Occupational stress in nursing

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Abstract

This article reports the results of a study of occupational stress undertaken with a large sample of Northern Ireland nurses, including qualified staff (both community and hospital based) up to and including sister/charge nurses. This study formed part of a wider interprofessional study of nurses, social workers and teachers. Publications for the latter two professions, along with interprofessional comparisons, are in preparation and this present article focuses on the nursing cohort.

The design and methods are described and demographic characteristics of the nursing sample are provided with their views about nursing. Stressors are identified in both professional and private lives. The effects of stress as manifested through the General Health Questionnaire and the Maslach Burnout Inventory are examined and nurses’ views on various stress-coping strategies are discussed.

Introduction

“Nursing is, by its very nature, an occupation subject to a high degree of stress. Every day the nurse confronts stark suffering, grief, and death as few other people do. Many nursing tasks are mundane and unrewarding. Many are, by normal standards, distasteful, even disgusting, others are often degrading; some are simply frightening” (Hingley, 1984).

Some parts of the above statement may seem an exaggeration, as nurses work in many different places, and not all necessarily encounter every day the conditions described. Nevertheless, there is evidence to support the belief that nursing is stressful and that some causes of stress are found in all specialities.

If anxiety is a reflection of stressful work, then some of the work carried out in the late 1950s and early 1960s is relevant to this discussion. Revans (1976) described hospitals as being characterized by anxiety and referred to the cycle of anxiety, uncertainty and communication blockage, which appeared related to relationships between nurses at different levels in the hierarchy, staff turnover, and patient's well-being. Menzies’ (1960) study of nurses’ defences against anxiety indicated that a task-oriented, fragmented pattern of care spread the responsibility and limited nurses’ emotional involvement with patients, thus reducing sources of anxiety. This is, perhaps, a particularly important consideration now that nurses are being encouraged and educated to provide a more personal and less fragmented pattern of care, more responsive to the needs of their patients/clients, which may mean nurses themselves needing more support. Anecdotal evidence and published letters (e.g. Hammonds, 1985) suggest that this is so.

There is a growing body of research about stress in nursing and there are some general indications of the stressful nature of the job. For example, Occupational Mortality (1979–1983) (HMSO) figures indicated that the suicide rate for female nurses was significantly higher than the national average. In addition, a nurse's life expectancy at age 45 is 26.9 years, only 1 year more than a miner working below ground (25.9 years) (Morton-Cooper, 1984).

The Disciplinary and Investigating Committees of the General Nursing Council for England and Wales, then the main statutory body for nursing, in 1980 expressed increasing concern at the unacceptable pressures put upon nurses, some of whom were “trying to bridge the gap between the desirable and what is physically possible” (Nursing Standard, 1980). Those coming before the Disciplinary Committee are often “… overly kind, competent and caring people—the sort with a reputation for being reliable … who, when their employers expect them to do the impossible, will actually try to do just that” (Pyne, 1981, p. 93). This is in accord with the description of people most at risk of the ‘burn-out’ syndrome as, “over-committed and over-dedicated, taking on too much for too long a time, working too intensely (Freudenberger, 1975).

The way in which an individual interprets a situation is central in determining whether or not that situation is regarded as stressful (Cox, 1978). Commonly identified sources of stress (Bailey, 1985) are: workload, patient care, interpersonal relationships with colleagues, knowledge of nursing and nursing skills, types of nursing, bureaucratic-political constraints. However, these may also be sources of satisfaction (Claus and Bailey, 1980). Nurses in one coronary care unit were found to be more hostile, depressed and anxious, than nurses in medical-surgical wards, and to state more ‘dislikes’ about their working conditions. Yet this was not so for those in another unit, who had essentially the same duties, with the same kind of patients, in almost identical physical surroundings (Gentry et al., 1972). It appeared to be lack of adequate help to care for patients properly, lack of necessary continuing education, and lack of deliberate effort to instil pride and ‘team spirit’ in the staff, which made one unit more stressful than another.

Some of the research on stress in nursing has examined the topic in relation to specific areas of clinical practice, e.g. intensive care nursing or psychiatric nursing. A number of studies have examined stress in relation to working in intensive care units, (Vreeland and Ellis, 1969; Cassem and Hackett, 1972; Huckaby and Jagla, 1979; Jacobson, 1979; Oskins, 1979).

Stehle (1981) has reviewed findings on stress in critical care nursing. Although these are specialized units, many of the factors found to cause stress in nursing staff in these units will also apply in other nursing settings. Many of the stressors identified concerned working relationships between nurse and doctor and other health care staff, communication and relationships with patient and relatives, the high level of knowledge and skill required, the necessity to respond immediately in an emergency, the very high workload and understaffing, lack of support and inability to ‘escape’ for a break. Nichols et al. (1981) also found criticism of the level and adequacy of support and the lack of feedback from senior nursing staff. In the area of psychiatric nursing there is a dearth of research-based literature on stress, although Jones (1987) reviews much of the work that is available. From the descriptive writing available, two major sources of stress are identified, patient contact, and administrative and organizational factors. However, the empirical evidence indicates that it is the administrative and organizational factors which cause most stress in psychiatric nursing (Cronin-Stubbs and Brophy, 1984; Dawkins et al., 1985; Jones et al., 1987).

An American study examined the differences in stress and burnout among nursing staff in various clinical areas. Burnout has been described by Maslach (1976) as the condition when the professionals “lose all concern, all emotional feeling for the people they work with, and come to treat them in a detached or even dehumanized way”. Cronin-Stubbs and Rooks (1985) studied 296 nurses working on medical units, critical care units, in operating rooms, or in psychiatric mental health in three hospitals, and investigated stress, social support and burnout, and the relationship between them. It was found that the staff of the three hospitals differed significantly on the frequency and intensity of occupational stress and burnout. Including the factor of hospital as a block factor in subsequent analysis, findings were that: (i) lower amounts of positive stress (resulting from positive changes in life) and emotional support are associated with higher degrees of burnout and vice-versa. (ii) Critical care and medical nurses encountered occupational stressors more frequently and intensely than psychiatric and operating room nurses, (iii) Critical care nurses experienced significantly more affirmation (i.e. recognition by others and positive feedback on actions) than psychiatric nurses and operating-room nurses experienced significantly more aid (i.e. direct assistance) than psychiatric nurses, (iv) No significant differences in burnout were found in the four clinical settings. Other stressors, related specifically to clinical practice in various settings, have been reported. These include physical stressors such as lifting (Scholey, 1983), disturbance of life-style and circadian rhythms by night duty (Felton and Ward, 1977; Folkard and Haines, 1977), overheated conditions in theatre, and ethical dilemmas related to critical care units (Lawrence and Farr, 1982), long-term care of the aged, or other areas, and anxiety of health visitors about continued relationships with the family when involved with children with, or at risk of, non-accidental injury (Weeks, 1982; Graham and Livesley, 1983). Qualified staff on surgical wards and in operating theatres may also experience stress related to administrative, environmental, and staff relationship situations on operating days (Astbury, 1983).

While some causes of stress are related to the clinical work of the nurse, some is a result of the role and organizational pattern within which she or he works. The role of the ward sister is very important in organizing the delivery of patient care, and has been shown to be very complex. The network of contacts (individuals or groups) may account for the interruptions of the work of ward sisters observed by Lelean (1973), Pembrey (1980), Runciman (1983) and others. The latter found that three-quarters of the sister's activities lasted for less than 2 min, and approximately half less than 1 min. Although this study examined in depth the work of only nine sisters, this finding is similar to that of Ashworth (1982). She found that 82% of the contacts between nurses and patients on two surgical wards lasted for 2 min or less, and on three geriatric wards 80% of contacts were equally short. The same paper reports similar findings over 2 years later (Ashworth, 1985).

It may be that nurses themselves work in a fragmented way, but Runciman (1983) found that the interrupting contacts were rarely unnecessary and caused a great deal of frustration. The work pattern of fragmentation, interruption, responsibility and the numerous people contacting a ward sister, were commented on in the Committee on Nursing Report (1972). Runciman (1983) also refers to the ‘occult interruptions’, interruptions of thought in the sisters’ ‘buzzing mind’. MacDonald (1981) noted that the complexity of sisters’ work could not be judged only by overt activity. Being interrupted was ranked third in the list of sisters’ problems (below not ‘having enough contact with patients’, and having difficulty ‘finding time to talk with patients in a leisurely way’) (Runciman, 1983). The demands from many people, some of which conflict and are incompatible, have been found to cause role conflict in ward sisters (Redfern, 1981; Runciman, 1983), and they sometimes have insufficient control over their work, or authority. Sometimes there is uncertainty related to responsibilities, limits of authority, and colleagues’ expectations (Redfern, 1981). There can be lack of information or information overload (Runciman, 1983). Redfern (1981) found that those aspects of the job which caused problems could be divided into those related to the workload, and those which referred to organisational support.

Lack of positive or other constructive feedback from senior staff has been cited as a problem in a number of studies (Nichols et al., 1981; Redfern, 1981; Runciman, 1983; Ashworth, 1985), and there is much anecdotal evidence in the nursing press on feedback which is either negative or absent. The editorial written by a non-nurse in contact with many nurses through her job as editor of a national nursing journal is worth considering. “Of the many things which puzzled me when I first explored nursing and nurses, two remain a mystery. One is how horrible nurses are to one another—in the form of seniors victimizing juniors, or of a mutual refusal to acknowledge stress, or an intolerance of colleagues who crack physically or mentally” (Dunn, 1979).

Professional relationships have often been cited as sources of stress and it would be possible to analyse, in relation to this aspect of the nurse–doctor relationship, decision making about patient care. A recent British study (Hingley, 1984) of ward sisters and senior nurses in one health authority, identified a number of factors causing stress: workload (both in terms of quantity and inability to provide the quality desired), relationships with senior staff, role conflict and ambiguity, dealing with death and dying, conflict between demands of work and of home, lack of job satisfaction related to low professional status and limited promotion prospects, interpersonal relationships with patients and relatives and with colleagues and subordinates, inadequate physical resources, coping with change in technology and in professional developments.

There is scope for further studies to examine precise causes of stress in different clinical contexts, and to investigate methods of alleviating stress or coping with stress in a way that promotes health. There is some evidence of work stress in some people increasing activities that are detrimental to health, e.g. work describing smoking behaviours (Hawkins et al., 1982; Murray et al., 1983).

There have been a few recent studies that have examined causes of stress in different clinical contexts and the methods of alleviating or coping with stress that promotes health. Firth and Britton (1987) examined professional depression, ‘burnout’ and personality in long stay nursing. They found that a number of distinct ‘burnout’ responses were evident amongst staff, including not only ‘professional depression’ and depersonalization but also the avoidance of problems and decisions. Ambiguity about supervisors’ expectations and success in meeting such expectations, were associated with increased scores on each of these variables. Personality appeared to be related to staff's responses. Staff prone to direct hostility inwards on themselves were more likely to show an avoidance of problems and decisions. Those staff prone to direct hostility outwards were more likely to report an awareness of depersonalization towards others. Both these processes may, in different ways, affect patient care and relationships with other professionals.

Hare et al. (1988) examined predictors of burnout in professional and paraprofessional nurses working in hospitals and nursing homes. They examined interpersonal, intrapersonal, and situational factors expected to contribute to the six dimensions of burnout among nursing staff who worked in acute care and long-term care health facilities. The following research question was explored using a series of stepwise multiple regression analyses of the following variables: (i) interpersonal (professional exposure to patients with poor prognosis for survival, work relationships, informal support), (ii) intrapersonal (coping strategies, fear of death, comfort working with patients with poor prognosis for survival) and (iii) situational (personal and work demographies), which are significant predictors of the six dimensions of burnout in professional and paraprofessional nurses? Findings revealed that work relationships, tension-releasing and instrumental, problem-focused coping, were the most powerful predictors of burnout. Based upon this, it was concluded that nursing burnout is both an organizational and a personal problem. The study suggested interventions for reducing burnout, and these focused upon organizational issues such as supervisory support and peer relationships, and upon assisting staff to use instrumental coping strategies, perhaps through staff training and work-related counselling. However, given that facilities have the greatest control over organizational, rather than personal issues (Cherniss, 1980), improving quality of the work environment relationships would appear to be the most effective intervention, aimed at reducing the risk of burnout among nursing staff in both acute and long-term care facilities.

Continuing change and discussion of possible change, in the organization of health care delivery and the resulting demands on the ward sister are stressful in themselves. The increasing patient turnover, in the quest for efficiency, increases the workload and associated stress for all staff. Within nursing, changes in the approach to care resulting from developments in the profession's own thinking, and now required by the National Boards for Nursing, Midwifery and Health Visiting, are leading to the close involvement of each nurse with a smaller number of patients than previously was the case. In this context, the behaviour described by Menzies (1960) for minimizing anxiety, cannot be used. There is little evidence as yet about the effect of this on the levels of stress in clinical nurses. However, some health authorities have recognized the potential for stress in nursing and have set up counselling services. It is not clear what resources nurses draw upon to help them cope with stress resulting from their work. Within Northern Ireland the political situation may itself add to stress experienced by those in the caring professions, either directly or through the effect on their patients/clients.

No research on occupational stress in nursing has ever been carried out in N. Ireland. Even within the UK most studies have concentrated on managerial stress in nursing. This paper hopes to provide insights into stress among those who care for patients directly.

Section snippets

Design and methods

In surveying the literature on occupational stress, the similarities of the findings for a number of caring professions were noted. It was therefore decided to carry out an interprofessional study of nurses, field social workers, and teachers. In Northern Ireland, public sector health and social services are organizationally integrated and provided through four statutory Area Health and Social Services Boards. Because of the resources available to the project, it was decided to sample clusters

Demographic profile

Of the 171 nurses who responded, 7% were male and 93% were female, which reflects the gender distribution within these grades included in nursing. Twenty-three per cent were younger than 25-years-old, 43% were aged between 26 and 35, 19% were 36–45, 11% were 46–55 and 4% were 56 or over. The nursing samples were, therefore, a relatively youthful workforce with some 66% under 35. The grades of staff responding were staff nurse (49%), sister (16%), enrolled nurse (26%) and community nurses (9%).

Discussion and conclusions

There is no reason to suppose that the 171 nurses who participated in this study differ greatly from other nurses employed in statutory health and social services departments in other parts of the United Kingdom, except for the additional burdens attributed to the seemingly endless endemic politically motivated violence and the lack of effective political structures. However, although the nursing staff generally feels positively towards nursing, they report themselves as experiencing

Acknowledgements

In addition to the authors, the people listed hereunder have been members of a multi-professional research team which collaborated on this project. Their contribution to the work reported in this article is gratefully acknowledged: P. Ashworth, F. Gibson, D. Houghton, P. Nellis and R. Wilson, all from the University of Ulster.

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    This paper has previously been published in International Journal of Nursing Studies (1989) 26, 359–368.

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