Withstanding the Pressure ofthe Profession

Brinda K. McKinney, MSN, RN

Nurses often practice in chaotic, demanding work

environments. Understanding the negative impact these

environments have on nurses and patients is paramount

to halting this epidemic. Researchers’ decade-old call for

administrators and managers to correct this occupational

hazard is ineffective in decreasing the effects of prolonged

work-related stress on nurses. Staff development educators’

modeling proactive conflict resolution skills can empower

nurses to create therapeutic environments for themselves

and patients.

The world of clinical nursing is stressful and aggra-vating and may cause nurses to lose their focus.Learning to deal with work-related stress in a

proactive and positive manner may be the most importantskill set a nurse may acquire for a career in nursing. Notperfecting those skills could be detrimentalVnot only tothe nurse’s career but to himself or herself.

WORK-RELATED STRESS FOR NURSESIt is no secret that the nursing profession is a particularlystressful occupation. Florio, Donnelly, and Zevon (1998)studied oncology nurses and identified significant nega-tive effects related to constant stressors. Shaikh (2004)studied 216 nurses and noted that almost all nurses re-port severe or moderate stress that specifically links toworking conditions. Nedic, Jocic, Filipovic, and Solak(2002) suggested that job stress increases when there iseconomic crisis in the society such as the United States iscurrently experiencing. Likewise, Lindo, McCaw-Binns,LaGrenade, Jackson, and Eldemire-Shearer (2006) cau-tioned that although hospital work involves some verystressful situations, nurses are also affected by non-work-related stress such as family responsibilities and fi-nancial difficulties. While the public may be unaware of

these facts, most practicing nurses are all too familiar withthis kind of stress.

SPECIFIC STRESSORS IDENTIFIEDMultiple stressors have been repeatedly identified for thepracticing nurse. Florio et al. (1998) cited coworker stress,ethical concerns, inadequate resources, negative thoughts,physician-related stress, and death and dying as majorsources of stress for oncology nurses. Yang et al. (2002)identified the lack of resources and conflict with other pro-fessionals as significant sources of stress for nurses ingeneral. Nurses have consistently identified failure to meetpatients’ needs, self-expectations, workload, and inexpe-rienced coworkers as a real source of work-related stress(Hall, 2004); perception of not having control over a situa-tion increases work-related stress and burnout for nurses(Schmitz, Neumann, & Oppermann, 2000). Shen, Cheng,Tsai, Lee, and Guo (2005) studied psychiatric nurses andidentified high job demand, low job control, and lowwork-place support as significant occupational stressors. French,Lenton, Walters, and Elyes (2000) identified nine subscalesof nursing stress, which include death and dying, conflictwith physicians, inadequate preparation, problems withpeers, problems with supervisors, workload, uncertaintyconcerning treatment, patients and their families, and dis-crimination. Nedic et al. (2002) studied physicians, nurses,and laboratory workers for causes of job stress and identi-fied criticism at work, sense of responsibility, low reward,and low support and security at work as significant stres-sors. In a study to identify variables affecting job sat-isfaction, 1,780 registered nurses said issues with patientcare, nursemanagers, and salaries and benefits contributedto their dissatisfaction (Fletcher, 2001). Consequently,Zager and Walker (2005) maintained that the most criti-cal issue is that nurses need to feel supported in theirwork environment. Stressors that have been identifiedas hazardous, if prolonged, to the mental and/or physi-cal well-being of nurses are listed in Table 1.

These stressors are common among nurses in variouspractice settings. In addition, research shows that thesestressors are not limited to a geographical area but are ex-perienced by nurses in many cultures. Ward and Parsons(2000) asserted that stress is unavoidable in today’s fast-paced healthcare environment, and nurses must be alert

Brinda K. McKinney, MSN, RN, is Service Excellence Coordinator,Arkansas Methodist Medical Center, Paragould.

ADDRESS FOR CORRESPONDENCE: Brinda K. McKinney, MSN, RN,Arkansas Methodist Medical Center, 900 W. Kingshighway, Paragould,AR (e-mail: Brenda.McKinney@arkansasmethodist.org).

DOI: 10.1097/NND.0b013e31820eee6a

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to the signs and symptoms of stress and how to deal withthem.

NEGATIVE EFFECTS OF WORK-RELATEDSTRESS ON NURSESNurses experience numerous negative effects from work-related stressors. Florio et al. (1998) discovered thatnurses frequently experience increased health com-plaints, sleep disturbances, burnout, job dissatisfaction,clinical depression, anxiety, and increased interpersonalproblems. These significant work-related stressors contrib-ute to lower mental health scores for nurses (Shen et al.,2005). In addition, Laposa, Alden, and Fullerton (2003)found work-related stress clearly linked to depressionand burnout in the emergency department and noted thatthe accompanying interpersonal conflict was significantlyassociated with posttraumatic stress disorder. Exposure todaily work stress has been identified as a cause of posttrau-matic stress syndrome for Jordanian nurses ( Jonsson &Halabi, 2006). Yayli, Yaman, and Yaman (2003) studied152 nurses in a Turkish hospital and concluded that themajority of them had depressive symptoms and were inneed of counseling concerning coping styles. Studiesshow that high-stress jobs such as nursing elevate levels

of anxiety, depression, and psychological distress (Corpley,Steptoe, & Joekes, 1999). Kalichman, Gueritault-Chalvin,and Demi (2000) blamed high rates of occupational stressfor nurses’ vulnerability to emotional exhaustion, leadingthem to use avoidance as a coping strategy. In a study of125 nurses, Kerasiotis and Motta (2004) found significantlyhigh levels of anxiety because of the perceived lack of con-trol in numerous traumatic nursing experiences over alifetime. Ekedahl and Wengstrom (2006) noted that thecoping of nurses under significant work-related stress ismore likely to become dysfunctional when there is a lackof human support and boundary demarcation. Hambly(2004) claimed that work-related stress causes psychologi-cal, physical, and behavioral problems for nurses andasserted that prolonged stress can produce long-term pro-blems such as hypertension. MacDonald (2006) noted thatworkplace stress seriously affects female nurses, who arefive times more at risk for metabolic syndrome than menare in the same situation. A study examining the effects ofjob stress/strain on over 21,000 nurses concluded nursesare at higher risk for declining health because of job stressthan other professions (‘‘Work-related stress causes de-cline in nurses’ health,’’ 2000). Maher-Brisen (2007) citesaddiction as an occupational hazard due to the fre-quency of which prescription drugs are used by nursesto combat the effects of work-related stress. Orji, Fasubaa,Onwudiegwa, Dare, and Ogunniyi (2002) claimed thatnearly half of the 78 nurses they surveyed admitted usingdiazepam or alcohol to cope with the stress of work.Tomas-Sabado, Aradilla, and Guix (2004) studied 240registered nurses and confirmed a clear linkage betweenwork-related stress in nursing and the nurse’s inability toidentify and articulate feelings, especially in communicat-ing with work colleagues. These negative effects areintensely disabling for nurses.

EFFECTS OF WORK-RELATED STRESS ONPATIENTS AND INSTITUTIONSWork-related stress also has a detrimental impact on pa-tients and institutions. Sveinsdottir, Biering, and Ramel(2005) claimed that occupational stress directly increasesturnover rates and decreases job satisfaction, which re-duces the quality of nursing care for patients. Kalichmanet al. (2000) fault high stress rates for the occupationalburnout that nurses experience, which again affectspatients. Numerous additional studies show that workenvironment affects patient outcomes negatively(Laschinger, Finegan, Shamian, & Almost, 2001; Morgan,Semchuk, Stewart, & D-Arcy, 2002; Thyssen, Vaglum,Gronvold, & Ekeberg, 2000).

Abu (2000) noted that excessive work-related stressexperienced by nurses puts institutions at risk for litiga-tion under the Occupational Safety and Health Act of1970, which holds employers responsible for the mental

TABLE 1 Hazardous Stressors if ProlongedCriticism at work Low job control

Conflict with otherprofessionals

Low workplace support

Coworker stress Low reward

Death and dying Low security at work

Discrimination Negative thoughts

Ethical concerns Overwhelming sense ofresponsibility

Failure to meet patients’needs

Perception of not havingcontrol over situations

High job demand Physician-related stress

Inadequate preparation Problems with patients andtheir families

Inadequate resources Problems with peers

Inexperienced colleagues Problems with supervisors

Issues with nurse managers Uncertainty concerning treatment

Issues with patient care Unrealistic self-expectations

Issues with salaries andbenefits

Workload

Lack of resources

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and physical well-being of employees. Nedic et al.(2002) concluded that job stress affects institutions andthe healthcare industry through reduced work produc-tivity, absenteeism, and increased medical treatmentexpenses. The high-stress environment of health care con-tributes to illness for nurses, translating into absenteeism,high staff turnover, unsafe behavior, and increased acci-dents (Harris, 2001). With all this at stake, somethingmust be done.

Hambly (2004) claimed that stress is treatable and itseffects are reversible, but only if treated early and well.Shader, Broome, Broome, West, and Nash (2001) calledfor healthcare institutions to consider factors causingstress for nurses and act promptly to create a working en-vironment that retains nurses. Hambly suggested givingclear explanations, addressing the cause of the stress, soft-ening the effects of stress, and changing how the nursethinks about the situation as helpful. Sveinsdottir et al.(2005) called on institutions to use research findings andimplement measures to diminish occupational stressamong nurses. Laposa et al. (2003) cited research findingsto underscore the important need for hospital administra-tors to improve the interpersonal workplace climate fornurses. Hambly claimed that work-related stress is causedby poormanagement and inadequate responses to the prob-lems that cause stress. After studying an intervention programaimedat reducingwork-related stress for nurses as ameans toincreasequality of care, Petterson,Donnersvard, Lagerstrom,and Toomingas (2006) emphasized the importance of in-volving middle management in planning interventions toreduce nurses’ work stress. Jonsson and Halabi (2006)stressed the need for administrators, teachers, and re-searchers to plan interventions to promote quality of lifefor nurses while ensuring adequate daily support to re-lieve work-related stress. Kalichman et al. (2000) calledfor specific interventions to assist nurses in managingoccupational stress to prevent the burnout that is certainto follow. Ohlson and Arvidsson (2005) found positiveworking conditions essential in helping nurses reflect, feelsupported, and have control, all of which prevent thenegative effects of occupational stress. Implementing sup-port to increase the nurses’ feeling of control in patientcare situations will decrease stress and burnout amongclinical nurses (Schmitz et al., 2000). Hall (2004) calledfor staff development educators to use interventionalstaffing and provide stress debriefing with active copingopportunities while educating clinical nurses. Likewise,Fillion, Fortier, and Goupil (2005) concluded that educa-tion is useful in decreasing work-related stress for nursesand improving quality of care for patients; these authorscited increased perceived self-efficacy and decreased psy-chological distress as outcomes for proper stress andresource education. Ekedahl and Wengstrom (2006)agreed that education should address the dysfunctional

coping strategies that nurses use for occupational stress.Mimura and Griffiths (2003) called for additional researchto develop and implement effective interventions. Jonesand Johnston (2000) echoed the need for additional re-search to clarify perceived stressors and interventionsto address the cause of work-related stress with specificstrategies to target health behaviors, lifestyle/risk factors,and self-management skills to amend problematic workenvironments.

Without a proactive approach to work-related stress,nurses are at high risk for numerous detrimental psycho-logical, physical, and behavioral problems. Stuttle (2005)claims that nurses may create their own work-relatedstress when they set unrealistic expectations for them-selves and decline to employ proven techniques tocreate a good workYlife balance. These unrealistic self-expectations are often birthed of the well-documented,current nursing shortage and high nurseYpatient ratiosat many institutions.

CALL FOR ACTIONAlthough many researchers and authors have addressedcontrolling the amount of work-related stress for nurses,there is a definite gap in the ‘‘how to.’’ It is evident thatnurses cannot wait for administrators, middle managers,or others to address their stress levels. Practicing nursesmust define an acceptable work environment and create itin a positive, proactive manner. Given the proper skills,nurses can craft a therapeutic milieu that will yield benefitsto all stakeholders.

Staff development professionals can be key players inequipping nurses for this monumental but extraordina-rily rewarding task. These educators can present theliterature and validate the nurses’ concerns about theirwork-related stress and consequently call on them tobe actively involved in righting the wrongs that creatework-related stress. This should happen at all levelsthroughout the organization. Nurse managers need toacquire the skills needed to model proactive problemsolving for staff. Through education and empowerment,nurses can become the best advocates for decreasingwork-related stress. As staff development educatorsteach and model positive reactions to stressful situationsdaily, they equip frontline nurses to do the same. Help-ing nurses understand how to positively approachstressors on the job and the value of healthy lifestylesto destress off the job will decrease the possibility ofmore nurse causalities (see Table 2).

Repeated stressors suchasunderstaffing, patient overload,lack of support, poor communication and cooperationamong professionals, and negative attitudes must bepromptly addressed with nursing leading the discussion.If a team member is not assuming his or her share ofthe workload, peers should not be hesitant to privately

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explain that he or she is needed to contribute to the teamin a productive manner. Nurses too often tolerate coun-terproductive behavior and attitudes. Team memberscan and should be held accountably for how they dotheir job in relation to attitude and behavior as well asskill and knowledge.

In addition, nurses should be encouraged to be profes-sional in their approach to dealing with conflict. An issueneed not arise numerous times before being addressed.Prompt attention to the sources of occupational stress al-lows nurses to be seen as the solution rather than theproblem and prevents prolonged internal distress. Thetemporary discomfort of dealing with problems immedi-ately is less disturbing than the long-term distress causedby avoiding and procrastination.

Lastly, nurses must take ownership of their own stressand well-being. Using healthy, positive stress-reducingtechniques can contribute to the overall health of thenurse (see Table 3).

CONCLUSIONIn today’s nursing world, there is too much at stake to notconsider work-related stress a serious issue. Nurses mustunderstand stressors, be empowered to deal with them,and be willing to develop solutions. Staff developmenteducators must display a positive approach to work-related stress, using their teaching skills to make positivechange and empowering nurses to design a fitting work

environment in which they and patients can be nurturedand cared for.

TABLE 2 Steps That Staff DevelopmentEducators Can Implement

Educate nurses on common stressors using literature,specific examples, and testimonials.

Encourage nurses to speak up when they identify a frequentor routine stressor.

Promptly validate nurses’ concerns with work-relatedconcerns/stressors.

Involve nurses in finding solutions to work-related issuesand concerns.

Share solutions to stressors in one area with nurses inother areas.

Teach seasoned nurses to empower new nurses to helpresolve concerns.

Encourage nurses to destress with appropriate activities.

Teach staff to know and accept their personal limitations.

Follow up after implementation of a stress-buster ideafrom staff.

Model appropriate stress resolution techniques whilemaintaining a positive attitude.

TABLE 3 Positive and Proactive Ways to DealWith Stress

Aromatherapy Learn to forgive and let go

Avoid alcohol, cigarettes, anddrugs

Look at the big picture

Be willing to compromise ifpossible

Look for the upside

Breathing exercises Manage time better

Biofeedback Meditation

Create a balanced schedule Music therapy

Color with a child Nurture oneself

Connect with others Pare down your to-do list

Curl up with a good book Plant or work in a garden

Delegate responsibility Play games

Do not try to control theuncontrollable

Play with a pet

Do something for someoneelse

Prioritize tasks

Do something enjoyableevery day

Reduce caffeine and sugarintake

Do not procrastinate Reframe problems

Drink green tea Self-hypnosis

Eat a healthy, balanced diet Set aside relaxation time

Exercise regularly Sex

Express feelings instead ofbottling them up

Spend time in nature

Focus on the positive Sweat out tension with agood workout

Get a massage Take a long bath

Get enough sleep daily Talk to a supportive friend

Go for a walk Use a stress journal

Guided imagery Watch a comedy

Keep a sense of humor andlaugh often

Write in a journal

Learn assertivecommunication skills

Write to a pen pal in aforeign country

Learn to say no Yoga

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