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Registered Nurses' Perceptions of Workplace Stress in Paediatric Registered Nurses’ Perceptions of Workplace Stress in Paediatric Intensive Care Units in Saudi Arabia: A Mixed- Method research study Submitted to the University of Hertfordshire in partial fulfilment of the requirement of the degree of Doctor of Philosophy By: Amany Anwar Alabdullah, BSc, MSc School of Health and Social Work University of Hertfordshire February 2020 Abstract Background: Workplace stress among nurses in Intensive Care Units (ICU) has been shown to variously affect their health, the quality of nursing care, healthcare delivery and national healthcare costs (Mokhtar et al., 2016). Although this is equally true for Paediatric Intensive Care Units (PICUs), research into this environment has remained scarce and no previous studies have focused on workplace stress in PICUs within a Saudi Arabian (SA) context. The current research study addressed this omission. Aims: This research study used a mixed-method approach to explore and understand workplace stress and its sources among nurses working in public hospital PICUs in Riyadh and Dammam, SA. Methods: In this mixed-method research study, 172 Registered Nurses from six PICUs in large public hospitals completed questionnaires in Phase 1 (quantitative data collection). These questionnaires comprised of the Expanded Nursing Stress Scale (ENSS) and personal characteristic questions. In the subsequent Phase 2 (qualitative data collection), 24 of the original 172 participants from Phase 1 took part in face-to- face semi-structured interviews. Results: The majority of the nurses suffered from a medium level of workplace stress; this was associated with tangible personal characteristics, such as gender, nationality and academic nursing qualifications. Sources of workplace stress related to ‘workload’, ‘caring for critically ill children’, ‘cultural challenges’ and ‘nursing management and nursing colleagues’. However, nurses in PICUs (both SA and expatriates) practiced effective coping strategies that were both individual to each person as well as work related – these helped them to deal with workplace stress and remain working in a PICU environment for several years. The results of this research study led to the development i of the dynamic model of workplace stress; this illustrates the complexity of workplace stress within a PICU context and highlights the interactions between both the sources and consequences of it. Conclusion and Implications: This research study found that nurses in public hospital PICUs in the cities of Riyadh and Dammam in SA, reported a medium level of workplace stress. However, interestingly, and importantly, the nurses perceived the PICU environment to be a most rewarding place to work. The results have implications for policy and practice for SA stakeholders in terms of how to enhance the working environment for nurses, raise healthcare professionals’ cultural awareness, provide insight into coping strategies and promote respect for the nursing profession in SA. These measures would potentially facilitate a reduction in PICU workplace stress and thus improve both the nurses’ health as well as the quality of the nursing care. ii Dedication By the grace and mercy of Allah This thesis is dedicated to My parents Anwar and Eman Who valued education and for their kind words and wisdom, for loving me unconditionally and for their support and encouragement in every way. My husband, Ahmad, my soulmate For being the person who was patient and understanding during my research study, who made sacrifices and who reassured me. I could not have accomplished my doctoral degree and fulfilled my dreams without him. He always believed in me and provided loving and endless support. My brothers and sisters Ayman, Omimah, Amna, Alaa and Ameen And all my extended family for always supporting me and understanding that my time away from them was necessary to complete my thesis. My only child, my little prince, Faisal For making my life so enjoyable and happy And to my nieces and nephew, who are so loving and who make me smile. My brothers-in-law and sisters-in-law for their belief in me and for always offering encouragement throughout this process. My close friends, for being there for me when I needed them. Finally, I dedicate this research study to every nurse in the world, because I value, appreciate and admire the work that we do every day. iii Acknowledgments First, my thanks and gratitude go to Allah (my GOD) for his guidance and for giving me the power, strength and patience to accomplish my doctoral degree thesis even with the struggles I went through while being between two countries. The completion of this research study would not have been possible without the assistance of many key people. First, I deeply thank my extraordinary supervisions team, Professor Brian Littlechild, Dr Lisa Whiting and Dr Ben Liu. I thank them for their continuous support, help, feedback, encouragement in difficult times and thoughtful suggestions throughout my doctoral degree journey. This was true from day one of developing my thoughts and plans, to the writing of my dissertation and to its final submission. My gratitude also goes to my research colleagues who supported me through my research study process by being beside me and assisting in my successes each in their own individual way. Specifically, I thank my friend, Alaa Alanazi, for her support while I developed my thoughts, collected data and began writing. It is also a pleasure to extend my gratitude to the Ministry of Health (MoH) for their kindness and willingness to provide me with an environment in which I was able to collect my data and so complete my research study. In addition, I would like to thank all the administrators at participating hospitals and Dr Hesham Aziz at the Administration of Researches and Studies in the MoH in SA who helped me to obtain the ethical approval needed to conduct this research study. A very special thank you to all the nurses who participated in this research study — this research study could not have been completed without your cooperation. Thank you to all the nurses’ supervisors who supported me during data collection in both phases of this research study. I am thankful for the Statistics Support Desk, available to all postgraduate students, research hub and the research development programme at the University of Hertfordshire (UH), Hatfield, United Kingdom (UK). All have been very helpful during my doctoral degree journey. In addition, the staff at the UH School of Health and Social Work and especially to Elizabeth Day, Research Degrees Administrator, who was always supportive. I extend my appreciation to the health sciences research data clinic at the Princess Nourah bint Abdulrahman University (PNU), Riyadh, SA, was very supportive through my quantitative data analysis and interpretation. Finally, I would like to express my gratitude to the Ministry of Higher Education (MoHE) and PNU for their valuable support and for this opportunity and the scholarship I received that has allowed me to pursue my dream. iv Table of Contents Abstract i Dedication iii Acknowledgments iv Table of Contents v List of Tables vii List of Figures xi Abbreviations and Definitions xii Chapter One: Introduction 1.1. Introduction 1 1.2. An overview of this research study 1 1.3. Personal interest in this research study 6 1.4. The research study aim and questions 7 1.5. The importance of this research study 10 1.6. Definitions of terms used in this research study 11 1.7. Structure of the thesis 14 1.8. Summary of the chapter 17 Chapter Two: Background 2.1. Introduction 18 2.2. Characteristics of Saudi Arabia 18 2.3. The Saudi Arabia healthcare system 26 2.4. The nursing workforce in Saudi Arabia 30 2.5. Summary of the chapter 49 Chapter Three: Literature Review 3.1. Introduction 50 3.2. Defining stress 51 3.3. Stressors 53 3.4. Workplace stress 55 3.5. Workplace stress in nursing 57 3.6. Summary of the literature review 75 3.7. A systematic literature review of workplace stress among nurses in Saudi 76 Arabia 3.8. The methodology of the systematic literature review 77 3.9. Description of the relevant studies included in the systematic literature 86 review 3.10. Synthesis of relevant studies 91 3.11. Summary of the chapter 102 Chapter Four: Methodology of the research study 4.1. Introduction 103 4.2. Philosophical foundations 103 4.3. Mixed-methods research 105 4.4. Setting 109 4.5. Ethical approval 110 4.6. Quantitative phase 111 4.7. Qualitative phase 127 4.8. Ethical Considerations 147 4.9. Challenges of the research process 150 4.10. Summary of the chapter 152 Chapter Five: Quantitative results 5.1. Introduction 153 5.2. Descriptive statistics analysis 153 v 5.3. Bivariate analysis 173 5.4. Multiple regression analysis 179 5.5. Summary of the chapter 197 Chapter Six: Qualitative results 6.1. Introduction 199 6.2. Participants in the qualitative phases of this research study 199 6.3. Results of qualitative data analysis 202 6.4. Participants’ views of source of workplace stress according to their personal 253 characteristics 6.5. Summary of the chapter 254 Chapter Seven: Discussion 7.1. Introduction 257 7.2. Dynamic interplay between sources of workplace stress 261 7.3. Dynamic interplay between the consequences of workplace stress 274 7.4. Dynamic interplay between the sources and consequences of workplace 277 stress 7.5. Managing workplace stress and the role of communication 280 7.6. Summary of the chapter 296 Chapter Eight: Conclusion and recommendations 8.1. Introduction 298 8.2. Main contributions
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