Job Stressors and Coping Strategies among Nurse Educators at Military Secondary Technical Nursing School in Alexandria : Comparative Study

Nurse educators are critical players in assuring quality of nursing education. They experience ever-changing health care environment while preparing the nursing work. If they are prepared to face this, quality of care provided to individual and community would improve. The aim of this study is to compare the stressors face and coping strategies used by nurse educators in the Military nursing school, with their peers in technical nursing schools affiliated to the Ministry of Health in Alexandria. The study was conducted on 25 Military nurse educators and 52 nurse educators of technical nursing schools of Ministry of Health. A structured interview – questionnaire was developed to collect the needed data. The study results revealed high level of stress among nurse educators of the Military nursing school regarding work shifts, sharing in the military training for parades and ceremonies. However, high level of stress was predominant among nurse educators of the nursing schools affiliated to the Ministry of Health with low salary, no chance for job promotion and inadequate supplies and equipment in clinical fields. The study recommended offering appropriate fringe benefits and to conduct stress relieve programs. INTRODUCTION Education as a profession is a complex activity, with different sources of jobrelated stressors. Nurse educators are faced with daily challenges in their roles as educators, while they strive to transform teaching practice for future health care needs. Many of these issues are new, complex, and require creative approaches. It was reported that within the last five years of teaching, 46% of teachers are likely to leave the field of education . 126 Bull High Inst Public Health Vol.39 No.1 [2009] Job-related stressors are emotional, cognitive, behavioral, and physiological reaction to aversive and noxious aspects of work environment and work organizations. It is a state characterized by high level of arousal and distress and is often concerned by feelings of not coping. These job-related stressors were categorized into personal and job/ work factors. The personal factors were family responsibility as well as personal illness. Job/ work factors include daily organizational problems, work overload, low payment, leadership responsibility of nurse-students whether in classroom or in the clinical areas, lack of supplies and equipment in clinical setting, the ability to make decisions and relate knowledge in different circumstances in clinical areas, conflicts between nurse educators and hospital staff and working hours (2, . The arrangement of working hours is a major factor in attracting, retaining and satisfying staff which means scheduling. Scheduling is developing a plan for where and when personnel are to work within the parameters dictated by law . It is the process of determining when each member will be on, or off duty and which shift she will work. When, the nursing school is an indoor school like the Military nursing school the nursing school managers and colleagues of nurse educators usually play a big role of support and control of nurse educators’ job related stressors , and the main factor of these stressors, again is scheduling. The staffing schedule plan should enable the staff to meet the objectives, standards and policies of the school. It should provide satisfaction of the staff in their work and some flexibility in meeting unexpected personnel changes such as sick leave and coverage for holidays and vacations . Nurse educators during their work are Abd El-Aziz & Ahmed 127 exposed to job/work stressors. These lead to emotional exhaustion and psychiatric morbidity at the same time, they are critical players in assuring quality of nursing education. They experience-ever changing health care environment while preparing the nursing work. If they were prepared to face this, quality of care provided to individual and community would be improved. On the other hand, when the degree of stress is not stimulating enough, lack of interest, boredom, low motivations, and even poor performance can result. Stress perception is highly subjective; it depends on the individual personality, overall human condition and available resources. Stress might be positive, motivator of energy, but if it becomes chronic or exceeding individual abilities, it would lead to negative effects resulting in physical complaints like headache, fatigue as well as cardiovascular diseases. Psychological problems like confusion, lack of concentration and mood changes don’t only affect individuals; but they also, become expensive problem in work place leading to less productivity . Coping strategies were defined as the process through which the individual mange the demands of the individual environment. Lazaras and Folkman (1984) had classified coping strategies into two types, namely: cognitive /emotional and the second was behavioral coping strategies. The cognitive/ emotional coping strategies could be used to alternate the way of thinking about response to the stressors. It included seeking help from God, seeking emotional support from family members and friends, and kept feeling to one self. Behavioral coping strategies (problem solving strategies) could be used to make action to adverse stressful 128 Bull High Inst Public Health Vol.39 No.1 [2009] circumstances for solving the problem. Any of these could be adaptive or maladaptive coping strategies based on its impact on dealing with stressful event. Many international studies attempted to study stressors affecting nurse educators. Harri (1995) found that 87% of nurse educators had emotional exhaustion, 70% of them felt psychological illness, their burn out reached 79% and on the personal level 18% of them were worried about their children. Harri added that the stressors affecting nurse educators had a negative impact on the quality of their working life which lead to change their job location in 65% where as absenteeism reached 50%. Moreover, these stressors induced a huge problem in nursing education, leading to teaching process deterioration. Moreover, in Northern Ireland, Hunter and Davis (1993) found the work overload, clinical training problems, heavy clerical activities, and lack of support of school manager were sources of nurse educators’ stressors. These stressors had high negative effects on the majority of them and their partners. In Egypt, the study that assesses job-related stressors was mostly related to nurses in clinical areas. Nurse educators stressors could be a real problem that had a negative effect on the nurses’ education, and health status leading to job dissatisfaction and inadequate performance. This study aimed to: compare the stressors faced and coping strategies used by nurse educators in the Military nursing school, with their peers in technical nursing schools affiliated to the Ministry of Health in Alexandria. SUBJECTS AND METHODS A) Setting of the study: Abd El-Aziz & Ahmed 129 The study was carried out in two settings: I-Military Technical Nursing School in Alexandria affiliated to the Army forces. IITechnical Nursing Schools affiliated to the Ministry of Health, namely: ElGommhoria, Dar-Ismail, Ras El-Teen, AlAmirraih, Borg El-Arab, and Abou Keer technical nursing schools. B) Subjects of the study: All nurse educators in the above mentioned 7 hospitals were included. From The Military Nursing School, participants were 25; 15 were holding Bachelor of Nursing Science; while, 10 were holding diploma degree of nursing. Nurse educators from the other 6 hospitals, which were affiliated to the Ministry of Health, were 52; classified as: 27 holding Bachelor of Nursing Science, and 25 holding diploma degree. C) Tools: A structured interview – questionnaire was developed to assess the nurse educators experienced stressors based on review of current related literature and items were modified after Licert. The questionnaire composed of 5 parts: Part 1: The socio-demographic characteristics of the sample including: age, marital status, educational qualifications, and years of experiences. Part 2: Work related stressors such as rules and regulations and working environmental conditions. Part 3: Personal stressors. Response of nurses was measured on five point Likert scale (1-5) ranging from no stress (1 point) to extreme stress (5 points). Stress rating scale total score was classified as follows: • 20% -39% low stress level. • 40% 69% moderate stress level. 130 Bull High Inst Public Health Vol.39 No.1 [2009] • 70% 100% high stress level. Part 4: Symptoms of stress. Part 5: Cognitive-emotional coping strategies among nurse educators. METHODS A) Pilot study: A pilot study was carried out on 15 nurse educators from the 7 schools included in the study in order to check and ensure the clarity of the questionnaire, Identify obstacles that may be encountered in collecting data. In the light of the findings of the pilot study, the questionnaire was put in its final form. B) Data collection: The technique used in this study was the individual interview. Each interview took a period of one hour. Three educators were interviewed daily after the work shift. Data were collected in three months period from 19 of November, 2006 to 18 of January, 2007. C) Statistical Analysis: Data were tabulated and statistically analyzed using (SPSS version 11.0). Frequencies and percentages were calculated. Mean and standard deviation, and X value were used to compare the study groups. The threshold of Significance was less than 5 %. RESULTS As regards the socio-demographic characteristics of the studied sample Table (1) showed that 72% of the sample of Military nursing school; their age ranged between 25-35 years with a mean age of 29.135± 3.572 and 59.6% of educators of the other schools, affiliated to Ministry of Health, their age ranged between 35-45 years with a mean of 31.672±501 years. The majority (92%) of nurse educators of the Military nursing school as well as 84.6% 


INTRODUCTION
Education as a profession is a complex activity, with different sources of jobrelated stressors.Nurse educators are faced with daily challenges in their roles as educators, while they strive to transform teaching practice for future health care needs.Many of these issues are new, complex, and require creative approaches (1,2) .It was reported that within the last five years of teaching, 46% of teachers are likely to leave the field of education (1) .
by high level of arousal and distress and is often concerned by feelings of not coping (1) .These job-related stressors conflicts between nurse educators and hospital staff and working hours (2,3) .The arrangement of working hours is a major factor in attracting, retaining and satisfying staff which means scheduling (4) .Scheduling is developing a plan for where and when personnel are to work within the parameters dictated by law (5) .It is the process of determining when each member will be on, or off duty and which shift she will work (6,7) .When, the nursing school is an indoor school like the Military nursing school the nursing school managers and colleagues of nurse educators usually play a big role of support and control of nurse educators' job related stressors (8,9) , and the main factor of these stressors, again is scheduling.The staffing schedule plan should enable the staff to meet the objectives, standards and policies of the school.It should provide satisfaction of the staff in their work and some flexibility in meeting unexpected personnel changes such as sick leave and coverage for holidays and vacations (10) .

Nurse educators during their work are
Abd El-Aziz & Ahmed 127 exposed to job/work stressors.These lead to emotional exhaustion and psychiatric morbidity at the same time, they are critical players in assuring quality of nursing education (11,12) .They experience-ever changing health care environment while preparing the nursing work.If they were prepared to face this, quality of care provided to individual and community would be improved (13,14) .On the other hand, when the degree of stress is not stimulating enough, lack of interest, boredom, low motivations, and even poor performance can result (15) .to less productivity (16,17) .
Coping strategies were defined as the process through which the individual mange the demands of the individual environment (18)  circumstances for solving the problem.
Any of these could be adaptive or maladaptive coping strategies based on its impact on dealing with stressful event (19) .
Many international studies attempted to study stressors affecting nurse educators.Harri (1995) found that 87% of nurse educators had emotional exhaustion, 70% of them felt psychological illness, their burn out reached 79% and on the personal level 18% of them were worried about their children.Harri added that the stressors affecting nurse educators had a negative impact on the quality of their working life which lead to change their job location in 65% where as absenteeism reached 50%.Moreover, these stressors induced a huge problem in nursing education, leading to teaching process deterioration (20) .Moreover, in Northern Ireland, Hunter and Davis (1993) found the work overload, clinical training problems, heavy clerical activities, and lack of support of school manager were sources of nurse educators' stressors.
These stressors had high negative effects on the majority of them and their partners (8) .In Egypt, the study that assesses job-related stressors was mostly related to nurses in clinical areas (21) .Nurse educators stressors could be a real problem that had a negative effect on the nurses' education, and health status leading to job dissatisfaction and inadequate performance (23) .

S SU UB BJ JE EC CT TS S A AN ND D M ME ET TH HO OD DS S
A) Setting of the study:

C) Tools:
A structured interviewquestionnaire was developed to assess the nurse educators experienced stressors based on review of current related literature and items were modified after Licert (24) .
The questionnaire composed of 5 parts: -Response of nurses was measured on five point Likert scale (1-5)   ranging from no stress (1 point) to extreme stress (5 points).
-Stress rating scale total score was classified as follows: • 20% -39% low stress level.

M ME ET TH HO OD DS S A) Pilot study:
-A pilot study was carried out on 15 nurse educators from the 7 schools included in the study in order to check and ensure the clarity of the questionnaire, Identify obstacles that may be encountered in collecting data.
-In the light of the findings of the pilot study, the questionnaire was put in its final form.

B) Data collection:
The technique used in this study was the

C) Statistical Analysis:
Data were tabulated and statistically analyzed using (SPSS version 11.0).
Frequencies and percentages were calculated.Mean and standard deviation, and X 2 value were used to compare the study groups.The threshold of Significance was less than 5 %.

RESULTS
As regards the socio-demographic characteristics of the studied sample

DISCUSSION
Job Stressors that affect nurse educators had a negative impact on the quality of their life.This could lead to deterioration in the teaching process, nurse educators turnover and increase their shortages that might be a threat to worsen the nursing education (8,24) .
Job-stress like any stressful event needs coping strategies to reduce its effects and adapt to it (25) .The findings of the present study revealed that the nurse educators of the Military nursing school are working from 7. .On the other hand the majority of nurse educators of the Military ng.school considered shifts costly because there is no meals offered to them during shifts.
Armstrong (29) emphasized that meals have to be considered for both day and night staff.
Data showed that nurse educators of the Military nursing school find difficulties in taking their annual vacation.
Exchanging their shifts with their peers is a prerequisite to get their annual vacation.In this respect, Armstrong (1981) reported that shortage of nurses may delay their annual leave and recommended to spread it evenly and fairly over the year (29) .
The findings of the study revealed that working on Fridays was considered as a stress workload factor for nurse educators of Military Nursing School.
Scheweiger (1986) mentioned that providing weekend coverage is a problem that faces the manager.Society views the weekend as a family time and often no work activities involvement around it (5) .The present study also showed that the majority of nurse  (31) .Hunter et al (1993)   added that heavy clerical activity was considered a load and induced stress to the nurse educators (8) .
The majority of nurse educators of improve (31) .They also considered low salary as high stress workload factor.In this respect, other studies agreed that the nurse educators job stress was due to low payment (8,32) .Moreover, in Alexandria; national studies, El Sash (2006) stated that low salary and low money incentive results in low job dissatisfaction and increased level of stress (33) .
The present study revealed that the majority of nurse educators of the six schools affiliated to the Ministry of Health mentioned that absence of job promotion had a high stress workload factor.This is in agreement with Davis and Newstrom (1985) finding (34) (8) .
The present study showed that the majority of the sample included in the study viewed that neglecting their opinions is a high stress workload factor.
These results were supported by Tyson et al (2002) who found that the most pressure distressing the experience of nurses work was due to decisions imposed by superiors without their knowledge or involvement (36) .In this context, Hunter et al (1993) stated that the nurse educators job stressors were caused by low decision latitude (8) .
Moreover, Langemo et al (1989) clarified that inabilities to share in policy increased nurse educators job stressors and burnout.The nurse educators' personal stressors were part of job stressors that played an important role to nurse educators' career life (37) .
Living away from school was reported as moderate personal stressors by high percent of nurse educators.
Living away from place of work considered as time, effort and money induced stress.This finding was on the same line with, Hallenge et al (1997)   findings that living-far-for any employees caused stress for them, due to money, time, and energy consumed in transporting employees to and from their jobs every day (39) .Presence of family problems, care of one or both parents, exhaustion from housing duties, helping children with studies were considered as moderate to high level nurse educators' personal stressors.This is in agreement with Javis (2002) (38) .
The most important finding of this study was that the highest percentages of nurse educators had moderate to high level of job stressor which is considered to have negative effects expressed in physical and psychological symptoms and signs.In the present study, most of the studied nurse educators reported that they had physical and psychological health problems perceived as a response to job stressors.The most frequently reported health problems were related to physical stressors responses, as fatigue, headache, backache, signs of gastro-intestinal disorders.This is in line with other studies who stated that stress lead to chronic fatigue and health problems (8,24,40,) .exhaustion and psychiatric morbidity (3,41) .Burke et al (1993) verified also that work stressors were strong predictors of psychological burnout among educators (42) .
Nurse educators face daily challenges in their roles, which need using effective coping strategies to deal with stressors (11) .The findings indicate that coping through religious practices (seeking God' help) was the most frequently reported effective cognitive/emotional coping strategy used by nurse educators.This might be attributed to the fact that religious coping Bull High Inst Public Health Vol.39 No. 1 [2009]   gave them inner strength, courage and encouragement to meet the challenges and stressors resulting from their work.
These findings in consistent with Chane et al ( 2007) and Ram-mohan (2002) who found that most nurses used religious beliefs to cope with stressful situations, where significant religious involvement had a positive effect on normal personal functioning (43)(44) .
Data indicated that the most of the sample viewed that seeking social support from friends and family, seeking assistance and support from each other, seeking advice from superior was moderate to highly effective coping strategies.Such trend was consistent with the findings reported by Hupcey (1998) that friends were most frequently perceived as emotional support, tangible support, and social companionship (45) .
On the other hand, crying, keep feelings to one self were the most utilized ineffective cognitive/emotional coping strategies by nurse educators of the Military nursing school.This could be attributed to that most of time they felt frustrated due to work problems.These results were in agreement with Green et al (1996) who stated that when educators used direct behavioral coping strategies and were not satisfied with the results, they tried to ignore the problem which is maladaptive, on the long run (46) .

CONCLUSION AND RECOMMENDATIONS
The present study findings showed -Based on these findings it is recommended that: -Compensation manners for shifted nurse educators in the Military nursing school as: fringe benefits, a free nursery available for 24 hours, a suitable time off after the afternoon and night shifts.
-Increase nurse educators' salary in relation to their assigned responsibilities.
-Attending continuing education program about how to reduce work stress.
-Modified nursing school policy to implement promotion to nurse educators to motivate them in their work and promote work upgrading.
were categorized into personal and job/ work factors.The personal factors were family responsibility as well as personal illness.Job/ work factors include daily organizational problems, work overload, low payment, leadership responsibility of nurse-students whether in classroom or in the clinical areas, lack of supplies and equipment in clinical setting, the ability to make decisions and relate knowledge in different circumstances in clinical areas, : : compare the stressors faced and coping strategies used by nurse educators in the Military nursing school, with their peers in technical nursing schools affiliated to the Ministry of Health in Alexandria.

Part 2 :Part 3 :
Work related stressors such as rules and regulations and working environmental conditions.Personal stressors.

Part 4 :Part 5 :
Symptoms of stress.Cognitive-emotional coping strategies among nurse educators.
individual interview.Each interview took a period of one hour.Three educators were interviewed daily after the work shift.Data were collected in three months period from 19 th of November, 2006 to 18 th of January, 2007.
30 a.m to 3 p.m daily.In addition, they worked afternoon and night shifts because the Military nursing school is the only boarding school of nursing where students leave every Thursday and return back on Friday.Data showed that the majority of them mentioned that the time of afternoon and night shifts is long and exhausting; this is because the afternoon shift starts from 2 p.m. to 8 a.m of the next day.In this respect, other studies reported that the mental exhaustion and tension Abd El-Aziz & Ahmed 135 increase by the end of a long hour shift (26-28) .Data also revealed that the majority of nurse educators of the Military nursing school viewed that shifts has conflicts with their family duties.This is in agreement with Hamdy et.al (1984), who mentioned that women workers might feel that hazards of shift work go beyond physical problems as the family could be put under stress and social life were suffered in the afternoon and night shifts (28) the six schools affiliated to the Ministry of Health considered that absence of criteria for nurse educators selection was a moderate stress workload factor.In this respect, Cosgrove (2001) stated that nurse educators should be selected according to certain criteria because nurse educators are critical players in assuring quality of nursing education.They experience ever-changing health care environment while preparing the nursing work.If they were prepared to face this; quality of care provided to individual and community would

Furthermore
frustration, feeling of sadness, disturbed sleeping hours and this may be due to their worked shifts, lack of motivation in their work, and no job promotion in schools which are affiliated to the Ministry of Health.The present findings was consistent with Barnard (2004) and McGrath et al (2003)who found that clinical roles for nurse educators lead to emotional that the high level of stress among nurse educators of the Military nursing school were related to working shifts and it's a negative effects on their social life, sharing in the Military Training for parades, difficulty in getting their annual vacations.On the other hand, the high level of stress among nurse educators of nursing school affiliated to the Ministry of Health is namely: low salary, no job Abd El-Aziz & Ahmed 141 promotion, lack of facilities and supplies in the clinical areas.All these stressors were associated with experience and negative physical and psychological symptoms in nurses.

Table (
1) showed that 72% of the sample of Military nursing school; their age ranged between 25-35 years with a mean age of 29.135± 3.572 and 59.6% of educators of the other schools, affiliated to Ministry of Health, their age Nursing School worked from 5-10 years in the school compared to 55.7% of educators of the other six schools.The Military Nursing School is the only boarding (indoor) school in Alexandria, while, the other schools are outdoor.Table (2) revealed that the most commonly reported workload factors rated by nurse educators of the military nursing school as highly stressful were; difficulties of gaining the annual vacations in summer (96%); facing the students' problems during afternoon and night shifts and rigid accountability for the educators on students' behavioral manner in shifts (80% each); exhausted military training and additional duties for educators beside duties for undergraduate students (52% each).stress, while, 76% of Military educators considered it as a low factor.Moreover data clarified that the majority of nurse educators in both Military nursing school (60%), and educators from the other six schools (55.7%) mentioned that lack of cooperation with nursing staff in clinical areas was a moderate stressful factor.