F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.152259.1 Research Article Articles Predictive Ability of Self-Care and Psychological Flow in Occupational Stress Among Nurses

[version 1; peer review: 1 approved, 1 approved with reservations]

 Salem Almahaireh Abdallah Conceptualization Data Curation Investigation Methodology Project Administration Resources Supervision Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-2579-2783 a 1 Suhail Shawaqfeh Baha' Conceptualization Formal Analysis Funding Acquisition Methodology Software Supervision Validation Visualization Writing – Original Draft Preparation https://orcid.org/0000-0003-1254-7671 2 Counseling, The University of Jordan, Amman, Jordan Counseling, Jordanian ministry of education, Amman, Jordan a.mahaere@ju.edu.jo

No competing interests were disclosed.

 17 6 2024 2024 13 641 10 6 2024 Copyright: © 2024 Salem Almahaireh A and Suhail Shawaqfeh B 2024 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background

The nursing workforce is crucial in healthcare systems worldwide and contributes to community well-being. also, Nurses experience numerous psychological, social, emotional, and behavioral shocks and challenges in their work. In Jordan, 43% of doctors and nurses suffer from high levels of burnout, around 55% experience high levels of emotional exhaustion, and 33% of doctors and nurses suffer from high levels of psychological pressure and job stress. Others found that 70% of nurses experience stress. these issues can be reduced by practicing self-care and psychological flow which impact in work-related tasks which are important in effectively addressing occupational stress healthily and soundly. This study aims to determine predictive ability of self-care and psychological flow in occupational stress among nurses

 Methods

This study follows the quantitative technique. sample consisting of 476 nurses in Amman Jordan was chosen. Three scales were developed to meet the study objectives: Occupational stress scale, Self-care scale, and psychological flow scale.

 Results

The study results indicate that self-care and psychological flow levels were low, while the occupational stress level was high. Also, there are a predictive ability of self-care and psychological flow in occupational stress among nurses.

 Conclusions

This study shows that of self-care and psychological flow predict occupational stress among nurses, which helps us to manage the occupational stress among them by giving them self-care and psychological flow practices and healing time.

 Self-Care; Psychological Flow; Occupational Stress; Nurses. The author(s) declared that no grants were involved in supporting this work. Introduction

Work is of utmost importance source as it is the way to unleash human energies and feel importance and self-realization, working in the field of medical and health professions is one of the most important professional fields in life, and its importance is due to the great role that those working in it provide in preserving the health and care of individuals. Working in hospitals requires dealing with various cases and direct or indirect interaction and contact with patients, particularly by nurses, who must carry out their duties with patients regardless of their health conditions. This may pose numerous challenges and difficulties for nurses, leading to negative psychological and health effects due to the occupational stress they are exposed to. Hence, the importance of balancing work and life, and practicing self-care to achieve psychological flow, which serves to protect individuals from psychological and professional problems and disorders, ultimately leading to psychological and professional adaptation.

It's worth noting that stress, to some extent, can be positive and a source of personal growth and motivation for achievement. But it also leads to negative consequences if it exceeds a certain level and persists for prolonged periods, hindering individuals' activity individual’s activity and ability to work and accomplishment, thus negatively affecting the employee, the work team, or even the workplace itself. Employees who experience stress often encounter problems, have higher rates of illnesses, exhibit less commitment to their workplaces, and consequently have higher resignation rates, which in turn leads to the loss of skilled employees and increased recruitment and training costs. ( Antares Foundation, 2012)

Occupational Stress is considered one of the ways through which stressors in the work environment (pressures) can lead to psychological, behavioral, or physiological manifestations of stress and long-term health effects, it is the physical and emotional responses that occur when work requirements exceed the capabilities, resources, or needs of the worker ( Levy, et al., 2018).

The impact of stress related to humanitarian work does not only affect the individual, but also extends to the environment in which he works, the group he works with, and even others around him. given the negative consequences of this impact on the individual, work, and society, many researchers have sought to identify the causes of work stress and factors that can increase or decrease occupational stress ( Soliman & Gillespie, 2011).

Additionally, they explore methods to prevent the development of more severe psychological disorders such as burnout, depression, emotional exhaustion, and others, and attempt to find solutions that enable individuals to continue working, reduce human and material losses, and adapt ( Hricova, et al., 2020; Parikh, et al., 2004).

Jachens et al. (2018) identified factors that specifically affect humanitarian work and interact with occupational stress, including emergency culture, rewards such as feelings of achievement and pride, constant and unpredictable changes in work, high job involvement, and the inability to withdraw when needed unrealistic job demands, limited availability of social support networks, and insufficient self-care practices.

One of the early theorists in self-care was nurse Dorothea Orem in the 1950s. She described self-care as an individual's ability to care for others while maintaining their performance and development ( Renpenning & Taylor, 2003). Orem's theory was directed at nurses, whose work inherently involves continuous care for others. She considered self-care to revolve around activities individuals engage in to maintain their well-being. where effective self-care sustains an individual's towards others and contributes to human development, she considers Self-care to include activities that people participate in to maintain, improve, or restore their health. Orem also believed that self-care practices are learned not only for necessities, but help create a balance among daily activities, pressures, relaxation, and rest, thus enhancing and preserving human life and promoting well-being ( Khademian, et al., 2020).

Self-care refers to the importance of practices that individuals engage in to take care of themselves, it is closely linked to professions that involve caregiving, such as nursing, where much of the research and theories originated from the field of nursing and healthcare. This is due to the nature of nurses' work, which requires engagement in environments where they are continually exposed to emergencies and the distressing stories and experiences of the populations they serve. Additionally, they face the psychological, social, and physical difficulties of their patients, along with accompanying feelings such as anger, fear, and despair. Nurses often feel helpless or powerless to find solutions for all the problems and concerns their patients face, which can lead to frustration and disability, exposing them to high levels of occupational stress. ( Santana et al., 2020; Li et al., 2021).

Self-care is defined as the ability of individuals, families, and communities to promote health, prevent disease, and manage illness or disability with or without the support of healthcare providers ( World Health Organization, 2009).

Nurses spend their entire practical lives caring for others, and sometimes this can become detrimental as they often neglect to provide themselves with the same level of care. nurses frequently encourage their patients to lead happier, healthier lives free of stress and psychological pressure but fail to follow this advice themselves. Self-care is measured by the ability of workers to recognize and monitor the impact of their work or personal life on their well-being, effectively perform their professional duties, and take appropriate steps to ensure self-care. Thus, self-care is a requirement for achieving improvement and maintaining a sense of satisfaction among nurses. it enhances their mental health and well-being and fosters more effective self-care practices in various dimensions: physical, psychological, spiritual, and professional, helping them remain balanced and prevent burnout and occupational stress ( Headington Institute, 2010).

Through the concept of self-care, which involves taking care of oneself, striving for personal well-being, and making healthy decisions that contribute to happiness by addressing emotional, social, spiritual, and professional aspects, a significant role is played in achieving psychological flow. this is characterized by a high level of focus and full engagement in life's activities, enjoying them, and feeling challenged. this indicates a correlational relationship between self-care and psychological flow, whereby achieving and maintaining self-care enhances the opportunity to reach a state of psychological flow ( Al-Hiary, 2023).

Psychological flow is defined as a deep state of immersion in enjoyable activities, where individuals perceive their performance as enjoyable and successful, viewing the activity as worthwhile even if it does not lead to further achievement ( Csikszentmihalyi, 2014). Psychological flow is an internal psychological state that engulfs the individual in the activity he is engaged in, with a sense of accomplishment in dealing with these activities. it is a crucial force in individual success in work, providing energy, self-awareness, and the ability to enhance performance and alleviate occupational stress ( Happell, et al., 2013). From this perspective, flow is an aggregate of psychological factors including focus, control, awareness, motivation, self-awareness, clarity of goals, clear feedback, balance, and challenge, and it is vital in the workplace, where individuals who frequently experience flow tend to have high job satisfaction, more productivity, and less occupational stress ( Joseph, 2013; Martínez-Zaragoza, et al., 2017).

Research problem

The nursing workforce plays a crucial role in healthcare systems worldwide and contributes to community well-being. Working in the nursing sector is complex, hazardous, and sometimes unsafe. Those responsible for the nursing sector should create suitable working conditions for nurses and consider their mental health and well-being because the quality of care provided by nurses partially depends on the quality of their work environment ( International Labor Organization and World Health Organization, 2017). The field in which nurses work may lead to occupational stress and neglect of self-care practices, affecting their psychological flow. Research has indicated that 43% of doctors and nurses in Jordan suffer from high levels of burnout, around 55% experience high levels of emotional exhaustion, 34% have decreased humaneness towards patients, 39% experience reduced personal accomplishment, and 33% of doctors and nurses suffer from high levels of psychological pressure and job stress ( Jordanian Ministry of Health, 2020; Santana et al., 2020). Additionally, a study by ( Dehdashti, et al., 2018) found that 70% of nurses experience stress.

Nurses experience numerous psychological, social, emotional, and behavioral shocks and challenges in their work, which can impact their psychological flow during work-related tasks ( Ekman & Halpern, 2015). Self-care in the medical field has evolved in response to the neglect of basic needs among healthcare providers in favor of focusing on patient treatment ( Lauder, 2001). while In nursing, self-care adopts a comprehensive approach to wellness and the acquisition of health-enhancing behaviors ( Denyes, et al., 2001).

Thus, the importance of self-care for nursing professionals has emerged as a fundamental and necessary component in effectively addressing occupational stress healthily and soundly. To provide efficient services to promote mental health, prevent occupational stress, achieve optimal healthcare quality and flow, and develop self-care mechanisms ( Zhang, et al., 2021; Barnett, et al., 2007; Smith & Moss, 2009).

Practicing self-care strategies supports mental health and well-being ( Mills, et al., 2018). If nurses neglect self-care, it may lead to health problems that can affect them professionally and personally, sometimes resulting in occupational stress and resignation from the nursing profession ( Kelbach, 2021). Several studies have indicated the detrimental long-term effects of insufficient self-care practices for nursing professionals, such as burnout, occupational stress, mental health disorders, and decreased professional efficacy ( Zhang et al., 2021; Barnett, et al., 2007; Smith & Moss, 2009).

Psychological flow is related to individuals' self-care, as it brings feelings of happiness, enjoyment, and satisfaction in life, and contributes to creating a positive mental state. Thus, understanding how flow experience affects individuals can offer insights that can be employed to improve individuals' quality of life, consequently impacting their professional lives and work quality, thereby contributing to providing comprehensive care services and reducing the risk of occupational stress among nurses ( Burke, et al., 2016; Heo, 2007). Hence, this study investigated the predictive ability of self-care and psychological flow on occupational stress among nurses in Jordan.

 Research questions

What are the self-care, psychological flow, and occupational stress levels among nurses in Jordan?

Is there a predictive ability of self-care and psychological flow in occupational stress among nurses in Jordan?

Methods Study design

This study follows the quantitative technique by prediction method. A sample of 476 nurses in Amman was collected voluntarily; the informed consent was taken verbally and written. Also, the researchers took approval from the institutions.

 Participants

The volunteering sample consisting of 476 nurses in Amman Jordan was chosen, which is 2.6% of the population. Their age ranged between 26-58 (M=35.6 ±9.14).

 Data collection tools

Occupational stress scale

The researchers developed a scale of 21 items from ( Kushal, et al., 2018; Belkic & Savić, 2008). Participants rated each item on a five-Likert scale, from 1 (I agree to a very small extent) to 5 (I agree to a very big extent). Higher scores reflect a higher level of occupational stress. The researchers extracted the validity and reliability and found that the discriminate evidence ranged between 0.343 and 0.874. Cronbach's alpha was 0.885 ( Shawaqfeh & Almahaireh, 2024).

Self-care scale

The researchers developed a scale of 22 items divided into 4 dimensions (physical, psychological, spiritual, and occupational) from ( Lichner, et al., 2018; Jallad, 2021). Participants rated each item on a five-Likert scale, from 1 (strongly disagree) to 5 (strongly agree). Higher scores reflect a higher level of self-care. The researchers extracted the validity and reliability and found that the discriminate evidence ranged between 0.771 and 0.942. Cronbach's alpha ranged between 0.742 and 0.913 ( Shawaqfeh & Almahaireh, 2024).

Psychological flow scale

The researchers developed a scale of 19 items from ( Alakili, 2015; Al-Hiary, 2023). Participants rated each item on a five-Likert scale, from 1 (strongly disagree) to 5 (strongly agree). Higher scores reflect a higher level of psychological flow. The researchers extracted the validity and reliability and found that the discrimination evidence ranged between 0.458 and 0.874. Cronbach's alpha was 0.818 ( Shawaqfeh & Almahaireh, 2024).

 Data collection

The researchers obtained approval for this study from the Institutional Review Board at the University of Jordan. The registration number is 1546/2024/21. The date was 12/5/2024. Anonymized data was collected by online instruments using Google Forms. The data collected between 13-18/5/2024.

 Data analysis

The researchers entered the data into the SPSS data sheet and used IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA) to analyze the data. Means, standard deviations, Pearson’s correlation, and multi-regression were calculated. There was no missing data because all questions were required to be answered in the Google form.

 Ethics and consent

The researchers obtained verbal and written approval for this study from the Institutional Review Board at the University of Jordan. The registration number is 1546/2024/21. The date was 12/5/2024.

The informed consent was taken verbally and written. Also, the researchers took approval from the institutions.

 Findings and discussion Preliminary analyses

Means, standard deviations, and Person correlations between occupational stress, self-care and psychological flow are shown in Table 1.

Person correlations between the variables.
Variable Mean SD level 1 2 3 Skewness Kurtosis
1. OS 3.91 0.41 High - - - 0.435 -0.071
2. SC 2.32 0.46 Low 0.390 * - - 0.751 -0.010
3. PF 2.13 0.88 Low 0.178 * 0.160 * - 0.366 -0.216

OS: Occupational stress. SC: Self-care. PF: Psychological flow.

Correlation is significant at the 0.01 level (2-tailed).

Table 1 shows a negative correlation between Occupational stress and each Self-care and Psychological flow. Also, there is a positive correlation between Self-care and Psychological flow. Furthermore, the Self-care and Psychological flow levels were low. The Self-care mean was (2.32±0.46), and the Psychological flow mean (2.13 ±0.88) while the Occupational stress level was high mean was (3.91 ±0.41). The results show that the data is normally distributed.

This result can be attributed to work pressures and stress experienced by nurses. According to statistics from the Jordanian Ministry of Health, there are only 37 nurses for every 10,000 citizens ( Jordan News Agency, 2017). To cover this shortage, hospitals allow nurses to work multiple shifts in a single day, leading to long working hours, caring for large numbers of patients, and receiving emergency cases. This diminishes their ability to balance home and work requirements and reduces their capacity for self-care ( Suleiman, et al., 2019). Consequently, nurses may experience feelings of boredom, routine, dissatisfaction, negativity, and disengagement from required tasks ( Zaki, 2018), along with an inability to keep up with life demands and a lack of satisfaction due to low-income levels ( Al-Hamdan & Bani Issa, 2022). This leads to a decrease in the level state of psychological flow.

The high level of Occupational stress can be explained by nurses lacking self-care skills and self-attention, as well as insufficient time for relaxation, experiencing flow state, and engaging in various activities due to work pressures. Additionally, the inability to express emotions, feelings of depletion, exhaustion, and fatigue result from a lack of Psychological flow skills and empathy toward patients. Nurses may also struggle to share their sad feelings and bear their emotional burdens ( Zito, et al., 2016).

The lack of providing self-care programs and recreational activities in hospitals which help nurses cope with and adapt to Occupational stress, along with insufficient social and psychological support ( Suresh, 2013), contributes to the low level of self-care. Nurses are assigned multiple quantitative and qualitative duties and tasks that exceed their capabilities, leading to role conflict due to the shortage of nursing staff in Jordanian hospitals ( Khani, & Jaafarpour, 2008; Jordanian Ministry of Health, 2019; World Health Organization, 2020).

One of the reasons for high Occupational stress levels and low levels of psychological flow among nurses is their lack of involvement in decision-making processes at their workplaces, significant disparities between financial income, rewards, and required tasks, as well as limited opportunities for promotion and career advancement with unclear paths, particularly in private hospitals. Additionally, conflicts and lack of harmony with supervisors and managers in nursing practice exacerbate internal dissatisfaction and decrease self-esteem ( Kumar, et al., 2011). The work environment in hospitals, in general, is perceived as stressful, and nurses in Jordan express dissatisfaction with the nursing work environment ( Suleiman, et al., 2019).

 The multi-regression results

To investigate the predictive ability of self-care and psychological flow in occupational stress among nurses in Jordan, a regression test was calculated, and Table 2 shows the results.

Multi-regression test to investigate the predictive ability of self-care and psychological flow in occupational stress.
Variable R R 2 F F Sig. Beta T T Sig.
Psychological flow 0.460 0.212 63.461 0.000 -0.379 -10.386 0.000
Self-care -0.114 5.972 0.000

Table 2 shows the predictive ability of self-care and psychological flow in occupational stress among nurses in Jordan was 21.2%, while the correlation was 0.460. Also, The Psychological flow has a more substantial influence on occupational stress, and there is a negative relationship between the variables.

The low practice of self-care and relaxation among nurses, along with diminished psychological flow, bring about feelings of sadness, job dissatisfaction, and dissatisfaction with life. This contributes to creating a negative psychological state, negatively impacting quality of life, professional life, and work quality, leading to increased job stress levels. This explains the inverse relationship between psychological flow and self-care with occupational stress. These findings are consistent with studies by ( Jallad, 2021; Shapiro, et al., 2007). Jachens, et al. (2018) clarified that working in the humanitarian field, such as nursing, interacts with occupational stress, and one of the reasons for its increase is the lack of self-care practice, relaxation, and weak social support. ( Renpenning & Taylor, 2003) demonstrated that self-care preserves and improves nurses' mental health and well-being.

Working in nursing is a stressful and traumatic job when exposed to severe medical cases. nurses' sense of enjoyment diminishes, making it difficult for them to perceive their performance as enjoyable and successful, especially when patients die during their shifts. Consequently, psychological flow is unattainable in this negative work environment, thereby increasing their occupational stress.

The explanation for 21.2% of the relationship between flow, self-care, and occupational stress can be attributed to the low level of psychological flow and self-care among nurses. They cannot enhance their physical, psychological, emotional, social, spiritual, and professional well-being due to workload burden, time pressure, lack of social and professional support, limited career advancement, and absence of self-care skills such as relaxation, meditation, spiritual practices, self-awareness, and reactive coping. They also struggle with concentration, integration into work, feelings of fatigue, boredom, loss of commitment and perseverance, task diversity, shift work, inability to communicate with others due to work pressure, and lack of work-life balance, resulting in high levels of occupational stress.

 Conclusion

This study shows that there are predictive ability of self-care and psychological flow in occupational stress among nurses, which helps us to manage the occupational stress among them by giving them self-care and psychological flow practices and healing time. addition, there is a high level of occupational stress among nurses and the managers and hospital mostly conduct this issue because it affects their job. However, the self-care and psychological flow among them were low which means they don’t give themselves good attention and it may cause many problems and mental illness. Organizations and Hospitals should provide them with more special assistance, support, and training. Thus, future research should consider social support, coping, and job satisfaction as potentially important variables.

Limitations and future directions

This study was conducted with a sample of nurses in the Capital Amman, Jordan enrolled in 2024. The study results were interpreted from the participants’ responses on self-care, psychological flow, and occupational stress scales. The researchers recommends further research on occupational stress among nurses to define it and to produce a program to decrease it which can give us better quality work.

Future research might also study coping, work environment, job satisfaction, and resilience variables. The creation of counselling and guidance programs to improve self-care and psychological flow among nurses may use technological applications.

 Ethics and consent

The researchers obtained verbal and written approval for this study from the Institutional Review Board at the University of Jordan. The registration number is 1546/2024/21. The date was 12/5/2024.

The informed consent was taken verbally and written. Also, the researchers took approval from the institutions.

 Data availability statement

Figshare. The predictive ability of self-care and psychological flow in occupational stress among nurses (Dataset.sav). https://doi.org/10.6084/m9.figshare.25892764.v2 ( Shawaqfeh, 2024)

Data is available under the terms of the CC0.

Repository name: Figshare

Checklist for predictive ability of self-care and psychological flow in occupational stress among nurses, at https://doi.org/10.6084/m9.figshare.25892764.v2 ( Shawaqfeh, 2024)

Funding details: The authors received no financial support for the research, authorship, and/or publication of this article.

 Acknowledgments

The researchers would like to thank the hospitals and nurses for helping them in collecting the data.

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Manag. 2016;24(1):E12–E22. 25612156 10.1111/jonm.12284 10.5256/f1000research.166997.r349181 Reviewer response for version 1 Al-Sagarat Ahmad 1 Referee Community and Psychiatric Nursing Department, Faculty of Nursing, Mutah University, AL-Karak, Jordan

Competing interests: No competing interests were disclosed.

 26 12 2024 Copyright: © 2024 Al-Sagarat A 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The article is searching one of the most issues that are facing the Jordanian nurses specifically. In some areas I would like the author to use the most recent studies and avoid using old literature older than 10 years old. I would like the author to expand more on the limitations from different perspectives such as: sample, type of hospital, different geographic areas, mixed method--- etc. Moreover, I would like the author to add the implication of this study for nursing practice, nursing administration, nursing education and future research. Finally, the overall article is highly recommended and approved  for indexing.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Mental health nursing

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Almahaireh Abdallah The University of Jordan, Amman, Amman Governorate, Jordan

Competing interests: No competing interests were disclosed.

 30 12 2024

Dear Ahmad Al-Sagarat

We wanna thank you for these notes that improve our work.

We made the changes you reported and used recent references as we could.

Best Regards,

 10.5256/f1000research.166997.r301709 Reviewer response for version 1 Khalil Amal I 1 2 Referee https://orcid.org/0000-0001-8419-2289 psychiatric nursing, king Saud bin Abdelaziz university for health sciences, college of nursing, Jeddah, Makkah Province, Makkah Province, Saudi Arabia College of Nursing, King Saud Bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia

Competing interests: No competing interests were disclosed.

 23 7 2024 Copyright: © 2024 Khalil AI 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

thank you for giving the opportunity to review this manuscript let's start with the title: :

despite it is concise but it is little bit unclear for the reader so i suggest to be changed into  

"Predictive Roles of Self-Care and Psychological Flow in Occupational Stress Among Nurses" or 

"Assessing the Predictive Power of Self-Care and Psychological Flow on Occupational Stress in Nurses"

 Abstract :As a peer reviewer, here are some potential drawbacks and areas for improvement in the abstract:

 The abstract is slightly wordy and can be more concise. This can be achieved by removing redundant phrases and ensuring each sentence adds new information.

 The objective of the study could be more clearly stated at the beginning of the abstract. Currently, it is embedded within a broader discussion of the context.

 The abstract mentions that three scales were developed, but it does not provide any details on their development, validation, or reliability. Including brief information on these aspects would strengthen the abstract.

The results section mentions that self-care and psychological flow levels were low, and occupational stress was high, but it does not provide any specific data or statistics to support these claims. Including key statistics would make the results more robust.

: The conclusion mentions that self-care and psychological flow practices can help manage occupational stress but does not provide specific recommendations or implications for practice. Adding this information would make the conclusions more actionable.

 The abstract contains some grammatical insufficiency and awkward phrasing that can be refined for clarity and readability.

Introduction :Here are some potential drawbacks of the provided introduction and suggestions for improvement:

 The introduction is quite lengthy and contains many ideas that could be more concisely presented. A more focused introduction would help readers quickly grasp the main points.

The introduction would benefit from clearer structure and organization. It jumps between different concepts without clear transitions. Organizing it into distinct paragraphs for context, problem statement, and the purpose of the study would improve readability.

Some points are repeated, such as the importance of self-care and psychological flow, which can be consolidated to avoid redundancy.

 While the introduction provides a lot of background information, it sometimes strays from the main focus of the study. Keeping the information relevant to the research question would make the introduction more impactful.

 The introduction includes many references, which, while supporting the points made, can overwhelm the reader. Select the most pertinent references to strengthen the key points.

The introduction could benefit from more specific statements about the research gap and the need for this study. It should more clearly highlight what is unknown or understudied about the relationship between self-care, psychological flow, and occupational stress among nurses.

research problem  it is better to say significance of the study and here some drawbacks:

Length and Conciseness: The problem statement is quite long and includes a lot of background information that could be more concisely presented. The main problem could be stated more directly.

Clarity and Focus: The statement introduces several related issues (e.g., burnout, emotional exhaustion, psychological pressure, self-care, psychological flow) without clearly connecting them to the main research problem. Focusing on the central issue of how self-care and psychological flow impact occupational stress among nurses would improve clarity.

Redundancy: Some points are repeated, such as the impact of occupational stress and the importance of self-care. These could be combined to streamline the text.

Lack of Specificity: The problem statement mentions various statistics and studies but does not clearly state the specific gap or need that the current study addresses. More emphasis on what is unknown or understudied would be beneficial.

Transition and Structure: The transitions between different points could be smoother. Organizing the statement into distinct paragraphs for background, problem identification, and the purpose of the study would enhance readability.

There are many references to other studies, which, while supporting the points made, can make the problem statement

Methods: first the definition of variables  "self care , psychological flow, occupational stress is important  for the readers ,the other thing Sample Representativeness: The sample, while sizable, represents only 2.6% of the nurse population in Amman. This could limit the generalizability of the findings to all nurses in Jordan, and how they calculate the sample size??The study's cross-sectional design limits the ability to draw causal inferences. While predictive relationships can be identified, causal conclusions cannot be definitively made. 

the scales used were adapted from other studies which may differ culturally as well the authors mention developed which is wrong as they adapted both scales

Data Collection Method:

Using online instruments such as Google Forms may exclude participants who are less tech-savvy or have limited internet access, potentially introducing sampling bias.

Limited Contextual Information:

The study might benefit from including more contextual information about the work environment, workload, and other stressors specific to the nursing profession in Jordan. These factors could provide a deeper understanding of occupational stress.

Ethical Considerations:

While informed consent was obtained verbally and in writing, ensuring that participants fully understand the study's aims and their rights is crucial. Detailed information on how consent was obtained and documented would enhance ethical transparency.he study does not account for other variables that might influence occupational stress, such as personal life stressors, job satisfaction, or organizational support. Including these factors could provide a more comprehensive analysis. as the authors didn't include demographic characteristics of the participants which is very important in interpreting the results 

also short data collection time   (13-18/5/2024) might not capture variations in stress levels that could occur over different times or under different circumstances.

results of the study: missed Demographic characteristics of the participants it is better to separate results from discussion for more interpretations and discussions 

big number of cited references are old and needs updates

where is the recommendations and clinical implications of these results 

a lot of limitations should be recognized in this study such as : self reported tools, lack of generalizability since the study was conducted only on Jordanians living in Amman, mediating variables should be considered as mentioned before

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

psychiatric, psychological and psychosocial research all types of research designs as well child ,adult ,and elderly psychological and psychiatric disorders.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Almahaireh Abdallah The University of Jordan, Amman, Amman Governorate, Jordan

Competing interests: No competing interests were disclosed.

 30 12 2024

Dear Amal I Khalil,

We wanna thank you for these notes that improve our work.

We made the changes you reported.

and Added a reference for the sample size.

Best Regards,