Occupational Fatigue Exhaustion Recovery Scale (OFER) for Work-Related Fatigue Research

This proposal discusses the development and validation of the 15-item Occupational Fatigue Exhaustion Recovery (OFER) scale for measuring work-related fatigue and its three subscales. It proposes a study to address the level of fatigue of male and female nurses in Jordan and their individual coping strategies to mitigate work-related fatigue. The proposal outlines the background and justification for the study, literature review, study aim, research questions, objectives, hypothesis, methodology, ethical considerations, and facilities and resources.

Running head: PHD PROPOSAL
PHD PROPOSAL
Name of Student
Name of University
Author’s Note

1PHD PROPOSAL
Abstract
Various empirical studies link persistent failure to recover from acute fatigue to the evolution
of chronic fatigue. However, existing fatigue measurement scales do not tend to distinguish
between acute and chronic fatigue elements well, and none include a measure of effective
recovery from fatigue. The 15-item Occupational Fatigue Exhaustion Recovery (OFER)
scale has been developed and validated in three study populations specifically to measure
work-related fatigue. The OFER scale possesses robust, gender-bias free psychometric
characteristics. Its three subscales identify and distinguish between chronic work-related
fatigue traits, acute end-of-shift states and effective fatigue recovery between shifts. These
studies confirm the mediating role of inter-shift recovery in the evolution of adaptive end-of-
shift fatigue states to maladaptive persistent fatigue traits. The OFER scale is suggested as a
potentially valuable new tool for use in work-related fatigue research.

2PHD PROPOSAL
Table of Contents
Introduction................................................................................................................................4
Background................................................................................................................................8
Literature review......................................................................................................................11
Prevalence of Work-related Fatigue.........................................................................................13
Type of Work-related fatigue...................................................................................................15
Factors associated with fatigue................................................................................................16
Consequences of work-related fatigue.....................................................................................17
Management of fatigue............................................................................................................18
Gender experience and expectation.........................................................................................19
Study Aim................................................................................................................................22
Research questions...................................................................................................................22
Research objectives..................................................................................................................23
Research hypothesis.................................................................................................................23
Significance of the study..........................................................................................................23
Significance of this study.........................................................................................................24
Methodology............................................................................................................................24
Study design.............................................................................................................................25
Study location...........................................................................................................................27
Sampling population and selection..........................................................................................28

3PHD PROPOSAL
Sampling frame........................................................................................................................28
Sampling techniques................................................................................................................28
Determination of sample size...................................................................................................29
Data collection process............................................................................................................30
Components of questionnaires……………………………………………………………….30
Semi-structured interviews…………………………………………………………………..30
Quality control.........................................................................................................................31
Content validity………………………………………………………………………………31
Pre-testing of the questionnaires……………………………………………………………..31
Face validity………………………………………………………………………………….31
Data analysis…………………………………………………………………………………32
Ethical considerations..............................................................................................................32
Beneficence…………………………………………………………………………………..33
Non-Maleficence……………………………………………………………………………33
Autonomy…………………………………………………………………………………..33
Justice………………………………………………………………………………………34
Confidentiality……………………………………………………………………………...34
Facilities and resources……………………………………………………………………..35
Gantt chart for study activities………………………………………………………………35
APPENDIX A: QUESTIONNAIRE........................................................................................56
SECTION B: Occupational Fatigue Exhaustion Recovery Scale (OFER 15).........................59

4PHD PROPOSAL
APPENDIX B: QUESTIONNAIRE........................................................................................62
Understanding the Reliability and Validity of the questionnaire.............................................64

5PHD PROPOSAL
Introduction
This doctoral research proposal will discuss the concept of fatigue as it relates to the
nursing profession. The context of the proposed study is Jordan, situated in the Middle East.
The proposal will outline the background and justification for the study and the search
strategy and literature related to fatigue generally. The methodology and design will be
discussed, as will the ethical considerations.
The study aims to address the level of fatigue of male and female nurses and what
their individual coping strategies are to mitigate work related fatigue. This is the first mixed
method nursing study of its kind in Jordan, especially as it addresses gender issues related to
fatigue in selected Jordan hospitals.
Nurses are present on the front line of healthcare, which is both a rewarding and tiring
experience. Due to the arising of different issues, like insufficient levels of staffing or
exponential increase in the responsibilities of healthcare, the pressures on the modern nurses
are immensely increased, which are often the instances of increased levels of fatigue in the
environment of healthcare (Parahoo, 2014). The reason behind these increased levels is
probably lack of sleep, which results in affecting the health issues and safety issues of both
patients and nurses. The American Nurses Association (ANA) is working to counter these
harmful effects because of the reality of the dangerous fatigue in workplace. This nurse
fatigue has become the primary concern, which further emphasizes the importance and need
of this proposal. This proposal will help in addressing the issues related to fatigue efficiently.
The following approval will help in generating data, which can be further used to solve these
fatigue issues in the field of Nursing (Holloway & Galvin, 2016). From the past surveys, it
was observed that the levels of mental fatigues were more than physical fatigue. In addition,

6PHD PROPOSAL
the levels of chronic fatigue were lesser than acute fatigue. Moreover, the increased levels of
total fatigue were due to the longer shift timings and hours in a week.
Nursing care is a 24-hour occupation, often requiring nurses to work two or three
shifts, as opposed to standard working hours, with the demands and expectations of patients
and hospitals placing nurses under considerable pressure (Yuan et al., 2011). Nurses may also
work extended hours without regular breaks, and they are likely to experience fatigue
(Corless et al., 2008).
The prevalence of fatigue among nurses is also attributed to these ongoing demands
of caregiving and other job-related fatigue factors, such as rapid admission and discharge
cycles and high patient acuity levels which require increasingly complex occupational skill
sets (Kubo, Takahashi, Sallinen, Kubo, & Suzumura, 2013). There are many negative
consequences of work-related fatigue of nurses working and health organizations that affect
the patients (Burton, 2010; Scott, Rogers, Hwang, & Zhang, 2006). Fatigue is known to
adversely affect the quality of care, client satisfaction, and patient and nurse safety (Nagai et
al., 2011; Witkoski & Dickson, 2010).
Fatigue has resulted in the negative performance of the nurses in the healthcare environment
(Rose et al., 2017). Often different terms like exhausted, lethargic and tired are used on the
behalf of Fatigue. It is a symptom, which is often misinterpreted with drowsiness by the
patients. Although, both the symptoms, fatigue and drowsiness, explains the sleep
requirement, but they are different and should be identified by the doctors (Naviaux et al.,
2016). Fatigue is a physiological process that can occur due to prolonged working hours,
disruption of circadian rhythms from a lack of sleep, or from doing the same type of
monotonous work for a long period (Sadeghniiat-Haghighi & Yazdi, 2015). Fatigue has been

7PHD PROPOSAL
characterized previously as a workplace hazard associated with the safety and health of
workers (Hairong Yu, Anli Jiang, & Jie Shen, 2016).
Previous studies found the prevalence rate of fatigue among nurses is different from
one country to another Norway, United Kingdom, Netherlands, Canada, and United States of
America the prevalence of the fatigue among nurses was 22%, 38% , 25% , 55.5%, 37.9%
respectively (Barker & Nussbaum, 2011; Bryant-Lukosius, 2010; Ho et al., 2013). In the
Middle East, 48.8%, of Palestinian Nurses suffered from work-related fatigue with a high
level of emotional exhaustion (Hamdan, 2017). As well as there is study has done in turkey
showed the rate of fatigue 40% among nurses (Kuguoglu, Aytekin, & Yilmaz, 2014).
Work-related fatigue risk management has been defined as a strategy to minimise the level
and cause of fatigues among workers in the workplace (Gander et al., 2011). Risk
management studies for fatigue are limited to the safety of patients and wellbeing of nurse in
the health care system (Aurich-Barrera, Wilton, & Shakir, 2012). So, is there a need for
broader more comprehensive studies ally? What are you trying to say here?
The majority of studies have focused on the development and improvement in risk
management systems to ameliorate fatigue in the workforce, as well as the general public
from fatal harms, which happens when the medicine have negative impact or it goes wrong
and negative consequences (Drury, Craigie, Francis, Aoun, & Hegney, 2014). The adequate
risk management strategies will be helpful for addressing the causes of fatigue and enhance in
satisfaction of job with minimisation of nursing fatigue (Van Mol, Kompanje, Benoit,
Bakker, & Nijkamp, 2015). Many hospitals still lack management policies for addressing and
monitoring the level of fatigue among nurses and measurement the experiences and
expectation for male and female nurses in the same place. Furthermore, most of the nurses
are using some individual’s strategies like prioritizing sleep by putting enough effort,

8PHD PROPOSAL
regardless of their work timings, participating in activities like swimming, jogging and other
physical activity to decrease the level of fatigue. In addition, nurses are modifying their diet
with proteins, nuts and whole grains, maintaining an active family and social life, consuming
their lunch in quiet place and monitoring personal health to bring down the levels of fatigue
(Ledoux, 2015). With the implementation of these strategies, nurses will feel more active and
fresh, which will help in enhancing their work environment, thereby reducing the fatigue
levels (Linsey M. Steege & Pinekenstein, 2016).
The nursing workforce plays a vital role in dealing with the challenges faced by the
healthcare system. The profession of the nurses has power which are harnessed by the
establishment of optimum conditions of unity among the nurses, thus their potential being
fulfilled (Whittington, 2002). Nursing has ranked highest in the Gallop poll for 16 years, for
the profession’s honesty, standards and ethics. This may also have some bearing on the
perspective that fatigue is ‘part of the job’ for nurses and can be considered when discussing
the issues surrounding nurses being responsible for acts of violence and aggression (Jones &
Lyneham, 2001; Lyneham, 2001). Phillips (2016), report that females tend to have higher
incidence of compassion fatigue than males. However, a study by Roberto Mercadilo on
Brain gender disparities, suggested that the experience of both the gender in terms of the
compassion is not different. However, the study suggested further, that there might be
differences in “how” the genders are experiencing compassion (Joseluisdiaz.org., 2019).
Further the study by Phillips (2016), also claims that, this compassionate difference may also
reflect the female dominance of nursing and their respective positions within facilities that
led to females being concentrated in the lower status and ‘caring’ jobs with greater face-to-
face contact (Phillips, 2016).

9PHD PROPOSAL
Background
Fatigue being a symptom of tiredness, can be experienced by any individuals but in
the field of healthcare, the fatigue is usually experienced more by the healthcare officials in
the emergency departments and other medical related issues. In addition, a study by Caldwell
et al., (2018) reported that Nurses feel fatigue more frequently than any other health
professionals because of their long shift timings and work load (Caldwell, Caldwell,
Thompson, & Lieberman, 2018). Currently, and projected into the future, the vast majority of
nurses in different countries will ? facing ? different type and level of fatigue during work in
a hospital. International studies have explored this experience from the perspective of nursing
students (Allchin, 2006; Van Rooyen, Laing, & Kotzé, 2005) new graduate nurses (Brisley &
Wood, 2004; Hopkinson, Hallett, & Luker, 2005; Tan et al., 2006) and nurses with several
years of experience (Costello, 2006; Dunn, Otten, & Stephens, 2005; Mok & Kam-yuet,
2002). The study found that caring for patients was challenging, confronting and causes
fatigue for nurses.
Fatigue is one of the main issues facing health care in Jordan, especially with nursing
staff in both public and private hospitals due to an increased number of people from war torn
countries fleeing across the border to the safe haven of Jordan (Higher Population Council,
2016).
Jordan is an Arab country that is located in Southwest Asia, which occupies an area of
89,000 km2 (Ahmad, 2014). Jordan the site proposed for this study is located in Middle East
with a population of roughly 10.061 million, of which 2.9 million are refugees, and Jordan
population is spread over twelve administrative governorates (Worldometers RTS algorithm,
2019). Jordan is divided into three regions that consist of; the central region comprising of
Amman, Balqa, Zarqa, and Madaba that constitutes about 62.8% of the total population with

10PHD PROPOSAL
a population density of 249.7 person per Km2. These area is served by Jordan University
Hospital (JUH), as the northern region including Irbid, Mafraq, Jarash, and Ajlouni, which
take 27.8% of the population with a population density of 55 person per Km2 which all of this
area served by King Abdullah University Hospital ( KAUH) (Ajlouni, 2011).
Jordan health care system is consisting of three main sectors: public, private, and non-
governmental organizations or international agencies as Ministry of Health and Royal
Medical Services comprises the public sector (Ministry of Health, 2016). There are 106
hospitals (31 public, 12 militaries, 2 university hospitals, and 61 private hospitals) with a total
bed capacity of 12,497 in addition to the Centre for Diabetes, Endocrinology and Genetics,
the King Hussein Cancer Centre, clinics and charity association. The total number of
registered nurses in Jordan was 25% for every 10000 people and all kinds of nurses was 45%
for every 10000. There are around 18500 nurses, 2700 (approx.) midwives and approximately
5000 associate nurses (Jnc.gov.jo., 2019). The healthcare system in Jordan comprises two
main sectors, the public and private sectors. Primary care clinics, hospitals, pharmacies and
ancillary services are comprised in these two sectors.
According to Jordan University Hospital web page (2019), JUH is the first university
teaching hospital in Jordan, lies North West of the Capital Amman campus of the University
of Jordan, annexed to the University of Jordan in 1975 under the Royal decree to become the
Jordan University Hospital. Furthermore, JUH is offering teaching and training programs for
students of healthcare faculties at the University of Jordan and other universities. JUH is
considered as one of the first teaching hospitals at the level of the Arab World and the Middle
East. Jordan University Hospital includes more than 25 specialized medical units it has (64)
specialty and a subspecialty in the different medical fields, and a bed capacity of 550. JUH is
a research and teaching center of excellence that provides training programs for students of

11PHD PROPOSAL
healthcare faculties it offered different training programs to (5928) nurses. JUH is recognized
as an international referral center in the Middle East.
The health sector in Jordan is characterised by the provision of quality and efficient
health services, which make it a distinctive regional medical centre in the Middle East
(Zamil, Areiqat, & Tailakh, 2012). The healthcare system in Jordan has grown tremendously
over the past two decades, with Jordan becoming “a referral medical station for clients in the
Middle East, especially those people from Arab Gulf countries” (Mrayyan, 2007, p. 83).
However, there are healthcare systems of different countries, which are facing challenges due
to different nursing issues like shortage of nurse staff (Blakeley & Ribeiro, 2008). The Jordan
health system is affected by the influx of Iraqi and Syrian refugees which leads to a high
demand on multiple health services and increases the workload and consequential fatigue
among health professions, especially nurses in hospital (WHO & High Health Council,
2019).
In Jordon, due to various issues like shortage of nurses, lack of supportive work
environment, poor work conditions and low income, the levels of fatigue have recently
increased among the nurses especially among male nurses. Because of which the nurses in
Jordon are looking for jobs in other countries (AbuAlRub, 2007; AbuAlRub & AL‐ZARU,
2008).
According to Ismail, Malak, and Alamer (2019), the data collected from the cross
sectional study conducted with 220 Jordon emergency nurses, which included measures of
Occupational Fatigue Exhaustion/Recovery Scale (OFER15) and Copenhagen Psychosocial
Questionnaire version Two (COPSOQ II) showed that there are high levels of fatigue among
male nurses in Jordan. A shortage of health provider in Jordon was prevalent due to the high
rates of turnover among nursing staff, especially in the Ministry of health (WHO & High

12PHD PROPOSAL
Health Council, 2019). Furthermore, the female (62%) to male nurse (38%) ratio in Jordan
reflects more female nurses in the workforce but the percentage of male nurses is higher than
the 10 % of male nurses in Western countries (BBC News, 2019) (Al-Maaitah & Shokeh,
2009). Polices and protocols in Jordanian hospitals are based on the Islamic law, Patients in
Jordan prefer same gender care such as bathing, that lead to increase the workload among of
nurses gender depending on patient gender (Ismail et al., 2019).
Apart from the fact that gender based care is preferred in Jordon, which is even
expected and lawful by Islam expectations, there are some experiences, which are derived
from the literature review conducted in Western Countries. The number of research studies
conducted in Jordon were focussed on burnout and compassion fatigue and only one study
was conducted work-related fatigue in emergency department, which showed that the levels
of fatigue among the nurses in Jordon are high (Ismail et al., 2019).
However, In Jordan, there have been limited published studies regarding fatigue
among nurses and the risk management strategies to reduce fatigue (Ismail et al., 2019). In
the Arab countries, the prevalence of fatigue is high among the nurses because the financial
systems and their health model are very weak, rapidly modified, overburdened and the
responds to the changes in the patterns of diseases and population status of health (Elbarazi et
al., 2017).
This study aims to identify fatigue and the individual risk management strategies used
by nurses and will describe the differences in fatigue expectations and experiences of male
and female nurses in Jordan.
Literature review
The health-related databases including MIDLINE, CINAHL, and SCOPUS were
searched for peer-reviewed studies published up to 2019. The search terms included (fatigue,

13PHD PROPOSAL
OR burnout, OR tiredness, AND “risk management” OR “prevent strategy” AND nurse* OR,
RN, OR “Registered nurse”). In addition, the researcher preferred the articles that were
published after 2008 and in the English language, in order to review the current statistics and
English being the universally known language, which helps the readers to understand
thoroughly. Many articles and research studies were excluded from the review including
articles that focused on specific populations rather than nurses.
For example, (industrial employees, paramedics, physicians, cancer patients, nurse students).
During the reviewed article process, the researcher focused on two points: 1) the prevalence
of work-related fatigue among nurses and 2) fatigue risk management among nurses. Most of
the literature was about fatigue, also fatigue among nurses in West Country as well as; there
are some of the studies in Middle East focusing on compassion fatigue, work-related fatigue
among nurses in the emergency department and intensive care unit. Subsequently, there was a
lack of researches about work-related fatigue among nurses in other hospital unit and
department in Jordan and fatigue risk management.
The field of nursing is affected by gender in three ways, which are interconnected.
Firstly, the nursing field is devaluated because it is often seen as “work of women”.
Secondly, the field of nursing is surrounded by the extreme labor of sexual division and the
medicine occupation by males, which results in over determining the inequalities of the inter-
occupations. Thirdly, inequalities based on gender has become an issue because of the
improved and developed predominant managerial elite of males (Black, 2016). The
expectations regarding the gender experience of the females were that the females were
conscious, as they believed that the significant factor behind the affection of their occupation
status is their gender, despite of the difference in the value judgments that they combined
with the fact. A small sector of nurses explained the differences in gender basis, that men
have careers while women, until they begin their family, have jobs (Chiarella, M., & Adrian,

14PHD PROPOSAL
2014). The number of male nurses in nursing represents a small number. Nevertheless, the
male nurses also experiences some gender related issues like those that they were not being
assigned of female patients, as the female patients were not comfortable with a male patient
and because of some stereotypical males, the non-stereotypical ones also suffered. Nurses
have different coping strategies to cope with the stress of job like controlling of conditions
based on the situation, monitoring the preventions of the situation, by seeking assistance, self-
control, by escaping and avoiding the situation and coping spiritually (McTiernan &
McDonald, 2014). All these strategies are quantitative, which used general predictions for
analyzing the coping methods.
Prevalence of Work-related Fatigue
There are many studies about work-related fatigue conducted among nurses in
different countries, including Western, European, and Eastern countries. However, it showed
a difference in degrees of the prevalence of nurses' work-related fatigue. The prevalence rate
of fatigue has been reported to be almost 30.9% and is very common among younger medical
personnel aged 20-29 years (Ho et al., 2013). The prevalence rate of fatigue in industries
varies and totally depends on the instruments used but usually is between 7 and 45%
(Shahraki & Bakar, 2011). The average incidence among the general population is in the
range of 18.3 to 27% (Dawson, Chapman, & Thomas, 2012). Many operating environments
are reported to have high fatigue prevalence, leading to health safety issues.
According to the Canadian Nurses Association and Registered Nurses Association of
Ontario in (2010) reported that a total of 55.5% of nurses suffered from fatigue during their
work, and 80% suffered from fatigue after work. Moreover, there is a study was conducted by
Hazzard, Johnson, Dordunoo, Klein, Russell, and Walkowiak in (2013) to assess work-
related fatigue among American post-anaesthesia care unit nurses the findings indicated that

15PHD PROPOSAL
the acute and inter-shift (recovery) fatigue were higher than chronic fatigue with average
scores (66.5 ± 19.3, 52 ± 18.6, 35.7 ± 17.2) respectively.
However, a qualitative study was conducted by Wolf, Perhats, Delao, and Clark
(2017) to assess the American nurses' experiences of working fatigue. The findings revealed
that the participants reported a high level of fatigue. Cochran (2014) conducted a study to
examine perceived work-related fatigue among 610 nurses in western North Carolina. The
results documented a high level of acute fatigue with a mean score of 67.2, moderate levels of
chronic and inter-shift (recovery) fatigue with mean scores of 47.1 and 52.1, respectively.
Steege and Rainbow (2017) indicated that all hospitals' nurses who participated in the study
were experiencing working fatigue
In Latin America, the prevalence of working fatigue among emergency nurses was
varied. The prevalence rate was 95.0%, while it was 52.0% in another study (Wolf et al.,
2017). In Eastern countries, a previous study was revealed that the Chinese nurses
experienced a high level of acute fatigue with average scores of 60.30 ± 22.02 and a high
level of chronic fatigue with average scores of 46.44 ± 23.33 (Huang et al., 2019).
However, a previous study by Sagherian, Clinton, Abu-Saad Huijer, & Geiger-Brown
(2017) indicated that 54.9% of Chinese nurses have complained of acute work-related fatigue
and 61.7% complained of chronic work-related fatigue. Ho, Lee, Chen, Chen, Chang, Yeh
and Lyu (2013) conducted a study among 1833 Taiwanese medical personnel including
nurses within two hospitals to assess the prevalence of work-related fatigue among health
care providers. The findings showed that 30.9% of nurses experienced work-related fatigue.
Furthermore, in Brunei Darussalam, the prevalence of work-related fatigue among
emergency and critical care nurses was 30.0% of acute fatigue, 36.0% of chronic fatigue, and

16PHD PROPOSAL
28.0% of inter-shift fatigue (Rahman, Abdul-Mumin, & Naing, 2016).In Europe, the previous
study found that 91.9% of nurses complained of working fatigue with a higher level among
female nurses (Van Mol et al., 2015). Furthermore, Jones, Hocine, Salomon, Dab, and
Temime (2015) found that 46.2% of French registered nurses and 52.1 % of aid nurses
reported having working fatigue.
According to Raftopoulos, Charalambous, and Talias (2012) reported a prevalence of
fatigue among nurses in Cyprus to be 91.9% in the overall sample of the study using a total
number of 1,482 subjects of which about 80% were female with a 93% higher prevalence rate
of fatigue than males with (87.5%) (p = 0.003). Likewise, conducted a study among 112
nurses of Kermanshah hospitals and discovered the incidence rate among male and female
nurse were 56.8% and 43.8% respectively (Yarmohammadi et al., 2017). The prevalence of
work-related fatigue among nurses and other medical personnel was higher than that of the
administrative workers and was due to overtime work pressure (Ho et al., 2013).
Type of Work-related fatigue
According to The University of Western Australia (2016) defined work-related
fatigue is “mental or physical exhaustion that stops a person from being able to function
normally as a result of prolonged periods of physical and/or mental exertion without enough
time to rest and recover”. Work-related fatigue can be classified into three types; acute
fatigue, chronic fatigue, and inter-shift (recovery) fatigue.
Acute fatigue is defined as a feeling of lack of energy as a direct consequence of
previous work activities and it can be considered as a human protective response to work
demands (Winwood, Winefield, & Lushington, 2006, p. 438). Chronic fatigue is resulted
from high levels of acute fatigue in addition to insufficient recovery between work shifts
which persists even on rest days and holidays (Rahman, Naing, & Abdul-Mumin, 2017). As

17PHD PROPOSAL
well as the inter-shift (Recovery) work-related fatigue exists when nurses did not feel
recovered from a previous shift at the start of the next shift (Rahman et al., 2017).
Factors associated with fatigue
Fatigue defined as mental or physical exhaustion that stops a person from being able
to function normally as a result of prolonged periods of physical and/or mental exertion
without enough time to rest and recover (Rose et al., 2017). Many factors lead to nursing
fatigue inside and outside workplace include physical, emotional determinants that are due to
excessive demands, insufficient recovery periods or enough sleep and workload (Cheryl A.
Smith-Miller, Shaw-Kokot, Curro, & Jones, 2014).
Causes of fatigue in the workplace can be assessed in three categories including
physical factors (i.e. lifting heavy objects or pushing it), environmental factors (i.e. extreme
temperature and wind), and mental factors, an extract invisible work (De Raeve, Vasse,
Jansen, van den Brandt, & Kant, 2007). Also, reported cases of nurses quitting their jobs due
to fatigue, exhaustion, emotional distress, and from working in an unfriendly workplace
(MacKusick & Minick, 2010). Work factors involving physical and mental demands that
effect on nursing such as lack of planning in relation to the work activities, rosters, and work
shifts; standing for long periods of time and environmental conditions (e.g., work demand)
are major causes of fatigue (Ferri et al., 2016).
Furthermore, other factors that contribute to fatigue outside of workplace affecting
recovery are lifestyle factors including alcohol or drugs misuse, lack of regular exercise,
sedentary behaviour like a pattern of work and sleep habits, which involve less activity,
physiological factors like circadian rhythms. In addition, psychological factors (e.g., stress,
alertness, and sleepiness), demographic factors (e.g., age, gender, marital status, and income)

18PHD PROPOSAL
and having a poor diet, are further complicating factors affecting the recovery (De Raeve et
al., 2007; RNAO, 2019). Various factors such as age, smoking, and job category were
reported to contribute to the onset of fatigue in nurses (Ho et al., 2013)
Consequences of work-related fatigue
Evidence has shown that employees experiencing fatigue at work
complain about many effects, including slow reaction time, reduced alertness, weakened me
mory, impaired concentration, irritability and unsafe decision-making (Ardichvili &
Manderscheid, 2008; Khalafi et al., 2017). Studies reported that the fatigue among nurse
personnel not only hampers patient safety but also enhanced the risk of Needle stick incidents
among the health caregiver (C. A. Smith-Miller, Harden, Seaman, Li, & Blouin, 2016).
Moreover, absenteeism, decreased job satisfaction, and leaving job among nurses increased
due to work-related fatigue (Botha, Gwin, & Purpora, 2015). Nurses who experienced
workload in clinical practice had complained more about fatigue than those without such
experience. Equally, nurses who had less number of resting time in their work had more
incidents of fatigue (Ann E Rogers, 2008).
Conversely, nurses with a Master’s degree qualification, nurses with evening and
overnight shifts, nurses who had dissatisfied with their work are reported to have a higher
percentage of work-related fatigue. Moreover, the psychological and physiological factors
that have a direct effect on work-related fatigue can be quantified. According to the study for
a different level of fatigue was measured among the randomly selected sample (n = 112)
nurses working in Kermanshah hospital. They found that 67.9% of total participants are
bound to have a low to moderate level of fatigue; 23.2% of the sample said that they had a
high level of fatigue (Yarmohammadi et al., 2017).

19PHD PROPOSAL
This may be attributed to the fact that nurses in Iran were mostly having less patients
to attend to during the period of the study. In addition, almost 8.9% of nurses had complained
about very high level of fatigue. The detection of various risk factors that are associated with
occupational fatigue will help in decreasing the work-related fatigue. The result of this study
also showed that more fatigue cases were reported among the evening and overnight shift
nurses in comparison to nurses who had rotational or morning shifts. It was also found that
the increased amount of work related fatigue can also create physical endeavour, physical
problems and lack of motivation in their work. Along with this, nurses experience more
drowsiness, which is reported to hamper patient safety. In hospitals, a 12-hour shift is very
much common among the nurses, and this is seen in most of the countries worldwide
(Dall'Ora et al., 2019; Estryn-Behar & Van der Heijden, 2012; A. E. Rogers, Hwang, Scott,
Aiken, & Dinges, 2004).
In summary, fatigue is associated with-
 medication errors in the clinics (Hammoudi, Ismaile, & Abu Yahya, 2018)
 sleep disturbance among nurses and medical personnel (Sun, Ji, Zhou, & Liu, 2019),
 cortisol level irregularities (Patacchioli, Angelucci, Dellerba, Monnazzi, & Leri,
2001),
 mental health disorders (Harvey, Wessely, Kuh, & Hotopf, 2009)
 poor decision making (Mullette-Gillman, Leong, & Kurnianingsih, 2015) and
 musculoskeletal disorders which are majorly reported problem bedevilling health
workers globally (Kant et al., 2003).

20PHD PROPOSAL
Management of fatigue
Because there are multiple causes of fatigue in the workplace, there is no single
comprehensive measure to manage or reduces fatigue in a profession like nursing (Caldwell
et al., 2018). However, there are two categories of preventive measures that are reported by
Dawson et al. (2012); preventive strategies applying before working hours and during rest
times, and operational strategies that are used during work and/or refinery operation. The
different methods employed in the past to reduce fatigue to the minimum and majority were
reported to relieve fatigue symptoms effectively. Also, there are Some of methods including
minimizing sleep loss, naps during night shifts, education of good sleeping habits to workers,
and acceleration in circadian adaptation to different shift types (Ferrara & De Gennaro, 2001;
Pasupathy & Barker, 2012).
Gender experience and expectation
Gender-related expectations and experience regarding nurse’s feelings and
perceptions of fatigue may provide useful information regarding how to tackle and manage
the fatigue itself in the hospital community. Gender is not a predictive factor for fatigue
because several findings on difference among male and female in terms of gender yielded
inconclusive results especially on their relationship strength and direction. Some studies
reported women to have suffered fatigue more than men (Adebayo & Ezeanya, 2010; Dyrbye
et al., 2011), while several others reported a contrary findings (Maccacaro et al., 2011;
Purvanova & Muros, 2010). Other studies reported no difference between male and female in
terms of fatigue (Adekola, 2012).
In Jordan, major population (92% approx.) practices Muslim as their religion and the
basic culture of Jordan is somewhat similar to the other Middle East countries. The different

21PHD PROPOSAL
cultural beliefs of the Islamic society regarding women are astonishing. They often believe
that Muslim men and women are not equal, that is women cannot be valued equally with
men. Men are superior in every aspect, than women, as stated by the Holy Qur’an, meaning
that women are to be deputy to men (Watt, 2017). One of the contradictory statement of the
society is, that they say that Allah has no gender and body, but at the same time they always
refer Allah as “He”. The limitation of the women’s education, employment, transportation,
making them dependent on men are quite few things, which are practiced in the society
(Joshanloo, 2013). Jordan has the lowest participation of women in workforce and around
14% in the formal sector (Richerson & Christiansen, 2013). The society wants the women to
have a submissive nature, thus the women are implied to lower down their eyes and speak
softly, but when it comes to men, there are no restrictions; they are free to do whatever they
want. The Islamic law of Sharia is still applicable even today, restricting and prohibiting
women from their freedom, happiness and opportunities (Saeed, 2017). Based on this, there is
no doubt that the women working as nurses in healthcare environment faces many challenges
and it is difficult for them to cope with these challenges. However, as nursing as a profession,
seems to be of care and kindness by the people in the society. Involvement of men in this
field, might be insulting for them because men are not supposed to work equally with
women, as said by Qur’an, men are always superior (Musa, 2015).
Working with women, especially in Nursing, both men and women have different
aspects. The attitude of men towards women working is always negative; they always want to
be ahead of women (Melhem et al., 2016). According to men in Islam, women are supposed
to do household works, take care of their children and be submissive. It is astonishing to find,
that most of the women in Jordan are more educated when compared to men, almost 95% of
the women have attended university, but on the other hand the percentage of women
involvement in workforce is around 15%, which clearly explains the gender discrimination in

22PHD PROPOSAL
the society (Khater et al., 2015). The contribution of women in the economy of Jordan is
around 12%. The cultural factors play a vital role in participation of women in workforce,
because women are often not allowed to choose nursing as their profession due to night shifts
and married women are asked to leave their jobs, if their husbands earn well. However, with
recent developments and interests of U.S. and Jordanian Governments to economically,
empower women, including their rights, is an approach that might result in benefitting the
women in the society. The percentage of men in nursing profession is almost 36% and the
percentage of male students in nursing profession is almost 65%, as of 2000 (Shteiwi, 2015).
The number of women employed after their studies is less than the number of men employed.
The percentage of women in nursing field is also very low, because of the cultural and
regional barriers. However, the nurses employed, are also exploring jobs in other countries,
because of the low payment and the gender biased work environment (Albashtawy, 2013).
The opinions of female nurses towards nursing, is to provide effective and efficient
care and treatment to the patients, by building a therapeutic relationship with them, they try to
understand the patient’s conditions and very kind to them (Dincer, Torun & Aksakal, 2018).
However, the male nurses also have this perception towards nursing, but they think of the
patient’s treatment more as their jobs, as in they do not generate any emotional attachment
with them. In addition, the male nurses in Jordan have a negative attitude towards the women
who are Nurses, because they are working.
The nursing force percentage in Jordon is different from the gender percentage in
western countries, because of the patient’s preferences and believes. From a study conducted
on the preference of nurses in Jordon, it was reported that female patients believed and
preferred female nurses, because they think that female nurses are more thoughtful and have
the ability to enhance the morale of the patients when compared with male nurses (Shteiwi,

23PHD PROPOSAL
2015). However, male patients believed that male nurses were more suitable for nursing
profession, as male nurses have the ability cope and avoid with panic situations and they can
survive with the strain of emotions, when compared with female nurses (Ahmad & Alasad).
In Islam, the nursing practices have more of a holistic approach that the nursing practices in
Western countries. The approach includes the treatment of the patient’s ailments and
spiritually supporting the patient (Nasr, 2013).
Existing literature has not only documented a class but also a gender discrimination.
In the past, gender was used as yardstick to influence or hide fatigue (Widerberg, 2006). This
may be associated with how gender roles is shared in the clinic or hospitals for examples
women or men may likely prefer certain role or task to be done by them as a result, fatigue
experience may be varied between them depending on the type of hospital task given to them.
Illness-related pain and fatigue have been reported to be gendered. For instance, women were
reported to complain more about severe fatigue and illness-related symptoms than men
(Miaskowski, 2004) even though they are slightly more likely to report or present fatigue
complain to their physician(Fuhrer & Wessely, 1995). The physiology of the women when
compared to men, are found to be weaker. In addition, the rate of metabolism of women are
slow than the rate of metabolism of man, thereby leading to more weakness in woman than in
man. Although, women are weaker than men are physically, but mentally and socially they
are way stronger than men (Hardy et al., 2013). Female nurses are able to build the
therapeutic relationship with their patients, which the male nurses are sometimes unable to
build such relationships. Nevertheless, gender-related patterns in terms of fatigue and fatigue-
related experience shall be investigated in this study.

24PHD PROPOSAL
Study Aim
To identify work-related fatigue and describe the gender expectations and experience
regarding fatigue and individual risk management among nurses in Jordan.
Research questions
I. What are the differences with work-related fatigue among male and female nurses in
Jordan?
II. What are the direction and the strength of relationships between socio-demographic
factors and work-related fatigue among Jordanian nurses?
III. What are the risk management strategies for work-related fatigue used by Jordanian
nurses?
Research objectives
I. To measure levels of work-related fatigue among male and female Jordanian nurses
II. To identify the direction and the strength of relationships between socio-demographic
factors and work-related fatigue among Jordanian nurses
III. To describe risk management strategies for work-related fatigue used by Jordanian
nurses
IV. To describe and critique the differences in fatigue expectations and experience among
male and female nurses in Jordan
Research hypothesis
I. H0: There is no work-related fatigue among Jordanian nurses.
II. HA: H0: There is no significant difference between the percentage of gender and work-
related fatigue.

25PHD PROPOSAL
III. H0 = There is no relationship between socio-demographic factors with fatigue among
nurses in Jordan.
Significance of the study
Fatigue is one of the major problems among nurse (Ho et al., 2013).
Nursing leaders need creative, healthy and secure job environment policies that minimize the
fatigue of nurses while preserving nursing satisfaction and retention (Lothschuetz & Geiger-
Brown, 2010; Scott, Hofmeister, Rogness, & Rogers, 2010). Nurse leader and hospital
policymaker have a responsibility to address fatigue (Steege & Dykstra, 2016). Currently,
there is a lack of research exploring the fatigues experienced among the nurses in Jordan
(Elbarazi, Loney, Yousef, & Elias, 2017; Ismail et al., 2019).
Significance of this study
This study has potential to inform hospitals policy makers, nursing management, and
employers of the labour of various healthcare institutions on the present status of fatigue
among their employees. In addition, this study will also provide a means of tackling work-
related fatigue in the workplace. The feedback mechanism served by the study, on whether
nursing staff are satisfied with what is being offered to them as a way to reduce, or manage
fatigue among them or not is another significant of this study. Therefore, this following
research will be a breakthrough for health care department in Jordan to have a key reason
behind the fatigue amongst the nurses in both genders male and female. Moreover, the
guideline and stepping stone served by the study to some other researchers who want to take
up and investigate further; especially on any aspect of health and risk, management for work-
related fatigue is of immense significance. This study can also be reference material for other
researchers intending to carry out the relevant study.

26PHD PROPOSAL
Methodology
This section contains the methods and procedures that will be utilised in the process
of data collection and analysis. These processes cover the study design, study duration, study
location, sampling and recruitment, selection criteria, sampling frame, sampling calculation,
an instrument for data collection, validity and reliability of instruments, data collection,
quality control, and data analysis.
This study contains two complementary research method will use to capture multiple
forms of evidence in an integrated mix method approach, quantitative data in phase 1 and
qualitative data in phase 2. In this study, the most suitable and appropriate in order to identify
level of fatigue and describe and critique the differences in fatigue expectations and
experience among male and female nurses and describe nurses individual coping strategies
(personal management of fatigue) in Jordan.
Mix method design will be employed to explore this phenomenon from a different
angle, using a different type of data. Therefore, both qualitative and quantitative methods will
used to drive the study. The qualitative methods will help in understanding the thoughts and
opinions of the nurses and will assist to dive deeper into the proposed hypothesis ((Morgan,
2013)). On the other hand, quantitative methods using both structured and semi-structured
techniques will help in collecting data in terms of numbers, which can be used to deduce the
results (Creswell & Creswell, 2017). According to Fetters, Curry, & Creswel (2013)
integration is important to consider at the first stage of design, and conceptualization of the
study. Mix method research involving both qualitative and quantitative methods is a powerful
synthesis of multiple methods of inquiry and the visual display is a powerful synthesis data
and form (Tashakkori & Teddlie, 2010). The mix method design will be quite helpful for

27PHD PROPOSAL
deeper understanding of the proposed topic, as no study has conducted in-depth interviews
with Islamic nurses regarding fatigue issues previously.
Study design
In this research design, the researcher will use a sequential, descriptive, explanatory
mixed-method design to explore the nursing fatigue and individual risk management, the
gender experiences and the expectation of Jordanian nurse in two university hospital. In a
sequential mixed method, the quantitative and qualitative phases of the study occur in
chronological order (Teddlie & Tashakkori, 2009). Explanatory sequential design the first
phase of quantitative data collection and analysis is followed by the collection of qualitative
data, which are used to explain the initial quantitative results (Schoonenboom & Johnson,
2017).
The decision to use mixed-method design will base on several factors.
Firstly, this study required a methodological approach capable of collecting data from
multiple perspectives in a single study. Collecting data from both an epistemological and
ontological perspective will enable the experience to be accessed in a more comprehensive
manner than compare to the previously conducted international single studies. Single method
studies present only one perspective of the phenomenon being investigated and therefore the
understandings gained are incomplete (Whitehead, 2007).
A mixed-method design, therefore, will have the potential to further build upon the
nursing knowledge already known in this field by gaining a deeper and more holistic
understanding of the experience (Gillis & Jackson, 2002; Whitehead, 2007). Secondly, the
experience and the expectation of nursing is complex and multidimensional, necessitating a

28PHD PROPOSAL
study design capable of revealing the many layers embedded within the experience and
making them visible to others.
The two phases of this study comprise a descriptive survey and semi-structure
interviews. A brief description of each phase follows. Phase one of the study will involve a
descriptive survey of Jordanian nursing fatigue. This information supported the
implementation and interpretation of phase two of the study.
Phase two of the study will frame by the qualitative paradigm and implement
following completion of phase one of the study. The purpose of phase two will be to elicit the
gender experience and expectation of Jordanian nurses. Phase two of the study involve the
conduct of semi-structure interviews informed by van Manen (1990). This element provides
an opportunity to gain a deeper understanding of a previously unexplored aspect of this
experience.
Phase 1: A descriptive, explanatory phase using a self -administered questionnaire a
socio-demographic data and Occupational Fatigue Exhaustion/Recovery Scale (OFER15) to
collect data from nurses.
Phase 2: A sequential explanatory phase using face to face semi-structured interview
will be conducted with nurses to characterize the fatigue and their experience and expectation
and individual coping strategy.
Study location
This study will be conducted at Jordan University Hospital (JUH) and King Abdullah
University Hospital (KAUH), situated in Amman city and Irbid of Jordan, The justification

29PHD PROPOSAL
for choosing Amman city and Irbid regions is that they are generally, where most of the
largest healthcare facilities are located.
King Abdullah University Hospital is the largest medical institution in the north of
Jordan, which was established in 1994 and inaugurated in 2002. It serves approximately one
million inhabitants from the northern governorates; KAUH is a multispecialty teaching
hospital with 527 beds which can be increased up to 800 beds (King Abdulla University
Hospital, 2018). KAUH provides a wide range of health services and is considered as a
referral hospital for 4 cities in the North of Jordan, Services provided by KAUH are in high
demand (Zamil, Areiqat, & Tailakh, 2012). KAUH supplies facilities providing medical,
dental and nursing students with internships, laboratories, practical’s, and residency (King
Abdullah University Hospital, 2014). This hospital-employed a total staff of 1186 in 2013 at
the time of the study. (Alafi, Al-Qeed, & Alkayed, 2013).
Sampling population and selection
Participation in the study base on several inclusion and exclusion criteria: Nurses will
be eligible to participate in this study if they are registered Nurses or assistant nurse of both
genders, working in one of the nominated hospitals for this study, with age between 22-50
years old (this is because its age limits for nurses working in Jordan hospitals). The inclusion
criteria include nurses who are permanent and full-time staff in the two hospitals, have least
one-year working experience in either KAUH or JUH, have fixed work shifts, have agreed to
participate in the study and have also signed the informed consent form (to be shared to them
while collecting data). While Nurses who are temporarily employed, on vacation, or who are
not Jordanian will be excluded from the study. Not a registered nurse or assistant nurse (for
example, enrollment) will also be excluded from the study. The criteria are carefully defined
to avoid biases that may arise in carrying out the study.

30PHD PROPOSAL
Sampling frame
The sampling frame consists of a list of registered nurses who are workers with JUH
and KAUH.
Sampling techniques
The samples are to be drawn from the working class of registered nurses from the two
University Hospitals mentioned above. Each of the registered nurses is considered an
independent unit, and proportional sampling technique will be used to obtain the sample
population. This is because a proportional sampling method permits more representatives to
be obtained from the stratum or unit with a high percentage of the accessible population
while fewer representatives from the unit with a lower percentage (Chipman & Massey,
1960; Zhukovskii & Chashechkina, 1972).
Determination of sample size
To determine the sufficient number of sample required to represent the study
population, the highest available prevalence of fatigue (21.39%) reported in a study by Yu,
Hairong, Jiang, Anli, Shen, Jie (2016). For this sample size calculation the G power software
version 3.1 has been used.
standard error when α = 0.05 (95% Confidence Interval) = 1.96
q = 1-b=1.96
P = prevalence of fatigue = 21.39% or 0.21
d = Acceptable difference using 5% (0.05)

31PHD PROPOSAL
Therefore, N = number of sample size is 301. However, since we have two different
hospitals, we multiply 290 times 2 to get the total number of samples size required (301 × 2)
= 602.

32PHD PROPOSAL
Data collection process
Components of questionnaires
An Arabic translated version of the three instruments (Appendix A) will be used to
collect the socio-demographic data and work-related information from the study participants.
The precision of the translated questionnaires will be ensured through the use of an expert in
the field of English versus Arabic translation.
Moreover, Occupational Fatigue Exhaustion/Recovery Scale (OFER15) (Winwood,
Lushington, & Winefield, 2006). It comprises of three subscales: acute fatigue (five items),
chronic fatigue (five items), and inter-shift recovery (five items). Using seven-points Likert
scale, nurses requested to choose the response of strongly disagree, disagree, slightly
disagree, neither agree or disagree, slightly agree, agree, and strongly agree.
Semi-structured interviews
The researcher with the help of his supervisory committee will create a semi-
structured interview guide. During the interview, the nurses in both hospitals will be asked a
series of demographic questions. This will serve two purposes: firstly, it will assist in
breaking the ice and developing rapport, and secondly, information gained will provide
further context to participants. Although the research question seeks to explore be tally based
on prior research of fatigue and individual risk management among nurses and gender
experiences and expectations, the conduct of the interview process and during the interview
session will be audio-recorded and transcribed prior to the main analysis.
Occupational Fatigue Exhaustion Recovery Scale (OFER 15)
In order to perform the quantitative research, a survey will be conducted with a set of
open-ended questions using OFER 15 with a sector of nurses and the data collected will be

33PHD PROPOSAL
added in the software for further analysis of the results, which is further explained in the data
analysis section.
Quality control
Content validity
The members of the supervisory committee including an expert in public health will
appropriately assess the content of the questionnaires for clarity and will be reviewed by
whom to avoid errors and to ensure that the survey is appropriate to the targeted study
group.
Pre-testing of the questionnaires
Pre-test of the questionnaires will be carried out using 30 registered Jordanian nurses
to measure the reliability by Cronbach’s coefficient alpha in order to understand the barriers
of conducting the research and to determine whether nurses will be able to understand the
questions that are asked in the questionnaire. This will help the researcher to trace any
ambiguous items to the respondent and make it clear for them. The aim of the study and how
the questions should be answered will be explained to the nurses. Analysis of Cronbach’s
alpha will be placed under internal consistency result.
Face validity
This will be assessed based on the response of the respondents to the questions in
the questionnaire. About twenty nurses who are not part of the main study will randomly be
selected and be given the questionnaire for testing of its validity. The respondents will be
asked to indicate their views about the questionnaire regarding the questions and whether
they are understood easily and if the questionnaire seems to be appropriate to apply in

34PHD PROPOSAL
Jordan. Respondents’ comments on the questionnaire will be taken and corrections will be
made where necessary.
Data analysis
While collecting the data, data will be keying into the Statistical Package for Social
Sciences (SPSS) software version 23.0 and data analysis will be carried out using the same
software. The researcher will carry out the data entry and exploratory data analysis himself to
identify outliers, describe and check the assumption of normality distribution of continuous
data. The descriptive statistic will be carried out and express in mean, median, standard
deviations for continuous data while frequencies and percentages will be used to express data
for categorical variables for quantitative data analysis. Chi-square test will be used to
determine the association between socio-demographic characteristics and work-related
fatigue. Spearman correlation will be used to determine the association between dependent
variables. With the use of software G*Power, statistical power analysis will be done for the
qualitative analysis.
Mann-Whitney U will be used to determine the differences in median scores of the
dependent variables if the data are found not normally distributed otherwise parametric
equivalent will be carried out. Multivariate analysis will be carried out to determine the major
factors contributing to fatigue and fatigue risk management among Jordanian nurses.
Qualitative data shall be analysed with the help of conceptualization and use of ATLAS it
software package. This process allows the researcher to align the acquired data with the
constructed literature review to verify or disagree with it. The idea is to compare and contrast
the findings and eventually draw final verdict from the interviews conducted. This shall allow
the researcher to have in-depth details and themes driven from the primary qualitative data.
The significance level will be set at 0.05.

35PHD PROPOSAL
Ethical considerations
Ethical approval will be obtained from the Human Research Ethics Committees
(HRECs). Human Research Ethics Committee and the ministry of health in
Jordan. Also, both nominate hospitals (JUH and KAUH). Further, the other ethical
considerations would also fulfill, such as confidentiality of the information provided by the
nurses, privacy of key personal data, as well as the security of the nurses. There will be a
complete right of withdrawal offered to the relevant respondents, so as separate themselves
through the study, before the given timeframe.
Beneficence
Beneficence is an ethical principle that addresses the idea that human actions should
do well and prevent harm (Holloway & Galvin, 2016). The principle of beneficence will be
upheld in this research. In this study, there will be an opportunity to recount their experiences
and level of fatigue and the individual strategies to manage the level and the causes of
fatigue.
Non-Maleficence
The principle of non-maleficence is ‘the basic premise of above all, do no harm; it is a
duty not to injure others’ (Johnson, 1990). Participants will be informed the participation is
voluntary and that they can withdraw from the study without any consequences.
Autonomy
Autonomy means “participants must be able to make an informed choice, freely,
independently and voluntarily, without coercion” (Holloway & Galvin, 2016, p. 54).

36PHD PROPOSAL
Informed consent is a precondition for autonomous decision-making (Holloway &
Freshwater, 2007). All participants will be aged 22 years or more because the nurses of age
22 years must have recently completed their education, thus they must be updated with the
new norms and policies of the Nursing, than the ones who have completed years ago and will
be able to provide consent (Flinkman & Salanterä, 2015). In addition, the few experience of
the young Nurses will help in giving unbiased responses from the questionnaire. The
information sheet provided to them will contain a full explanation of the study (including the
purpose, inclusion criteria and requirements of participation) and will emphasize that
participation will be voluntary.
In the phase one descriptive survey study informed consent will be implied and
gained on two levels. The survey will be accompanied by a cover letter which informed
potential respondents of the study’s aims, the benefits to be gained and an outline of study
requirements.in phase two, the researcher will send the participant information sheet for all
interested participants and the consent form will be signed at the beginning of the interview.
Justice
The principle of justice refers to equal share and fairness (Miller, Birch, Mauthner, &
Jessop, 2012). In this study, all potential participants that enquire about the study and meet
the inclusion criteria will have the opportunity to participate. Each participant will receive the
same information about the study and the risks that may result from it, and will also be
informed that they have the right to withdraw from the study at any time.
Confidentiality
Each participant will be assigned an identification (ID) number stipulated in the
questionnaire prior to data collection. Data collected will be coded and placed in a file that is

37PHD PROPOSAL
fully protected and only accessible to the research team. Only the researcher and his
supervisor will have access to the storage data for downstream analysis. Once the data
analysis is completed, the data will be appropriately disposed in a manner of privacy and
confidential maintenance. When publishing the results of the analysis, it will be in a way that
will keep the participant's identity secret in the public domain.
Facilities and resources
Statistical Package for Social Science (SPSS) and R for Bioconductor programs will
be used in most of the data analysis either through Newcastle University or purchase.
Requisite funds for questionnaire printing will be sourced from the student consumables and
fieldwork expense allowance.
Gantt chart for study activities
Year Month Goals
2019 March-October  Complete Confirmation of
Candidature (CoC) document &
CoC by October 3, at 12 noon.
August – November  Complete HREA form and
submit.
 Await ethical approval before
commencing recruitment and
data collection.
December - March  Commence recruitment and data

38PHD PROPOSAL
collection
 Continue to work on the
literature review and methods
chapter and published 1.
2020 January – March  Continue data collection and
data analysis concurrently.
 Continue to develop literature
review and methods chapter.
2020 March – July  Finalise data collection and
analysis
 Write up findings chapters
2020 July – December  Finalise literature review and
methods chapters of the thesis.
 Write discussion chapter for the
thesis
 Complete first full draft of thesis
2021 January - May  Make revisions and finalise
thesis and submit.

39PHD PROPOSAL
 Aim to publish findings,
literature or other sections of the
thesis as appropriate and
discussed with supervisors.

40PHD PROPOSAL
References
AbuAlRub, R. F. (2007). Nursing shortage in Jordan: what is the solution? Journal of
professional Nursing, 23(2), 117-120.
AbuAlRub, R. F., & AL‐ZARU, I. M. (2008). Job stress, recognition, job performance and
intention to stay at work among Jordanian hospital nurses. Journal of nursing
management, 16(3), 227-236.
Adebayo, S., & Ezeanya, I. (2010). Effects of job autonomy, task identity and profession on
burnout among health workers in Jos, Nigeria. European Journal of social sciences,
14(1-2), 116-124.
Adekola, B. (2012). Work burnout experience among university non teaching staff: A gender
approach. International Journal of Academic Research in Business and social
sciences, 2(1), 128.
Ahmad, M. (2014). Jordanians knowledge and beliefs about cancer. Global Journal on
Advances in Pure & Applied Sciences [Online], 4, 38-41.
Ahmad, M., & Alasad, J. Who is preferred more in Jordan: Male or female nurses.
International journal of nursing practice, 13(4), 237-242.
Ajlouni, M. J. E. W. H. O. (2011). Jordan Health System Profile.
Albashtawy, M. (2013). Workplace violence against nurses in emergency departments in J
ordan. International nursing review, 60(4), 550-555.
Al-Maaitah, R., & Shokeh, D. (2009). The nursing workforce in Jordan: A policy oriented
approach. Amman: Jordanian Nursing Council.
Alafi, K. K., Al-Qeed, M., & Alkayed, W. (2013). Prevalence and factors affecting employee
satisfaction: The case of King Abdullah University Hospital in Jordan. International
Journal of Business and Management, 8(23), 40.

41PHD PROPOSAL
Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice &
Palliative Nursing, 8(2), 112-117.
Ardichvili, A., & Manderscheid, S. V. (2008). Emerging practices in leadership development:
An introduction. In: SAGE Publications Sage CA: Los Angeles, CA.
Aurich-Barrera, B., Wilton, L. V., & Shakir, S. A. (2012). Use and risk management of
carvedilol for the treatment of heart failure in the community in England: results from
a modified prescription-event monitoring study. Drug Safety, 32(1), 43-54. Retrieved
from http://ezproxy.uws.edu.au/login?url=http://ovidsp.ovid.com/ovidweb.cgi?
T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med6&AN=19132804
https://ap01.alma.exlibrisgroup.com/view/uresolver/61UWSTSYD_INST/openurl?
sid=OVID:medline&id=pmid:19132804&id=doi:10.2165%2F00002018-200932010-
00004&issn=0114-5916&isbn=&volume=32&issue=1&spage=43&pages=43-
54&date=2009&title=Drug+Safety&atitle=Use+and+risk+management+of+carvedilo
l+for+the+treatment+of+heart+failure+in+the+community+in+England
%3A+results+from+a+modified+prescription-
event+monitoring+study.&aulast=Aurich-Barrera.
Barker, L. M., & Nussbaum, M. A. (2011). Fatigue, performance and the work environment:
a survey of registered nurses. Journal of Advanced Nursing, 67(6), 1370-1382.
BBC News. (2019). Why are only one in 10 nurses men?. [online] Available at:
https://www.bbc.com/news/uk-scotland-48125231 [Accessed 5 Aug. 2019].
Black, B. (2016). Professional nursing-E-book: Concepts & challenges. Elsevier Health
Sciences.

42PHD PROPOSAL
Blakeley, J. A., & Ribeiro, V. E. (2008). Early retirement among registered nurses:
Contributing factors. Journal of Nursing Management, 16(1), 29-37.
Botha, E., Gwin, T., & Purpora, C. (2015). The effectiveness of mindfulness based programs
in reducing stress experienced by nurses in adult hospital settings: a systematic review
of quantitative evidence protocol. JBI Database System Rev Implement Rep, 13(10),
21-29. doi:10.11124/jbisrir-2015-2380
Brisley, P., & Wood, L.-M. (2004). The impact of education and experience on death anxiety
in new graduate nurses. Contemporary nurse, 17(1-2), 102-108.
Bryant-Lukosius, D. (2010). The clinical nurse specialist role in Canada: forecasting the
future through research. CJNR (Canadian Journal of Nursing Research), 42(2), 19-
25.
Burton, J. (2010). WHO Healthy Workplace Framework and Model: Background and
Supporting Literature and Practices. World Health Organization, Geneva. Retrieved.
Retrieved from
http://www.who.int/occupational_health/healthy_workplace_framework.pdfedn
Caldwell, J. A., Caldwell, J. L., Thompson, L. A., & Lieberman, H. R. (2018). Fatigue and its
management in the workplace. Neuroscience & Biobehavioral Reviews.
Canadian Nurses Association, R. N. A. o. O. (2010). Nurse fatigue and patient safety.
Retrieved from
http://www.cna-aiic.ca/CNA/practice/safety/full_report_e/files/fatigue_safety_2010_r
eport_e.pdf
Chipman, J. C., & Massey, M. T. (1960). Proportional sampling system for the collection of
an integrated auto exhaust gas sample. J Air Pollut Control Assoc, 10, 60-69.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/13809885.

43PHD PROPOSAL
Chiarella, M., & Adrian, A. (2014). Boundary violations, gender and the nature of nursing
work. Nursing ethics, 21(3), 267-277.
Cochran, K. R. (2014). A measure of perceived fatigue among nurses in western North
Carolina.
Corless, I. B., Voss, J. G., Nicholas, P. K., Bunch, E. H., Bain, C. A., Coleman, C., . . .
Holzemer, W. L. (2008). Fatigue in HIV/AIDS patients with comorbidities. Applied
Nursing Research, 21(3), 116-122.
Costello, J. (2006). Dying well: nurses’ experiences of ‘good and bad’deaths in hospital.
Journal of Advanced Nursing, 54(5), 594-601.
Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and
mixed methods approaches. Sage publications.
Dall'Ora, C., Griffiths, P., Redfern, O., Recio-Saucedo, A., Meredith, P., & Ball, J. (2019).
Nurses' 12-hour shifts and missed or delayed vital signs observations on hospital
wards: retrospective observational study. BMJ Open, 9(1), e024778.
doi:10.1136/bmjopen-2018-024778
Dawson, D., Chapman, J., & Thomas, M. J. (2012). Fatigue-proofing: a new approach to
reducing fatigue-related risk using the principles of error management. Sleep medicine
reviews, 16(2), 167-175.
De Raeve, L., Vasse, R. M., Jansen, N. W., van den Brandt, P. A., & Kant, I. (2007). Mental
health effects of changes in psychosocial work characteristics: a prospective cohort
study. J Occup Environ Med, 49(8), 890-899. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/17693787.
doi:10.1097/JOM.0b013e31811eadd3

44PHD PROPOSAL
Dincer, M., Torun, N., & Aksakal, H. (2018). Determining nurses’ perceptions of patient
safety culture in palliative care centres. Contemporary nurse, 54(3), 246-257.
Drury, V., Craigie, M., Francis, K., Aoun, S., & Hegney, D. G. (2014). Compassion
satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in
A ustralia: Phase 2 results. Journal of nursing management, 22(4), 519-531.
Dunn, K. S., Otten, C., & Stephens, E. (2005). Nursing experience and the care of dying
patients. Paper presented at the Oncology Nursing Forum.
Dyrbye, L. N., Shanafelt, T. D., Balch, C. M., Satele, D., Sloan, J., & Freischlag, J. (2011).
Relationship between work-home conflicts and burnout among American surgeons: a
comparison by sex. Archives of surgery, 146(2), 211-217.
Elbarazi, I., Loney, T., Yousef, S., & Elias, A. (2017). Prevalence of and factors associated
with burnout among health care professionals in Arab countries: a systematic review.
BMC Health Services Research, 17(1), 491.
Estryn-Behar, M., & Van der Heijden, B. I. (2012). Effects of extended work shifts on
employee fatigue, health, satisfaction, work/family balance, and patient safety. Work,
41 Suppl 1, 4283-4290. doi:10.3233/wor-2012-0724-4283
Ferrara, M., & De Gennaro, L. (2001). How much sleep do we need? Sleep medicine reviews,
5(2), 155-179.
Ferri, P., Guadi, M., Marcheselli, L., Balduzzi, S., Magnani, D., & Di Lorenzo, R. (2016).
The impact of shift work on the psychological and physical health of nurses in a
general hospital: a comparison between rotating night shifts and day shifts. Risk
Manag Healthc Policy, 9, 203-211. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/27695372. doi:10.2147/RMHP.S115326

45PHD PROPOSAL
Fetters, M. D., Curry, L. A., & Creswell, J. W. (2013). Achieving integration in mixed
methods designs—principles and practices. Health services research, 48(6pt2), 2134-
2156.
Flinkman, M., & Salanterä, S. (2015). Early career experiences and perceptions–a qualitative
exploration of the turnover of young registered nurses and intention to leave the
nursing profession in F inland. Journal of nursing management, 23(8), 1050-1057.
Fuhrer, R., & Wessely, S. (1995). The epidemiology of fatigue and depression: a French
primary-care study. Psychological medicine, 25(5), 895-905.
Gander, P., Hartley, L., Powell, D., Cabon, P., Hitchcock, E., Mills, A., & Popkin, S. (2011).
Fatigue risk management: Organizational factors at the regulatory and
industry/company level. Accident Analysis & Prevention, 43(2), 573-590.
Gillis, A., & Jackson, W. (2002). Research for nurses: Methods and interpretation: FA Davis
Company.
Hamdan, M. (2017). Burnout among workers in emergency Departments in Palestinian
hospitals: prevalence and associated factors. BMC Health Services Research, 17(1),
407.
Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication
administration errors and why nurses fail to report them. Scand J Caring Sci, 32(3),
1038-1046. doi:10.1111/scs.12546
Hardy, R., Cooper, R., Sayer, A. A., Ben-Shlomo, Y., Cooper, C., Deary, I. J., ... & Starr, J.
M. (2013). Body mass index, muscle strength and physical performance in older
adults from eight cohort studies: the HALCyon programme. PloS one, 8(2), e56483.

46PHD PROPOSAL
Harvey, S. B., Wessely, S., Kuh, D., & Hotopf, M. (2009). The relationship between fatigue
and psychiatric disorders: evidence for the concept of neurasthenia. J Psychosom Res,
66(5), 445-454. doi:10.1016/j.jpsychores.2008.12.007
Hazzard, B., Johnson, K., Dordunoo, D., Klein, T., Russell, B., & Walkowiak, P. (2013).
Work- and nonwork-related factors associated with PACU nurses' fatigue. Journal of
Perianesthesia Nursing, 28(4), 201-209. Retrieved from
https://www.scopus.com/inward/record.uri?eid=2-s2.0-
84880686113&doi=10.1016%2fj.jopan.2012.06.010&partnerID=40&md5=d46233c2
f8e751e6f018142ded16a999. doi:10.1016/j.jopan.2012.06.010
Higher Population Council. (2016). The national strategy for health sector in Jordan 2015-
2019. Retrieved from www.hhc.gov.jo/
Ho, Lee, M. B., Chen, R. Y., Chen, C. J., Chang, W. P., Yeh, C. Y., & Lyu, S. Y. (2013).
Work-related fatigue among medical personnel in Taiwan. J Formos Med Assoc,
112(10), 608-615. doi:10.1016/j.jfma.2013.05.009
Ho, J.-C., Lee, M.-B., Chen, R.-Y., Chen, C.-J., Chang, W. P., Yeh, C.-Y., & Lyu, S.-Y.
(2013). Work-related fatigue among medical personnel in Taiwan. Journal of the
Formosan Medical Association, 112(10), 608-615.
Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare: John
Wiley & Sons.
Hopkinson, J. B., Hallett, C. E., & Luker, K. A. (2005). Everyday death: how do nurses cope
with caring for dying people in hospital? International Journal of Nursing Studies,
42(2), 125-133.
Huang, H., Liu, L., Yang, S., Cui, X., Zhang, J., & Wu, H. (2019). Effects of job conditions,
occupational stress, and emotional intelligence on chronic fatigue among Chinese

47PHD PROPOSAL
nurses: a cross-sectional study. Psychology research and behavior management, 12,
351.
Ismail, K. M., Malak, M. Z., & Alamer, R. M. (2019). Psychosocial correlates of work-
related fatigue among Jordanian emergency department nurses. Perspectives in
Psychiatric Care.
Jnc.gov.jo. (2019). National Strategy for Nursing and Midwifery:A Road Map to 2025.
[online] Available at:
http://www.jnc.gov.jo/Documents/%D8%A7%D9%84%D8%A5%D8%B3%D8%AA
%D8%B1%D8%A7%D8%AA%D9%8A%D8%AC%D9%8A
%D8%A9%20%D8%A7%D9%84%D9%88%D8%B7%D9%86%D9%8A
%D8%A9%20%D9%84%D9%84%D8%AA%D9%85%D8%B1%D9%8A
%D8%B6%20%D9%88%D8%A7%D9%84%D9%82%D8%A8%D8%A7%D9%84%D8%A9
%20%D9%84%D9%84%D8%A3%D8%B9%D9%88%D8%A7%D9%85%202016-2025.pdf
[Accessed 6 Aug. 2019].
Johnson, J. L. (1990). Report of Faculty Perceptions of Community College of Maine
Instructional Television System: Spring, 1990: University of Southern Maine.
Jones, G., Hocine, M., Salomon, J., Dab, W., & Temime, L. (2015). Demographic and
occupational predictors of stress and fatigue in French intensive-care registered nurses
and nurses' aides: A cross-sectional study. International Journal of Nursing Studies,
52(1), 250-259.
Jones, J., & Lyneham, J. (2001). Violence: part of the job for Australian nurses? Australian
Emergency Nursing Journal, 4(1), 10-14.

48PHD PROPOSAL
Jordan University Hospital. (2019). Medical Tourism. Retrieved from
http://hospital.ju.edu.jo/medical/juhospital/Lists/HospPages_List/Disp_page.aspx?
UrlTitle=MedicalTourism
Joseluisdiaz.org. (2019). Perception of suffering and compassion experience: Brain gender
disparities. [online] Available at:
http://www.joseluisdiaz.org/wp-content/uploads/2011/04/PerceptionSuffering_MenW
omen_Mercadillo2011.pdf [Accessed 5 Aug. 2019].
Joshanloo, M. (2013). A comparison of Western and Islamic conceptions of happiness.
Journal of Happiness Studies, 14(6), 1857-1874.
Kant, I. J., Bultmann, U., Schroer, K. A., Beurskens, A. J., Van Amelsvoort, L. G., & Swaen,
G. M. (2003). An epidemiological approach to study fatigue in the working
population: the Maastricht Cohort Study. Occup Environ Med, 60 Suppl 1, i32-39.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12782745.
Khalafi, T., Mohebbi, S. R., Moradi, F., Khanipour, F., Mahmoudian, R., Montaseri, M., . . .
Ansari, M. (2017). The trend of antibiotic resistance of Staphylococcus aureus
isolated in clinical specimens in a referral hospital Shahid mohammadi hospital at
Bandar abbas, South of Iran (2009-2014). International Electronic Journal of
Medicine, 6(2), 53-57.
Khater, W. A., Akhu‐Zaheya, L. M., Al‐Mahasneh, S. I., & Khater, R. (2015). Nurses'
perceptions of patient safety culture in J ordanian hospitals. International Nursing
Review, 62(1), 82-91.
King Abdullah University Hospital. (2014). About the Hospital. Retrieved from
https://translate.google.com/translate?hl=en&sl=ar&u=http://www.kauh.jo/
&prev=search

49PHD PROPOSAL
Kubo, T., Takahashi, M., Sallinen, M., Kubo, Y., & Suzumura, H. (2013). How are leisure
activity and shiftwork schedule associated with recovery from fatigue in shiftwork
nurses? Sangyo eiseigaku zasshi= Journal of occupational health, 55(3), 90-102.
Kuguoglu, S., Aytekin, A., & Yilmaz, F. (2014). Burnout levels in neonatal intensive care
nurses and its effects on their quality of life. Australian Journal of Advanced Nursing,
31(2), 39-47. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0-
84898493452&partnerID=40&md5=72641655f2b36be13affbe4be0838259.
Ledoux, K. (2015). Understanding compassion fatigue: understanding compassion. Journal of
advanced nursing, 71(9), 2041-2050.
Lemeshow, S., Letenneur, L., Dartigues, J.-F., Lafont, S., Orgogozo, J.-M., & Commenges,
D. (1998). Illustration of analysis taking into account complex survey considerations:
the association between wine consumption and dementia in the PAQUID study.
American Journal of Epidemiology, 148(3), 298-306.
Lothschuetz, K. M., & Geiger-Brown, J. (2010). Is it time to pull the plug on 12-hour shifts?:
Part 2. Barriers to change and executive leadership strategies. The Journal of nursing
administration, 40(4), 147-149.
Lyneham, J. (2001). violence in New south wales emergency departments. Australian
Journal of Advanced Nursing, 18(2), 8-20.
Maccacaro, G., Di, F. T., Ferrai, P., Bonatti, D., Bombana, S., & Merseburger, A. (2011). The
effort of being male: a survey on gender and burnout. La Medicina del lavoro, 102(3),
286-296.
MacKusick, C. I., & Minick, P. (2010). Why are nurses leaving? Findings from an initial
qualitative study on nursing attrition. Medsurg Nurs, 19(6), 335-340. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/21337990.

50PHD PROPOSAL
McTiernan, K., & McDonald, N. (2015). Occupational stressors, burnout and coping
strategies between hospital and community psychiatric nurses in a D ublin region.
Journal of psychiatric and mental health nursing, 22(3), 208-218.
Melhem, G. A. B., Zeilani, R. S., Zaqqout, O. A., Aljwad, A. I., Shawagfeh, M. Q., & Al-
Rahim, M. A. (2016). Nurses’ perceptions of spirituality and spiritual care giving: A
comparison study among all health care sectors in Jordan. Indian journal of palliative
care, 22(1), 42.
Miaskowski, C. (2004). Gender differences in pain, fatigue, and depression in patients with
cancer. JNCI Monographs, 2004(32), 139-143.
Miller, T., Birch, M., Mauthner, M., & Jessop, J. (2012). Ethics in qualitative research: Sage.
Ministry of Health. (2016). General Information About the Ministry of Health. Retrieved
from https://jordan.gov.jo/wps/portal/Home/search/#/searchResults?q=health%20care
%20system%20composes%20of%20three%20major%20sectors
Mok, E., & Kam-yuet, F. (2002). The issue of death and dying: employing problem-based
learning in nursing education. Nurse Education Today, 22(4), 319-329.
Morgan, D. L. (2013). Integrating qualitative and quantitative methods: A pragmatic
approach. Sage publications.
Mrayyan, M. T. (2007). Nursing practice problems in private hospitals in Jordan: Students’
perspectives. Nurse Education in Practice, 7(2), 82-87.
Mullette-Gillman, O. A., Leong, R. L., & Kurnianingsih, Y. A. (2015). Cognitive Fatigue
Destabilizes Economic Decision Making Preferences and Strategies. PLoS One,
10(7), e0132022. doi:10.1371/journal.pone.0132022

51PHD PROPOSAL
Musa, A. (2015). Spiritual beliefs and practices, religiosity, and spiritual well-being among
Jordanian Arab Muslim university students in Jordan. Journal of Spirituality in Mental
Health, 17(1), 34-49.
Nagai, M., Morikawa, Y., Kitaoka, K., Nakamura, K., Sakurai, M., Nishijo, M., . . .
Nakagawa, H. (2011). Effects of fatigue on immune function in nurses performing
shift work. Journal of occupational health, 1107180194-1107180194.
Nasr, S. H. (2013). Islamic life and thought. Routledge.
Naviaux, R. K., Naviaux, J. C., Li, K., Bright, A. T., Alaynick, W. A., Wang, L., ... &
Gordon, E. (2016). Metabolic features of chronic fatigue syndrome. Proceedings of
the National Academy of Sciences, 113(37), E5472-E5480.
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International
Higher Education.
Pasupathy, K. S., & Barker, L. M. (2012). Impact of fatigue on performance in registered
nurses: Data mining and implications for practice. Journal for Healthcare Quality,
34(5), 22-30.
Patacchioli, F. R., Angelucci, L., Dellerba, G., Monnazzi, P., & Leri, O. (2001). Actual stress,
psychopathology and salivary cortisol levels in the irritable bowel syndrome (IBS). J
Endocrinol Invest, 24(3), 173-177.
Phillips, J. P. (2016). Workplace violence against health care workers in the United States.
New England journal of medicine, 374(17), 1661-1669.
Purvanova, R. K., & Muros, J. P. (2010). Gender differences in burnout: A meta-analysis.
Journal of vocational behavior, 77(2), 168-185.

52PHD PROPOSAL
Raftopoulos, V., Charalambous, A., & Talias, M. (2012). The factors associated with the
burnout syndrome and fatigue in Cypriot nurses: a census report. BMC Public Health,
12(1), 457.
Rahman, H. A., Abdul-Mumin, K., & Naing, L. (2016). A study into psychosocial factors as
predictors of work-related fatigue. British Journal of Nursing, 25(13), 757-763.
Rahman, H. A., Naing, L., & Abdul-Mumin, K. (2017). Validation of the Occupational
Fatigue Exhaustion Recovery (OFER) scale among emergency nurses in a Brunei
public hospital. The Malaysian Journal of Nursing, 8(3), 48-53.
RNAO. (2019). Preventing and Mitigating Nurse Fatigue in Health Care
Retrieved from https://rnao.ca/bpg/guidelines/preventing-and-mitigating-nurse-fatigue-
health-care
Richerson, P. J., & Christiansen, M. H. (Eds.). (2013). Cultural evolution: Society,
technology, language, and religion (Vol. 12). MIT Press.
Rogers, A. E. (2008). The effects of fatigue and sleepiness on nurse performance and patient
safety. In Patient safety and quality: An evidence-based handbook for nurses: Agency
for Healthcare Research and Quality (US).
Rogers, A. E., Hwang, W. T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The
working hours of hospital staff nurses and patient safety. Health Aff (Millwood),
23(4), 202-212. doi:10.1377/hlthaff.23.4.202
Rose, D., Seidler, A., Nübling, M., Latza, U., Brähler, E., Klein, E., . . . Wild, P. (2017).
Associations of fatigue to work-related stress, mental and physical health in an
employed community sample. BMC psychiatry, 17(1), 167.

53PHD PROPOSAL
Sadeghniiat-Haghighi, K., & Yazdi, Z. (2015). Fatigue management in the workplace. Ind
Psychiatry J, 24(1), 12-17. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/26257477. doi:10.4103/0972-6748.160915
Saeed, A. (2017). Freedom of religion, apostasy and Islam. Routledge.
Sagherian, K., Clinton, M. E., Abu-Saad Huijer, H., & Geiger-Brown, J. (2017). Fatigue,
work schedules, and perceived performance in bedside care nurses. Workplace Health
& Safety, 65(7), 304-312.
Schoonenboom, J., & Johnson, R. B. (2017). How to construct a mixed methods research
design. KZfSS Kölner Zeitschrift für Soziologie und Sozialpsychologie, 69(2), 107-
131.
Scott, L. D., Hofmeister, N., Rogness, N., & Rogers, A. E. (2010). An interventional
approach for patient and nurse safety: a fatigue countermeasures feasibility study.
Nursing Research, 59(4), 250-258.
Scott, L. D., Rogers, A. E., Hwang, W.-T., & Zhang, Y. (2006). Effects of critical care
nurses’ work hours on vigilance and patients’ safety. American Journal of Critical
Care, 15(1), 30-37.
Shahraki, S., & Bakar, N.-B. A. (2011). EFFECTS OF NERVOUS FATIGUE ON
WORKFORCE PRODUCTIVITY. International Journal of Academic Research,
3(5).
Shteiwi, Musa. (2015). Attitudes towards Gender Roles in Jordan. British Journal of
Humanities and Social Sciences. 12.
Smith-Miller, C. A., Harden, J., Seaman, C. W., Li, Y., & Blouin, A. S. (2016). Caregiver
Fatigue: Implications for Patient and Staff Safety, Part 2. J Nurs Adm, 46(7-8), 408-
416. doi:10.1097/nna.0000000000000366

54PHD PROPOSAL
Smith-Miller, C. A., Shaw-Kokot, J., Curro, B., & Jones, C. B. (2014). An Integrative
Review. Journal of Nursing Administration, 44(9), 487-494. Retrieved from
http://ezproxy.uws.edu.au/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=rzh&AN=107818140&site=ehost-live&scope=site.
doi:10.1097/NNA.0000000000000104
Steege, L. M., & Dykstra, J. G. (2016). A macroergonomic perspective on fatigue and coping
in the hospital nurse work system. Applied Ergonomics, 54, 19-26. Retrieved from
https://www.scopus.com/inward/record.uri?eid=2-s2.0-
84958087696&doi=10.1016%2fj.apergo.2015.11.006&partnerID=40&md5=2b6a6d4
64bf271e49127b0f434b57299. doi:10.1016/j.apergo.2015.11.006
Steege, L. M., & Pinekenstein, B. (2016). Addressing Occupational Fatigue in Nurses.
Journal of Nursing Administration, 46(4), 193-200. Retrieved from
http://ezproxy.uws.edu.au/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=rzh&AN=114455216&site=ehost-live&scope=site.
doi:10.1097/NNA.0000000000000325
Steege, L. M., & Rainbow, J. G. (2017). Fatigue in hospital nurses — ‘Supernurse’ culture is
a barrier to addressing problems: A qualitative interview study. International Journal
of Nursing Studies, 67, 20-28. Retrieved from
https://www.scopus.com/inward/record.uri?eid=2-s2.0-
84998610748&doi=10.1016%2fj.ijnurstu.2016.11.014&partnerID=40&md5=3d6772
36fb37d0358e855c1754f33dd9. doi:10.1016/j.ijnurstu.2016.11.014
Sun, Q., Ji, X., Zhou, W., & Liu, J. (2019). Sleep problems in shift nurses: A brief review and
recommendations at both individual and institutional levels. J Nurs Manag, 27(1), 10-
18. doi:10.1111/jonm.12656

55PHD PROPOSAL
Tan, J., Low, J. A., Yap, P., Lee, A., Pang, W. S., & Wu, Y. (2006). Caring for Dying
Patients and those Facing Death in an Acute-Care Hospital in Singapore: A Nurse s
Perspective. Journal of Gerontological Nursing, 32(5), 17-24.
Tashakkori, A., & Teddlie, C. (2010). Sage handbook of mixed methods in social &
behavioral research: sage.
Teddlie, C., & Tashakkori, A. (2009). Foundations of mixed methods research: Integrating
quantitative and qualitative approaches in the social and behavioral sciences: Sage.
The University of Western Australia, S. a. H. (2016). Fatigue Management. Retrieved from
http://www.safety.uwa.edu.au/health-wellbeing/health/fatigue
Van Manen, M. (1990). Researching Lived Experience: Human Science for an. In: Action
Sensitive Pedagogy Althouse Press, Ontatio.
Van Mol, M. M., Kompanje, E. J., Benoit, D. D., Bakker, J., & Nijkamp, M. D. (2015). The
prevalence of compassion fatigue and burnout among healthcare professionals in
intensive care units: a systematic review. PLoS ONE, 10(8), e0136955.
Van Rooyen, D., Laing, R., & Kotzé, W. (2005). Accompaniment needs of nursing students
related to the dying patient. Curationis, 28(4), 31-39.
Watt, W. M. (2017). Islamic philosophy and theology. Routledge.
Whitehead, D. (2007). An overview of research theory and process. Schneider, WD, Ed.,
Nursing & Midwifery Research. Methods and Appraisal for Evidence-Based Practice,
Elliott D. Mosby Publication, Sydney.
Whittington, D. (2002). Improving the performance of contingent valuation studies in
developing countries. Environmental and resource economics, 22(1-2), 323-367.

56PHD PROPOSAL
WHO., & High Health Council. (2019). The National Strategy for Health Sector in Jordan
2015- 2019. Retrieved from https://jordankmportal.com/resources/jordan-national-
health-sector-strategy-2015-2019
Widerberg, K. (2006). Embodying modern times: Investigating tiredness. Time & Society,
15(1), 105-120.
Winwood, P. C., Lushington, K., & Winefield, A. H. (2006). Further development and
validation of the Occupational Fatigue Exhaustion Recovery (OFER) scale. Journal of
Occupational and Environmental Medicine, 48(4), 381-389.
Winwood, P. C., Winefield, A. H., & Lushington, K. (2006). Work‐related fatigue and
recovery: the contribution of age, domestic responsibilities and shiftwork. Journal of
Advanced Nursing, 56(4), 438-449.
Witkoski, A., & Dickson, V. V. (2010). Hospital staff nurses' work hours, meal periods, and
rest breaks: A review from an occupational health nurse perspective. Aaohn Journal,
58(11), 489-497.
Wolf, L. A., Perhats, C., Delao, A. M., & Clark, P. R. (2017). Workplace aggression as cause
and effect: Emergency nurses’ experiences of working fatigued. International
Emergency Nursing, 33, 48-52.
Worldometers RTS algorithm. (2019). Population of Jordan (2019 and historical). Retrieved
from https://www.worldometers.info/world-population/jordan-population/
Yarmohammadi, A., Zangwill, L. M., Diniz-Filho, A., Saunders, L. J., Suh, M. H., Wu,
Z., . . . Weinreb, R. N. (2017). Peripapillary and macular vessel density in patients
with glaucoma and single-hemifield visual field defect. Ophthalmology, 124(5), 709-
719.

57PHD PROPOSAL
Yu, H., Jiang, A., & Shen, J. (2016). Prevalence and predictors of compassion fatigue,
burnout and compassion satisfaction among oncology nurses: A cross-sectional
survey. International Journal of Nursing Studies, 57, 28-38.
Yu, H., Jiang, A., & Shen, J. (2016). Prevalence and predictors of compassion fatigue,
burnout and compassion satisfaction among oncology nurses: A cross-sectional
survey. Int J Nurs Stud, 57, 28-38. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/27045562. doi:10.1016/j.ijnurstu.2016.01.012
Yuan, S. C., Chou, M. C., Chen, C. J., Lin, Y. J., CHEN, M. C., LIU, H. H., & KUO, H. W.
(2011). Influences of shift work on fatigue among nurses. Journal of nursing
management, 19(3), 339-345.
Zamil, A. M., Areiqat, A. Y., & Tailakh, W. (2012). The impact of health service quality on
patients' satisfaction over private and public hospitals in Jordan: a comparative study.
International Journal of Marketing Studies, 4(1), 123.
Zhukovskii, G. S., & Chashechkina, I. V. (1972). [Use of proportional sampling in clinico-
statistical research]. Sov Zdravookhr, 31(4), 21-25. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/4677528.

58PHD PROPOSAL

59PHD PROPOSAL
APPENDIX A: QUESTIONNAIRE
SECTION A: DEMOGRAPHIC INFORMATION
The following are questions on personal information of the respondents. Please tick (
) the appropriate answer and write where it is required.
1. Gender Male [ ]
Female [ ]
2.
Age (in years) ( )
3. BMI Height [ ]
Weight [ ]
3. Marital status Single [ ]
Married [ ]
Divorced [ ]
Widowed [ ]
4. Yes [ ]

60PHD PROPOSAL
Shift work
experience
No [ ]
5. Shift work Day [ ]
Night [ ]
A
BC
[ ]
[ ]
6. Unit of work ……………………………………………………………..
8. Is call required Yes [ ]
No [ ]
9.
Highest
educational
qualification
Bachelor degree [ ]

61PHD PROPOSAL
Master degree
[ ]
Doctorate degree
[ ]
10. Your rank Nursing officer [ ]
Senior Nursing
Officer
[ ]
Principal Nursing
Officer [ ]
Assistant Chief
Nursing Officer [ ]

62PHD PROPOSAL
Chief Nursing
Officer
RN [ ]
SECTION B: Occupational Fatigue Exhaustion Recovery Scale (OFER 15)
FOR QUANTITATIVE RESEARCH
Instruction: Please answer all questions, kindly CIRCLE your appropriate answer
(circle only one number that applied to you, please).
I. Occupational Fatigue Exhaustion Recovery Scale (OFER 15)
These statements are about your experience of fatigue and strain at work and home over
the last few months. Circle a number from 0 to 6 – “Strongly Disagree” to “Strongly Agree”.
# Questions
0 1 2 3 4 5 6
Strong
ly Dis-
agree
Dis-
agree
Slightl
y Dis-
agree
Neithe
r agree
or
disagr
ee
Slightl
y
Agree
Agre
e
Strong
ly
Agree
1 I often feel I’m ‘at the
end of my rope’ with

63PHD PROPOSAL
my work.
2
I often dread waking up
to another day of my
work.
3
I often wonder how
long I can keep going at
my work.
4
I feel that most of the
time I’m just “living to
work”.
5
Too much is expected
of me in my work.
6
After a typical work
period, I have little
energy left.
7
I usually feel exhausted
when I get home from
work.
8
My work drains my
energy completely
every day.
9 I usually have lots of
energy to give to my

64PHD PROPOSAL
family or friends.
10
I usually have plenty of
energy left for my
hobbies and other
activities after I finish
work.
11
I never have enough
time between work
shifts to recover my
energy completely.
12
Even if I’m tired from
one shift, I’m usually
refreshed by the start of
the next shift.
13
I rarely recover my
strength fully between
work shifts.
14
Recovering from work
fatigue between work
shifts isn’t a problem
for me.
15 I’m often still feeling
fatigued from one shift
by the time I start the

65PHD PROPOSAL
next one.
APPENDIX B: QUESTIONNAIRE FOR QUALITATIVE RESEARCH
Have you ever experienced fatigue in work environment? If yes, then When? and How was
the experience? What did you do about it?
Do you think fatigue can result in poor patient safety? Why?
What measure you take, when you experience fatigue?
What measures you take to avoid fatigue?
What all preventions are required to eliminate fatigue?
Do you think the long shift hours are the reason behind fatigue? Why?
According to you, what are the reasons, which leads to fatigue?
Does fatigue and drowsiness have same meaning? Explain.
When do you experience fatigue the most?
Do you think fatigue concerns your health? Explain.
Do you force yourself to get up and work, when you experience fatigue?
How often do you experience fatigue?
How often you need medical assistance because of fatigue?
How easily you experience fatigue?
Does fatigue makes it difficult for you to take decision? Explain.

66PHD PROPOSAL
How many times have you experienced fatigue? How have you cope up with the experience?
Justify your answer.
Do you think fatigue is different for male and female nurses in Islam (Jordan)?
What work as a nurse makes you tired?
What is your Gender?
What do you think of gender inequalities?
Do you think that there is influence of gender in the choice of conflict management style? If
yes, Why?
What do you think of working with the opposite gender?
Do you think that the opposite gender is better than you?
What kinds of rewards like financial or materialistic rewards keeps you motivated? Justify
your answer.
What do you think of both the genders working together?
Do you feel any kind of gender discrimination in working place environment? What solutions
can you provide to resolve the issues?
Do you think that the other gender is benefitted more? Justify your answer.
Do you practice stereotypical roles of gender on a regular basis? Justify your answer.
Do you think that females are more suitable for the Nursing profession than males? Justify
your answer.
Do you think women are weaker than men, both physically and mentally? Justify your
answer.

67PHD PROPOSAL
What do you think of work stress?
Have you ever been stressed at work? Explain.
What measures are suitable to cope with the stress?
How have you cope with the stress in your life?
Do you think work stress is good for better outcomes? Justify your answer.
In nursing, how do you cope up with your patient`s stress?
What are the dos and don’ts you need to focus, in order to cope up with the stress?
How do you encourage others to handle their stress?
Do you think of work stress as a challenge in the work environment? Justify your answer.
What are the coping strategies, you think organizations should perform, to reduce the stress
of the working environment?
Do you think stress during work is harmful for health? Justify your answer.
Understanding the Reliability and Validity of the questionnaire
The questionnaire’s reliability is to be done, to check whether the questionnaire is
reliable or not, by finding repetition of similar answers and measuring correlation coefficient
relation. The reliability of the questionnaire is done to understand the stability of the results
obtained, to ensure homogeneity measurement and to understand the inter-rater reliability. A
Senior Nurse Official will validate the above questions prepared and the feedbacks will be
incorporated within the questionnaire, before used for interviewing different nurses, in order
to evaluate the question’s quality, question’s ability and efficiently validate the proposal.
Thank you for your cooperation.

68PHD PROPOSAL