Table 3
Cronbach’s Alpha for Each Sub-Scale
NSI Subscale Number of Items Cronbach’s Alpha
1. Managing Workload 1 3 0.85
2. Managing Workload 2 7 0.88
3. Organizational
Support & Involvement
5 0.86
4. Dealing with Patients & Relatives 6 0.85
5. Home & Work Conflicts 5 0.84
6. Confidence & Competence in Role 4 0.83
Descriptive Statistics for Instrument Sub-Scales
The calculated means for the NSI sub-scales ranged from 19.47 for the Managing Workload 2 sub-scale to 7.93 for the Confidence and Competence in Role sub-scale. The overall mean for the NSI was 74.91 (sd = 25.47) as shown in Table 4.
Table 4
Range of Possible Scores, Mean Scores, and Standard Deviations for NSI
NSI Subscale Range of
Possible Scores
Mean SD
1. Managing Workload 1 3-15 9.24 2.83
2. Managing Workload 2 8-35 19.47 6.81
3. Organizational Support & Involvement
5-25 12.08 5.68
4. Dealing with Patients & Relatives
6-30 16.07 5.77
5. Home & Work Conflicts 5-25 10.12 1.02
6. Confidence & Competence in Role Total 4-20 31-150 7.93 74.91 3.36 25.47
Occupational stress was also examined by the nursing department. Table 5 presents the data respectively. Four Tower had the highest mean score of occupational stress (M = 101.80, SD 37.27) while the 5 Heart presented the lowest mean score of occupational stress (M = 63.11, SD 26.27). A one-way ANOVA test was used to determine if the variance between the means were significantly different. The F value was calculated at 13.41 with a p < 0.00001. A p value of < 0.05 was used for reference as to whether there is a significant difference in stress between the different hospital units. Table 5
Mean Scores for Occupational Stress in Relation to Hospital Unit
Unit Mean SD 8 Tower (n=7) 72.42 23.12 7 Tower (n = 3) 67.68 18.64 6 Tower (n=12) 79.73 30.88 6 Pavilion (n = 2) 83 42.39 5 West (n = 3) 65.32 16.28 5 Heart (n = 14) 63.11 26.27 5 North (n = 7) 4 Tower (n = 5) 4 Heart (n = 14) 3 Tower (n = 7) Overall Score 71.02 101.8 71.27 90.3 76.55 25.49 37.27 19.83 33.11
Summary
Two research questions were presented by the results of the study in relation to stress of nurses in the workplace. Simple proportion values were used to answer question one while question two was answered using one-way Analysis of Variance (ANOVA). The first question was: What is the overall measured stress of nurses at working within medical-surgical, telemetry, and medical-telemetry nursing departments? Overall, the nurses are not stressed in the workplace. Based on the data, a significant 1,229 out of 2,220 responses (55%) reported very little to no pressure. This was measured amongst six NSI sub-scales.
The second question asked if there are differences in levels of occupational stress amongst nurses based on their work departments in the hospital. As shown in Table 5, 4 Tower portrayed the highest mean score for occupational stress (M = 101.80, SD = 37.27), followed by 3 Tower (M = 90.3, SD 33.11). A one-way between groups analysis, ANOVA was performed to determine the influence of work unit on measured stress. There was a statistically significant difference when observing the p value < 0.5 in level of occupational stress, F = 13.41, p = < 0.00001. Therefore, the hypothesis that there is no significant difference between levels of stress in the different work departments is rejected.
CHAPTER V DISCUSSION
The nursing role is a vital part of healthcare quality. As the patient is
hospitalized, the nurse will have the most face to face time with patients throughout the hospital stay. The majority of patient tasks are carried out through the hands of a nurse; further signifying the importance of the role. Excellent nursing care requires a focused mind, competence, and confidence. All of these characteristics can be inhibited by stress. The study goal was to explore levels of stress for nurses working within medical-surgical, telemetry, and medical-telemetry nursing departments. Hopefully with the identification of stress as an inhibitor to nursing excellence, efforts can be made to minimize stress as a barrier.
Implications of Findings
It is safe to assume, stress is a consistent barrier in the profession of nursing. Although this study merely analyzed nurses working within nursing departments on medical-surgical, telemetry, and medical-telemetry departments, most nurses are stressed at some point or another regarding some aspect of the nursing role. The levels of stress are fairly constant among the different types of nursing departments. However, the more important task is to acknowledge moderate to extreme levels of stress as a barrier to the quality of nursing care as this problem arises.
As a collective view of the raw data, the stress levels among the nursing
participants were moderate to extreme in several areas; however, there was no statistical significant evidence of overall stress. Out of the five greatest questions demonstrating stress as a problem, two of those questions involve time. The five greatest areas where
moderate to extreme pressure was felt were the following: Time and pressure deadlines, difficult patients, time to complete assigned duties, fluctuations in workload, and dealing with relatives. See Figures 2-6.
Figure 2. Frequency of Responses to Question 2 on NSI.
Figure 4. Frequency of Responses to Question 3 on NSI.
Figure 5. Frequency of Responses to Question 7 on NSI.
Application to Theoretical/Connectional Framework
The Transactional Theory on Stress and coping simply sums up the disparities within nursing. The theorists suggested that stress can represent thoughts resulting from an imbalance between demands and resources or as occurring when pressure “pressure surpasses one's conceivable capacity to survive the situation at hand (Lyon, 2012). Nursing is a conglomeration of medical duties and task, all for the purpose of assisting a patient back to baseline in reference to health. However, working as a nurse in an acute care facility, change can occur at a moment’s notice for multiple reasons. A patient’s medical status can change which may prompt an emergent response. This scenario would easily cause an imbalance between demands and resources. Although in a real life
situation, a rapid response team or a code blue team would be signaled to respond. These type teams kicking into action will offset some of the demands of this emergent situation; thus, relieving stress.
Another example could be a nurse becoming sick in the middle of a shift causing the other nurses to run with one less person. This situation would increase the number of patients assigned to each nurse potentially causing time delays and/or unhappy patients. In this example (same as the first), the nurse may or may not endure coping issues in response to the imbalance. However, if an imbalance presents, negative feelings may be elicited which may transition into stress. To make this scenario even more complicated, let’s add one more variable. Imagine the nurse with the patient declining in health status requiring the need of immediate emergent attention. The shift is short staffed so there’s an increased number of patients assigned to this nurse. This nurse would be torn between
several important needs. This scenario has a greater potential for an imbalance with resources and demands thus eliciting a stress response from the nurse.
“Stress management was developed and premised on the idea that stress is not a direct response to a stressor but rather one's resources and ability to cope mediate the stress response and are amenable to change, thus allowing stress to be controllable” (Models of Stress Management Transactional Model, 2014-2015, p. 1) Lazarus’ theory recommends the identification of the factors that are central to a person controlling his/her stress, and to identify the intervention methods which effectively target these factors. In analysis of the questions within the NSI, this thesis challenged nurse leaders to view and respond by pinpointing areas in nursing potentially stealing time and increasing workload. The identification of these potential stressors has the potential limiting stress consequently creating a healthier environment.
Limitations
The tool of measure, which was the Nursing Stress Index (NSI), was recreated electronically through SurveyMonkey. This allowed the original intent of the Likert scale to be maintained. Appropriate consent and explanation of the survey tool were explained prior to taking the survey making it nearly impossible to damage or sway the results. The only possible falsification would be the participants failing to give honest feelings regarding the level of pressure felt for each question. It is the sincere confidence that the participants of the study would have appreciated the purpose of the study enough to provide honest responses to the survey. Consequently, there were no limitations affecting the validity and reliability of the findings from the study. However, there were
several questions skipped by some participants. These questions were removed to prevent the production of skewed data.
One weakness of the study, may involve the actual survey. The Nursing Stress Index (NSI) covered issues related to nursing. However, the questions were broad. For example, question four asked if the demand of others for time is a conflict. This is an important issue but it needed to be more specific. Several other questions could have been pulled from this one question providing more specific elements of pressure. Specific elements of pressure would narrow the data clarifying the true barriers of stress and potentially resolving the problem.
The survey was sent to all nurses working autonomously within 10 different nursing departments giving a potential of 300 or more participants. However, only 83 participants completed the survey. As surveys were rejected for incompletion, this left approximately 74 surveys to conduct the experiment. The lack in numbers limited the true representation of the whole. The study would have been more beneficial with a greater participation.
Implications for Nursing
Stress as a barrier in nursing is more than marginally different than other challenges throughout the history of nursing. Stress can be a hidden catalyst to many major healthcare catastrophes. Yet at the same time, some stressors are growing pains while other stressors are simply a part of the role. As the world continues to grow and change, new challenges in nursing are un-expectantly encountered every day causing moderate to extreme levels of pressure. With this said, the problem of stress will never be totally eradicated. Nevertheless, moderate to extreme stress must be confronted and
addressed. Although attacking the indirect elements causing the stress would be beneficial; this strategy alone is not enough. Stress awareness and stress modification must be a deliberate tactic to keep nurses at the best side.
Recommendations
As an overarching strategy, the reduction of stress for bedside nursing is essential. Simply analyzing stress and burnout through employee surveying will not rectify this problem. On the contrary, anticipating this stress as a problem and proactively managing each particular element triggering the stress. With stress management as a principle strategy, major chronic problems in healthcare may be improved such as staffing shortages, patient outcomes, and patient experience.
The first recommendation involves altering patient ratios to facilitate more face to face time with each patient. Higher patient ratios for medical-surgical, telemetry, and medical-telemetry departments are due to the perception of patients being less critical and more stable. However, it is a common occurrence for patients to become unstable and critical suddenly. Nevertheless, even as the patients are stable and progressing, progression and maintenance of the patient’s health status continues to be the nurse’s highest priority. Allowing the nurse to decelerate will foster focus and critical thinking which will greatly impact patient outcomes.
The second and third recommendations are connected: improving team dynamics and team support. Great teamwork will always be a morale booster amongst the
members of the team. A cohesive team nurtures growth, competence, confidence, and creates time and resources to accomplish the work. However, what happens when a team member doesn’t want to help? Should this be allowed or should there be proactive
strategies to avoid minimal teamwork? In addition, what type of team is appropriate for this nursing care area? For example, trauma nursing departments tend to be more chaotic and unpredictable. Nurse leaders should assess which personalities would foster the most cohesive and positive relationships in this type environment; and conversely, which personalities would be more challenged. Above all, what is the formula to create the type of nurse needed for this area?
Because stress will never depart from nursing, managing and coping with stress is very important. This fourth recommendation must be preemptive by providing specific tactics to achieve rational resolutions for each challenge before nurse burnout becomes an epidemic. Furthermore, actual coaching for stressful situations to should be ongoing and start with new graduate nurses as early as possible. Coaching sessions may include conflict resolution, communication skills, and time management. One favorable example of coping with stress involves new patient arrivals. New patients for nurses increase workload and bring about uncertainly; thus, potentially triggering stress. This tactic allows the patient to receive the onset of care in the nursing department efficiently and the assigned nurse can continue scheduled routines with minimal interruption.
Conclusion
It was a pleasant surprise to find stress as an insignificant problem and an equal issue among the different departments. However, there continues to be a need to monitor and respond to the problems causing stress. Today’s nurses have many options and will not remain in an occupation where moderate to extreme levels of stress are on a
continuum. Although the pioneer nurses courageously created and paved the way, unnecessary pressures were perceived to have been endured. The younger generations
are not made the same and will not remain in a consistent overbearing fight for humanity. As previously mentioned, stress will remain in some form due to the nature of the
profession. As the leaders of the profession toy with the question of should or should not this cycle be broken, the more difficult question is how. Nonetheless, it is owed to the profession to try. This attempt will not be without cost or pain but as the cycle is broken there will be a better way. Perhaps something never dreamed as possible; a discovery of freedom and peace in the ability to practice in the beautiful profession of nursing.
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Appendix A
Nursing Stress Index Scale
1. Which Nursing department do you work in? o 8 Tower o 7 Tower o 6 Tower o 4 West o 5 West o 5 North o 4 Heat o 5 Heart
The Nurse Stress Index
Harris, P. (1989). The nurse stress index. Work and Stress, 3(4), 335-346. Instructions: Please rate by circling the number that corresponds to the amount of pressure you feel from each item.
1. No pressure
2. Very little pressure 3. Moderate pressure 4. High pressure 5. Extreme pressure
Items Rate
1. Time pressures and deadlines 1 2 3 4 5
2. I have too little time in which to do what is expected of me 1 2 3 4 5 3. The demands of others for my time at work are in conflict 1 2 3 4 5 4. I spend my time ‘fighting fires’ rather than working to a
plan
1 2 3 4 5
5. Trivial tasks interfere with my professional role 1 2 3 4 5
6. Fluctuations in workload 1 2 3 4 5
7. Management expects me to interrupt my work for new priorities
1 2 3 4 5
8. Deciding priorities 1 2 3 4 5
9. My nursing and administrative roles conflict 1 2 3 4 5
10. Shortage of essential resources 1 2 3 4 5
11. Decisions or changes which affect me are made ‘above’, without my knowledge or involvement
1 2 3 4 5
12. Management misunderstands the real needs of my department
1 2 3 4 5
13. Lack of support from senior staff 1 2 3 4 5
14. I only get feedback when my performance is unsatisfactory 1 2 3 4 5
16. Difficulty in dealing with aggressive people 1 2 3 4 5
17. Difficult patients 1 2 3 4 5
18. Involvement with life and death situations 1 2 3 4 5
19. Bereavement counseling 1 2 3 4 5
20. Dealing with relatives 1 2 3 4 5
21. Over-emotional involvement 1 2 3 4 5
22. Job versus home demands 1 2 3 4 5
23. My supervisors do not appreciate my home pressures 1 2 3 4 5 24. Domestic/family demands inhibit promotion 1 2 3 4 5 25. I need to absent myself from work to cope with domestic
problems
1 2 3 4 5
26. Bringing about change in staff/organization 1 2 3 4 5
27. Tasks outside of my competence 1 2 3 4 5
28. Coping with new technology 1 2 3 4 5
29. Lack of specialized training for present task 1 2 3 4 5 30. Uncertainty about the degree or area of my responsibility 1 2 3 4 5
Appendix B
Appendix C Informed Consent
Title of Study:
Exploring Nurse Stress Levels
Researcher:
You are being asked to participate in a research study being conducted by Andrea Butler, a Master of Science in Nursing student at Gardner-Webb University.
Purpose:
The purpose of this study is to explore the levels of occupational stress of nurses working on medical-surgical units, medical-telemetry units, and telemetry units.