Development and psychometric evaluation of a workplace psychological hazards scale for operating room nurses

Abstract

Background

Assessment of psychological hazards in the operating room requires application of valid instruments designed to measure this type of hazards. The present study aims to develop and evaluate the psychometric properties of a workplace psychological hazards scale for operating room nurses.

Methods

This study is a methodological work carried out in two stages. In the first stage, a pool of items was created using the findings of a qualitative study. Subsequently, a systematic review of existing research across academic databases was performed to identify relevant constructs and generate additional scale items. Eventually, item analysis and validity and reliability tests were implemented to decrease the number of the items and evaluate the psychometric properties of the scale.

Results

Following iterative revisions, the initial 106-item pool was streamlined to 49 items. Redundant or ambiguous items were discarded based on expert feedback and assessment of face and content validity. Exploratory factor analysis identified seven latent constructs, including job stress, feeling incompetent in one’s role, bullying, ineffective communication, injustice, lack of emotional support, and burnout. The reliability of the scale was confirmed by internal consistency analysis, with a good Cronbach’s alpha (0.95), and test–retest analysis, with good values of interclass correlation (0.95).

Conclusion

By using the scale developed and tested in the present study, operating room managers can determine the psychological hazards which operating room nurses are exposed to. In addition, by identifying psychological hazards, more effective strategies can be developed and employed to manage the psychological well-being of the personnel.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05072-2.

Introduction

Occupational hazards in the workplace refer to the factors which can put the mental health and job safety of the personnel at risk [1]. In other words, any factor which disrupts the mental peace of the personnel is known as a psychological hazard. Stress, anxiety, depression, and burnout are psychological hazards which ensue from poor work conditions, lack of job security, ineffective organizational relationships, a negative work environment, and wrong organizational policies [2, 3]. The negative consequences of psychological hazards include a decrease in job satisfaction, poor performance, an increase in absence rates, and even physical issues, including cardiovascular disease and sleep disorders. These problems can inflict high costs on organizations [4]. Operating rooms are complex and hazardous environments with unique characteristics [2], where operating room nurses should work under stress for long hours [5]. In addition, operating room nurses are exposed to many biological, chemical, ergonomic, and physical hazards, including constant exposure to disinfectants, x-ray, anesthetic gasses, electrosurgery smoke, sharp objects, and the risks of standing for long periods and holding surgical tools. All of the above factors can increase the risk of psychological hazards for operating room nurses [6]. Other causes of psychological hazards for operating room nurses include working under pressure in emergencies, working shifts in an enclosed space, complexities in being familiar with specialized equipment and having advanced work skills, work overload [2], and exposure to hostile behaviors by patients and their companions [7].

A review of literature showed that the following instruments, among others, can be applied to assess the risk of psychosocial hazards or measure psychological health: Quality of Work Life (QWL) [8], Copenhagen Psychosocial Questionnaire (COPSOQ) [9], Brief Job Stress Questionnaire (BJSQ) [10], Work Stress Questionnaire (WSQ) [11], Perceived Stress Scale (PSS) [12], and Maslach Burnout Inventory (MBI) [13]. The global trend of globalization and computerization has resulted in major changes in professional and cultural contexts, which necessitates renewal of the existing instruments or development of new instruments. In addition, novel theories and approaches regarding concepts about psychological hazards, e.g. Stress-as-Offense-to-Self theory, underline the need for new scales designed to psychological hazards in work environments [14]. Several of the existing instruments have not gone thorough psychometric testing or the processes of their development and psychometric testing have not been explained. Also, many of these instruments do not specifically measure psychological hazards in workplaces and address other issues, including work organization hazards, task-related demands and control, and workplace physical environment and different aspects of well-being and social welfare. Furthermore, many of the above-mentioned scales are general and can be used for different types of work environments. The instruments which have been specifically designed for healthcare professionals measure one of the general aspects of psychological hazards, e.g. burnout or stress, and fail to address other important factors in care providers’ mental health, including support from managers, organizational justice, emotional demands and labor, bullying, and workplace violence. Thus, the available scales are limited in scope and do not address all the different aspects of psychological hazards.

In general, reviews of literature and academic reports show that there is a lack of a reliable and valid instrument for measuring psychological hazards in the operating room. For an instrument to be valid enough, it must address the various aspects of the concept or construct it has been designed to measure and consider the socio-cultural context and mindset of its target population. It should also be based on feedback from experts on the target phenomenon and an extensive review of literature. To plug the existing gap in the theoretical and applied knowledge, the present mixed-method study was conducted to develop and evaluate the psychometric properties of a scale for measuring operating room personnel’s psychological hazards.

Method

Design & setting

The present methodological study was carried out in two stages: (1) scale development (for generating items for the scale) and (2) psychometric evaluation (for refining the scale and evaluating the psychometric properties of the scale). The setting of the study was five teaching hospitals affiliated with a university in the largest city in southern Iran.

Stage one: scale development

In the first stage of the study, the construct and different dimensions of the concept under study were established. For item generation, the researchers used three sources to extract items: the findings from the interviews in a qualitative study, an extensive review of literature, and expert consensus. Initially, a pool of items was created using the findings of a qualitative study which investigated occupational hazards for operating room personnel via conventional content analysis. The participants of the study were 24 members of the operating room personnel who were selected by purposeful sampling. The data were collected through semi-structured interviews, observation, and document analysis [2]. In the present study, the quotes, codes, subcategories, and categories related to psychological hazards in that qualitative study were converted to measurable items.

To determine the construct of the scale, in addition to the findings of the above-mentioned qualitative study, the researchers conducted an extensive review of literature. Accordingly, all the relevant articles published in English, regardless of the time of publication, on PubMed, Science Direct, Google Scholar, Scopus, CINAHL, ProQuest, Embase, and UpToDate were extracted by the first author. To ensure a comprehensive search, the initial search was done using a combination of the keywords, including “psychological hazards,” “safety,” “hazard,” “questionnaire,” “risk factor,” “operating room,” “nurse,” “scale,” “tools,” “burnout,” “stress,” “bullying,” “job security,” “workload,” “work intensification,” “work-related stress,” and “psychometric evaluation,” and the Boolean operators AND and OR. The keywords were extracted from MeSH and the relevant articles were extracted according to appropriate syntax search in each database. The researchers also checked the gray literature on organizational websites, including AORN and WHO. The titles and abstracts of the extracted articles were examined by two of the authors, and any disagreements about selecting articles were discussed by all the authors until consensus was reached. All the articles published in English and related to the objective of the study were included. Repeated articles, irrelevant articles, and articles whose full texts were not available were excluded.

By the end of this stage, a pool of items had developed. In the course of development and psychometric evaluation of the scale, all the items were evaluated for reliability by a panel of experts, consisting of instrument developers, psychiatric nurses, operating room managers, clinical instructors, and operating room personnel. The inclusion criteria were having theoretical knowledge and clinical experience of practice in operating rooms, being familiar with the concept of psychological hazards, and being willing to participate in the study. By the end of this part of the study, the initial version of the psychological hazards for operating room nurses scale had been developed. All the participants consented to participate in the study and signed an informed consent form. The Participants were informed about the research objectives, voluntary nature of participation, their right to withdraw, and confidentiality of their information.

Stage two: psychometric evaluation

In this stage, the initial version of the scale was evaluated: item analysis and tests of validity and reliability were applied to decrease the number of the items, and the psychometric properties of the scale were measured.

Item analysis

The researchers used item analysis to determine which of the items on the initial version of the scale should be retained or eliminated. For item analysis, the Cronbach’s alpha and inter-item correlations should be calculated [15]. In the present study, item analysis was conducted with a sample of 40 individuals.

Validity analysis

The validity of a scale indicates the extent to which the instrument measures the target construct. In the present study, validity was measured in terms of face validity, content validity, and construct validity.

Face validity

To determine the face validity of the scale qualitatively, the researchers had 15 experts assess the items in a face-to-face interview. The experts consisted of 10 members of the operating room personnel and five faculty members from the operating room and psychiatric nursing departments. The face validity of the scale was tested quantitatively using the index of impact score of each item. Accordingly, 15 members of the operating room personnel were asked to rate each item on a 5-point Likert scale.

Content validity

To determine the content validity of the scale qualitatively, the researchers asked 15 experts on instrument development who were familiar with the concept of psychological hazards in operating rooms to rate the items in terms of syntax, vocabulary, placing, and scoring in writing. The content validity of the scale was tested quantitatively using content validity ratio (CVR), content validity index (CVI), and scale-level content validity index (SCVI).

Construct validity

The construct validity of the scale was tested via exploratory factor analysis (EFA). The suitability of the items was determined using the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test of sphericity. The subscales were extracted through EFA and principal components analysis with varimax rotation. For EFA, 5 to 10 subjects per item are required [16]. In the present study, 300 operating room nurses (more than six subjects per item) who were practicing in teaching hospitals were recruited by quota sampling: after the teaching hospitals were designated as strata, the number of operating room nurses in each hospital was set as the proportion of each stratum. For data collection, the first author visited the hospitals during morning, afternoon, and night shifts and asked the nurses who met the inclusion criteria to participate in the study. Sampling continued until the quota for each stratum was reached.

Reliability analysis

The reliability of the scale was measured to determine the internal consistency and stability of the scale. To determine internal consistency, the researchers calculated the Cronbach’s alpha and Spearman-Brown correlation coefficient of the scale. The stability of the scale was measured by calculating the test-retest reliability of the instrument with a two-week interval and determining the intraclass correlation coefficient (ICC) between the test results.

Statistical analyses

The collected data were analyzed in SPSS v. 22. The demographic characteristics of the participants were presented via descriptive statistics, including frequency, percentage, mean, and standard deviation. Item analysis was carried out using Cronbach’s alpha and ICC. In this method, each item must have a correlation coefficient of greater than 0.3 with at least one other item and the total score of the scale and a correlation coefficient of smaller than 0.7 with the other items [17].

The validity of the scale was measured in terms of face, content, and construct validities. Face validity was determined quantitatively using the item impact index: impact scores of greater than 1.5 were considered as satisfactory. The content validity of the items was measured using I-CVI and S-CVI. A CVR of equal to or greater than 0.46, I-CVI of greater than 0.79 [16], S-CVI/UA of greater than 0.70, and S-CVI/Ave of greater than 0.90 are considered as acceptable values [18].

Prior to factor analysis, sampling adequacy was tested. To determine whether the correlation matrix is an identity matrix, the researchers applied Bartlett’s test of sphericity, in which significant results indicate the need for further evaluation of the factorability of the data. As for construct validity, exploratory factor analysis (EFA) with principal component analysis and Varimax orthogonal rotation was conducted. A factor loading of 0.4 and above indicates the power and strong correlation of an item with the factor. The index of appropriate factor extraction is an eigenvalue of one or above with at least 50% of the variance [17]. For internal consistency, a Cronbach’s alpha of greater than 0.80, and for stability, test-retest results with an intraclass correlation coefficient (ICC) of greater than 0.70 indicate excellent reliability [19].

Findings

Scale development

In total, 43 items were extracted from the qualitative study, and 63 items emerged in the review of literature. In the meetings of the panel of experts, of the 106 items, 11 items were eliminated because they were repeated and 18 items were eliminated or merged because they overlapped. Eventually, 77 items made it to psychometric testing.

Psychometric evaluation

In this stage of item analysis, validity and reliability tests were conducted to screen the items and determine the psychometric properties of the scale.

Face validity

In qualitative evaluation of face validity, of the 77 items, 14 items which overlapped with other items were eliminated, leaving 63 items on the scale.

In quantitative evaluation of face validity, the impact score of all the items was greater than 1.5 and, therefore, none of the items was eliminated.

Content validity

In qualitative evaluation of content validity, the content of four items was found to overlap, and they were eliminated. Thus, 59 items made it to the next stage.

In quantitative evaluation of content validity, the CVR, CVI, and S-CVI of the scale were measured. CVR was determined by 15 experts who weighed the necessity of each item. According to Lawshe table, a score equal to or greater than 0.49 is considered significant and the item in question is retained. In this stage, 10 items were eliminated and 49 items were retained. In evaluation of CVI, the scores of all the items were greater than 0.79 and none of the items was eliminated. The S-CVI of the scale was measured by determining two indices: (SCVI/Ave) and (SCVI/UA), which were found to be greater than 0.8 (0.98) and 0.7 (0.85) respectively.

Item analysis

Prior to factor analysis, the items were analyzed using a sample of 40 individuals. In this stage, the reliability of the scale was tested using item analysis and found to equal a Cronbach’s alpha of 0.951. The correlation between all the items with the total score was greater than 0.3. Also, every item had a correlation of greater than 0.3 and smaller than 0.7 with at least one other item. Therefore, none of the items was eliminated and all the 49 items made it to factor analysis.

Construct validity

The construct validity of the scale was tested by exploratory factor analysis. Accordingly, in a descriptive survey, 300 operating room nurses selected by quota sampling completed the scale. The participants’ demographic characteristics are shown in Table 1.

Table 1.

Demographics of the participants

Variable		Absolute frequency	Relative Distribution (%)
Age (years)	Under 25	25	8.3
	26–30	117	39
	31–35	65	21.7
	36–40	65	21.7
	Over 40	28	9.3
Gender	Male	144	48
	Female	156	52
Marital Status	Single	151	50.3
	Married	149	49.7
Education	Associate degree in operating room nursing	46	15.3
	Bachelor’s degree in operating room nursing	244	81.3
	Master’s degree in operating room nursing	10	3.3
Work experience (years)	0–5	132	44
	6–10	95	31.7
	Over 11	73	24.3

Initially, sampling adequacy was calculated using the KMO test, which was found to be a satisfactory 0.934. Next, Bartlett’s test of sphericity was applied, and the results showed that chi-square equaled 7866.623 and was significant at P < 0.001 with a freedom degree of 300, indicating an acceptable execution of factor analysis given the correlation matrix obtained from the sample. The subscales of the instrument were determined by an analysis of eigenvalue greater than one, which demonstrated that the scale consisted of seven subscales which explained 56.140% of the variance. EFA was conducted using principal component extraction and varimax rotation to make the extracted constructs easier to interpret. The results showed that the variables which were highly correlated were within one of the seven subscales. The factor loadings of the items ranged from 0.406 to 0.763. At this point, since the factor loadings of all the items were above 0.4, none of the items was eliminated (Table 2).

Table 2.

Subscales extracted by EFA and their factor loadings

No.	Item	Factor loading	Variance (%)
Subscale 1: job stress			16.711
1	Working with some members of the surgical team makes me nervous.	0.649
2	Encounters with patients with severe injuries disturb me.	0.677
3	Encounters with patients with a contagious disease, e.g. AIDS and hepatitis, make me nervous.	0.588
4	Workplace hazards, e.g. exposure to x-ray and surgical smoke, disturb me.	0.408
5	Working with irresponsible colleagues gives me emotional distress.	0.518
6	Lack of job security is a constant source of agitation for me.	0.519
Subscale 2: feeling incompetent in one’s role			11.038
7	Lack of skill in some operations makes me feel incompetent.	0.537
8	Lack of opportunities for promotion in my job upsets me.	0.760
9	I feel I am not able to manage my work conditions.	0.763
10	I feel insecure when I address my questions to the other members of the surgical team.	0.746
11	Sensitive situations in operations make me nervous.	0.697
12	I find learning new work skills stressful.	0.652
13	Adverse work conditions incline me to neglect my duties.	0.572
14	The stressors in my job prevent me from having a satisfactory professional performance.	0.610
15	Work overload makes me mentally fatigued.	0.636
16	I feel guilty that I cannot give enough attention to my family because of my job.	0.654
Subscale 3: bullying			8.591
17	During operations, I am humiliated if I am not familiar with a piece of advanced equipment.	0.721
18	I am reprimanded for shortage of supplies that I am not responsible for.	0.711
19	I am reprimanded for no reason for the wear and tear of the surgical tools and other equipment.	0.660
20	I am disturbed when a surgeon intentionally throws a tool on the table.	0.483
21	I cannot stand it when the surgical team disrespects my human dignity.	0.471
Subscale 4: ineffective communication			5.593
22	The surgical team treats me in a cold and detached manner.	0.653
23	I feel that some surgeons see the other personnel as their slaves.	0.554
24	The members of the surgical team do not treat me with respect.	0.669
25	Being criticized by my superiors in the presence of others upsets me.	0.600
26	Conflicts with the members of the surgical team disturb me.	0.593
27	Being reprimanded for not performing tasks beyond my job description makes me nervous.	0.472
28	I am disgusted by some of my peers’ toadying to the surgeons or managers.	0.407
	Subscale 5: injustice		5.322
29	I am offended when the surgeons ask to work with certain members of the personnel.	0.591
30	Unfair allocation of facilities and rest areas to the doctors bothers me.	0.411
31	The considerable difference between the doctors’ and the other personnel’s incomes makes me feel worthless.	0.580
32	The unfair distribution of tasks between me and my peers disturbs me.	0.566
33	In the operating room, it is obvious that the doctors see themselves as superior to the other personnel.	0.485
34	It frustrates me that my income and benefits are not proportional to my efforts.	0.464
35	Delays in receiving my paycheck and benefits make me lose my motivation.	0.406
Subscale 6: lack of emotional support			5.115
36	In case of unintentional errors, I am not supported by the head nurse or managers.	0.627
37	The managers’ indifference to verbal or physical violence in the operating room bothers me.	0.622
38	Disregard for my views and suggestions makes me feel worthless.	0.612
39	My requests for selecting my shift are ignored.	0.664
40	Ignoring me in decision making makes me feel worthless.	0.536
41	At work, I am not given a chance to express my problems and concerns.	0.634
Subscale 7: burnout			3.411
42	Stress in the workplace has made me suffer from mental/physical issues, e.g. stomach pains, back pain, etc.	0.588
43	Experiencing pains in my back, hands, feet, or neck after prolonged shifts makes me anxious.	0.650
44	I think I am suffering from work fatigue.	0.631
45	Work fatigue makes me irritable in the face of problems.	0.581
46	Work overload makes me lose my concentration.	0.430
47	My work conditions have made me feel worthless and empty.	0.689
48	I have lost interest in my job.	0.496
49	I think I have suffered burnout.	0.669

At the end of this stage, the identified subscales were labeled based on their content: subscale 1 = job stress (6 items), subscale 2 = feeling incompetent in one’s role (10 items), subscale 3 = bullying (5 items), subscale 4 = ineffective communication (7 items), subscale 5 = injustice (7 items), subscale 6 = lack of emotional support (6 items), and subscale 7 = burnout (8 items).

To verify that the number of extracted subscales was accurate, the researchers also used a scree plot. The scree plot showed that the majority of the variance was explained by the seven subscales, and after the seventh subscale, the plot line was almost flat (Fig. 1).

Fig. 1.

A scree plot for the extracted subscales

Reliability analysis

The Cronbach’s alpha of the entire scale was 0.958, and the Cronbach’s alphas of the subscales of psychological hazards ranged from 0.68 to 0.84. A Spearman-Brown coefficient of 0.897 indicated that the internal consistency and reliability of the scale were satisfactory. The test-retest reliability results showed that the intraclass correlation coefficient (ICC) of the entire scale was 0.959 (P < 0.000). The ICCs of the subscales of the instrument ranged from 0.78 (P < 0.000) to 0.88 (P < 0.000) (Table 3).

Table 3.

Internal consistency and test-retest reliability

	Test-retest reliability
	Cronbach’s alpha		ICC	Pearson’s r
Factor 1	0.75		0.90	0.91
Factor 2	0.84		0.99	0.99
Factor 3	0.77		0.98	0.98
Factor 4	0.72		0.98	0.98
Factor 5	0.68		0.94	0.94
Factor 6	0.81		0.99	0.93
Factor 7	0.83		0.98	0.99

Determining the ease-of-use of the scale

The ease-of-use of the scale was determined based on the length of time required to complete the scale and the percentage of respondents who did not answer each item. The average length of time required to complete the psychological hazards scale was found to be five minutes (in the range of four to six minutes). The rate of non-response for the items of a questionnaire should be between 0 and 5%, as was the case with the present scale.

Floor and ceiling effects

The floor and ceiling effects apply when more than 15% of the respondents obtain the highest or lowest possible score on a scale. In the present study, the floor and ceiling effects were tested using a sample of 300 respondents. The results showed that less than 15% of the respondents obtained the maximum or minimum score on the entire scale and the subscales, indicating that the effects in question were absent in the scale.

Scoring

All the items on the present scale are scored positively. On a 5-point Likert scale (1 to 5) for all the 49 items, the minimum and maximum total scores are 49 and 245 respectively (Supplementary file 1). The cut-off point was determined using the subtraction of the maximum score from the minimum divided by three and it was found to be about 65. Accordingly, the lower score range was from 49 to 114, the middle range was from 115 to 180, and the higher range was between 181 and 245.

Discussion

The present study aimed to develop and evaluate a comprehensive and standard scale for measuring psychological hazards for operating room personnel. The developed scale encompasses a wide range of factors associated with psychological hazards, including job stress, feeling incompetent in performing one’s role, bullying, ineffective communication, injustice, lack of emotional support, and burnout. Psychometric evaluation of the scale showed that it possesses sufficient face, content, and construct validity and reliability for measuring psychological hazards in operating rooms.

Prior to developing a new measurement tool for a concept, it is essential to examine its various dimensions through a comprehensive literature review and expert consultation [20]. In the present study, the researchers conducted an extensive review of literature to create the pool of items and consulted a panel of experts consisting of many members. Items were refined from an initial pool of 106 to 49, eliminating redundancy and enhancing specificity. This process involved both quantitative (e.g., CVR ≥ 0.49) and qualitative (expert feedback) methods.

Generally, for psychometric evaluation of instruments, the two indexes of reliability and validity are measured. According to Hogan (2019), establishing on instrument’s validity involves examining its face validity, content validity, and construct validity [21]. As for reliability, DeVellis and Thorpe (2021) recommend measuring test-retest reliability, parallel forms reliability, and internal consistency [15]. In the present study, in addition to qualitative and quantitative face and content validity and construct validity, the researchers measured the reliability and consistency of the instrument. The scale’s strong content validity, construct validity, and reliability support its use in identifying psychological hazards in operating room settings. In all the stages of psychometric evaluation of the scale, i.e. face validity (measured qualitatively and quantitatively with 15 individuals), content validity (measured qualitatively and quantitatively with 15 individuals), construct validity (300 individuals), and reliability (40 individuals), sampling adequacy was observed.

The psychometric findings of this study demonstrate the robustness of the developed scale in assessing psychological hazards among operating room nurses. The scale exhibited excellent content validity (CVI = 0.98, SCVI/Ave = 0.98), ensured through iterative revisions by a panel of experts (including operating room nurses, psychiatric nurses, and instrument developers). EFA revealed a 7-factor structure explaining 56.14% of the total variance. These findings are consistent with prior research on job stress, burnout, and organizational injustice in stressful healthcare settings like operating theaters [5, 6, 13]. Polit and Beck (2018) recommend a cutoff value of 0.40 for factor loadings [16]. In the current study, all items had factor loadings above this threshold. The scree plot further validated the 7-factor solution, showing a clear elbow after the seventh factor. Internal consistency was high (Cronbach’s alpha = 0.95 for the full scale; subscales ranged from 0.68 to 0.84). Test-retest reliability (ICC = 0.95) indicated excellent temporal stability, critical for longitudinal monitoring of psychological hazards.

Among the most vital groups of professionals in the healthcare system, the operating room personnel are faced with various challenges in terms of occupational safety and health [2]. Research shows that psychological/emotional hazards are among the most serious occupational hazards in hospitals and can adversely affect operating room nurses’ work quality and health [22]. Toxic workplaces are characterized by negative behaviors, including bullying, discrimination, hostility, harassment, and lack of support, which have a negative impact on the personnel’s mental health, leading to increased stress, anxiety, and depression and poorer work outcomes [23]. In a descriptive study, researchers showed that most occupational hazards in hospital staff are associated with psychological hazards and biological hazards, ergonomics, safety, physical and chemical are the next category. Most occupational hazard related to orthopedic surgeon and the lowest occupational hazard associated with hospital statistics staff [24]. In a qualitative study in Iran, the operating room personnel referred to psychological hazards as a threat to their occupational health and safety. The researchers concluded that strategies should be developed to help the personnel manage their stress and workplace conflicts [2]. These findings underline the need for a scale which measures psychological hazards in operating rooms.

In the scale developed in the present study, six items address job stress. These items indicate that job stress is caused by certain negative experiences a care provider faces as a result of workplace hazards, work overload, irresponsibility on the part of one’s colleagues, encounters with patients in critical conditions, and job insecurity. A study in China found that 70.3% of operating room nurses were under job stress [25]. According to another study, the causes of job stress in operating rooms were excessive workload, poor control over one’s duties, unsatisfactory relationships with one’s colleagues, and lack of job security [26]. Another study reported that their duties, teamwork, technology, and time pressure exposed the operating room nurses to job stress [27]. In addition, the emergence of advanced surgical tools and procedures requires operating room nurses to upgrade their knowledge and skills, which can cause greater job stress among them [6]. Another stressor for operating room personnel in the present study was encounters with patients with a contagious disease, e.g. AIDS and hepatitis. On a similar note, the results of a study showed that the primary source of stress among the operating room personnel was fear of being infected by the patients [28]. Job stress for nurses correlates with less job satisfaction, inefficiency and reduction in the quality of nursing services, reduced retention, increased attrition, and burnout [29].

The second subscale, consisting of 10 items, is feeling incompetent in one’s role. The items of this subscale showed that the personnel experience incompetence when expectations of them exceed their abilities. Under these circumstances, the personnel question their own competence and feel inadequate, unsuccessful, and inefficient. Moreover, they feel that they have no control over their work conditions and see no prospects for growth in their career. Feelings of incompetence often ensue from unrealistic expectations, comparing oneself with others, and previous negative experiences and can undermine caregivers’ motivation and performance in their personal and professional lives [25]. In a study in Iran, one of the stressors in operating rooms was lack of skill [28]. In a qualitative study, the participants listed lack of self-confidence, fear of being judged, and feelings of incompetence as the primary causes of lack of psychological safety in operating rooms, which is consistent with the findings of the present study [30].

The third subscale, consisting of five items, concerns bullying. Bullying occurs when, due to complications in advanced operations, lack of supplies, and wear and tear of equipment, the personnel are exposed to constant criticism and verbal or physical violence. A review of literature shows that bullying can lead to mental health disorders, including burnout, anxiety, depression, and PTSD [31], as well as work-related issues, including decline in work quality, job satisfaction, and productivity [32]. The nurses who are in practice in hospitals, especially in intensive care and operating rooms, are not only at risk of physical hazards, but are prone to many psychological hazards, including verbal abuse, hostile threats, physical violence, and job stress [2, 33]. In a study in Turkey, among the healthcare personnel, operating room nurses were found to be at the highest risk of harassment and bullying [34]. The findings of qualitative and observational studies show that technical complications, lack of supplies, teamwork and inter-professional conflicts, time constraint, and emergencies in operating rooms expose the operating room personnel to psychological tension [2, 6].

The fourth subscale of the present instrument is ineffective communication. The seven items of this subscale indicate that negligence of the personnel’s feelings, ideas, and views leads to misunderstanding, cold relationships, and conflicts in the workplace. Similarly, other studies report that the major causes of ineffective communication in operating rooms are differences between professional roles and some surgeons’ sense of superiority over the other personnel and their overbearing attitude toward nurses [35, 36]. A study cited poor teamwork, ineffective planning, inadequate skills, and immediate need for decision-making as the mental stressors in operating rooms [28]. Exposure to discourteous behaviors or destructive relationships lead to fear, insecurity, disrespect, and despair in operating rooms [37]. Moreover, ineffective communication between the members of the surgical team can cause medical errors, including retention of surgical items in patients’ bodies or operating on the wrong organ [38, 39]. Operating rooms are among the most emotionally sensitive environments in hospitals, where professional relationships play an important role [35].

The fifth subscale, consisting of seven items, is injustice. Based on the items of this dimension of psychological hazards, injustice is lack of equal opportunities for job benefits. In this situation, individuals in similar professional roles do not enjoy the same social benefits, and certain groups receive fewer benefits for no reason. Likewise, a study reported that, from the nurses’ perspective, the most common form of professional discrimination was differentiating between nurses and doctors, as evidenced by the considerable gap between doctors’ and nurses’ salaries and benefits, doctors’ dominance, and unfair distribution of resources [40]. On the other hand, appointment of doctors to managerial positions and lack of similar opportunities for job promotion for nurses continuously widen the gap between doctors and nurses. These discriminatory practices have an adverse effect on nurses’ mental health and contribute to job dissatisfaction in clinical environments [2]. Injustice in the workplace can undermine the personnel’s motivation and work quality and lead to tension [41]. Experiencing discrimination is associated with stress, fatigue, and frustration and inclines the personnel to lose their commitment to their work, get involved in conflicts, and quit their jobs [40]. Moreover, discrimination can lead to vindictiveness, negligence, and hostility among the personnel [2].

The sixth subscale, consisting of six items, concerns inadequate emotional support, which refers to managers’ failure to support the personnel emotionally. This category encompasses showing disregard for the personnel’s views and requests, refusing to allow them to participate in decision-making, and not giving them a chance to express their concerns. A study in Iran found that head nurses’ disregard for nurses’ problems, the managers’ failure to support the personnel, and lack of empathy among the personnel adversely affected the mental health of operating room nurses, which is consistent with the findings of the present study [6]. In a qualitative study in Australia, nurse anesthetists’ experiences showed that ignoring their views and not involving them in decision-making by the other members of the surgical team exposed them to despair and loss of self-confidence [42]. Several studies have reported that support from their peers and managers improve operating room personnel’s mental health [2, 6, 30, 43].

The seventh subscale of psychological hazards, consisting of eight items, is burnout. Based on the items of this subscale, job burnout is a manifestation of extreme physical, emotional, and psychological fatigue, which results in physical pains, loss of concentration, absent-mindedness, feelings of emptiness and uselessness, and loss of interest in one’s job. Burnout is a long-term response to chronic stress in the workplace [44]. Maslach lists the following as the three main symptoms of burnout: excessive exhaustion, cynicism or loss of interest in one’s work, and feeling incompetent [13]. Studies also report that job stress is a contributory factor in burnout among operating room nurses [6, 43, 45]. Risk of job burnout is seven times greater in stressful work environments than in workplaces with low levels of stress [46]. Operating rooms are among the most stressful work environments, where nurses are exposed to high levels of physical and mental stress [25].

This study employed Exploratory Factor Analysis (EFA) to examine the underlying factor structure. The EFA approach was guided by three key considerations: [1] the factor extraction method [2], the number of factors to retain, and [3] the rotation technique. It should be noted that the distinction between EFA and Confirmatory Factor Analysis (CFA) is not always clear-cut, as they represent endpoints on an exploration-confirmation continuum [47]. Since the objective of this study was to identify the extracted factors, the researchers used EFA to assess the scale’s construct validity.

Strengths and limitations

The existing psychological hazards in operating rooms underscore the need for a reliable instrument for assessing the psychological state of the operating room personnel. Even though there are several scales which measure psychological hazards, none of them specifically addresses the psychological state of the personnel in operating rooms. Moreover, some of the available scales designed to measure psychological hazards have not had their reliability or validity tested properly or completely, which is one of their weaknesses. Another strength of the present study is that the items were developed using a variety of methods: qualitative research, extensive review of literature, interviews with the study population, and consultation with a panel of experts.

In the present study, the subscales were identified by exploratory factor analysis. Although EFA addressed the current study’s aims, subsequent validation through CFA is recommended to enhance the scale’s psychometric properties and generalizability. As the present scale was developed using an Iranian population, the findings of the study may not be transferrable to other countries. However, because the researchers conducted a review of literature to generate the items of the scale, it seems that the present scale can be used in other societies too. It is suggested that future studies validate this scale in other settings.

Conclusion

Because of the nature of their profession, operating room nurses are constantly exposed to psychological hazards, making this type of hazards a focus of interest in nursing studies. Prevention of work-related psychological hazards should be an integral part of preventive programs in healthcare organizations. Accordingly, managers should continuously evaluate the operating room personnel with regard to their exposure to psychological hazards, which requires application of standard tools. The present scale is a valid and reliable tool for measuring psychological hazards in operating rooms. Clinical managers can use the present scale to identify the current weaknesses and, subsequently, develop safety policies aimed at improving the mental health of the personnel and creating a safe work environment.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

QWL

Quality of Work Life

COPSOQ

Copenhagen Psychosocial Questionnaire

BJSQ

Brief Job Stress Questionnaire

WSQ

Work Stress Questionnaire

PSS

Perceived Stress Scale

MBI

Maslach Burnout Inventory

MeSH

Medical Subject Headings

AORN

Association of periOperative Registered Nurses

WHO

World Health Organization

CVR

Content Validity Ratio

CVI

Content Validity Index

SCVI

Scale-level content validity index

EFA

Exploratory Factor Analysis

KMO

Kaiser-Meyer-Olkin Index

ICC

Intraclass correlation coefficient

S-CVI /Ave

Scale-content validity index/ Average

S-CVI/UA

Scale-Content Validity Index/Universal Agreement

SPSS

Statistical Package for the Social Sciences

AIDS

Acquired Immunodeficiency Syndrome

PTSD

Posttraumatic Stress Disorder

Author contributions

CT was responsible for the study conceptualization and performed the data curation. CT and SA performed the investigation, and methodology. CT, MA, AF, and PT supervised the study. CT, SA, MA, PT and AF were responsible for data collection and analysis. CT, MA, and SA led the writing of the manuscript. All authors helped to reviewing and editing of the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The present article was extracted from a master’s thesis registered at Shiraz University of Medical Sciences, Shiraz, Iran (No. 29141), and was approved by the Ethics Committee of Shiraz University of Medical Sciences (Ethics code: IR.SUMS.NUMIMG.REC.1402.146). The research was carried out in accordance with relevant guidelines and regulations of Declaration of Helsinki. Informed consent was obtained from all of the participants in the study after clarifying the research objectives and introducing the researchers.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.