1. INTRODUCTION:

According to the foreigner policy statistical annual report (2012), the number of foreigner living in Korea as of the end of 2012 turned out to be approximately 1.5 million that was increased by 3.5% (about 50 thousand people) compared to the 2011¹. Foreigners living in Korea are eligible to use medical service if they suffer from health-related problems while staying in Korea. Nurses provide many of the services that are usually performed in the diagnosis department for patients². Especially, when providing foreigners in the diagnosis at hospital, nurses tend to experience job stress due to communication problem from language barrier or the difference of organizational culture.

If they repeatedly and continuously experience the job stress and are not able to solve it, they end up confronting the exhaustion³. Fatigue and Burnout induced nursing job stress may create problems of patient safety and dissatisfaction^4,5.

What is usually used to deal with these stress circumstances is to manage self-control, plan problem solving, and seek for social support method. It is required to respect cultural and social etiquette and value between nursing service providers and foreign patients and make an effort to fulfill social, cultural, and linguistic requirements of patients⁶, and this will be an important instruction on improvement of medical service of patients. Nurses working in the clinical field for foreign patients tend to find it difficult to communicate with foreign patients without well-created foreign patients diagnosis system and witness an increasing job stress due to foreign patients diagnosis service system that has not been established. In fact, measures have not been established to cope with such situations. Hereupon, this study aims to prepare for fundamental resources of effective intervention by identifying the job stress related to service provided by clinical nurses to foreign patients in university hospitals and also how to solve such stress.

The objective of this study is to identify the job stress and stress-related circumstances of clinical nurses while providing service to foreign patients and also the correlation of them. Particular objectives of the study are as follows.

First of all, it is to confirm the job stress and stress-related circumstances of subjects while providing service to foreign patients.

Secondly, it is to confirm the difference on job stress and circumstances for coping with stress according to general characteristics of subjects while providing service to foreign patients.

Third, it is to confirm the relationship between job stress and circumstances for coping with stress while providing service to foreign patients.

2. RESEARCH METHODS:

2.1 Research Design:

This study is a descriptive investigation research designed to confirm job stress and circumstances of coping with stress among clinical nurses related to the service provided to foreign patients and identify the correlation among them.

2.2 Subjects and Method of Collecting Data:

Convenient sampling was proceeded on nurses who worked at a university hospital located in Seoul. This study has been conducted upon approval from hospital clinical research ethical committee (approval number, ECT 13-23-03), and written agreement form has been provided to research subjects explaining them with the objective and methods of the research. The period of collecting data was from September 2nd to 13th, 2013, and four copies with incomplete responses were excluded. Total 241 copies were used for the final analysis. The sample size of 138 subjects turned out to be required by calculating with the medium size of effectiveness in the G* Power 3.1 program, significance level (α= 0.5), and statistical power (1-β= .95). In addition, the sample large enough for analysis was acquired.

2.3 Research Tools:

In order to measure the job stress of clinical nurses, what was modified and supplemented by Choi(1998) based on the stress measurement tool developed by Kim (1989) on clinical nurses was used⁷. This tool was comprised of 26 questions including 9 questions about nursing work, 14 questions about interpersonal relationship, and 3 questions about hospital administration and management. They were applied with 5 point Likert scale that the higher the score was, the higher the job stress was. In the study by Choi (1998), the reliability of tool was Cronbach' α=.97, and Cronbach' α=.92 was calculated in this study.

In order to measure how clinical nurses coped with stress, researcher has modified and supplemented the tool developed by Lazarus and Fokman (1984) for this study⁸. This tool was comprised of 24 questions including 12 questions about active coping and 12 questions about passive coping and was applied with 4 point Likert scale. The higher the score was, the better they were able to cope with stress. The reliability of tool used in this study was Cronbach's α=.88.

2.4 Data Analysis Methods:

Collected data were analyzed by using PASW (Predictive Analytics Software) 18.0

1) Average and standard deviation were used for the job stress and coping with stress.

2) The difference between job stress and coping with stress according to the general characteristics was represented by using t-test and ANOVA, and follow-up verification was provided with Duncan test.

3) Correlation of job stress and stress coping was analyzed with Pearson's correlation coefficient.

3. RESULTS:

3.1 General Characteristics of Subjects:

Average age of research subjects was 29 that 99.2% of the research subjects were women. 69.3% of them were single. As for the highest level of education, 60.2% of them graduated three-year college. As for the religion, 32.8% of them were Christian. Average working period turned out to be 7 years and 9 months, and 32.8% of them worked more than 5 years but less than 10 years. As for the working department, 22.0% of them worked at internal medicine department, and 29.0% of them worked at surgery department. As for position, 91.3% of them were general nurses, and 64.7% of them were works in three shifts. As for job satisfaction, 56.4% of them responded as normal, and 26.1% of them responded to be satisfied. 35.7% of them were able to communicate in foreign language. Among them, 91.9% of them were able to communicate in English. 2.3% of them responded to be fluent in communication in foreign language, and 27.9% of them responded that they were not at all fluent in foreign language. As for the method of improving foreign language communication ability, 51.2% of them responded that they studied foreign language by themselves. 51.3% of them responded that they have never experienced foreign culture. 64.7% of them responded that they had one or two times of serving for foreign patients.

3.2 Job Stress and Stress Coping of the Subjects:

The level of job stress and stress coping pattern of the subjects are shown in table 1. Average score of job stress of research subject turned out to be 2.91±.55 out of 5. As for each of the items, average score of hospital administration and management turned out to be the highest as 3.12±.75, and the one of stress related to nursing service and interpersonal relationship turned out to be 2.80±.55.

As for the stress-coping measures of research subjects, the average score was 2.46±.35 out of 5. As for each of the items, score for active coping was 2.60±.37. The score for passive coping was 2.33±.40 (Table 1).

Table 1: Job stress and stress coping of the subjects

Variables	M±SD
Job stress	2.91±.55
Nursing job	2.80±.55
Relationship	2.80±.55
Management	3.12±.75
Stress coping	2.46±.35
Active coping	2.60±.37
Passive coping	2.33±.40

3.3 Job Stress and Stress Coping According to General Characteristics:

According to the result of difference with job stress based on the general characteristics, there has been a similar difference among working departments. According to the result of follow-up verification, stress score of nurses working in the psychiatry department turned out to be higher than the one of those working at newborn baby room (F=2.433, p=.012), and the score was calculated in an order of psychiatry department (average 3.64±.52), obstetrics and gynecology department (average 320±36), and internal medicine department (average 2.98±.62). As for the work type, those in three shifts turned out to have a significantly lower score of job stress than those with two shifts (F=10.523, p=.000).

As for the method of coping with stress, there has been a significant difference depending on the work type, job satisfaction, and communication ability in foreign language. The average score of those with two shifts in coping with stress turned out to be the highest (F=4.02, p=.008). It was confirmed that the higher the job satisfaction was, the higher the average score of coping with stress was (r=.222, p=.001). The average score of coping with stress among those without fluent communication ability in foreign language at all turned out to be higher than those with fluent communication ability (F=3.557, p=.033).

3.4 Correlation Between Job Stress and Stress Coping:

The correlation of job stress and stress coping of the subjects are shown in table 2.According to the correlation between job stress and stress coping, there was a significantly positive correlation (r=.559, p=.000). Especially, stress on the hospital administration and management turned out to be more related with significance of active coping (r=.50, p=.000) than the one of passive coping (r=.383, p=.000),(Table 2). In other words, the more research subjects were stressed out with hospital administration, the more active they utilized the measurement in solving them.

Table 2: Relationships among job stress and stress coping

Stress Coping Stress		Stress of relationship	Stress of management	Active coping	Passive coping	Stress coping
Stress of nursing job	r	0.841	0.639	0.463	0.461	0.507
Stress of nursing job	p	0.000	0.000	0.000	0.000	0.000
Stress of relationship	r		0.663	0.477	0.476	0.523
Stress of relationship	p		0.000	0.000	0.000	0.000
Stress of management	r			0.500	0.383	0.482
Stress of management	p			0.000	0.000	0.000
Active coping	r				0.661	0.905
Active coping	p				0.000	0.000
Stress	r					0.559
Stress	p					0.000

4. DISCUSSION:

The average score of job stress of research subjects turned out to be 2.91 out of 5, and this value was similar with 2.86 from the study by Kwon & Lee (2012) conducted on clinical nurses, 2.75 from the study by Kim (2012), and 2.93 from the study by Baek (2007)⁹. According to the result of dividing the job stress into three areas, the average score of interpersonal relationship turned out to be the highest in 3.12 (±0.75). The average score of nursing work was 2.80 (±0.55) that was lower than 3.55 (±0.52) from the study by Kwon & Lee (2012)⁹. This assumes that the communication and cultural difference occurring in the nursing treatment and administrative procedures to be provided by nurses on foreigners were the biggest source of stress since it was the study conducted on clinical nurses who served for foreign patients.

There has been a significant difference on the job stress according to each department. Job stress score of nurses working in psychiatry department was higher than the one of those working in the newborn baby room (F=2.433, p=.012). The score of job stress turned out to be higher in an order of psychiatry department (average 3.64±.52), obstetrics and gynecology department (average 320±36), and internal hospital (average 2.98±.62). Psychiatry hospital tends to place high priority in interpersonal relationship that requires psychiatric consultation and emotional aspects through therapeutic communication unlike other general hospital buildings. Aforementioned results seem to be derived since nurses might find it difficult to serve foreign patients in such nursing situations.

There has been a statistically significant difference on the degree of work stress in terms of work shift. Those with two shifts turned out to have a significantly higher score of job stress than those with three shifts or full-time employment (F=10.523, p=.000). The score of job stress turned out to be the lowest on those with three shifts. As for two-shift work, the time for taking care of foreign patients tended to be longer compared to full-time employment or three-shift work.

Therefore, it was assumed that nurses had more burdens. In general, stress tends to cause negative results if it maintains for a long time without being solved and hence reduces profitability while interfering the work performance in the end¹⁰. Raeda (2004) suggested the necessity of establishment for strategies for social support on clinical nurses and emphasized that it was important to promote the organizational culture characterized by the social integration and teamwork among nurses¹¹. Hereupon, it implies the necessity in actively seeking for alternatives so that nurses less experience job stress by forming the supportive system including the distribution of qualified agents in the department in need of service for foreign patients, short-time working schedule, and employee education for communication ability in foreign language.

Average score of stress-coping on research subjects turned out to be 2.46 out of 5 that was lower than the one of clinical nurse, 2.86⁹and also the one of nurses working at intensive care unit, 2.63¹². What was the most used was active coping with the score of 2.60, and the score of passive coping was 2.33 that was consistent with the result of study by Kim (2011)¹². According to the relationship between job stress and stress coping, it turned out that there was a positive correlation between them (r=.559, p=.000).

There was a positive correlation among sub-variables of job stress including nursing work, interpersonal relationship, hospital administration and management, and stress coping. Especially, it was confirmed that there was a significantly positive correlation among hospital administration and management, and active coping (r=.50, p=.000) and also among hospital administration and management, and passive coping (r=.383, p=.000). Administration management procedures for nursing foreign patients tend to experience more error due to procedural or cultural causes compared to domestic patients. However, nurses were solving problems by more actively dealing with issues. This was a contradicting result for how there was no statistically significant correlation between job stress and stress coping (r=-.005, p=.924), and job stress was not correlated with all the sub-variables of job stress.

There were many of the studies in dealing with job stress on nurses who provided service to regular groups of patients. However, there has not been any study for comparing and analyzing a degree of job stress of clinical nurses on foreign patients. Since it was confirmed that characteristics of foreign patients, working department, and shift-work types influenced on the job stress, it is required to consider them and develop and apply the differentiated job stress management program.

5. CONCLUSION:

This study has been conducted to prepare for fundamental resources of effective intervention by identifying the job stress and stress coping methods related to the service provided by clinical nurses to foreign patients. According to the result of this study, interpersonal relationship turned out to have the highest job stress among three areas; namely, nursing work, interpersonal relationship, and hospital administration/ management when serving for foreign patients. In addition, there was a significant difference of job stress depending on the working department and shift-work. There was a positive correlation between job stress and stress coping. As for the stress coping, it was confirmed that active coping method was the most preferred. According to the result of such research, it implies that there was a necessity in actively seeking for alternatives so that nurses less experience job stress through employee education for the distribution of qualified agents, short-time work schedule, and improvement of communication ability in foreign language if required to serve foreign patients in preparation for communication issues occurring in nurse treatment and administrative procedures to be provided on the service for foreign patients and interpersonal relationship when clinical nurses serve foreign patients. Therefore, it is not only required for individuals to make an effort to improve foreign language skills but also needed to provide financial support from hospital including education for employees serving patients closely and improvement of work environment.

6. REFERENCES:

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5. Rhemkupar Lyngkhoi, G. Brindha. A Study on Patient Satisfaction of Outpatient Department. Indian Journal of Science and Technology, Vol 8(32), pp.1-5, 2015.

6. Inthira Pandey A Study of Required English Skills for Healthcare Personnel in Bangkok-Based International Hospitals. Leksika, 1, pp. 35-44, 2013.

7. Kim, Y. T. The relationship with the stress cause of the intensive care unit nurse and degree of the Social Support. Unpublished master's thesis, Hanyang University, Korea, 1989.

8. Lazarus, R, S., & Folkman, S. Stress, appraisal and coping, New York: Springer, 1984.

9. Kwon, K. J, Lee, S. H. Occupational Stress and Coping Styles as Factors Affecting the Burnout of Clinical Nurses, Journal of Korean Academy Nursing Administration,vol.18, no.4, pp.383-393, 2012.

10. Kingma M. Nurses on the move: a global overview. Health Services Research. vol.42, no.3, pp.1281-1298, 2007.

11. Raeda, F. A. Job Stress, Job Performance, and Social Support Among Hospital Nurses. Journal of Nursing Scholarship, First Quarter, pp.73-78 2004.

12. Kim, H. K. Occupational Stress and Copying Pattern of the Intensive Care Unit Nurse. Unpublished master's thesis, Hallym University, Korea, 2011.

Received on 12.10.2018 Modified on 17.11.2018

Research J. Pharm. and Tech. 2019; 12(7):3313-3317.

DOI: 10.5958/0974-360X.2019.00558.4