Berry, Nazm
(2023)
Exploring the relationship among stress, psychological wellbeing, and performance in healthcare professionals and healthcare students.
PhD thesis, University of Nottingham.
Abstract
Background: The prevalence of high stress in healthcare professionals (HCPs) and healthcare students has gained immense attention over the past decade; and more so since the onset of the COVID-19 pandemic. High levels of stress have been shown to have adverse consequences on the psychological wellbeing, and aspects related to performance, in both HCPs and healthcare students, and particularly in the nursing sector. While prior quantitative research has demonstrated a significant relationship among stress, psychological wellbeing and work performance in HCPs worldwide, there is a need to better understand the factors entailed in this dynamic relationship, and gain more in-depth insight from a qualitative perspective too, particularly in nurses working for the National Health Service (NHS). Likewise, such factors warrant further exploration in nursing students too as they comprise a highly stressed population as compared to students in other fields due to the prevalence of complex and challenging issues that start to arise early in their education and training. Besides exploring the various stressors and factors associated with stress and other aspects of psychological wellbeing and performance, it is also important to look into the various coping strategies and resources that are employed in nursing staff and students within the context of stressful situations, including their uptake and views of available wellbeing courses or other sources of support offered within the healthcare settings.
Aim: Following an Introduction (Chapter 1) to the key constructs and background pertinent to the current PhD project, the thesis presents a scoping review (Chapter 2) intended to look into psychological wellbeing intervention studies in NHS employees in terms of outcomes associated with improved psychological wellbeing and aspects related to work performance. The next chapter (Chapter 3) presents the core theoretical and practical aspects of the Methodology employed in the three studies which follow: Study 1 (Chapter 4) was intended to cast light into the relationship among stress, psychological wellbeing, aspects of work performance, and coping in nurses working for the NHS. Study 2 (Chapter 5) evaluated the effectiveness and acceptability of an eight-week mindfulness-based cognitive therapy programme (MBCT) delivered to NHS employees. Study 3 (Chapter 6) explored the relationship among perceived stress, coping strategies, emotional intelligence, and self-efficacy in UK nursing students. Finally, the findings across all studies and their implications are integrated in the General Discussion (Chapter 7) wherein an account of the project strengths and limitations is offered along with future directions for research and practice.
Method: A mixed-method design was adopted across all three studies for data collection and analysis; quantitative data has been derived through validated self-report questionnaires via an online survey platform. Qualitative data has been collected through semi-structured interviews conducted via Microsoft Teams, including also a series of focus-groups in Study 3. Study 2 adopted a pre-/post- intervention, mixed-methods design, with quantitative assessments obtained at baseline (pre-intervention) and post-intervention and qualitative data obtained through interviews post intervention.
Results: In study 1, regression analysis demonstrated a significant positive relationship between stress and impaired work performance; a significant negative relationship between stress and work satisfaction; a significant negative relationship between stress and overall work activity impairment; including a partially mediating role of emotional intelligence between stress and impaired work performance. Thematic analysis revealed the presence of various stressors pre and during the global pandemic, with workload being a major factor; impact of stress on several aspects of psychological wellbeing (in terms of low mood or depression, feelings of frustration, difficulty switching off, anxiety, lifestyle changes, and negative work-life balance); impact of stress on work performance (in terms of inefficient delivery of tasks, poor decision making skills, concentration difficulties, limited attention span, increased errors, forgetting important information, and feelings of frustration towards other colleagues); seeking social support as a major coping mechanism adopted by majority of nurses (from peers, seniors, professionals, and loved ones); receiving support from the organisation (including line managers) although some staff reported lack of adequate support. Uptake of certain wellbeing interventions was reported, but some staff reported lack of awareness and other barriers associated with engagement such as long waiting lists, lack of time, or simply not feeling the need to participate). With regard to study 2, Wilcoxon Signed Rank test findings revealed at post-intervention stage significant reductions in depression and stress, and a significant increase in levels of mindfulness and overall quality of life. Emerged themes reflected beneficial perceived changes in stress and other aspects of psychological wellbeing or state and perceived acceptability of the MBCT programme, while offering recommendations for improvement in future implementation. In study 3, a weak negative correlation was revealed between problem-focused coping and stress; a strong positive correlation between stress and avoidance coping; and no association was found between stress and emotion-focused coping. Emotional intelligence and self-efficacy had a positive significant correlation; a negative association was found between stress and emotional intelligence; and a strong negative correlation between stress and self-efficacy. Finally, a weak positive correlation was found between problem-focused coping and emotional intelligence; and between problem-focused coping and self-efficacy. Further, emotional intelligence did not moderate or mediate the relationship between self-efficacy and stress. Emerged themes highlighted various stressors experienced by nursing students, with balancing between academic and clinical placements being the major source of stress; the impact of stress on psychological wellbeing (in terms of low mood, feelings of demotivation, feelings of frustration with oneself and others around them, feeling overwhelmed difficulties switching off and experiencing low self-esteem); seeking social support as the most common coping strategy (from peers, teachers, university welfare services, professionals, and loved ones); and high perceived self-efficacy. Findings from focus-groups revealed a mixture of problem-focused and emotion-focused coping strategies when placed under stressful academic and placement situations.
Conclusions: The combined pattern of quantitative and qualitative findings across all three studies has demonstrated high stress levels among HCPs and students, along with associated negative effects on psychological wellbeing and work or academic performance. However, it also placed emphasis on the significance of personal resources (EI, coping strategies, and self-efficacy) as well as job resources for improving one’s psychological wellbeing and aspects related to one’s work or academic performance. While stress is an inevitable aspect in healthcare settings, the NHS organisations and educational institutions should consider providing enhanced support for improving personal and organisational resources in healthcare staff and students in order to promote or improve their psychological wellbeing and performance.
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