Death at workplace and associated stress in the context of nursing - Essay Example

? Dealing with death at work Introduction In the last three to four decades, there are increase evidences of work related stress in almost all segments of employment leading to various unwanted consequences for the workers’ overall health, individual safety and for the overall productiveness of the organisations (ILO, 1986). Union groups and scientific and professional groups working on job related stress have expressed this opinion repeatedly, and there has been especially a great deal of concern over the consequences of stress for those working in heath related sectors. Working in a field that emphasises on caring and healing, the factor of death may seem like a failure, leading to stress in the caregiver. Nurses, who are the primary caregivers, often undergo emotional anguish and grief when dealing with patient deaths and a lack of psychological support at this time can lead to trauma (Cain and Ter-Bagdasarian, 2003; Hanna and Romana, 2007). In a review on health profession related stress, Moreton-Cooper derived that nursing, as a profession is a ‘stressful’ one, owing to the very nature of activities associated with it (1984, 16-19). This observation is further reaffirmed by Hingley who stated, “Every day the nurse confronts stark suffering, grief and death as few other people do. Many nursing tasks are mundane and unrewarding. Many are, by normal standards, distasteful and disgusting. Others are often degrading; some are simply frightening” (1984, 19). Nurses, who are forced to face such tasks and incidents of patients’ deaths, also known as death anxiety (Mallett, Price, Jurs and Slenker, 1991), very naturally are known to go through high stress levels (which are often exaggerated by organisational apathy and other management issues). Observations reveal that when specific incidents tend to take over an individual’s normal skills for coping, it leads to trauma and distress, which makes it necessary for specialised intervention (Cain & Ter-Bagdasarian, 2003). Often, after experiencing trauma on a patient’s death, nurses are provided with basic and informal help in the name of intervention to cope with emotional upheaval, which they may be experiencing at that particular moment (Antai-Otong, 2008, 789-811). It is largely the responsibility of the hospital management to provide for a stress management program in order to help their nurses overcome death related trauma. Stress management programs include various forms of therapeutic interventions, which are created especially to assist nurses in exploring and analysing their experiences, which helps them to relax, reduce anger levels, while improving their coping strategies in dealing with death at work (Irving and Long, 2001). The hospital management’s responsibilities towards improving and maintaining good health of their nurses is framed by various laws, both at national and international levels, based on theories of risk management and those of control cycle (Cox and Cox, 1993). The European Union’s Framework Directive 89/391/EEC gives a distinct outline of the framework to be followed by a hospital management, while dealing with stress at work (The Council of the European Communities, 1989). While a large part of the guidelines tend to highlight effects of job hazards that are corporeal in nature, experts contend that they can be expanded to include stress management and hazards that are more psychosocial in nature (Cox, Griffiths, and Rial-Gonzalez, 2000). Although nurses are trained deal physiologically with diseases and stress, it is necessary that they comprehend the seriousness of the effect that stress may have on one’s emotions and learn methods to handle stress at work (Antai-Otong, 2008, 789-811). It is necessary for nurses to release stress and emotional disturbances they might experience while taking care of their patients or after the death of their patients. Without an opportunity to study and analyse their traumatic experiences, the nurses would start showing symptoms of stress like anxiety, lack of attachment, depression, and even depersonalization. In this context, the paper will study and analyse work related stress in the context of nurses coping with death related trauma in various care homes and will find ways or systems that aim at improving stress related to death at work. Discussion Stress and workplace related stress in the context of nursing The term stress denotes “a reaction to some stimulus or demand that produces an elevated state of arousal or readiness. The greater the stimulus, the greater is the stress reaction” (Vallone, nd, 4). When a person experiences stress, it represents a psychological state of being which may occur due to thereat of exposure or direct exposure, or both, to the psychosocial or corporeal hazards associated with any workplace scenario. Therefore, experiencing stress is a result of being exposed to work hazards or certain dangerous situations within workplaces and these are known as stressors. Work stress is acknowledged as one of the main challenges to workers’ health and the wellbeing of the firms in which they work, and the stressed workers are not only unhealthy and unsafe in their workplace environment, they also lack motivation to work and hence are less productive (Cox, Griffiths and Leka, 2004). In turn, with less productive workers the organizations are most likely to lose out in the competitive marketplace, especially in the present era of globalisation of stiff completion in almost arenas. Workplace stress is considered the emotional and physical manifestation, which takes place when there is a mismatch between job demands and the control that a worker has while handling the demands. Whenever there is stress, it translates into the fact that job demands on a worker have crossed the individual’s personal resources or control over the situation (the personal resources maybe emotional, spiritual, physical, social, or economic). Therefore, work related stress occurs when work demands and challenges become very high and goes beyond a worker’s capability to handle them, and turning job satisfaction to a feeling of extreme frustration and subsequent burnout. Here there is a difference between the terms work pressure and work stress. Work pressure is an unavoidable factor owing to the various demands of the current working scenario, and reasonable amounts of pressure might even keep the workers motivated, interested and make them want to learn new things in order to perform better, depending on their personal characteristics and available resources (Cox, Griffiths and Leka, 2004). When the same work pressure turns too high or becomes excessive and unmanageable, it causes stress in the workers. Therefore, a healthy job place environment is a place where work pressure on the employees are relatively balanced, as regards their assets and capabilities, their control over work pressure, and the support received from colleagues, supervisors and family members (Cox, Griffiths and Leka, 2004). As WHO suggested, health does not signify only the lack of disease or affliction of some kind, but reflects “a state of complete physical, mental and social well-being” (WHO, WHO definition of Health, 2003). Therefore, one can derive that a healthy working environment is a place where harmful factors (that create stress) are not only lacking, instead many health-promoting factors are present that actively work towards improving the workers’ health. A work hazard is a dimension within a work situation that has possibilities for causing for harm to the workers. There are two basic forms of work hazards, the physical hazards (encompassing chemical, radiological or biomechanical dangers within the workplace environment) and psychosocial hazards (Cox, Griffiths and Leka, 2004). Psychosocial hazards refer to issues that might occur when there is interplay between organisation of the work, work content, management, workplace environment, on one hand, and skills, knowledge, competencies and requirements of workers’ on the other (Cox, Griffiths and Leka, 2004). The interactions that produce harmful effects, tend to influence workers’ health (mental and physical) through their experiences and viewpoints, and being exposed to both or any one of the hazard, might pose to be serious threat for the physical and mental wellbeing of an individual (ILO, 1986). Fig 1: “Cooper’s model of the dynamics of work stress” (Cox, Griffiths and Rial-Gonzalez, 2000, 44). Stress, which is a psychological state, is part of a wider process that involves interaction between an individual (the nurse) and work environment (patients, colleagues, seniors, physicians, etc.). Currently many scholars have opined that using a psychological approach to stress, allows one to understand better the causes and effects of distress in any individual. Various models have also been formulated to represent the stress process, of which Cooper’s model is considered as the most noteworthy (Cox, Griffiths and Rial-Gonzalez, 2000), as shown in Fig1. In the model by Cooper, the chief focus is on the type and element of work related stress, and their organisational and individual results. As Cox, Griffiths and Rial-Gonzalez explained, “The stress state is a conscious state but the level of awareness of the problem varies with the development of that state. Part of the stress process are the relationships between the objective work environment and the employee’s perceptions of work, between those perceptions and the experience of stress, and between that experience and changes in behaviour and physiological function, and in health” (2000, 45). Stress, which is a direct outcome of a worker’s exposure to a variety of work related demands, produces varying range of health results, and is thus is the single connection between health and hazard. In context of nursing and stress, some of the modern stress theories suggested that a stressful situation involves threatening work pressure; work which is not well matched with the skill sets, knowledge levels and abilities of the nurses concerned (Aiken, Clarke, and Sloane, 2002); the allocated work fails to accomplish their requirements where they have very little control over their work (Chapman, 1993); lack of support at workplace or outside it (Cheng, Kawachi, Coakley, Schartz, and Colditz, 2000), and dealing with death or dying patients (Lambert, Lambert and Ito, 2004). Despite the number of researches on stress experienced by nurses' from their work demands is limited, there have been few qualitative researches that suggest high work pressure, relationship with colleagues and seniors, lack of adequate treatment facilities and patient’s death to be the most frequently cited stressors. Coping which is another significant part of stress management is also relatively poorly researched, especially in the context of helping nurses cope with their daily stressors. As per the reports by Cox and Cox (1993), nine psychosocial traits are seen associated with workplaces, jobs, and organizations that are considered as hazardous for an average worker. These traits are associated with various aspects of organisational activities and culture, career growth, the latitude to participate and take part in decision-making processes, work matter, role within the firm, workload, relationships with colleagues and superiors at work, and the integration of work and home. The authors contended that under specific conditions, each one of the aforementioned nine work traits have proven to cause stress and are hence harmful to the workers’ health. As for example, conditions that delineate the hazardous trait of workload include quantitative or qualitative work overload/ under-load, lack of control over work pressure, persistent time pressure, sustained pressure of meeting deadlines, and high levels of pacing with no control over it (Cox and Cox, 1993). Work traits simply may not add on to the health outcome of an average worker, but they might mix collectively in relation to these outcomes (Karasek, 1979). Karasek, while collecting data from the United States and Sweden, found that employees working in organisations that place high job demands along with poor decision latitude were more likely to produce low job satisfaction and poor health. The results as put forth in the report by Karasek, was later confirmed through other researches, even though there were also many questions raised on the actual validity of the test results. Of the researches that deal with nurses and work related stress, the work of Gray-Toft and Anderson (1981) are considered the most noteworthy. In their report, the authors distinguished seven primary sources that caused stress to nurses. These were, caring for dying patients and death of patients, confrontation with physicians, lack of preparation to meet the emotional requirements of patients, absence of organisational support; confrontation with colleagues and supervisors; high work pressure and ambiguity as regards patient’s treatment (Gray-Toft and Anderson, 1981). Similarly, it has been seen that Bailey, Steffen and Grout (1980) prepared another list of sources that apparently caused stress to nurses, which included problems while caring for patients (dying patients or dealing with patient’s death), work load, management issues, interpersonal relationships with colleagues and other staff, problems in technical knowledge and skills, and career growth within the organisational framework. Ivancevich and Smith (1981) in their researches distinguished three main stressor sources, which included conflicts within workplace, work overload, relationship with the supervisor or head nurse. Dewe (1987) in his reports distinguished five major stressors: nursing of terminally ill patients or dealing with patient’s death, heavy work pressure, problems with other staff in the hospital, concerns over lack of basic treatment facilities provided to patients and dealing with difficult patients or futile medical care. In this context, from a study of the above research papers it can be derived that a nurse’s activities are associated with various demands that are conflicting in nature often imposed superiors and by others in administration, which causes work overload and subsequent conflict in role playing (Gray-Toft and Anderson, 1981). This is apparent in many of the surveys where there are frequent mentions of conflicts related to the goal-backed demands of improving a patient’s health, and demands related to alleviating patient’s stress and supporting them emotionally (Gray-Toft and Anderson, 1981). This kind of a conflict in a nurse’s role is most apparent while caring for terminally ill patients and those in the palliative care, although the conflict may be a little less when dealing with the patient’s families. Each of the stressors by itself forms to be an intricate mixture of various incidents and bearings; as for example, nurses generally tend to worry persistently while dealing with dying patients, especially those in the intensive or critical care units. However, a study of the research papers reveal that the stress that the nurses experience at this time is just one dimension of highly intricate situation, which is surrounded by various other problems related to treatment and patient care Death at workplace and associated stress in the context of nursing Various studies show that patients often “die in hospitals with poor quality of life” (Granda-Cemeron, Lynch, Mintzer, Counts, Pinto, and Crowley, 2007, 772), while terminally ill patients often suffer prolonged agony, before finally dying, owing to the various invasive medical procedures. Such poor health facilities, lack of proper treatment mechanism and inadequate measures for providing pain relief for palliative care tend to affect the patient and the nurse negatively (Ferrel, Dahlin, Campbell, Paice, Malloy and Virani, 2007). Currently there are increasing worries on issues of health care facilities, which in the modern context include various ethical, legal and social questions, in cases of futile medical care, where survival of the patient is unlikely (Ferrell, 2006). However, there have not been many researches on the aspect that deal with psychological study of nurses who take care of such patients placed under futile medical care, knowing that it is quite likely the patients would not survive (Ferrell, 2006). Many scholars have claimed that nurses who are relatively more influenced by issues related to death or futile medical care are also more prone to suffer from distress and emotional anxiety. Once a stressful event takes place, there various physical, behavioural, cognitive and emotional responses observed in an individual (Help Guide.org, 2007). Cognitive problems seen at times of stress include problems in remembering things, lack of concentration, lack of ability to judge correctly, persistent negative feeling, anxiety and constant depression (Help Guide.org, 2007). Emotional symptoms observed are irritability, moodiness, a feeling of agitation, not being to relax, a sense of being overwhelmed, a feeling of being isolated and lonely, and depression (Help Guide.org, 2007). Physical symptoms include bodily pains, persistent nausea, complaints of pain in the chest, diarrhoea, constipation, increased heartbeat, decrease in sexual desires and intermittent colds (Help Guide.org, 2007). Behavioural symptoms include sudden change in eating and sleeping patterns (increase or decrease), nail biting, remaining isolated from colleagues/ family members/ friends, delaying or not taking responsibilities, alcoholism, smoking too many cigarettes, or resorting to substance abuse in order to relax (Help Guide.org, 2007). Often there may be multiple effects of stress, where nurses start responding less with their patients and colleagues (Hanna and Romana, 2007). As caregivers, nurses remain at the frontline of providing medical assistance and hence are at the side of dying patients, and from a perspective of human emotions and feelings, such situations are often intense ones, which might cause the nurses to experience stress. In this context, one scholar claimed, “of all health professionals, nurses are in the most immediate position to provide care, comfort, and counsel near the end of life for patients and families” (Dickenson, 2007, 741). Studies that deal with end of life or palliative care identifies the need to address the emotional requirements of nurses who cope with dying patients and subsequently deal with the trauma of patient’s death. Nurses are viewed upon as a source for seeking assurance by the patient and his or her family and are often seen as the only human link within the entire process of healthcare (Zuzelo, 2007). The relationship between a patient and nurse is also considered an essential aspect within any health care system and this tends to puts further stress (mental) on the nurses (McVicar, 2003). Studies show that more than half the terminally ill patients in US who die within the setting of an acute care hospital, have nurses as their primary caregivers, thus making palliative care one of the primary sources of stress for the nurses (Weigel, Parker, Fanning, Reyna, and Gasbarra, 2007). The emotional or psychological demand that is associated with caring (a necessary aspect for meeting the requirements of heath industry) is a persistent pattern, which has been identified by many nurses. This form of work that demands emotional or psychological involvement can cause increased feeling of frustration and may lead to a nurse slowly becoming less personal with patients, making him or her more mechanical, which may finally lead to deterioration in quality of care provided, especially in context of palliative care (White, Wilkes, Cooper, and Barbato, 2004). Besides this, persistent demand on one’s emotions or psychology can cause the nurse too face an early professional burnout (Huynh, Alderson, & Thompson, 2008). There is another emotional problem faced by those serving in the health industry where one must remove all feelings of empathy to cope with patients’ deaths that cause stress and drains one emotionally (Guppy and Gutterridge, 1991). The sharp division that exists between responding emotionally to provide optimal care and later switching off to remain uninfluenced by patient’s suffering and death can cause high levels of stress (Gentry and Parkes, 1982). Stress responses in cases of patient’s death (whom a nurse may have been taking for some time and with whom he or she may have become emotionally attached) may be harsh and attenuating enough to stop the nurse form taking part in normal daily activities (Robinson, 2004). Stress responses develop from incidents where a person experiences helplessness, horror or fear (Berman & Davis-Berman, 2000). In the cases of Post-Traumatic Stress Disorder or PTSD (diagnostic criterion), a person experiences various stress related symptoms that continue for more than one month after an incident that caused fear or horror has taken place. As per the American Psychological Association or APA (1994), there are four such diagnostic criteria, where the first one involves an incident where the nurse experienced trauma, while dealing with patient’s death or near-death or serious injuries. The second one involves is re-living the entire incident through thoughts or dreams, while the third one is where the person starts avoiding meeting people who were involved or were present at the time of the incident, facing similar situations or feelings associated with the event. Fourthly, the nurse starts exhibiting stress symptoms like lack of sleep, anger, irritability, increased or decreased sexual desire. Acute stress disorder after an incident is manifested through various human emotions like those of helplessness, sadness, depression, worry and anger (Weigel, Parker, Fanning, Reyna, and Gasbarra, 2007), which are commonly reported by nurses working in the end-of- life industry. Here the nurses must make themselves emotionally vulnerable in order to respond to the dying patient’s needs, but must once again switch off their feelings care support system or dealing with a patient’s death. Various researches reveal that patient suffering and death are two stressors that nurses experience persistently throughout their working careers (Desbeins and Fillion, 2007). Futile medical care often arouses strong psychological responses from the nurses, where they feel that the entire system of futile medical care is cruel towards the patient and violent in its form (Ferrell, 2006). Therefore, nurse who feel strongly against futile medical care feel distressed when asked to care for such patients, which can adversely influence the nurse’s ability to respond appropriately, and cause mental disturbances and burnout (Zuzelo, 2007). McVicar (2003) has identified dealing with death and dying patients as major workplace stressors that influence nurses, which adversely influences a nurse’s capability to function effectively at work and home, and lead to emotional problems. Therefore, it is necessary that nurses, especially those in the palliative care or futile medical care, are made familiar to incidents like death of a patient, along with various stress response symptoms, and are made aware during their training that the nature of their job raises chances of experiencing workplace stress almost on a daily basis. With this knowledge, they must also be trained to handle or cope with stress that is a part of nursing and medical duty. Coping with stress from handling death at workplace by the nurses It is an acknowledged fact that nurses working in hospices and taking care of patients must handle the trauma of dealing with dying patients, and coping with patient’s death. Coping is an essential component of stress management and is defined as “constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus and Folkman, 1984, 19).  Coping activities may be either problem-oriented (externally aimed) where they attempts to control or modify the problem that gives rise to stress, or they may also be emotion oriented in that is aimed internally and works at lowering emotional stress (as seen in fig 2). Problem-oriented methods of coping includes facing the stress-creating situation through use of activities that involve taking a certain level of risk, problem-solving activities, and comprehending one's role in problem solving. Emotion oriented coping includes avoiding any form of conflicts, and detaching or dissociating oneself from that that stressful situation. Fig 2: “Transactional model of stress” (Vallone, nd., 6). This shows the various components within the process of studying and analysing stressors (in any stressful situation) in order to cope with it. According to Lazarus and Folkman (1984), an individual when faced with stress tries to deal with the situation by using both the aforementioned methods. In this context, Lazarus and Folkman (1984) have distinguished eight primary strategies for managing stress. These include self-control, escape-avoidance, confrontive coping, positive reappraisal, distancing, accepting responsibility, looking for social support, escape-avoidance, positive reappraisal and planful problem-solving (Lazarus and Folkman, 1984). Self-control is the process where an individual makes efforts to control one's emotions and functions. Confrontive coping refers to aggressive attempts at changing a situation, which comprises of making use of behavioural tactics that may appear as hostile or risky. Positive reappraisal is a spiritual aspect which aims at giving a positive meaning to an event emphasizing on factor of personal growth form that experience. Distancing is dissociating oneself from a stressful situation in order to minimize the harmful effects of the situation. Looking for social support refer to finding emotional and psychological support from others in the community. Accepting responsibilty is acknowledging one's role in problem solving while efforts to avoid facing a stressful event are known as escape-avoidance. Planful problem solving is modifying a situation, using an analytical approach. In the context of nurses coping with work related stressors, various researchers showed that the topmost stressor was identified as dealing with patient’s death and other death related issues followed by high workload, in almost all countries worldwide. However, differences were observed in methods of coping that depended on a country’s socio-cultural values (Lambert, Lambert, Itano, Inouye, Kim, Kunaviktikul, et al. 2004; Snelgrove, 1998). Chang, Bidewell, Huntington, Daly, Johnson, Wilson, et al. (2007) in their experiments derived that self-control, positive reappraisal, and planful problem-solving worked best for Chinese nurses while Japanese nurses coped better using planful problem-solving, self-control, and seeking social support. Australian nurses’ preferred social support, planful problem solving, and self-control on the other hand nurses from New Zealand coped best through social support, planful problem solving, and self-control. South Korean nurses used social support, self-control and positive reappraisal; Thai nurses adopted positive reappraisal, self-control, and planful problem solving, while Hawaiian nurses coped best with positive reappraisal, self-control and planful problem solving. Therefore, it is evident that a pattern emerges where the nurses are seen to prefer social support, planful problem-solving, positive reappraisal and self-control, as primary coping methods within their workplace. There are debates on the use of emotion-oriented or problem-oriented form of coping strategies, as regards which one of the two produce better mental health, with scholars contending that nurses in western countries respond better to problem-focused ones, while others claiming that nurses from Asian cultures respond better to emotion-focused strategies (Chang, Bidewell, Huntington, Daly, Johnson, Wilson et al, 2007). Here it must be remembered that in nursing, as in any other workplace, a total stress free working environment is not possible. Despite how much one wishes to work in a stress free environment, he or she must necessarily face some degree of stress almost daily in various situations. Keeping this in mind, stress management may be adopted in order to avoid the ill effects of stress at work. While it is definitely not possible to avoid all kinds of stress, there are various ways to eliminate some of the stressors. The best coping strategies for reducing work related stress focuses on workers’ knowledge and capabilities, work demands, adequate control and support, and include: “Changing the demands of work (e.g. by changing the way the job is done or the working environment, sharing the workload differently). Ensure that employees have or develop the appropriate knowledge and abilities to perform their jobs effectively (e.g. by selecting and training them properly and by reviewing their progress regularly). Improve employees’ control over the way they do their work (e.g. introduce flexi-time, job-sharing, and more consultation about working practices). Increase the amount and quality of support they receive (e.g. introduce ‘people management’ training schemes for supervisors, allow interaction among employees, encourage cooperation and teamwork)” (Cox, Griffiths, and Leka, 2004, 18). Since the very nature of the medical profession exposes all those working within it, including nurses, to stressors involving patients’ deaths, it is necessary for hospitals to adopt the aforementioned measures as advocated by Cox, Griffiths and Leka (2004) as it helps in training the nurses to handle stressful situations in a better manner. It is important for healthcare organizations to recognise the fact that nurses are often adversely affected by a patient’s death (as has been proven through researches). They must in turn offer assistance to the nurses when they are going through a difficult time adjusting to an emotional situation that may have arisen from a patient’s death (even though hospitals may encounter deaths almost on a daily basis). Support from their colleagues and superiors are important factors that help a nurse in coping emotionally and releasing one’s stress. Cox, Griffiths and Leka, recommended certain measures for organisations to follow while helping an individual (its employee) to cope with work related stress: “An individual worker’s problems and the solutions to those problems should be discussed with the worker, described and agreed. Timing of such discussions may depend on worker’s state of well-being. Possible interventions, both individual (e.g. training, medical treatment, counselling) and organizational (e.g. job re-design, changes in management practices) should be planned, implemented and evaluated. Careful records should be kept, and progress evaluated. Records should be accurate, deal with facts and points of evidence. Opinions and judgements should not be represented as facts. Proposed actions and the reasons for their selections should be agreed where possible and recorded” (2004, 22). Conclusion Stress at workplaces is currently recognised as a major global challenge for the overall wellbeing of the workers’ and their organizations. Work related stress is a real issue for the modern workers as well as the organizations in which they work. Workers that remain stressed while at work are more likely to be mentally and physically unhealthy, show low motivation, poor productivity and are less safe while at work (Cox, Griffiths and Leka, 2004). Owing to these reasons, the organisations with stressed employees are liable to fail within a competitive market. Stress can be brought about by workload pressure at the office or through personal problems at home. It is not possible for employers to help their employees in handling stress that has its origin outside the workplace, but they can accord protection from stress that may come from work. This can be achieved through good management and well-organised and safe workplace conditions, which are the best ways to prevent stress prevention. The superiors or managers must be aware as to which employees are undergoing stress and they must be aware of the procedures that would help the workers to cope with the stress. Nursing is acknowledged as being stressful in nature; hence, it is necessary to comprehend the actual nature of a problem in order to handle it better. Death anxiety (from dying patients) and dealing with the aftermath of a patient’s death can make the nurses experience stress. This can lead to psychological disturbances, emotional problems and deterioration of physical health, which in turn would affect one’s productivity. Stress in nursing can be best reduced through the application of the problem-focused or emotion-focused strategies (based on a country’s socio-cultural values) that help a nurse to cope well when dealing with trauma arising from a patient’s death. References Aiken, L., Clarke, S., and Sloane, D. (2002). Hospital staffing, organization and quality of care: Cross-national finding. Nurs Outlook 50, 187-94. APA. (2004). Diagnostic and statistical manual of mental disorders (3rd Ed.). Washington, D.C.: American Psychiatric Publishing. Antai-Otong, D., (2008). “Individual psychotherapy.” In, D. Antai- Otong (ed.), Psychiatric Nursing: Biological and Behavioral Concepts. New York: Delmar. Bailey, J., Steffen, S., and Grout, J. (1980). The stress audit: Identifying the stressors of ICU nursing. Journal of Nursing Education 19, 15-25. Berman, D., and Davis-Berman, J. (2005). Reconsidering post-traumatic stress. Journal of Experiential Education 28(2), 97-105. Caine, R., and Ter-Bagdasarian, L. (2003). Early identification and management of critical incident stress. Critical Care Nurse, 23(1), 59-65. Chang, E., Bidewell, J., Huntington, A., Daly, J., Johnson, A., Wilson, H., et al. (2007). A survey of role stress, coping and health in Australian and New Zealand hospital nurses. Int J Nurs Stud 44, 1354-62. Chapman J. (1993). Collegial support linked to reduction of job stress. Nurs Manage 24:52-4. Cheng, Y., Kawachi, L., Coakley, E., Schartz, J., and Colditz, G. (2000). Association between psychosocial work characteristics and health functioning in American women: Prospective study. Br Med J 320, 1432-6. Cox, T., Griffiths, A., and Leka, S. (2004). Work Organization and Stress. Protecting Workers’ Health Series No. 3, WHO. Nottingham: Institute of Work, Health & Organizations Cox, T., Griffiths, A., and Rial-Gonzalez, E. (2000). Research on Work-related Stress. Luxembourg: Office for Official Publications of the European Communities. Cox, T., and Griffiths, A. (1994). "The nature and measurement of work stress: Theory and practice." In, N. Corlett and J. Wilson (eds.), Evaluation of human work: A practical ergonomics methodology. London: Taylor and Francis. Cox, S., and Cox, T. (1993). Psychosocial and organizational hazards: Monitoring and control. European Series in Occupational Health No. 5. Copenhagen, World Health Organization. Dewe, P. (1987). New Zealand ministers of religion: Sources of stress at work. Work and Stress l, 351-363. Dickenson, G. (2007). End of life and palliative care issues in medical and nursing schools. Death Studies 31, 713–726. Ferrell, B., Dahlin, C., Campbell, M., Paice, J., Malloy, P., and Virani, R. (2007). End of life nursing education consortium (ELNEC) training program: Improving palliative care in critical care. Critical Care Nursing Quarterly 33, 206- 212. Ferrell, B. (2006). Understanding the moral distress of nurses witnessing medically futile care. Oncology Nursing Forum 33(5), 922-930. Gentry, W., and Parkes, K. (1982). Psychological stress in an intensive care unit and non-intensive care unit nursing: A review of the last decade. Heart and Lung 11, 43-47. Gray-Toft, P., and Anderson, T. (1981). Stress among hospital nursing staff: Its causes and effects. Social Science and Medicine 15A, 539-647. Granda-Cameron, C., Lynch, M., Mintzer, D., Counts, D., Pinto, S., and Crowley, M. (2007). Bringing an inpatient palliative care program to a teaching Hospital: Lessons in leadership. Oncology Nursing Forum, 34(4), 723-33. Guppy, A., and Gutterridge, A. (1991). Job satisfaction and occupational stress in UK general hospital nursing staff. Work and Stress 5, 315-332. Hanna, D., and Romana, M. (2007). Debriefing after a crisis. Nursing Management 8, 39-47. Help Guide.org. (2007). Understanding Stress Symptoms, Signs, Causes, and Effects. [Online] available at http://www.helpguide.org/mental/stress_signs.htm#signs [accessed 9th May 2012] Hingley, P. (1984). The humane face of nursing. Nursing Mirror 159, 19-22. Huynh, T., Alderson, M., and Thompson, M. (2008). Emotional labor underlying caring: An evolutionary concept analysis. Journal of Advanced Nursing 64(2), 195- 208. ILO. (1986). Psychosocial factors at work: Recognition and control. Occupational Safety and Health Series No. 56, Report of the Joint ILO/WHO Committee on Occupational Health Ninth Session Geneva, 18-24 September 1984 [online] available at  http://www.who.int/occupational_health/publications/ILO_WHO_1984_report_of_the_joint_committee.pdf. [Accessed 9th May 2012] Ivancevich, J., and Smith, S. (1981). Identification and analysis of job difficulty dimensions: An empirical study. Ergonomics 24, 351-364. Karasek, R. (1979). Job demands, job decision latitude and mental strain: Implications for job redesign. Administrative Science Quarterly 24, 285-308. Lambert, V., Lambert, C., and Ito, M. (2004). Workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health of Japanese hospital nurses. Int J Nurs Stud 41, 85-97. Lambert, V., Lambert, C., Itano, J., Inouye, J., Kim, S., Kunaviktikul, W., et al. (2004). Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii). Int J Nurs Stud 41, 671-84. Lazarus, R., and Folkman, S. (1984). Stress, appraisal and coping. New York: Springer. Mallett K., Price, J., Jurs, S., Slenker, S. (1991). Relationships among burnout, death anxiety, and social support in hospice and critical care nurses. Psychol Reports 68, 1347-1359. McVicar, A. (2003). Workplace stress in nursing: A literature review. Journal of Advanced Nursing 44(6), 633-642. Moreton-Cooper, A. (1984). The end of the rope. Nursing Mirror 159, 16-19. Robinson, R. (2004). Counterbalancing misrepresentations of critical incident stress debriefing and critical incident stress management. Australian Psychologist 39(1), 29-34. Snelgrove, S. (1998). Occupational stress and job satisfaction: A comparative study of health visitors district nurses and community psychiatric nurses. J Nurs Manage 6, 97-104. The Council of the European Communities. (1989). Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work. [Online] available at http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31989L0391:en:HTML [accessed 9th May 2012] Vallone, D. (nd.) Home and Work Health: Nurses Dealing with Life Stresses. [online] available at http://www.vanurse.org/Home%20and%20Work%20Health%20Nurses%20Dealing%20with%20Life%20Stresses.pdf [accessed 9th May 2012] Weigel, C., Parker, G., Fanning, L., Reyna, K., and Gasbarra, D. (2007). Apprehension among hospital nurses providing end of life care. Journal of Hospice and Palliative Nursing 9(2), 86-91. White, K., Wilkes, L., Cooper, K., Barbato, M. (2004). The impact of unrelieved patient suffering on palliative care nurses. Int J Palliat Nurs 10, 438-44 WHO. (2003). WHO definition of Health.[Online] available at http://www.who.int/about/definition/en/print.html [accessed 10th May 2012] Zuzelo, P. (2007). Exploring the moral distress of registered nurses. Nursing Ethics 14(3), 344-359. Read More