Introduction
Nurses play a fundamental role in the delivery of the quality care model. Most recently, the impact of the COVID-19 pandemic on the healthcare industry highlighted the growing need for registered nurses (RNs). In March 2020, approximately 28,000 nurses got relocated to Hubei Province to be on the frontline in COVID-19 control, isolation, and public health (Ardıç et al., 2022). Before COVID-19, nurses mainly focused on advocating for positive health outcomes in the frame of the quality care model. During post-COVID times, the quality care model of nurses, on the contrary, centered around the process of providing patient-centered and evidence-based care, and not about the outcome (Chinn & Kramer, 2018). Cooper and Quick (2017) state that nurses work collaboratively to validate health outcomes for reforms and improve patient care. However, the dramatic changes in globalization and technological advances are defining new patterns in the healthcare system, causing a significant impact on the nursing structure. Consequently, pressure to meet rising patient needs coupled with heavy workloads and long hours potentially leads to occupational stress.
The paper deals with the concept of stress and dwells on stress bringing adverse impacts on nurses’ health and their overall performance. It concentrates on the several reasons that cause nurses to get stressed out, such as time pressure, lack of social support, exposure to infections and work-related threats, understaffing, lack of development programs, and role conflict (Cooper & Quick, 2017; Prosen, 2021; Said & El-Shafei, 2021). After that the paper identifies negative effects of stress such as restlessness, anxiety, fatigue, drug and substance abuse, and irritability, which result in decreased productivity (Al Maqbali et al., 2021; Jarrad et al., 2018). Then the work states that risk factors of stress in the care setting and providing behavioral and cognitive intervention programs are essential in improving nurses’ professional values and quality of life. Therefore, the purpose of this paper is to investigate the stressors and effective strategies for managing occupational stress among registered nurses.
Theoretical Perspective
General Adaptation Syndrome Theory
A lot of relevant research on stress is dedicated to the identification of stress and its symptoms. Saquib Mulla et al. dwell on the first theoretical concepts of stress pioneered by Hans Selye (2021). Scholars examine the general adaptation syndrome (GAS) theory and then evaluate each of the three stages in response to stress: alarm, resistance, and exhaustion. The first stage, alarm, happens when an individual first encounters a specific stressor. This mechanism is closely regarded in a second relevant research article.
Buckner et al. explain how the amygdala release distress signals to the hypothalamus that emits energy and releases hormones, which activates the sympathetic nervous system that regulates heart and breathing rate, blood pressure, and the functions of the muscles, stomach, and bladder (2020). Next scientists describe how the activation of the sympathetic nerve stimulates the adrenal glands that release certain hormones, including cortisol and adrenaline. Then Buckner et al. highlight how the secretion of cortisol stimulates the body’s fight-or-flight response and rise in blood glucose levels.
The Emergency Theory
People feel emotions and experience physiological reactions in response to stress simultaneously. In the third relevant research article, in tandem with Ponce argued that stress begins in the brain such that the amygdala translates potential danger to the hypothalamus (2018). Then he highlighted that the theorist used decorticated cats in an attempt to prove his assumptions. The decorticated cats displayed emotional behavior during stressful events, which manifested in body changes such as the baring of teeth. He then analyzed the experiment arguing that the thalamus, a lower stem structure of the brain, produces emotional responses (Ponce, 2018). In the conclusion of the paper, the scholar states the emergency theory stipulates that physiological and emotional responses to stressful events occur simultaneously.
Transactional Theory
Stress is a significant concept in nursing because it is a primary risk factor for poor psychological well-being and the overall health of medical staff. Lazarus and Folkman defined stress as an imbalance between internal and external demands, plus perceived resources linked to stress responses (Lazarus & Folkman, 1987). This understanding of stress is somewhat similar to the definition that Ponce gives: he states that stress is a non–specific response of the body to any change in conditions that requires adaptation (2018). In the dictionary, stress is usually defined as a state of mind caused by increased nervous tension under strong influence of negative factors. The antecedents and consequences of this approach are associated with the creation of an exclusively negative perception of stress while the scientific definition contains important information about the benefits of short-term stress.
The transactional theory emphasizes the affective and cognitive aspects of a person’s environmental interactions and the coping strategies one lacks: Individual appraisal processes impact stress responses (Lazarus & Folkman, 1987). Coping efforts essentially affect stress responses, social functioning, plus long-term health. Lazarus and Folkman (1987) argued that people can either adopt emotion or problem-focused coping mechanisms. An emotion-based approach such as avoidance or denial changes one’s relationship with the current situation to reduce stress responses. Conversely, problem-based coping attempts to make the situation manageable and can result in real change.
Risk Factors of Stress
Registered nurses often face high healthcare expectations that make them vulnerable to burnout and severe stress. Among the primary sources of occupational stress in nursing include staff relationships, workload, lack of personnel, patient-nurse relationships, and complex care systems (Brown et al., 2018; Schoberer et al., 2022). In terms of workload, caring for many patients can be challenging, especially with limited autonomy and the need to maintain high standards. Sturm et al. (2019) asserted that the increasing demand for nurses, reduced hospital length of stay, increased overtime, and reduced staffing exacerbates higher workloads among RNs. In the occurrence of nursing shortages, the workload increases for remaining nurses. Consequently, healthcare organizations increase medical costs to reduce the length of stay, making patient care more intensive (Stafseth et al., 2022). However, a high nursing workload negatively affects job satisfaction, as a result, contributing to occupational stress.
Death can further trigger stress among RNs when they fail to maintain high competence levels in their practice. For example, consider a nurse working in the family planning center. Family planning units serve as the primary healthcare system interface for mothers, fathers, and prospective parents. RNs provide and support abortion care in various practices, including the diagnosis, treatment, prevention, and management of sexually transmitted infections, unplanned pregnancies, and other facets of sexual health. However, providing advice regarding unplanned pregnancy and elective abortion procedures can be daunting for nurses. Lyon and Botha (2021) stated that induced abortions due to unintended pregnancies occur frequently despite education, financial, or health status. However, performing an abortion may lead to negative psychological experiences for nurses since the procedure is emotionally demanding.
Moreover, RNs’ primary responsibility is to care for and support patients while respecting their autonomy as the patients’ families adjust to the impending reality of loss. In certain areas of health care, hospitalization can be prolonged, especially for patients dealing with chronic health conditions or trauma cases such as accidents, gunshots, and stab wounds. As such, nurses meet the patients and their families frequently for positive health outcomes. Kostka et al. (2021) connected the care for dying patients with enormous stress and strong emotions, contributing to high occupational burnout. Additionally, the fear of clients’ death can result in longer working hours and late nights to care for a dying patient. Uncertainty of the treatment effect takes a psychological toll on RNs, affecting their behavior, both professionally and at a personal level. In some cases, nurses must work with difficult patients or risk getting exposed to infection as they cope with the emotions regarding death.
In efforts to provide safe and quality care, RNs selflessly support patient needs out of professional and ethical responsibility. However, occupational risk factors, including staffing, work demands, time management, organizational structure, and resources, can escalate stress levels among RNs. Likewise, non-occupational risk factors such as financial, health and marital status, age, and gender attribute to RNs’ psychological stress. For example, shift work can negatively impact family relations, disrupting social activities between spouses, which significantly affects general health (Azimian et al., 2017). Plus, given that health and financial satisfaction affects health, nurses face various stressors to achieve workplace goals and at home because of the multiplicity of responsibilities, making them vulnerable to family-work conflicts and as a consequence, heightened stress levels.
In my career I have also encountered stress: first, I started with pulmonary medicine for one year. Then I worked at PACU (phase1) for 11 years, after that I moved to family planning unit of elective abortion procedure and recovery for year, and went back to critical care unit (Surgical ICU) due to the COVID-19 emergency where I currently work. Even though I have worked in the same hospital at the Level 1 trauma center in South Bronx, NY and always dealt with similar trauma cases – gunshot, stab wounds and accident – as SICU RN, I still get a lot of stress from my work.
Impact of Stress
Psychological Health
Stress can adversely affect one’s thoughts, feelings, well-being, and overall health when left unchecked. For one, stress precipitates mental health problems such as anxiety and depression. A plethora of research exists on the correlation between stress and anxiety. Plus, stressful events such as a patient’s death are some of the chief predictors of depression. Accordingly, the onset of anxiety and depression among RNs often gets preceded by major occupational stressors. Scholars concur on stress as a necessary and normal response that the body needs to protect itself from harm. However, during prolonged stress, the body produces more cortisol for longer periods. The increased presence of cortisol further triggers clinical anxiety and depression that affect sleep and lead to exhaustion. Another study associated depression severity with poor social relationships, concentration difficulties, and poor performance. Apart from mental health issues, occupational stress increases the risk of substance abuse. Alharbi and Alshehry (2019) categorized substance use as a maladaptive coping strategy given its association with adverse health consequences. Instead of returning the body to a more relaxed state, drugs and substance abuse trigger more stressful events.
Despite the negative consequences of stress on health, it can be positive. For example, RNs who can work under pressure and effectively manage stress can get promoted or receive more responsibilities. Stress negatively affects the body when an individual faces continuous challenging without an effective coping mechanism. The body reacts to stressful events with psychological and physical responses. For this reason, RNs become overworked, building up stress-related tensions. Research suggested that stress can worsen or contribute to the development of certain health issues such as blood pressure, diabetes, and heart disease, preventable physical health issues such obesity and other chronic non-communicable diseases. Therefore, stress is an important factor contributing to poor physical health among RNs.
Performance
Registered nurses must be psychologically secure to deliver safe and quality care. However, positive and negative emotions directly influence performance and engagement. The effects of these emotions get determined by one’s environment and individual appraisal of stressful situations, including coping mechanisms and social support. Raeissi et al. (2019) stated that elevated stress impedes performance, especially on tasks that demand working memory, decision-making, and divided attention. Nevertheless, in some cases stress can be beneficial, for example, performance increases in presence of effective stress management. Stressors such as work pressure can facilitate better-coping styles, and in turn, improve performance. For example, RNs provide individualized and evidence-based care because of the pressure to minimize patient deaths. Additionally, a reasonable stress level can motivate nurses to perform tasks faster to meet impending deadlines. Overwhelming pressure, workload, and lack of support contribute to panic and frustration affecting successful task completion (Prada-Ospina, 2019). When stress becomes unmanageable, RNs can experience a gradual or drastic decrease in performance, affecting patient safety and care.
Moreover, motivated nurses have heightened job satisfaction and performance. Occupational stress among medical staff interferes with their motivation, negatively affecting performance. Alharbi and Alshehry (2019) established that nurses working in cardiac intensive care units (ICUs) experience higher stress levels compared to those working in surgical ICUs. Coping with occupational stress implies handling unavoidable situations and converting problems into positive challenges. RNs may fail to cope with the stressful environment of ICUs, making them less motivated, which can further result in a career change. Azdic et al. (2022) established that motivation plays a mediating role in the impact of stress on performance among nurses during health emergencies. Motivation through rewards, recognition, effective communication, and morale enhance RNs’ sense of responsibility toward ensuring the safety of patients, inversely helping them manage or overcome occupational stress. Therefore, the extensive impact of stress on performance, well-being, and overall health necessitates effective management strategies.
Strategies to Reduce Occupational Stress
Registered nurses often confront daily occupational stressors that threaten to undermine the effectiveness of coping mechanisms, well-being, and performance. Psychological interventions such as cognitive behavioral therapy (CBT) can positively impact nurses’ quality of life, ultimately improving performance. For example, Sun and Zhuang’s (2022) evaluation established that CBT decreases stress levels more than peer support groups. Cognitive behavioral interventions essentially decrease perceived stress, depression, and anxiety, improve social support, and facilitate problem-focused coping. According to Holman (2018), CBT helps an individual identify and develop new conceptions about the nature and causes of role stress. Thus, CBT supports antecedent-focused behavioral and emotional strategies to reappraise stressful events. Other effective psychological interventions for reducing stress include mindfulness-based strategy and relaxation with assisted biofeedback and guided imagery (Holman, 2018). For instance, mindfulness-based intervention such as commitment and acceptance therapy helps improve self-care, improves burnout symptoms, and supports the management of anxiety and depressional, in turn, leading to positive stress responses (Scheepers et al., 2020). Thus, through mindfulness training, nurses can achieve behavioral and cognitive change.
Relaxation techniques have the same impact as mindfulness and cognitive behavioral interventions. According to Holman (2018), increasing relaxation levels can potentially reduce stress levels. In this view, relaxation techniques consider the state of stress and relaxation as antithetical. While various psychological interventions induce relaxation, they are primarily response- and emotion-focused strategies since they aim at reducing stress-related symptoms. Techniques involving relaxation include meditation, yoga, and muscle relaxation. For example, yoga can involve breathing techniques, balance, and flexibility to improve physical and mental strength. On the other hand, meditation prioritizes mental wellness by giving an individual a sense of peace and calm, positively impacting emotional well-being and overall health. Generally, relaxation techniques are key in developing mental awareness and managing triggers for stress (Chinn and Kramer, 2018). Drawing from psychological interventions, resilience training, and interpersonal skill development can equip nurses with the skills to effectively manage stress and engage in activities that promote well-being.
Organizational-level interventions at the primary and secondary levels can nurses cope with stressful events. Working schedules, management training, and job design include some of the Primary organizational strategies aimed at modifying occupational characteristics to enhance employee well-being (Holman, 2018). Changing organizational policies and practices concerned with health, safety, and leadership can implement secondary-based interventions less complex, including conflict management, improving decision-making and communication channels, and peer support groups. Holman (2018) asserted that effective organizational-level interventions involve preparation, action planning, screening, and implementation. Healthcare institutions should secure support to identify at-risk nurses and then develop and embed change initiatives within their operations to help nurses cope with occupational stress. Nonetheless, the success of these interventions largely depends on the level of participation. RNs should be involved in the development and implementation of care-based interventions to modify occupational procedures and reduce workload. Plus, nurses’ active involvement during the intervention process draws on individual expertise making them contextually appropriate and increasing nurses’ commitment to change initiatives.
Conclusion
Nurses play a central role in the delivery of safe and quality care: they are at the center of the healthcare system. Among their numerous roles include advocating for positive health outcomes, educating the public on available health resources, participating in patient rehabilitation, and providing support. Most importantly, nurses provide patient-centered and evidence-based care that fosters patient safety, well-being, and health. Therefore, it is the nurses’ role to provide care continuity while building trust with patients to create a safe environment for treatment, rehabilitation, and healing. However, the demands of the healthcare industry today have changed the medical landscape, contributing to occupational stress; the purpose of the paper was to evaluate its effect on the nurses.
A number of factors can trigger stress among nurses, including staff relationships, patient-nurse relationships, workload, and understaffing. Nurses perform several tasks in every aspect of healthcare, which can be physically and emotionally demanding. Plus, RNs often interact closely with patients and their families as they administer treatment. However, multitasking and being emotionally available for every patient can be changing, especially when dealing with difficult patients or those with chronic health conditions. Consequently, work pressure can increase stress levels, negatively affecting one’s health and performance. Employing key intervention strategies such as cognitive behavior therapy, meditation and relaxation can help decrease stress levels. Health institutions can support nurses’ well-being and overall health by developing and embedding change initiatives focused on decreasing stress levels among nurses. Stress can negatively affect well-being and overall health if left unchecked and thus, employing key intervention strategies is necessary.
References
Al Maqbali, M., Al Sinani, M., & Al-Lenjawi, B. (2021). Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of Psychosomatic Research, 141, 110343. Web.
Alharbi, H., & Alshehry, A. (2019). Perceived stress and coping strategies among ICU nurses in government tertiary hospitals in Saudi Arabia: A cross-sectional study. Annals of Saudi Medicine, 39(1), 48-55. Web.
Ardıç, M., Ünal, Ö., & Türktemiz, H. (2022). The effect of stress levels of nurses on performance during the COVID-19 pandemic: The mediating role of motivation. Journal of Research in Nursing, 27(4), 330-340. Web.
Azimian J, Piran P, Jahanihashemi H, Dehghankar L. (2017). Investigation of marital satisfaction and its relationship with job stress and general health of nurses in Qazvin, Iran. Electron Physician. Web.
Brown, L. G., Johnson, T. L., McMillan, L. R., & Brandon, A. (2018). Two heads are better than one: Partnering to improve a critical care work environment. Nursing Management, 49(7), 22-29.
Buckner, S.L., Jessee, M.B., Mouser, G.J., Dankel, S.J., Mattocks, K.T., Bell, Z.W., Abe, T. and Loenneke, J.P. (2020). The basics of training for muscle size and strength: A brief review on the theory. Medicine & Science in Sports & Exercise, 52(3).
Chinn, P. L., & Kramer, M. K. (2018). Knowledge development in nursing: Theory and process. Elsevier.
Cooper, C., & Quick, J. C. (Eds.). (2017). The handbook of stress and health: A guide to research and practice. John Wiley & Sons.
Holman, D., Johnson, S., & O’Connor, E. (2018). Stress management interventions: Improving subjective psychological well-being in the workplace. Handbook of well-being. Salt Lake City, DEF Publishers.
Jarrad, R., Hammad, S., Shawashi, T., & Mahmoud, N. (2018). Compassion fatigue and substance use among nurses. Annals of General Psychiatry, 17(1), 1-8. Web.
Kostka, A. M., Borodzicz, A., & Krzemińska, S. A. (2021). Feelings and Emotions of Nurses Related to Dying and Death of Patients–A Pilot Study. Psychology Research and Behavior Management, 14, 705. Web.
Lazarus, R. S., & Folkman, S. (1987). Transactional theory and research on emotions and coping. European Journal of Personality, 1(3), 141-169.
Lyon R, Botha K. (2021). The experience of and coping with an induced abortion: A rapid review. Web.
Mo, Y., Deng, L., Zhang, L., Lang, Q., Liao, C., Wang, N., Qin, M. and Huang, H. (2020). Work stress among Chinese nurses to support Wuhan in fighting against COVID‐19 epidemic. Journal of Nursing Management, 28(5), pp.1002-1009. Web.
Ponce, J. S. (2018). Origin and evolution of the concept stress. Journal of Anxiety and Depression, 1(1), 101.
Prada-Ospina, R. (2019). Social psychological factors and their relation to work-related stress as generating effect of burnout. Interdisciplinaria, 36(2), 39-53. Web.
Prosen, M. (2021). Strengthening nurses’ resilience and reducing burnout during the COVID-19 pandemic. Kontakt, 23(1), 1-2. Web.
Raeissi, P., Rajabi, M. R., Ahmadizadeh, E., Rajabkhah, K., & Kakemam, E. (2019). Quality of work life and factors associated with it among nurses in public hospitals, Iran. Journal of the Egyptian Public Health Association, 94(1), 1-8. Web.
Said, R. M., & El-Shafei, D. A. (2021). Occupational stress, job satisfaction, and intent to leave: Nurses working on front lines during COVID-19 pandemic in Zagazig City, Egypt. Environmental Science and Pollution Research, 28(7), 8791-8801. Web.
Saquib Mulla, D., Shaju, S., Bathija, S., & Poothulil, N. (2020). Prevalence of anxiety and fear in living with COVID-19 virus from the perspective of practicing dentists: A short study. International Journal of Applied Dental Sciences, 6(3), 19-22.
Scheepers, R. A., Emke, H., Epstein, R. M., & Lombarts, K. M. (2020). The impact of mindfulness‐based interventions on doctors’ well‐being and performance: A systematic review. Medical Education, 54(2), 138-149. Web.
Schoberer, D., Reiter, L., Thonhofer, N., & Hoedl, M. (2022). Occupational relationships and working duties of nursing management staff during the COVID‐19 pandemic: A qualitative analysis of survey responses. Journal of Advanced Nursing. Web.
Stafseth, S. K., Skogstad, L., Ræder, J., Hovland, I. S., Hovde, H., Ekeberg, Ø., & Lie, I. (2022). Symptoms of anxiety, depression, and post-traumatic stress disorder in health care personnel in norwegian ICUs during the first wave of the COVID-19 pandemic, a prospective, observational cross-sectional study. International Journal of Environmental Research and Public Health, 19(12), 7010.
Sturm, H., Rieger, M.A., Martus, P., Ueding, E., Wagner, A., Holderried, M., Maschmann, J. and WorkSafeMed Consortium (2019). Do perceived working conditions and patient safety culture correlate with objective workload and patient outcomes: A cross-sectional explorative study from a German university hospital. PloS One, 14(1), p.e0209487. Web.
Sun, M., & Zhuang, L. (2022). Effect of cognitive behavioral therapy on stress disorder, cognitive function, motor function, and daily living ability of patients with a traumatic brain injury. Emergency Medicine International, 20(3), 1-6. Web.