Alleviating Job Stress in Nurses
Rashaun Roberts, PhD; Paula L. Grubb, PhD; James W. Grosch, MBA, PhD
Posted: 06/25/2012
Job Stress and the Nursing Profession
Nurses are exposed to many stressful demands and pressures and are therefore at heightened risk for an array of health, safety, and other problems. This article provides an overview of stress among nurses, including job features and workplace characteristics that contribute to the high stress levels. It also describes the effect that nursing stress has on the individual's health, safety, and well-being as well as on healthcare organizations. Finally, it discusses approaches that healthcare organizations can take to prevent or reduce nursing stress and its negative consequences.
Stress as a Workplace Problem
Stress is pervasive in the American workforce. One fourth of workers in the United States view their jobs as the top stressor in their lives,
[1] and 26%-52% of workers report moderate-to-high levels of stress at work.
[2-4] Furthermore, 75% of employees believe that they incur more on-the-job stress than workers did a generation ago. Work-related stress is more strongly associated with health complaints than are financial or family problems.
[5]
How is this ubiquitous concept defined? As it has garnered increasing attention from public health and other researchers,
several definitions of job stress have surfaced over the past few decades. The National Institute for Occupational Safety and Health (NIOSH) defines job stress as "the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources or needs of the worker."
[1] Other definitions of job stress emphasize that it is an adverse reaction to excessive job pressures and demands.
[6] Still other definitions assert that job stress occurs when workers do not have the decision-making authority and skill levels to meet the demands of the job and when the efforts they make on the job are not matched by the job's rewards (eg, support, respect, security, or opportunities for advancement and income).
[7,8] Although these concepts differ slightly, each conveys the general idea that job stress arises when a person lacks adequate resources (eg, skills, equipment, support, training) to manage the demands of his or her job effectively.
Stress engendered by an inability to meet work demands can lead to illness, injury, and psychological distress.
[9,10] An impressive body of empirical research supports the link between job stress and problems in health and safety. Mood and sleep disturbances, upset stomach, headaches, and disrupted familial relationships are common early manifestations of job stress.
[1,11-13] In addition, rapidly accumulating evidence suggests that stress at work plays an important role in high blood pressure and elevated cholesterol levels,
[14] cardiovascular disease,
[15,16] infectious and autoimmune diseases,
[17] anxiety and depression,
[18] and accidents and injuries.
[19]
Job stress has far-reaching consequences, not only for the health and safety of workers but also for employers. Stress contributes to outcomes that threaten organizational success, including physical injuries at work, absenteeism, turnover, reduced productivity, diminished job satisfaction,
[20] low morale, and burnout.
[21] Job stress is believed to account for approximately 50% of all workplace absences and for as much as 40% of employee turnover.
[22,23] These and other stress-related outcomes result in considerable losses to industry, costing employers up to $60 billion per year.
[24]
Significant financial costs associated with job stress also are absorbed by the US economy. Econometric analyses show that healthcare expenditures have increased nearly 50% for workers who perceive their jobs as stressful and nearly 200% for those who report high levels of job stress and depression.
[20] According to national estimates, the total cost of job stress incurred by the US economy ranges from $250-$300 billion annually.
[25]
Stress in Nurses
Nursing has long been considered one of the most stressful professions.
[26-28] Stress in nursing is attributed largely to the physical labor, suffering and emotional demands of patients and families, work hours, shiftwork, interpersonal relationships (eg, inter- and intraprofessional conflict), and other pressures that are central to the work nurses do.
[29-35] Factors that have increased stress among nurses since the 1980s include the rising use of sophisticated healthcare technologies, budget cuts, increasing workload, and constant organizational changes in some healthcare environments.
[35-37]
Research findings support the conclusion that the multiple pressures associated with nursing responsibilities and the healthcare setting translate into significant stress levels among nurses. Over the past decade, nurses have consistently reported the highest levels of job stress of all healthcare professionals.
[38-43] Surveys have consistently found that nurses identify stress and overwork as one of their top two safety and health concerns.
[44,45]
Risk Factors for Stress in Nurses
Occupational safety and health researchers and practitioners agree that nurses are heavily exposed to a myriad of "psychosocial stressors" in their daily work. The term "psychosocial stressors" refers to stressful working conditions and/or job characteristics that relate to how tasks are designed. Psychosocial stressors can also refer to management style, aspects of interpersonal relationships, and work roles. Examples of these stressors include heavy workload, conflicting job demands, long working hours, and shiftwork.
Nurses seem to be overexposed to a range of psychosocial stressors, including the following
[46]:
- Lack of control;
- Long work hours;
- Shiftwork;
- Interpersonal conflicts;
- Insufficient resources;
- Poor reward systems;
- Inadequate structure of communication flow in hospitals and other healthcare settings; and
- Bullying and physical violence.[33,47-56]
Although all of these stressors are significant, workplace bullying and physical violence are of growing concern. The American Nurses Association found that 17% of surveyed nurses reported that they had been physically assaulted at work in the past year and 56.9% had been threatened or verbally abused.
[44] Physical violence against nurses is typically perpetrated by patients, patients' family members, or strangers (eg, in emergency departments), whereas nonphysical, or "lateral," violence in the form of incivility, disruptive behavior, verbal aggression, and bullying tend to be perpetrated by other nurses, nurse managers, physicians, and other coworkers.
[57-59]
Effect of Stress on Nurses
Nursing studies have firmly established that excessive exposure to psychosocial stressors produces considerable job stress, resulting in various problematic short- and long-term outcomes. Depression and sleep problems have been reported as frequent stress-related outcomes.
[60,61] Job stress has been associated with reduced job satisfaction,
[62] increased psychological distress,
[63] physical complaints,
[64,65] and absenteeism.
[66] Several studies have found that high levels of job stress contribute to feelings of inadequacy, self-doubt, lower self-esteem, irritability, and somatic disturbance in nurses.
[67-73] As a group, nurses tend to have higher rates of mortality
[74,75] and disproportionately high rates of general illness, stress-related disease, psychiatric outpatient consultation, and psychiatric admissions.
[75-77]
Moral distress and compassion fatigue are consequences of nursing stress that have received special attention from researchers in recent years.
[78-84] Owing to the personal, intimate nature of caring as a nursing professional, nurses may be conflicted in their roles and may make moral judgments about a proper course of action with respect to medical treatment.
[80] Moral distress can arise from issues surrounding end-of-life care, depersonalizing patients on an institutional level, policy constraints, and other situations that nurses believe may affect their ability to provide quality patient care.
[80-83] Contemporary business practices and politics in healthcare have led to corporate or commercial value systems being instilled into a profession that is traditionally considered a moral practice involving caring and compassion.
[82] The disconnect between a corporate marketing model and the philosophy of nursing creates an ethical dilemma that can lead to compassion fatigue. Compassion fatigue occurs when a nurse psychologically withdraws and becomes disengaged from the caring nature of the job. Both moral distress and compassion fatigue have serious effects in terms of dissatisfaction, feelings of powerlessness, and poor physical and mental health outcomes.
[80,82,84]
Related to compassion fatigue, burnout is another adverse consequence of stress that nurses may experience from their work. Burnout has been studied extensively by job stress researchers.
[85-88] Conceptualized in the literature as a severe consequence of prolonged stress at work,
[87,89] burnout is described as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment.
[90] Emotional exhaustion is a feeling of being overextended, depleted of energy, and exhausted by one's work; depersonalization is an increased mental distance from one's job that results in an unfeeling or impersonal response toward recipients of one's service, care, treatment, or instruction.
[90] The final component of burnout -- reduced personal accomplishment -- is a feeling of incompetence and lack of success in one's work with people.
[90]
Studies have shown that nurses have very high rates of burnout.
[42,91] Aiken and colleagues
[85] found that more than 40% of hospital staff nurses scored in the high range for burnout, with 43.2% of nurses reporting high levels of emotional exhaustion.
Declining energy, depersonalization, and increased feelings of incompetence in hospital nurses have significant effects on their health and well-being. Burnout affects individuals physically, psychologically, and socially.
[42,92] In nursing studies, it has been associated with psychological distress and somatic complaints.
[67,93,94] In addition, nurses experiencing burnout have been found to be more likely to eat poorly, smoke cigarettes, and abuse alcohol and other drugs, all of which can lead to negative health conditions and diminished well-being.
[95-97]
Effect of Nursing Stress on Healthcare Organizations
Stress not only adversely affects the health, safety, and well-being of nurses at the individual level, it also negatively affects healthcare organizations. Research indicates that the stress fostered by workplace bullying, psychological aggression, incivility, and disruptive behavior affects healthcare costs, turnover, retention, and formal grievances and lawsuits.
[56-58] Moreover, lateral workplace violence has been shown to jeopardize patient safety, satisfaction, and health outcomes.
[57,98,99]
Implications for the quality and efficacy of the healthcare an organization provides have been a particular focus of investigations on stress and burnout, both generally and specifically with regard to workplace bullying and psychological aggression.
[97] Studies have found that stress and burnout are strongly linked to suboptimal patient care as reported by nurses,
[97,100] and other studies have found that stress and burnout in nurses negatively affect patients' perception of the quality of their care. For example, in a review of the literature, Halbesleben and colleagues
[101] found a significant relationship between higher levels of emotional exhaustion and depersonalization in nursing staff and lower patient satisfaction. They explained that burned-out nurses may not be as alert or mentally aware, which compromises their ability to provide high-quality patient care. Lack of mental alertness due to burnout also contributed to a higher likelihood of medical errors.
[101]
Nursing stress produces other organizational consequences. It has been linked to a number of poor outcomes, such as lower morale, reduced job performance, increased tardiness, and absenteeism.
[55,67,93,94] It also seems to fuel job dissatisfaction, a precursor to staff turnover.
[102] Rates of job dissatisfaction are extraordinarily high in nurses. Aiken and colleagues
[85] found that 41.5% of nurses were dissatisfied with their jobs and that 1 in 5 nurses surveyed intended to leave his or her job as a result of dissatisfaction, burnout, and stress.
[85]
Stress-related attrition can generate considerable labor costs for healthcare organizations that are not recoverable from private or public insurance sources.
[85] A survey of turnover in acute care facilities found that replacement costs for nurse positions were equal to or greater than 2 times their annual salaries.
[103] Annual turnover rates for registered nurses are estimated by the Joint Commission
[104] to range from 18%-26%, with cost estimates for each turnover ranging from $62,100-$67,000.
[105]
Stress-related attrition contributes to suboptimum patient outcomes and exacerbates already-inadequate nurse-to-patient ratios.
[106] Aiken and colleagues
[85] found that each additional patient per nurse resulted in a 7% increase in the likelihood of a patient dying within 30 days of hospital admission. Other studies have found associations between low nurse staffing levels and hospital-acquired pneumonia, urinary tract infections, sepsis, nosocomial infections, pressure ulcers, upper gastrointestinal bleeding, shock and cardiac arrest, medication errors, falls, and longer-than-expected lengths of stay.
[107]
Approaches to Reducing Job Stress in Nurses
Because job stress and its consequences are serious, growing concerns for nurses, patients, hospitals, and the healthcare industry as a whole, approaches to reduce nursing stress must be identified. Effective approaches could ensure better safety and health outcomes in nurses, leading to safe, efficient, and high-quality patient care, ultimately alleviating the economic consequences of stress on hospitals, industry, and the economy.
[13,108]
Some approaches to addressing nursing stress target the worker (person-focused interventions), others target the work environment (organization-focused interventions), and still others target both.
Person-Focused Interventions
A stress management program (SMP) is an example of a person-focused intervention. Almost half of employers in the United States provide some type of stress management training for their workforces.
[1] These programs improve the ability of workers to cope with difficult work situations by educating them about the nature and sources of stress and the effects of stress on health, and build skills to reduce stress (eg, time management or relaxation skills).
[1] SMPs can rapidly reduce the symptoms of stress, such as anxiety and sleep disturbance, and have the advantage of being inexpensive and easy to implement.
[109]
However, SMPs tend to be generic. Through a participatory approach in which job stress practitioners work collaboratively with nurses, SMP content that is directly relevant and applicable to the specific work environment, interpersonal issues, and job characteristics or tasks encountered by nurses can be developed, implemented, and evaluated. Customized nurse SMPs that are practical for use on and off the job may have the best potential for positively influencing the health and well-being of nurses.
Organization-Focused Interventions
The disadvantage of SMPs -- even if they are customized -- is that they don't address the psychosocial stressors of the healthcare environment. Organization-focused interventions, however, can address this deficit. These interventions involve identifying the stressful aspects of the job (eg, excessive workload, conflicting expectations) and then designing strategies to reduce or eliminate these stressors. The advantage of this approach is that it directly addresses the root causes of work-related stress. Some examples of organization-focused interventions include the following:
- Ensuring that the workload is in line with workers' capabilities and resources;
- Designing jobs to provide meaning, stimulation, and opportunities for workers to use their skills;
- Clearly defining workers' roles and responsibilities;
- Giving workers opportunities to participate in decisions and actions affecting their jobs;
- Improving communication;
- Reducing uncertainty about career development and future employment prospects;
- Providing opportunities for social interaction among workers; and
- Establishing work schedules that are compatible with demands and responsibilities outside the job.
Similar to SMPs, organization-focused interventions should be customized according to work setting. Nurses and management staff can work with job stress practitioners to diagnose organizational and work-unit conditions that contribute to stress. Once these conditions are properly diagnosed, approaches to counter or eliminate them can be developed. For example, in hospital settings such interventions could target staffing ratios, adjust work hours or shifts, incorporate rest breaks, and provide a more balanced workload.
Integrated Stress Prevention
The strongest efforts to improve working conditions using organization-focused interventions are unlikely to eliminate stress completely. Consequently, a combination of person- and organization-focused interventions is often the most useful approach for preventing stress at work.
[110] An integrated stress prevention program should include the following:
- Building general awareness about job stress (causes, costs, and control);
- Securing top management commitment and support for the program;
- Incorporating employee input and involvement in all phases of the program; and
- Establishing the technical capacity to conduct the program (eg, specialized training for in-house staff or use of job stress consultants).
If well-planned and implemented, integrated programs potentially can be effective in reducing or eliminating job stress for nurses. Each approach has unique advantages: Person-focused interventions have a more positive effect on individual outcomes, and organization-focused interventions have a more positive effect on organizational outcomes.
[110]
Integrated job stress and other health and safety interventions targeted to the special needs of nurses and their work settings will facilitate the overarching goal of improving their health and safety.
