CHAPTER II

LITERATURE REVIEW

In this chapter, the researcher reviewed existing literature and researches on

job satisfaction, job stress, role conflict, and role ambiguity. The researcher studied

concepts of job satisfaction and job stress, role stress. Related information was

grouped under these topics.

1. Job satisfaction

1.1 Concepts of job satisfaction

1.2 Job satisfaction in nursing

1.3 Measurements of job satisfaction

2. Job stress

2.1 Concepts of job stress

2.2 Job stress in nursing

2.3 Measurements of job stress

3. Role conflict and role ambiguity

3.1 Concepts of role conflict and role ambiguity

3.2 Role conflict and role ambiguity in nursing

3.3 Measurements of role conflict and role ambiguity

4. Relationships between job stress, role conflict, role ambiguity and job

satisfaction.

5. Health Care System in Vietnam

Job satisfaction Job satisfaction is a multifaceted construct with a variety of definitions and

related concepts, which has been studied in a variety of disciplines for many years to

now. Many theories and articles of interest to managers, social psychologist, and

scholars, focus on job satisfaction because most people spend their life-time for work,

and understanding of the factors that increase satisfaction is important to improve the

well-being of individuals in this facet of the living (Gruneberg, 1997). Below is some

information related to job satisfaction.

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1. Concepts of job satisfaction

In a literature review, Lu, While, and Barriball (2005) mentioned the

traditional model of job satisfaction focuses on all the feelings about job of an

individual. However, what makes a job satisfying or dissatisfying does not depend

only on the nature of the job, but also on the expectations that individuals have of

what their job should provide.

Maslow (1954 cited in Huber, 2006) arranged human needs along a five-

level hierarchy from physiological needs, safety and security, belonging, esteem to

self-actualization. In Maslow’s pyramid, needs at the lower levels must be fulfilled

before those rise to a higher level. According to Maslow’s theory, some researchers

have approached on job satisfaction from the perspective of need fulfillment (Regis &

Porto, 2006; Worf, 1970). Job satisfaction as a match between what individuals

perceive they need and what rewards they perceive they receive from their jobs

(Huber, 2006). However, overtime, Maslow’s theory has diminished in value. In the

current trend, the approach of job satisfaction focuses on cognitive process rather than

on basic needs in the studies (Huber, 2006; Spector, 1997).

Another approach as proposed by Herzberg (Herzberg et al., 1959; cited in

Huber, 2006) is based on the Maslow’s theory. Herzberg and colleagues built

Herzberg’s motivation-hygiene theory of job satisfaction. Theory proposed that there

are two different categories of needs, which are intrinsic (motivators) and extrinsic

(hygiene) factors. Theory postulates that job satisfaction and/or is dissatisfaction is the

function of two need systems. Intrinsic factors are related to the job itself. Intrinsic

factors seem to influence positively on job satisfaction. The motivators include

advancement, growth and development, responsibility for work, challenging,

recognition, and advancement. In other words, extrinsic factors are closely related to

the environment and condition of the work. The hygienes relate to job dissatisfaction

including supervision, company policy and administration, working condition and

interpersonal relation (Lephalala, Ehlers, & Oosthuizen, 2008; Shimizu et al., 2005).

This theory has dominated in the study of job satisfaction, and become a basic for

development of job satisfaction assessment (Lu et al., 2005).

In summary, some previous theories have proposed many factors contributed

to job satisfaction such as the Maslow’s hierarchy of needs and the set of Herzberg’s

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motivation-hygiene theory. This study is going to measure job satisfaction in two

categories, including motivator and hygiene factors, which are related to Herzberg’s

theory.

2. Job satisfaction in nursing

In health care field, job satisfaction is a complex phenomenon. Many factors

contribute to nursing satisfaction, both positive and negative. In a literature review,

Garon, and Ringl (2004) indicated factor variables that influence job satisfaction of

hospital-based RNs. These factors are: 1) working conditions including workload and

staffing; 2) working environment: empowerment, autonomy, shared governance, and

control over practice; 3) salary, benefits and educational support; 4) stress; 5)

leadership issues; 6) role conflict and confusion; 7) professional recognition; 8) nurse-

physician communication and collaboration; 9) hours, shift work and scheduling; and

10) peer group and sense of belonging. Blegen (2001) meta-analyzed factors related

to nurses’ job satisfaction on 48 studies. The results of the study indicated that 13

factors were most strongly associated with job satisfaction. These were stress,

commitment, communication (with supervisor and peers), autonomy (and locus of

control), recognition, routinization, and fairness. Researchers noticed that job

satisfaction is a complex concept and it cannot be affected by one factor, but must be

a combination of many factors. A study (Lephalala et al., 2008) determined factors

influencing nurses’ job satisfaction in selected private hospitals in England. The

results indicated no satisfaction with salaries. In contrast, nurses were reported

satisfied with the other extrinsic factors including organization and administration

policies, supervision and interpersonal relations. Nurses identified factors influencing

job satisfaction including lack of promotions, lack of opportunity for advancement,

being in death-end jobs, and lack of involvement in decision-and policy-making

activities.

It has been reported that difference in working environment may create the

difference in job satisfaction. Aiken et al. (2001) conducted a survey on nurses’ job

satisfaction in 5 countries. Findings were low satisfaction among nurses. Job

dissatisfaction among nurses was highest in the United States (41%) followed by

Scotland (38%), England (36%), Canada (33%) and Germany (17%). One third of

nurses in England and Scotland and more than one fifth in the United States planned

15

on leaving their job within 12 months of data collection, in that, there were 27–54%

of nurses under 30 years of age planned on leaving in all countries. Regarding the

work climate, only about one third of nurses in Canada and Scotland felt that they

have autonomy in their work in comparison with more than half in the other three

countries. When compared with other countries, the nurses in Germany (61%)

reported that they were more satisfied with the opportunities for advancement while

the nurses in the United States (57%) and Canada (69%) felt more satisfied with their

wages.

However, there are some studies that also have shown nurses were

satisfaction with work. Bjørk, Samdal, Hansen, Tørstad, and Hamilton (2007)

conducted a survey with 2095 nurses in four different hospitals in Norway. The

results showed nurses’ actual satisfaction with their job, the most satisfaction is

professional status (5.50) followed closely by interaction as second, and autonomy as

third. However, 3 remaining components have the score that is much lower, with task

requirement (3.75), organizational politics (3.77), and pay (2.62).

There were different levels of job satisfaction between countries. A survey

was conducted by Curtis (2007) in Ireland with a sample of 2000 nurses. The results

reported that had moderate levels of job satisfaction. In that, they felt satisfied with

professional status, interaction and autonomy, while pay and organizational policies

were reported to make the least contribution nurses’ job satisfaction (Curtis, 2007).

Some studies have been conducted to determine nurses’s job satisfaction in

Bhutan. Job satisfaction was measured by Job Satisfaction Survey developed by

Spector (Norbu, 2010; Pemo, 2004). The findings of these studies indicated that

nursing staffs had moderate levels of job satisfaction. They found that staff nurses felt

satisfied with coworkers and nature of work, while less satisfied with fringe benefits,

contingent rewards, and operating procedures. Norbu (2010) revealed supervisor

social support had positive correlation, and workload had negative correlation with

job satisfaction among staff nurses.

In brief, many studies have explored nurses’ job satisfaction from various

perspectives. Some studies have shown that many factors in working environment

associated with nurses’ job satisfaction following either positive (i.e. such are as pay,

benefits, promotion, recognition, communication with partner, autonomy, etc.) or

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negative ways. From the review, there are negative factors which are job stress and

role stress. This study concerns to examine level of nurse’s job satisfaction among

these factors.

3. Measurements of job satisfaction

Measuring job satisfaction is difficult, for it is abstract personal cognition

that only exists in the mind of individual. However, most researchers select a more

objective and in-depth survey instrument (Spector, 1997). Spector suggested using an

existing job satisfaction scale for the following advantages: 1) it has been reported to

exhibit acceptable levels of reliability, 2) it has been used a sufficient number of times

to provide norm, 3) it has been used in research to provide good evidence for

construct validity, and 4) using known scales saves the considerable cost and time

necessary to a develop a scale.

Many instruments were developed to measure the level of job satisfaction.

Originally Index of Work satisfaction (IWS) was develop in the 1972s (Stamp, 1997

cited in Norbu, 2010). It is a scale to measure the relative importance of various

components of job satisfaction. It contained six components: 1) professional status,

2) task requirements, 3) pay, 4) interaction, 5) organizational policies, and 6)

autonomy. This scale was developed based on the combination of Maslow’s theory

and Herzberg’s theory. It consisted of 48 items and ranged on a 7-point Likert scale.

Previous studies have reported the Cronbach coefficient alpha in the range of .82-.91

for the overall scale.

Originally the McCloskey/Muller Satisfaction Scale (MMSS) was developed

in the 1974s (McCloskey & Muller, 1990). This scale measures hospital nurses’ job

satisfaction from 8 subscales: 1) extrinsic rewards, 2) scheduling, 3) the balance of

family and work, 4) co-worker, 5) interaction opportunities, 6) professional

opportunities, 7) praise and recognition, and 8) control responsibility. This scale was

developed based on theories of Maslow and Burn. It consisted of 31 items and ranged

on a 5-point Likert scale. Previous studies have reported the Cronbach coefficient

alpha of .89 for the overall scale and validity of .556. This scale is well established

instrument for measuring job satisfaction (Arab, Pourreza, Akbari, Ramesh, &

Aghlmand, 2007; Duong, 2003).

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The Job Satisfaction Survey (JSS) was developed in 1985s (Spector, 1985).

This scale assesses employee attitudes about the job and aspects of job from 9

separate facets of the job satisfaction: 1) pay and pay raises, 2) promotional

opportunities, 3) fringe benefits, 4) contingent reward, 5) supervision, 6) coworker, 7)

nature of work, 8) communication within the organization, and 9) operating

procedures. The scale was summated rating scale format which is the most popular for

job satisfaction scales. It consisted of 36 items and ranged on a 6-point Likert scale

from 1-dissagree strongly to 6-agree strongly. It has some of the items written in

negatives direction. These items have to be reverse scored before summing up the

score. Spector reported coefficient alphas ranging .60-.91 for the overall measure

(Spector, 1997). The higher mean score is the higher level of job satisfaction. Level of

job satisfaction is low when the mean score is less than 3.00, moderate when the mean

score is 3.00-4.00, high when the mean score is greater than 4.00 (Spector, 2007).

Although, the JSS was developed to measure of employees’ job satisfaction

to human service, public, etc. However, JSS along with 9 facets was provided overall

picture about job satisfaction. JSS measured using both the positive and the negative

ways. Hence, JSS tool was selected in this study.

Job stress 1. Concepts of job stress

People spend most of their time on their work because they need to earn

money to serve the basic needs of life, as well as to meet some other needs, and the

job helps them expand the relationships with community, create the link with society.

Thus, they always face with stressors in environment.

Stress has been defined in many ways. Selye’s general stress Theory (Selye,

1976; cited in Huber, 2006) described stress as a non-specific response that appears

inside human biological system as a reaction to the stimuli of a stressor. When the

person interacts with a stressor, a characteristic syndrome of physical reactions will

occur. Selye (1976) describes effort or non-specific response as the essence of the

stress, the demand as stressor. He proposed that failure to adapt adequately may lead

to prolonged stress and eventually to exhaustion and morbidity.

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Lazarus and Folkman (1984 cited in Sullivan & Decker, 2009) viewed stress

as a relationship between the person and environment that is appraised as taxing or

exceeding their sources and as endangering well-being. The individual cognitive

appraisal of a given situation and the use of his coping mechanisms in dealing with

the situation are described as a transactional process.

Stress and the negative outcomes of stress have been recognized as

financially costly to any health care organization. Negative outcomes of job stress

among nurses include physical illness, burnout, or coping (Huber, 2006). Job stress

describes the stress associated with the professional or work environment. Tension is

created when the demands of the job or the job environment exceed the capacity of

the person to respond effectively. Job stress varies with each work environment. Job

stress is defined as a tension or an uncomfortable sensation arising in a person that

related to the demands of job or work of the nurse (Huber, 2006; McVicar, 2003).

Beehr and Franz (1985) described job stress as a process in which some

characteristics of the work or the workplace have harmful consequences for

employees. There are 3 sources of stressors in the workplace that are the task and its

characteristics, interpersonal relationships, and characteristic of organization. An

element of the workplace becomes a stressor when it-self can cause a strain of

employees.

Briefly, there are many approaches related to stress. Commonly, stress is

often seen as negative results or non-specific response and it can affect the well-being

not only of individual, but also of organization. This study considers to level of job

stress.

2. Job stress in nursing

Stress is as normal as the nature of the resistance of life (Sullivan, & Decker,

2009), people have been faced with the situations or events from daily life which

created stress, tensions. Huber (2006) proposed that nursing work is one of the most

stressful and challenging. Moreover, the nurses always have faced special, complex

situation, and requirement to hand emergency events.

Job stress can be accumulated with day-to-day, and if it is not resolved or

adapt, it will evolve too high and consequences will lead to burnout occurs, decrease

individual productivity (Huber, 2006), this is really very dangerous if a sufficient

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amount of stress it would create momentum in the process of working, and conversely

(Adeb-Saeedi, 2002; Sullivan & Decker, 2009). Symptoms of stress impact on the

organizations, these express majors on the job such as leading to job dissatisfaction,

high absenteeism, as well as labor turnover, poor quality control (Cooper & Marshall,

1976 cited in Sadri & Marcoulides, 1994). Here are some valid evidences that stress

impacts on health of humans. Therefore, studies on job stress is needed and including

its levels.

Chen, Lin, Wang, and Hou (2009) were performed the study on 121 nurses

working at seven hospitals in Yunlin and Chiayi Counties to determine the stressors,

the stress coping strategies, and the job satisfaction. They found that stress level and

frequency perception of nurses was significantly related to the type of hospital; the

most intense stressor perceived by nurses was patient safety. They noticed that

differences in working environment and administrative management can receive job

satisfaction and job stress differently. Besides, they also found that nurse older than

40 years and who had worked for more than 20 years perceived more stress than

others; nurses who were single or had no children more frequently adapt difficultly

with stress than the others; nurses with monthly salaries less than NT$30,000 (950

USD) perceived lower satisfaction than others. Furthermore, those employed in their

present hospital for more than 20 years perceived higher self-esteem satisfaction than

those employed in their present hospital for less than 5 years.

Hamidi and Eivazi (2010) determine the levels of employees’ job stress and

in urban health centers in Hamadan, Iran. They surveyed 120 employees. The result

showed that the participants in all of the health centers were at moderate level of

stress. There was a positive correlation between performance and the midlevel of

employees’ stress was found (r = 0.69, p < 0.05).

The results of a study by Christina and Konstantinos (2009) support the

above findings. Christina and Konstantinos explored nurses’ job stress in Greek

registered mental health and assistant nurses. They survey 85 register mental health

and assistant nurses working in six acute psychiatric wards. The results reported that

nurses experienced moderate level of stress and overall were satisfied with their job.

Piko (1999) investigated the relationship between levels of stress among

nurses, and some of the psychosocial and organizational characteristics of their job in

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public hospitals in Csongrad County, Hungary. They surveyed 218 nurses. The

findings showed that the frequency of common psychosomatic symptoms, regular

alcohol drinking, heavy smoking, and frequent use of tranquilisers and sleeping pills

can be an indicator of nurses' work-related stress level. Nurses with only primary

education had the highest such levels, while those with baccalaureate-level education

had the lowest. Furthermore, nurses aged 51-60 years and those on rotating night shift

were easily injured by stress. The researchers notice that supportive relationships with

peers may reduce the occurrence of high stress levels among nurses, leading the

author to conclude that social support and the psychosocial work climate should be

improved in health care institutions.

To sum up, nursing are always faced with stress from work than other

sectors. It is because the job of nurses is directly related to human. The most reported

job stress for staff nurses in the hospital are experiencing with stress from moderate to

high level. This study is going to explore level of job stress among staff nurses.

3. Measurements of job stress

There are a lot of scales to measure job stress such as The Perceived Stress

Scale (PSS) (Cohen-Mansfield, 1995), the Nursing Stress Scale (NSS) (Gray-Toft, &

Anderson, 1981b), the Expand Nursing Stress Scale (ENSS) (French et al., 2000).

Original Nursing Stress Scale was developed in 1981 (Gray-Toft &

Anderson, 1981b). This scale measures the frequency of stress experienced by nurses

in the hospital environment. This scale consisted of 34 items in 7 dimensions:

1) Death and dying, 2) Conflict with physicians, 3) Inadequate preparation, 4) Lack of

support, 5) conflict with other nurses, 6) Work load, and 7) Uncertainty concerning

treatment. Previous studies have reported the Cronbach coefficient alpha of .87 for the

overall. Validity was determined. Nursing Stress Scale is the best known and most

widely used scale.

Original Expanded Nursing Stress Scale (ENSS) was developed in 1995

(French et al., 2000). This scale measures sources and frequency of stress perceived

by nurses. It contained 9 dimensions: 1) Death and Dying, 2) Conflict with Physicians,

3) Inadequate Emotional Preparation, 4) Problems Relating to Peers, 5) Problems

Relating to Supervisors, 6) Work Load, 7) Uncertainty Concerning Treatment, 8)

Patients and their Families, and 9) Discrimination. ENSS consisted of 59 items and

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ranged on 5-point Likert scale. Previous studies have reported the Cronbach

coefficient alpha of 0.96. French et al. (2000) mentioned that major changes in health

care delivery and the work environment of nurses since the development of the NSS

stimulated to identify stressful situations not reflected in the NSS and develop an

expanded version useful for diverse work settings. Hence, ENSS is an update

instrument which has developed appropriately with the recent situation.

There are some well-known tools to measure job related stress. However,

ENSS is one of the tools designed specifically for nursing. It is considered as an

update measure overall work-related stress, and in accordance with changes in the

health care industry, because of these reasons that ESNN was chosen in this study.

Role conflict and role ambiguity 1. Concepts of role conflict and role ambiguity

Role is defined as a set of expectations about behavior corresponding to a

particular position in society (Sullivan, & Decker, 2009). Role stress will be occurred

when incompatibility exists between a person’s perception of the characteristics of a

specific role and what the role expectations. Role stress is conceptually and

empirically different from job stress (Lambert et al., 2004). In fact, research has

indicated that role stress is a salient antecedent of job stress for many correctional

workers (Lambert, Hogan, & Tucker, 2009). Role stress includes many kinds, there

are: role ambiguity, role conflict, role overload, role incongruity, role underload

(Hardy, 1978 cited in Yoder-Wise, 2007). In consequence, the role stress may create

the role strain, which is subjective feeling of discomfort experienced as the result of

role stress. Clear, realistic role expectations can reduce the role stress for nurses and

increase productivity. Among role stress, role conflict and role ambiguity the first two

stressors have received much attention from organizational psychologists because

they influence psychological work climate and the organizational behavior (PiKo,

2006; Kalliath & Morris, 2002).

Role conflict and role ambiguity are two concepts, which were first

introduced by Kahn et al. (1964). Role ambiguity is lack of clarity on one’s job

profile. The employee remains confused about his or her role or tasks, caused by lack

of required information, lack of communication of available information, or receipt of

22

contradictory messages regarding the role (Kahn et al., 1964). Amabile and

Gryskiewicz (1987) noticed that management must establish clear organizational

goals to achieve high production. Sherman (1989) postulated that role clarity is a

positive motivator for personnel, and when motivated properly, they tend to solve

problems that require a high level of effort and innovation to complete a project.

Moreover, role clarity is also positively related to innovation (Jansen & Gaylen,

1994). Role clarity refers to how clearly a set of activities expected from an individual

are expressed. Role ambiguity or role uncertainty is the reverse situation (Jansen &

Gaylen, 1994). This implies that role ambiguity may be source of uncertainty for

employees (O’Driscoll & Beehr, 2000), and they are associated to work attitude in

which are commitment and satisfaction (Tankha, 2006). In addition, the work

environment is always change, so nurses have to perform in new role and under new

events. Hence, managers need to provide the education and necessary supports to

nurses who need to coping with their role changes. Clear understanding of role

changes and planned programs to support them will reduce role stress and prevent

role strain (Huber, 2006).

According to role theory, role conflict results from two or more sets of

incompatible demands involving work-related issues (Kahn et al., 1964; Katz &

Kahn, 1978). Role conflict usually arises from the employee’s membership in

multiple groups, opposing pressures from different role senders, and a conflict

between personal values and prescribed role behavior. Role theory (cited in

Swansburg & Swansburg, 2002) also point out role conflict may make employee

experience stress, dissatisfaction and ineffective performance. As the result, role

conflict may reduce trust of and personal liking and esteem for the person in

authority, it also reduces communication and decreases employee effectiveness.

According to managers, role conflict associates with more dysfunctional.

Lack of congruent expectations and demands from other people in the

workplace are psychologically uncomfortable and may induce negative emotional

reactions, diminish effectiveness and job satisfaction, and decrease the employee’s

intent to remain a member of the organization (O’Driscoll & Beehr, 1994).

In conclusion, role conflict and role ambiguity related to the content of their

work and the tasks, and responsibilities assigned to their positions. Clearly role

23

description and reduce conflict have indicated a positive effect on the nursing care

delivery system. This study concerns to level of role conflict and role ambiguity.

2. Role conflict and role ambiguity in nursing

In nursing, numerous nursing studies have been conducted regarding role

conflict and role ambiguity. The literature indicated that role ambiguity, and role

conflict exists in complex organizations affecting to members, that it causes

dysfunctional individual and organizational consequences (Rizzo et al., 1970).

A study investigated role stress five acute care teaching hospitals in Taiwan.

They conducted on a convenience sample of 129 nurse specialists in 2004 (response

rate 81%). The results indicated that role stress variables predicted 24.8% of the

variance in job satisfaction. Role ambiguity (p < 0.001) and role overload (p < 0.01)

were the best predictors, but role conflict was not statistically significant. Role stress

explained statistically significant proportions of the variance for each component of

job satisfaction: professionalism (10.6%), interaction (16.7%), demand/reward

(27.1%) and control/recognition (18.5%). Role ambiguity predicted all four

satisfaction components, role overload predicted demand/reward and role

incompetence predicted interaction (Chen, Chen, Tsai, & Lo, 2007)

Lu et al. (2007) have been conducted a study about role perception and

actual role content on 520 hospital nurses in Beijing participated representing a

response rate of 81%. The findings were found in the actual role content aspect, the

respondents who reported that they always assumed the roles itemized experienced a

lower level of role conflict and role ambiguity compared to those who reported that

they sometimes undertook these roles (p < 0.05). The differences between role

perception and role conflict and role ambiguity could be related to nurses’

expectations of their role as an internal source of role conflict and role ambiguity.

Tankha (2006) conducted a study to investigate the effect of role stress in a

sample of 120 nursing professionals of government and private hospitals. Role stress

was measured by Organisational Role Stress Scale develop by Pareek. The results

revealed that male nurses experienced significantly higher stress than females. Male

nurses from private hospitals showed significantly higher level of stress levels than

the government nurses.

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McGillis Hall (2003) conducted a study with a random sample of 30 adults,

acute care patient units within eight hospitals located in Toronto, Canada; and 30

randomly Registered Nurses from selected hospital. The results were shown that

Registered Nurses in this study experienced high levels of role conflict. In this study,

role conflict may have reflected issues related to lack of resources, differing

perceptions of how work should be carried out, and incompatible requests.

A study explored the relationship between burnout, and role conflict and role

ambiguity in nurses and physicians at a university hospital in Turkey. They survey

251 health-care professionals (170 physicians and 81 nurses) responded to the survey.

Variables in this study were measured by Maslach's Burnout Inventory (MBI), and

Rizzo's Role Conflict and Role Ambiguity Scales. The results showed that there was a

strong positive correlation between the MBI and Rizzo's Role Conflict and Role

Ambiguity Scales. The nurses showed significantly higher levels of role conflict, role

ambiguity, and burnout compared to the physicians (Tunc & Kutanis, 2009)

Huber (2006) has noticed that the level of stress should be moderate levels.

At too low a stress level, nurses may become apathetic or nonproductive. At too high

a stress level, nurses only engrossed in trying to deal with stress and therefore reduce

quality of productivity.

Shortly, many studies have been paid attention in role stress, specifically

role conflict and role ambiguity. They also indicated the negative relationships

between role stress, which include role conflict and role ambiguity, and job

satisfaction. This study is going to measure level of role stress.

3. Measurements of role conflict and role ambiguity

Role Conflict and Ambiguity Scale (RCAS) was developed in 1970 (Rizzo

et al., 1970). It measured role stress from 2 dimensions: 1) role conflict, and 2) role

ambiguity. RCAS consisted of 14 items and ranged on a 7-point Likert scale from

1- strongly disagree to 7 - strongly agree (Rizzo et al., 1970). The RCAS were

reported to have good reliability and validity in these studies. Cronbach’s Alphas

were reported 0.82 for role conflict, and 0.80 for role ambiguity (Lu et al., 2007).

25

Relationships between job stress, role conflict, role ambiguity, and

job satisfaction The relationships between stressors and job satisfaction are the focii of some

theories and researchers. Firstly, there are several theories which indicate relationship

among job stress, role stress and job satisfaction, such as Cooper’s Dynamics of Work

stress model (Cooper & Marshall, 1976 cited in Sadri & Marcoulides, 1994),

Lazarus’s stress and coping model (Lazarus & Folkman, 1984). However, Cohen-

Mansfield’s Model is developed specifically for nursing, the concept of the model has

been explained very clearly and it is easy to apply.

Cohen-Mansfield's stress-coping model

Cohen- Mansfield’s comprehensive model of occupational stress was

developed first in the 1995s (Cohen-Mansfield, 1995). The model indicated stress is

seen as resulting from an lack of the person-job fit between a person and his or her

environment. The model proposed the cycle of the person-job fit. It consists of three

components including (1) sources of stress, (2) the person-job fit, and (3) outcomes.

Sources of stress are the interaction of stressors and needs with ‘work

resources’, ‘the individual’s personality’, and ‘non-work resources’.

First of all, sources of individual stress consist of ‘work-related demand &

stressors’, ‘individual needs’, and ‘non-personal stressors’. They are divided into

three levels including institutional level, unit level, and patient level.

1. “Institutional level” relates to the functioning of the workplace as a whole

and to all employees. Stressors are workplace-related stress, such as policies (salary,

health policy, career ladder), attitudes, institutional, communication patterns,

problems relating staffing, problems with medical doctor or leadership style.

2. “Unit level” relates to the interaction between the individual worker and

immediate co-workers within the unit. Stressors are related to social climate, and role

definition (i.e. poorly defined roles, role ambiguity, role conflict). It also can be stress

related to social climate (i.e. problems relating coworkers) can include, leadership

style, staff attitudes, staffing level and quality, educational development, unfair work

allocation, low work quality.

26

3. “Patient level” relates to the interaction between the worker and the

individual patients (and their families) and the specific types of work done. Stressors

are as workplace-related stress, such as type of disability, frequency of death, attitude

of patient and their family, relationship with patient and their family, specific kinds of

work (i.e. physical work, caregiving, providing support), patience, cleaning.

Moreover, ‘Individual needs’ are those that relate to individual feeling

toward the work. They relate to feelings toward work such as poor self-esteem,

feelings of insecurity, self-actualization needs, and ethnic identity, etc.

Secondly, ‘individual’s personality’ includes social support, and coping

mechanisms.

Thirdly, ‘non-work resources’ include life difficulties not directly related to

work, such as financial problems, life event changes, family problems, being

overweight, more people in household, and lack of family support, etc.

The person-job fit lies at the center of the model. It refers to the match

between the needs of the employee and needs of the organization. If lack of fit occurs,

it will impact outcomes to the work and the individual.

Outcomes are individual’s stress responses which include physical,

psychological, emotional, cognitive, and/or behavioral response. From that, these can

impact on individual (confusion, burnout, depression, dissatisfaction, quitting job,

etc.) or organization (i.e. deteriorated quality of care, greater absenteeism, higher

turnover, etc.) or both. Job dissatisfaction is one of stress responses in that individual.

These outcomes of model change initial inputs and resources both at the job

and at the personal levels, and the process continues in a new cyclic. (Figure 2).

In this study, this model was applied because it was develop for nursing, and

several researchers have applied Cohen-Mansfield’s Model in their study on nurse

samples (Hawes, 2009; McGilton, Hall, Wodchis, & Petroz, 2007).

This research explores ‘job stress’ at the institutional level, regarding

conflict with physicians, problems relating to supervisors, problems relating to peers,

and workload; and the patient level regarding death and dying, patients and their

families, inadequate emotional preparation, and uncertainty concerning treatment; and

‘role conflict’ and ‘role ambiguity’ to refer to staff nurse’s stress at the unit level.

27

Figure 2 Theoretical framework for studying job satisfaction among staff nurses

derived from Cohen-Mansfield’s occupational stress model (Cohen-

Mansfield, 1995)

Secondly, many studies about the relationships between job stress, role

conflict, role ambiguity and job satisfaction have been conducted in Western

countries, and some Asia countries. The major researches indicated negative

correlation exists among them.

Rosse and Rosse (1981) have conducted a study to explore level of role

conflict and ambiguity among staff nurses. They survey 504 registered staff nurses,

licensed practical nurses, nurse aides and head nurses/supervisors in five hospitals.

The findings were reported that levels of role conflict and ambiguity were low for

most nurses. However, nurses were significantly related to job stress, organizational

commitment, job satisfaction, and intentions to quit.

28

A study conducted to investigate the effects of perceived supervisory

support provided by registered nursing staff on job stress and job satisfaction among

nurse aides (NAs) working in long-term care in 10 facilities in Ontario (McGilton et

al., 2007). They surveyed 222 nurse aides. The variables were measured by

Supportive Supervisory Scale, and Expanded Nursing Job Stress Scale, and Job

Satisfaction Scale. Multiple linear regression analysis supported an adaptation of

Cohen-Mansfield's stress-coping model. The results indicated 33% of the total

variance in job satisfaction was explained by supervisory support, stress, birthplace,

and first language spoken. The researchers noticed greater supervisory support may

associated with reduced job stress.

A study on relationships between professional commitment, job satisfaction,

and work stress in Public Health Nurses in Taiwan was conducted by an author

groups in Taiwan (Lu et al., 2007). They surveyed 287 PHNs of Pingtung County in

Taiwan (90% of a response rate). The variables were used by Job Satisfaction Scale.

The results has been shown that job satisfaction has a direct negative effect on work

stress, which coefficient of = 0.29 (p < .05).The higher the nurses’ satisfaction with

their job, the lower is their perceived work stress.

Christina and Konstantinos (2009) explored the relationships between

inter-professional working, clinical leadership, stress and job satisfaction in Greece.

They studied 85 Greek nurses working in six acute psychiatric wards. They found that

nurses were at moderate stress and satisfied with their work. There were a significant

negative relationship between occupational stress and nurses job satisfaction

(r = -0.453; p < 0.01). They mentioned occupational stress reduced nurses' job

satisfaction. they also revealed the main sources of occupational stress were reported

workload, time pressure, lack of adequate staff in relation to potential physical threats

from a psychiatric patient. In addition, organizational structure and processes such as

lack of support from management and poor supervision were high stressors for

participants, as well as relationships and conflicts with other professionals.

A meta-analysis of 31 studies (Zangaro & Soeken, 2007) conducted to exam

the strength of the relationships between job satisfaction and autonomy, job stress and

nurse-physician collaboration among staff nurses. The results showed job satisfaction

was most strongly relationship with job stress (ES = -43).

29

Chen at el. (2007) studied to illustrate the unique relationship between role

stress and job satisfaction in five acute care teaching hospitals in Taiwan. They

surveyed on 129 nurse specialists. They found that role stress variables predicted

24.8% of the variance in job satisfaction. Role ambiguity

(p < 0.001) and role overload (p < 0.01) were the best predictors, while role conflict

was not statistically significant. Role stress explained statistically significant

proportions of the variance for each component of job satisfaction: professionalism

(10.6%), interaction (16.7%), demand/reward (27.1%) and control/recognition

(18.5%). Role ambiguity predicted all four satisfaction components, role overload

predicted demand/reward and role incompetence predicted interaction.

Lu et al. (2006) explored nurses’ views and experience regarding their

working lives in Mainland China. They surveyed 512 hospital nurses in Beijing in

2004. They found that about 40% of the variance in job satisfaction could be

explained by the set of independent variables including organizational commitment,

occupational stress, professional commitment, role conflict, role ambiguity,

educational level, age and working years (R2 = 0.396). Organizational commitment

had the strongest impact on job satisfaction, which explained 31.3% of the variance in

this, followed by occupational stress and role conflict (5.5% and 1.9% respectively).

In addition, both nurses’ role perception and actual role content influenced job

satisfaction as well as occupational stress, role conflict and role ambiguity (p < 0.05).

Nurses’ educational level was also a factor related to role perception, professional

commitment and role conflict (p < 0.05). Role ambiguity did not participate in the

model.

Health Care System in Vietnam At present, the Public Health Care System plays the leading role in

healthcare, the public health care services in Vietnam are divided into a four-tiered

pyramid. At the bottom of the pyramid are commune health centers responsible for

providing primary health care. Above the commune health centers are inter-

communal polyclinics and district general hospitals (the third tier). Provincial

hospitals form the second tier of the health care system. National hospitals and central

specialty institutes are the tertiary care referral centers and professional training and

30

medical research centers are at the top of the pyramid. The private health sector is

more active in outpatient care, with inpatient care still taken care of by the public

sector (Deolalikar, 2002).

In 2009, there are 1002 general hospitals, total hospital beds are 163,900,

and nursing staffs are 71,500 working in different level of health care system in

Vietnam (Vietnam Living Standards Survey [VLSS], 2009).

Thai Nguyen province is one of the political, cultural and economic centre in

Northeast part of Viet Nam. It is also a gateway to exchange the information in many

ways. It links the mountainous areas and midland plains of Northern location (Thai

Nguyen Journal, 2009). Thai Nguyen health care services have been known as a

representative of the medical centers of the Northeast region, the population is 1149.1

thousand persons, emphasizing the population density is 325 persons per 1 km² (Linh

Khang, 2010).

There are 9 public hospitals in Thai Nguyen province. One of them is the

national general hospital (tertiary care level) which is under the jurisdiction of the

MoH, its name is Thai Nguyen Centre General Hospital. Three hospitals are

provincial general hospitals (secondary care level) under the jurisdiction of the Thai

Nguyen Provincial Department of Health, namely are the A hospital, the C hospital

and the Gang Thep hospital. 5 hospitals are specialized hospitals including the

psychological & mental hospitals, the traditional medicine hospital, the therapy

hospital of tuberculosis and lung disease, the nursing and rehabilitation hospital, the

eyes hospital, the treatment institute of leprosy (Department of Planning and

Investment, 2010; Thai Nguyen Portal, 2009). There are 3.826 medical staffs. Nursing

staffs have about 1,500 people, accounting for 50% of the health personnel (Bui,

2011).

These 3 provincial hospitals in Thai Nguyen Province are the public

hospitals. They are quite similar about organizational structure and policies, but only

differently about total number of staffs, and number of the beds. These hospitals have

approximately 500 staff nurses. In that, the A hospital has about 170 staff nurses, the

C hospital has about 200 staff nurses, the Gang Thep hospital has about 150 staff

nurses (Thai Nguyen Portal, 2009). Beside, the A hospital consists of 320 beds, the C

hospital consists of 350 beds, and the Gang Thep hospital consists of 300 beds (Thai

31

Nguyen Portal, 2009). In average, these provincial hospitals perform to diagnosis and

treatment for approximately 216,978 people in each year, in that, medical inpatients

were treated more than 30,000 people, ICU patients had more than 200 cases, total of

surgery were more than 6,000 cases (Department of Health, 2009).

Additionally, Thai Nguyen General Provincial Hospitals are also known as

the leading role in providing health care services. These hospitals are secondary care

level (Department of Planning and Investment, 2010). They are the important line

because the three hospitals are responsible examination and treatment of people in the

province and people live nearby that patients often come from the North-East areas of

Vietnam. Moreover, Thai Nguyen provincial general hospitals are similar to

organization structure, policies, and responsibilities. These hospitals are quite

different about number of beds, number of staffs. Some hospitals near Thai Nguyen

Provincial general hospitals such as Bac Kan provincial general hospital has 320 beds

with 150 staff nurses; Tuyen Quang provincial general hospital has about 450 beds

with approximately 250 staff nurses..

In other way, Thai Nguyen province has the military healthcare system,

including the 91 hospital with 200 beds, and some clinics, health centers. They

provide health care service for special and specific subjects who relate to the army

(Thai Nguyen Portal, 2009).

Nature of Nursing Work in Vietnam

In Vietnam, Vietnam Nurses Association (VNA, 2009b) is a socio

occupational organization responsible for management and supervisor Vietnamese

individual operating in nursing specialty and relevant professions. Organization layout

of the VNA is as follow: 1) the central level is Vietnam Nurses Organization; 2) the

Provincial and municipal level includes Provincial and municipal Nurses Association

(collectively called as Provincial Nurses Associations); and 3) Branches include

Branches directly under Central Vietnam Nurses Association: provinces and cities

directly under Center which do not have enough conditions to establish Association in

provincial level can set up branches under Central Vietnam Nurses Association; at

Central level, they are specialized nurses branches; and Branches at grassroots level:

are nursing branches of institutes, hospitals, district medical centers, nursing schools

under associations at provincial levels.

32

MoH (1993) decided the responsibilities of staff nurses in the hospital as

follow:

1. To receive patient, fulfill personal information, and guide patients and

their families to understand the regulations of using about room, furniture, time for

examination and treatment, time for their families’ visiting.

2. Follow up vital sign (pulse, blood pressure, etc.) before doctor examine

patient. In some special situation, the nurses follow up more mental state, knowledge,

and the amount incharge or discharge, such as (vomit, urine, sweat, etc.) pain, etc.

3. To carry out nursing technique and implement following the doctor such

as providing medication, injection procedures following doctor orders.

4. To take care following patient’s classifications (how to feed, bathe,

change closthes, clean bed).

5. To assist and subordinate doctor during patient’s examination, diagnosis,

and treatment skills

6. In serious case, follow up on evolution of patient’s diseases and report in

time to doctor when their disease becomes serious.

7. To care and resolve issues for patients who are dying or have already

died.

8. To fulfill information about nursing care process and symptom in

document.

9. To oriented patient and patients’ relatives on how to care and give care to

the patient after hospital discharge.

At present, there are some innovations about the ordinances in Vietnam.

MoH (2011) decided Vietnamese nurses have to carry out 3 roles toward patient

centered nursing care including provider of care, cooperation role, and teaching role.

Provider of care: directly give care to the patient to fulfill the physical and

psychological needs, provide care to rehabilitation, and in palliation.

Cooperation role: assistant and subordinate doctor during examination,

diagnosis, and treatment process.

Teaching role: planning and teaching the patient and patients’ relatives in

how to restore, maintain and promote health care status, and supervising new nurses.

33

Ministry of Health (MoH, 2005) has decided specific responsibilities for

each level of nursing as follow:

Level 1. Staff nurses had achieved the certificate from secondary school:

Being nursing technical employees of the health sector, direct implementation of basic

nursing techniques in the medical establishment. The particular responsibilities are as

follows:

A1-Direct the implementation of comprehensive care for patients in

accordance with professional regulations and provisions of health facilities.

A2-Perform basic nursing techniques following each specialist and assist the

other nursing staff, who had higher levels, in the implementation of complex technical

to follow physician orders and the assignment of the supervisor nurse.

A3-To monitor and record the daily happenings of the patients, especially

those seriously ill and emergency cases; detecting and promptly reporting unusual for

the patient's treating to physician and supervisor nurse to solve problem.

A4-Perform primary emergency care of serious illness or accident.

A5-Reception of patients to medical examination, admission, discharge, and

para-medical examination; implementation of the regulations when the patient died

under the doctor's medical orders and assigned by supervisor nurse.

A6 - Prepare complete, correct and timely means, instruments, medicines,

medical records for the medical examination and treatment of emergency patients.

A7-Preservation of drugs and assets (medical instruments, machinery,

equipment ...) is assigned to management; timely detection of failure to repair

requests. Individuals have to responsible for certain medications and asset which is

assigned to management.

A8-Implementing health education, urging, reminding the patient, patient

family hygiene and no noise.

A9-Implement programs to primary health care (care for maternal and child

health, family planning, vaccination ...) and sanitation to prevent disease.

A10-Participate in the guidelines to practice for basic nursing technical for

students.

34

A11-Implementing the ordinances about medical ethics, and professional

regulations, the technical process of health sector and other provisions of law relating

to the field of nursing.

Knowledge required that nursing staff have to know the process of basic

nursing techniques, routine care and disease prevention and hygiene; Regulation on

rational drug use and safety; Responsibilities and duties of health officials in the field

of nursing; patient classification systems and Law to protect people's health and the

regimes and policies of the State and of the health sector to the service object.

Level 2. Staff nurse had achieved the diploma degree: Being professional

and technical employees of the health sector, implementation of basic nursing

techniques and some specialized nursing techniques in the medical establishment. The

particular responsibilities are as follows:

B1-Planning for comprehensive patient care and direct implementation of

the plan comprehensive patient care in accordance with professional regulations.

B2-Perform basic nursing techniques and made some complex techniques of

nursing specialty under doctor’ order and assigned of the supervisor nurse.

B3 B9 similar to A3 A9; B11 similar to A11

B10-Participate in the guidelines to practice for basic nursing technical for

nurses who are lower levels, and Participate in research of nursing sciences related to

take care humans.

Knowledge required add more that nursing staff have to know Knowledge of

primary health care and sanitation, disease prevention and The basic technical

nursing, some technical and specialist nursing care for the disease process.

Level 3. Staff nurse had achieved the baccalaurate degree: Being

professional and technical employees of the health sector, implementation of basic

nursing techniques and technical specialist nurses in the health facilities. The

particular responsibilities are as follows:

C1-Plan care and coordinate with physicians in the implementation plan for

comprehensive patient care in accordance with professional regulations.

C2-Implement monitoring and supervision of nursing staff, who is lower

level, in the implementation follow the physician’ orders and the implementation of

comprehensive patient care.

35

C3-Perform proficiently the basic nursing techniques and complex nursing

techniques of the specialty field.

C4 similar to A5; C5 similar to A3; C6 similar to A4; C8, C9 similar to A7;

C12 similar to A11.

C7-Plan and organize the preparation of complete, correct and timely

equipment, facilities, medicines, medical records for the medical examination,

emergency treatment and patient care.

C10-Organize the work of counseling, health education and train to no

noise, hygiene and disease prevention.

C11-Participate Guidance for nursing techniques to nursing students, as well

as nurses in the lower levels; and to carry out the direct route; and participate in the

scientific research in the field of nursing.

MoH (2003, cited in Nursing administration division, 2009) decided to

implement the comprehensive patient care model. The particular responsibilities of

staff nurse are as follow: (Figure 3)

1. To receive and examine the initial holistic of patient when patient admit

hospital.

2. To plan the nursing care for each patient regarding holistic.

3. To provide the basic care for patient such as nutrition, hygiene and

posture.

4. To implement the physician’ orders.

5. To monitor the vital signs, abnormal signs or symptoms of disease of

patient and fully recorded on nursing care document.

6. To provide the health education for patients during hospitalization.

7. To coach and supervise the nursing student (if have).

8. To provide the knowledge of disease prevention and complete records for

patients discharged from hospital.

9. To guide the patient observe the laws of ward such as self-management

properties of own, responsibilities for the properties of ward, maintaining hygiene and

no noise.

36

Figure 3 The comprehensive patient care model (MoH, 2003)

Since 1996, in response to the demand for quality patient care and

strengthening development management system nursing, the President of the Ministry

of Health decided to expand the roles of staff nurses to a limited extent in conjunction

with the development of the patient-centered nursing care (MoH, 1999; MoH, 2003).

The roles now reflect the job performances by nurses in many other countries such as

America, Thailand, etc. with developed health care systems and include: assessing the

physical, psychological and social status of patients, consulting with patients about

planned care, evaluating the outcome of care and working closely with other members

of the health care team (Li, 2003). However the perspective of the role of staff nurses

has not been updated to be compatible with the actual situation (Kim, 2007). In

addition, there is a lack of role descriptions in working, so that the nurses don’t know

the extent of their authority, and that can cause confusion when they do their work

(Tran, 2005). This will cause further particularly role conflict and role ambiguity.

At present, Vietnamese nurses have low socioeconomic status (Duong,

2003). The high positions of hospital usually held by the medical doctors such as the

director of hospital, head of the ward, they are also who decide mainly in the curing

and caring of patients. Tran (2010) mentioned the staff nurses often have the habit of

depending on medical doctors in working such as decision making, problem solving

37

in the taking care for patient. Moreover, the media portrays look like a nurse as who

does not nice manner and has low intelligence. Tran (2010) also mentioned from

perspective of people about nurses, it has made nurse have low self-esteem and they

are thought easy to accept everything. In addition, the nurses had achieved a low

degree of education. The most of them have a certificate degree from the secondary

nursing school and carry out the basic nursing techniques and specialist techniques in

the health facilities, and subordinate for doctor. Hence, the nurses have to work

depends.

Nursing profession in Thai Nguyen is managed under the management of

Health Department. There are about 1,500 staff nurses in Thai Nguyen province,

accounting for 50% of the health personnel. They include all educational levels from

certificate to bachelor and are called under a common name to be ‘Nurse’ (Bui, 2011).

The Thai Nguyen provincial hospitals have approximately 500 staff nurses. In that,

the A hospital has about 170 staff nurses, the C hospital has about 200 staff nurses,

the Gang Thep hospital has about 150 staff nurses (Thai Nguyen Portal, 2009). These

hospitals are secondary care level (Department of Planning and Investment, 2010),

similar about working condition, serve various kinds of patients in the province and

people live nearby that patients often come from the North-East areas of Vietnam.

The patients come from various kinds of socioeconomic background, and speak

different dialects, with various complex sick and complications. Nurses must to cope

with many different emotions and behaviors of both patients and their families, whilst

quality of are always requires high. Add more, the nurses are not only take care the

patients, but also supervise to students for their clinical practice. In addition, Thai

Nguyen province is not far from Hanoi capital (70km) so patients can easily go to

Hanoi hospitals to be treated. These points indicate that there always have been high

competition in behavior and treatment among hospitals in Thai Nguyen.

In Vietnam, there have been some studies conducting on job satisfaction,

occupational stress, and conflict among staff nurses. Below is some useful

information from study:

Tran et al. (2005) explored job satisfaction and related-factors in 2800

hospital nurses and midwifes in Vietnam. Job satisfaction was measured by a 46 items

in the questionnaire to modify based on Quality Work Index of Whitley 1994. The

38

reliability of this instrument was not reported. They found that 50.9% nurses were

dissatisfied with job. Staff nurses had less satisfied with salary and incomes, followed

by opportunity for growth, relationship nurse-patient and working condition. Staff

nurses had satisfied with relationship with coworker and support from the family and

relatives. There were significant relationships between nurses’ job satisfaction and

working environment, educational level, workload, health equipment insufficiency,

psychological tension, opportunity for advancement, relationship with coworker and

support from family and relatives (p < .001). There was no significant differences in

nurses’ job satisfaction in different locations, genders, working experiences, marital

status or salary & incomes (p < .05). Moreover, they reported that 92.6% nurses are

certificate degrees among staff nurses, 63% nurses had incomes less than 1.000.000

(VND, approximately 50$), nurses provided care for 14 patient/dayshift and 21

patient/nightshift in average. 70% nurses stated nursing professional having less

opportunity for growth and over 60% nurses don’t desire their child to learn nursing

professional. In contrast, over 70% nurses were reported having good relationships

with co-workers, good collaborative with physicians and receiving good support from

family and relatives. Nurses had proposed the most satisfied is care for patient,

reducing suffering for patient, gained patients from the death and useful with their

family and relatives. However, special findings were found that 8.2% nurses intend to

move to private health facilities and 5.1% nurses intend to turnover in next five years.

Duong (2003) has conducted a study in Can Tho general hospital to

determine level of nurse’ job satisfaction. They surveyed 148 nurses. Job satisfaction

was measured by the Nurses Job Satisfaction Scale developed by the researcher. The

reliability of the instrument was reported α-value of .81. The study showed the level

of job satisfaction was at moderate satisfied level. The nurses were reported that very

satisfied with recognition and praise, and achievement & responsibilities. The results

indicated differences in mean scores of job satisfaction in different salary, working

experience, departments. According to marital status, single nurses were more

satisfied than married nurses. According to year of working experience, nurses with

working experience (> 10 year) were less satisfied than the others. According to

salary, nurses with salary < 30$ expressed greater job satisfaction than others.

However, the results from other studies did not support the above findings

39

about job satisfaction (Tran et al., 2005; Le & Le, 2009). The result (Le & Le, 2009)

from 142 health employees (i.e. include 100 nurses, 20 medical doctor, and 21 other

staffs) working at the hospitals, preventive medicine center and commune health

stations in Vinh Phuc province showed that overall job satisfaction of health worker

were at high satisfied (71.1%). Health workers were reported high satisfied with

relationship with colleague, followed by learning and developing, relationship with

leaders and knowledge, skill and performance results. Health workers also were

reported less satisfied salary and benefit, physical facilities. The job satisfaction was

measured by the 40-item survey of Overall Job Satisfaction developed by the

researchers. The reliability was not reported. Tran et al. (2005) conducted a study on

987 nurses working at 14 health facilities in Ho Chi Minh City. They found that 60%

staff nurses felt proud with career. Staff nurses reported the career has many

opportunities for advancement, more sufficient equipments. However, the researcher

reported that nearly 70% staff nurses were “not happy”/ “don’t want”/

“uncomfortable” if their child study nursing profession, some reasons provided for

explain that 62.11% of salary is not disproportionate with responsibilities and work,

55.83% thought that nursing professional had too much psychological pressure at

work, 50.66% of recognition about work from family is not high, 44.38% though that

heavy workloads (from 11-20 direct care to patients per night). This suggests that the

nursing profession is not their priority, and nurses still are not satisfied with career,

and work environment could create stress factors.

Le et al. (2008) examine nurses’ occupational stress in Can Tho central

hospital, Can Tho provincial hospital and Chau Thanh - Hau Giang general hospital.

They surveyed 378 staff nurses. Occupational stress was measured by David Fontana

questionnaire developed by Fontana (1989). The reliability was not reported. They

found that 55% nurses did not have job stress, 43% nurses were at moderate stress,

only 2% nurses were at high stress and no nurses were at extreme stress. There were

differences in job stress in different hospitals, high level was more stress than low, in

that, Can Tho central hospital was the highest stress (53.1%), followed by the Can

Tho provincial hospital (33.9%) and Chau Thanh-Hau Giang general hospital

(32.5%). There were relationships between nurses’ job stress and length of

experience, working time, not interested in the job, working environment, conflict

40

with supervisor and co-worker, lack of security, income, social reputation, and

opportunity for growth (p < .05). The staff nurses also reported that nursing

professional had less opportunity for growth, salary was paid inadequate, the public

lacks respect, working and protecting equipments were inadequacy, the assignments

were unclear, working environment exists noise, complaints of the patient and their

families, easily injured by sharp objects or common reaction and working too many

hours and work pressure and. Moreover, the result also indicated that nurses with

many years of experience were easier stress than younger. However, there were no

relationship between job stress and age, gender, educational level, making decision

when physicians not present, workload (i.e. responsibilities for >8 patients/shift) and

working monotonousness.

Truong et al. (2009) conducted a study in Ba Ria - Vung Tau province to

explore mental disorders of nurses and midwifes. They surveyed 382 nurses and

midwives in the public health services. Study variables were measured by general

health questionnaire (i.e. assessment based depression care), Groningen’ sleep quality

developed (i.e. assessment of sleep disorders), Beck’ depression scale and Zung’

anxiety disorders scale. The reliabilities were not reported. The result indicated 61%

nurses having mental disorder, nurses working at ICU, surgery and medical unit

having mental disorder were higher than other wards (i.e. over > 60% nurses

respectively). There were relationships between mental disorder and working

environment, jobs requiring observation or correct choice, heavy workload, heavy

work pressure, risk losing their jobs. However, there were no relationships between

mental disorder and conflict with supervisor and strict behavior of supervisor with

staff. Researchers still noticed that conflict with supervisor and strict behaviors of

supervisor with staff seem reduce susceptibility to mental disorders.

An investigation by the Institute of Medicine Labor and Sanitation and

Hanoi Medical University (Nguyen & Nguyen, 2006) surveyed 974 healthcare

workers in three Hanoi Central Hospitals in 2004-2005. They found that 1/3 health

care workers surveyed felt very tired after work, 21.8% suffered from insomnia or

sleep disorders, 35% headache, 21.5% quick-tempered, excitable, 43.5 osteoarthritis

pain muscle fatigue and 11.3% feel worry. These are signs of job stress. The results

also showed that most of participants not happy with working conditions. Participants

41

reported that the offices are not clear, hot and stuffy; hospital is noisy; they often have

to exposure to toxic chemicals, to radiation and to the virus, bacteria, disease

mushrooms, even exposure to hepatitis viruses and HIV, and to work with prolonged

standing. Moreover, participants noticed that they also had great tension and stress

caused by patient response and their family, of which were verbal abuse, threatened

and even exposed to violence.

In addition, a survey by Labor Medicine and Environmental Sanitation

Institute (Nguyen, 2007) indicated exposure rate of hepatitis B virus in health care

workers is 18 - 25%, of which incidence is 6.3%. They noticed that great pressure of

work made for medical staff ratio be very high stress. The results of this survey in a

ICU indicated that nearly 23% of employees had high levels of stress, 42% were at

moderate stress. Symptoms were reported that prolonged motor reflexes, reduced

memory, reduced focused. Results of heart rate monitor showed that the tension

appeared soon after starting work until the end, the stress tends to increase at the end

of shift. This situation could increase in the large hospitals (which receive hundreds of

emergencies every day).

Nguyen (2001) conducted a study to examine perceived conflict among 136

secondary staff nurses working in the general hospital in Mekong River Delta,

Vietnam. Conflict was measured by a questionnaire constructed by the researcher.

The reliability was reported Cronbach’s α to be .80. The results showed that staff

nurses were at minimal level of conflict. There were no significant differences in

perceived conflict in different working experiences, working areas. The researcher

noticed that younger ages were less conflict than other ages, receiving the support for

good work from manager, having good relationship with coworker and opened

communication will reduce conflict and increase satisfaction with job. Moreover,

adequate nursing staff has been assigned and received motivation, assistant, reward in

time will increase proud of the work.

In short, previous studies have been conducted to investigate the sources of

satisfaction, stress among staff nurses. Some studies have shown nurses have been

facing with many stressors in the work and having mental disorder, unhappy with

work (Tran et al., 2005; Nguyen & Nguyen, 2006, Nguyen, 2007, Truong et al., 2009;

Le et al., 2008).

42

Educational preparation for nurse in Vietnam

At present, there are 3 kinds of educational curriculum for nurses in Vietnam

including 1) certificate from secondary nursing school, 2) diploma nursing education,

3) bachelor of nursing and bachelor associate of nursing.

1. Certificate from secondary nursing school

In 1968, MoH began to establish training programs for secondary nursing

school. Students were recruited from the junior middle school graduates (i.e. school

grade 7). In 1975 this standard changed, the students have to finish high schools and

of course have granted certificates. They will have to take the exams to enter the

secondary nursing schools. After studying in two years they will be certified from the

secondary nursing school with the certain standard of knowledge and some other

criteria. The Ministry of Health approved only a 2 years program. The curriculum

consists of general subjects including foreign languages, information technology,

politics, sports, military; the basic subjects such as anatomy - physiology,

microbiology - parasites, pharmacology, nutrition, hygiene and disease prevention,

communication skills and health education, management and health organizations; the

specialized subjects such as fundamental of nursing, medical nursing, surgical

nursing, pediatric nursing, obstetric nursing, infectious disease nursing, production

gynecology nursing, disease specialist nursing, traditional medicine, primary

emergency, rehabilitation-physiotherapy, community nursing (Ministry of Education

and Training [MoET], 2007). At the present, most of hospital nurse graduate from this

level.

2. Diploma nursing education.

In 1975, diploma nursing educational program was established. Total time of

this educational program is 3 years, there are 2 ways to enroll in this program. The

way to enroll is recruited students who have graduated from high school. The students

must pass an entrance exam, and they will have to study full-time with this program.

Second way students can enroll is to study part-time with this educational program.

They also must pass an entrance exam. The students are staff nurses who have at least

two years of experience after they graduate from secondary nursing schools, total time

is for 1 year of the study (VNA, 2009b).

43

3. Bachelor of nursing and bachelor associate of nursing

In 1985, the Ministry of Health along with the Ministry of Educational

Training have allowed to open educational program of bachelor’ nursing. Bachelor's

degree nursing class was first opened at the Hanoi Medical University. This program

also has two kinds of students including bachelor of nursing and bachelor associate of

nursing. Total time of study is 4 years. Firstly, if students want to enroll this program,

they must graduate from high school and they must pass an entrance exam. They have

to study full-time with this program during 4 years. Alternatively, this educational

program will recruit from staff nurses who have at least two years of experience after

they have diploma degree, or at least three years of experience after they have

certificate of the secondary nursing school. They can study part-time with this kind of

enrollment (VNA, 2009b).

Summary In summary, job satisfaction is very important to promote well-being of the

organization, positive attitude and behaviors of employees toward work. Moreover,

improving job satisfaction results in better quality of care, less physical and mental

problems to health care staff. Staff nurses experience with stress in their work and

work environment. In addition, there are relationships between job stress, role

conflict, role ambiguity and job satisfaction. In Vietnam, some researches pointed out

that staff nurses are satisfied with their work. However, some researchers reported

that Vietnamese nurses experience job stress and role conflict. This study is going to

examine the predictive effects of job stress, role conflict and role ambiguity on job

satisfaction among staff nurses by applying the Cohen-Mansfield’s a comprehensive

model of occupational stress.