Stress in the Nurse

by: Tina Moore

Caring for the critically ill patient may be stressful. If stress remains unrecognised or unalleviated, burn-out is likely to occur. The quality of care may deteriorate (clinical errors) and staff may avoid or distance themselves from all but the absolutely necessary interactions with the patient. Staff dissatisfaction at work may become evident in the form of sickness and absenteeism.

Causes

Causal factors of stress can be interpersonal (conflicts within a multidisciplinary team, bureaucracy, inadequacies of nursing care by others) or extrapersonal (environmental). Kincey et al. (2003) identified that a combination of workload, resources and a global sense of the NHS caused stress.

Clinical features

Stress can interfere with individuals’ appraisal of their situation – ‘can’t see the wood for the trees’ syndrome. Clinical features of stress (Roberts, 1986) may be:

n Emotional – increasing irritability

n Behavioural – indecisiveness

n Psychological – increasing suspiciousness and distrust

n Cognitive – inability to concentrate or listen

n Physiological – stress response (discussed earlier).

Long-term stress can lead to ill health, e.g. gastric ulcers, coronary heart disease and a compromised immune system (increased infection, common colds).

Management

Management comprises prevention and coping strategies. Crisis situations cannot be totally avoided, but strategies involve identifying the stress and taking owner­ship in working towards reducing stress to a manageable level.

Albert Einstein (cited in Davidson, 1999) suggested that the significant prob­lems we face cannot be solved at the same level of thinking we were at when we created them. Therefore, stress challenges us to take a ‘mental helicopter’ to a point above the situation so that we can get a different view on it and be pre­pared to entertain new thoughts and ideas and develop a new focus and perspect­ive. Strategies involve identifying the stress and taking ownership in working towards reducing stress, but in order to do this, stress needs to be of a manage­able level.

Kincey et al. (2003) identified that junior staff are more vulnerable to the negative aspects of stress. Coping with stress needs a supportive working environ­ment through preceptorship and effective teamwork. Keeping a diary or journal as a way of expressing oneself may be useful. The use of reflection through clini­cal supervision may help nurses to examine their practice critically and learn through this process, identifying areas for future development. Debriefing can be offered by a supervisor, but this requires great skill (see Chapter 38). Active teaching programmes and regular appraisals can help facilitate knowledge and skill development, and detailed induction programmes for new staff should help to reduce stress.

Nurses need to be able to prioritise the management and delivery of care. This involves breaking work down into series of tasks and placing these tasks in a logical order. Implications of those tasks should be examined.

Thinking ahead, making predictions and creating deadlines for the completion of tasks should help nurses to manage their time and efforts effectively and effi­ciently. This will leave time for real crises, should they arise.

As a coping mechanism, some nurses detach themselves from patients by being ‘too efficient’ or ‘too busy’, and therefore adopt a depersonalised approach to care. Balancing engagement and detachment should enable nurses to care effi­ciently and effectively for the patient and themselves.

Carmack (1997) suggests the following strategies to aid the balancing of engagement and detachment:

n Maintain consciousness and pragmatism – be realistic about what can and cannot be achieved, and be aware of your limitations

n Set limits and boundaries

n Monitor yourself – a sense of personal control is essential

n Practise self-care – it is important not to become too immersed in care; looking after yourself is also important

n Let go of the outcomes and the need to control the outcome.

Sumber: Tina Moore & Philip Woodrow (2004). High Dependency Nursing Care Observation, Intervention and Support. London: Routledge