stress and coping
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Research paper about ways for nurses to cope with stress. Please do not plagiarize this paper has been turned in through turnitin.com.TRANSCRIPT
Stress and Coping 1
Running head: Stress and Coping in New Nurses
Stress and Coping Mechanisms in New Nurses
Jordan Harris
Florida Atlantic University
Stress and Coping 2
Nursing in general has always been a stressful field, but new nurses particularly both feel
the stress of nursing and are susceptible to it. For many new nurses if the stress load becomes
too intense this can lead to burnout and eventually perhaps leaving the profession as well as
critical errors in patient care. As the nursing field is experiencing a shortage of nurses it is
important to retain every nurse; especially if they leave because they are not provided with a few
tools to help them cope with stress. In addition to providing opportunities to learn coping
mechanisms, nursing leaders can also institute organizational changes to improve stress levels
not only for new nurses but also for all nurses under their management. New nurses themselves
can be proactive in learning these coping mechanisms and exploring ways they can protect
themselves from excessive stress. The consequences of not dealing with stress in the nursing
industry will lead to nurse burnout, decrease in quality of patient care, patient accidents such
as medication errors, and ultimately nurses leaving the profession.
DEFINITION OF STRESS
Nurses are in general a group vulnerable to stress as they deal with patients’ and
relatives’ suffering, a high level of physical exhaustion, a quickly changing healthcare field and
understaffing (Campos de Carvalho 205). The National Institute of Occupational Safety and
Health defines job stress as “the harmful physical and emotional responses that occur when the
requirements of the job do not match the capabilities, resources, or needs of the worker”
(Wellker-Hood 2006 p.104). Nursing has historically been a stressful field and likely always
will be. Florence Nightingale’s experience during the Crimean war in the barracks of Scutari
were stressful as they were in a situation with too few funds, supplies and trained personnel to
Stress and Coping 3
care for the hundreds of young soldiers dying from battle wounds and infections (Milliken &
Tillman 2007). Things have not changed too much since that time as hospitals today still find
themselves short on funds and trained personnel on a daily basis. Nurses find that they have a
shorter period of time to provide complete patient care to the “sicker” and to do so “quicker”
(Milliken & Tillman 2007). However, stress itself is not necessarily damaging. Some stress is
good and in fact necessary- for example the stress and adrenaline that kicks in during a Code
Blue. Positive stress is referred to as eustress and can heighten and focus attention as well as
increasing mental acuity (Wellker-Hood 2006). However, at some point the level of stress
becomes too high and then no longer improves a person’s performance but rather starts to impair
their ability to meet the challenges their job presents (Wellker-Hood 2006). Stress has also been
described as a type of anxiety or as an experience of change (Hurley 2007). No matter how it is
described it is clear that while things can be done to ameliorate the experience of stress it is not
something than can ever be banished and so consequently it must be coped with instead.
Stress causes the sympathetic nervous system to flood the body with cortisol and
adrenaline; this constant triggering of the sympathetic nervous system can exhaust the body and
lead to health problems (Milliken & Tillman 2007). These high levels of stress can lead to a
myriad of physical symptoms: heart disease, migraines, hypertension, irritable bowel syndrome,
muscle tension, back and joint pain and duodenal ulcers (Milliken & Tillman 2007). High levels
of stress can also lead to mental health problems: depression, insomnia, anxiety and feelings of
inadequacy (Milliken & Tillman 2007). Chronic high levels of stress can lead to a depressed
immune system, decreased cognitive functioning and ultimately even degenerative changes to
the brain structures responsible for storing new information (Pipe, Bortz, Dueck, Pendergast,
Buchda & Summers 2009). In fact chronic stress appears to affect cellular aging by shortening
Stress and Coping 4
telomeres, which is a biological indicator of age. Ultimately these degenerative changes, which
are linked to high levels of stress perception, translate to an average loss of 10 years of life (Pipe
et al 2009). Stress particularly affects high-level cognitive skills such as attention and memory,
which are critical components in quality nursing care (Pipe et al 2009). High levels of stress can
lead to the phenomenon of burnout. Burnout is a feeling of being overworked, emotionally
drained, and leads to lower productivity in both work and home life (Davies 2008). Nurses find
this syndrome of burnout to be a pervasive source of distress (Leiter & Laschinger 2006).
Nurses who become burnout can also become cynical and exhausted leading to lack of patient
care (Laschinger & Wong 2006). Burnout is particularly common in the health care professions
because of the emotional intensity of the relationships with their patients. Physical symptoms of
burnout include headaches, dizziness, insomnia, skin problems and gastrointestinal distress
(Sardiwalla, Vandenberg & Love 2007).
New graduates nurses are eager to join the workforce, but they are especially vulnerable
to the stressors that exist in the current workplace. New nurses are statistically more likely to
leave their first nursing position within 1 year and can cost $40,000-$100,00 to replace
(Winfield, Melo & Myrick 2009). They experience a transition from school to the reality of
professional nursing that can be shocking when they realize there are gaps between their
knowledge and what they are expected to know as new nurses (Winfield et al 2009). Stressors
that are particularly common to new nurses include: lack of confidence/competence in their
skills, worry about making errors and fear of new situations and procedures (Winfield et al
2009). New nurses have this set of stressors as well as the ones that are common to all nurses:
critical nature of their work, staffing shortages, working more shifts, inadequate rest, potential
for lawsuits, working with potentially deadly communicable disease, aches and pains from lifting
Stress and Coping 5
patients, watching people suffer, job layoffs or insecurities and difficulties with co-workers or
supervisors (Winfield et al 2009). The question then becomes what are the consequences of
stress and ultimately burnout on nurses, the economy and patients?
CONSEQUENCES OF STRESS
The most serious consequence of overstressed or burnt out nurses is adverse incidents
with patients. Medication errors are one of the most common and most serious adverse events
that can befall a patient in the hospital; research studies have shown a clear correlation between
stressed and unfocused nurses leading to medication and other patient care errors (Wellker-Hood
2006). Nurse focused research has found work overload was the most perceived stressor among
nurses (Hays, Mannahan & Wallace 2006). A study by Aiken et al examined the association
between staffing and patient mortality. This study found each additional patient resulted in a 7%
increase in odds of failure to rescue, and 7% increase in 30-day mortality (Garrett 2008). This
study also found that each additional patient increased odds of burnout 23% and job
dissatisfaction by 15% (Garrett 2008). Not only does an overload of patients increase nurses’
stress but also directly affects the patients’ care and outcomes. Many nurses list excessive work
hours and overtime shifts as significant sources of stress. A study by Whitman et al found that
the higher the amount of hours worked the higher the likelihood that patients would have more
falls, nurses would more often place patients in restraints, and that nurses would make
medication errors (Garrett 2008). Lower staffing rates were also shown to directly relate to the
rate at which patients in the hospital acquired pneumonia and the study found that by adding only
half an hour of RN staffing per patient they could reduce the rate by 4% (Garrett 2008). Often
times when understaffing leads to stressed or tired nurses making critical errors in medication,
Stress and Coping 6
assessments, or overall care the nurse is blamed (Wellker-Hood 2006). Blaming the nurse can
start a vicious cycle as it leads to more stress and ultimately doesn’t address the underlying cause
of the error caused by understaffing or other stressors (Garrett 2008).
Excessive stress can cause a plethora of somatic symptoms in nurses such as: headaches,
nausea, dizziness, insomnia, skin problems, gastrointestinal symptoms, heart disease, irritable
bowel syndrome, back and joint pain and a myriad of mental health problems. These physical
and mental problems become issues not only on a personal level but an administrative level as it
leads to absenteeism and therefore requires administration to use expensive replacement staff or
mandatory overtime (Milliken et al 2007). Mandatory overtime can then also cyclically lead to
nurses feeling overworked and burnt out. Nurses often cope with stress and the physical
symptoms of stress by calling out sick; when nurses call out sick, especially if they cannot be
replaced, patient care and safety is compromised (Garrett 2008). The estimated national cost of
health care worker stress is about $250 to $300 billion annually (Milliken et al 2007). This
estimate takes into account: dollar effects of reductions in operating effectiveness, poor decision
making, medical expenses and staff attrition due to overwork (Milliken et al 2007).
Burnout is a major consequence of excessive stress and is a particular problem in the
nursing field (Leiter & Laschinger 2006). Burnout is a syndrome characterized by emotional
exhaustion, depersonalization and feeling a lack of personal accomplishment that occurs after a
period of chronic and unrelieved job related stress (Barnard et al 2006). One way to measure
burnout is the Maslach Burnout Inventory (MBI). This inventory consists of 22 items with 3
subscales: emotional exhaustion, depersonalization and lack of personal accomplishment
(Sardiwalla et al 2007). Nurses score high on the burnout scale with younger nurses reporting
even higher levels of emotional exhaustion. Close to 53% of nurses surveyed in this study were
Stress and Coping 7
in the severe burnout category according to the MBI scale (Laschinger & Wong 2006). Heavy
workload is the strongest predictor of nurses’ emotional exhaustion and ultimately burnout
(Laschinger & Wong 2006).
Stress can lead to nurses, particularly new nurses, deciding to leave the nursing field
entirely. Currently 1 in 5 nurses plan to leave the profession within the next 5 years and almost
50% think about leaving often (Letvak & Buck 2008). This is a negative trend as our nurse
workforce is currently aging and an influx of new nurses is needed. About 1/3 of the current
workforce is over the age of 50 and possibly approaching retirement age (Milliken et al 2007).
The average age of nursing faculty is also on the rise and is currently approximately 49 years of
age (Milliken et al 2007). Ultimately, as many as 20% of nurses will leave the industry, citing
stress or burnout as their reason (Milliken et al 2007). Nurse turnover, which is often caused by
burnout, ranges annually between 18-26% and averages a cost of $62,100-$67,000 per incident
of turnover (Milliken et al 2007). In addition we currently have a predicted nursing shortfall of
36% by 2020 so it is important to retain the new nurses who come into the profession (Letvak &
Buck 2008). A current nurse shortfall nationally of 8.5-14% is affecting patient safety and
quality of care and leading to overwork and stress of the nurses currently in the field (Letvak &
Buck 2008).
COPING MECHANISMS
Identifying strategies to help nurses deal with stress can be problematic as often the staff
is unaware of the extent that stress is building up and affecting not only them but their ability to
care for patients (Repar & Patton 2007). Anna Halprin, an esteemed author in the area of
expressive arts theories states; “the inability to relax is often so enmeshed in emotional blocks
Stress and Coping 8
that we are unaware of making relaxation the most difficult skill to achieve” (Repar & Patton
2007 p.182) The front line of defense for nurses, and new nurses in particular, against stress is to
use coping mechanisms to help them deal with the stress they feel on a daily basis. Coping is
defined as “the cognitive and behavioral efforts exerted to manage external and/or internal
demands. Which were perceived as taxing to an individual. The function of coping was to
manage or alter demands that occur externally in the environment or internally within oneself”
(Hays et al 2006 p.185). It was through the framework of scientists like Freud, Menninger, Haan
and Erikson that we as a society were first introduced to strategies for individuals to reduce their
level of stress (Hays et al 2006). Coping mechanisms such as planful problem solving and the
seeking of social support are the most frequently reported coping mechanisms. Planful problem
solving includes delegating work, rationalizing the situation and speaking with someone who can
do something concrete about the problem (Hays et al 2006). Social support can be within the
workplace such as coworkers or outside the workplace with friends, families, or other supportive
environments such as church groups (Hays et al 2006). Peer support can reinforce “feelings of
competence and successful achievement of one’s work with people” which can lead ultimately to
lower rates of burnout (Barnard et al 2006 p.343). New nurses in particular benefit from more
peer support from experienced nurses (Barnard et al 2006). Patricia Repar believes that nurses
“who wish to have effective and enjoyable working careers should consider integrating into their
every day self-care, some practices designed to identify and overcome stress, chronic grief, and
compassion fatigue” (Repar & Patton 2007 p.183).
Some of the main somatic symptoms of stress are muscular tension, headaches and
general pain and tension in the neck, arms and the shoulders. One way to treat both the muscle
tension and the underlying stress is massage, which has been cited in numerous studies as a
Stress and Coping 9
specific and effective way of reducing not only the effects of stress but also the stress itself and
thereby ultimately improving the overall health of the massagee (Repar & Patton 2007). In a
meta-analysis of 37 studies on massage therapy, which included 1802 participants, those that
received the massage therapy showed lower levels of anxiety, blood pressure and heart rate
(Repar & Patton 2007). While massage can be an expensive therapy it may be worth pursuing to
see if it is covered under a nurses’ health benefits as it is sometimes covered when it is done
through a chiropractic or physical therapy practice. One nurse who participated commented
before the massage that she felt “overwhelmed, rushed very stressed, tired” and afterward stated
“I feel like I’ll be more able to manage my assignment” (Repar et al 2007 p. 185). Another
massage participant stated “as I was getting massaged and my body began to relax I envisioned
entering a patient’s room with that sense of calm and peace which in turn can be transferred to
my patients. I have a much deeper understanding of the importance of self –care today than I
think I ever had” (Repar et al 2007 p.185) Overall massage therapy provides a tool that can
stimulate full body relaxation and when combined with other therapies or coping mechanisms
can help nurses stay ahead of the stressors of their jobs (Repar et al 2007). It can be hard to
convince nurses to participate in massage or other therapies as they often think they are too busy
to take the time or that it is too expensive (Repar et al 2007). Another idea is that perhaps
hospital administration could arrange for a massage therapist to visit each floor once a month and
cover the cost. It could very well be more than worth the cost if it decreased absenteeism and
worker’s comp claims. If nurses found it beneficial they may then seek out more massage
therapy using their own time and money, which might ultimately also benefit the hospital.
Exercise is another coping mechanism/therapy that can help reduce stress. Exercise, in
addition to its obvious health benefits, can also help trigger the relaxation response, which is a
Stress and Coping 10
“state of deep rest that changes the physical and emotional response to stress” (Billingsley et al
2007 p.50). Exercises, which can be done in the hospital such as stretching or deep breathing,
can provide immediate relief from stress buildup (Billingsley et al 2007). Many larger hospitals
have added gyms to their buildings or allowed employees access to gyms used for physical
therapy. Almost any hospital can encourage exercise either through a physical gym on location,
or a discount program to a local gym.
Another coping strategy nurses can use to deal with stress is called Mindful Meditation.
This type of meditation is based on the ancient contemplative tradition of Vipassana and is a type
of cognitive exercise that “enhances the experience of the quiet mind and teaches recognition and
control of intrusive thoughts” (Davies 2008 p.33). Regularly practicing meditation can help
increase mental clarity, concentration, and the ability to deal with stress. (Davies 2008).
Meditation, unlike massage, is not something that brings about an immediate drop in stress.
However, long term it can help practitioners gain perspective on life events and better ways to
cope with them (Davies 2008). Most programs that teach Mindful Meditation are 8 weeks long,
but research has shown that even brief amounts of training can have a positive correlation with
improving levels of stress and negative emotions (Davies 2008). While the length of training is
not essential it is actually after the training how often the person practices meditation that has the
most impact on their stress level (Davies 2008). Meditation teaches the practitioner to reduce
extraneous thoughts and improve cognition. As nurses are often faced with situations where they
must sort through many conflicting messages meditation can help them sort the information and
prioritize therefore ultimately saving time, money and patients’ lives (Davies 2008). One study
found that after an 8-week meditation program, which consisted of 90% nurses, those
participants reported increases in self-acceptance, self-compassion, self-awareness, self-care, and
Stress and Coping 11
self-confidence (Davies 2008). Other than Vipassana another types of Mindful Meditation is
Hatha Yoga, which is a type of yoga that uses physical poses along with breathing exercises to
develop strength, flexibility and balance (Davies 2008). Yoga “allows one to become aware of
the sensations that arise as one places one’s body in various positions or postures….yoga is done
without striving or forcing the body to do something, so while practicing yoga, one learns to
work within the body’s limits all the while focusing on being mindful of what sensations,
feelings, and thoughts occur (Davies 2008 p.35) . Nurses tend to live compartmentalized lives
and practices like meditation or yoga provide the potential to link all their experiences and offer
them a means to see their true selves without those barriers (Davies 2008). Yoga classes can be
found not only at private yoga studios, but today most community centers offer the classes for a
small fee. Since most yoga classes only require an empty room, a qualified teacher and a mat it
would even be possible for hospitals to provide yoga classes to its employees for a minimal cost
which could be either absorbed by the hospital or passed on to their employees. Other
alternative therapies that have been shown to reduce stress are aromatherapy, guided imagery,
music therapy, reflexology, dream work, light therapy and therapeutic touch (Hurley 1007).
Some of these alternative stress therapies, such as aromatherapy or music therapy, can be
accessed through a trip to the library and a small investment in materials.
One set of stressors that is unique to new nurses is the expectation from their employers
that they can hit the ground running. However, many studies show that this expectation is not
really feasible and that programs to help orient and preceptor new nurses can do a lot to lessen
the stress of their transition from school to practice (Winfield et al 2009). It is financially
important for hospitals to retain new nurses as the cost is estimated at between $20,000-$50,000
to replace them (Winfield et al 2009). Therefore it is to both the hospitals’ and the new nurses’
Stress and Coping 12
benefit to have a nurse internship or residency program to ease that transition. There are many
programs out there of varying lengths that offer new nurses an internship or residency period. It
has been shown that despite some differences in length and program content that as a whole
these programs provide their hospitals a lower rate of staff turnover and an improved
commitment to the hospital from those nurses who completed these programs (Winfield et al
2009). While these programs differ they do have a few common characteristics: a commitment
to build competence and confidence in the new nurse, a longer than average orientation period
and the opportunities for new nurses to become involved in interdisciplinary collaborations
(Winfield et al 2009). A study of a one year internship pilot program at Children’s Hospital in
Los Angeles found that retention of new graduates went from 63% to 86% and that there was a
67.3% return on the investment in this internship program (Winfield et al 2009). In addition to
better retention, graduates of internship programs show better interpersonal skills, problem
solving and critical thinking skills (Winfield et al 2009). As there is currently a nursing shortage
in many parts of the country new graduates can be perceived as “an immediate solution to
staffing shortages” and so orientation periods may be shortened instead of lengthened (Winfield
et al 2009 p.E12). If more hospital administrators see the financial rewards of having new nurse
residency or internship programs they may become more amenable to implementing them in
their hospitals. New nurses themselves should speak up if their orientation period comes to an
end and they don’t feel prepared. If this occurs they should speak to their nurse administrator
about possibly extending their orientation period.
Stress and Coping 13
CONCLUSION
Nursing is not going to get less stressful in the near future and as the nursing shortage
increases it is likely to get more stressful. Therefore new nurses need to seize the reins and be
proactive in their knowledge of work stress, ways they can personally deal with stress, and
programs they can encourage their hospital or place of work to implement. By understanding
how stressful a new nurses’ transition can be it prepares him/her to deal with it and perhaps
experience less shock. There are many coping mechanisms out there that can help head off
stress before it gets to the level of burnout. Some, like massage, may seem like a pipe dream due
to expense and time, but it is important for the new nurse to try it to see if it helps them and then
pursue whether their health insurance might cover it. If it doesn’t cover it there are many places
that provide mini massages for under $15 that may provide some relief from both muscle tension
and stress. Other strategies may simply entail a little research and some small startup costs such
as aromatherapy. By raising a new nurses’ level of stress awareness in the workplace it may be
possible to decrease stress and head off burnout. However, it is important for nurses to seek
counseling or talk therapy if they feel they need it . It is also important that hospitals provide
employee assistance programs or mental health benefits in their benefits package as well as
encouraging employees to make use of them as they are needed. Co-workers and administrators
should not place any stigma on hospital staff that chooses to use these mental health benefits.
Administrators, even those with modest budgets, can do much to alleviate stress in their
hospitals. They can make break rooms warm and inviting places for nurses to get away from the
stress of their jobs. They can provide comfortable seating and adequate facilities within the
break rooms while keeping postings to a minimum or keeping the tone of those postings
Stress and Coping 14
encouraging rather than harsh. If incentives are offered for any reason it is a great opportunity
to make those rewards ones that can help alleviate employees’ stress levels such as massage gift
certificates, gym memberships or paid time off. Another idea is to bring in professionals to
educate on stress and stress management techniques; this may cost a bit more but research shows
that the investment pays itself off in many ways. New nurses are entering a stressful and volatile
career field, but with adequate education and coping mechanisms they can keep their stress level
down and avoid burnout.
Stress and Coping 15
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