Purpose This study aimed to investigate the relationship between socio-cognitive mindfulness, job stress, social support, and turnover intention among general hospital nurses and identify the factors influencing nurses’ turnover intention.
Methods A descriptive survey was conducted among 218 nurses from five general hospitals located in G metropolitan city. The participants completed a questionnaire measuring the study variables, and the data were analyzed using t-tests, ANOVA, Pearson’s correlation coefficient, and hierarchical multiple regression analysis in SPSS/WIN 28.0.
Results Significant differences were found in turnover intention by gender (t=-2.12, p=.036), family type (t=-3.09, p=.002), work department (F=7.01, p<.001), and work type (t=2.55, p=.011). Socio-cognitive mindfulness was positively related to social support (r=.331, p<.001), and turnover intention was positively related to job stress (r=.347, p<.001). The factors influencing nurses’ turnover intention included job stress (β=.317, p<.001), work department (artificial kidney room: β=-.287, p=.004; emergency room: β=-.219, p=.015), social support (β=-.183, p=.005), and work type (shift work: β=.170, p=.036), respectively. These factors explained 23.4% of the variance.
Conclusion The findings indicate the need to develop programs to effectively cope with job stress and implement mentoring systems or psychological support programs to reduce turnover intention among nurses at the organizational level.
Purpose This study aimed to examine the moderating effect of calling on the relationship between post-traumatic stress and turnover intention among nurses caring for COVID-19 patients. Methods Data were collected from 151 nurses caring for COVID-19 patients at three university hospitals located in D City. Participants completed selfreported online surveys on post-traumatic stress (IES-R-K), calling (CVQ-R), and turnover intention. Descriptive statistics, t-tests, one-way ANOVA, Scheffé test, Pearson's correlation coefficients, and hierarchical multiple regression were performed using SPSS 25.0. Results The mean scores of post-traumatic stress, calling, and turnover intention were 0.83±0.70, 1.51±0.71, and 2.89±1.10, respectively. Post-traumatic stress had positive correlations with calling (r=.20, p=.011) and turnover intention (r=.29, p=.001), whereas calling had a negative correlation with calling and turnover intention (r=-.17, p=.029). Calling had a moderating effect in the relationship between post-traumatic stress and turnover intention (β=-.16, p=.032). Conclusion Calling has a moderating effect on the relationship between post-traumatic stress and turnover intention. Therefore, developing and implementing a program is necessary to strengthen nurses' perceptions of calling to prevent nurses with post-traumatic stress from leaving their jobs.
Purpose This study aimed to compare and identify factors affecting delirium nursing stress among nurses in comprehensive nursing care service wards and general wards. Methods Using structured questionnaires, data were collected from 230 nurses working in two tertiary university hospitals. Data were analyzed using descriptive statistics, t-tests, ANOVA, Pearson's correlation coefficient, and multiple regression analysis using SPSS/WIN 27.0. Results The average delirium nursing stress score for nurses in comprehensive nursing care service wards was 2.98±0.30 out of 4 points, which was significantly higher than 2.89±0.29 points for nurses in general wards (t=2.17, p=.031).
Factors influencing delirium nursing stress among comprehensive nursing care service ward nurses included nursing work environment (β=-.58, p<.001) and conflicts with medical staff and other departments related to delirium patients (β=.24, p=.006), explaining power of 44% (F=12.13, p<.001). For general ward nurses, the nursing work environment(β=-.39, p<.001) was the main influencing factor, explaining power of 17% (F=3.93, p<.001). Conclusion Both types of nurses require improvements in their work environment. Strategies to reduce conflict between medical staff and other departments are essential in comprehensive nursing care service wards.
Purpose This study aimed to identify the mediating effects of positive psychological capital on the relationship between occupational stress and organizational commitment in physician assistant nurses. Methods The participants were 152 physician assistant nurses recruited from two university hospitals. Data was collected through a survey. The SPSS/WIN program (version 25.0) was used for the data analysis. Data was analyzed using descriptive stastics, t-test, ANOVA, Pearson’s correlation analysis, and hierarchical regression. Results There was a significant negative correlation organizational commitment and occupational stress (r=-.57, p<.001), and a positive correlation with positive psychological capital (r=.47, p<.001). There was a negative correlation (r=-.32, p<.001) between occupational stress and positive psychological capital. In addition, positive psychological capital had a partial mediating effect on the relationship between occupational stress and organizational commitment (β=.32, p<.001). Conclusion Positive psychological capital serves as a partial mediator in the relationship between occupational stress and organizational commitment among physician assistant nurses. The results of this study can be used reduce occupational stress and improve organizational commitment by improving the positive psychological capital of physician-assistant nurses.
Purpose This study aimed to understand the relationships between depression, post-traumatic stress, job demands, and social and organizational support among nurses working at general hospitals during the COVID-19 pandemic and to identify the factors influencing depression. Methods Data were collected from 240 nurses using a self-reported questionnaire between April 28 and May 7, 2023. Data were analyzed using descriptive statistics, an independent t-test, one-way ANOVA, Scheffé’s test, Pearson's correlation coefficient, and multiple regression. Results The mean scores for depression and post-traumatic stress were 15.49 and 17.90, respectively. Approximately 43% nurses experienced depression. Depression was positively related to job demands and post-traumatic stress and negatively related to social and organizational support. Multiple regression showed that post-traumatic stress (β=.33, p<.001), social support (β=-.30, p<.001), and job demands (β=.21, p<.001) explained 26.4% of the variance for nurses’ depression. Conclusion These findings indicate that efforts are needed to mitigate depression and post traumatic stress among nurses, even after the COVID-19 pandemic. Programs that can enhance social support and reduce post-traumatic stress and job demands are needed to prevent and decrease depression. In particular, hospitals and the government must prepare for national disasters, such as new infectious diseases, to reduce job demands.
Purpose This study aimed to determine the impact of work environment, missed nursing care, and non-nursing tasks on the job stress of hospital nurses. Methods A descriptive, cross-sectional survey of 164 nurses working in three hospitals was conducted. Data were collected using structured questionnaires and analyzed using descriptive statistics, t-test, one-way analysis of variance, Pearson’s correlation coefficient, and multiple regression analysis using SPSS/WIN 26.0. Results Hospital Nurses' job stress was negatively correlated with the work environment (r=-.37, p<.001). Job stress had a statistically significant positive correlation with non-nursing tasks (r=.34, p<.001); however, it had no significant correlation with missed nursing care (r=.05, p=.552). Regression model analysis revealed that the variables associated with job stress were non-nursing tasks (β=.29, p<.001) and the foundation for quality nursing care (β=-.25, p=.034), which are subdomains of the work environment. In contrast, missed nursing care was not determined to be a significant factor. Conclusion To effectively manage nurses' job stress, nurse managers should provide higher quality care by reducing the number of non-nursing tasks and creating a positive work environment, especially by providing adequate nursing workforce and material support.
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Purpose To examine the effects of a remote videoconferencing-based expressive writing program on the posttraumatic stress, resilience, and posttraumatic growth among traumatized nurses. Methods A randomized controlled group study with a pretest-posttest design was adopted. Data were collected between August 18 and November 6, 2020 from 48 nurses who experienced trauma working at a hospital in Jeonbuk Province (24 participants each in the experimental and the control groups). The experimental group participated in six sessions of the expressive writing program following the principles of Pennebaker’s expressive writing. Sessions (duration 90 minutes) were conducted twice a week for three weeks. Results Compared with the control group, the experimental group exhibited a statistically significant difference in posttraumatic stress (F=135.41, p<.001), resilience (F=94.88, p<.001), and post-traumatic growth scores (F=109.28, p<.001) immediately following intervention, and these scores were maintained at the 3-week follow-up. Conclusion The findings suggest that the expressive writing program can be effectively used for the prevention and management of posttraumatic stress in nurses at a risk of trauma.
Purpose This study aimed to identify the effects of job stress, social support, and infection control fatigue on professional quality of life among nurses in designated coronavirus disease 2019 (COVID-19) hospitals. Methods As a descriptive study, data were collected from 157 nurses working at four designated COVID-19 hospitals employing self-report questionnaires. The data were collected from September 1 to September 30, 2021, and analyzed using descriptive statistics, t-test, one-way ANOVA, Pearson’s correlation coefficients and stepwise multiple regression analysis. Results Job stress, marital status and social support affected compassion satisfaction with the professional quality of life, showing 30% of explanatory power. Job stress and social support affected burnout with the professional quality of life, showing 34% of explanatory power. Infection control fatigue affected secondary traumatic stress in the professional quality of life and the explanatory power was 11%. Conclusion Efforts are needed to improve nurses' professional quality of life by preparing and applying interventions to reduce job stress and improve social support for nurses working in hospitals dedicated to COVID-19. Further, nursing efforts and institutional support will be needed to reduce infection control fatigue.
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Purpose This study investigated the effects of job embeddedness and resilience on the relationship between job rotation stress and nursing work performance among clinical nurses. Methods: We conducted a nationwide online survey with 205 nurses employed at advanced general or general hospitals. Data were collected from August 17 to October 5, 2021. We analyzed the data using various descriptive statistics, independent t-tests, one-way analysis of variance, Scheffé test, Welch test, Games-Howell test, Pearson's correlation coefficients, multiple regression, and the PROCESS macro with a 95% bias-corrected bootstrap confidence interval. These analyses were conducted using SPSS Windows Software version 23.0 and SPSS PROCESS macro version 3.5.2. Results: Nurses' job embeddedness mediated the relationship between job rotation stress and nursing work performance (B=-0.02, p<.05). Furthermore, their resilience moderated this mediated relationship, also known as moderated mediation, with job embeddedness as the mediating factor (B=-0.02, p<.05). Conclusion: These findings imply that, when devising a strategy to improve the nursing work performance of nurses undergoing job rotation, their resilience levels should be considered. Reducing job rotation stress while concurrently enhancing job embeddedness is essential for enhancing the nursing work performance of nurses with high levels of resilience.
Purpose This study aimed to examine the differences in COVID-19 work-related characteristics, workload, anxiety, stress, and burnout between nurses working in the COVID-19 designated units and those in the general units caring for both COVID-19 and non-COVID-19 patients and to identify factors related to burnout in these two nurse groups. Methods The study was conducted using data from 192 nurses in the COVID-19 designated units and 340 nurses in the general units from two general hospitals. The data were collected using self-report, structured questionnaires.
Independent t-test, chi-squared test, and logistic regression analysis were performed. Results There were no significant differences observed in workload and burnout between the two groups. For nurses in the general units, workload, stress, adequacy of the number of patients assigned, and the experience of temporary, floating staff were significant factors associated with burnout, while only clinical experience in the current unit was a significant factor among those in the COVID-19 units. Conclusion Findings indicate significant differences in factors related to burnout between the two nurse groups. Thus, substantial support and strategies tailored to the working environments of each nursing unit are required to prevent burnout among nurses caring for COVID-19 patients.
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Purpose This study aimed to confirm the mediating effect of social responsibility on the relationship between nurses' stress and burnout from coronavirus disease (COVID-19) in tertiary general hospitals. Methods For this descriptive cross-sectional study, online survey data from 193 nurses in three tertiary general hospitals were analyzed. Data were collected from March 30 to April 4, 2021. The following statistical analysis were conducted: t-test, ANOVA, Scheffé test, Pearson's correlation coefficient analysis, and Hayes Process Macro Model 4 (to test the mediating effect). Results COVID-19 stress was positively associated with burnout (r=.28, p<.001) and social responsibility (r=.22, p=.002). Social responsibility was negatively associated with burnout (r=-.31, p<.001). Furthermore, the mediation analysis indicated that social responsibility mediated the relationship between COVID-19 stress and burnout. Conclusion According to the results, the impact of COVID-19 stress on the burnout was mediated by social responsibility. Therefore, to prevent the burnout from COVID-19 of nurses, developing educational programs to enhance social responsibility are recommended.
Purpose This study was to examine the influential factors on patient safety management activities of operating room nurses in general hospitals. Methods The subject of this study were 133 operating room nurses of seven general hospitals in B metropolitan city. Data were collected from July 23 to August 14, 2020 using self-report questionnaires.
For data analysis, a descriptive analysis and stepwise multiple regression were utilized with IBM SPSS Statistics for Windows version 22.0. Results The significant predictors of patient safety management activities were perception of patient safety culture (β=.73, p<.001) and physical burden (β=-.13, p=.025). These variables were found to contribute 56.3% to the outcomes of patient safety management activities. Conclusion Based on the research results, to promote patient safety management activities of operating room nurses, it is required to establish active and multifaceted strategies and systems at the hospital level to enhance awareness of patient safety culture and reduce physical burden.
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Purpose The purpose of this study was to identify the relationship between job stress and turnover intention and the mediating effect of job embeddedness on the relationship among hospital nurses in rural areas.
Methods: This is a descriptive study. A total of 277 registered nurses were enrolled in the study from three hospitals in rural areas of South Korea from April 29 to May 10, 2019. The participants completed self-reporting questionnaires, which measured job stress, turnover intention, and job embeddedness, and collected demographic information. The data were analyzed using IBM SPSS Statistics 25.0, for multiple regression, and a simple mediation model applying the Hayes PROCESS macro with a 95% bias-corrected bootstrap confidence interval (5,000 bootstrap resampling).
Results: Job stress had a direct effect (c’=0.35, p<.001) on turnover intention. It was also demonstrated that job embeddedness partially mediated the relationship between job stress and turnover intention among the hospital nurses (a ․ b=-0.40 × -0.58=0.23, 95% Boot C).
Conclusion: The job stress and turnover intention of nurses in rural areas are not higher than those in large cities. Nevertheless, hospital administrators need to provide a nursing workforce policy to increase job embeddedness and reduce nurses’ turnover intention.
Purpose This study aimed to identify the factors that affect post-traumatic growth among frontline nurses during a COVID-19 pandemic.
Methods: This study included 187 nurses working in nationally designated infectious disease hospitals as participants. Data were collected from January 11 to March 2, 2021 using structured questionnaires. Independent t-tests, one-way ANOVA, Pearson correlation coefficients, and hierarchical multiple regressions were performed to examine influencing factors of post-traumatic growth.
Results: Posst-traumatic growth was positively correlated with traumatic event experience (r=.26, p<.001), post-traumatic stress (r=.32, p<.001), supervisor support (r=.39, p<.001), and colleague support (r=.36, p<.001). Factors affecting post-traumatic growth were emotional support of supervisors (β=.76, p<.001) and evaluative support of colleagues (β=.46, p<.018). Overall, approximately 40.0% of the variability in post-traumatic growth was explained by these two variables.
Conclusion: To increase emotional support of supervisors and evaluative support of colleagues, the most influential factors for post-traumatic growth of frontline nurses who fought against COVID-19, a positive culture must be established. This includes horizontal communication, a safe working environment, and securing of appropriate nurse to patient ratio.
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Purpose This study aimed to elucidate the situational context and describe the factors and attributes pertaining to occupational stress among hospital nurses in Korea.
Methods: Secondary data from focus group interviews conducted with 26 hospital nurses were analyzed using the content analysis method. Data were analyzed using Graneheim and Lundman’s content analysis method.
Results: Based on the job demand-resource theory, the contents were divided into two major themes: the “excessive job demands” and the “shortage of job resources”.
The first theme was summarized into the following four categories: excessive workload and work intensity, complex and difficult work demands, hazardous work environment, and role- and relationship-related conflicts. The second theme was summarized into the following five categories: inadequate staffing, insufficient education and training, lack of support system, poor monetary compensation, and low internal compensation.
Conclusion: The occupational stress factors of Korean hospital nurses can be summarized as excessive job demands and a lack job resources.
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Purpose This study aims to determine the influence of clinical nurses’ second-victim experience and second-victim support on their negative work-related outcomes.
Methods: We used a cross-sectional design with a convenience sample of 179 clinical nurses from two Korean tertiary hospitals. The data were collected through a structured self-questionnaire survey and analyzed via descriptive analysis, independent t-tests, one-way ANOVA (analysis of variance), Pearson correlation coefficients, and hierarchical multiple regression.
Results: Second-victim experience revealed a significant negative correlation with second-victim support and a significant positive correlation with negative work-related outcomes. The second-victim experience was found to be a significant predictor of negative work-related outcomes. These factors explained 46.3% of the negative work-related outcomes in the regression model.
Conclusion: It is necessary to determine the degree of second-victim experience among clinical nurses and provide second-victim support to prevent future occurrences of negative work-related outcomes.
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Purpose The purpose of this study was to identify the factors influencing of job stress and positive psychological capital on turnover intention among novice nurses.
Methods: A descriptive correlational study design was used. Participants were 161 novice nurses with less than 12 months of work at one of two university hospitals in D city. Collected data were analyzed using descriptive statistics, t-test, ANOVA, Scheffé test, Pearson’s correlation, and multiple regression analysis with the SPSS statistics 23.0 program.
Results: Factors Influencing turnover intention were satisfaction with salary (β=.18, t=2.47, p=.015), length of work (β=.20, t=2.91, p=.004), satisfaction with relationships with (β=.17, t=2.52, p=.013), job stress (β=.18, t=2.52, p=.012) and positive psychological capital (β=-.27, t=-3.90, p<.001). These variables accounted for 25.0% of novice nurses’ turnover intention.
Conclusion: To prevent novice nurse turnover and a stable workforce management, it is necessary, in considering work periods, to develop an appropriate compensation system, apply programs to improve interpersonal relations, develop and provide programs to reduce job stress and improve positive psychological capital.
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Purpose The purpose of this study was to investigate the relationships between verbal abuse, professional quality of life, and job stress among emergency nurses and to identify the mediating effect of job stress on professional quality of life.
Methods: The participants were 121 emergency nurses working in general hospitals. The data were collected from December 1st, 2017 to February 1st, 2018. Collected data were analyzed using descriptive statistics, t-test, ANOVA, Pearson correlation, and three-step mediated regression analysis.
Results: As a result of correlation analysis, verbal abuse job stress had significant negative correlations with the professional quality of life, whereas verbal abuse experience had a positive correlation with job stress. Job stress showed significant effects on verbal abuse experience and the professional quality of life, with the explanatory powers being 43% and 29%, respectively, indicating partial mediator effects in the relationship between the three variables.
Conclusion: Verbal abuse experience and job stress in emergency nurses could reduce the professional quality of life, and their relationship by manifested partial mediating effects. Therefore it is necessary to decrease verbal abuse experience and job stress to further improve the professional quality of life in emergency nurses.
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Purpose The purpose of this study was to investigate the moderating mediation effect of health-promoting lifestyle in the relationships between clinical nurses’ job stress, appreciation and mental health problems. Methods The participations were 230 clinical nurses working in general hospitals in Seoul City and Gyeonggi Province. Data were collected in November 2019 via an online survey that covered job stress, appreciation, health-promoting lifestyles and mental health problems. The collected data were analyzed using SPSS 25.0, SPSS PROCESS Macro(Model 4, Model 7) and bootstrapping method. Results Appreciation had a significant mediation effect in the relationship between job stress and mental health problems. Health-promoting lifestyle had a significant moderation effect in the relationship between job stress and appreciation. Further, health-promoting lifestyle significantly moderated mediation effect of job stress on mental health problems through appreciation. Conclusion The results of this study suggest that it is necessary to effectively manage health-promoting lifestyle in the context of clinical nurses’ mental health problems due to job stress. In order to improve clinical nurses’ mental health, it is necessary to provide them with increased appreciation and lead health-promoting lifestyle.
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Purpose This study was done to analyze effects of leader-member exchange as perceived by nurses who returned to work after parental leave: conflict between work and family via job stress. Methods A cross-sectional study design was adopted and data were collected from 140 nurses. Collected data were analyzed using the SPSS 23.0 program (descriptive statistics, t-test, ANOVA, Pearson correlation, and regression analysis). Results Mean scores were 3.44±0.64 out of 5 for leader-member exchange, 3.45±0.59 out of 5 for job stress, and 2.82±0.80 out of 5 for conflict between work and family. The leader-member exchange had negative correlations with job stress (r=-.31, p=.003) and conflict between work and family (r=-.36, p<.001). The leader-member exchange had direct impacts on conflict between work and family (β=-.26, p=.002) and indirect via job stress (β=.35, p<.001). Job stress had partial mediating effects on relations between leader-member exchange and conflict between work and family (Z=-3.00, p<.001). The leader-member exchange and job stress explained 41% of the conflict between work and family. Conclusion The findings from this study indicate that active human resource management policies should be established in order to increase the leader-member exchange.
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Purpose The purpose of this study was to examine the influences of nursing professionalism and job stress on problem solving ability of community health practitioners. Methods The participants were 167 community health practitioners. Data were collected from December 18 to 28, 2019. Self-report questionnaires were administered to collect data regarding general characteristics, degree of nursing professionalism, job stress, and problem solving ability. Data were analyzed using descriptive statistics, independent t-test, One-way ANOVA, Pearson correlation coefficients and multiple regression analysis. Results The factors influencing the degree of problem solving ability of the community health practitioners were professionalism of nursing (β=.29, p<.001), and interpersonal factors (β=-.25, p=.001). It was found that 15% could explain problem solving ability. Conclusion It is necessary to strengthen the professionalism of nursing and to decrease the interpersonal factors due to job stress for the community health practitioners. The results indicate a need to increase development of educational programs for capacity building of community health practitioners.
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Purpose The purpose of this study was to investigate the factors that affect post-traumatic growth of general hospital nurses after they experience traumatic events. Methods A cross-sectional correlation study design was used. Participants were 232 nurses from general hospitals in South Korea. Data, including self-report questionnaires, were collected from July 11th to 31st, 2019, and analyzed using descriptive statistics, t-test, One-way ANOVA, Scheffé test, Pearson's correlation coefficients and hierarchical multiple regression analysis in IBM SPSS Statistics 25.0. Results Post-traumatic stress (r=.24, p<.001), resilience (r=.36, p<.001), and social support (r=.37, p<.001) for general hospital nurses had a positive correlation with post-traumatic growth. The factors that affected post-traumatic growth were a) sleep disturbance, emotional paralysis and dissociation symptom subcategory of post-traumatic stress (β=.34, p<.001) and b) persistence subcategory of resilience (β=.33, p<.001) and c) evaluation support subcategory of social support (β=.29, p<.001). Conclusion Results indicate that it is necessary to develop and provide programs to nurses to improve post-traumatic stress management, strengthen their resilience and provide social support.
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Purpose This study was done to provide basic data for nursing intervention to increase communication ability of operating room nurses by identifying the relation among their verbal violence experience, job stress, resilience, and communication ability. Methods The participants were 136 nurses, working in the operating rooms of six academic and general hospitals located in Seoul and Gyeonggi-Do. Data were collected from May 1st through October 31st, 2016. Collected data were analyzed for frequency and percentage, mean and standard deviation, association among related factors, and stepwise multi-regression using the SPSS 21.0 program. Results It was found that the strongest factor influencing the communication ability of operating room nurses was persistence (β=.41, p <.001; sub-item of Resilience), followed by support (β=.26, p =.001; sub-item of Resilience). These two sub-items have positive influences on communication ability of operating room nurses. The lack of professional knowledge and skill (β=-.19, p <.001; sub-item of job stress) and verbal violence experience from nurse (β=-.16, p <.001; sub-item of verbal violence experience) have negative influences on communication ability of operating room nurses. These sub-items explained 47.0% of communication ability of operating room nurses. Conclusion The study results can be used as basic data to develop effective communication. Also, the results show the necessity of developing and applying concrete nursing interventions to improve job satisfaction of operating room nurses.
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PURPOSE This study was done to verify relationships among occupational stress, labor intensity, fatigue and musculoskeletal disorder symptoms, and especially to identify factors influencing musculoskeletal disorder symptoms among hemodialysis nurses in tertiary hospitals. METHODS A cross-sectional design was used, with a convenience sample of 125 hemodialysis nurses from 13 tertiary hospitals. Data were collected through self-evaluation questionnaires during July and August, 2018. Data were analyzed using t-test, χ² test, factor analysis and binary logistic regression analysis with SPSS/WIN 25.0 program. RESULTS Of the hemodialysis nurses 96 (76.8%) were in the musculoskeletal symptomatic group and 29 (23.2%) in asymptomatic group. Occupational stress (p < .001), labor intensity (p < .001), and fatigue (p=.011) were higher in the symptomatic group compared to the asymptomatic group. Logistic regression analysis showed that occupational stress (OR=1.13, 95% CI: 1.03~1.25), labor intensity (OR=5.60, 95% CI: 1.25~24.97), no leisure life or hobbies (OR=4.67, 95% CI: 1.48~14.80), hemodialysis unit career 2~4 year (OR=4.58, 95% CI: 1.04~20.78), and hemodialysis unit career 8+ year (OR=14.10, 95% CI: 2.53~78.64) were effect factors for the musculoskeletal symptomatic group. CONCLUSION For effective improvement of musculoskeletal disorder symptoms in hemodialysis nurses, multidimensional intervention programs are needed. Programs should include occupational stress, labor intensity and strategies to reduce symptoms.
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