Withstanding the Pressure of

the 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.
T
he 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 important
skill set a nurse may acquire for a career in nursing. Not
perfecting those skills could be detrimentalVnot only to
the nurses career but to himself or herself.
WORK-RELATED STRESS FOR NURSES
It is no secret that the nursing profession is a particularly
stressful 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 to
working conditions. Nedic, Jocic, Filipovic, and Solak
(2002) suggested that job stress increases when there is
economic crisis in the society such as the United States is
currently experiencing. Likewise, Lindo, McCaw-Binns,
LaGrenade, Jackson, and Eldemire-Shearer (2006) cau-
tioned that although hospital work involves some very
stressful 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 with
this kind of stress.
SPECIFIC STRESSORS IDENTIFIED
Multiple stressors have been repeatedly identified for the
practicing nurse. Florio et al. (1998) cited coworker stress,
ethical concerns, inadequate resources, negative thoughts,
physician-related stress, and death and dying as major
sources 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 in
general. Nurses have consistently identified failure to meet
patients 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 and
identified high job demand, lowjob control, and lowwork-
place support as significant occupational stressors. French,
Lenton, Walters, and Elyes (2000) identified nine subscales
of nursing stress, which include death and dying, conflict
with physicians, inadequate preparation, problems with
peers, problems with supervisors, workload, uncertainty
concerning 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 patient
care, nurse managers, and salaries and benefits contributed
to their dissatisfaction (Fletcher, 2001). Consequently,
Zager and Walker (2005) maintained that the most criti-
cal issue is that nurses need to feel supported in their
work environment. Stressors that have been identified
as 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 various
practice settings. In addition, research shows that these
stressors 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 todays 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 with
them.
NEGATIVE EFFECTS OF WORK-RELATED
STRESS ON NURSES
Nurses experience numerous negative effects from work-
related stressors. Florio et al. (1998) discovered that
nurses frequently experience increased health com-
plaints, sleep disturbances, burnout, job dissatisfaction,
clinical depression, anxiety, and increased interpersonal
problems. 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 depression
and burnout in the emergency department and noted that
the accompanying interpersonal conflict was significantly
associated with posttraumatic stress disorder. Exposure to
daily work stress has been identified as a cause of posttrau-
matic stress syndrome for Jordanian nurses ( Jonsson &
Halabi, 2006). Yayli, Yaman, and Yaman (2003) studied
152 nurses in a Turkish hospital and concluded that the
majority of them had depressive symptoms and were in
need of counseling concerning coping styles. Studies
show 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 stress
for nurses vulnerability to emotional exhaustion, leading
them to use avoidance as a coping strategy. In a study of
125 nurses, Kerasiotis and Motta (2004) found significantly
high levels of anxiety because of the perceived lack of con-
trol in numerous traumatic nursing experiences over a
lifetime. Ekedahl and Wengstrom (2006) noted that the
coping of nurses under significant work-related stress is
more likely to become dysfunctional when there is a lack
of human support and boundary demarcation. Hambly
(2004) claimed that work-related stress causes psychologi-
cal, physical, and behavioral problems for nurses and
asserted that prolonged stress can produce long-term pro-
blems such as hypertension. MacDonald (2006) noted that
workplace stress seriously affects female nurses, who are
five times more at risk for metabolic syndrome than men
are in the same situation. A study examining the effects of
job stress/strain on over 21,000 nurses concluded nurses
are at higher risk for declining health because of job stress
than other professions (Work-related stress causes de-
cline in nurses health, 2000). Maher-Brisen (2007) cites
addiction as an occupational hazard due to the fre-
quency of which prescription drugs are used by nurses
to combat the effects of work-related stress. Orji, Fasubaa,
Onwudiegwa, Dare, and Ogunniyi (2002) claimed that
nearly half of the 78 nurses they surveyed admitted using
diazepam or alcohol to cope with the stress of work.
Tomas-Sabado, Aradilla, and Guix (2004) studied 240
registered nurses and confirmed a clear linkage between
work-related stress in nursing and the nurses inability to
identify and articulate feelings, especially in communicat-
ing with work colleagues. These negative effects are
intensely disabling for nurses.
EFFECTS OF WORK-RELATED STRESS ON
PATIENTS AND INSTITUTIONS
Work-related stress also has a detrimental impact on pa-
tients and institutions. Sveinsdottir, Biering, and Ramel
(2005) claimed that occupational stress directly increases
turnover rates and decreases job satisfaction, which re-
duces the quality of nursing care for patients. Kalichman
et al. (2000) fault high stress rates for the occupational
burnout that nurses experience, which again affects
patients. Numerous additional studies show that work
environment 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 stress
experienced by nurses puts institutions at risk for litiga-
tion under the Occupational Safety and Health Act of
1970, which holds employers responsible for the mental
TABLE 1 Hazardous Stressors if Prolonged
Criticism at work Low job control
Conflict with other
professionals
Low workplace support
Coworker stress Low reward
Death and dying Low security at work
Discrimination Negative thoughts
Ethical concerns Overwhelming sense of
responsibility
Failure to meet patients
needs
Perception of not having
control over situations
High job demand Physician-related stress
Inadequate preparation Problems with patients and
their 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 and
benefits
Workload
Lack of resources
70 www.jnsdonline.com March/April 2011
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and physical well-being of employees. Nedic et al.
(2002) concluded that job stress affects institutions and
the healthcare industry through reduced work produc-
tivity, absenteeism, and increased medical treatment
expenses. 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, something
must be done.
Hambly (2004) claimed that stress is treatable and its
effects are reversible, but only if treated early and well.
Shader, Broome, Broome, West, and Nash (2001) called
for healthcare institutions to consider factors causing
stress for nurses and act promptly to create a working en-
vironment that retains nurses. Hambly suggested giving
clear explanations, addressing the cause of the stress, soft-
ening the effects of stress, and changing how the nurse
thinks about the situation as helpful. Sveinsdottir et al.
(2005) called on institutions to use research findings and
implement measures to diminish occupational stress
among nurses. Laposa et al. (2003) cited research findings
to underscore the important need for hospital administra-
tors to improve the interpersonal workplace climate for
nurses. Hambly claimed that work-related stress is caused
by poor management and inadequate responses to the prob-
lems that cause stress. After studying an intervention program
aimedat reducingwork-relatedstress for nurses as a means to
increasequalityof care, Petterson, Donnersvard, Lagerstrom,
and Toomingas (2006) emphasized the importance of in-
volving middle management in planning interventions to
reduce nurses work stress. Jonsson and Halabi (2006)
stressed the need for administrators, teachers, and re-
searchers to plan interventions to promote quality of life
for nurses while ensuring adequate daily support to re-
lieve work-related stress. Kalichman et al. (2000) called
for specific interventions to assist nurses in managing
occupational stress to prevent the burnout that is certain
to follow. Ohlson and Arvidsson (2005) found positive
working conditions essential in helping nurses reflect, feel
supported, and have control, all of which prevent the
negative effects of occupational stress. Implementing sup-
port to increase the nurses feeling of control in patient
care situations will decrease stress and burnout among
clinical nurses (Schmitz et al., 2000). Hall (2004) called
for staff development educators to use interventional
staffing and provide stress debriefing with active coping
opportunities while educating clinical nurses. Likewise,
Fillion, Fortier, and Goupil (2005) concluded that educa-
tion is useful in decreasing work-related stress for nurses
and improving quality of care for patients; these authors
cited increased perceived self-efficacy and decreased psy-
chological distress as outcomes for proper stress and
resource 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 research
to develop and implement effective interventions. Jones
and Johnston (2000) echoed the need for additional re-
search to clarify perceived stressors and interventions
to address the cause of work-related stress with specific
strategies to target health behaviors, lifestyle/risk factors,
and self-management skills to amend problematic work
environments.
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-related
stress when they set unrealistic expectations for them-
selves and decline to employ proven techniques to
create a good workYlife balance. These unrealistic self-
expectations are often birthed of the well-documented,
current nursing shortage and high nurseYpatient ratios
at many institutions.
CALL FOR ACTION
Although many researchers and authors have addressed
controlling the amount of work-related stress for nurses,
there is a definite gap in the how to. It is evident that
nurses cannot wait for administrators, middle managers,
or others to address their stress levels. Practicing nurses
must define an acceptable work environment and create it
in a positive, proactive manner. Given the proper skills,
nurses can craft a therapeutic milieu that will yield benefits
to all stakeholders.
Staff development professionals can be key players in
equipping nurses for this monumental but extraordina-
rily rewarding task. These educators can present the
literature and validate the nurses concerns about their
work-related stress and consequently call on them to
be actively involved in righting the wrongs that create
work-related stress. This should happen at all levels
throughout the organization. Nurse managers need to
acquire the skills needed to model proactive problem
solving for staff. Through education and empowerment,
nurses can become the best advocates for decreasing
work-related stress. As staff development educators
teach and model positive reactions to stressful situations
daily, they equip frontline nurses to do the same. Help-
ing nurses understand how to positively approach
stressors on the job and the value of healthy lifestyles
to destress off the job will decrease the possibility of
more nurse causalities (see Table 2).
Repeatedstressors suchas understaffing, patient overload,
lack of support, poor communication and cooperation
among professionals, and negative attitudes must be
promptly addressed with nursing leading the discussion.
If a team member is not assuming his or her share of
the workload, peers should not be hesitant to privately
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explain that he or she is needed to contribute to the team
in a productive manner. Nurses too often tolerate coun-
terproductive behavior and attitudes. Team members
can and should be held accountably for how they do
their job in relation to attitude and behavior as well as
skill and knowledge.
In addition, nurses should be encouraged to be profes-
sional in their approach to dealing with conflict. An issue
need 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 the
problem and prevents prolonged internal distress. The
temporary discomfort of dealing with problems immedi-
ately is less disturbing than the long-term distress caused
by avoiding and procrastination.
Lastly, nurses must take ownership of their own stress
and well-being. Using healthy, positive stress-reducing
techniques can contribute to the overall health of the
nurse (see Table 3).
CONCLUSION
In todays nursing world, there is too much at stake to not
consider work-related stress a serious issue. Nurses must
understand stressors, be empowered to deal with them,
and be willing to develop solutions. Staff development
educators must display a positive approach to work-
related stress, using their teaching skills to make positive
change and empowering nurses to design a fitting work
environment in which they and patients can be nurtured
and cared for.
TABLE 2 Steps That Staff Development
Educators Can Implement
Educate nurses on common stressors using literature,
specific examples, and testimonials.
Encourage nurses to speak up when they identify a frequent
or routine stressor.
Promptly validate nurses concerns with work-related
concerns/stressors.
Involve nurses in finding solutions to work-related issues
and concerns.
Share solutions to stressors in one area with nurses in
other areas.
Teach seasoned nurses to empower new nurses to help
resolve 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 idea
from staff.
Model appropriate stress resolution techniques while
maintaining a positive attitude.
TABLE 3 Positive and Proactive Ways to Deal
With Stress
Aromatherapy Learn to forgive and let go
Avoid alcohol, cigarettes, and
drugs
Look at the big picture
Be willing to compromise if
possible
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 the
uncontrollable
Play with a pet
Do something for someone
else
Prioritize tasks
Do something enjoyable
every day
Reduce caffeine and sugar
intake
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 of
bottling them up
Spend time in nature
Focus on the positive Sweat out tension with a
good 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 and
laugh often
Write in a journal
Learn assertive
communication skills
Write to a pen pal in a
foreign country
Learn to say no Yoga
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