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The Hashemite University

Faculty of Nursing

Foundation of Nursing Theory

Subject: Nursing Stress Concept Analysis

Submitted to:

Jamila abu Idhail

Submitted by:

Eman. M. Dardas

970186
Introduction

Nursing is repeatedly referred to in the literature as an inherently taxing

profession. In fact, one third of nurses report their occupational stress as high (Allan

et al, 2009), and only seven percent of registered nurse participants in a study

conducted by Tervo-Heikkinen et al. (2008) reported feeling no work-related stress.

Stress has a different meaning for different people under different conditions

(Fink, 2009). Stress which results from performing the job of a nurse has been

identified frequently in the nursing literature as a significant cause of nursing burnout.

In fact, recent studies suggest 50–60% of all lost working days are associated with

occupational stress (Golubic et al, 2009, p. 2057), and more than 10% of total claims

for occupational diseases are attributed to stress at work (Marine et al., 2009). The

media and nursing literature continue to claim that nursing is in the midst of a national

shortage, with researchers estimating by 2020, the available registered nurse

workforce will drop 20% below expected requirements (Shirley, 2004). Shirley

(2004) emphasizes the importance of understanding the association between nurse

stress and the impact of concepts and strategies to proactively remedy the issue.

Purpose

The purposes of my analysis is to understand and explore the concept of stress,

explore the uses and attributes of nursing stress as much as possible, examining its

implications to nurses, and establishing nurse stress as a distinct phenomenon of

interest to staff nurses and management, and to get an excellent progress by

achieving the requirements of the theoretical foundation for nursing course so that I

can get an excellent evaluation mark..


Definitions

According to Walker and Avant (1999), concept analysis allows one to

explore the attributes or characteristics of a concept. The purpose of a concept

analysis is to distinguish between concepts. Concept analysis is a careful examination

and description of a word.

Stress is used as both a noun and a verb. A search within the Microsoft Word

thesaurus identifies pressure, strain, anxiety, constant worry, nervous tension, tension,

trauma, and hassle as synonyms for stress.

Within the Compact Oxford English Dictionary, stress is also used as a verb to

mean ‘subject to pressure, tension, or strain. Keil (2004) stated that it is worth noting

that stress “is defined by reference to two types of physical force that are, in fact, in a

sort of opposition to each other” (p. 662).

Based on Merriam-Webster’s Online Dictionary (2004), stress means the

deformation caused in a body by such a force. Or a physical, chemical, or emotional

factor that causes bodily or mental tension and may be a factor in disease causation.

Also means strain, pressure. ). Similarly, Copstead & Banasik (2005) described stress

as a state of tension leading to a disruption or threat to homeostasis.

The first and most generic definition of stress was proposed by Hans Selye:

“Stress is the nonspecific response of the body to any demand.” mentioned by Fink,

(2009).

Nursing staff is reported to be under extreme state of stress, leading to burnout

syndrome. The majority of the nursing staff at Saudi Arabia hospital were in a state of

burnout with high frequency of emotional exhaustion and depersonalization. (Al-

Turki et al., 2010).


Defining Attributes

Walker and Avant (1995) explained defining attributes as characteristics of the

concept that appear over and over again, which help to differentiate the phenomenon

from other similar or related ones. Defining attributes of stress appearing repeatedly

in the literature are explored here. The first defining attribute of stress is that it results

in some form of harm or damage, which may be manifested in physical,

physiological, behavioral, and emotional changes. Within the consequences section

of this analysis, these damages will be elaborated upon, as this defining attribute of

stress is also a consequence of the concept. Of interest to this first defining attribute,

as well as to this analysis in general, is the following quote from Keil (2004) from her

own analysis of coping and stress:

“[Stress] is generally seen as something negative or harmful or unwanted.

Furthermore, as in the physical world, stress is seen as tending towards damage;

either on the physical level leading towards biological illness, or on the psychological

level towards neurosis. The idea that certain types of stress or small amounts of

stress can be beneficial does not necessarily contradict this, although it is an arguable

point. In ordinary usage, it is probably true to say that tension is never seen as

physically or psychologically beneficial, whereas pressure, in the sense of potentially

beneficial stimulus, may be thought to contain elements of being good for you.

Perhaps stress lies somewhat ambiguously between these terms” (p. 662).

The argument that stress may be a “good thing,” most prevalent within the

organizational behavior arena, does not negate the defining attribute of stress, which

is that it always results in damage and change of some sort. Thus, the final

assumption that stress is damaging to an individual appears to be supported.

The second defining attribute of stress is a perceived disparity between

resources and demand. According to Robbins and Judge (2009), demands include

responsibilities, pressures, obligations, and even uncertainties that individuals face. In


addition, resources are things that individuals use to resolve demands that are within

their control. Further, Robbins and Judge (2009) explained that adequate resources

help reduce the stressful nature of demands when demands and resources match. “If

emotional demands are [causing stress], then having emotional resources in the form

of social support is especially important” (Robbins and Judge, 2009, p. 638).

Dewe (1989) suggested that stress arises from any situation an individual

perceives to tax his/her physical or emotional resources. This definition emphasizes

the idea of excess demand. When experiencing stress, an individual perceives that

there is something of importance at stake, and that they do not possess the resources

available to deal with it (Dewe, 1989). Marine et al. (2006) explained that stress

among healthcare workers results from high expectations coupled with insufficient

time, skills and/or social support at work. The stress experienced by these nurses can

then lead to severe distress, burnout or physical illness, and finally to a decrease in

quality of life for the nurse and quality of care for the patient. The disparity between

demand and resources in this situation is the nurse’s perception that the organization

has high expectations of her, but that she lacks adequate time, skills and/or support to

succeed at her job. This disparity may result in emotional and physiological signs of

stress.

The third and final defining attribute of stress as it relates to nurses is the

perceived lack of self-efficacy and inability to cope by the individual. Cox et al. (as

cited in Currid, 2009) suggested that nurses experience stress when their work

demands threaten their ability to cope, when their needs are not being fulfilled, and

when they feel they have little power over the outcome of the situation. Marine et al

(2009) explained that “often burnout is self-perpetuating because of inadequate

coping strategies that are associated with the syndrome. Burnout and occupational
stress are both considered to result from exposure to stressors at work, the effects of

which are mediated by personal coping or the ability to deal with environmental

stressors at a personal level” (p. 2).

Hertel (2009) claimed that to decrease stress and tension, and to increase

perceived work effectiveness, a sense of empowerment must be obtained. “This

empowerment in the workplace includes a sense of opportunity, information, support,

resources, and power. This leads to increased levels of individual empowerment, as

well as in confidence and job satisfaction. As a sense of empowerment increases,

staff nurses report less emotional exhaustion and depersonalization, as well as a

greater sense of personal accomplishment” (Hertel, 2009, p. 17). The fourth

assumption, that there may be an inverse relationship between high levels of

experience and/or self-efficacy and stress is supported in the literature.

Antecedents

Nurses reported major stressors including shortage of staff, high work

demands and conflict at work, experiences of aggression. (Lim, Bogossian, & Ahern,

2010). So, Stress can come from any situation or thought that makes the individual

feel frustrated, angry, nervous, or anxious.

Sherring and Knight (2009) identify multiple antecedents to stress among

nurses in particular. The stressors identified were long hours and shift work, too

much or too little work, lack of control and conflicting demands, poor management,

poor relations with work colleagues, repetitive work, boredom and lack of job

satisfaction, working alone, lack of job security, organizational or job change, low

pay, significant emotional demands, actual or threatened violence, harassment, and

poor or dangerous working conditions.


Knezevic et al (2009) also identified poor organization at work and financial

issues (insufficient work recourses), public criticism and the intellectual demands of

the job of a nurse, and communication with superiors and emotional work as

antecedents to stress.

Consequences

Walker and Avant (1995) explained that consequences are the events or

incidents that occur as a result of the occurrence of the concept.

Physiological symptoms such as an increase in heart rate, respiratory rate, and

blood pressure result from the experience of stress. Those experiencing stress may

also suffer from headaches, back pain, chest pain, upset stomach, and an increased

susceptibility to illness and heart disease (Stress symptoms).

Psychological symptoms resulting from stress include job dissatisfaction,

tension, anxiety, irritability, boredom and procrastination (Robbins and Judge, 2009).

Restlessness, worrying, forgetfulness, sadness, anger, depression, and a lack of

motivation and focus are also results of stress (Stress symptoms).

Behavioral symptoms of stress include reduced productivity, absence from

work, increased turnover, changes in lifestyle habits, increased speech, fidgeting, and

sleep disorders (Robbins and Judge, 2009). Stress may also result in over- or under-

eating, angry outbursts, drug or alcohol abuse, increased smoking, social withdrawal,

crying spells, and relationship conflicts (Stress symptoms).

As discussed previously, the related concept of burnout is defined as a

consequence of stress. Stress at work may spill over into nurses’ personal lives,

causing conflict (Allan et al, 2009). Hertel (2009) explained that the effects of stress

are felt outside of work, “as there is an inability to feel refreshed by one’s personal

life” (p. 16). In mental health environments, Currid (2009) explained that due to the
stressors related to the job, when nurses go home they are unable to “switch off from

work” (p. 40).

Stress among nurses results in a decrease in the quality of life (Marine et al,

2006). Allan et al (2009) explained that nurses experiencing stress at work take more

time off and are more likely to resign from their jobs, further resulting in a decrease in

the skilled nursing workforce. High levels of stress, as well as moderate levels of

stress over a longer period, result in decreased performance, job dissatisfaction and

burnout (Robbins and Judge, 2009). Voluntary turnover is more probable among

people who experience more stress (Robbins and Judge, 2009).

Stress experienced by nurses on the job adversely affects the quality of their

nursing care and the safety of their patients (Golubic et al, 2009). “It is the draining

of emotional resources that limits the ability of the med-surg nurse to engage

effectively with the patient on a psychological level and results in the nurse simply

“going through the motions.”

Model case. Rem is a new RN, who recently began working in the medical-

surgical unit at a local hospital. In addition to learning how to adapt to her new role

and keep up with the continued learning that takes place within a residency program,

Rem is a full-time graduate student, pursuing a master’s degree in nursing. With a

full-time school and work commitment, the demands on Rem appear to grow larger

by the day. Rem also has a continuous stream of ‘busy work’ for school to complete

every day. In addition, each day she goes in to the hospital, she is expected to

perform tasks and procedure she does not know how to do. When she asks for help at

the hospital, nobody is willing to help her. Lately, Rem has been unable to sleep and

has been suffering from chronic headaches. When asked by her mother how she is

doing, Rem exclaims, “there aren’t enough hours in the day, and to make matters
worse, I can’t seem to fight off this cold I’ve had for three weeks!” Now, every time

Rem walks into the hospital, she begins to feel sick to her stomach. Her heart begins

to race and she begins to perspire. Rem recently told a classmate, “I just don’t have

what it takes, I can’t do this anymore.”

In the previous case, the demands on Rem (i.e., her full time Rem perceives

that she does not have enough time to complete all that needs to be done in order to

succeed. At work, her coworkers are not supportive and she lacks many of the skills

she is expected to perform. At school, she is given too many time consuming

assignments in which her work schedule prevents her adequate time to complete.

Rem has begun to experience physiological and emotional manifestations of the

condition of stress, such as headaches, increased heart rate and illness, which are

damaging to both her body and her emotional stability. Rem does not have the self-

efficacy to overcome her situation, and admits that she is not able to cope with her

new life as a full-time student and full-time RN. It can be concluded, that based on

the defining characteristic, Rem is experiencing stress.

Borderline case. Rem classmate Faith has also recently begun working at a

hospital in the emergency department as a new RN. Like Rem, Faith is going through

a residency program of her own in which she is expected to attend classes and learn a

large number of new skills. Taking all the same classes as Rem, Faith has just as

many demands placed upon her. During their last class together, Faith told Ashley, “I

know how you feel. They do expect a lot of us, and nobody is really willing to help.

For the first few days, I felt butterflies in my stomach when I would go to work, and I

would feel really anxious before each shift.” When asked by Rem how she is dealing

with it, Faith replied, “I have really stepped up my time-management at home to

include study time for all the work skills and information I am expected to learn so I
can work on them at home. I even work ahead sometimes so I can be extra prepared

for my next shift. I don’t feel bad anymore because I know I can do this. If I made it

through nursing school, I can do anything!”

In this case, Faith also has a discrepancy between her resources and demands.

She suffers from damaging physiological and emotional changes, but she is coping.

She has changed her behaviors in order to adapt to these new demands, and she has

the self-efficacy and confidence that she can control and survive her situation.

Related case. When Rem went in to see her first patient of the day, she was

alarmed to find the patient slumped over in bed. The woman’s lips were blue and she

was clutching the side rail. The patient had taken off the mask that was delivering her

oxygen, and it was now dangling from the wall. The patient was wide eyed and

breathing erratically. The patient was gasping, and finally managed to whisper, “Help

me, I’m dying!” In a panic, Ashley shouted at the charge nurse walking by who ran

in to see what the commotion was all about. The charge nurse told Rem: “call the

Rapid Response Team STAT! This patient is in respiratory distress!”

As previously discussed, concepts related to nurse stress include strain,

distress and burnout. The previous case is an example of distress. In the case, both

the patient and Rem were experiencing conditions far more severe than stress. As a

related concept, the word distress would be more appropriately describe the condition

experienced by the patient, given the severe nature of the situation.

Contrary case. When the Rapid Response Team arrives, Cindy, one of the

Team nurses approaches the patient. She has a reassuring smile on her face and

speaks calmly to the patient. She tells the patient, “I’m Cindy, I’m a nurse and I’m

here to help you breathe.” Cindy has all the equipment she needs. She quickly

administers some medication and places the oxygen mask back on the patient. Cindy
tells Rem and the charge nurse, “I’ve got it under control. Thank you. I can handle it

from here.”

This is a contrary case because it does not include any of the defining

attributes of stress. The Rapid Response Team nurse remains calm, has all the

resources she needs and is confident that she has control over the situation. Thus,

Cindy is likely not experiencing stress.

Conclusion

This concept analysis attempted to explore the concept of nurse stress by

investigating the background, assumptions, definitions and uses, defining attributes,

antecedents, and consequences of stress. It is important for nursing leaders to

understand the concept of stress in order to develop effective systems to remedy stress

in the work environment. If stress is not corrected for, the U.S. is sure to experience

an exacerbation of the current nursing shortage, resulting in a country that is ill

prepared to care for its aging population.


References

Allan, J., Farquharson, B., Choudhary, C., Johnston, D.W., Jones, M.C., & Johnston,

M. (2009). Stress in telephone helpline nurses: research protocol for a study

of theoretical determinants, physiological aspects and behavioural

consequences. Journal of Advanced Nursing, 65(10), 2208–2215.

Copstead, L.C. & Banasik, J.L. (2005). Pathophysiology (3rd ed.) St. Louis: Elsevier

Saunders.

Currid, T. (2009). Experiences of stress among nurses in acute mental health settings.

Nursing Standard, 23, 44, 40-46.

Dewe, P.J. (1989). Stressor frequency, tension, tiredness and coping: some

measurement issues and a comparison across nursing groups. Journal of

Advanced Nursing, 14, 308-320.

Distress. (2009). In Merriam-Webster Online Dictionary. Retrieved December 7,

2009, from

http://www.merriam-webster.com/dictionary/distress

Golubic, R., Milosevic, M., Knezevic, B. & Mustajbegovic, J. (2009). Work related

stress, education and work ability among hospital nurses. Journal of Advanced

Nursing 65(10), 2056-2066.

Hawkins, A.C., Howard, R.A. & Oyebod, J.R. (2007). Stress and coping in hospice

nursing staff: the impact of attachment styles. Psycho-Oncology, 16, 563-572.

Hertel, R. (2009, May/June). Burnout and the med-surg nurse. Med-Surg

Matters, 18(3), 15-19.

Keil, R.M.K. (2004). Coping and stress: a conceptual analysis. Journal of Advanced

Nursing, 45(6), 659-665.


Marine, A., Ruotsalainen, J.H., Serra, C., Verbeek, J.H. (2006). Preventing

occupational stress in healthcare workers. Cochrane Database of Systematic

Reviews, Issue 4. Art. No.: CD002892. DOI:

10.1002/14651858.CD002892.pub2.

Morgan, D. (2009, April). Caring for dying children: assessing the needs of the

pediatric palliative care nurse. Pediatric Nursing, 35(2), 86-90.

Neufeldt, V., Guralnik, D.B. (Eds.). (1988). Webster’s new world dictionary of

American English (3rd ed.). New York: Webster’s New World.

Payne, N. (2001). Occupational stressors and coping as determinants of burnout in

female hospice nurses. Journal of Advanced Nursing, 33(3), 396-405.

Peterson, S.J. (2009). Introduction to the nature of nursing knowledge. In S.J.

Peterson & T. S. Bredow, Middle range thoeries: Application to nursing

research (pp. 3-45). Philidelphia, PA: Lippincott Williams & Wilkins.

Ridner, S. (2004). Psychological distress: concept analysis. Journal of Advanced

Nursing 45(5), 536–545.

Robbins, S.P. & Judge, T.A. (2009) Organizational behavior (13th ed.). New Delhi,

India: PHI Learning Private Limited.

Sherring, S. & Knight, D. (2009). An exploration of burnout among city mental health

nurses. British Journal of Nursing, 18(20), 1234-1240

Shirley, M.R. (2004). Social support in the workplace: Nurse leader implications.

Nursing Economics, 22(6), 313-319.

Strain. (2009). In Merriam-Webster Online Dictionary. Retrieved December 7, 2009,

from

http://www.merriam-webster.com/dictionary/strain
Stress. (2008). In The Compact Oxford English Dictionary. Retrieved November 2,

2009, from Dictionary.com website: http://www.askoxford.com

Stress. (2009). In The American Heritage Dictionary of the English Language (4th

ed.). Retrieved

November 2, 2009, from Dictionary.com website:

http://dictionary.reference.com/browse/stress

Stress. (n.d.). In Dictionary of American Slang and Colloquial Expressions. Retrieved

November 2, 2009, from Dictionary.com website:

http://dictionary.reference.com/browse/stress

Stress symptoms: Effects on your body, feelings and behavior. (n.d.) Retrieved

December 3,

2009, from The Mayo Clinic website:

http://www.mayoclinic.com/health/stress-symptoms/SR00008_D

Tervo-Heikkinen, T., Partanen, P., Aalto, P., and Vehvilainen-Julkunen, K. (2008).

Nurses’ work environment and nursing outcomes: A survey study among

Finnish university hospital registered nurses. International Journal of Nursing

Practice, 14, 357–365.

Venes, D., et al (Eds.). (2005). Taber’s cyclopedic medical dictionary (20th ed.).

Philadelphia: F.A. Davis.

Walker, L.O. & Avant, K.C. (1995). Strategies for theory construction in nursing (3rd

ed.). Norwalk, CT: Appleton & Lange.

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