Work Stress among Nurses - Research Paper Example

WORK REKATED STRESS AMONG NURSES INTRODUCTION Among healthcare providers, nurses are constantly under pressure to provide a concrete and authentic definition of quality care. Since, the notion of ‘quality care’ is the primordial ethos that drives and distinguishes the nursing profession from other healthcare providers. (Charalambous et al 2008) Being such, there is a demand to relentlessly define and redefine the idea of quality care in nursing in order for nurses to be fully equipped with the necessary skills – physically, intellectually and emotionally - as they provide care response to their patients. This daily scenario opens to us the reality of the day to day challenge face by nurses as they strive for quality care. As such, this paper dares to ask “who cares for the nurses? how are they coping up?” These questions even become more compelling as it is claimed and ascertained that nursing is inherently stressful (Demerouti et al 2000; Severinsson 2003). And this is due to the fact that on top of providing quality care to their patients, nurses always have to be abreast with the developments in medical technologies. Nurses are with the patients 24/7. As such, they- the nurses- are in the frontline of healthcare. Nurses have to transact, deal with the patients, the patient’s family, with other nurses, with their managers, with the doctors and all the other members of the healthcare team. They also have to deal with budget and budget cut as well. The complex work environment that nurses find themselves in increases probability of nurses becoming afflicted with work related stress. As such, this paper intends to look into the issue of work related stress among nurses. AIM In this paper, the researcher intends to understand the background of work related stress among nurses, to identify the risks and implications involve in the issue of work related stress in nursing, to know its implications in terms of workforce, health and economy and to be able to discuss the effective solutions proposed in addressing this issue. SEARCH METHOD The electronic database PubMed and MedLine were searched using the combination of the following key terms: nursing, stress, work, nursing and burnout. Included in the research were empirical studies and literature review regarding the subject matter. Excluded in the research were editorials, opinions, and books. The reference list of the articles was searched to identify additional relevant publications. JOB STRESS: IDENTIFIED As we have mentioned earlier, there is this common opinion that nursing is inherently stressful. As such, there has been a surging interest among scholars (eg. Sehlen et al 2009; Severinsson 2003; Severinsson E, Hummelvoll JK 2001) regarding the subject matter of job stress among nurses. Nursing as stressful per se is not surprising as the work demand of nurses – direct contact with their patients and the patient’s family - makes them vulnerable to stress. Being such, what is stress? job stress in nursing? burnout? What are the major stressors among nurses? Stress “should be viewed as a continuum along which an individual may pass, from feelings of eustress (positive response to stress) to those of mild/moderate distress (negative response to stress), to those of severe distress.” (McVicar 2000 p 634) Moreover, stress has both psychological and physiological manifestation. Being such, it is important that necessary actions be undertaken in order to address the problems that arise out from stress. However it should be noted that certain amount of job stress is common and, actually, welcomed. This is possible on the premise that stress in a way brings out the best in the person as the saying goes “working best under pressure”. Nonetheless, the job stress that we are trying to understand in this paper is not the kind of job stress that pushes a person to work better. Rather, the job stress that we are referring to is the negative response to stress which is also known as distress. And severe distress manifested is known as burnout. Burnout is “emotional exhaustion which is defined as a feeling of being emotionally worn out and having reached the end of one’s rope.” (van den Tooren & de Jonge 2008, p 78) It is considered as a “syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do people work.” (McCranie et al 1987, p 376) Maslach and Leiter defined it as “the index of dislocation between what people are and what they do. It represents and erosion of values, dignity, spirit and will – an erosion of the human soul. “ (Maslach & Leiter as cited in Kalliath & Morris 2002, 648) And in a study conducted by Sehlen et al (2009) it has turned out that “nurses and physicians showed the highest level of job stress” (p 4). Being such, it is necessary that the major stressors of nurses be identified. McCranie et al (1987) stipulates that the major stressors that staff nurses typically encounter are “death and dying, emotional demands of patients and their families, inadequate staffing, work overload, conflict with administrators, physicians and other nurses.” (p 374) Furthermore, nurses are always subject to time pressure as it is expected that they should have dispensed all of their functions before the end of their shift. Nurses, especially in the United States, are burdened with too much documentation. Underpayment is also a concern among nurses, most especially those nurses who are coming from developing countries. High physical work load is also a major stressor among nurses. Likewise, the imbalance between material and human resources and insufficient financial resources also causes stress among nurses. (Sehlen et al 2009) This imbalance produces a negative effect in the work environment. An example of this imbalance is when a nurse is asked to take care of patients beyond that which she/he can manage well. This problem is clearly perceptible in developing countries wherein nurses normally handle 30 – 40 patients. Distrust is also a possible source of stress. (Sehlen et al 2009). What’s more, “Hospital politics and irregular work schedules” (Albrecht 1982, p 3) are considerable stressors. Breaking the bad news to the patient is also a source of stress for the nurses (Sehlen et al 2009). This becomes a stressor since it is recognized that nurses are not adequately trained in handling situations like this. Furthermore, “inadequate preparation, discrimination, and uncertainty concerning treatment” (McVicar 2003, p 635) are also considered as major stressors among staff nurses. Likewise, rapid changes in the field of medical technology also contribute to the stress of the nurses. Rout (2000) also included “lack of communication, minimal career development, work/home interface and social life” (p 307) as part of nurses’ major stressors. Finally, Severinsson (2003) in her study has found out that nurses inability to participate in the decision making process contributes to major stressors of nurses. The identification of the various stressors that nurses confront in their job together with the recognition of the fact that nursing is inherently stressful compound the experience of work related stress by nurses. However, it should be noted, that just like in any other field, individual nurse’s response and coping mechanisms to stress varies. As such, indicators of stress act as a signpost that may guide us in knowing what the level of stress only. RISKS AND IMPLICATIONS In becoming aware of the various facets of work related stress that nurses are constantly exposed due to the nature of their job, it is not surprising to see and know that certain risks with weighty implications are inferred from nurses’ experiences of job stress. The following are the risks and its implications in the nursing profession: First is the risk of emotional exhaustion. (Demerouti 2000) Emotional exhaustion is the feeling that you have reached the end of your rope. There is the feeling of being emotionally drained, tired. It is the feeling of being trapped, empty and lost in a situation that the person does not want to be in. (McCranie et al 1987) This particular risk has a very serious implication in the manner with which nurses who are experiencing burnout maybe discharging their duties. Nursing becomes a moral practice (Gastmans et al 1998) because of the caring response that they provide to their patients. Quality care becomes a reality when nurses “respect the truth of the person” (Naef 2006) but if the nurses themselves cannot enter into the caring relationship that they establish with their patients because they feel empty inside, then the ideal of attaining quality care is gone. The meeting of persons epitomize in the nurse-patient relationship is not attained. In so doing, failing to provide and establish that which is significant in the nurse-patient relationship – care relation. Second risk is depersonalization. (Demerouti 2000). According to Demerouti (2000), depersonalization is “is the development of negative, cynical attitudes towards the recipient towards one’s services or care.” ( p 455). Kalliath & Morris (2002) refer to this negative attitude as caring burnout. They claim that caring burnout is the “disengagement of the self from the caring cycle of emphatic attachment – active involvement- felt separation.” (p 649). This risk posits a huge problem to the performance of nursing functions and presents contradiction to the core or foundation of nursing - nurse-patient relationship. (Dowling 2008) Without a doubt, it is recognized that it is necessary that mastery of technical skills is significant in the performance of nursing functions. However, nursing is not only the mastery of technical skills. Mckie (2004) even warns nurses and the nursing institution itself to be constantly on guard against the danger of functionalism. He claims that nursing should learn from the experience of the Holocaust. In his article, he has cited how nurses during World War II have participated in the genocide of the Jews and then justified their actions on the premise that they were just ‘fulfilling’ or ‘performing’ their assigned task. This scenario is a concrete instance of caring burnout, depersonalization. Nurses focus solely on the execution of their tasks and not really minding whether what they are doing is for the good of the recipient of their action. Depersonalization, technically, is the failure to recognize the patient as a human person who shares with the nurse the same human condition. In depersonalization, the patient is turned into a mere passive recipient of ‘care’, an object of care. While the nurse is turned into a robot dispensing function bereft of emotions. Looking at this, depersonalization is, in effect, the objectification of two persons. (Ricoeur 1992) Third risk is developing physiological exhaustion. (Demerouti 2000; McCranie et al 1987; McVicar 2003). Physiological exhaustion is the physical manifestation of burnout. These include clinical hypertension, coronary heart disease, gastric disorders, menstrual problems in women and an increase in asthma attacks in sufferers. Physiological exhaustion resulting from burnout causes illnesses which are preventable if stress is kept at a minimum. Physical exhaustion, basically, affects the actual performance of the nurses’ duty and function. In fact, we may ask, in a situation where in the nurse too is suffering from disease, ‘who is the patient?’. The point is a sick nurse an effective nurse. Harm is done both to the nurse herself and to the patient. Fourth risk is mental exhaustion. (McCranie et al 1987) Mental exhaustion is manifested by feeling of worthlessness, disillusionment, meaninglessness, apathy, burnout. Mental exhaustion undermines the dignity and authentic worth both of the nurse and the patient. This is basically the refusal to see the authentic existence of two human persons in a caring relation. (Ricoeur 1992) All of these four risks combined together give rise to “Self-care deficits in the areas of emotional development, intellectual growth, and physical wellness, followed by powerlessness, loss of purpose, and existential crisis diminish the meaning of work. Individual burnout ensues, with declining quality of patient care, decreasing productivity, breakdown of the work community, and abandonment of nursing as a profession, precipitating organizational crises.” (Kalliath & Morris 2002 p 649) Therefore, an uncheck work related stress, burnout among nurses is the beginning of the end of nursing as an institution and as a profession. The effect of job related stress or burnout is not only felt by the person who is suffering from it. The effects of burnout afflict the larger group or community as well. Although, others may claim that burnout’s effect is only indirect in terms of the group, what can be denied is the fact that the repercussions of stress, burnout is far reaching than just the personal level. STRESS AND ITS CONSEQUENCES IN THE COMMUNITY As we have shown in the above discussion, job stress or burn out directly afflicts the individual person. The intellectual, mental, physiological, emotional and even the personal dignity of the individual person is put to question as the person is undergoing or suffering from stress. If we are going to look at nurses who are badly affected by stress (distress and burn out) we can claim that they themselves have become vulnerable in their condition. This is due to the fact that they have become constrained in their personal appreciation and enjoyment of their lives. Leaving the image of a walking dead – the person goes to the rudiments of living necessary for survival but unable to find joy and pleasure in the live life with others. This is the microcosm. The parochial world of the person suffering from burn out or severe stress related to work. At the larger picture, the entire community is in fact affected by the suffering of that one person. How? Stress has been related to tardiness and absenteeism in work. (McCranie et al 1987) this has huge repercussion in the work force. If one or two nurses are absent during their duty, it means that either all the present nurses will be getting an extra patient to compensate which in turn will redound to over workload for everybody in the unit. Or they will be getting from pool nurses which are an additional expense for the hospital. And this ‘additional expense’ is unnecessary since there is supposed to be an assigned nurse for the duty but he/she is absent. Or they may also get or pull out nurses from other wards, and this in turn will act as stressor for other nurses due to uncertainty in treatment, over workload or limited preparation. And all of these movements are done because some nurses are absent. And the same picture also holds for tardiness. Stress has also been identified as one of the possible causes of increase use of tranquilizers, increase consumption of alcohol and cigarettes and also attributed as the possible cause for an increase in weight or a lost in weight among nurses. (McVicar 2003; McCranie 1987) These coping mechanisms in face of stress do more harm than good especially in terms of the performance of the nursing function. While an increase or lost of weight, although has not direct bearing in the performance of the nursing function, can trigger and aggravate burnout. As noted earlier, mild stress, burn out or severe stress can lead to physiological exhaustion which may manifest in various forms of somatic diseases like clinical hypertension, coronary heart disease, gastric disorders, more severe asthma attacks and irregular menstrual period. (Demerouti 2000; McCranie et al 1987; McVicar 2003) Stress related illnesses clearly show the connection amongst stress, absenteeism and health. Another downside of this scenario, is that if the nurse is always absent due to somatic illnesses related to stress, then definitely, she/he will be getting smaller pay check and it will just perpetuate the cycle of distress. Moreover, since the person is suffering from intellectual, mental, emotional and physiological exhaustion, it is highly probable that the person suffering from severe stress will just keep to himself and withdraw from others. Thus, stress disrupts not only the intrapersonal make up of the individual person but it also destroys and devastates the interpersonal relationship that the individual person has established with others – family, friends and the community. As such, conflict between nurses, conflict with the doctor, and misunderstanding with the manager ensues. Severe stress uncheck, has the power to undermine the very institution of nursing. Thus, endangering the nursing institution itself. This is possible as the risks and implications of burn out both on the personal level and on the social/community level threatens the core of nursing – nurse –patient relationship and the nature and task of nursing – providing quality care. The gravity of the effect of job related stress to the individual persons-nurses and to the community where the individual person belongs is undeniable. It has the power to obliterate and ruin both the intrapersonal and interpersonal relations of the individual human person. Being such, the response of nursing scholars to understand the phenomenon of burnout is geared not only for conceptual analysis of the problem but more so to provide guidelines and means with which nurses who are experiencing burn out may find support within peers and the institution itself. FEASIBLE SOLUTIONS In the study conducted by Skinner et al (2007), they have found out that nurses and midwives are aware and even ‘expecting’ that there will be “certain levels of workplace stress with which [they have] to contend” (p 11) and this is normal. In fact, this kind of perspective paves the way for eustress. On the other hand, what we seek to avoid and, as a matter of fact, we have to “intervene early in the process” (Gelsema et al 2006, p 300) in the spiralling of negative response to stress. Since, “prevention of burnout in nurses is essential to the provision of high quality health care” (Shimizutani et al 2008, p 327) In lieu with this, answers to the phenomenon of burnout have already been proffered and these are: First, is social support. Gelsema et al (2006) suggested that there should be a stronger support coming from the managers and the leaders of nursing. The strain of auditing and continual checking for high level performance is not dissuaded. However, what should be noted is that the harmonious relation between nurses and nurses and managers are also of primordial importance in maintaining and sustaining eustress in the unit or in the ward. Being such, social support can be fortified by facilitating the free flow of information between nurses, among the team of health providers and between the nurse and the patient. Furthermore, fostering the conditions necessary in the creation of trust and trustworthiness between the nurse and the patient (Sellman 2005, 2006 & 2007) and between nurses is necessary if high quality care is to be attained and human flourishing is to be achieved in spite the ‘presence’ of stress in the workplace. Second is reward. (Gelsema et al 2006; Demerouti 2000; McVicar 2003) The important role of financial reward is undeniable. Since, a well compensated job liberates the person from the worries of day to day existence and allows him/her to pursue other needs which are necessary in becoming better person or attaining human growth. This is essential as in Maslow’s (1954) hierarchy of needs theory, individuals who have fulfilled their basic needs for survival will try to attain the final stages of psychological development which is self-actualization. Thus, reward, to be more specific, financial reward should be utilized in achieving job satisfaction and reducing job stress. Furthermore, rewards may come in the form of career development and not necessarily monetary rewards only. Again the justification for this is that there is a driving need in the person for self actualization. And the chance to further one’s craft with the support of the institution is a sufficient factor to motivate the person to work harder and at the same time keep at bay the expansion of job stress. Third is control over their work. (Gelsema et al 2006; Severinsson 2003; Demerouti 2000) If nurses will be given proper and “comprehensive orientation” (Kalliath & Morris 2002 p 653) regarding their role, their tasks, what is expected of them, and are trusted that they can make their own decisions and carry out their decisions in the workplace, job stress is kept to the minimum. This solution is simply the recognition of the dignity, integrity and mastery of the technical skills necessary in the discharge of nursing function. If nurses are treated as persons and not as automatons who are expected to be passive followers, then mental exhaustion, feelings of self-worthlessness and ineptness are avoided. Becoming a decision maker and your decision being respected is a good and sure way to combat feeling of being trapped and lost. And as such, it limits both emotional and mental exhaustion. Moreover, giving nurses control over their work, the chance in becoming a decision- maker and the opportunity to act and implement what you have decided upon is empowering. In the context of contemporary healthcare service, nurse empowerment is necessary as health care service becomes the function of the team and not just of the doctor. Fourth, is a change in the approach of the education of the nurses. (Murphy 2008) In her article, she claims that positive percepting can reduce the stress in the workplace. This is substantiated by the fact that preceptors afford students the picture of what is the actual environment that they will be experiencing the moment that they become full pledged nurses. This is not to downplay the important role of the faculty but it is to highlight the mutual importance of the distinct role that both the faculty and the preceptor play in the education of future nurses. In this sense, it can be impugned that as the faculty provides the necessary theories to intellectually and technically equipped future nurses in the performance of their function, “the preceptor serves as a role model, mentor and coach” (Murphy 2008, p 184) as she/he presents to the assigned student the real work environment, the actual clinical set up. Hence, according to Murphy (2008) “faculty and preceptor are formidable team when they collaborate to increase the quality of the clinical experience, enhance learning opportunities and prepare the student for the real world of practice.” (p 187) Fifth, find the balance for the appropriate number of working hours for nurses in a week. In a study conducted by Patrick & Lavery (2007), they claim that there is a seeming direct correlation between the numbers of hours spend per week in work and emotional exhaustion. They further stipulated that more hours spend in work, the higher the probability of developing mental exhaustion and depersonalization. Sixth, there is a demand for an organizational reform in the National Health Service in order that they may sustain a sufficient supply of nurses. And that the nurses together with all health professionals will be properly supported. (Stevens 2004). Finally, the seventh is the recognition that: 1. Coping mechanisms or behaviors vary from one individual to another. 2. That there is no one sole factor that can be pointed at as the sole cause of caring burnout on nurses. 3. The cause of burn out is multifactorial. 4. There is a need for collaboration among the hospitals, nurses themselves, nursing institutions, scholars in coming up with tools for assessment of burn out among nurses. 5. There is a necessity to come up with policies that geared directly towards reducing stress even if stress is inherent in nursing. RECOMMENDATIONS The following are the researcher’s recommendations on the issue of burnout among nurses. 1. Policies that empower nurses should be given priority. 2. The development of reward system that helps nurses attain self-actualization should be prioritized. 3. Reform the National Health Service. The reform should be geared towards attaining sufficient supply of health professionals. 4. The education of future nurses should enable them to become aware of the actual work environment that they will find themselves in the future. 5. The recognition of stress as inherent in nursing is good. But we should bear in mind that what we have to control is negative stress and not positive response to stress. 6. To control job stress among nurses, the cooperation and involvement of all stakeholders in the profession of nursing should be solicited. CONCLUSION Nursing is inherently stressful. But this does not mean that negative response to stress be left unchecked. 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