Background

Stress has been categorized as an antecedent or stimulus, as a consequence or response, and as an interaction. It has been studied from many different frameworks (or perspectives?). For example, Selye¹ proposed a physiological assessment that supports considering the association between stress and illness. Conversely, Lazarus² (p. 19) advocated a psychological view in which stress is “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.”

Stress is not inherently deleterious, however. Each individual’s cognitive appraisal, their perceptions and interpretations, gives meaning to events and determines whether events are viewed as threatening or positive.² Personality traits also influence the stress equation because what may be overtaxing to one person may be exhilarating to another.³

Nevertheless, stress has been regarded as an occupational hazard since the mid-1950s.⁴ In fact, occupational stress has been cited as a significant health problem.^5–7 Work stress in nursing was first assessed in 1960 when Menzies⁸ identified four sources of anxiety among nurses: patient care, decisionmaking, taking responsibility, and change. The nurse’s role has long been regarded as stress-filled based upon the physical labor, human suffering, work hours, staffing, and interpersonal relationships that are central to the work nurses do. Since the mid-1980s, however, nurses’ work stress may be escalating due to the increasing use of technology, continuing rises in health care costs,⁹ and turbulence within the work environment.¹⁰

In 1974, Freudenberger¹¹ coined the term “burnout” to describe workers’ reactions to the chronic stress common in occupations involving numerous direct interactions with people. Burnout is typically conceptualized as a syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment.¹² Work life, however, is not independent from family life; these domains may even be in conflict.^{13, 14} Stress may result from the combined responsibilities of work, marriage, and children.^15–17 The effects of both work and nonwork stress among nurses have been studied infrequently.¹⁸ And yet, nonwork stress may be particularly salient to nursing, a predominantly female profession. Women continue to juggle multiple roles, including those roles related to the home and family, for which the women may have sole or major responsibility.

Nevertheless, work stress and burnout remain significant concerns in nursing, affecting both individuals and organizations. For the individual nurse, regardless of whether stress is perceived positively or negatively, the neuroendocrine response yields physiologic reactions that may ultimately contribute to illness.¹ In the health care organization, work stress may contribute to absenteeism and turnover, both of which detract from the quality of care.⁹ Hospitals in particular are facing a workforce crisis. The demand for acute care services is increasing concurrently with changing career expectations among potential health care workers and growing dissatisfaction among existing hospital staff.¹⁹ By turning toxic work environments into healthy workplaces, researchers and nurse leaders believe that improvements can be realized in recruitment and retention of nurses, job satisfaction for all health care staff, and patient outcomes—particularly those related patient safety.²⁰

Research Evidence

Work stress continues to interest researchers, as illustrated by studies identified in this review that focused on occupations other than health care. For example, in a 3-year study of 14,337 middle-aged men, there was no strong evidence that job demands or job strain were predictors of coronary heart disease (CHD).²¹ Findings did verify, however, that a supportive work environment helped reduce CHD. The importance of work support was corroborated in a study of 1,786 lower-ranking enlisted Army soldiers where support helped decrease psychological strain from job demands.²² A study of 472 Air Force personnel illustrated high levels of work stress in 26 percent of the respondents, with 15 percent claiming work-related emotional distress and 8 percent noting work stress negatively affected their emotional health.²³ Finally, in a sample of 25,559 male and female German workers, the combined effects of exposure to work stress and downsizing contributed to more symptoms than either experience alone.²⁴

Evidence-Based Practice Implications

Based on current empirical evidence on stress and burnout in nursing, there is difficulty in making recommendations regarding how to enhance patient safety. Although findings consistently indicated that nurse burnout was negatively related to job satisfaction, only two studies explored the relationship between nurse burnout and patient satisfaction.^{90, 99}

Additionally, findings are inconsistent for two studies that examined the relationship between nurse burnout, 30-day mortality, and failure to rescue for surgical patients.^{40, 56} Data for one of these studies were collected from nurses and patients throughout Pennsylvania.⁴⁰ Data for the other study were collected from nurses and patients at a single site.⁵⁶ Some of the differences can be accounted for by numerous methodological variations between the two studies. Other differences might be attributed to the strong collective bargaining unit at the single-site study that had negotiated staffing based on nurse-patient ratios that were adjusted for patient acuity.⁵⁶ Moreover, fewer nurses from the single-site study reported being either dissatisfied or very dissatisfied with their jobs, compared with the Pennsylvania study (8 percent versus 25 percent, respectively).

Practice implications are also unclear regarding the effects of work stress on nursing staff. The lack of clarity derives, in part, from the complexities of the work stress concept. In one study, for example, nurses were grouped into one of four clusters based on their level of stress, affective and physical symptoms, burnout, and unit social support.⁵⁹ In another, the nurse ratings of job strain placed them in four groups ranging from high to low strain.⁶⁸ This heterogeneity suggests that many dynamics are operational in relation to stress and burnout. The effects of shift length on stress is one of the dynamics that is not yet understood.^{60, 95} Likewise, evidence about how verbal abuse⁸⁸ and generational differences⁷⁷ operate in the stress equation is just beginning to emerge. The role of personality, family-work conflict, and other features of stress require further study.

Evidence is accruing about the utility of empowerment and social support in mitigating stress. Some caution is warranted in regard to empowerment, however, because the work of one investigator dominates the field.^{57, 62, 64–68} Findings related to social support indicated that interpersonal exchanges with coworkers and supervisors may enhance security, mutual respect, and positive feelings—which helped to reduce stress.^{31, 39, 72, 96} Overall, however, the assessments of social support were often founded on weak conceptualization and relied upon psychometrically weak instruments to measure the concept. Moreover, the analytical models did not always consider the direct, indirect, and interactive effects of social support.

Although the evidence is sparse, the studies have practice implications for nurse managers. First, managerial behaviors were linked to stress and burnout. Managerial support³⁸ and participative management⁷⁰ helped to reduce stress. Similarly, burnout and work stress were reduced when administrators created work environments that provided staff with access to opportunity, information, resources, and support—the features of empowerment.^{64, 65} Second, and studied even more infrequently, nurses in supervisory positions may encounter stress⁶⁹ and burnout⁶⁶ themselves. There is no existing evidence, however, that empirically illustrates how managerial stress affects staff stress or the manager’s ability to behave in a way that reduces staff stress. Given the current emphasis on improving the work environment, there is an imperative to carefully investigate both aspects of the nurse administrator in relation to stress and burnout.

Despite lacking absolute clarity, there is a body of research addressing work stress that spans more than 50 years in the nursing profession. Stress is pervasive in nursing and health care. Moreover, working conditions seem to be deteriorating at the same time that a severe and protracted nursing shortage is occurring. Leaders of health care organizations can no longer ignore these findings. Just as institutional leaders need to understand their financial standing, they also need to assess how environmental stress is affecting patients and staff and take action to alter unhealthy situations.

Research Implications

To derive a better understanding of stress and burnout in the workplace, solid conceptualizations are needed that bring together the various pieces of the stress puzzle. At present, research is often conducted absent a solid theoretical and conceptual base. A more comprehensive blueprint of nurse stress and burnout in the work place needs to be developed. Empirical studies could then be conducted to investigate these very complex relationships, prospectively, over time. Once work stress is examined from a more solid theoretical and conceptual basis, then intervention studies can be initiated to assess the most useful ways to mitigate work stress.

Studies need to move beyond the tendency to use descriptive designs. There is sufficient evidence to believe that work stress is a factor among health care personnel. What is less well understood is the effect of stress on patient outcomes. Studies are needed to enhance the understanding of stress and burnout on patient safety. Studies are also needed to better understand stress beyond the acute care setting.

In addition, because nurse administrators are responsible for creating the environment in which nursing is practiced and patient care is given,¹⁰⁶ it is important to explore interventions that will reduce the stress and burnout experienced by nurse administrators. Findings from studies of this nature could have a threefold effect. By reducing the stressful nature of the nurse administrator’s work, nurse administrators could be more satisfied in their positions. This role satisfaction, in turn, could lead to enhancing those managerial behaviors that improve the work environment for staff nurses. Finally, improved working conditions for nurse administrators might make the role more appealing and help correct the serious dearth of individuals interested in pursuing administrative positions.¹⁰⁷

Conclusion

Stress and burnout are concepts that have sustained the interest of nurses and researchers for several decades. These concepts are highly relevant to the workforce in general and nursing in particular. Despite this interest and relevance, the effects of stress and burnout on patient outcomes, patient safety, and quality care are not well defined by evidence. In fact, the link between stress and burnout to patient outcomes has been explored in only four investigations. There is a great need for comprehensive studies that will examine these dynamics in a way that will yield more solid evidence on which to base practice.

Search Strategy

Both MEDLINE^® and CINAHL^® databases were searched to locate literature for this review. A reference librarian conducted the searches after working with the author to specify search terms. The search terms for MEDLINE^® were psychological stress, professional burnout, work stress, and occupational health. The search terms for CINAHL^® were occupational stress, professional burnout, and nursing units. For both databases, the searches were limited to research articles published in the English language between 1995 and 2005.

There were 1,145 articles identified in the CINAHL^® search and 392 identified by the MEDLINE^® search, with some duplication in the citations identified by the two databases. All 1,537 abstracts were reviewed. Numerous abstracts were eliminated from further consideration. For example, articles about instrument development, stress in specific populations (e.g., children, adolescents, pregnant women, parents, caregivers) and occupations other than health care (e.g., the police force, fishermen, flight crews, farm workers) were omitted from this review. Likewise, dissertations, literature reviews, concept analyses, and physiologic and immunologic studies of stress in general were not included.

Once the unrelated articles were eliminated, 138 articles remained as candidates for this review. A complete copy of each of these papers was acquired and read, following which an additional 53 articles were removed from further consideration. Dominant among the reasons for excluding these papers were that they were not research based or they were short reports that were lacking essential details.

Evidence Table

Acknowledgments

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library for their considerable support of this work. They conducted the database searches and assisted in acquiring numerous papers considered in this review.

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