Impact of Organizational Support on Nursing Job Stressors: A Comparative Study

Purpose: The purpose of this study was to assess stress level and organizational support in nurses working in Jordan and Egypt and to identify the relationship between perceived stress and organizational support among nurses in both countries. Methods: A descriptive comparative design utilizing selfadministered questionnaire was utilized to evaluate the distinctions in response to organizational support in Jordanian and Egyptian nurses. The data was collected from two educational affiliated hospitals. Findings: The results of this study indicated that that the both Jordanian and Egyptian nurse perceived very high level of stress and a relatively poor organizational support. Also, the results implied significant negative correlation between perceived stress and perceived organizational support r=-0.23, P<0.01 in Jordanian sample, r=-0.29, P<0.01 in the Egyptian sample. Conclusions: This study shows that the both Jordanian and Egyptian nurses are exposed to different stressors during their job. Unfortunately, with these stresses the nurses didn’t find enough organizational support from their organization. Study implications: Such study has a many implications for nurses in different settings. The application might include the education sectors of nursing, managers, organization and for sure the nurses in practice.


Introduction
Healthcare professions are amongst the most stressful occupations. Job stress is pervasive in the health care settings [1]. Many internal and external stimuli might provoke the stress level in health care providers. Nurses, in general, and the specialized nurses such as psychiatric and oncology nurses are in more risk for job stress [2]. Stress can be defined as a nonspecific physiologic response to a need. However, the occupational stress is a health related concern and associated with workplace environment [3].
The stress level might vary among nurses because the stress is an individual experience. The success or failure in dealing with new or recurrent stressors is reflected by nurse's support system and nurse's ability to adapt. Therefore, for organizations, it is important to provide organizational support for nurses to help them dealing with their recurrent stressors [4].
Perceived organizational support is known as employees' perceptions that their works, efforts and contributions are valued by an organization. Organizational support can help nurses to exhibit a positive attitude, make ethical decisions, increase their commitments, influence turnover intention, and ultimately decrease the job stress. The concept of organizational support is derived from the social theory. The theory proposes that when someone held respectful feelings with someone else, the other will respond positively. So, it is believed that the same reaction is occurred between the employee and the employer, because the organizations are the source that fulfills the employee needs. Otherwise, the stress and a state of non-satisfaction will surface.
Few studies highlighted job stress among nurses in the Middle East region. An Egyptian study indicates that the most stressful factors associated with job stress among nurses are security with employment, coping with new situations, unrealistically high expectations by others and workload, respectively [5]. A study conducted with Jordanian nurses suggested that lack of support, uncertainty, conflict with others, workload, and dying are the most reported stressors among Jordanian nurses [6]. However, there are different stressful factors that affect the nurses in USA, which are related to workload, non-adequacy orientation and unfair compensation. Although the studies conducted in the Middle East reported different types of stressors experienced by nurses, none of them identified the role that organizational support plays in stress level among nurses. Accordingly, the researchers in the current study were ambitious to identify the relationship between stress and organizational support among nurses from different countries in the Middle East regions including Jordan and Egypt. Each of these countries has a unique health care system. Therefore, purpose of this study is to assess stress level and organizational support in nurses working in Jordan and Egypt and to identify the relationship between perceived stress and organizational support among nurses in both countries.

Research design
A descriptive comparative design utilizing a selfadministered questionnaire was utilized. The sociodemographic and clinical variables examined in the present study were: gender, age, marital status, period of experiences, and level of education.

Data Collection
Data were assembled from two great educational hospitals in two nations; Jordan and Egypt. The first hospital is the university of Jordan hospital affiliated to a governmental university in Amman, Jordan. The hospital's capacity is nearly 550 beds with a yearly inhabitance rate of 70%. The healing facility gets patients from all nations' areas. Subsequently, the nurses are collaborating with numerous cases every day and ordinarily they are overstrained. The second hospital is the Monofia University hospital affiliated to governmental university in Qahrah, Egypt. The hospital's capacity is nearly 1000 beds with yearly inhabitance rate of 80%. The healing facility gets patients from all country's districts.

Ethical considerations
An agreement about research proposal was acquired from Institutional Research Board (IRB) at Zarqa University. Acceptance for data collection was also acquired form IRB committee in the selected hospitals. Thus, data was gathered from April to June, 2015. All nursing attendants who accomplished the consideration inclusion criteria were welcome to take an interest, intentionally, in this study. The data were assembled by the fundamental researchers to empower participation by clarifying the significance of the study and it is constructive outcome on the nature of consideration.
Anonymity and confidentiality of participants' information were totally assured. Cohesion in data collection was covered. The questionnaires were illustrated obviously for every member. The questionnaires took almost twenty five minutes to be filled by each nurse.

Participants and Instruments
A convenience sampling technique was utilized to induce participants in the current study. Sample size was calculated by utilizing G * Power Software, with a power of 0.80, alpha of 0.05, and a medium effect size. The minimum sample size required for multiple regression analysis was 107 respondents from each nation. The total sample size of the existing study was raised to one hundred and fifty nurses from each nation to avoid the negative impact of attrition. The inclusion criteria were including Jordanian and Egyptian nurses, and having an experience of no less than one year in the chose units. These inclusion criteria undertaking that the nurses had been exposed to job stressors and can express their perceptions about organizational support.
Two instruments were utilized to study the combination between nurses' job stressors and organizational support. To start with, the Perceived Stress Scale -10 Items (PSS-10) which was produced by Kohen et al. is one of the greatest generally utilized mental instruments for measuring the view of anxiety for people. The (PSS-10) consists of multiple choice questions which include choices on a 5-point likert scale (0=never to 4=very often). Items number 4, 5, 7 and 8 have a reverse score coding. The (PSS-10) is a reliable scale: for the original total scale, a cronbach alpha of 0.78 was accounted for total scores ranges from (0 to 40); (0-7) indicates very low stress, (8)(9)(10)(11) indicates low stress, (12)(13)(14)(15) indicates average stress level, (16)(17)(18)(19)(20) indicates high level of stress, and (21 and over) indicates very high level of stress.
The second scale is the Survey of Perceived Organizational Support (SPOS) which was created by refers to employees' perception concerning the extent to which the organization values their continued membership. It has 36 items, 15 of them have a reverse score coding. Reactions for each item were indicated on a seven-point Likert-type scale ranging from "1=Strongly Disagree" to "7=Strongly Agree." This yields a total score between 36 and 252, with a middle cut point of 144. The higher scores indicate higher levels of perceived organizational support. Example items include: "The organization values my contribution to its well-being," and "Even if I did the best job possible, the organization would fail to notice." As of late, there is four versions of the instrument (i.e., 36, 16, 8 and 3-items). The original survey with 36 items have never used in a single study aside from the original study in which the instrument was developed. POS has been found to have critical results on employee performance and well-being. It mirrors the employee volubility within the organization. For the original total scale, a cronbach alpha of 0.97 was reported.

Data Analyses
For the research purposes, Statistical Package for Social Sciences (SPSS) version 20 was used to generate descriptive and inferential statistics at a significance level of .05. Mean, median, SD, and minimum and maximum values were reported to estimate the levels of perceived stress and perceived organizational support among study participants. Pearson product-moment correlation was used to assess the relationship between the study variables. Multiple hierarchical regression analyses were used to assess the relationship between nurse's job's stress and organizational support controlling for the nurse's characteristics.

Results
The current study aimed to investigate the association between nurses' job stressors and organizational support among nurses in Jordan and Egypt. Table 1 presents demographic characteristics of the study sample for all participants. As shown in Table 1, the majority of the participants in both samples are females. The age of participants in both samples ranged between 20 and 30 years. More than half of the participants in both groups are married (56%). About 39% of the Jordanian participants had experience more than 5 years in comparison with 60% of the participants from Egypt who had experience of more than 5 years. About 85% of the participants in Jordan had Bachelor degree or less in nursing in comparison with 97.3% of participants with the same level of education from Egypt. Furthermore, 40% of the participants in Jordan were employed in close units, while about 64% of participants from Egypt were employed in close units. There were significant differences in the experience, education level and unit between the study samples.
The mean scores of perceived stress and organizational support in the study sample are presented in Table 2. These scores suggest that both Jordanian and Egyptian nurses perceived very high level of stress and a relatively poor organizational support. The results of Independent Samples ttest indicated that there was a significant difference in perceived stress and perceived organizational support between Jordanian and Egyptian nurses. Jordanian nurses reported lower mean scores on perceived stress and higher mean scores on organizational support than Egyptian nurses.
Pearson's product-moment correlation was used to identify the relationship between the perceived stress and perceived organizational support among the study sample. The results also implied significant negative correlation between perceived stress and perceived organizational support (r=-0.23, P<0.01 in Jordanian sample, r=-0.29, P<0.01 in the Egyptian sample, r=0.32, P<0.01 in the whole sample combined groups), which indicated that sample study nurses who perceive low level of organizational support perceive higher stress level.
Independent samples t-test was conducted to examine if there was a significant difference in perceived stress based on selected sample characteristics as indicated in Table 3, while the Jordanian sample demonstrated significant difference in perceived stress based on sample characteristics (age, gender, marital status, and level of education), the Egyptian sample had not demonstrated a significant relationship between sample characteristics and perceived stress level.    Table 4 presents the results of hierarchical multiple regression analysis to explore the correlation between organizational support and perceived stress in the study sample, after controlling other predictor variables such as participants' age, gender, marital status, educational level, department, and experience in both Jordanian sample and Egyptian sample. The regression analysis was conducted in two steps. In the first step, all the predictor variables of perceived stress were included in the model except the organizational support. In the second step, the organizational support was added to the previous model. In the first step, the participants' age, gender, marital status, educational level, department, experience, had significantly correlated with perceived stress in Jordanian nurses only, F (6,143)=3. 4, p<0.01. Together, these variables accounted for 13% of the variance in perceived stress. In contrary, the demographic variables had not significantly correlated with perceived stress in the Egyptian nurses, F (6,143)=1.7, p=0.12, while they accounted for 7% of the variance in perceived stress.
Only the second step was reported in Table 4. In this step, the regression examining whether organizational support was significantly correlated with perceived stress among nurses, after controlling participants' age, gender, marital status, educational level, department, and experience was found to be significant in both samples. For the Jordanian sample, the organizational support added 8% additional variance above and beyond the 13% accounted for by all other predictors, F (7,142)=5.01, p<0.001. For the Egyptian sample, The organizational support added 8% additional variance above and beyond the 7% accounted for by all other predictors F (7,142)=3.38, p<0.002.

Discussion
In this paper, we described the association between nurses' job stressors and organizational support among nurses in Jordan and Egypt. The findings of the study are supported by the literature regarding the high stress level and relatively low organizational support. These findings highlight the importance of stress management programs to decrease the stress [7,8].
The results indicated significant negative correlation between perceived stress and perceived organizational support for both Jordanian and Egyptian nurses. That is, nurses who perceived less organizational support experience more stress. Such findings are congruent with studies of Pronost et al. [9], Arafa et al. [10] and Alzayyat and Al-Gamal [11]. From these studies, the most vital factors for quality workplace are peer and supervisor recognition. Nurse Managers need to pay more attention for a positive relationship with their nurses which significantly alleviate the stress. Therefore, it is an organizational role in helping the managers and administrators to adopt strategies to support the nurse.
There were several noteworthy findings. In Jordan, the male nurses were experiencing a higher stress level than females. Also, the married nurses were in more job stressors compared with unmarried. Recent literature has shown that male nurses and those who have families to care about are demonstrating a moderate to severe stress [9,12]. An explanation of this result is that the male and/or married Jordanians have many social commitments to think about; such obligations put them in more stressful situation than females or unmarried nurses. However, among Egyptian nurses, there were no significant changes in stress level based on any demographical characteristics. A reason might be related to political and economic pressures that encounter all Egyptian. Such stressful factors can evoke the stress regardless of demographical background.
After controlling all demographical factors for both Jordanian and Egyptian nurses, the organizational support was a significant predictor of job stressors. This finding is parallel with studies of AbuAlRub [13] and Reeve et al. [14], in which nurses reported low salaries, failure in problem solving and inflexibility are a major factors for a high stress. Hence, it is a necessity to make the organizational environment as healthy as possible. It is an indispensable requirement for all nurses. To come across such prerequisite, the employers need to engage the nurses in educational programs with endure evaluation. Hence, the managers can detect or expect the nurses' stress, subsequently; the job stressors could be prevented [15,16].

Conclusion
The findings of the study suggest the importance of organizational support from the managers and other nurses. The results showed that organizational support is strong predicator of job stressors. Thus, nurse managers and organizations need to generate a work atmosphere with values support. Moreover, decreasing the job stress is among the important strategies that increase nurse's satisfaction and improve the quality of patients care.