (smoking, alcohol consumptionand the use of hypnotics, anxiolytics or antacids). Thefindings suggested that smoking was prevalent in shiftworkers and, especially, in nurses reporting job stress.Thus, shift workers should be considered a high-riskpopulation for smoking-related diseases (Barak et al.,1996).

The only study on role stress related to gender wasconducted in Israel. As nursing is a female-dominatedprofession, researchers surveyed 154 male nurses to identify which gender style appeared to be mostcompatible for dealing with work stress. Krausz et al. (1992) found that even in a female-dominatedwork environment, ‘masculine-type’ male nurses werethe best adapted while the ‘feminine-type’ malenurses were the least adapted. ‘Androgynous-type’male nurses ranked highest in work satisfaction, eventhough they ranked high in pressure and strain stem-ming from their work environment.

Greece


The only study conducted in Greece focused on workenvironment factors. By surveying 368 nurses, whoworked in a variety of clinical settings, the researchersfound that although nurses may display symptoms ofburnout, they do not always display symptoms ofdepression (Iacovides et al., 1999).

South Africa


South Africa produced only two studies that focusedon work environment factors. The qualitative studyconducted on nurses working in an adult intensivecare unit found that the following factors can con-tribute to a stressful work environment: impairedcommunication with management; racism; lack of faircompetitive remuneration and disregard for profes-sional worth; non-conducive physical and psychologi-cal surroundings (Pope et al., 1998). A large portion ofthe article, however, dealt with the method of phe-nomenological qualitative research.

The second study conducted was on military nursesserving in isolated installations of the South AfricanNational Defense Force. Nurses were asked to fill out questionnaires and to be involved in a semi-structured interview. The findings suggested that lackof support from supervisors, high responsibility, longworking hours and task overload were the four mostcommon work stressors reported (van Wijk, 1997).

SUMMARY

In summary, the following assessments can be maderegarding studies conducted on role stress/strain onnurses, reported in English language journals fromaround the world:

• Most studies have been carried out by USA andUK researchers.

• Few studies have utilized physiological measures.

• No studies with original experimental designscould be located.

• Only one cross-cultural study was found.• Few qualitative studies were conducted.• The majority of the studies were on the identifi-

cation of stressors in the work environment.• A limited number of the studies examined pre-

dictors of role stress/strain.• A fair number of studies examined the role

stress differences among nurses working in a varietyof clinical practise settings.

• No intervention studies were located.• In most studies, the questionnaires used were

valid and reliable with a number of the studies utiliz-ing measurement tools that are considered ‘classical’and popular for use. Some studies did use instrumentsdeveloped specifically by the investigators for the par-ticular study.

• The sample sizes varied widely. Sample size wasdetermined by the study design, the number of vari-ables examined and whether the data came from anational data set. Some studies had a very smallnumber of subjects; this could have influenced the sta-tistical findings and subsequent general applicability.

• Only one study could be found that was con-ducted on role stress/strain exclusively in male nurses.

• Very few studies listed the limitations of thestudy design and findings.

RECOMMENDATIONS

Given the aforementioned factors, it appears thatfuture research on role stress/strain in nurses needs tofocus on the following issues:

• More studies need to be conducted in countriesother than the USA and the UK.

• Studies are needed that have a cross-culturalapproach.

• Intervention studies on how to assist nurses indealing with role stress need to be developed.

• More studies on predicting factors and theiroutcomes are needed.

• More qualitative studies are needed.

• More studies done exclusively on male nursesare needed.

• All studies need to indicate the limitations ofthe design and findings.

• Research designs other than surveys using ques-tionnaires need to be developed.

• More model testing is needed.• More studies on instrumentation need to be

conducted.• Studies using both physiological and psychologi-

cal measures are needed.• Studies using experimental design need to be

developed.• The use of subjects from sources other than

convenience samples is recommended.Research on role stress/strain on nurses from aroundthe world is certainly a field of study that can providerich opportunities for examination and discovery.

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