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Received: 30 March 2018    Revised: 13 May 2018    Accepted: 16 May 2018

DOI: 10.1111/jonm.12667

ORIGINAL ARTICLE

Exploring the psychological status of Jordanian nurses working

with cancer patients

Ahmad Rajeh Saifan1 | Ahmad M. Al Zoubi2 | Intima Alrimawi3  | Omar Melhem1

1
Nursing Department, Fatima College of
Health Sciences, Abu Dhabi, United Arab Abstract
Emirates Aim: This study aims to explore the psychological status of nurses working with can‐
2
Hematology Unit, Ministry of Health,
cer patients in Jordan.
Amman, Jordan
3 Background: Literature shows that nurses face many stressors in their job, in particu‐
School of Nursing, Stratford University,
Falls Church, Virginia lar oncology nurses. Some of them have psychiatric illness such as anxiety and de‐
pression. Most of the reviewed studies were conducted in developed countries, and
Correspondence
Intima Alrimawi, School of Nursing, Stratford none in the Middle East.
University, 7777 Leesburg Pike, Falls
Method: A qualitative descriptive approach was adopted, whereby interviews were
Church, VA 22043.
Email: [email protected] conducted with 24 nurses that were selected from the oncology departments of one
governmental hospital.
Results: Participants identified coping with death and dying in nursing care and some
cultural issues (that they encountered) as the main factors that influence their psy‐
chological well‐being, which in turn may have contributed to a reduced quality of
care for patients.
Conclusion: Findings indicated that the working environment within oncology is
highly stressful, which might negatively affect the nurses’ job satisfaction and the
quality of care that they provided.
Implications for Nursing Management: Findings of this study could help health care
managers to understand the impact of psychological stressors on nurses’ perfor‐
mance, and the importance of improving the psychological status of oncology nurses.

KEYWORDS
cancer patients, job satisfaction, Jordan, nurse, oncology, psychological status

1 |  I NTRO D U C TI O N neglect it and keep working without paying attention to the conse‐
quences (Lievrouw et al., 2016). Some nurses may even stop going
Registered nurses who work in hospitals are exposed to vary‐ to work (Barker, 2008; Watson, 1999). It is, therefore, important to
ing degrees of psychological pressure (Barker, 2008; Seligman & support nurses and enhance their work environment to improve
Csikszentmihalyi, 2014). This psychological pressure is thought their performance and meet their needs.
to have consequences on nursing in term of patient safety, loss of The literature showed that oncology nurses are exposed to psy‐
control and miscommunication between health team members and chological stress more than nurses in other departments are (Escot,
organisations (Toh, Ang, & Devi, 2012). Other negative outcomes Artero, Gandubert, Boulenger, & Ritchie, 2001; Faria & Maia, 2007;
of working under severely stressful conditions include absentee‐ Toh et al., 2012; Uitterhoeve et al., 2009). They provide care for pa‐
ism and staff turnover, and physical and psychological problems tients with cancer, some of whom are terminally ill. Working in these
(Atindanbila, 2012; Russell, 2016). settings can be emotionally taxing and nurses may have grieving
The reaction to these psychological stressors is different be‐ feelings when their patients die (Tuna & Baykal, 2017). It is a chal‐
tween nurses; some of them adapt to the pressure, while others may lenge for many nurses to detach themselves from feelings of grief

J Nurs Manag. 2018;1–8. © 2018 John Wiley & Sons Ltd |  1

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2       SAIFAN et al.

when their patient dies (Dhotre, Adams, Herbert, Bottai, & Heiney, the study objectives and provides representative views about the
2016; Nelson, 2002; Tuna & Baykal, 2017). This contributes to the subject under investigation. Additionally, this hospital is the biggest
psychological pressure on these nurses and may explain why they medical centre in Jordan, and is home to most of the health care
become more stressed and anxious (Faria & Maia, 2007). These psy‐ specialists and services in the governmental hospitals.
chological stressors are highly expected to reduce levels of satisfac‐
tion, and affect the quality of health care provided to patients. Most
2.3 | Population and sample
of the reviewed studies were conducted in developed countries
(Cheung, 2015; Haslam, 2005; Oechsle, 2013), although a few stud‐ The study adopted the purposive sampling approach, which is a pre‐
ies were conducted in developing countries (Jayawardene, 2013; ferred one in qualitative design (Patton, 2005). It is often used when
Mahmoudi, 2009; Nelson, 2002). However, none was conducted in researchers search for a sample with specific criteria that serve the
Middle Eastern countries. purpose of the study. In this case, all the selected participants were
Levels of psychological distress differ from one country to an‐ registered nurses with at least a diploma or bachelor degree, they
other and, sometimes between areas of the same country (Boya, had at least 3 months’ experience in cancer departments and they
2008; Cheung, 2015; Schmidt, 2011; Zandi, 2011). There are also provided care directly to patients with cancer. Participants were ex‐
differences in the distress levels between nurses’ demographical cluded if they had mental or psychological disorders, or if they were
characteristics such as age, marital status and experience (Cheung, not in a caring role with the patients.
2015; Ko & Kiser‐Larson, 2016). The current study examines these
issues within the Jordanian context and compares the Jordanian sit‐
2.4 | Sample size
uation with the global one.
Having a healthy psychological status would help nurses to The sample size in qualitative research is usually small because the
work in an atmosphere of satisfaction and high morale (Utriainen qualitative research concern is about how phenomena occur rather
& Kyngäs, 2009; Wu, Singh‐Carlson, Odell, Reynolds, & Su, 2016). than the extent to which they are statistically significant. It was
To achieve a good psychological stability for the nurses, several difficult to decide in advance how many participants needed to be
issues need to be considered: respecting the need for appreciation, included to meet the study aims; however, in qualitative research,
providing a comfortable working environment and addressing the the researcher should continue recruiting participants until reaching
need for achievement and self‐realisation (Barker, 2008; Wu et al., saturation point (Patton, 2005). In this study, the saturation point
2016). was reached after 24 interviews. Table 1 show the characteristics of
The evidence presented in this section suggests that across the the nurses who were interviewed.
globe nurses are susceptible to psychological health issues, mainly
in the oncology units (Jones, Wells, Gao, Cassidy, & Davie, 2013;
2.5 | Data collection method
Kaewboonchoo et al., 2009; Yoon & Kim, 2010). Researchers may
thus need to address the specific psychological needs of health care The nurses were visited in their departments where the researcher
professionals to optimise their well‐being. To this end, this study aims gave them invitation letters. They were asked to return the invitation
to explore the psychological status of oncology nurses in Jordan. letters to an easily located box. Where the letters were returned
with the contact details of the nurses, the author made arrange‐
ments to interview them. The recruitment and the data collection
2 |  M E TH O D O LO G Y
phases took almost 6 months (from January 2017 to the end of July
2017).
2.1 | Study design
Semi‐structured face‐to‐face interviews were used to collect
A qualitative design was adopted, as this approach is expected to data. The role of the researcher was more to direct the discussion
produce rich and deep information about the subject under investi‐ than question (Patton, 2005), as this kind of interview relies on the
gation (Graneheim & Lundman, 2004). Qualitative research seeks to participants’ thinking and behaviours being garnered without the in‐
understand the underlying causes, reasons and motivations of the terference of the researcher’s own preconceived views (Dearnley,
social phenomenon (Creswell, 2013). 2005).
An interview schedule was used to gain insights from the partic‐
ipants regarding the phenomenon under investigation. It also helped
2.2 | Settings
to organise the author’s thoughts. The schedule was prepared ac‐
The research was conducted in one of the major public hospi‐ cording to the questions that were raised in the literature and the
tals in Jordan. This hospital was purposively selected because it author’s own experiences (see Table 2). Participants were informed
is in Amman, where about 40% of the Jordanian population lives. that each interview would take about 30 min to 1 hr, although this
Patients come from different regions of Jordan to seek medical was flexible, depending on how the interviews proceeded. They
treatment in this hospital, and the nurses who works there are also were conducted in private rooms within the work setting, and only
from different regions. This variety in nursing backgrounds meets one was conducted per day.
SAIFAN et al. |
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TA B L E 1   Main characteristics of the participants

Years of Level of
No. Pseudonym Age Sex experience Department education Years in oncology Marital status

1 Saif 27 M 5 Haematology MSN 5 Single

2 Muhammad 28 M 7 Oncology BSN 7 Married
3 Rawan 26 F 4 Haematology BSN 1 Single
4 Nour 33 F 12 Haematology BSN 10 Single
5 Adel 29 M 2 Haematology BSN 1 Single
6 Najah 40 F 16 Haematology BSN 14 Married
7 Zainab 26 F 4 P. oncology BSN 2 Married
8 Ahmad 32 M 11 Oncology MSN 3 Single
9 Walid 38 M 14 Oncology MSN 10 Married
10 Shima’ 32 F 10 Oncology MSN 10 Single
11 Dand 25 F 3 Oncology BSN 1 Single
12 Maha 25 F 3 Oncology BSN 1 Single
13 Maher 33 M 12 Haematology BSN 11 Single
14 Rami 27 M 4 Oncology MSN 2 Married
15 Mustafa 26 M 4 Oncology BSN 4 Married
16 Amjad 25 M 3 Oncology BSN 2 Single
17 Ghada 41 F 16 Oncology BSN 16 Single
18 Bassam 42 M 18 Haematology BSN 12 Married
19 Alia 34 F 12 Oncology MSN 1 Single
20 Doa'a 23 F 1 Haematology BSN 1 Single
21 Rbeaat 28 M 6 Oncology MSN 4 Single
22 Jaber 38 M 10 Haematology BSN 6 Married
23 Mona 23 F 1 Oncology BSN 1 Single
24 Abeer 36 F 12 Oncology BSN 8 Married

MSN, Master of Science in Nursing; BSN, Bachelor of Science in Nursing; NO, participant number; P. oncology, paediatric oncology.

TA B L E 2   Semi‐structured interview guide questions

directly after each interview. After that, they were translated from
1 How do you feel about nursing in general? How do you feel about Arabic to English. The data were analysed using Braun and Clarke’s
being an oncology nurse? (2006) technique of thematic analysis, which employs six phases.
2 Please, tell me about clinical experiences that might affect your The first step involves listening carefully to the taped interviews, and
psychological status?
then reading and re‐reading them. The second step generates initial
3 Tell me about the communication with cancer patients? codes by examining all of the interviews line‐by‐line. The third step
4 Do you have past personal experiences, either negative or involves searching for themes, which includes giving all respondents’
positive, influence on care provided to cancer patient?
sentences, phrases and texts one or more codes. The fourth step is
5 Does oncology work limit you to achieve work‐life balance? How
to review the themes, refining them to reduce their number, elimi‐
come?
nate duplications and permit the development of more sophisticated
6 Do you feel tense or worry during providing health care for cancer
analytical categories. During the fifth step, themes are defined and
patients? How?
named. After finishing the process of coding and collating codes, re‐
7 Do you think the work environment impact on psychological
domain for you? How? reading of all these codes and their texts is conducted. The last phase
is to produce the report.
8 How do you deal with stressors in your work?
9 Do you think it is possible to deal with the psychological distress
of oncology nurses? Do you have suggestions? 2.7 | Ethical considerations
Ethical approval was obtained from the IRB committee of the Applied
2.6 | Data analysis
Science Private University, and the hospital where the research was
Data analysis started congruently with the process of data collection. conducted. Moreover, all the participants received an information
All of the interviews were digitally recorded and then transcribed sheet about the study, and an informed consent form was signed by
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4       SAIFAN et al.

each participant before the interview. All participants were informed TA B L E 3   Main themes and subthemes that emerged from the
that their responses would be treated confidentially, and their names data analysis
replaced with pseudonyms. Subthemes Themes

Most of patients are received in late stage High mortality

Coping strategies with death and dying rate and relapse
3 |   R E S U LT S
patients
Social relationship between nurses and Cultural issues
Several issues emerged from the interviews; the main themes and patients with cancer
subthemes that were produced from the analysis are shown in
Keeping balance between emotional responses
Table 3. and role function

3.1 | High mortality rate and relapse

in all cases... in addition, my communication skills
were improved.  (Mohammed, male RN)
3.1.1 | Most patients are received at a late stage
Most of the participants stated that providing care for patients with
cancer, particularly terminally ill ones, produced negative psycho‐
3.1.2 | Coping strategies with death and
logical effects. Many of them expressed having stress and anxious
dying patients
feelings when working with these patients, as well as feelings of
helplessness. The participants discussed watching patients’ hopes and strengths
diminish over time, which generated feelings of helplessness and
Most of the patients come in at late stages; I do not depression among them. These feelings pushed many nurses to do
deny that this thing causes frustration and the fact their best and try to avoid making mistakes. However, most of them
that we are dealing with death. It is different from in talked about feelings of anxiety and depression in cases of death
other clinical areas. This has led to significant changes or the deterioration of patients’ conditions despite all their efforts.
in my life.  (Walid, male RN)
I talked to other nurses from other departments and
The participants reported that patients arriving during the terminal found that some of them have more stressful situ‐
stages are usually overwhelmed, and more time and effort is required ations, like the emergency department. However,
to build a trusting relationship with them. This could contribute to raise they have different stories as some patients die and
anxiety levels of nurses who deal with terminally ill patients compared others survive. Their experiences are different from
to nurses who take care of patients during the early stages. ours, because our experience is almost like a story
of war with cancer. In oncology departments, you
Communication with the cancer patients is not easy deal with completely different patients, patients
and it is difficult to build a trust relationship with with no support system, patients of all ages, patients
them. It is so difficult especially with patients in late with huge families and huge causes to want to live.
stages, because these patients do not complain just  (Maha, female RN)
about physical illnesses, but they also have psycho‐
logical issues. This may cause depression... so the Many of the participants said that conversations with patients and
communication depends on nurses and whether they relatives about death and dying were very stressful and difficult for
are capable to communicate with them or not. I do not them. They expressed finding difficulties with choosing the appropri‐
deny that this is one of the things that makes me feel ate words to provide comfort and predominantly wondered if there
anxious and tense  (Alia, female RN) was something they “should” say to the patients and their families.

On the other hand, two nurses reported that dealing with patients Actually, I still have not learned how to answer any
during the late stages had a positive impact on their psychological and questions related to the patient’s condition. I still do
personal lives. They felt that their communication skills improved, and not know how I should handle these situations. This
that patients and nurses at this stage became closer to God and coped makes me feel like I want to cry, especially when deal‐
better: ing with children. I keep silent and leave the place.
 (Dana, female RN)
I learned patience, and my view of life changed dra‐
matically. Being in these situations brought me back Some of the participants felt that effective communication and
to God and to the belief that humans must be positive teamwork, and support from cooperative leaders helped them to cope
SAIFAN et al. |
      5

better with stressful issues in the oncology environment, and when Communicating and responding to patients’ and fami‐
dealing with death and dying patients. lies’ emotional needs requires advanced nursing skills
and knowledge. Imagine, a patient in internal conflict
and we are talking about end of life issues, or parents
3.2 | Cultural issues
that are watching their sons or daughters and cannot
do anything.  (Rawan, female RN)
3.2.1 | Social relationship between nurses and
patients with cancer
In agreement with the above discussion, some participants who did
All nurses, regardless of their different roles, described the signifi‐ not have much experience in oncology found it difficult to deal with
cance and value of their relationships with patients and families. patients with cancer. They said that being in these departments with‐
The majority of the participants felt that their relationships with out experience and good preparation produced enormous challenges
the patients and their relatives usually had a negative influence in maintaining balance and adaptation between personal life and work
on their psychological well‐being. This resulted from strong rela‐ demands. These nurses thought of leaving their jobs many times due
tionships developing between the nurses and patients and family to these conditions:
members. Most of the participants explained that many nurses in
Jordan develop personal relationships with patients and relatives. It was difficult for me. I used different ways to adapt
Consequently, they may grieve and suffer when losing patients: to this. Immediately after going home, I used to sit
down with my family and tell them my story and talk
The nature of our society, in which people cannot about all the details. I started to cry sometimes and
differentiate between different relationships. Some they used to provide support and calm me down. I
nurses build strong relationships with patients and know that this may be exaggerated, but death is diffi‐
families. Some nurses become sick and sometimes cry cult and is a scary thing. You see someone die in front
in front of patients and family members. Therefore, of your eyes and you cannot do anything, this is not
you have to withdraw and not go deeper into relation‐ easy.  (Zainab, female RN)
ships with patients.  (Maher, male RN)

Two of the participants contradicted the above statement, stat‐

ing that forging strong relationships with patients gives nurses the 4 | D I S CU S S I O N
chance to inform them about their diseases and treatments. Strong
relationships with patients and family members were also viewed This study showed that the interviewed nurses had several psy‐
as a starting point to help patients and families to cope with these chological stressors. Most of the participants expressed some
situations. negative feelings such as anxiety, depression, helplessness and ex‐
haustion. These findings were similar to some studies conducted
I am working with patients who are coming for chemo‐ in other settings (Dhotre et al., 2016; Jones et al., 2013; Onan et
therapy … what we do here is important, and you can see al., 2015; Potter et al., 2010). Jones et al. (2013) explained that ex‐
that we achieve good results for these people because of hausting work and psychological stressors negatively affect per‐
our strong relationship with them.  (Alia, female RN) sonal performance and achievement. Similarly, Kent, Anderson,
and Owens (2012) showed that nurses with little experience of
patient death and dying might sustain permanent effects on their
professional and personal lives.
3.2.2 | Keeping a balance between emotional
In this study, some of the participants also point out that nurses
responses and role
who could not maintain professional relationships with patients and
Most of the participants stressed the importance of maintaining family members usually experienced acute emotional, psychological,
a good balance between their professional roles and their emo‐ spiritual and physical exhaustion (McMullen, 2007). In other words,
tional responses to the patients with cancer. Nevertheless, many when nurses attach emotionally to patients with cancer and are un‐
of the participants highlighted the difficulty of maintaining this able to control the relationship in a professional manner, they might
balance in their work due to the time that they spent with their experience a higher level of stress.
patients. The inability to separate professional roles and emotional re‐
The interviewees recognised that a major part of their role is to sponses among oncology nurses could arise for several reasons,
provide health education and psychological support to oncology of which lack of experience could be the most important. Burgess
patients. However, some participants found this goal difficult to (2010) explained that nurses who were less experienced usually
achieve for many reasons such as lack of experience, staff shortages reported more stress than experienced nurses when dealing with
and lack of continuing education for nurses. work or family conflicts did. This point seems to be borne out by the
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6       SAIFAN et al.

current study, where most of the nurses who raised the issue only interviewees more relaxed. This study was conducted in one hospi‐
had a few years of work experience. tal and in only one city, which may reduce the representativeness of
Another explanation for this phenomenon centres on the un‐ the study sample to Jordanian nurses.
availability of any social or psychological support for nurses in their
workplace. Several studies showed the importance of supporting
4.3 | Implications for nurse managers
oncology nurses in clinical environments (Cummings, 2008; Friese,
Lake, Aiken, Silber, & Sochalski, 2008; Medland, 2004; Wu et al., The results of this study could be useful to nursing managers and
2016). These authors recommended special programmes to support organisational leaders, helping them to understand the challenges
nurses psychologically. The absence of this kind of support pro‐ nurses face in the working environment. Showing consideration to
gramme raises an important question regarding who would support all the above issues would be expected to increase nurses’ produc‐
oncology nurses facing critical or bad experiences. tivity and reduce turnover among oncology nurses.
The current study showed similar findings to those of some Nurses’ stress levels should be monitored and accounted for in
previous studies (Barrett, 2002; Lagerlund, 2015; Russell, different oncology settings. Moreover, nurses’ managers should ini‐
2016; Sherman, 2006; Tuna & Baykal, 2017), where some of tiate supportive policies to encourage nurses to perform debriefings
the participants reported a desire to leave their jobs to es‐ and express their feelings.
cape from their psychological distress. Grunfeld et al. (2000) With support from their managers, nurses might become more
found that oncology team members experienced burnout and ready to consult experts such as psychologists or psychiatrists, so
increased levels of stress. They reported that many of these that emergent disturbances may be discovered and treated early.
nurses thought about either leaving their work or going part‐ Additionally, education about stress management, and cognitive–
time. Berrios, Joffres, and Wang (2015) found that increased behavioural therapy could help nurses and increase their flexibility
psychological and physical demands on nurses are strongly in dealing with stress and working challenges.
associated with job dissatisfaction, disengagement and burn‐
out, as well as anxiety and depression. AbuAlRub and Alzaru
4.4 | Research implications
(2008) reported similar findings. However, their work described
the situation for Jordanian nurses in general, whereas the cur‐ Further research is needed to validate the themes of the current
rent study included only oncology nurses, where psychological study. Empirical and quantitative studies are recommended for the
stress and dissatisfaction might be greater. future. More qualitative studies would also be useful to provide fur‐
The literature suggests that health care professionals and pol‐ ther explanations about the phenomenon under investigation. It is
icy makers should understand the influence of culture on health also recommended that future studies include other hospitals and
care‐seeking behaviour (Brach & Fraserirector, 2000). Recognising other cities in Jordan. We also recommend conducting other studies
cultural needs and practices would result in improving cooperation about oncology nurses’ satisfaction and turnover.
and communication between the health care professionals and the
patients and their relatives (Esposito, 2013).
5 | CO N C LU S I O N
4.1 | Strengths
This study provided many details about the psychological chal‐
This is one of the few studies in Jordan that have adopted a qualita‐ lenges that oncology nurses may face in their work. The findings
tive design to date. Using this design helped to illuminate the unique discussed the influence of high mortality rates and the relapse of
features of the Jordanian context and to produce rich and detailed patients, as well as some important cultural issues that influence
information about the subject of interest. Moreover, this study in‐ the nurses’ psychological status. It was recommended that policy
cluded a purposive sample of Jordanian oncology nurses with dif‐ makers and managers address oncology nurses’ psychological
ferent levels of experience, which can facilitate the understanding concerns.
of the phenomenon of interest. The findings of the current study
could be transferable to other countries and settings with similar
AC K N OW L E D G E M E N T S
conditions.
We would like to thank all of those who helped us during the comple‐
tion of this research. This study could not have been accomplished
4.2 | Limitations
without the contribution of the nurses who agreed to take part in
The subject of this study is a sensitive one. Nurses sometimes find this study, who must necessarily remain anonymous. All authors had
it difficult to talk about their feelings. To overcome this issue, the a major input into the design, analysis and interpretation of the data,
researcher tried to break the ice with interviewees by starting with as well as drafting the article or revising it critically for important
a general discussion with each interviewee before moving on to the intellectual content. All authors have seen and approved the final
interview, which also started with general questions. This made the version of the manuscript.
SAIFAN et al. |
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ORCID Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in

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