Stress: Effects on nursing staff

Job stress has become an increasingly common outcome of today’s dynamic life. Stress in the workplace is better understood as the psychological state that represents an imbalance or inconsistency between an employee’s perceptions of the demands and their ability to cope with those demands. Most jobs consist of situations or events that employees find stressful; however, some jobs encounter more job-related stress than others.

It is now an established fact that the profession of nursing is full of stress and challenges. Female nursing staff faces crying and dying patients on daily basis. The tasks performed by them are almost mundane and unrewarding. If measured by normal standards, nurse’s job is disgusting and distasteful, degrading and frightening (Hingley, 1984). [i] “

The ILO has commissioned a manual on the job stress and its prevention among female nursing staff entitled “work relating stress in nursing, controlling the risk of health” by Dr. A. Griffiths, Professor S. Cox, due to its great significance. (ILO, 2001). [ii] 

1.2) THE MAIN SOURCES/CAUSES OF JOB STRESS AMONG NURSES:

The job of female nurses is daunting and daring. Everyday multiple and conflicting demands are imposed on nurses by their supervisor, managers, administrative staff and others. Such situation usually leads to work burden and role conflict. The role conflict is inherent in the job of female nurses due to goal oriented demands put on them such as “getting patients better very early”. The nurses are given the task of providing emotional support and relieving stress of dying and crying patients. Role conflict is common among nurses looking after those patients who are critically ill and dying. It is worth mentioning here that intensive care unit and critical units of our hospitals attracted particular attention these days. Here, the female nurses faces, on daily basis, stark suffering, grief and death. It is now universally accepted that health care in the current era suffer high rate of violent behavior.

In recent times, many research studies have measured and determined the effects of job stress on health and well being of nurses in the hospital settings and elsewhere. Job stress detracts nurses from qualitative working lives, enhances psychiatric morbidity and contributes towards physical illness, such as musculoskeletal problems and depression. [iii] 

1.3) International council of nursing (ICN,2001) has reported that if we want to develop an optimum environment for the production of stress, a lot of stressors, we would include, would be obviously recognized by female nurses as events in the hospital settings which they confront on routine basis. The stressors are long hours, unpleasant noises, sights, undue quiet, sudden shift from intense to mundane tasks, time pressure, no second chance, and enclosed environment etc [iv] .

1.4) Stress usage in its historical perspective.

Stress is a recent term used frequently and generally after 1950s. It is semi-psychological term, always refers to hardship and coercion. In Middle English destress, in Latin stringere- to draw tight. In physics, stress is the internal distribution of a force exerted on a material body, resulting in strain. During the year 1920s and 1930s, stress is used in psychological circles; here it is mental strain or unwelcome happenings. The advocate of holistic medicine refers stress to harmful environmental agent, the implication of which is illness.

Following Hans Seyle’s laboratory experience during 1930s, a new scientific usage of stress developed. Stress is the state of organism as it responded and adapted to the environment. Seyle’s theories of universal non-specific stress response attracted great interest in the academic circle in physiology.

Seyle endeavored to assimilate stress to the non academic physician as well, by writing a good piece entitled “stress of life” for general public.

A thorough and detailed study of job stress would help employees achieve health and happiness by successfully responding to challenges and problems of the modern globalized world. Eustress is the positive stress as against destress which represents negative stress. Stressors are the causative events/ stimulus.

A large amount of research has been conducted during the late 1960s and early 1970s, to establish a link between stress and diseases of various kinds, stress and decline in performance. To better address the critical issue of stress, research on stress in medical circle has become a focal point during the recent years.

By 1990s, job stress has become significant segment of modern sciences, in all areas of physiology and human functioning. Focus, recently, developed on stress in certain settings, such as stress in work environment. And stress intervention and stress management techniques were developed (how to cope or handle stress).

Stress may be viewed as perceived difficulties in life or a way of referring to hurdles, impediments and eliciting sympathy without being explicitly confessional, just “stressed out”.

Stress includes a wide rang of outcomes, from mild irritation to intense and severe problems that might give real breakdown of health. Generally any event or situation between these extremes could be termed as stressful.

The most critical and extreme situation result in burn out and the implication is post traumatic stress disorder (PTSD), an anxiety disorder that can develop after exposure to one or more frightening and terrifying events that result in great physical loss. PTSD is a critical and ongoing emotional reaction to an extreme psychological trauma. It is associated with some occupations such as emergency human resource departments, police personnel and army men etc.

These type of stressors may include events as someone actual death, threat to patient’s life or someone else, serious physical injuries or partial or total disablement, threat to psychological integrity, over whelming usual psychological defenses coping. Sometimes, it may result from profound psychological and emotional trauma apart from any physical harm. Often, however, the two are combined.

Life is full of stressful events. We frequently confront challenges and obstacles, and sometime the pressure put on us is very hard to cope with. When we are definitely unsure of how to meet demands set for us, we experience stress. It is worth mentioning here that in small amount stress can be a good thing. It can give us the push, we need, motivating us and to concentrate and remain conscious, focus and alert. [v] 

Stress keep us on our toes during presentation or it stimulate us to curiously study for exam and stay focused when we would be rather in cinema. But when the stress become too hard and the life’s demands exceed our capabilities to handle, then our physical and emotional well being is threatened.

We always consider the stressors as being negative, such as rocky relationship, death of near one, over work, an exhausting schedule etc. However, anything that compels us to accommodate and to cope can be a stressor. Stress includes as well, positive events such as promotion, transfer to new post, getting married and changes etc. Regardless of whether an event is positive or negative, if the changes it brings strain, our handling ability and adaptive resources are stimulated, the implication is the subjective feeling of being stressed and the biological stress response of the body.

The sources of stress are manifold. Our stress may be associated to outside factors such as working environment, conditions of the world, family affairs etc. Sometime, stress may be the outcome of our own irresponsible behavior, unrealistic goal, negative perception, and attitude etc.

The causes of the stress are highly individual. What we think stressful is associated with many factors, including our personality outlook on life, problem solving skills and social support system of our society. Sometimes, that is stressful to us may not be stressful for others. For example, our morning journey may make us worry that traffic jam will make us late, others, however, may find the trip relaxing because they allow more than enough time and enjoy talking, viewing and listening to music or reading books. (NIOSH 1987) [vi] 

Stress experienced by the masses in our modern and industrialized society mainly originates in the Enterprises; much of the stress that originates elsewhere affects our behaviour and performance in this enterprises-spill over effect.

Stress means different thing to different peoples. From the perspective of layman, stress can be described as feeling tense, anxious or worried or having the blues. Scientifically such feelings are indication of the stress experience, an intriguingly complex programmed response to perceived threat that can have negative or positive implication. The term stress has been defined in multiple ways in the research and professional literature. All the definitions can be placed in two categories, stimulus and response.

According to stimulus definition, stress is an event, situation or characteristic that result in potentially disruptive circumstances.

In physics, stress refers to the external force applied to an object, for example a bridge girder. The response is strain, which is the impact the force on the girder.

In a response definition, stress is seen partially as a response to some stimulus, called a stressor. A stressor is a potentially harmful or threatening external event or situation. Stress is more than simply a response to a stressor. However, in a response definition stress is the consequence of an interaction between an environment stimulus (a stressor) and an individual’s response. That is, stress is the result of a unique interaction between stimulus condition in the environment and an individual’s predisposition to respond in a particular way. (Ivancevich, 2001) [vii] 

1.5) Stress Defined:-

One of the complicating issues in understanding stress is the fact that it has been defined in a multitude of ways.

An adaptive response moderated by individual differences, that is a consequence of any action, situation or event that places special demands on a person.( Ivancevich,Olekalns,2008) [viii] 

Stress is a psychological and physiological response to events that upsets our personal balance in some way. These events or demands are known as stressors.(NIOSH, 2010) [ix] 

Stress is the general term applied to the pressures, people feel in life.(Newstorm,Devis, 2002) [x] 

Any adductive demand caused by physical , mental or emotional factors that requires coping behavior(Bohlander,Snell, 2004) [xi] 

A dynamic condition in which an individual is confronted with an opportunity, constraints or demand related to what he or she desires and for which the outcome is perceived to be both uncertain and important.( Robbins, 2001) [xii] 

Stress is a complex pattern of emotional states, physiological reactions and related thoughts in response to external demands.(Greenberg, Baron, 2000) [xiii] 

The interaction between individual and environment characterized by physiological and psychological changes that cause a deviation from normal performance.

A situation where in job-related factors interact with a worker to change his or her psychological and/or physiological condition such that the person is force to deviate from normal functioning.(Bernardin, 2003) [xiv] 

Some environmental force affecting the individual, which is called a stressor.

The individual’s psychological or physical response to the stressor.

In some cases, an interaction between the stressor and the individual’s response.

Stress is a dynamic condition in which an individual is confronted with an Opportunity, demand, or resource related to what the individual desires and for which the outcome is perceived to be both uncertain and important.(Robbins, Timothy, 2007) [xv] 

(11) Behr and Newman define job stress as” a condition arising from the interaction of people and their jobs and characterized by changes within people that force them to deviate from their normal functioning”.(Pfeffer, 1992) [xvi] 

(12) When a person is confronted with a situation which poses a threat or demand, and perceives that she or he does no have the capability or resources to match or exceed the stressor, the imbalance that results at that point in time is termed stress.( Luthan, 2005) [xvii] )

(13) An Individual’s adaptive response to a situation that is perceived as challenging or threatening to the person’s wellbeing.(Mc Shane, Travaglione, 2004) [xviii] 

(14) Stress is an individual’s physiological and emotional response to stimuli that place physical or physiological demands on the individual and create uncertainty and lack of personal control when important outcomes are at stake. (Samson, Richard, 2003) [xix] 

(15) Stress is the excitement, feeling of anxiety, and/or physical tension that occur when the demands place on an individual are thought to exceed his ability to cope. (Hellriegel, John 2004) [xx] 

(16) “Stress is a negative emotional state occurring in response to events that are perceived as taxing or exceeding a Person’s recourse or ability to cope”. (Hockenbury, 2003) [xxi] 

For our purposes, we think it is useful to view stress as the response a person makes and to identify the stimulus conditions (actions, event or situation) as stressor. This allows us to focus our attention on aspects of the organizational environment that are potential stress producers. Whether stress is actually felt or experienced by a particular individual will depend on that individual’s unique characteristics. Furthermore, note that this definition emphasizes that stress is an adaptive response. The great majority of our responses to stimuli in the work environment does not require adaptation and thus are not really potential sources of stress.

In the context of our stress definition, stress is the outcome of handling something that places ‘special’ demands on the individual. Special here means unusual, physically or psychologically threatening, or outside an individual’s usual set of behaviors. Starting a new assignment, changing bosses, having a flat tier, missing a plane, making a mistake at work, having a performance evaluation meeting with the boss, giving a speech – all of these are actions, events or situations that may place special demands on individuals. In that sense, they are potential stressors. Not all stressors will always place the same demand on all people.

In order 0f an action, event or situation to result in stress, it must be perceived by the individual to be a source of threat, challenge or harm. If there are no perceived consequences – good or bad – there is no potential stress. At least three additional factors play a role in determining whether what an individual is experiencing is likely to result in stress. These factors are; importance, uncertainty and duration. Importance is related to how significant the event is for the individual. For example, let us suppose that an employee is facing a job lay-off. The more significant or important that event is to the individual, the greater the stress potential. If the employee expects such an event to be followed by a period of prolonged unemployment, it will probably be viewed as a more important event than if immediate employment is assured

Uncertainty refers to a lack of clarity about what will happen. Rumors of an impending lay-off may be more stressful for some people than knowing for certain that they will be laid off. At least in the latter case, they can make plans for dealing with the situations. Frequently, ‘not knowing’ places more demands on people than knowing, even if the known result is perceived as negative.

Finally, duration is a significant factor. Stressor can be either acute or chronic. Acute stressors are major events in our lives that have a relatively short time frame. Getting married, losing your job or failing in exams are all events that leave a big impact on us, but they do not endure overtime (we do not fail an exams every day). Chronic stressors have a less profound impact on us when they occur, but we are exposed to them on an almost continual basis. They are represented by daily hassles that fit with seyle’s representation of stress as the ‘wear and tear of every day life’. Such things as shopping, cooking or finding a study space in the library are all minor irritation that we face on an almost daily basis. They may not affect us at a time, but their affect slowly built over time. Generally speaking, the longer special demands are placed on us, the more stressful the situation. Giving an unpleasant job assignment that lasts for only a day or two may be mildly upsetting, while the same assignment lasting for months may be excruciatingly painful. Although there are some acute stressors in the workplace (job loss or transfer, promotion or demotion, and entering or leaving the job market), most of the work place stressor are better thought of as daily hassles.

1.6) THE GENERAL ADAPTATION SYNDROME (GAS)

Stress includes both psychological and physical components. Dr. Hans’s Seyle, the pioneer of stress research was the first to conceptualize the psycho physiological responses to stress. Seyle consider stress a non-specific response to any demand made upon an organism. He labeled the three phases of the defense reaction that a person establishes when stressed as the general adaptation syndrome (GAS). Seyle called the defense reaction ‘general’ because stressor had effects on several areas of the body.

Adaptation refers to a stimulation of defenses designed to help the body adjust to or deal with, the stressor. And syndrome indicates that individual pieces of the reaction occur more or less together. The three distinct phases, which can be seen in exhibit no.1, are called alarm, resistance and exhaustion.

The alarm stag is the initial mobilization by which the body meets the challenges posed by the stressor. When a stressor is recognized, the brain sends forth a biochemical message to all the body’s systems. Respiration increases, blood pressure raises, pupils dilate, muscles tense up and so forth.

If the stressor continues, the GAS proceeds to the resistance stage. Sign of being in the resistance stag include fatigue, anxiety and tension. The person is now fighting the stressor. While resistance to a particular stressor may be high during this stag, resistance to other stressor may be low. A person has only finite sources of energy, concentration and ability to resist stressors. Individuals are often more illness-prone during periods of stress than at other times.

The final GAS stage is exhaustion. Prolonged and continual exposure to the same stressor may eventually use up the adaptive energy available, and the system fighting the stressor becomes exhausted.

It is important to keep in mind that the activation of the GAS places extraordinary demands on the body. Clearly, the more frequently the GAS is activated and longer it remains in operation, the more wear and tear there is on the psycho physiological mechanisms. The body and mind have limits. The more frequently a person is alarmed, resist and becomes exhausted by work, non-work or the interaction of these activities, the more susceptible he or she becomes to fatigue, disease, aging and other negative consequences. (Ivancevich, 2001) [xxii] 

Stage 1

Normal level of resistance

Stage 3

ALARM REACTION

The body shows the changes characteristic of the first expose to the stressor. At the same time, its resistance is diminished.

Workplace example:

A request by a manager to submit a budget in 3 days

RESISTANCE

The second stage ensures if continued exposure to the stressor is not compatible with adaptation. Resistance increase above normal.

Workplace example:

Flying off the handle at a meeting because the budget was still unfinished & time is passing with no budget work occurring.

EXHAUSTION

The third stage follows long continued exposure to the same stressor, to which the body has become adjusted. Eventually adaptation energy is exhausted.

Workplace example:

No sleeps, insomnia, worry about the budget. Totally and physically exhausted.

Stage 2

Exhibit no.1

1.7) THE CAUSES OF STRESS

The causes of stress, which may rightly be called stressors, include any environmental condition that place a physical or emotional demand on a person. There are numerous stressors in organizational settings and other life activities.

Exhibit no.2 lists the four main types of work-related stressor:

Physical environment stressors,

Role-related stressors,

Interpersonal stressors and

Organizational stressors.

1.7.1) STRESSORS INHERENT IN PHYSICAL ENVIRONMENT (PHYSICAL ENVIRONMENT STRESSORS)

The physical environment of organization contains some physical environmental stressors; safety hazards, poor lighting, and excessive noise etc. For example, a study of textile workers in a noisy plant found that there level of stress decreased measurably when they were supplied with ear protectors. Another study reported that clerical employees experience significantly higher stress level in noisy, open office than in quiet areas. Physical stressors also include poorly designed office space, lack of privacy, ineffective lighting and poor air quality.

1.7.2) ROLE-RELATED STRESSOR

In this concept of role related stressors, employees have difficulty in assimilating and reconciling or performing the multitude roles that they play in their life.

Main role-related stressors are;

Role conflict,

Role ambiguity,

Workload

Task control:

Role conflict

Accordingly, when masses confront competing demands role conflict occurs. An employee may have two roles that are in conflict with each other (called interrole conflict) or may receive contradictory messages from different people about how to perform a task (called intraoral conflict). Role conflict also occurs when organizational values and work obligations are incompatible with personal values (called person-role conflict). For example, a recent study described how Australian managers experience the stress of people-role conflict when they observe unethical practices involving partners located in other countries.

Work related stressors

Physical environment stressors

Role-related stressors

Interpersonal stressors

Organizational stressors

Non-work

stressors

Individual

Differences

stress

Consequences of distress

Physiological

Heart disease

Ulcers

High BP

Headaches

Sleep disturbance

More illness

Psychological

Job dissatisfaction

Depression

Exhaustion

Moodiness

Burnout

Behavioral

Lower job performance

More accidents

Faulty decisions

Higher absenteeism

Workplace aggression

Exhibit no.2

1.7.2.2 Role ambiguity When workers are unsure of meeting job responsibilities, performance, expected level of authority and job conditions, role ambiguity is said to exist. This tends to occur when people enter new situations, such as joining the organization or taking an overseas assignment, because they are uncertain about task and social expectations.

1.7.2.3Work load-work under load – providing small amount of work or assignment to workers that do not match their talent is a stressor. However, work overload is the most common stressor these days in our dynamic organization. Employees are required to perform too much work in too short time. Long hour work leads to unhealthy lifestyles, which in turn, cause heart disease and stokes. This is a concern in Singapore and Hong Kong where cultural values encourage long work hours. Work hours in Australia are also creeping up, with almost one-third of the workforce clocking in 49 hours or more per week. Work overload is such a problem in Japan that death from overwork has its own name – karoshi.

1.7.2.4) Task control – employees feel more stress when they have no control over their assignment, performance and pace of their activities. Work is potentially more stressful when it is paced by a machine, involves monitoring equipment or the work schedule is controlled by someone else. This is the reason why techno stress-stress caused by information technology-has become one of the leading health hazards in the workplace. Australian now identifies e-mail as their biggest source of stress. One-quarter of British managers also say that email is creating stress. Over two-thirds of employees in large American companies feel overwhelmed by the incessant demands of electronic communication.

1.7.3) STRESSOR – INTERPERSONAL

These include ineffective supervision, office politics and other conflicts with masses. High turnover of front-line staff at Australia’s Commonwealth Bank is apparently partly cause by stress from increasingly angry customers. One survey indicate that 88 per cent of call center employees in Australia say that they have high or extreme level of stress, mainly due to angry customers and unsupportive management. ‘It’s one thing dealing with one angry costumer on the odd occasion, but when you are dealing with people like that all day, it is tough’, says JAG Marketing executive Jonathon Gross, who has worked in a call center.

Teamwork is a potential interpersonal stressor. A study of West rail, the government-owned rail transportation company in Western Australia, revealed that employees experienced higher stress when they were formed into work teams. Sexual harassment is another powerful interpersonal stressor. Victims of sexual harassment experience trauma (especially from rape or related exploitation) or must endure tense colleague relations in a hostile work environment. Moreover, they are expected to endure more stress while these incidents are investigated.

1.7.3.1) Workplace violence

Another serious interpersonal stressor is the rising wave of physical violence in the workplace. In the United States, one thousand workers assassinated on job each year and two million other experiences lesser forms of violence. But the international labor organization reports that the highest incidence of workplace assaults and sexual harassment isn’t in the United States; it occurs in France, Argentina, Romania, Canada and England. Workplace violence is less common (or less reported) in Pacific Rim countries, but it is significant stressor in some industries. New Zealand’s department of work and income has banned 170 people from entering its offices because of their violent or intimidating behavior. All 260 nurses who responded to a survey in New South Wales had experienced some form of violence at least weekly; many cited incidents involving lethal weapons.

Employees have usually symptoms of severe stress, when experiencing violence, or after traumatic events. It is not uncommon for these primary victims to take long-term leave. Some never return to work. Workplace violence is also a stressor to those who observe the violence. After a serious workplace incident, counselors work with many employees, not just the direct victims. Even employees who have not directly experienced or observed violence may show signs of stress if they work in high-risk jobs. For example, one study reported that the greater cause of work-related stress among British bus driver is their perceived risk of physical assault.

1.7.3.2) Workplace bullying

Although less dramatic than workplace violence, workplace bullying is becoming so common that it is considered as more serious interpersonal stressor. It has become enough of a concern that some Scandinavian countries have passed laws against it. Humiliating behavior, intimidating or offensive attitude that insults and ridicules or degrade another workers at organization is better refer to work place bulling. People with higher authority are more likely to engage in bullying or incivility towards employees in lower positions. What studies here in Australia and around the world are showing is that significant source of workplace stress is bullying-intimidating behavior from employers and bossy attitude.

Workplace bullying produces stress and its physiological, psychological and behavioral consequences. Australian studies estimates that almost three-quarters of victims experience or seek counseling for depression, fatigue, sleep disorders and higher blood pressure following incidents of bullying. Workplace bullying also imposes enormous costs on organizations. Australian research has found that victims take an average o