Anxiety level among newly hired nurse in a specialized oncology hospital: An observational study

Abbreviations

ANOVA: Analysis of variance

CRN: Clinical Resource Nurse

GNO: General Nursing Orientation

HAS: Hamilton Anxiety Scale

HCAC: Health Care Accreditation Council

IDRAAC: Institution for Development Research Advocacy and Applied Care

JCI: Joint Commission International

SPSS: Statistical Package for the Social Sciences

Introduction

Anxiety is defined as “something felt, an emotional state that involved feelings of apprehension, tension, nervousness, and worry followed by physiological arousal” (Freud, 1977). Freud stated that anxiety is an adaptive behavior that helps individuals cope with stressful situations. Intense anxiety is commonly associated with many psychiatric diseases. Cattell highlighted the types of anxiety, including emotional state and personality trait anxiety (Cattell, 1966).

A systematic review identified 87 studies published between 1980 to 2009 across 44 countries found that the global prevalence of anxiety rate after adjusted methodological differences was 7.3% (Baxter et al., 2013). Another systematic review conducted by the Institution for Development Research Advocacy and Applied Care (IDRAAC) reviewed epidemiological anxiety disorders studies among Arab countries; the results revealed that anxiety disorder is common among the participants. Therefore, they concluded the importance of having studies about anxiety disorder and its impact on individuals and communities (Tanios et al., 2009). Several studies assessed anxiety rates amongst some Arab populations; the results showed that the anxiety rate in Saudi Arabia was 16%, 16.7% in Lebanon, and 28.2% in Jordan (Karam et al., 2008; Tanios et al., 2009).

Anxiety is common among healthcare professionals, including nurses (Chen et al., 2016; Cheung et al., 2016; Creedy et al., 2017; Huang et al., 2018; Wang & Zhang, 2017). Nurses represent a large portion of healthcare professionals; nursing is a stressful profession by its nature (Roberts & Grubb, 2014). The workload, caring for sick patients, and work-related conflict with other healthcare providers are a few factors that cause nursing anxiety (Jafari et al., 2018). Moreover, the demand related to the tasks nurses perform at different shifts, the types of patients, and the lack of resources cause nursing job-related anxiety (Khodadadi et al., 2016; Shen et al., 2016).

Anxiety is also more evident among oncology nurses; they may encounter more job-related anxiety and depression (Hegney et al., 2014; Karanikola et al., 2016) due to complex treatment and patient conditions (Nia et al., 2016; Rodrigues & Chaves, 2008). Anxiety among this specific population needs more emphasis, especially newly hired nurses in oncology settings (Karanikola et al., 2016). Newly hired nurses exposed to the oncology environment would have more anxiety and may lack proper stress coping skills (Hinds et al., 1994; Rodrigues & Chaves, 2008; Wazqar, 2019; Wazqar et al., 2017).

The nursing induction program is vital to prepare newly hired nurses to smoothly fit into a new working environment and enable them to provide safe patient care. Applications to several accreditation agencies at the national and international level are required, such as the Health Care Accreditation Council (HCAC), Joint Commission International (JCI), and Magnet accreditation. Yet, the anxiety level of newly hired nurses in the oncology setting is not studied well. Thus, the findings of this study will add valuable information about the anxiety level among newly hired oncology nurses.

Anxiety among nurses is a common problem and has been studied extensively worldwide (Chen et al., 2016; Cheung et al., 2016; Creedy et al., 2017; Glazer & Gyurak, 2008; Huang et al., 2018; Wang & Zhang, 2017; Xianyu & Lambert, 2006). One study assessed the prevalence of anxiety and other mental disorders among 102 clinically active Australian nurses who work at hospitals showed that 41.2 % of nurses had anxiety (Maharaj et al., 2019). In China, a study conducted in seven governmental hospitals in one city found that the anxiety prevalence rate among Chinese nurses was around 43.4% (Gao et al., 2012). Another study was conducted in the Czech Republic, comparing anxiety prevalence between general nurses and Intensive Care Unit (ICU) nurses at three different hospitals found that 44% of general nurses had anxiety. Simultaneously, the prevalence of anxiety among ICU nurses was 28% (Janda & Jandová, 2015). Furthermore, Taghinejad et al. assessed 86 Iranian nurses working in the mental health sector at three different general hospitals; they found that 16% of nurses had an anxiety symptom (Taghinejad et al., 2014).

Hospital settings are a very stressful working environment for healthcare professionals, especially for front-line nurses. A study that examined nursing workplace stressors at different hospitals found that increased work demands, caring for dying patients, and conflict with other healthcare providers are common sources of nursing work-related anxiety (Jafari et al., 2018; Khodadadi et al., 2016). In another study, Janda and Jandová (2015) performed specific tasks, types of patients, and the increasing work demands were the causes of nurses' work-related anxiety. Moreover (Saquib et al., 2019), studied the anxiety and stress prevalence among non-Saudi foreign nurses associated with job dissatisfaction; the results showed that the anxiety level was significantly associated with the workload.

A study was conducted to assess anxiety intensity symptoms of Greek oncology nurses using the Hamilton Anxiety Scale (HAS), and it showed that 11% of oncology nurses had a moderate intensity of anxiety symptoms (Karanikola et al., 2016). Furthermore, in Iran, at a teaching hospital, Molavynejad et al. (2019) investigated the relationship between burnout level and personality traits among 106 oncology nurses; the results revealed that 32.1% of the oncology nurses had severe burnout with a significant positive correlation with anxiety (Molavynejad et al., 2019).

Newly hired oncology nurses may lack proper anxiety and stress coping skills (Hegney et al., 2014). Therefore, it is crucial to assess the anxiety level among newly hired oncology nurses and implement intervention programs to prepare them for the new working environment safely. Many studies have been conducted to explore GNO's effect on improving newly hired nurses' skills and knowledge (Cockerham et al., 2011; Woolwine et al., 2019). In one study, Cockerham et al. (2011) evaluated the average of the pretest scores was 66% and after completing the program, the average score increased to 92%. GNOs also showed that newly hired nurses were successfully integrated into the hospital team (Bahouth & Esposito-Herr, 2009).

Furthermore, other researchers conducted a literature review focused on the effect of the GNO program versus the one-year residency program on nurses' retention and turnover. They found that newly-graduated nurses' satisfaction and retention were higher with the one-year residency program versus the orientation program alone (Eckerson, 2018). Nurses reported improvements in their perception of patient care quality when a senior CRN accompanied them. A quality improvement project, conducted at a labor and delivery floor in an academic medical center to assess the efficacy of the CRN role in supporting units with high percentages of new-to-practice staff, found that the perception of quality patient care increased from 16 % pre-implementation of the CRN role to 50% post-implementation (Maloney & Nelson, 2013).

Another study was conducted to assess anxiety changes among newly hired nurses at different points in time during their first year of employment; the results indicated that the anxiety level was 12.21 after one week of the residency program to 14.17 after one month and 15.30 at the end of the second month (Lin et al., 2020).

The current study aimed to assess the anxiety level among newly hired nurses in a specialized oncology hospital throughout their initial period of employment, deploying a GNO and the CRN role.

Methods

Results

Discussion

The current study's primary objective was to assess the anxiety level among newly hired oncology nurses at three different times during the nursing induction program. A large portion of nurses included in this study were newly graduated nurses.

This study's results indicate an increase in the anxiety level among newly hired nurses in the oncology hospital from the beginning of employment to the end of the induction program. Overall, the findings revealed that newly hired oncology nurses in this study had different levels of anxiety. This finding is consistent with previous studies, which showed that nurses reported anxiety (Karanikola et al., 2016; Molavynejad et al., 2019). Compared to other nursing specialties, a study was conducted among Critical Care nurses in Greece, which showed that around a quarter of participants reported moderate to severe anxiety symptoms (Karanikola et al., 2012). In another study conducted in China, almost 43.4% of nurses experienced anxiety (Gao et al., 2012), which was also consistent with another study conducted among nurses in Iran (Kayalha et al., 2013). Other nursing studies reported a high to moderate anxiety levels among non-oncology nurses worldwide (Chen et al., 2016; Cheung et al., 2016; Creedy et al., 2017; Glazer & Gyurak, 2008; Huang et al., 2018; Wang & Zhang, 2017; Xianyu & Lambert, 2006).

The study findings indicate that newly hired oncology nurses' anxiety levels were consistently increasing from the beginning of the GNO program to the end of the GNO, and three months period subsequently. These results are similar to the findings of Lin et al. (2020); who reported that anxiety level reaches the peak after three months of employment among newly hired nurses despite enrolling them in a well-structured nursing residency program (Lin et al., 2020). This result could be viewed in the context of our nursing induction program schedule and timetable as the first ten days of the GNO program include class-based lecturing away from the clinical setting. These lectures focus primarily on general concepts related to policy, procedure, and oncology patient care; therefore, the newly hired nurses' anxiety level is low. However, as the induction program progressed, the workload of newly hired oncology nurses increased gradually to meet the orientation program expectations, which led to increasing the nurse's anxiety.

Other studies also revealed that having a complex relationship with other healthcare providers was a factor causing work-related anxiety among nurses in the oncology setting (Escot et al., 2001; Isikhan et al., 2004). The direct supervision role performed by the senior CRN could contribute to increasing newly hired nurses' anxiety in the clinical setting, along with the fact that they have to pass all required competencies to become independent practitioners. Additionally, by the end of three months of employment, a probationary evaluation would increase the levels of anxiety of the newly hired nurses. Most participants were new graduate nurses, young with little previous clinical experience, which meant a lack of proper stress coping skills. Similarly, Hegney et al. in 2014 showed that anxiety levels are higher among younger nurses, a full-timer, and without specific postgraduate qualification and training (Hegney et al., 2014).

Another explanation of the current study findings that, in oncology hospitals, nurses are looking after patients who require frequent nursing care; the workload increases gradually as the program goes on, which leads to an increase in nurses' anxiety. Additionally, nurses working in oncology settings might encounter more job-related anxiety and depression due to the type of medical situations such as treatment complexity and patient conditions. Keskin et al. found that workload and an increasing number of patients lead to anxiety and depression among oncology nurses (Keskin et al., 2018). Subsequently, nurses witness the patients' suffering, family distress, and possible death at a certain disease progression stage. In such situations, newly hired oncology nurses' ability to cope with end-of-life situations influences the oncology nurse's death anxiety level.

The unavailability of a psychological support intervention for newly hired oncology nurses during the hospital induction program could explain the current study findings. The program focused on improving nurses' knowledge and skills through the oncology training course and introducing the end-of-life concept. The absence of psychological support intervention flags the importance of how to support newly hired oncology nurses once they are exposed to stressful and unpleasant situations. Several studies highlighted the importance of integrating psychological support intervention in clinical environments such as art and music therapy (Doo et al., 2018), using emotional intelligence as anxiety tool management (Kadda, 2014), mindfulness-based programs (Foureur et al., 2013), and guided imagery (Boehm & Tse, 2013).

The newly hired nurses in this study had anxiety despite completion of the nursing induction program; limited literature looked at the effect of GNO and mentorship program by CRN on newly hired nurses at the oncology center. Our results are consistent with Cockerham et al., who investigated the effect of GNO and mentorship programs on improving newly hired nurses' knowledge and skills; they found that the average of the pretest scores was 66%, and after completing the program, the average score increased to 92%. Hence Lin et al. (2020) focused on exploring changes in anxiety level and work stress among newly hired nurses over the two-year residency program. They conclude that anxiety reached its peak at the first three months of employment and then stabilized until the end of the program. The current study results provide baseline data for the further nursing study. Furthermore, the organization invests in human resource development creating clinic-oriented educator role such as CRN to facilitate unit-based orientation programs and mentorship. Thus, this would ease the new nurses' enrollment and decrease the anxiety associated with the new role and/or environment.

The current study has clinical implications and suggestions for planning interventions to assist oncology nurses in reducing levels of anxiety. Nurse leaders, managers, and educators should create new interventions such as support groups, physical and mental exercises, counseling support, and anxiety control sessions, motivating nurses to verbalize their feelings to help nurses completely control their own anxiety (Aycock, 2009; Henry, 2014). Oncology hospitals should provide healthy working environments and create particular interventions to decrease nurses' stressors. Given these results, anxiety-related work should be addressed and controlled to avoid growing tension among nurses and support nurses during the first phase of employment to reduce or eliminate anxiety.

Conclusion

Nurses working in oncology workplaces frequently encounter several anxiety conditions in their settings, leading to psychosocial and physical problems. So, nurses should be willing to care for themselves to maximize the optimization of their health and to decrease anxiety at work; on the other hand, seeks Nursing administrator attention to address this phenomenon and modify nursing induction programs in order to apply proper strategies to reduce anxiety level among newly hired nurses also help them to fit into a new team smoothly to ensure safe patients care.

Data availability