Literature Review For Nursing Stress Interventions

Stress is a well-known and identified problem within the nursing profession. According to Atkinson stress occurs when one is faced with events or encounters that they perceive as an endangerment to their physical or psychological well-being (as cited in McGowan, 2001). Additionally stress levels will increase when controllability and predictability in a situation decrease. There is an inverse relationship between stress and job satisfaction, as stress goes up, job satisfaction falls. As a result this increased stress could commonly results in decreased job satisfaction and decreased quality of life. This could potentially contribute to nurses leaving the profession and as an end consequence, account for the current nursing shortage.


The cause of stress for nurses has found to be related to the nature of the profession. Included in these stressors are an intense work environment with extended work hours, weekends, night and holidays. According to Ruggiero (2003) stress could be related to variables of shift work, which is both physically and mentally taxing. This study also found varying degrees of depression in nurses ranging from mild to severe. Finally this study revealed that nurses were indifferent and disconnected to the job by feeling neither satisfied or unsatisfied with the work. Results such as these expose how large a problem stress is for the profession of nursing.

Factors of the intense emotional support that is needed for the patient and family is yet another burden of stress placed on nurse. In addition, exposures to pain, suffering and traumatic life events that the nurse experience on a daily basis can contribute to stress (Cohen-Katz, Capuano, Baker, & Shapiro, 2005). These concerns can lead to emotional exhaustion for nurses.

The lack of organizational support and involvement, which are outside of the control of nurses can greatly affect job satisfaction (McGowan, 2001). There is also a lack of control and power in an environment predominantly controlled by physicians. These stressors can contribute to psychological exhaustion and increased stress.

Consequently this leads to the question of what supportive interventions have been implemented for nurse, to decrease their stress thereby increasing their coping mechanisms. Would the availability of stress reducing programs contribute to coping mechanism and increase job satisfaction? Additionally how effective are these interventions?

In my initial search for stress interventions I encountered many studies located in the Ovid database that site stress in nursing and other related health care field. Key words such as stress management, burnout, job satisfaction, nursing retention, quality of life, environment and alternative therapies were utilized for this search. These studies revealed definitions of stress and countless and various causes and explanations for the stress experienced by nurses and other health care workers.

There were comparative studies between different nursing backgrounds and environment. For example medical-surgical nursing verses home-health nursing (Salmond & Ropis, 2005), which examined and compared the differences in both backgrounds. Ultimately it found both areas of practice had their own version of stress and it identified common stressors. Unfortunately no concrete measures were utilized to combat the problem

There were also illustrations comparing different styles of management and how nursing stress is affected. Magnet organizations were compared with traditional organization (Upenieks, 2003). The results of this particular study did prove that positive and supportive administration could make a difference in the levels of stress but again no specific stress intervention measures were used

There is a clear recognition and acknowledgement of the problem of stress in nursing but there is a significant lack of information that actually addressed the problem with potential positive interventions. The few studies discovered were all found to show positive results to some degree. These findings support the positive outcome that the initiation of actual stress interventions or programs within the workplace can offer.

The first study used the physical intervention of massage therapy over a 5 week period for nurses in a hospital facility (Bost & Wallis, 2006). This intervention was identified to reduce stress as well as support nurses individually and organizationally. The effects measured were physical and psychological. The study found no change in the physical findings of blood pressure and urinary cortisol levels, however there was decrease in the State-Trait Anxiety Inventory (STAI) in the treatment group compared to the control group. Although there was no physical benefits measured it did reduce the psychological effects of stress. These results suggest that offering the intervention of massage therapy is beneficial in decreasing anxiety levels, which in turn could reduce stress.

The other interventions researched involved a more interactive process. These studies called upon the motivation of the participants or nurses to take part in the intervention. The involvement of these nurse participants supports a need to decrease stress by their desire to assist in making changes internally that will affect them externally.

The use of mantra to relieve stress was one of these interventions. This examined the effectiveness of using a mantra or repeated mantra to affect the level of stress and emotional and spiritual well being. Mantra utilization was taught to health care workers through a 5-part intervention program offered through the hospital prior to the study (Bormann et al., 2006). This is a good example of a valid and tangible intervention that can be offered to increase coping mechanism while decreasing stress. The findings supported the positive results of this study by showing a significant reduction in perceived stress (Perceived Stress Scale), trait anxiety (State-Trait Anxiety Inventory), and trait anger (State-Trait Anger Inventory) post intervention. There was also an increase in quality of life and existential and total spiritual well-being.

Mindfulness-Based Stress Reduction (MBSR) Program was a series of quantitative and qualitative studies offered and taught within the hospital work environment. This program specifically addressed the issue of stress for nurses. MBSR is based on the concept of becoming mindful and fully present in the moment without judgment (Cohen-Katz et al., 2005). The study measured levels of burnout, emotional exhaustion, emotional overextension and psychological distress.

This particular intervention program not only decreased the stress level post treatment but the control group also experienced a benefit prior to treatment while waiting for the program. This could be related to the desire to reduce stress in anticipation of participating in the program. This further support the need nurses have to make changes for the better by decreasing stress levels.

This MBSR study again found a reduction in emotional exhaustion and an increased feeling of personal accomplishment in the treatment group post intervention. Furthermore these effects led to a decrease in stress that had a lasting affect over a three-month period. This validates the positive effects of the use of this intervention in the reduction of stress.

A third positive interactive intervention study was a program, which offered a conflict-management training class in order to decrease potential stress for employees in health care organizations. This particular study also supported the need to offer a way to prevent or decrease stress by creating a positive environment through personal empowerment. There was a significant reduction pretest and posttest in role overload, interpersonal strain, role boundaries and psychological strain. The participants reported that they were better able to find balance in their position and were able to manage the demands of their job (Haraway & Haraway, 2005). These findings confirm the need to make available even brief interventions such as this in an effort to reduce conflict. This could in turn reduce stress and increase perceived control and empowerment, which increases job satisfaction. Furthermore this would improve work environment by making it more supportive

All of these programs discussed, offered intervention for at least one aspect of possible stress factors. Reducing physical or emotional stress and offering more control and empowerment while creating a more positive working environment are all successful interventions to increase job satisfaction. Consequently increased job satisfaction leads to decreased stress. The results of this study suggest a strong link was identified between the two issues (Ruggiero, 2003).

There is a common thread within all these interventions. They are available and effective interventions that can be implemented to become a part of nursing practice and other health care workers in many different health care settings. These actual structured group interventions could be more effective to create a decrease in stress individually. Programs such as these have a proven value and are a simple easy and relatively inexpensive intervention. Offering them to nurses and other health care employees could be considered a preventative measure for potential stress.

In addition these findings substantiate the need for regular stress reduction programs to be offered through hospitals and other medical employment organizations. The use of these and similar programs provide a far reaching benefit for the nursing profession. Anticipatory measures for the reduction of stress can increase job satisfaction, potentially increase nursing retention. Goals for these programs could include guidance in the stress management techniques, increase social support, open communication, role strengthening and empowerment and individual growth to fully utilize positive interventions (Cohen-Katz et al., 2005).

Future studies in programs for stress intervention should include additional similar studies offered to a larger sample with long term and ongoing evaluations of their effectiveness. Consideration of other alternative adjunct intervention therapies that assist in stress reduction could be examined such as yoga and mediation. The use of these physically and emotionally stress-reducing techniques may also be effective in stress lessening and coping measures increasing.

It is my hope that in the future interventions to prevent stress in nurses and health care workers will be offered as a standard part of a benefit package within all health care organizations. Stress prevention can be a win-win situation where everyone will benefit. Nurses will have decreased stress and increased coping mechanism, which will increase job satisfaction. This could lead to increased nurse retention. Subsequently as result of this contentment and increased quality of life the nurse will be a superior employee and better able to provide care for themselves and their patients.

Bormann, J. E., Becker, S., Gershwin, M., Kelly, A., Pada, L., & Smith, T. L. et al. (2006). Relationship of frequent mantram repetition to emotional and spiritual well-being in healthcare workers. The Journal of Continuing Education in Nursing, 37(5), 218-224. Retrieved October 3, 2006, from Ovid data base 
Bost, N., & Wallis, M. (2006). The effectiveness of a 15 minute weekly massage in reducing physical and psychological stress in nurses. Australian Journal of Advanced Nursing, 23(4), 28-33. Retrieved September 6, 2006, from Ovid data base 
Cohen-Katz, J., Capuano, T., Baker, D. M., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout, part II. Holistic Nursing Practice, , 26-35. Retrieved September 27, 2006, from Ovid data base 
Haraway, D. L., & Haraway, W. M. (2005). Analysis of the effect of conflict-management and resolution training on employee stress at a healthcare organization. Hospital Topics: Research and Perspectives on Healthcare, , 11-17. Retrieved October 28, 2006, from Ovid data base 
McGowan, B. (2001). Self-reported stress and it's effects on nurses. Nursing Standard, 15(42), 33-38. Retrieved September 28, 2006, from Ovid data base 
Ruggiero, J. S. (2003). Health, work variables, and job satisfaction among nurses. JONA, 35(5), 254-263. Retrieved October 3, 2006, from Ovid data base 
Salmond, S. & Ropis, P. E. (2005). Job stress and general well-being: a comparative study of medical-surgical and home care nurses. Retrieved September 28, 2006, from Ovid data base 
Upenieks, V. V. (2003). The interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manager, 22(2), 83-98. Retrieved September 27, 2006, from Ovid data base

Christine Ross ARNP-BC 
Christine is a Nurse Practitioner Board Certified in Family Practice and currently working in a retail clinic, also a Certified Yoga Instructor and Certified Holistic Life Coach.

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