International Journal of Nursing Studies 63 (2016) 48–57

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International Journal of Nursing Studies

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Do hospital shift charge nurses from different cultures experience

similar stress? An international cross sectional study
Hanna Admia,* , Yael Eilon-Mosheb
a
Interdisciplinary Research, Rambam Health Care Campus, Haifa, Israel
b
Nursing Research Coordinator, Rambam Health Care Campus, Haifa, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Background: There is a need to improve understanding of role stress and how it affects nurses’ wellbeing,
Received 12 January 2016 burnout and health; and hence the quality and safety of patients’ care, organizational outcomes and costs.
Received in revised form 2 June 2016 The focus is on shift charge nurses in hospitals who are accountable during a specific shift for the patients’
Accepted 14 August 2016
care and staff functioning in accordance with hospital and unit policy.
Objective: To compare perceptions of stress and its intensity among hospital shift charge nurses amongst
Keywords: three countries: Israel, USA (state of Ohio) and Thailand.
Hospital management
Design: A cross-sectional study was performed across three countries, focusing on a convenience sample
International comparative
Nursing
of 2616 hospital shift charge nurses recruited from 23 general hospitals.
Role stress Methods: A validated shift Charge Nurse Stress Questionnaire was used to assess impacts of four factors:
Shift charge nurse patient & family complaints, lack of resources, responsibility burden and professional conflict.
Descriptive statistics were used to describe demographic and professional characteristics of the
participants. Chi square and the Fisher Exact Test were performed to test for demographic differences
amongst the three samples. Parametric and non-parametric tests were used to compare mean stress
levels amongst the study samples.
Results: The mean stress level for the total sample was 2.84 (0.71) on a Likert scale of 1–5, implying
moderate stress levels. Significant differences in stress levels were found among countries, with Thai
nurses scoring the highest and Israeli nurses the lowest. Similar perceptions of stress intensity were
found for all countries, with the factors “responsibility burden” and “lack of resources” considered the
most stressful. Israeli and American nurses perceived similar situations as stressful and different from
those perceived by Thai nurses. The findings can be partially explained by demographic, professional and
cultural differences.
Conclusions: Similarities along with differences were found in the nature and levels of stress experienced
across the studied countries. A prerequisite educational program should be mandatory for nurses prior to
their nomination as shift charge nurses. Programs should be tailored to address the stress experienced by
shift charge nurses. Ongoing mentorship and workshops are recommended to develop and maintain
leadership abilities to cope with role stress. Future research should explore internationally the unique
nature and stress of the shift charge nurse’s role and replicate this study by using the Charge Nurse Stress
Questionnaire in other countries. Further international comparative studies are recommended to
evaluate stress perceptions of nurses in other roles and in different practice areas.
ã 2016 Elsevier Ltd. All rights reserved.

What is already known about the topic?
 Shift charge nurses’ stress affects their health, wellbeing and
burnout; and can impact quality and safety of patient care,
organizational outcomes and costs.
 The role of shift charge nurses is complex and crucial for
effective management of wards/units in hospitals.
 Most studies of nurses’ stress use standardized general stress
instruments not tailored to specific nurses’ roles and not always
congruent with stress theories.

* Corresponding author.
E-mail address: h_admi@rambam.health.gov.il (H. Admi).

http://dx.doi.org/10.1016/j.ijnurstu.2016.08.005
0020-7489/ã 2016 Elsevier Ltd. All rights reserved.
 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57 49

What this paper adds
 An instrument to measure perceptions of specific stress
situations typical to the role of hospital charge nurses was
implemented in this study.
 The study revealed similarities and differences in the types and
intensity of stresses among shift charge nurses, across three
countries: Israel, USA and Thailand.
 Shift charge nurses in hospitals perceive managerial responsi-
bility as the leading most stressful situations compared to
clinical related stress situations.
1. Introduction
In light of the worldwide shortage of nurses, growing demand
for high standards of safety and quality of care, and rising public
expectations and economic constraints; it is important to examine
stress in the nursing profession. A better understanding of work-
related stress amongst nurses is an essential step in reducing the
adverse consequences to patients, nurses and health care
organizations (Adecco Group, 2013; Brown et al., 2013; Johansson
et al., 2013).
Over the past three decades, awareness of the importance of
reducing nurses' stress in the work place has increased.
Researchers found that nurses’ overload (i.e., nurse-to-patient
ratio) impacts patients safety, quality of care, mortality and
satisfaction (Aiken et al., 2012; Aiken et al., 2014). Many studies
document the adverse effects of nurses’ work-related stress on
various aspects of their health and well-being; including emotional
exhaustion, job dissatisfaction, burnout, tendency to leave the
workplace, fatigue and sleep difficulties (Van Bogaert et al., 2014;
Garrosa et al., 2011; Jones et al., 2015; Judkins, 2004; Lee and
Cummings, 2008). The cost of stress to organizations is enormous
in terms of absenteeism, medical care expenses and turnover
(Atencio et al., 2003).
The literature includes multiple review articles and empirical
studies (mostly cross-sectional), examining stress and related
concepts among nurses in a variety of roles and occupational fields.
However, the many theoretical and methodological problems in
nursing stress research makes it difficult to compare studies and
draw conclusions. Researchers use different conceptual theories of
stress and some do not use any explicit theories. Frequently there is
a lack of congruency between theory, concepts definition and
instrument use. For example, stress can be conceptualized as a
stimulus or demand (i.e. stressor), resource or lack of resource,
response (i.e. stress reaction, distress) or as an interaction between
a demand and a resource (Hayes et al., 2015; Jones et al., 2015; Kath
et al., 2013; McVicar, 2003).
Lazarus and Folkman (1984) theory of stress was chosen as the
theoretical framework for the current study. The assumptions
underlying this theory are that stress is a subjective dynamic
phenomenon related to a specific interaction between a person
and his or her environment. In other words, people may perceive
differently the same stressful situation, or even the same person
can experience stress differently in similar situations. For example,
a patient needs resuscitation during a nurse's shift. The stress
experienced by the nurse depends on personal characteristics (e.g.
coping abilities, knowledge and clinical experience), the environ-
ment (e.g. other team members, access to necessary equipment)
and the nurse's subjective interpretation of the specific interaction.
Therefore, nurses' work stress must take into account the
different practice areas and varying roles of nurses. Namely, a
community health nurse is likely to be exposed to different
situations than a nurse in a hospital emergency room, and staff
nurses are likely to perceive situations differently than their nurse
manager in the same practice area. Accordingly, in this study we
chose to examine the phenomenon of work-related stress among
shift charge nurses in hospitals, by using a stress tool tailored
specifically for this nurse population (Admi and Moshe-Eilon,
2010; Admi et al., 2015).
1.1. The role of a shift charge nurse
Ambiguity and lack of explicit definitions characterize the field
of managerial nursing roles at the unit level internationally. The
same terms are used for different roles, similar roles are given
different titles, and terms are frequently used interchangeably
with no universal consistency or standardization (Table 1). The
tendency is to confuse the roles at the unit/ward level between the
unit manager, the shift charge nurse and the clinical staff nurse.
They are all considered front line roles with different degrees of
authority and responsibilities. Whereas the unit nurse manager is
accountable for all patient care and nursing staff on the unit over
24 h, the shift charge nurse is accountable only for a particular
shift. The nurse manager has the responsibility to translate the

Table 1
Titles frequently used for front line managerial nursing roles in hospitals.

Level Role Title Country Reference

Department/ Head nurse US Falex Medical dictionary, 2012
Ward/ Nurse manager Canada Brown et al., 2013
Unit US Kath et al., 2012
Nurse unit manager Belgium Van Bogaert et al., 2014
Ghana Adatara et al., 2016
Front line nurse leader US Schwarzkopf et al., 2012
Front line nurse manager Canada Lee and Cummings, 2008
First line nurse manager Sweden Johansson et al., 2013
Ward sister UK Royal College of Nursing, 2009
Charge nurse UK Royal College of Nursing, 2009
Ward manager UK Pegram et al., 2014
Clinical nurse manager UK Gould et al., 2001
Assistant nurse manager US Schwarzkopf et al., 2012
Evening/night Shift charge nurse US Krugman and Smith, 2003
Shifts Israel Admi and Moshe-Eilon., 2010
Thailand Admi et al., 2015
Finland, Greece Lundgrén-Laine et al., 2013
Team leader Australia Williams et al., 2009
Shift leader Israel Goldblatt et al., 2008
Finland, Greece Lundgrén-Laine et al., 2013
50 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57
vision and mission of the organization into unit practice, while the
shift charge nurse is responsible to translate the unit policy into a
specific shift practice. The clinical staff nurse is accountable and
responsible to manage the care of a designated group of patients
and reports to the nurse manager during the day and to the shift
charge nurse during shifts (Thrall, 2006).
Katz (1955) competency theoretical framework provides a
useful way to examine leadership competencies. According to
Katz’s theory, three skills vary with the level of management
responsibility: technical skills (i.e. specialized knowledge about a
specific activity), human skills (i.e. working with people) and
conceptual skills (i.e. ability to view the organization as a whole).
At lower levels, technical skills are crucial to efficient operation.
Human relation skills are essential at all levels and conceptual
skills are crucial at the top levels of management (Katz, 1955).
Three American national nursing organizations: The American
Organization of Nurse Executives (AONE), the Association of
periOperative Registered Nurses (AORN), and the American
Association of Critical-Care Nurses (AACN) developed a Nurse
Manager Leadership Collaborative framework (NMLC, 2006) to
identify competency domains required by current and future nurse
leaders at the unit level. The framework includes an inventory of
key skills essential for developing leadership for nurse managers
within three competency domains: the science, managing the
business; the art, leading people; and creating the leader within,
creating the leader in yourself. Examples of relevant skills and
behaviors include: managerial and clinical critical thinking,
personal and professional accountability, leading the nursing
team, patient and workplace safety, knowledge of the organization
systems and behavior, problem solving skills and information
technology (Chase, 2010).
Although the role of a shift charge nurse is well established and
is critically important in hospitals, there is little research
examining this position. The shift charge nurse is the nurse
manager of the unit during evening and night shifts. This role is
commonly a rotational position. For example, on one shift a nurse
may be in charge and on a subsequent shift a colleague they
previously supervised is in charge (Eggenberger, 2012; Mccallin
and Frankson, 2010).
For the purpose of this study, the role of the shift charge nurse
refers to a front-line manager held accountable during a given
Table 2
The role of shift charge nurse: responsibilities and examples of tasks.
Responsibility Examples of tasks
area
Management  Delegating nurses and nurses-aid assignments for the shift
 Prioritizing the work and ward resources (e.g. physical, human)
 Making staffing decisions
 Evaluating staff performance
 Mediating between patients, families and nursing staff
Quality and safety  Providing direct patient care based on the workload and clinical considerations
of  Updating patient care plans, documentation
Patients care  Supervising and monitoring the quality of care provided by the team
 Conferring with physicians on patient's progress and reporting special circumstances
 Investigating patient complaints
 Identifying safety issues for patients or staff members
 Managing emergency and disaster situations
Teaching and  Coaching and acting as preceptors for new nursing staff
counseling  Counseling in case of conflicts and dilemmas.
 Teaching and providing clinical guidance and advice
Administrative  Supervising the admissions, discharges and transfer of patients to and from the ward
 Maintaining adequate supplies, equipment and medicines
 Organize the shift flow and unit operations
hospital shift for patients’ care and staff functioning, in accordance
with the policies of the hospital and specific unit. The shift charge
nurse has a dual role: managerial and clinical. The management
role is assigned formally to a specific shift. The clinical role includes
direct patient care and supervision of the quality and safety of
patients’ care provided by nurses and support staff during the shift.
Areas of responsibility and examples of tasks are delineated in
Table 2.
The confusion that characterizes the role definition and
responsibility areas of the shift charge nurse is also reflected in
the qualities and skills required. Berbarie (2010) referred to the
following list of essential characteristics for a shift charge nurse:
educator, change agent, innovator, mentor, leader, mediator,
financial steward, evaluator and celebrator. A focus group of 44
generation Y nurses (born during 1980–2000) interviewed during
an Emerging Nurse Leader Master’s degree program gave the
following expectations for nursing leaders: flexibility, clinical
expertise, administrative capability, assist with patient care when
needed, know staff members, advance knowledge, accessible and
advocate for staff members (Dyess et al., 2016). A survey conducted
among 400 charge nurses in Florida rated the ability to manage
good communication as the most critical quality for success. Other
qualities rated as important by the charge nurses were: acting as
team coach, seen as approachable, work like an air traffic controller
and viewed as a professional (Sherman et al., 2011). Another study
found that in order to make effective decisions, the charge nurse
needs to be flexible, decisive, develop tactful communication skills
and stay aware of the big picture (Wilson et al., 2011).
Documentation of leadership development for nurses in
management positions is evident in the literature (Chase 2010;
Dyess et al., 2016; Titzer et al., 2013). However, the effectiveness of
these programs vary and some studies were inconclusive (Yazdani
et al., 2010). Most hospitals require some type of educational
program that cover topics such as: leadership, communication,
delegation of authority and conflict management (Connelly et al.,
2003a,b; Krugman and Smith, 2003). Frequently charge nurses
possess clinical competencies but lack necessary leadership and
management skills, as adequate training fails to support them in
coping with stress and management issues.
In summary, considerable confusion exists in the literature with
different terms used to describe management roles at the unit
Reference
Kalisch et al.,
2009
Jasper et al., 2010
Sherman et al.,
2011
Ambrose, 1995
Eggenberger,
2012
Goldblatt et al.,
2008
Connelly et al.,
2003a,b
Jasper et al., 2010
Sherman et al.,
2011
Jasper et al., 2010
Sherman et al.,
2011
 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57
level, across countries. Most studies refer to the permanent
daytime role of the nurse unit manager and few to the role of the
rotational shift charge nurse. However, many similarities were
found when describing responsibilities, tasks and skill require-
ments for the role of a shift charge nurse across countries.
Consensus exists among researchers as to the need to develop
leadership and provide mentorship to front-line nurse managers in
order to help them cope better with the complex and demanding
requirements of their role.
1.2. Theoretical framework of stress
Lazarus’ stress model (Lazarus, 1999; Lazarus and Folkman,
1984) provided the theoretical framework that informs this study.
According to Lazarus, stress is determined by an individual’s
subjective perceptions and interpretations of a given situation as
taxing or exceeding their resources, thereby endangering their
health and well-being. In other words, stress results from an
imbalance between demands and resources. Thus, individuals
become stressed when environmental demands exceed their
ability to cope with stress. The key concept of this theory is that
subjective interpretation of the stressful event is more important
than the event itself.
In order for the study to be congruent with its theoretical
framework, the tools to measure stress should reflect the main
ideas underlining the theory. Most research on stress among
nurses uses standardized occupational scales that are often very
general and not specific to nursing practice. In addition, they do not
reflect the gap between the role demand and the nurses’ resources.
Therefore measurement of shift charge nurses’ role must reflect: 1.
specific stress situations typical to this role; 2. every stress item in
the questionnaire must be defined as a gap between a specific
demand and a resource (e.g., as the charge nurse you urgently need
the physician on duty and cannot find them).
Our literature review on nurses’ stress found that most survey
instruments were borrowed from psychosocial occupational
disciplines and represent general work stress. The most frequently
stress categories were role ambiguity, role overload, role conflict,
organizational constraints, interpersonal conflict, uncertainty and
lack of support (Johansson et al., 2013; Jones et al., 2015; Kath et al.,
2013; McVicar, 2003). Little research has been conducted on the
shift charge nurse's role. Most studies were conducted on the
stress of unit or ward managers, although some countries also used
the term “charge nurse”. The literature is void of international
stress studies comparing stress among nurses in the same roles in
different countries. Most research on stress in nursing was
conducted in western countries with few studies comparing
Western and Asian countries (Lambert et al., 2004).
1.3. Study aims
1. To compare shift charge nurses’ perceptions of stress amongst
three countries: Israel, USA and Thailand.
2. To compare shift charge nurses’ intensity of stress levels
internationally.
2. Materials and methods
2.1. Study design and sample
This descriptive cross-sectional study was conducted during
2011–2013, in three countries (23 hospitals): Israel (6), USA—state
of Ohio (6) and Thailand (11). All hospitals were general non-profit
acute care settings of varying sizes: 12 small hospitals (fewer than
500 beds), 7 mid-size hospitals (500–800 beds), and 4 large
51
hospitals (more than 800 beds). The questionnaire was dissemi-
nated to all acting charge nurses in their hospitals. A convenience
sample of 2616 nurses was recruited by nursing research
coordinators in each hospital; unit head nurses distributed the
Charge Nurse Stress Questionnaire (CNSQ). To ensure anonymity,
completed and unsigned questionnaires were returned via sealed
envelopes. The nurse research coordinator collected the sealed
envelopes weekly, returning to each ward up to 3 times to
maximize participation.
2.2. Ethical considerations
Approval was granted by the institutional Human Research
Ethics Committee of the Israeli, Ohio, and Thai hospitals.
Participation was voluntary, and consent implied by completing
the questionnaire.
2.3. Instrument
The CNSQ was initially developed in Israel in Hebrew to identify
specific stress to the role of shift charge nurses. Through a
qualitative descriptive study conducted at the largest tertiary
hospital in northern Israel (N = 129, 60% response rate), a valid and
reliable questionnaire was developed comprised of six stress
factors and 50 statements (Admi and Moshe-Eilon, 2010).
Following publication, nurse researchers from Ohio and Thailand
requested to translate the survey instrument in order to assess
shift charge nurses’ stress in their countries and gain international
perspective through a collaborative research.
Consensus was achieved among the researchers from all three
countries regarding the definition and characteristics of the shift
charge nurse role. The questionnaire was translated into English
and Thai and retranslated backwards to Hebrew by professional
translators. Content validity was performed along the translation
process and the statements meaning was verified by expert nurse
researchers. In order to test the validity and reliability of the
English and Thai CNSQ version, we conducted internal consistency
reliability (ICR) analysis, exploratory factor analysis (EFA) and
confirmatory factor analysis (CFA). The EFA and CFA resulted in the
final shortened version of four stress subscales (i.e., factors) and 25
stress statement describing commonly encountered stress sit-
uations as a shift charge nurse (Admi et al., 2015).
The final CNSQ is a valid and reliable international instrument,
enabling the assessment of the shift charge nurses' role related
stress. The tool includes demographic data (e.g. age, gender),
professional data (e.g. experience, education) and 25 stress
statements. Nurses were asked to indicate, on a five-point Likert
scale (from “very little” to “very much”) the level of pressure/stress
they felt about a described situation. The CNSQ is comprised of four
stress factors: patient & family complaints (8 items), lack of
resources (7 items), responsibility burden (6 items) and profes-
sional conflict (4 items) (Table 3). A moderate to high inter-factor
correlation was found across countries (0.46–0.84), implying the
four stress factors are common themes for the items selected
(Admi et al., 2015).
2.4. Data analysis
According to the aims of the study, the following data analyses
were conducted:
1. Descriptive statistics: frequencies, means and standard devia-
tions were determined in order to describe demographic and
professional characteristics of the participants. Chi square and
the Fisher Exact Test were used to test for demographic
differences amongst the three samples.
52 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57
Table 3
The Charge Nurse Stress Questionnaire (CNSQ): factors and examples of related items.a
CNSQ Subscales (Factor)
Patient and Family Complaints
Lack of Resources
Responsibility Burden
Professional Conflict
a
The CNSQ instrument is available upon request from the corresponding authors.
2. The normality of the distribution of the quantitative parameter
(total stress level) was determined using the Kolomogorov-
Smirnov test. Subsequently, parametric (ANOVA or T-test) and
non-parametric (Krosskal-Wallies or Mann-Whitney) tests were
used to assess differences in mean stress levels relative to
demographics.
Statistical analyses were performed using the SPSS statistical
package for Windows, version 21.00; a p-value of <0.05 was
considered significant for all tests.
3. Results
3.1. Sample characteristics
The study population included a total of 2616 shift charge
nurses (Israel—758, Ohio—260, Thailand—1598). CNSQ response
rate was 26% for the Israeli sample, 41% for the Ohio sample and
83% for the Thai sample. The demographic and professional
characteristics of the participants are presented in Table 4.
Participants were predominantly female (93.2%), registered nurses
(69.8%), worked full time (88.6%) and the largest age group was 31–
40 years (44.5%). Most participants worked as nurses for 15 years
or more (39.3%) and had taken up the role of charge nurses less
than 5 years prior (35.2%).
Several significant demographic and professional differences
were noted among the three countries:
1. Gender: more male nurses were noted in the Israeli compared
with the Thai and Ohio sample populations.
2. Age: the Thai sample had the highest percentage of young
nurses—less than 40 years of age (72% versus 57% and 51% in
Israel and Ohio respectively). The Ohio sample had the highest
percentage of older nurses—over 51 years of age (23% versus 5%
and 11% in Thailand and Israel respectively).
3. Experience in nursing and as charge nurse: the Ohio sample had
nurses with fewer years of general nursing work experience—
Related items
Delayed procedure.
Complaint about a nurse.
A patient demands to talk only with the doctor.
A patient yells at you.
A patient is unsatisfied with your answer.
The patient’s family is angry with you.
A patient complaint about another team member.
Unfulfilled promise to a patient.
A nurse calls in sick.
You cannot find the physician on duty.
There is chaos on the unit.
Negative feedback from the head nurse.
No help with a deteriorating patient.
Doubts about a doctor’s medical order.
Unable to leave the unit on time.
New admission on a nearly full ward.
Fear of forgetting important data.
Direct patient care vs. shift management.
Uncompleted tasks.
Unable to meet patient's needs.
Decision-making related to priorities.
Threatened by a patient's family.
Forgot something important.
Unable to help a patient due to restrictions in your authority.
Unable to implement professional values.
less than ten years (57.6%) and less than ten years as a charge
nurse (76%).
4. Professional education: The Israeli sample had the highest
percentage of Bachelor or Master degrees (73.1% versus 43.5%
and 5.6% in Ohio and Thailand respectively).
5. Job partiality: The Thai sample has the highest percentage of
nurses working full time (99% versus 69.7% and 83.1% in Israel
and Ohio respectively).
In summary, the Israeli sample is characterized by a signifi-
cantly high percentage of male and bachelor or master degrees. The
Ohio sample is characterized by a significantly higher percentage
of older nurses with less experience in nursing and especially in
the role of a shift charge nurse. The Thai sample is characterized by
a significantly high percentage of female nurses, young nurses, a
diploma (RN) degree and full time workers. The sample size differs
among the three countries; however characteristics of the samples
are representative of the nursing population in hospitals in each
country.
3.2. Stress across countries
Mean stress level of the total sample is 2.84 on a scale of 1–5,
implying a moderate stress level. Overall stress levels were
significantly different among all three countries (Table 5). The
highest overall stress level was measured among the Thai charge
nurses (2.96  0.67) and the lowest among Israeli charge nurses
(2.63  0.75). The factor “responsibility burden” contributed to the
highest stress level in the Thai sample (3.32  0.70) and was
significantly lower in the Ohio and Israeli samples; though it was
the second most stressful factor in the Israeli and Ohio populations.
“Lack of resources” was the leading stress factor for the Ohio
and the Israeli samples (2.92 and 2.77 respectively) with no
significant difference between Ohio and Thailand, though stress
levels were significantly higher in comparison with the Israeli
sample. “Patient and family complaints” was the lowest ranked
stress factor among all three countries. The level of stress of this
factor was significantly higher in the Thai sample.
 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57 53

Table 4
Study population: nurses’ demographic and professional characteristics.

Population Characteristics Israel (N = 758) Ohio (N = 260) Thailand (N = 1598) Total (N = 2616) p-value
Gender:
1,2,3
Male 16% 8% 2% 6.5% p < 0.001
Female 83% 92% 98% 93.2%
Missing 0.5% 0.4% 0.2%
Age:
2
<30years 17% 20% 23% 21% p < 0.001
31–40 years 40% 31% 49% 44.5%
1,2,3
41–50 years 30% 26% 23% 25.2% p < 0.01
2
51+ years 11% 23% 5% 8.6% p < 0 .0001
1,2,3
Missing 0.9% 3.1% 0.19% 0.7% p < 0.001
Nursing Experience:
1,2
<5years 16.3% 28.4% 19.2% 19.2% p < 0.0001
1,2
6–10 years 19.9% 29.2% 18% 18% p < 0.01
1,2,3
11–15 years 21.4% 14% 23.6% 23.6% p < 0.01
1,2,3
15+ 42.3% 28.4% 39.3% 39.3% p < 0.0001
Missing 2.1% 1.1% 0.01% 0.04%
Charge nurse experience:
1,2,3
<5years 40.2% 50% 30.5% 35.2% p < 0.001
2
6–10 years 21.6% 26% 28.3% 21.6% p < 0.001
2,3
11–15 years 12.1% 8.3% 19.4% 16.2% p < 0.001
1,2
15+ 26.0% 15.7% 21.9% 22.5% p < 0.0001
3
Missing – 2.3% 1% 0.8% p < 0.05
Professional Education:
2,3
Diploma (RN) 23% 55.8% 94.2% 69.8% p < 0.0001
Bachelor/Master degree 73.1% 43.5% 5.6% 28.9%
Missing 3.8% 0.8% 0.2% 1.3%
Job partiality:
1,2,3
Full time 69.7% 83.1% 99% 88.6% p< 0.001
Part Time 29.9% 15.8% 1% 10.6%
Missing 0.3% 1.1% 0.9% 0.7%
1
Israel vs. Ohio.
2
Thailand vs. Israel.
3
Ohio vs. Thailand.

In summary, similarities were found in the perceptions of the
nature of charge nurses' stress across the three countries with the
factor “responsibility burden” leading as the most stressful,
following by “lack of resources”. Situations related to “patient
and family complaints” were perceived as least stressful. However,
the levels of stress differ significantly among the countries with
Thai nurses self-reporting as the most stressed nurses and Israeli
nurses as the least stressed in the role of charge nurse.
3.3. Demographic and professional differences in stress levels within
countries
In the Israeli sample significant higher stress levels were found
among younger nurses, with fewer years of work experience or
experience as charge nurses. No significant differences were found
in gender and job partiality. In the Ohio sample, the highest
significant stress levels were found amongst nurses with 6–10
years of experience as charge nurses. No significant differences
were found among all other characteristics (i.e., gender, age, job
partiality and work experience). In the Thai sample, significant
higher stress levels were found among younger nurses (31–40
years), nurses with 6–10 years of experience as charge nurses or
with lower professional education. No significant differences were
found among other characteristics (i.e. gender, work experience
and job partiality) (Table 6).
In summary, within each one of the three countries, no
significant differences in levels of stress were found between
female and male nurses or between nurses working full time or
part time. In Israel and Thailand, the levels of stress decrease with
age and professional role experience. In Ohio, to the contrary, the
stress level increases after the first 5 years as a charge nurse. In
Thailand, the level of stress of Diploma RNs is significantly higher
than for nurses with Bachleor or Master degrees.

Table 5
Stress factors by countries: mean, standard deviation (SD), internal consistency*.

Stress Factor No. of Israel (N = 758) a Ohio (N = 260) a Thailand (N = 1598) a Total P value
items Mean  SD Mean  SD Mean  SD Mean  SD
2,3
Patient & Family 8 2.47  0.88 0.90 2.53  0.76 0.90 2.70  0.87 0.91 2.62  0.87 p < 0.01
Complaints
1
Lack of resources 7 2.77  0.91 0.84 2.92  0.79 0.82 2.92  0.75 0.82 2.87  0.80 p < 0.05
2
p < 0.01
1,2,3
Responsibility burden 6 2.63  0.90 0.83 2.87  0.83 0.84 3.32  0.70 0.84 3.08  0.84 p < 0.001
2
Professional conflict 4 2.61  0.96 0.77 2.74  0.84 0.77 2.87  0.85 0.81 2.78  0.88 p < 0.001

1
Total 25 2.63  0.75 0.93 2.76  0.68 0.94 2.96  0.67 0.95 p < 0.05
2,3
p < 0.001

*a Cronbach.
1
Israel vs. Ohio.
2
Thailand vs. Israel.
3
Ohio vs. Thailand.
54 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57

Table 6
Comparison of stress levels by demographic and proffesional characteristics within and across countries.

Demographics (category:1–4) Stress levels within countries Stress levels across countries

Israel Ohio Thailand

Mean  SD P Mean  SD P Mean  SD P P

Gender:
Woman 2.66  0.75 NS 2.70  0.55 NS 2.96  0.66 NS 2,3***
Male 2.55  0.73 2.76  0.69 3.00  0.72 2**
Age (years):
(1) 30 2.79  0.73 B* 2.67  0.67 NS 2.98  0.69 D* NS
(2) 31–40 2.66  0.74 C* 2.68  0.70 2.99  0.66 2,3***
(3) 41–50 2.54  0.73 2.93  0.65 2.88  0.64 2,3***
(4) 51+ 2.52  0.78 2.75  0.67 2.82  0.66 2*
Work Experience (years):
(1) 5 2.81  0.72 C** 2.73  0.61 NS 3.01  0.68 NS 2* 3**
(2) 6–10 2.70  0.73 2.74  0.74 2.97  0.69 2,3**
(3) 11–15 2.61  0.75 2.72  0.78 3.01  0.66 2*** 3*
(4) 15+ 2.53  0.76 2.80  0.64 2.90  0.66 1** 2***
Experience as CN (years):
(1) 5 2.76  0.74 C*** 2.62  0.63 A** 2.98  0.68 E* 2,3***
(2) 6–10 2.64  0.75 2.99  0.73 3.03  0.69 1* 2***
(3) 11–15 2.54  0.67 2.64  0.67 2.92  0.65 2***
(4) 15+ 2.45  0.75 2.87  0.65 2.88  0.64 1** 2***
Professional Education (years):
***
RN 2.61  0.77 NS 2.70  0.67 NS 2.98  0.66 2,3***
RN +BA/MA 2.63  0.74 2.82  0.68 2.61  0.62 1*
Job Partiality:
Full time 2.63  0.77 NS 2.77  0.69 NS 2.96  0.67 NS 1* 2*** 3**
Part time 2.62  0.69 2.72  0.64 2.90  0.52 NS

Within countries: A = category 1 vs. 2; B = category 1 vs.3; C = category 1 vs.4; D = category 2 vs.3; E = category 2 vs.4; F = category 3 vs.4.
Across countries: 1Israel vs. Ohio, 2 Thailand vs. Israel, 3 Ohio vs. Thailand.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.

3.4. Demographic and professional differences in stress levels across
countries
The cross country analysis enables control of different
characteristics among countries, in order to compare stress levels
of nurses with similar demographic and professional character-
istics across countries. As demonstrated in Table 6, only for two
characteristics (nurses under the age of 30 years or working part
time) were there no significant differences in the stress level of
nurses. In other words, young nurses and nurses working part time
experienced similar levels of stress in Israel, Ohio and Thailand.
However, the analysis of all other characteristics revealed
significant differences in stress levels across countries.
Although no significant gender differences were found in stress
levels within countries, differences were detected across countries.
The very small percentage of male nurses in the sample probably
accounts for this result. The stress level of Thai charge nurses is
significantly higher in comparison to Israeli nurses with the same
years of experience. The stress level of Thai Diploma RNs is
significantly higher than for Israeli and Ohio Diploma RNs. The
stress level of nurses working full time is significantly different
among the countries, with Thailand having the highest stress level
and Israel the lowest one. No such differences were found among
nurses working part time.
In summary, the level of stress of charge nurses across Israel,
Ohio and Thailand was compared along 6 different characteristics
(overall 18 categories). Results show that for two categories: young
charge nurses under the age of 30 years and nurses working part
time, stress levels were similar in all three countries. In addition,
many similarities were found in the level of stress between Israeli
and Ohio nurses (13 out of 16 characteristics). To the contrary,
many differences in stress levels were found between Thai nurses
compared to Israeli nurses (15 out of 16) and Ohio nurses (9 out of
16).
3.5. The most stressful situations
Out of the 25 stress situations (items) for charge nurses
described in the CNSQ tool, nine were identified as the most
stressful with different ranking among the countries (Table 7).
“Cannot find the physician on duty” (lack of resource) was selected
as the most stressful situation by nurses in all three countries, but
was ranked differently among the three countries: first in Israel,
third in Thailand and fourth in Ohio. Four situations were noted as
stressful by at least two sample populations “unable to help a
patient due to restrictions in your authority”(professional conflict);
“new admission on a nearly full ward”; “patient care versus shift
management”; and “unable to meet patient's needs” (responsibili-
ty burden). An additional four situations were noted by only one
country: “unable to leave the unit on time” (Israel); “the patient’s
family is angry with you” (Israel); “there is chaos on the unit”
(Ohio); and “decision-making related to priorities” (Thailand).
The level of stress of the five most stressful situations in all
three countries ranged between 2.98–3.62 (on a 5point scale),
indicating a moderate to high stress level. Interestingly, no
significant differences were identified between Israeli and Ohio
nurses, implying similarity in what nurses in both countries
perceived as most stressful in the role of charge nurse.
4. Discussion
The study provides two main contributions: (1) reveals the
unique stress of shift charge nurses' role in hospitals, and (2)
compares stress perceptions and intensity amongst different
countries by using the same stress measurement tool unique to
nurses' roles. This is important, as the use of different theories and
tools to measure work stress across different countries, practices
and roles hinders international comparisons of research findings
(McVicar, 2003). No other study, to the best of our knowledge,
 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57
Table 7
Five most stressful situations (items) identified by two or more countries.
Country
Most Stressful Situation (Factor)
You cannot find the physician on duty (lack of resources)
Unable to help a patient due to restrictions in your authority (professional
conflict)
New admission on a nearly full ward (responsibility burden)
Patient care vs. shift management (responsibility burden)
Unable to meet patient's needs (responsibility burden)
a
Ranking No. I–IV (i.e., I = Ranked 1 st most stressful situation).
1
Israel vs. Thailand.
2
Thailand vs. Ohio.
measured the stress of shift charge nurses focusing on the actual
stressful situations encountered during a hospital shift. Most
studies use questionnaires from the field of psychosocial occupa-
tion to measure work stress, comprised of general questions such
as “To what extent do you feel overloaded?" or “Do you get support
from your manager?" (Johansson et al., 2013; Kath et al., 2013). In
this study we used the CNSQ tool in congruent with Lazarus'
theory, tailored to measure daily stressful situations typical to
nurses who manage a hospital shift.
“Responsibility burden” was perceived by shift charge nurses in
all three countries as the leading most stressful factor in this study,
while “patient and family complaints” was the least stressful
factor. These results may reflect unique stressful situations
inherent to the nature of the shift charge nurse role. The shift
charge nurse position is rotational in contrast to nurse managers'
permanent positions. Therefore, it appears that the shift charge
nurses feel more comfortable with clinical demands such as
dealing with patient and family complaints, which are everyday
situations in their role as clinical staff nurses. Managerial demands,
such as a new admission on a nearly full ward or decision-making
related to management priorities, is perceived as stressful. Another
explanation might be the responsibility of dealing simultaneously
with both direct patient care and shift management, which is
frequently inherent in the role of a shift charge nurse. These results
demonstrate the strength of the survey instrument that is sensitive
to specific stressful situations as opposed to tools that refer to
general standardized stress situations such as: overload, ambigui-
ty, conflict and lack of support.
Our results indicate significant differences amongst the three
populations for some personal and professional characteristics,
enabling examination of the stress phenomenon in a “quasi field
experiment” design. Demographic and professional characteristics
such as age, gender, education, and work experience are variables
that impact work related stress. Studies that examined age, gender,
and education differences in occupational stress suggest that as
people grow older they experience less stress, women experience
higher levels of occupational stress than men; and the lower the
educational and socio-economic levels, the higher the levels of
stress experienced (Finkelstein et al., 2007; Michael et al., 2009).
Within the nursing occupation, Shirey et al. (2010) found that
experienced nurse managers (especially co-managers) used more
effective problem focused coping strategies and had fewer
negative health-related outcomes compared to novices who
predominantly used emotion-focused coping strategies, and
experienced negative psychological, physiological, and functional
outcomes. These findings imply that over time nurses improve
55
Israel N = 758 Ohio N = 260 Thailand N = 1598 P value
Mean  SD (Ranking Mean  SD (Ranking Mean  SD (Ranking
No.)a No.) No.)
3.15  1.31 3.16  1.1 3.53  1.1 p1,2< 0.01
(I) (IV) (III)
3.04  1.23 3.05  1.1 NS
(III) (V)
3.57  1.1 3.62  0.9 NS
(I) (I)
3.30  1.2 3.44  0.9 NS
(II) (IV)
2.98  1.23 3.55  0.9 p1 < 0.01
(IV) (II)
their coping abilities for similar stressful situations. A study
exploring the impact of demographic factors on role stress of
French ICU nurses and nurses aids (n = 536) found women to be
significantly more likely than men to have higher stress levels
(Jones et al., 2015).
Thai nurses had the highest stress level whereas Israeli nurses
reported the lowest overall stress levels. The Thai sample was
characterized by significantly younger nurses and female nurses
with only diploma degrees in Nursing, compared to the Israeli and
Ohio samples. These characteristics might explain in part the
higher stress level of the Thai nurses. In contrast, the relatively low
stress levels experienced by Israeli nurses might be related to
significantly more male nurses, more experience and higher
academic education when compared to Ohio and Thailand. In Israel
and Thailand, the increase in age and role experience correlates to
lower stress levels. The reverse trend in Ohio can be explained by
the late entrance of American nurses into the nursing profession as
a second career. The level of stress of the Ohio sample,
characterized by older female nurses with little experience in
Nursing, was intermediate to the reported stress levels of Israeli
and Thai nurses.
The study concludes that some differences in the levels of stress
among the countries can be explained by demographic and
professional characteristics of the nurses. However, when stress
levels reported by nurses with similar demographic and profes-
sional profiles are compared across countries, many differences
remain. This finding points to the importance of examining
cultural differences. A comparative study on daily stress and
coping of nurses from Western (Queensland, Australia) and Asian
(Singapore) cultures, found that Singaporean nurses experienced
higher frequencies and levels of stress compared to Queensland
nurses. Singaporean nurses were more concerned with work-
related stress and employed more emotion-focused coping while
Queensland nurses were affected by domestic and personal
concerns and employed more problem-focused coping. (Lim,
2010).
Cultural values and traditions are likely to play a role in the
perception of stress at work. The cultural aspects contribute to a
better understanding of the higher stress levels of nurses from the
Thai eastern culture found in this study, in comparison to the
western Israeli and American cultures. No significant differences
were found between Israeli nurses and American nurses in their
perceptions of the nature of role stress and the most stressful
situations in their shift charge nurse role. However, significant
differences were found in the level of stress between the two
countries. The explanation might be related to the fact that nurses
56 H. Admi, Y. Eilon-Moshe / International Journal of Nursing Studies 63 (2016) 48–57
in the Ohio sample, although older, had the least experience in
nursing and in the role as shift charge nurses. This is due to the
growing trend in the USA of second careers for women returning to
work after their children grow up, to help support their families.
This finding points to the significance of professional experience in
the perception of stress and ability to cope with job stress.
In summary, the differences in stress levels among the
countries are explained partly by demographic and professional
differences and partly by cultural differences. Characteristics such
as age, gender, professional education, job partiality, professional
experience as a nurse and a shift charge nurse were all found to be
significantly related to the level of stress, across the three
countries. In addition, the perceptions of work stress and its
intensity probably also reflect cultural values and traditions.
4.1. Strength and limitations
The limitations of the study are the differences in sample size
among the three countries and in response rates. In addition, the
sample populations differ significantly in demographic and
professional characteristics, suggesting caution in drawing general
conclusions. However, each sample is representative of its nursing
population (e.g., the male percentage in the Israeli sample is
similar to the percentage of male nurses in hospitals in Israel; older
nurses in the Ohio sample represent the age groups of nurses in
Ohio hospitals; and the high proportion of full time jobs represent
nursing employment in Thailand).
Another limitation, is the cross sectional design, which does not
allow for conclusion of causal relationships. The strength of our
study is the use of a valid and reliable tool (CNSQ) for evaluating
the unique stressful situations of the role of shift charge nurses in
hospitals, despite the mentioned limitations. International gen-
eralizations should be examined carefully, as the study compared
only three countries representing eastern and western cultures.
4.2. Conclusions and implications
The study illustrates the importance of identifying nurses' work
related stress in different management roles in general and
internationally, as this provides a deeper understanding of the
complex stress phenomena that nurses encounter. The use of the
shift charge nurse questionnaire measures not only personal and
professional aspects or organizational demands, but rather,
subjective perceptions of the gap between personal and profes-
sional abilities and work related demands. These findings have
important implications for policy, practice, education and future
research. Performance expectations for nurses in managerial
positions in acute care hospitals continue to increase, making
coping more difficult. The identification of specific role stressors
and their link to personal and professional characteristics provides
a basis for decision makers to plan stress reduction interventions.
Organizational policy makers should invest in prevention and
reduction of shift charge nurses work stress, as it has an impact on
nurses' health, wellbeing, and burnout. In addition to personal
consequences, stress can impact patient safety, quality of care,
organizational outcomes and costs. Programs should be tailored
to shift charge nurses' perceptions of role stress and take into
consideration their level of experience in this role. Nurses prior to
their nomination to the role of shift charge nurses should attend a
mandatory prerequisite educational program. Acting shift charge
nurses can benefit from mentorship and leadership coaching.
Experimental learning activities using simulations of daily
practical situations followed by discussions and feedback are
recommended (Chase, 2010; Titzer et al., 2013). Ongoing
mentorship and workshops can strengthen shift charge nurses'
personal resilience, provide collegial support and develop
leadership abilities to cope with role stress. In addition, evidence
based research is needed to assess the effectiveness of such
programs.
Future research should: (1) further explore internationally the
unique nature and stress of the shift charge nurse’s role and
replicate this study by using the CNSQ in different settings and
countries, (2) evaluate stress perceptions of nurses in different
roles and practice areas.
Conflict of interest
None declared.
Funding
None.
Ethical approval
None.
Acknowledgement
The authors thank Ms. Ronit Leiba for her statistical assistance
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