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.



13
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 Maslows pyramid, needs at the lower levels must be fulfilled
before those rise to a higher level. According to Maslows 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, Maslows 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 Maslows theory. Herzberg and colleagues built
Herzbergs 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 Maslows hierarchy of needs and the set of Herzbergs



14
motivation-hygiene theory. This study is going to measure job satisfaction in two
categories, including motivator and hygiene factors, which are related to Herzbergs
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 2754%
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. Bjrk, Samdal, Hansen, Trstad, 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 nursess 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



16
negative ways. From the review, there are negative factors which are job stress and
role stress. This study concerns to examine level of nurses 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 Maslows theory
and Herzbergs 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).



17
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. Selyes 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.



18
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



19
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



20
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



21
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 persons 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 ones 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 (ODriscoll & 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 employees 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 employees
intent to remain a member of the organization (ODriscoll & 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.



24
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. Cronbachs 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 Coopers Dynamics of Work
stress model (Cooper & Marshall, 1976 cited in Sadri & Marcoulides, 1994),
Lazaruss stress and coping model (Lazarus & Folkman, 1984). However, Cohen-
Mansfields 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- Mansfields 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 individuals 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, individuals 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 individuals 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-Mansfields 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 nurses stress at the unit level.




27


Figure 2 Theoretical framework for studying job satisfaction among staff nurses
derived from Cohen-Mansfields 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 (R
2
= 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 km (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 patients classifications (how to feed, bathe,
change closthes, clean bed).
5. To assist and subordinate doctor during patients examination, diagnosis,
and treatment skills
6. In serious case, follow up on evolution of patients 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 A3A9; 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 dont 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$), nurses provided care for 14 patient/dayshift and 21
patient/nightshift in average. 70% nurses stated nursing professional having less
opportunity for growth and over 60% nurses dont desire their child to learn nursing
professional. In contrast, over 70% nurses were reported having good relationships
with co-workers, good collaborative with physicians and receiving good support from
family and relatives. Nurses had proposed the most satisfied is care for patient,
reducing suffering for patient, gained patients from the death and useful with their
family and relatives. However, special findings were found that 8.2% nurses intend to
move to private health facilities and 5.1% nurses intend to turnover in next five years.
Duong (2003) has conducted a study in Can Tho general hospital to
determine level of nurse job satisfaction. They surveyed 148 nurses. Job satisfaction
was measured by the Nurses Job Satisfaction Scale developed by the researcher. The
reliability of the instrument was reported -value of .81. The study showed the level
of job satisfaction was at moderate satisfied level. The nurses were reported that very
satisfied with recognition and praise, and achievement & responsibilities. The results
indicated differences in mean scores of job satisfaction in different salary, working
experience, departments. According to marital status, single nurses were more
satisfied than married nurses. According to year of working experience, nurses with
working experience (> 10 year) were less satisfied than the others. According to
salary, nurses with salary < 30$ 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/ dont 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 Cronbachs 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-Mansfields a comprehensive
model of occupational stress.