The Job Conditions and Stress in Nursing - Research Paper Example

Comparing the stress level and stress source between the nurses working in Accident and Emergency department and Nurses in other department. For example, out patient department Part One – Research Proposal 1. Introduction One of the most common problems in healthcare systems of countries around the world is the lack of sufficient staff, especially nurses, across the services of the particular sector. The main reason for this phenomenon is the fact that all professionals that work in the healthcare sector are working under extremely difficult conditions having to respond to difficult and emergent cases on a daily basis. Particularly the nurses that work in the Emergency Department present extremely high level of stress if compared with their colleagues that work in other departments. The impact of stress on the performance of nurses in the Emergency Department can be significant; however in many cases it may takes several years until the problem is revealed. It should be mentioned that in a survey conducted among Heads of Midwifery in England it was revealed that ‘recruitment and retention were getting harder in 2006 comparing 2005 with 2004, although the proportion thinking it was getting easier had also fallen; where recruitment and retention was reportedly getting harder, the main factors were identified as heavy workloads and stress, although the number of Heads of Midwifery (HOMs) citing these as factors was slightly down on previous years’ (Morris, 2006, 33). In other words, stress is considered to be among the most significant problems for nurses working in the National Health System of Britain. Current paper refers especially to the stress levels of nurses working in the Accident and Emergency Department in comparison with the relevant levels of stress in nurses working in the outpatient department. The development of the appropriate methods for the limitation of stress across the above presented professionals is examined in terms of its feasibility. It seems that such an effort could be successful. However, it is necessary that appropriate preparation is made in advance taking into account the working conditions of professionals in the healthcare sector (especially at the specific departments). The reference to a study that explores the particular issue has been also considered to be extremely helpful towards the effective analysis and evaluation of the specific problem. 2. Significance of the study The healthcare sector is one of the most significant in most countries around the world. Moreover, because healthcare services are significant for human life, it would be necessary to identify and evaluate appropriately any problem appeared within the particular sector. In this context, the work conditions of nurses in healthcare industry around the world are considered to be of high importance. From this point of view, the issue examined in this paper, i.e. the stress level and stress sources of nurses working in the emergency department should be regarded as quite important for the particular field (medical and healthcare services). More specifically, stress can influence the performance of nurses (as of all professionals) and in this way the safety of the patients involved could be at risk (referring especially to the emergency department). However, in other hospitals’ departments, like the outpatient department, stress can cause a severe limitation of nurses’ performance in terms of their ability to response on time when they are required to handle a specific case. For all the above reasons the examination of the specific issue is regarded as having a major importance for medical community around the world – people that do not belong in this community would be also interested to be informed on the potential influence of stress on nurses’ behaviour and performance. 3. Literature review The level of stress and the causes of stress in nurses have been extensively examined by researchers. In accordance with most studies published on this issue, it seems that stress among nurses of all departments has been increased the last 5 years. More specifically, in the data presented in Figure 1 below (which have been gathered through a research conducted by the National Audit Office in UK in 2003), the work related stress has been increased for nurses working in all NHS sectors. The highest increase can be noticed in nurses working in the Acute sector of NHS. However, it should be noticed that the particular research should be criticized as of its credibility especially regarding a particular health services sector, this of mental health where the participation of nurses was limited. More specifically, about 31% of nurses did not respond to the question whether the work – related stress in their work has been increased or not. In other words, the percentage of 60% (positive opinions regarding the increase of work-related stress in the healthcare services sector) represents just a 2/3 of nurses working in the particular sector. However, in the Acute sector (a similar one with the Emergency sector) the number of participants in the relevant research was high – actually only 14% of nurses that were asked to participate in the above research refused to give a clear answer. Figure 1 – Stress of employees in hospitals (source: UK, National Audit Office, Comptroller and Auditor General, 2003, pg. 26) On the other hand, in Figure 2 below, the interaction of stress with specific skills and behaviours of nurses is clear. More specifically, in accordance with this diagram, stress in healthcare can lead nurses directly to burnout unless specific personal attitudes (mainly effective coping skills) intervene. Figure 2 – Nurses and stress (source: Mims et al., 2003, pg. 2) However, the personal attitudes of people working in the healthcare industry – as the nurses – cannot be entirely comprehensive in advance. They also differentiate in accordance with personal experiences and the influence of social environment. For this reason, in some cases the increase of stress cannot be stopped and therefore the burnout is not avoided. This can happen as an example in nurses who are characterized by ineffective coping skills (this example has been used in the diagram presented in Figure 2 above). The direct relation between stress and job performance in nurses has been also proved by Judkins (2001). In accordance with the study of the above researcher ‘interest in the consequences of job stress for both employees and organizations is increasing as stress is linked to poor work performance, acute and chronic health problems, and employee burnout; estimates of the total cost of stress to American organizations assessed by absenteeism, reduced productivity, compensation claims, health insurance, and direct medical expenses range from $4.2 to $60 billion a year’ (Judkins, 2001, 3). The above study refers to all employees in the healthcare sector (i.e. there is no differentiation among employees of particular departments or levels of hierarchy). However, this study could be also applied in nurses who constitute a significant part of workforce in the healthcare services industry. From another point of view, it has been suggested by Pitts (2004) that stress has been a major problem for nurses for many years. In fact, the research of Pitts (2004) showed that ‘tension and pressure are also the frequent companions of nursing students – the relevant study was one of many that Dr. Lynne Young (assistant professor with UVic’s School of Nursing on the Lower Mainland) who supported that “we were amazed, when we got into the research literature, at the high level of stress reported among nursing students; but we only found two examples of stress reduction intervention programs for student nurses reported in the literature”’ (Pitts, 2004). In accordance with the above study, the development of stress in professionals within the healthcare services industry is a rather common phenomenon; moreover, its appearance can be observed at the first steps of people entering the particular industry, as in the case of nursing students. It is not made clear however, whether the level of stress observed in nursing students is related with specific causes (in fact no reference to specific causes is made). In order to understand the possible causes of stress for nurses we could refer to the work of McVicar (2003) who found that the following issues can be related with stress in nurses: ‘workload, leadership/management style, professional conflict and emotional cost of caring; lack of reward and shift-working may also now be displacing some of the other issues in order of ranking’ (McVicar, 2003, 633). All the above issues should be thoroughly examined as of their relation with stress in nurses of all departments within a specific healthcare services organization. Other causes of stress could be also identified within the above industry; however it depends in each case on the culture of the particular organization and the provisions made for employees of all levels (including nurses). In other words, in organizations of the healthcare industry where analytical and effective provisions are applied for employees (including nurses) the chances for employees to be involved in high level of stress are limited. The importance of stress for the performance of nurses in all medical departments has been extensively examined in the literature. All relevant studies prove that stress can severely affect the performance of nurses in all medical departments but particularly in those working in Accident and Emergency Units. The study of Chang et al. (2007) showed that ‘high patient acuity, heavy workload, and patient deaths can all contribute to work-related stress for pediatric oncology nurses; the intensity of work-related stress experienced by nurses in this study is significantly less (P < .001) on shifts staffed with a CSN compared with shifts without a CSN’ (Chang et al., 2007, 340). In accordance with the above results, stress in nurses is higher as their responsibilities increase (as for example in the case of care of children that suffer from cancer, presented by Chang et al. above). In order to estimate the level of stress related with nurses, Ben-Zur et al. (2007) conducted a survey. The above researchers used this survey in order: ‘(1) to compare stress appraisals, coping strategies, social resources, and burnout at work between social workers, psychologists and nurses; and (2) to assess the effectiveness of appraisals and support in reducing burnout and enhancing effective coping strategies’ (Ben – Zur et al., 2007, 63). The above survey was conducted through questionnaires completed by approximately 249 nurses. The findings of the above result support the view that stress can negatively influence the performance of nurses. The impact of stress on the nurses’ performance is increased in accordance with the nurses’ responsibilities (i.e. their position within a specific medical organization). More specifically, the above research showed that ‘high challenge/control appraisal of the job was directly related to all burnout outcomes, contributing to less exhaustion and depersonalization and to more personal accomplishment; the stress/load appraisal contributed to more exhaustion at work, while emotion-focused coping contributed to higher depersonalization’ (Ben – Zur et al., 2007, 63). In accordance with the above results, the high pressure caused by the workload can lead to increased level of stress among nurses working in a particular medical organization. The department in which a nurse works does not seem to have particular effect on the stress developed to nurse – at least such an assumption can be made through this study. However, it is not made clear whether nurses working in specific medical departments can develop higher level of stress. It should be noticed that the work of nurse has been traditionally characterized as quite stressful. In fact, it has been proved that ‘throughout the history of nursing there is a seeming legacy of personnel shortage, lack of funds, and, based on the nature of the role and related services, heightened levels of stress involved in patient care’ (Milliken et al., 2007, 203). Because of the above reasons, most of which continue to exist today, the work of nurses is closely related with stress which should be appropriately faced through the provision of continuous support to nurses of all medical departments – especially those working in the Accident and the Emergency unit. Towards this direction, it is noticed that ‘there are many methods of stress management, and sometimes the best and most effective begin with simple recognition, validation, and visible and committed efforts by the nurse executive’ (Milliken et al., 2007, 203). From a different point of view it is noticed that ‘every person's perception of stress, responses to stress and coping methods are different; it is important to examine the relationships between these phenomena and personality traits’ (Sheu et al., 2001, 233). Towards this direction, in order to evaluate the level of stress of nurses working in the Accident and Emergency department we should primarily focus on the personal characteristics of the nurses involved and their reactions to specific events (related with their daily activities in the workplace). Regarding the above it has been proved that ‘the perception of stress, coping behaviors and psychosocial status are significantly related to personality characteristics, including introversion-extroversion, social adaptiveness, and emotional stability’ (Sheu et al., 2001, 233). The most important issue when dealing with stress in nurses working in the Accident and Emergency department is to ensure the existence of the appropriate framework in order to protect nurses from extremely high workload (workload is the most critical factor for the development of stress among nurses in all medical departments). As for the rest of the causes of stress (lack of funds for compensation of extra working, shortage of staff and so on) could be effectively handled by nurses if the workload was kept at standard (and feasible to be controlled) levels. 4. Research Methodology – qualitative research The research used in current paper is based on a series of studies that have published in the particular field. In other words, this paper is based on qualitative research, i.e. the views and the findings of researchers regarding the issue under examination. The particular type of research has been considered to be most appropriate if taking into account the needs of the specific issue in terms of current working conditions in hospitals around the world – relevant studies have been chosen as indicative examples of level and causes of stress for nurses internationally. On the other hand, it should be noticed that current research examines a particular study referring to the influence of stress in the performance of nursed in the Accident and Emergency department and those working in other departments. More specifically, the paper of Makie, V. (2006) [Stress and Coping Strategies Amongst registered nurses working in a South African Tertiary Hospital, University of the Western Cape] has been extensively analyzed in order to support current research. 5. Data collection strategies As already explained above, current research will be based on the literature that has been published regarding the issue under examination. No primary data are going to be presented and analyzed. In this context, the data that are going to be presented will be secondary one. The main source of these data will be organizations and Institutes that operate in the healthcare industry (either of the private or the public sector). These data are going to be analyzed and evaluated as possible following by a personal view related with this paper’s main subject. 6. Data analysis strategies As already stated above, current research focus on the presentation of a series of studies related with the influence of stress on the performance of nurses working in the Accident and Emergency department and the out - patient department. On the other hand, other studies that refer to stress and its influence on the performance of nurses in various sectors within the healthcare industry are also going to be presented because they include a series of data that are considered to be valuable for the analysis of the issue under examination. However, all the information revealed through these studies has the form of assumptions and theories. Just few statistical data have been released. In this context, the data analysis used in this study cannot be conducted using particular software; instead only graphical representation of the data released, is achievable. 7. Limitations of the study Current study is limited by the fact that no primary data have been used for its support. More specifically, the retrieval of primary data regarding the issue under examination would involve the long term observation and interviewing of professionals (especially nurses) in the healthcare services industry. However, such a task would be extremely time consuming while the result would be uncertain in terms of its validity (the structure and the terms of work within a particular hospital may protect nurses from stress while in another hospital the relevant results would be reversed). In other words, if primary data were to be used in current paper a long term research would be required while the exact time limit for its completion could not be estimated in advance (because of the possible implications mentioned above). From this point of view, current study could be considered as limited regarding the types of data used for its support. However, the validity and the credibility of data used throughout the paper could not be doubted as they are going to be gathered by a series of published studies having been examined carefully as of their relevance with the issue under examination. (words: 2823) Part 2 – Development of Makie’s paper (Stress and Coping Strategies amongst registered nurses working in a South African Tertiary Hospital. University of the Western Cape, 2006) The role of stress in the performance of nurses has been thoroughly examined by Makie (2006) in her study referring to the stress among nurses working in a hospital of South Africa. The study of Makie begins with an extensive presentation of definitions of stress trying to explain its relation with the medical profession. In this context, it is noticed that stress can be defined as the ‘adaptive response that is a consequence of any external action, situation or event that places special physical and or psychological demands upon a person’ (Kushnir, 1986, 13, in Makie, 2006, 14). From another point of view it is stated that stress could be characterized as the ‘psychobiological reaction of the body to physical or psychological demands that threaten or challenge the organism’s well being’ (Laposa et al, 2003, 24, in Makie, 2006, 14). Both the above definitions are considered to be valuable for the explanation of the importance of stress to the performance of nurses across the particular medical departments. At a next level, in the particular study it is noticed that ‘how individuals perceive or appraise any specific problem will determine what coping strategies they use; coping can include attempts at “managing or altering the problem (problem focused coping) or regulating the emotional response to the problem (emotion focused coping)’ (Makie, 2006, 17). The above part of Makie’s study refers to the ability of nurses to cope with stress if provided with the appropriate support. In practice, it is quite difficult to identify possibly solutions that would be used for the limitation of stress among nurses working in all medical departments. Selection of the appropriate policies should take place choosing the strategies that are more feasible (in accordance with the needs of the particular department and the ability of nurses to respond to the required/ attempted changes). Because of the existence of many parameters that can influence the effectiveness of a particular coping strategy (referring to the effort of nurses to cope with stress) it is noticed by Makie (2006, 17) that ‘traditional models, however, emphasize traits or styles that operate as stable dispositions to cope in particular ways irrespective of the situations; yet studies of life stressors by Folkman & Lazarus (1988a) and organizational stressors by Parkes (1986) have found that coping varies the type of stressors and the situation’. In other words, the schemes applied for the limitation of stress of nurses should focus primarily on the conditions of their daily activities in the workplace. In the case of the nurses working in the Emergency and Accident department the development of such a plan is considered to be quite difficult as the workload of the particular department is very difficult to be estimated. Moreover, for the nurses working in the out-patient department the workload of nurses could be relatively estimated but only in cases that patients are accepted for exams after a relevant notification. In accordance with the study of Makie the ‘work-related stress is estimated to affect at least a third of the workforce in any one year; it costs organizations billions of pounds a year in lost productivity and accounts for over half the working days lost through sickness absence’ (Makie, 2006, 20). In other words, stress can have a significant impact not only on the performance of nurses, but also on the financial status of the particular medical organization. More specifically, because of stress the performance of nurses is often reduced and this fact can have a direct effect on the financial performance of the relevant organization. Despite the fact that the above assumption is clear, it could be stated that the development of stress within medical organizations across the world is very difficult to be controlled. It could just limited only through the appropriate measures – also difficult to be applied (hiring of additional staff, increase of wages for nurses working in extremely demanding departments like the Accident and the Emergency department). On the other hand, stress has been found to be related with severe diseases among all people. Specifically for nurses stress could cause severe health problems especially if no measure has been taken for the limitation of stress on nurses’ daily activities. Generally referring to stress, Makie notices that ‘stress has been linked to a wide variety of diseases and the European Foundation estimates that lifestyle and stress-related illness accounts for at least half of all premature deaths’ (Makie, 2006, 20). In the case of nurses working in the Accident and Emergency Department stress could be related with severe problems of health if taking into account the extremely severe events that nurses working in this department have to face on a daily basis. In order to propose the appropriate measures for the effective coping with stress to nurses working in the Stress and Emergency Department and the out-patient department it would be necessary to identify primarily all the particular signs of stress (identification of stress could help towards the proposal of effective coping strategies on time). Because of the above, Makie refer to a series of ‘symptoms’ that are related with stress. More specifically, it is noticed that ‘the following list describes some of the changes that may indicate that someone is suffering from stress: a) altered appearance; b) lack of care in appearance; c) looks miserable; d) looks tired; e) reduced performance and so on’ (Williams and Cooper 2002:16-17, in Makie, 2006, 22). However, it should be noticed that in many cases the identification of stress is not sufficient for its handling. In fact, coping with stress could be proved particularly difficult even if effective coping strategies would be proposed. From another point of view, it is noticed by Makie that the design of the appropriate strategies for nurses working in the Accident and Emergency department could be easily achieved because the activities/ duties of nurses working in this department is extensively documented in the literature and the empirical research. In this way the general framework of the nurses’ work in this department (included the level of stress developed by nurses) is well known and an appropriate policy would be easily proposed and applied. Indeed it is supported by Makie that ‘the job stress of nurses working on acute and specialized care units has been widely studied; heavy workload, poor staffing, dealing with death and dying, inter-staff conflict, strain of shift work, careers, and lack of resources and organizational support have been identified as the major sources of job stress’ (Makie, 2006, 24). However, it should be noticed that the response of nurses to stress cannot be the same. In fact, because many factors involve in the development of stress (including the personal attitudes, the social life and the cultural/ educational background) it would be extremely difficult for appropriate policies to be developed in relation with the stress involving in the work of nurses within the Accident and the Emergency department. At a next level, it is stated that ‘the longer the nurses had worked in their units the more likely they were to experience stress, regardless of their seniority’ (Lee 2003:87, in Makie, 2006, 24). In other words, the period of work in a particular position is directly related with stress. In case of the nurses working in the Accident and Emergency, a long term work in the particular position could not be considered as feasible mostly because the stress involved is extremely high. If a nurse would remain for a long period in the above position she would suffer from severe health problems. In order to identify the stress developed among nurses, Matlakala (2002:100) conducted a study using a questionnaire that was distributed to 110 registered nurses in a series of countries including South Africa, Malawi and Swaziland. His study is mentioned by Makie. The findings of the above study led to the following results: ‘post basic critical care students, experienced a variety of problems such as stress and shock during their placement; positive experiences included rotation to different hospitals, exposure to different ways of managing of patients and being able to correlate theory with practice; the negative experiences included shortage of staff, exhaustion from work and travelling and staff’s negative attitudes towards students’ (Mackie, 2006, 39). It should be noticed that nurses that participated in the above survey experienced the exposure into difficult cases (in terms of their needs for medical care) without having the time to be appropriately prepared. The role of specific events to the development of stress to nurses has been examined by Govender (1995) and his study is presented by Makie. This study has been considered of particular importance mostly because it refers to the influence of specific events and conditions in the increase of stress levels among nurses. In the above study, it has been found that the level of stress developed within the particular medical departments can be differentiated in accordance with the needs of the department and the appropriate preparation (and experience) of the nurses involved to face effectively all unexpected events and negative outcomes related with their daily work. In the study of Govender (1995) it was proved that ‘the coronary care unit perceived higher levels of workload as compared to intensive care unit nurses; it was suggested that this was possibly due to a qualitative workload overload as opposed to a quantitative one’ (Govender 1995:117-136, in Mackie, 2006, 40). However, despite the fact that differentiations could be identified in the level of stress developed among nurses working in different departments, it is suggested by Govender (1995) that such a differentiation cannot lead to the assumption that stress developed in nurses within specific medical units can differ at a significant level from that of nurses working in other units – only minor changes are possible to be observed. In accordance with the studies presented throughout the paper of Makie (2006) it can be assumed that there are some factors that can influence the productivity of nurses; stress has been found to be one of these factors than have a negative impact on the performance of nurses. In accordance with the above researcher ‘workload was identified as the most frequent source of stress for the present sample of nurses; the second most reported stressor was emotional issues related to death and dying’ (Makie, 2006, 101). It should be noticed that the studies used by Makie cover a wide range of medical departments however there have been studies that refer specifically to emergency units. The examination of the development of stress in nurses working in a variety of medical units can lead to the assumption that nurses of all departments face the same risk to be exposed to high level of stress especially if the conditions in the work change unexpectedly. On the other hand, the causes of stress (as they have been identified through the studies presented above) are difficult to be eliminated. More specifically, the shortage of nurses in specific departments and the increase of wages could not be easily handled because of the cost that such an initiative could have. 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