Nursing is recognised as an occupation

Is work stress in nurses a cause for concern? A literature review Louise Peters, Robyn Cant, Kenneth Sellick, Margaret O Connor, Susan Lee, Sue Burney Nursing is recognised as an occupation that is associated with stress on both professional and personal levels. For example, in a study of 4000 workers in the UK, nurses were in the top three most stressed occupational groups, with teachers and managers (Smith et al, 2000). Work stress is an important cause of job dissatisfaction in nursing (Keidel, 2002) and may influence decisions to stay in the job or leave (Flanagan and Flanagan, 2002). In their caring role, nurses frequently experience stressful situations related to death and dying. However, the nursing literature suggests that stress and its effects can be moderated in these nurses through personal coping strategies and social support (Lim et al, 2010). Palliative care is unique in that the service focuses on the needs of dying patients and their families as opposed to focusing on maintaining critical bodily functions, as in critical care nursing, or on improving functional capacity, as in rehabilitation nursing (Martens, 2009). The philosophy of nursing includes providing care to patients using medical science combined with compassion and caring. Patients may be cared for in hospital wards in acute care settings, in specialist hospice or units, in aged care homes, or in their own home. Palliative care specialist nurses primarily have generalist nursing skills with various levels of specialisation and post-registration education, including certification. Although stress and ensuing burnout have been the focus of studies of acute care nurses, cancer nurses, emergency nurses, and others (Chang et al, 2007; Lim et al, 2010), there have been few studies of nurses who work in settings. Early studies of the stress experienced by Australian nurses focused on their roles in community or in-patient settings (McNamara et al, 1995; Byrne and McMurray, 1997) or on their professional needs (Redman et al, 1995). However, there is little contemporary evidence regarding the effect of workplace stress on Abstract Palliative care nurses are at risk of work stress because their role involves exposure to frequent deaths and family grieving. Little is known about their degree of stress or whether they suffer stress or burnout more than nurses in other disciplines. Aim: The aim of this paper is to critically examine the current literature concerning stress and burnout in nurses. Results: Sixteen papers were included in the review. Although work demands were a common cause of stress in the studies reported, there was no strong evidence that or hospice nurses experienced higher levels of stress than nurses in other disciplines. Common causes of stress were the work environment, role conflict, and issues with patients and their families. Constructive coping styles appeared to help nurses to manage stress. Conclusion: Managers have a key role in providing education and training for nurses to support their personal development and to help reduce vulnerability to and the impact of stress in the workplace. Key words: Burnout l Coping l Nurses l Palliative care l Psychological stress nurses or coping strategies that these nurses may use to alleviate stress. The aim of this review was to critically examine the literature regarding levels of stress, issues that contribute to stress, and coping with stress in nurses. Methods Publications in English between 1990 and May 2010 were sought using the health-care databases Medline Ovid, ProQuest, PsycINFO, and CINAHL Plus, as well as GoogleScholar. The key search terms used were: nursing or health personnel,, psychological stress, psychological burnout, job satisfaction, psychological adaptation, resilience, and coping. The reference lists of relevant papers were also searched and a hand search was conducted of the journals International Journal of Palliative Nursing (2000 2010) and American Journal of Hospice and Palliative Medicine (2000 2010). Louise Peters and Robyn Cant are Research Fellows, Kenneth Sellick is Senior Research Fellow, Margaret O Connor is Vivian Bullwinkel Chair in Palliative Care Nursing, and Susan Lee is Foundation Member, Palliative Care Research Team, School of Nursing and Midwifery, Monash University, Melbourne, Australia; Sue Burney is Head, Cabrini Monash Psychooncology Research Team, and Adjunct Senior Lecturer, School of Psychology and Psychiatry, Monash University Correspondence to: Louise Peters louise.peters@monash. edu International Journal of Palliative Nursing 2012, Vol 18, No 11 561

... palliative care nurses frequently experience stressful situations... However, the literature suggests that stress and its effects can be moderated in these nurses... Paper selection The search identified 113 papers. All study designs were included provided that they focused on palliative care nurses. Studies involving oncology or other nurses whose role was not exclusively to care for patients with needs were excluded. This left 15 papers, the titles and abstracts of which were assessed for relevance by two of the authors. All 15 papers were selected for inclusion. In addition, one study that was conducted by some of the authors of the present paper and which has been accepted for publication was also included (Peters et al, in press). Data synthesis The papers were synthesised using checklists from the Critical Appraisal Skills Programme (CASP; http://www.casp-uk.net/) for assessing qualitative research, case control, and cohort studies. These include three items: Are the results of the study valid? What are the results? Will the results help locally? There are 10 questions to help make sense of qualitative studies, 12 questions to help make sense of a cohort study, and 11 questions to help make sense of a case control study. As a result of variation in the designs of the studies and in the levels of evidence, no assessment was undertaken of their quality. Results Of the 16 papers, 8 reported on stress in palliative care or hospice nurses (McConigley et al, 2000; Newton and Waters, 2001; Wilkes and Beale, 2001; Bruneau and Ellison, 2004; Fillion et al, 2007; Hackett et al, 2009; Martens, 2009; Peters et al, in press). Five others were studies of coping strategies used by nurses (McNamara et al, 1995; Byrne and McMurray, 1997; Vachon, 1998; Fillion et al, 2005; Ablett and Jones, 2007). Three studies were on burnout in nursing (Payne, 2001; Keidel, 2002; Abendroth and Flannery, 2006). Each study s design, setting, instruments, and outcomes are presented in Table 1. There was some overlap between the topics covered by the papers, as the constructs of stress and burnout were frequently reported concurrently. Validated survey instruments used included the Nursing Stress Scale (NSS), the Depression Anxiety and Stress Scale (DASS 21), and the Maslach Burnout Inventory (MBI). As shown in Table 1, most of the papers were crosssectional surveys with or without valid survey instruments. Two qualitative studies used interviews and one a mixed-methods approach. The majority of the studies appeared to have been conducted by nurses. As there was little evidence of theoretical frameworks explaining stress, information from additional nursing studies has been used here to provide theoretical context. The results of the review are presented under the three themes that were identified from the tabulated results of the studies relating to work stress: degrees of stress, stressors at work, and mediators of stress. The stressors at work theme had three subcategories. Degrees of stress As the same situation may induce stress in one individual and not another, the perception of stress is highly individual (Chang et al, 2007). Seven studies assessed nurses levels of stress quantitatively, using a range of instruments. In a study by Payne (2001), female hospice nurses who completed the NSS and MBI (n=82) identified death and dying, conflict with staff, accepting responsibility, and a higher nursing grade as contributing to their emotional exhaustion. Although overall NSS scores were not reported, the level of burnout (characterised by high emotional exhaustion, high depersonalisation of patients, and low personal accomplishment) was reported as being low in this group compared with nurses from other disciplines. Bruneau and Ellison (2004), who surveyed 18 nurses in a UK hospital, found that average work-related stress was low, with a highest participant score on the NSS of 38% (64/170). Martens (2009), who surveyed 146 hospice nurses in the USA using a modified NSS scale, reported mean scores of 64% (3.86/6) for in-patient hospice nurses and 59% (3.56/6) for home hospice nurses. Hackett et al (2009) found that UK hospice workers and nurses (n=91) had depression and anxiety scores very similar to UK community norms using the DASS 21. A cross-sectional survey of Australian palliative care nurses using a modified NSS reported a total stressor mean score of 74.70 out of 159 (47%), with a highest score of 118 (74%) and a lowest score of 34 (21%) (Peters et al, in press). The nurses overall level of stress was low, with a mean score of 4.06 out of 10 (where 10 is extremely stressed). The use of various designs and instruments and the reporting of subscales rather than overall scores limits the scope for direct comparison between the studies. However, stress ratings for or hospice nurses appeared to be rated in the lower two-thirds of each score range. Conversely, moderate to high levels of stress have been identified in other nurses in high-dependency services (such as critical or intensive care, emergency care, and cardiac care) and in ward nurses using stress scales or 562 International Journal of Palliative Nursing 2012, Vol 18, No 11

Table 1 (part 1). Studies included in the review Study Setting Participants and sample size Design/methods Focus and instruments Outcome Abendroth and Flannery (2006) Ablett and Jones (2007) Bruneau and Ellison (2004) Byrne and McMurray (1997) Fillion et al (2005) Fillion et al (2007) Hackett et al (2009) Keidel (2002) Martens (2009) US hospice Nurses from 22 hospices (n=216) Descriptive design; cross-sectional survey Prevalence of and relationship between nurses characteristics and compassion fatigue risk using ProQOL version 3 78% of the nurses were at moderate high risk of compassion fatigue; trauma, anxiety, life demands, and excessive empathy were key determinants UK hospice Palliative care Qualitative Hospice nurses experiences of Nurses showed high levels of nurses (n=10) semi-structured work and interpersonal styles commitment and ascribed a sense of interviews enabling resilience and wellbeing meaning to their work UK in-patient palliative care unit Hospital nurses providing palliative care (n=18) Mixed methods: quantitative: before/ after design and qualitative semistructured interviews before and after programme Work-related stress and evaluation/impact of stress reduction programme, using the NSS and NCWSQ. Two stress reduction sessions were given in 14 weeks, with a debriefing session at the end of the study Australian Hospice and In-depth qualitative Nurses experience of coping with hospice interviews, caring for dying patients nurses; purposive phenomenological sample (n=9) approach Canadian Palliative care Quasi-experimental Exploration of nurses educational hospice and nurses (hospital design, needs using the Educational palliative n=88; community cross-sectional Needs Questionnaire, the POMS, care unit n=109) quantitative survey and a purposely developed perceived self-efficacy questionnaire Canadian Nurses (n=209) Quantitative survey Evaluation of stress model using hospital and who spent >20% the General Satisfaction subscale community of their working of the JDS, the POMS, Karasek s palliative time on palliative JCQ, the ERI-Q (two subscales), a care care modified NSS, a self-efficacy questionnaire developed for the study, and part of an organisational policy/practices scale UK hospice Hospice staff: Cross-sectional Assessment of levels of staff stress nurses, doctors, quantitative survey using the DASS 21 and HSE MSI social workers, tools assistants (n=91) US hospice Hospice nurses Case study Exploration of burnout and compassion fatigue in hospice care nurses US hospice and home palliative care Nurses (n=146) from 14 hospices Quasi-experimental electronic quantitative survey Comparison of stress factors and self-efficacy in in-patient and home-care hospice nurses, using modified NSS No significant change in total stress/ coping scores. Some nurses found work stressful and felt ill-prepared to cope. Future programmes should consider external environmental barriers to coping (lack of opportunity to share experiences/feelings with colleagues, time constraints) as well as improving the coping skills of individual staff members Four themes emerged around caring and a fifth around nurses developing strategies to cope with their experiences. Self-awareness was important for coping The nurses educational needs were related to psychological distress and self-efficacy, with preferred types of education described Predictors of job satisfaction were job demand, effort, reward, and peopleorientated culture. Best predictors of emotional distress were reward, professional and emotional demands, and self-efficacy The MSI tool highlighted several stressors e.g. role ambiguity. Staff experienced average strain: according to the DASS 21. 3% were below the NHS average of reported stress Burnout and compassion fatigue should be addressed with staff education in settings Five main stressors were all related to the work environment. No significant difference in mean NSS response for in-patient and home-care nurses DASS 21, Depression Anxiety and Stress Scale; ERI-Q, Effort Reward Imbalance Questionnaire; HSE MSI, Health and Safety Executive Management Standards Indicator; JCQ, Job Content Questionnaire; JDS, Job Diagnostic Survey; NCWSQ, Nurses Coping With Stress Questionnaire; NSS, Nursing Stress Scale; POMS, Profile of Mood States; ProQOL, Professional Quality of Life measure International Journal of Palliative Nursing 2012, Vol 18, No 11 563

Table 1 (part 2). Studies included in the review Study Setting Participants and sample size Design/methods Focus and instruments Outcome McConigley et al (2000) Australian community Rural palliative care nurses (n=6) Qualitative theoretical sampling (interview and participant observation) Exploration of role stress of nurses in the community Three themes related to stress were multiple role demand, nurses expectations, and coping strategies McNamara et al (1995) Australian hospice Hospice nurses (n=22) (in-patient and community) Qualitative study using interview (ethnographic approach) Describes stressors and coping among hospice nurses. No ratings given Nurses can negotiate coping strategies and support in the hospice environment Newton and Waters (2001) UK community Community clinical nurse specialists (n=21) Qualitative semi-structured questionnaire (open-ended questions) Describes nurses perceptions of stressors Three major themes were pressure of workload, relationship with health professionals, and impact of sadness Payne (2001) UK hospice Hospice nurses (n=72); female nursing assistants (n=17) Quasi-experimental design (quantitative survey) Examined predictors of stress, coping, and burnout using MBI, NSS, and WOCS Level of burnout was low: stressors made the highest contribution to burnout; demographic factors such as age contributed least Peters et al (in press) Australian hospice and community Palliative care nurses (n=71) Vachon Canadian Palliative care and (1998) oncology nurses Wilkes and Australian Community Beale community (2001) nurses (rural n=5; urban n=7) Quantitative cross-sectional survey Explored nurses stressors and level of stress using modified NSS and three subscales of the NSI Workload and death/dying were predictors of stress. Low level of overall stress. Nurses older than 50 years were less stressed than younger nurses. Individual stressors were highly stressful for some nurses Literature review Described occupational stressors in oncology and settings. Key coping strategies were development of a team philosophy, individual support, and team building Qualitative unstructured interviews Exploration of perceived stressors for urban and rural nurses Major stressors for both groups were impact of family relationships and role conflict in the community. For rural nurses, additional stressors were providing a 24-hour service over great distances and a lack of financial resources MBI, Maslach Burnout Inventory; NSI, Nurse Stress Index; NSS, Nursing Stress Scale; WOCS, Ways of Coping Scale the MBI. For example, Butterworth et al (1999) found that ward nurses and community practice nurses were in the high-burnout category. Critical care nurses were found to have high levels of emotional exhaustion and moderate levels of depersonalisation on the MBI (Butterworth et al, 1999; Losa Iglesias et al, 2010). Around one-third of a sample of mental health nurses in the UK showed high levels of burnout (Edwards et al, 2006). Hospital nurses in China were moderately stressed, with a mean Personal Strain score of 43% (86.9/200) (Wu et al, 2010). Thus, a broad range of stress scores has been reported across various nursing specialties, and nurses have been found to be no more stressed than nurses in other fields. It may be that nurses have developed strategies for coping with stress and avoiding burnout. Stressors at work Environment The environment in which nurses work was strongly associated with the experience of stress with organisational work demands known to be predictors of stress (Hackett et al, 2009). For example, in a review by Vachon (1998) it was reported that the organisational environment itself was a key stressor for and hospice nurses, specifically factors related to inadequate resources, team communication difficulties, or unrealistic expectations of the organisation. High workloads were a major contributor to stress in several of the studies. In the UK, for example, workload pressure was found to be a major stressor for community-based palliative care nurse specialists by Newton and Waters (2001). In this study stress was associated with staff shortages and erosion of support systems. In 564 International Journal of Palliative Nursing 2012, Vol 18, No 11

England, job stress for hospice nurses was related to busy periods with less manageable workloads, shift work, and staff shortages, with relieving staff presenting extra demands (Ablett and Jones, 2007). These issues were also stressors for nurses in Canada. Few studies have been undertaken into the views of nurses in Australia regarding workplace stressors. However, in one study by Wilkes and Beale (2001) workload was an important stressor for rural and urban nurses working with home-care palliative care clients in New South Wales (NSW). Service limitations (e.g. no after-hours care) and isolation because of distance from colleagues and health services were additional stressors. Fillion et al (2007) found that organisational stressors were a more important consideration for nurses in both hospice and community settings than were professional issues such as philosophical differences concerning delivery of care, challenging inter-professional cooperation, lack of ongoing education, or the emotional factors involved in caring for their patients. In another study hospice nurses viewed their overall environment as a stressor, reporting stress arising from living with sadness because of their close nurse patient interactions and frequent loss (McNamara et al, 1995, p228). Role conflict In the reviewed studies, occupational role concerns were rated as stressful, with role conflicts emerging from many directions. Misperceptions of the nursing role on the part of both the patients and other professionals were stressful, as were role changes (Newton and Waters, 2001). Nurses working with home-care clients in NSW found that other professionals (e.g. GPs) had differing expectations of their roles and conflicting perceptions of best practice in end-of-life care (Wilkes and Beale, 2001). Rural nurses in West Australia experienced demands to fulfil multiple roles in sparsely serviced regions (McConigley et al, 2000). Both work role and workloads are therefore potential stressors for nurses. Vachon (1998) raised the need to care for the caregiver in resolving conflicts around role overload, role ambiguity, role conflict, and the perception of a lack of control in the work environment. Support at work has been raised as an important factor because of lack of support by other staff or those in leadership roles (Healy and McKay, 2000). This can be either a stressor or, when support is present, a method of providing assistance for distressed staff (Healy and McKay, 2000). Patients and families As may be expected in a service in which nurses experience frequent deaths, patients and families were a common source of nursing stress. Nurses working in rural in Australia found family dynamics one of the most stressful situations with which they had to cope (Wilkes and Beale, 2001). Examples of this included dealing with families who were in denial of approaching death, with families who were physically and emotionally distressed in caring for a family member at home, and with families anger, as well as having difficulty separating their professional and personal roles in local community work. Furthermore, other nurses reported stressful situations arising when families had coping problems or personality issues, with families with whom communication was difficult, and in instances where identification with the family or the patient was difficult (Vachon, 1998). Of note, nurses perceptions of work stress were not so much related to personal distress caused by death and dying, medical treatment issues, or any lack of clinical competence. Rather, stress was related to many other factors at play in the nursing workplace. Mediators of stress Several studies have suggested that feeling well supported at work can be important in minimising the effect of stressful situations (Healy and McKay, 2000; Edwards et al, 2006). For example, studies of stress in nursing have focused on social support and coping strategies as potential mediators. Coping is defined as cognitive and behaviour styles or strategies that counter the negative consequences of stress (Hopkinson et al, 2005, p126). Thus, individuals with highly developed constructive coping may possess strategies that allow avoidance, reduction, or delay of the effects of stress. In one study, hospital nurses in the UK exhibited a strong capacity for coping with stress, scoring 48 75% (98/200 to 150/200) on the Nurses Coping with Stress Questionnaire (Bruneau and Ellison, 2004). As noted in the research literature, nurses have a range of coping styles. For example, problemfocused coping may be enacted by nurses to eliminate or reduce a stressor (Chang et al, 2007). One example is the employment of casual nursing staff to fill roster gaps to enable nurses on duty to cope with workloads. Conversely, an emotion-focused style of coping generally results in denial or attempts to consciously block mental perceptions of the stressor so that negative emotions can be contained (Chang et al, 2007).... a broad range of stress scores has been reported across various nursing specialties, and nurses have been found to be no more stressed than nurses in other fields. International Journal of Palliative Nursing 2012, Vol 18, No 11 565

Misperceptions of the nursing role on the part of both the patients and other professionals were stressful, as were role changes... However, this style may postpone the effects of stressors rather than resolving their causes. Thus, it would seem important to work toward an equilibrium between workload and work stress in the work environment. In a recent review of the coping styles of Australian nurses in all fields of work it was suggested that both problemfocused coping and emotion-focused coping are used by nurses to deal with causes of stress, with a preference for positive problem-focused coping (Lim et al, 2010). Another constructive coping strategy is self-care, which may be the most available choice and the best option for educating nurses about how to manage their stress. Byrne and McMurray (1997), who studied Australian hospice nurses experiences of their work, concluded that the nurses who coped best were those who took care of themselves, kept work in perspective, and maintained enough emotional distance. Others described the phenomenon of nursing as a journey of personal self-development (Barnard et al, 2006). It follows that when nurses learn to cope with work stress they may become more effective professionals. Discussion The major work of services is to address the needs of patients approaching the end of their life, as well as their families needs. As nurses described in the studies reported above, this means that they are routinely faced with potentially stressful situations. However, when the literature was examined, there was evidence that the levels of stress and distress experienced by and hospice nurses were no greater than those experienced by nurses from other specialties. This suggests that nurses who are well-trained and experienced may be at less risk of psychological distress and burnout than other nurses, for example because they may better utilise self-care strategies to reduce work-related stress. Wakefield (2000), who explored the lived experiences of nurses caring for the dying, described a need for these nurses to practice relentless self-care to cope with their feelings of loss. Furthermore, once the stressors in work have been identified, another way forward is to address issues that can be resolved or diminished. Barnard et al (2006) suggested that high degrees of nursing competence, expertise, and skill are required to manage the care of dying patients. The review revealed that both clinical nursing skills and relationships with patients were seen as important, and these relationships may affect nurses experiences of stress. In addition, it can be concluded from the results of the review that organisational factors in the work environment are key stressors for this group of nurses. A context model that portrayed the depth of the role was developed by Barnard et al (2006). In this model the nursing role involved nurses doing everything they can, developing closeness, working as a team, creating a sense that life has meaning, and maintaining themselves. From this explanatory model it may be concluded that many nurses have considerable understanding of the psychological adjustments that need to be made to manage this work environment. Given the breadth of skills required to perform in this role, well-prepared nurses may have ways of coping with the stress of their work environment that mitigate their stress levels. Stress and burnout are known to negatively influence job satisfaction and to consequently affect staff retention and recruitment, as nurses choose to avoid such work conditions (Lu et al, 2005). Burnout is a long-term adverse effect of stress that is characterised by high levels of emotional exhaustion, high depersonalisation, and perceptions of low personal accomplishment (Payne, 2001). Studies have associated high stress and burnout with a lack of coping and reduced mental health in nurses (Healy and McKay, 2000). With the current global shortages of nurses, an increased focus on the mental health of nurses is likely to have measurable employment benefits. The reviewed studies reported that stress reduction strategies that may assist nurses included more social support from both staff and managers, and enhanced coping strategies. The implications of this review are that organisations and their managers have a key role in communicating support to their nurses to minimise work stressors. Furthermore, stress management was a preferred topic for professional education requested by nurses (Fillion et al, 2005), as was opportunities for professional development (Redman et al, 1995). Organisational interventions such as structured debriefing, mentoring, and professional supervision are well-known staff support mechanisms that have been reported as having a positive effect on staff (Medland et al, 2004; Edwards et al, 2006). Critical incident stress debriefing based on a small group storytelling process has been used to help staff recover from stress (Mitchell, 2006). Although this type of debriefing is often used in nursing with the intention of supporting nurses and reducing distress, a lack of support at work was also not implicated in managing nurses levels of stress (Healy and 566 International Journal of Palliative Nursing 2012, Vol 18, No 11

McKay, 2000; Chang et al, 2007). This suggests that the results of the studies reviewed are equivocal about the impact of stress management and the types of communication that nurses can use to reduce stress. For example, McNamara et al (1995) found that hospice nurses used both formal and informal support strategies in coping with their work. These included informal gatherings of staff and weekly meetings that featured reflective discussions to help nurses in their professional development. More needs to be learnt about effective staff support and the techniques that can help nurses ameliorate work stress. Conclusion Palliative care nurses accompany a patient through the final phases of their life. Organisational, workplace, patient, and patient family factors were stressors implicated in the stress experienced by such nurses. However, their levels of stress were no greater than those of nurses in other specialties. 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