ORIGINAL CONTRIBUTION

Occupational Stress and Job Satisfaction Among Flight Nurses

A Survey of National Flight Nurses Association Members by Theodore W. Whitley, PhD; Nicholas H. Benson, MD;

E. Jackson Allison, Jr., MD/MPH; and Dennis A. Revicki, PhD

Abstract A mail survey of members of the National Flight

Nurses Association was conducted to assess occupa- tional stress and job satisfaction. In addition to scales measuring stress and job satisfaction, the question- naire requested demographic information and in- cluded a depression scale.

The anticipated direct relationship between stress and depression was observed (r = .56, p .0001), as were the expected inverse relationships between stress and job satisfaction (r = -.54, p .0001), and be- tween depression and job satisfaction (r = -.45, p .0001). Responses to statements on the stress scale in- dicated that work interference with family life and failure to receive recognition were important sources of stress, while avoidance behaviors such as tardiness

and daydreaming were used infrequently to cope with stress.

Inadequate recognit ion, particularly by ad- ministrators and supervisors, and lack of involvement in decision-making processes surfaced as sources of dissatisfaction, as did inadequate feedback about job performance. The tasks performed by flight nurses and being members of cohesive work groups were im- portant sources of job satisfaction.

The results indicate that although flight nurses basically are satisfied with their jobs and enjoy work- ing in air medical transport, they want to know that they are performing well. They also want to be in- volved in decision-making processes and to be recog- nized for the stressful jobs they perform.

Introduction Interest in the occupational stress

perce ived by air c rew m e m b e r s (ACMs) is reflected in a growing body o~ literature. Further evidence of this interest is provided by the inclusion of stress management as a topic in a prototype education program for flight nurses. 1 However, the lack of sys- tematic studies of stress levels among flight nurses has been noted, 2 as has the absence of studies examining the relationships between aspects of the work environment of flight nurses, such as staffing, scheduling, and crew composition and stress. 3 Finally, the safety of air medical transport has resulted in considerable media atten-

4,5 tion during the past several years. In fact, the potential impact of two specific crashes in a southeastern state on the stress perceived by ACMs served as the impetus for an earlier survey. 6 B a s e d on the pos i t ive response to this survey, support was

Table 1

Personal characteristics of the respondents

Age n 367 a Range 24-62 Median 32 Mean 33.4 Standard Deviation 5.6

Gender n %b Women 285 77.4 Men 83 22.6

Race. White 364 99.2 Other 3 8

Marital Status Single 1133 0.7 Married 181 49.2 Separated 8 2.2 Divorced 64 17.4 Widowed 2 .5 an<369 due to incomplete responses bpercentages based on complete responses

provided by the National Flight Nur- ses Association (NFNA) to survey its membership to investigate occupa- tional stress, depression and job satis- faction in this larger group.

Materials and Methods The questionnaire administered in

this survey requested demographic in- formation about the respondent and his or her program, and contained scales designed to assess occupational stress, depression, and job satisfac- tion. Briefly, the three affective scales are four-point Likert scales.

Respondents indicate the extent to which each of the 18 statements on the Health Professional Stress Inventory (HPSI) describes their beliefs or be- havior in the areas of personal produc- tivity, ability to disengage from work during off-duty hours, and relation- ships with co-workers.

The 20 statements of the Center for Epidemiologic Studies - Depression

6 Hospital Aviation • July 1989

ORIGINAL CONTRIBUTIOf

Scale (CES- D) describe emotions and behaviors characteristic of depressed moods. Respondents indicate the ex- tent to which they experienced these emotions or behaviors during the preceding week. Respondents com- plete the job satisfaction scale by in- dicating the extent to which they believe 25 characteristics or aspects of jobs apply to their jobs in air medical transport. The internal consistency reliability coefficients (Cronbach's alpha) for these scales were .88 (n=368) for the HPSI, .89 (n=365) for the CES-D, and .93 (n=368) for the job satisfaction scale.

The 31 NFNA members from the state in which the initial survey was conducted were not resurveyed for two r ea sons . First , the r isk of misunderstandings resulting from resurveying some, but not all, mem- bers of air medical transport services in the state seemed to outweigh the value of obtaining a relatively small number of additional responses.

The second, and most important reason was the belief that unbiased comparisons of the results of the two surveys would be far more useful than adding a few potentially redundant responses to the current survey, which would compromise the independence of the two data sets.

Surveys were mailed to the 767 NFNA members on the organization's mailing list in August, 1987. Four sur- veys were undeliverable, and 14 mem- bers declined to participate. The most frequently given reason for declining was that the member was no longer working as a flight nurse. Of the remaining 749 potential respondents, 380 (50.7%) returned completed ques- tionnaires.

Since 11 respondents indicated that they were not registered nurses, their responses were not included in the analyses reported in this article.

Descriptive statistics and Pearson Product-Moment correlation coeffi- cients were computed. An alpha level of .05 was used to determine the statis- tical significance of correlation coeffi- cients.

Results The demographic characteristics of

the respondents are summarized "in Tables 1 and 2, and descriptive statis- tics for the affect ive scales are presented in Table 3. Although two respondents did obtain the maximum score on the HPSI, the mean score for this scale was less than one-half of the maximum score (Table 3). The dis- tribufion of these scores indicated that the scores were massed at the lower end of the score scale.

Scores on the CES-D were similar in that the highest score for any respondent was well below the maxi- mum possible score, the mean was well below the maximum possible score, and the scores were massed at the lower end of the score distribution.

Conversely, the mean score on the job satisfaction scale was above one- half of the maximum possible score and the scores were massed at the

Table 2

Education, certification, and experience of the respondents

n a %b Highest Degree Diploma 48 13.1 Associate 95 26.0 Bachelor's 182 49.7 Master's 39 10.7 Other 2 5

Certification ~MICN 44 CEN 180 BCLS 314 ACLS 347 BTLS 116 ATLS (Nursing) 128

Crit Emer Exp (Yrs) Care Dept n c 316 293

Range 1-30 1-21 Median 6 5 Mean 6.8 5.6 Std Deviation 4.6 3.9

12.1 49.3 86.0 95.1 31.8 35.1

Cur Prog 362

1-23 3

3.4 2.8

an<369 due to incomplete responses

bpercentages based on complete responses

Cn = respondents indicating experience

high end of the scoring scale. In fact, 81 (21.9%) of the respondents obtained scores of 90 or higher on this scale, and six (1.6%) respondents obtained the maximum possible score.

Finally, the correlations among the scales (Table 4) were statistically sig- nificant and corroborated the direct re la t ionship be tween s t ress and depression and the inverse relation- ships between stress and job satisfac- tion and between depression and job sa t i s fac t ion o b s e r v e d in o the r studies. 6,7

Examination of the mean ratings for individual items on the HPSI (Table 5) suggested that interference with fami- ly life and inadequate recognition were important sources of stress for the respondents. Specifically, statements dealing with work interference with family life (statement 5) and difficulty disengaging from work (statement 7) had relatively high mean ratings. However, increased arguments at home (statement 15) did not appear to be an especially important source of stress.

Specific s ta tements with mean ratings reflecting stress associated with unmet needs for recognition in- cluded failure to be recognized for one's contribution (statement 9), lack of suppor t for one 's contribution (statement 18), and perceptions that colleagues were not adequately fulfill- ing their obligations at work (state- ment 4).

On the o ther hand, the mean ratings for s tatements describing avoidance behaviors such as tardiness (statement 13), increased daydream- ing (s ta tement 16), and avoiding others (statement 14) indicate that such behaviors were relatively less im- portant manifestations of stress for the respondents.

Similar examina t ion of mean ratings assigned to statements on the job satisfaction scale (Table 6) indi- cated that the respondents derived satisfaction from accepting respon- sibility for personal performance of their jobs (statements 18-19), from positive interactions with their co-

Hospital Aviation • July 1989 7

ORIGINAL CONTRIBUTION

workers (statements 21-23), from having opportunities to develop and use special skills and abilities (state- ments 6-7) and to perform varied tasks (statement 5) with a definite purpose (statement 25).

Statements on the job satisfaction scale with comparatively low ratings confirmed the respondents' relative dissatisfaction with the recognition they receive, from both the public (statement 15) and particularly from

ment i- ~. i h r e e other statements with lower

mean ratings deal with managerial is- sue s inc luding par t ic ipa t ion in decision-making processes (statement 13), feedback about job performance (statement 20), and support from su- pervisors or administrators (statement 24).

Mean ratings for statements about the adequacy of ongoing training (statement 9) and time pressure (state- ment 1 I) were relatively low, also.

Discussion The demographic characteristics of

the respondents were similar to those of respondents to the earlier survey 6 and to the experience and certification levels of flight nurses surveyed by Bat- terman and Markel. 8

One evident finding is that the respondents have acquired a con- siderable amount of education and training during a short time. Based on their past achievement, the expecta- tion that the respondents will be motivated to maintain their knowledge

and skills and to keep abreast of trends and developments in the field of air medical transport seems reasonable.

As in other surveys, 6'7 the direct re la t ionship be tween s t ress and depression was observed. Once again, however, the mean scores on the HPSI and the CES-D suggested that the respondents did not experience ex- treme levels of either construct. Fur- thermore, the respondents to this su rvey r epo r t ed that they were generally quite satisfied with their

that the job saustactmn scale may not

Individual s t r e s s p r even t ion measures suggested by Baldwin, 9 such as aerobic exercise or utilization of relaxation techniques, in conjunc- tion with steps which may be taken by the entire t-light team such as prompt conflict resolution, may help alleviate stress from these sources.

One potentially pertinent point is that the respondents did not report coping with stress by avoiding others or the work setting.

The statement on the HPS! dealing

rating of the i8 possible ratings, and i n o h l d o e n r n • i n a n n t ' l - n n t - n n r n r n , , ~ f ~ r e n , + t h , , ~ ~ t n t o m o ~ t a b o u t i~crea .~ed

job satisfaction. Although a longer scale, or more

scales , may have enhanced the precision of this survey in measuring job satisfaction, the scale used in the earlier survey 6 was repeated to provide a basis for comparison. Also, it was hoped that a shorter task would en- hance the response rate. As noted pre- viously, 6 the content validity of the job satisfaction scale is considered ade- quate for an exploratory survey such as this one.

NFNA members identified similar sources of stress to those identified by respondents to the earlier survey 6 of ACMs. Since many flight nurses work

8 12-hour shifts, the fact that work inter- feres with family activities is to be ex- pected.

When this factor is compounded by the inability to put work-rela ted thoughts out of one's mind during off- duty hours, the stress level of flight nurses may be substantial.

daydreaming had the second lowest rating. The s t a t e m e n t abou t deliberately avoiding others at work also had a very low rating.

The resu l t s in the p r e c e d i n g paragraph also are consistent with the relatively high mean ratings for state ments reflecting satisfaction stem- ming *- ~,o,,, having opportunities to develop and use special skills and abilities, some of which may expand the flight nurse's scope of practice. 5

These findings are not surprising when the working environment of flight nurses is considered. Flight nur- ses are part of a patient care team con- sisting of one or two other members, s providing care without the immediate resources of a medical center. The respondents to this survey certainly appear to be responding positively to the challenges of flight nursing.

The resu l t s in the p r e c e d i n g paragraph also are consistent with the relatively high mean ratings for state-

Table 3

Descriptive statistics for the HPSI, CES-D and job satisfaction scales

Job HPSI CES-D Satisfaction

n a 368 365 368 Range 18-72 0-43 40-100 Maximum 72 60 100 Median 30.0 7 80 Mean 31.1 9.6 78.3 Standard Deviation 9.3 8.4 13.3 Skewness 0.9 1.3 -0.5 an<369 due to incomplete responses

Table 4

Correlations between HPSI, CES-D, and job satisfaction scale scores

Job HPSI CES-D Satisfaction

HPSI 1.00 56* -.54* n=364 n=367

CES-D 1.00 -.45* n=364

Job 1.00 Satisfaction *p <.0001

8 Hospital Aviation ° July 1989

ORIGINAL CONTRIBUTION

ments reflecting satisfaction stem- ming from having opportunities to develop and use special skills and abilities, some of which may expand the flight nurse s scope of practice. 5

However, the relatively low ratings assigned to statements concerned with the adequacy of ongoing training and time pressure suggest that flight nurses should be permitted to identify additional training which will enhance their job performance, and to work at their own pace whenever circumstan- ces permit.

As has been noted, 6 identification of time pressure as a potential source of dissatisfaction for providers of emer- gency medical care should not be surprising. The positive responses to statements pertaining to interactions with co-workers and having a clear sense of purpose also mirror findings from earlier surveys, 6'7 and support Baldwin's 9 ideas on the importance of attention to the development and main- tenance of cohesive work groups.

Recru i tmen t and re tent ion of capable flight nurses, 9 providing op-

portunities for them to become ac- quainted with each other outside work settings, 9 and establishing open com- munication channels 7 which permit flight nurses to communicate neces- sary information within the work group and to other individuals in the organization may be expected to con- tribute to job satisfaction.

The importance of communication to job satisfaction is also emphasized by the relatively low mean ratings as- signed to statements on the job satis- faction scale related to recognition and suppor t from supervisors or ad- ministrators, participation in decision- making processes, which was also impor tan t to respondents in the earl ier survey, 7 and f eedback about job perfor- mance.

Remembering 1. tha t the mean 2. ratings for these 3. s t a t emen t s are 4. low only in com- 5.

Table 5

Mean (and 1 standard deviation) ratings for statements on the HPSI

Std Statement Mean a Dev

1. Decreased personal contribution 1.6 0.9 2. Unrealized job expectations 1.8 1.0 3. Decreased personal productivity 1.6 0.9 4. Colleagues' failure to contribute 2.0 1.0 5. Work interference with family life 2.3 1.0 6. Professional stagnation 1.7 1.0 7. Difficulty disengaging 2.1 1.0 8. Increased edginess 1.9 1.0 9. Failure to receive recognition 2.0 1.0

10. Guilt over failure to understand patients 1.8 0.9 11. Increased effort yielding less 1.6 0.8 12. Being taken advantage of 1.6 0.9 13. Frequent tardiness 1.2 0.6 14. Avoiding others at work 1.5 0.8 15. Increased arguments at home 1.5 0.8 16. Increased daydreaming 1.4 0.7 17. Different responsibilities than expected 1.8 1.0 18. Lack of support for contribution 1.9 1.0

aRating scale: 1 = Does not apply to me (low stress) 4 = Does apply to me (high stress)

parison to mean ratings for other state- ments, they suggest that relationships with supervisors should be monitored carefully so that positive behaviors can be encouraged, negative behaviors can be modified, and disagreements between flight nurses and managers can be settled as quickly as possible.

The provision of timely, appropriate feedback and some participation in decision-making processes seems reasonable in light of the profes- sionalism expected of flight nurses. Such behaviors should reduce dis- satisfaction attributable to lack of ad- ministrative support and inadequate recognition.

Table 6

Mean (and 1 standard deviation) ratings for statements on the job satisfaction scale

Std Statement Mean a Dev

Clearly defined tasks 3.1 0.9 Clearly defined roles 3.1 0.8 Clearly defined responsibilities 3.2 0.8 Clear performance standards 3.0 0.9 Opportunities to do different things 3.4 0.8

6. Opportunities to develop special skills or abilities 3.3 0.9

7. Opportunities to use special skills or abilities 3.3 0.8 8. Adequate initial training 3.0 1.0 9. Adequate ongoing training 2.9 1.0

10. Opportunities for professional growth 3.0 1.0 11. Time to complete tasks 2.9 0.9 12. Appropriate work schedules 3.0 1.0 13. Satisfactory participation in decision-

making processes 2.8 1.0 Freedom to express personal views or ideas 3.2 0.9 Appropriate recognition by the public 2.9 1.0 Appropriate recognition by co-workers 3.1 0.9 Appropriate recognition by supervisors or administrators 2.7 1.0 Acceptance of personal responsibility for job performance 3.7 0.5

19. Acceptance of personal responsibility for task decisions 3.6 0.6 Useful feedback about job performance 2.8 0.9 Friendly co-workers 3.4 0.7 Mutual support among co-workers 3.3 0.8 Sense of teamwork 3.2 0.8 Supportive supervisors or administrators 2.8 1.0 Clear sense of purpose 3.3 0.8

aRating scale: 1 = Very dissatisfied 4 = Very satisfied

14. 15. 16. 17.

18.

20. 21. 22. 23. 24. 25.

10 Hospital Aviation - July 1989

ORIGINAL CONTRIBUTION

In a s i m i l a r m a n n e r , t h e re- spondents' relative dissatisfaction with recogni t ion they receive f rom the public surfaced in the earlier survey. 6 Given the negative publicity air medi- cal transport services have received recently, 4'5 efforts to direct attention to successes should reduce the stress perceived by flight nurses consider- ably.

Additional support for these views is provided by Janelli and Jarmuz, 10 who found that factors such as recog- nition and achievement had more im- pact on job satisfaction than work conditions and interpersonal relation- ships.

Finally, a limitation which may af- fect the ability to generalize the results of this survey is the somewhat disap- po in t ing r e s p o n s e ra te of 50.7%. However , Babb ie 11 c o n s i d e r s a response rate of 50% to be adequate for analysis and reporting, and Fowler 12 notes that some studies based on mail surveys report response rates from 5% to 20%.

Based on the initial survey 6 and the information provided by Batterman and Markel, ~ the re is no apparent reason to suspect that the respondents to this survey are unrepresentative of flight nurses in general.

Conclusions Despite experiencing patterns of

occupational stress and depression characterist ic of members of other health care professionals, flight nurses basically enjoy their work. Relation- sh i p s wi th s u p e r v i s o r s and ad- ministrators, however, are a potential source of dissatisfaction. In addition to applying standard management tech- niques, managers need to recognize flight nurses for the stressful jobs they perform.

Flight nurses should be given the opportunity to actively participate in the operation of the organization, par- ticularly decision-making processes, to the extent circumstances and pru- dent management permit.

Finally, managers need to evaluate the performance of flight nurses in an

appropriate, timely manner, recogniz- ing jobs well done and provid ing vehicles for maintaining current levels of pe r fo rmance and acquiring new knowledge and skills. These actions should help flight nurses provide the best possible patient care in the safest possible environment.

Theodore W. Whitley, PhD, Nicholas H. Benson, MD, and E. Jackson Allison, Jr., MD/MPH, are with the Department of Emergency Medicine, East Carolina Univer- sity School of Medicine, Greenville, NC. Dennis A. Revicki, Phd is from the Battelle Human Affairs Research Centers, Washington, DC. The original paper was supported in part by the National Flight Nur- ses Association. It was presented at the Rocky Mountain Conference on Emergency Medicine and Nursing, January 1989, where it received Best Paper - MD/PhD Category. The authors wish to thank Ms. Joni Farmer for her assistance with data and manuscript preparation.

References 1. Campbell P: A prototype flight nurse

education program.JEN 1987; 13:235-240. 2. Katz M: Burn-Out syndrome (Abstract).

AeromedicaIJourna11986; 1(July/Aug) :30. 3. England CG: Aeromedical staff turnover.

AeromedicalJournal 1986; l(July/Aug):l~b15. 4. Elton S: Blinded by the light (Opinion).

AeromedicalJourna11987; 2 (May/June) :30. 5. Hensleigh CN: Flight nursing: Oppor-

tunities, risks, and rewards (Editorial). JEN 1987; 13:197.

6. Whitley TW, Landis SS, Revicki DA, et al: Stress, depression~ and job satisfaction in aeromedieal flight personnel. AeromedicaIJour- na11988; 3 (Nov/Dec): 10-14.

7. Revicki DA, May HJ: Organizational characteristics, occupational stress, and mental health in nurses. Behav Med 1989; 15:30-36.

8. Batterman K, Markel N: Profile of a flight nurse. Aeromedical Journal 1986; 1(July/Aug): 26-28.

9. Baldwin A: Stress prevention in flight nurs- ing. AeromedicalJourna11986; 1 (July/Aug) :27.

10. Janelli LM, Jarmuz PA: Motivational fac- tors that affect the retention of reserve nurses in eight aeromedical evacuation flights. Aviat Space Environ Med 1987; 4:375-378.

11. Babbie ER: Survey Research Methods. Bel- mont, CA, Wadsworth Publishing Co., 1973.

12. Fowler FJ: Survey Research Methods. Beverly Hills, CA, Sage Publications, 1984.

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Hospital Aviation ° July 1989 11