Alleviating Job Stress in Nurses

Rashaun Roberts, PhD; Paula L. Grubb, PhD; James W. Grosch, MBA, PhD


June 25, 2012

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Stress in Nurses

Nursing has long been considered one of the most stressful professions.[26,27,28] Stress in nursing is attributed largely to the physical labor, suffering and emotional demands of patients and families, work hours, shiftwork, interpersonal relationships (eg, inter- and intraprofessional conflict), and other pressures that are central to the work nurses do.[29,30,31,32,33,34,35] Factors that have increased stress among nurses since the 1980s include the rising use of sophisticated healthcare technologies, budget cuts, increasing workload, and constant organizational changes in some healthcare environments.[35,36,37]

Research findings support the conclusion that the multiple pressures associated with nursing responsibilities and the healthcare setting translate into significant stress levels among nurses. Over the past decade, nurses have consistently reported the highest levels of job stress of all healthcare professionals.[38,39,40,41,42,43] Surveys have consistently found that nurses identify stress and overwork as one of their top two safety and health concerns.[44,45]

Risk Factors for Stress in Nurses

Occupational safety and health researchers and practitioners agree that nurses are heavily exposed to a myriad of "psychosocial stressors" in their daily work. The term "psychosocial stressors" refers to stressful working conditions and/or job characteristics that relate to how tasks are designed. Psychosocial stressors can also refer to management style, aspects of interpersonal relationships, and work roles. Examples of these stressors include heavy workload, conflicting job demands, long working hours, and shiftwork.

Nurses seem to be overexposed to a range of psychosocial stressors, including the following[46]:

  • Lack of control;

  • Long work hours;

  • Shiftwork;

  • Interpersonal conflicts;

  • Insufficient resources;

  • Poor reward systems;

  • Inadequate structure of communication flow in hospitals and other healthcare settings; and

  • Bullying and physical violence.[33,47,48,49,50,51,52,53,54,55,56]

Although all of these stressors are significant, workplace bullying and physical violence are of growing concern. The American Nurses Association found that 17% of surveyed nurses reported that they had been physically assaulted at work in the past year and 56.9% had been threatened or verbally abused.[44] Physical violence against nurses is typically perpetrated by patients, patients' family members, or strangers (eg, in emergency departments), whereas nonphysical, or "lateral," violence in the form of incivility, disruptive behavior, verbal aggression, and bullying tend to be perpetrated by other nurses, nurse managers, physicians, and other coworkers.[57,58,59]

Effect of Stress on Nurses

Nursing studies have firmly established that excessive exposure to psychosocial stressors produces considerable job stress, resulting in various problematic short- and long-term outcomes. Depression and sleep problems have been reported as frequent stress-related outcomes.[60,61] Job stress has been associated with reduced job satisfaction,[62] increased psychological distress,[63] physical complaints,[64,65] and absenteeism.[66] Several studies have found that high levels of job stress contribute to feelings of inadequacy, self-doubt, lower self-esteem, irritability, and somatic disturbance in nurses.[67,68,69,70,71,72,73] As a group, nurses tend to have higher rates of mortality[74,75] and disproportionately high rates of general illness, stress-related disease, psychiatric outpatient consultation, and psychiatric admissions.[75,76,77]

Moral distress and compassion fatigue are consequences of nursing stress that have received special attention from researchers in recent years.[78,79,80,81,82,83,84] Owing to the personal, intimate nature of caring as a nursing professional, nurses may be conflicted in their roles and may make moral judgments about a proper course of action with respect to medical treatment.[80] Moral distress can arise from issues surrounding end-of-life care, depersonalizing patients on an institutional level, policy constraints, and other situations that nurses believe may affect their ability to provide quality patient care.[80,81,82,83] Contemporary business practices and politics in healthcare have led to corporate or commercial value systems being instilled into a profession that is traditionally considered a moral practice involving caring and compassion.[82] The disconnect between a corporate marketing model and the philosophy of nursing creates an ethical dilemma that can lead to compassion fatigue. Compassion fatigue occurs when a nurse psychologically withdraws and becomes disengaged from the caring nature of the job. Both moral distress and compassion fatigue have serious effects in terms of dissatisfaction, feelings of powerlessness, and poor physical and mental health outcomes.[80,82,84]

Related to compassion fatigue, burnout is another adverse consequence of stress that nurses may experience from their work. Burnout has been studied extensively by job stress researchers.[85,86,87,88] Conceptualized in the literature as a severe consequence of prolonged stress at work,[87,89] burnout is described as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment.[90] Emotional exhaustion is a feeling of being overextended, depleted of energy, and exhausted by one's work; depersonalization is an increased mental distance from one's job that results in an unfeeling or impersonal response toward recipients of one's service, care, treatment, or instruction.[90] The final component of burnout -- reduced personal accomplishment -- is a feeling of incompetence and lack of success in one's work with people.[90]

Studies have shown that nurses have very high rates of burnout.[42,91] Aiken and colleagues[85] found that more than 40% of hospital staff nurses scored in the high range for burnout, with 43.2% of nurses reporting high levels of emotional exhaustion.

Declining energy, depersonalization, and increased feelings of incompetence in hospital nurses have significant effects on their health and well-being. Burnout affects individuals physically, psychologically, and socially.[42,92] In nursing studies, it has been associated with psychological distress and somatic complaints.[67,93,94] In addition, nurses experiencing burnout have been found to be more likely to eat poorly, smoke cigarettes, and abuse alcohol and other drugs, all of which can lead to negative health conditions and diminished well-being.[95,96,97]

Effect of Nursing Stress on Healthcare Organizations

Stress not only adversely affects the health, safety, and well-being of nurses at the individual level, it also negatively affects healthcare organizations. Research indicates that the stress fostered by workplace bullying, psychological aggression, incivility, and disruptive behavior affects healthcare costs, turnover, retention, and formal grievances and lawsuits.[56,57,58] Moreover, lateral workplace violence has been shown to jeopardize patient safety, satisfaction, and health outcomes.[57,98,99]

Implications for the quality and efficacy of the healthcare an organization provides have been a particular focus of investigations on stress and burnout, both generally and specifically with regard to workplace bullying and psychological aggression.[97] Studies have found that stress and burnout are strongly linked to suboptimal patient care as reported by nurses,[97,100] and other studies have found that stress and burnout in nurses negatively affect patients' perception of the quality of their care. For example, in a review of the literature, Halbesleben and colleagues[101] found a significant relationship between higher levels of emotional exhaustion and depersonalization in nursing staff and lower patient satisfaction. They explained that burned-out nurses may not be as alert or mentally aware, which compromises their ability to provide high-quality patient care. Lack of mental alertness due to burnout also contributed to a higher likelihood of medical errors.[101]

Nursing stress produces other organizational consequences. It has been linked to a number of poor outcomes, such as lower morale, reduced job performance, increased tardiness, and absenteeism.[55,67,93,94] It also seems to fuel job dissatisfaction, a precursor to staff turnover.[102] Rates of job dissatisfaction are extraordinarily high in nurses. Aiken and colleagues[85] found that 41.5% of nurses were dissatisfied with their jobs and that 1 in 5 nurses surveyed intended to leave his or her job as a result of dissatisfaction, burnout, and stress.[85]

Stress-related attrition can generate considerable labor costs for healthcare organizations that are not recoverable from private or public insurance sources.[85] A survey of turnover in acute care facilities found that replacement costs for nurse positions were equal to or greater than 2 times their annual salaries.[103] Annual turnover rates for registered nurses are estimated by the Joint Commission[104] to range from 18%-26%, with cost estimates for each turnover ranging from $62,100-$67,000.[105]

Stress-related attrition contributes to suboptimum patient outcomes and exacerbates already-inadequate nurse-to-patient ratios.[106] Aiken and colleagues[85] found that each additional patient per nurse resulted in a 7% increase in the likelihood of a patient dying within 30 days of hospital admission. Other studies have found associations between low nurse staffing levels and hospital-acquired pneumonia, urinary tract infections, sepsis, nosocomial infections, pressure ulcers, upper gastrointestinal bleeding, shock and cardiac arrest, medication errors, falls, and longer-than-expected lengths of stay.[107]


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