8

Stress in Nursing

Pratibha P. Kane

Stress is experienced when demands made on us outweigh our resources. A moderate level of stress or ‘Eustress’ is an important motivating factor and is considered normal and necessary. If stress is intense, continuous and repeated, it becomes a negative phenomenon or ‘Distress’, which can lead to physical illness and psychological disorders. Psychosomatic illnesses are disorders that involve both the body and the mind. These illnesses are mental or emotional in origin and have physical symptoms. Running hospitals as businesses have changed the working pattern of nursing as a whole. Stress levels are on the rise and little is being done about assessing this malady and actively managing its effects. Nurses are expected to give sensitive quality patient care, have patience, and help disposition and, at the same time, save costs and increase efficiency by keeping a rapid throughput.

Nurses are the backbone of any healthcare unit. The pressures of overtime and long working hours create a work–personal life imbalance, which begins to affect the health of employees. Other factors such as long commuting hours and chaotic traffic conditions adding to their stress affect employees’ efficiency and effectiveness. It can undermine an employee's relationship at home as well as on the job. This can have a negative influence on their physical and emotional health and lead to psychosomatic disorders. Economic loss to the organization due to errors, wrong decisions, wrong choice, lack of attention and injury are some of the serious effects of chronic stress. The trend of nurses working overtime started with downsizing of organizations and the trend to have only skeletal manning. Absenteeism is compensated by others doing overtime. This increases the take-home pay but is likely to injure their health. Such nurses experience severe stress and require more sick leaves. This risk increases with the length of overtime.

All nurses have to do shift work or attend emergencies at night. The stress of shift work can also aggravate health conditions and lead to heart disease or digestive disorders. Fatigue can lead to error, injury and carelessness. Long hours are a source of depression, low morale and low motivation. Shift workers are on the job in the evening or on weekends, and they sleep during the day. Hence, they often miss out on social or family activities.

There is a stark difference in causes of stress in nurses in developed countries and in India. Nurses in India are poorly remunerated compared to the world standards. For the kind of intense work that the nurses do, the salary and benefits are not adequate. The fact that rewards are not proportional to workload is a source of great stress as it is difficult to have decent standards of living based only on their basic salary.

Lack of professional respect and recognition by authorities and doctors is the major cause of dissatisfaction in nurses abroad. Poor relationship with physicians was related to musculoskeletal disorders, which is seen as the most important reason for nurses leaving hospitals. Lack of autonomy, poor participation in patient care due to lack of sufficient knowledge and empowerment deprive them from job satisfaction.

Nurses in India are mainly from the lower economic strata and have low educational qualifications. Their main motivators are salary and benefits to support their home and maintain a decent standard of living. Shortage of staff makes them easily succumb to increasing their pay package by doing excessive hours of overtime at the expense of their health. They have limited access to claims and compensation for occupational hazards.

Many studies of stress in nurse in developed countries have shown chronic stress as a major contributor to suicide or suicidal thoughts, smoking, excessive coffee consumption and alcohol intake.

Resurfacing of repetitive problems and feeling of the work never getting done added to stress in this study. Turnover for skilled nurses is instigated by internal, on the job factors, which cause dissatisfaction and stress (poor salary, lack of recognition, workplace bullying) and a desire to leave. Replacement is mostly with less-skilled staff, which increases the responsibility and load of the remaining skilled staff. Shortage of staff increases the burden of non-nursing jobs, like shifting patients, picking up food trays, making beds, and even filing and keeping record.

Poor nutrition leading to anaemia contributes to the poor health of the nurses in this study. Meals are usually not taken in time. Missing breaks to finish work also increases stress. Shift work can interfere with regular eating and digestive circadian rhythm. This could lead to acidity and other stomach problems. However, digestive problems also could be caused by the tendency for excessive consumption of tea or coffee in the night shift.

In the absence of doctors, nurses are on the front line and have to face verbal abuse from patients and relatives for issues that may not be directly connected to their work. Physical violence and aggressiveness is also on the rise in patients and their relations. Demanding patients and their relatives can cause conflict and lead to more stress. Patients’ expectations from nurses are sometimes unreasonable and they tend to be aggressive. No training is given to them to deal with confrontation.

Stress-related illness is not imaginary. It is very tricky to diagnose and treat. The key is to look for a source of stress that the person is not coping with.

Chronic stress decreases motivation. It can lead to increased absenteeism and increased turnover and attrition rates. Thus, it is mandatory for healthcare organizations to address this issue urgently. There is urgent need for proactive stress management, especially preventive strategies, as are encouraged in the industry and IT sector. There is need for coping techniques like team building, counseling, learning assertiveness and communication skills, which should be taught to all nurses, even incorporated in their training curriculum.

Elimination of all stressors is a utopian goal. Effective solutions can be found, like increasing skills, enriching work, and increasing the participation of nurses in the organization. Adequate staffing, which reduces job stress and overtime, could lead to improved efficiency along with cost effectiveness.

An ounce of prevention is worth a pound of cure: every organization should assess the magnitude of stress and analyse it to recognize the need for action. This is also called a ‘stress audit’. Earlier, stress was viewed as a personal problem to be tackled at an individual level with palliative or remedial measures. Now, the approach is to be proactive, with emphasis on prevention and elimination rather than treatment. Improving the quality of work life of nurses may go a long way to decrease attrition.

References

1. Feskanich, D., J.L. Hastrup, J.R. Marshall, G.A. Colditz, M.J. Stampfer, W.C. Willett, et al., 2002, ‘Stress and Suicide in Nurses Health Study’, J. Epidemiol Community Health, 56(2): 95–8.
2. O' Brian-Pallas, L., J. Shamian, D. Thomson, C. Alksnis, M. Koehoorn, M. Kerr, et al., 2004, ‘Work-related Disability in Canadian Nurses’, J. Nurs Scholarsh, 36: 352–7.

Vocabulary

1. Undermine: Weaken
2. Chronic: Persistent
3. Downsize: Economize
4. Musculoskeletal disorder: Disorders that affect the body's muscles, joints, tendons, ligaments and nerves
5. Autonomy: Independence
6. Empowerment: Control over one's own life or situation
7. Turnover: Earning
8. Instigate: Originate
9. Circadian rhythm: Rhythm of digestion: keeping time in the gastrointestinal tract
10. Attrition: Employee turnover within a company
11. Utopian: Idealistic
12. Palliative: Soothing

Reading Comprehension

1. When is stress experienced?
2. What are psychosomatic illnesses?
3. What stress factors affect nurses’ efficiency and effectiveness?
4. What can be the reasons for job dissatisfaction among nurses?
5. Give the causes of poor health conditions among nurses.
6. Issues related to nurses should be urgently addressed by healthcare organizations. What are they?
7. What is a stress audit?

Language

1. Present Indefinite

[VERB] + s/es in third person

Present Indefinite or Simple Present is used to express the idea that an action is repeated or is usual. The action can be a habit, a hobby, a daily event, a scheduled event or something that often happens or a general truth. It can also be something a person often forgets or usually does not do.

1. To express habitual actions
   • He drinks two cups of coffee every morning.
2. To express general truths
   • Stress is experienced when demands made on us outweigh our resources.
   • Nurses are the backbone of any healthcare unit.
   • The sun rises in the east.
3. In stories, as substitute for Simple Past
   • The thief opens the door and enters the house.
4. To express a future event that is part of a fixed timetable or fixed programme
   • The next train leaves at 6.

2. Present Continuous

(am/is/are + present participle)

Present Continuous is used with Normal Verbs to express the idea that something is happening now, at this very moment. It can also be used to show that something is not happening now.

Examples:

• You are learning English now.
• You are not swimming now.
• Are you sleeping?
• I am sitting.
• Is he sitting or standing?
• They are reading their books.
• What are you doing?

3. Present Perfect Tense

[has/have + past participle]

Study the following sentences from the text and notice the structure of the items in bold. It is has/have + past participle and this use is of Present Perfect Tense.

• Many studies of stress in nurses have shown chronic stress as a major contributor to suicides.
• Running hospitals as business has changed the working pattern of nursing as a whole.

We use the Present Perfect to say that an action happened at an unspecified time before now. The exact time is not important. You CANNOT use the Present Perfect with specific time expressions such as: yesterday, one year ago, last week, when I was a child, when I lived in Japan, at that moment, that day, one day, etc. We CAN use the Present Perfect with unspecific expressions such as: ever, never, once, many times, several times, before, so far, already, yet, etc.

Examples

• I have seen that movie twenty times.
• I think I have met him once before.
• There have been many earthquakes in California.
• People have travelled to the moon.
• Have you not read the book yet?
• Nobody has ever climbed that mountain.
• I have had a cold for two weeks.

Past Indefinite and Present Perfect

Sometimes the Past Simple and the Present Perfect are confused. It is important to remember that the Past Simple is used to express a finished past action which occurs at a specific moment in the past. The present perfect is used to express something that happened at an unspecified moment in the past. For example, if I visited Paris in 2004, I could express this in two ways:

Past Indefinite

I visited Paris in 2004.

• Note that the moment in time is specific—‘in 2004’, ‘a few years ago’.

Present Perfect

I've been to Paris.

In this case, the moment of my visit is not specific. I am speaking about an experience that I have had in my life up to this moment in time.

Pronunciation

The following words are commonly mispronounced by non-native speakers of English. Speak them loudly and look for their correct pronunciation in a dictionary:

Writing

Write a letter to the Director, ‘World Health Organization’, apprising him of the unfavourable working conditions of nurses in developing countries.