Job Stress and Safety Climate in Cancer Treatment Centers: Upgraded Model for Dimensions

Background: Stress has always been with human despite all the progress in science and technology. Stressful conditions reduce concentration and lead to the lack of focus. This can increase human errors and bring about catastrophe. The aim of this study is to present a model to increase safety climate by controlling job stress among the personnel of Iran’s medical centers. 
Methods:  In this study, 680 personnel of Iran’s hospitals were chosen in random. Demographic, job stress (35 questions) and safety climate (37 questions) questionnaires were filled. The data were inserted in SPSS 20 software. Descriptive statistics method and Pearson’s correlation coefficient were used to describe the data and evaluate the relation between the variables, respectively. 
Results: The scores of safety climate and job stress were 3.40 and 3.21, respectively which imply that they are suitable. The overall fitness of the model was acceptable. In this model, χ2 = 6366.17, df= 2452, χ2/df = 2.596, RMSEA = 0.054 (90% CI = 0.000–0.084), NFI = 0.901, GFI=0.913, and CFI=0.856. In the regression analysis, there were positive significant relationships between job stress and safety climate, job stress and any of its components, and safety climate and any of the components. 
Conclusion: Job stress is directly related to safety climate. Since in this study job stress was in a suitable level, it influenced the safety climate. If job stress is high, then it can affect safety climate in a negative way. We suggest that further studies be done regarding this subject.


Introduction
technology. No human has ever been able to free himself from stress. Organizations also have paid much attention to studying, controlling and reducing the effects of tress in work places to improve the efficiency of the employees [7]. So far more that 100 thousand articles and books have been publish about stress control and management and countries devote over 3 percent of their budgets to prevent stress. These indicate the importance of stress.

Safety climate
Safety climate is widely considered as a criterion for assessment of safety level in work places [8]. It presents an overall image of the safety situation of an organization [9]. Safety climate is multi-dimensional, but there is no consensus over the aspects of the safety climate [8][9][10].
Safety climate is defined as the common image workers have in mind about policies, processes, actions, and priorities in workplace [11][12]. This was first measured by Zoher et al. [12]. It is a measurement of the current state of the organization and it is relatively unstable based on time and place and changes due to circumstances [13]. So, safety climate is highly under the influence of organizational and personal elements. It might affect safety behaviors of the personnel [14]. Researchers also found out that the attitude of the workers regarding safety makes them search for safer environments, which in turn reduces unsafe behaviors and consequently improves safety situation [15][16]. Safety climate is defined as a psychological fundamental procedure in which workers share the quality of workplace [17]. Safety climate indicated that at the moment safety policies are in action and it can have a direct effect on safety behaviors of the workers. It can also predict future events [18][19]. Many researches on the other hand indicate that there is a robust connection between job accidents and the elements related to safety behaviors like job stress [20][21]. Stress is one of the subjects that need to be addressed in the area of safety management and organizational behavior [7].

Job stress
Job stress is an important subject in the 21st century. It is proven to have effects on family, job and life quality [22]. If it not managed properly it affects the performance and health of the workers [10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Job stress can be defined as harmful physical and emotional reactions; they occur when work job circumstances are not compatible with capabilities, resources and the workers' needs [22]. On the other hand, the personnel in organizations, and especially medical ones experience a high level of stress and psychological tension [24]. Job stress influences the health of people especially in cognitive, psychological, physiological and behavioral aspects. Also, in highly stressful situations, concentration decreases and ignorance increases [25]. This increases human error and leads to accidents [17]. These accidents include all types of mistakes and accidents in the hospitals [25]. Teachers, medical personnel, nurses and social workers, and emergency services are among the most stressed workers [24]. Nurses experience higher stress in comparison with other jobs [25][26][27]. The American National Association of Safety and Hygiene placed nursing at the top of 40 most stressful professions [28]. It is reported that %93 of the nurses are under constant stressful situations [29]. So, they probably suffer from cognitive impairment that may lead to safety accidents for the patients [25]. According to NIOSH, stress and psychological disorders are among the 10 major job damages in the US [30]. Every year about 1.1 million people lose their lives because of job stress and stress-related illnesses [7]. According to recent studies, counts for 50 to 60 percent of the lost days [31]. The Safety and Hygiene Bureau states (2004) that stress-related cost of society in England is £3.7 billion annually and job stress cost is about £381 million annually [32]. Stress also can lead to other behaviors like smoking and drinking [26]. Stress occurs when a human body is in an environment that is under constant change. Such changes leave physical and emotional effects and may provoke positive or negative feelings [33]. Job stress may vary from little to much, based on design, organization, job management, and social structure of the workplace [34][35]. Stressful circumstances are divided into intra-and extra-organizational groups [29]. Though there is generally a negative image regarding stress in the mind of people, human needs a balanced degree of stress to be able to operate efficiently. Without stress, people do not tend to make any effort to do anything. Some scholars believe that life without stress equals death. But too much stress leads to disorders and lack of efficiency [36][37][38]. Yet, job stress and its costs can be prevented [39]. This paper intends to offer a model to increase safety climate by controlling job stress among the personnel of Iran's hospitals.

Design
In this study, a descriptive analysis was performed on the personnel of Iran's hospitals. The main variables, here, job stress and safety climate; and personal and professional characteristics are considered as background variables.

Data gathering tools
Data gathering tools consisted of three questionnaires as follows: A. Demographic information questionnaire: This part consisted of 9 questions including age, gender, marital status, education, major, job title, experience in the field, experience in the unit, and salary.
B. Job stress questionnaire: Job stress questionnaire included 35 questions, consisting of 5 alternative Likert scale (never, rarely, sometimes, often and always). Question scores indicate the measured amount for every item ranging from 1 to 5 in which 1 is unfavorable and 5 is the favorable state. This questionnaire includes 6 aspects of demand (8 questions), control (6 questions), support (9 questions), connection (4 questions), role (5 questions) and change (3 questions). Azad et al. studied the reliability and validity of the questionnaire for 749 military personnel of Iran. In their research the samples answered to HSE and GHQ questionnaire. Correlation coefficient of HSE and GHQ equaled r=-0.48. The results also indicate a strong correlation between the extracted elements from factor analysis and the aspects of the questionnaire. Validity of the questionnaire was 0.78 and .65 using Cronbach alpha and splitting methods. Finally the questionnaire was proved to be a reliable and credible one for studying job stress [40].
C. Safety climate questionnaire: This questionnaire consisted of 37 questions in form of Likert scale with 5 alternatives (quite disagree, disagree, no idea, agree and quite agree). Question scores indicate the measured amount for every item ranging from 1 to 5 in which 1 is unfavorable and 5 is the favorable state. This questionnaire includes 8 aspects of management commitment for safety and priority of safety matters (10 questions), apjec.waocp.com Saeed yari, et al: Job Stress and Safety Climate in Cancer Treatment Centers: Upgraded Model for Dimensions the study and were guaranteed confidentiality and anonymous presentation of the results. They were informed that their participation was voluntary, that they could withdraw from the study at any time. Written informed consent was obtained from all participants, to maintain anonymity and confidentiality during the entire process each consent was marked with a unique digit for each participant and the unique digit were kept during all stages of the research process.

Correlation coefficient
Pearson's correlation coefficient for the measured variables is presented in Table 2. Job stress is directly related to the components of job stress (demand, control, support, communication, role, and change). Also, safety climate is directly related to the components of the safety climate (commitment, knowledge, attitude, participation, environmental safety, personal readiness, priorities, and ignorance). The mean of demand, control, support, communication, role and change, commitment, knowledge, attitude, participation, environmental safety, individual readiness, priority and ignore were 2.93, 3.16, 3.39, 2.59, 3.84, 3.25, 3.33, 3.67, 3.90, 3.65, 3.50, 2.77, 2.82, and 290 respectively. Also the average safety climate and job stress were 3.40 and 3.21 respectively, both of which are appropriate.
In this study, gender (p<0.001), marital statues (p=0.037), education (p=0.008), position (p=0.005), job experience (p=0.045), work experience in the unit (p=0.028), and salary (p=0.031) were all significant in job stress. Also, gender (p=0.003), education (p=0.007), and position (p=0.042) were significant in safety climate. Figure 2 shows the coefficients of the standard the knowledge of the workers and following safety rules (7 questions), the attitude of the workers regarding safety (4 questions), cooperation of the workers and commitment to following safety (5 questions), safety of workplace (4 questions), priority of safety over products (2 questions), and neglecting dangers (2 questions). Zeidi et al. in a study through exploratory factor analysis showed that the 8 aspects of the questionnaire are able to explain 68.42 percent of the overall variance and Cronbach alpha coefficient for all the aspects and the whole of the tool was approved [41].

Sampling method
The studied population here was all the personnel of Iran's hospitals. The logic here was selecting 10 sampled for every variable according to James Stevens' proposal. He assumes that 10 to 15 items are required for each predictor variable, multiple regression analysis with the standard method of the least standard squares, as well as verifiable factor analysis models and structural equations [42][43]. Based on this 720 people were selected according to simple random sampling. Finally 680 questionnaires were filled and analyzed.

Data gathering method
The criteria for the participants entering the research were being volunteers and honesty. Then, they were assured that their answers were confidential and the data would be collected, evaluated and reported regardless of the names. Data gathering method was interview by the research team.

Conceptual Model
The aim of this study was evaluating the interaction between job stress and safety climate in Iran's hospitals. This model allows to study outside hidden variables (independent) and inside hidden variable simultaneously. The primary model and conceptual models are presented in Figure 1.

Data analysis
The gathered data were entered into SPSS 20 software. Descriptive statistics method was used to describe them. Also, Pearson's correlation coefficient was used to evaluate the relation between the variables. Structural Equation Modeling, which is a type of multivariate analysis, was used to evaluate the relation between job stress and safety climate [3]. Structural equations model was created using AMOS 22 software. The fitness of the model was controlled by χ2 and the root mean squares estimated error (RMSEA) was evaluated. The amount of χ2 ration to a degree of freedom smaller than 3 (χ2/df<3) was chosen as a criterion to fit the model. RMSEA<0.08 was another criterion for the fitness of rhea model. Also, goodness of fit index (GFI), Comparative fit index, and normal fit index (NFI) were used.

Ethical considerations
Participants were informed about the nature of Figure. 1 Conceptual Model between Job Stress and Safety Climate estimation of the structural equation model. All paths are at a significant level. However, according to the values obtained for fitting indexes in Table 3: χ2/df, GFI, CFI and NFI are not within the defined range. Therefore, it was concluded that fitting the model obtained at this stage does not indicate a good fit. So the model was corrected for a better fitting. These modifications were implemented in the proposed model and the results of the fitting indexes improved (Figure 3). Finally, the overall fitting of the model was acceptable. In this model: χ2 = 6366.17, df = 2452, χ2/df = 2.596, RMSEA = 0.054 (90% CI = 0.000-0.084), NFI = 0.901, GFI=0.913, and CFI=0.856.
Also, according to the structural equation model, standard and non-standard coefficients of the final model and the significance level between variables and factors affecting it are presented in the following table.

Discussion
In a study conducted by Chen et al., it was found out that promoting a positive safety climate and creating educational programs could improve the safety performance of an organization due to improved mental health of employees, especially after traumas [10]. Park et al. found out that safety accidents of the patients are under the influence of job transfer, cognitive impairment and job stress. They also suggest that reduction in job instability and a definition of job limits is required for the patients' safety [25]. In a study done by Zarei et al. in medical organizations of Iran they concluded that there is a significant relationship between safety climate, unit type,   job satisfaction, job interests, and stress. The results of structural equation modeling support a negative correlation between job burnout and safety climate [44]. In this paper we concluded that the variables of gender, marital status, education, position, job title, work experience in the unit and salary had significant effects on job stress. Also, the variables of gender, education and position had significant effects on safety climate. In a study about the relationship between safety culture and occupational stress, Zamanian using independent t-test showed that there was a significant and negative relationship between these two variables [7]. Avram regards job satisfaction as a minor mediator between safety climate and organizational trust [45]. Elshaer et al., in a study about occupational stress and burnout syndrome among health care workers, express that since there is a high stress and burnout among health care workers, more support is needed in this regard [24]. Hoboubi in a study calls for of corrective actions for shift jobs. He states that supervisor needs to offer support for job stress reduction and job satisfaction and productivity increase [35]. Kim addresses the importance of safety climate and psychological elements like job stress of the workers [17]. Yau's findings indicate that nurses have a relatively high level of stress, and "work environment and resources" and "workload and time" are known as stressors [46]. Dollard states that the safety climate can  reduce job stress as an organizational feature and a proper climate enables the personnel to do their job [47]. Su states that hospital managers can help reduce work-related stress and improve the flexibility of tension among the nurses [48]. A study by Berland shows that the demand of a work environment with less control and social support from the colleagues increases stress, which can often affect patient safety [49]. Unlike the previous studies, the stress level among the staff working in hospitals in Iran was at an acceptable level. Job stress had a significant and positive relationship with the safety climate. In a study conducted by Idris et al. with the aim of a conceptual differentiation and its impact on occupational and mental health demand among Australian and Malaysian communities, it was found that the level of cognitive safety climate was significantly lower than the physical safety climate in both countries. This is an evidence of global lack of attention to mental health in working environments [39]. Understanding the professional perceptions of the patient's immediate safety climate in emergency service can help improve healthcare, reduce side effects and improve patient care through assessment of safety culture [50]. Mosadeghrad found out that organizational policy have strong bonds with job stress of the personnel. So, policies and hospital strategies need to change for the stress to decrease [51]. McLinton presents three methods used by managers and policymakers that can reduce social and psychological risks and bring about positive changes to the safety climate [52]. In a study by Ray et al. with the aim of employment arrangements, occupational stress and quality of life related to health they concluded employment arrangement played as an important predictor of occupational stress. Compared to stress-free individuals, people affected by employment arrangement have more unhealthy days or more activity restrictions [53]. MohammadFam believes that for the adjustment or removal of identified factors effective in creating stress and reducing unsafe actions, investments and stress management programs are needed [54]. Clarke argued that psychological depression has important impacts on safety outcomes, such as accidents and injuries [55]. Siu concluded that the tension in Western culture is not only about the West, but it seems to be a global problem [56]. Several other studies have strongly supported the links between worker safety and occupational stress and safety behaviors [57].
In conclusion, according to previous studies, in order to perform optimal activities, humans need a decent level of stress because without stress people do not make the necessary effort to do things. According to some scientists, life without stress equals death [36][37][38]. In this study, due to the fact that stress is favorable, it has increased the safety climate for the hospital staff. However, excessive stress, leads to impairment in performance and reduction of staff productivity. In the high stress societies, the relationship between occupational  stress and safety climate can be significant and negatively affected. An increased stress can lead to a reduction in the safety climate. So, more research is needed in this area.

Suggestions
-One of the factors that may affect the results of this study is the sampling of all the staff working in the hospital. It is recommended that in future, studies focus on high stress societies, such as nurses.
-Considering that with an increase in the level of awareness job stress decreases, it is recommended that hospital managers make appropriate training in problem solving and stress management.
-To improve the level of patient safety in a hospital, job stress needs to be controlled and the climate and culture of safety should increase.

Conflicts of interest
All authors declare to have no financial or personal relationships that could inappropriately influence the research described.