Background: The nursing profession is considered a stressful occupation with aggressive patient management, massive workloads, shift work, and high turnover rates. The situation in Australian nursing has been studied comprehensively, although the understanding of stress and resilience is ambiguous. This literature review considers the impact of stressors and coping strategies in Australian nurses.
Aim: To investigate contemporary and substantial evidence of stress factors, considering the possible coping strategies and its effectiveness in Australian nurses.
Method: A literature search was conducted in four databases, and a total of six relevant articles were found. The studies identify stress factors and coping strategies in the Australian nursing population.
Results: Stressors included aggressive or dying patient management, nursing skill deficits, and nurses’ family issues. The literature portrays the detrimental impact of stressors in nurses’ physical and psychological health, which would progressively impact on patient care. Minimum considerations were given to non-work related risks, hospital management issues, culture shock and undergraduate nursing students. Coping strategies involved social support, mindfulness and emotional distance from patients. Findings depict that the coping strategies were successful in enhancing nurses' health while alleviating stress.
Conclusion: Recommendations include further research to identify stressors and innovative coping strategies while providing support through family and social interactions, education, and professional training. Further studies to identify coping strategies to overcome stressors in patient mortality is required, involving palliative care education. Culture shock, undergraduate nursing student involvement, non-work related issues and hospital management issues also need further investigations in diverse nursing specialities.
The aim of this literature review is to investigate contemporary stress factors and possible coping strategies for Australian nurses. Nursing is recognised as stressful in many healthcare settings, in wide multinational and cultural backgrounds (Azizollah, Jassem, Mahnaz, Ebrahim, & Nabileh, 2016). Stressors involve massive workloads, aggressive patient care and shift work. It would not only relieve the professional burden of stress levels, but would also decrease the career retention (Coomber & Barriball, 2007). Stress projected that 85,000 registered nurses by 2025, and 123,000 registered nurses by 2030 would shortfall (Commonwealth of Australia, 2014). In order to remain in the workforce with the rapidly developing technology and responsibilities, regardless of the fact that it is intrinsically tense, there is a vital demand for identifying the stress factors and coping strategies.
IMPLICATIONS OF STRESS
Nurses experience a variety of stressful occupational incidents. “Moral distress” impacts nurses perilously, involving “psychological, emotional, and physiological suffering” due to ethical concerns (McCarthy, Gastmans, and Peter, 2015, p. 132). It can be a “nonspecific and predictable” physiological response, which occurs “when an individual appraises situational demands as exceeding available resources” (Goodnite, 2014, p. 71). This defines the correlation between the environment and the person, in relation to mental and cognitive aspects. Foureur, Besley, Burton, Yu, and Crisp (2013) declared that the nursing workforce encounters enormous levels of stressors, due to the nature of their workload.
Stress can be a causative factor in high turnover in some nursing settings (Mosadeghrad, 2013). Increasing turnover would encounter deficient welfare of nurses (Hayes et al., 2006). Also, reinforcing international nurses into the Australian workforce could be overwhelming, due to culture shock and language barriers, triggering a “moderate level of accumulated stress and sense of coherence” (He, Lopez, & Leigh, 2012, p. 345). Drury, Craigie, Francis, Aoun, and Hegney (2014, p. 520) claimed that “anxiety, depression, post-traumatic stress disorder, secondary traumatic stress and burnout” in nurses including nurse managers could be due to environmental stressors. Furthermore, environmental stressors such as “role ambiguity, role overload, role conflict, organizational constraints, and interpersonal conflict” contribute to nurses stress at work (Kath, Stichler, Ehrhart, & Sievers, 2013). Often nurses’ stress is associated with multiple factors including interpersonal relationships. Consequently, this might result in astounding outcomes, for instance, veterinary nurses in Australia reported high suicidal rates during 2001 to 2012 (Milner, Niven, Page, & Lamontagne, 2015). However, stress could include “good stress”, which refers to being challenged and rewarded, or “chronic stress”, which involves negative impacts (Herman, Maroun, & Richter-Levin, 2015, p. 267). If the stressors are managed earlier, effects of toxic stress could be avoided (Lupien, 2012). Therefore, stress is a great burden, affecting individual and organisational outcomes.
The literature was reviewed via RMIT library search engine, using ProQuest Central, ProQuest Psychology Journals, MEDLINE and Scopus databases, involving keywords ‘Australia’ or ‘nurse’ or ‘stress factors’ or ‘coping strategies’ (figure 1). Regardless of the massive quantity, initial results (as shown in flowchart) after excluding irrelevant and uncontemporary results, were down to 62. After abstract reviews, 19 desirable articles were found, and 6 most relevant articles were selected for the review, considering the relevance to the literature review after detailed analysis and excluding literature reviews. Further categorisations included ‘stress factors’ and ‘coping strategies’.
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Figure 1. Flowchart of the search strategy
Patient Death as a Stress Factor
Bloomer, Endacott, O’Connor, and Cross (2013) conducted a qualitative study of two acute medical wards in Melbourne, excluding critical and palliative care. In this study, 25 nurses were included with 20 incidents of death, aiming to identify nurses’ response to dying patients. Originally, the researcher observed acute care wards utilising a “clinician’s eye” (Bloomer, Cross, Endacott, Connor, & Moss, 2012, p. 25). Nurse unit managers individually and other nurses in groups were interviewed. Study samples showcased different levels of discomfort, displaying that they were under-prepared to manage the stress levels with dying patients. However, the study was limited to certain focus groups, and additionally, non-permanent staff were involved.
Patient Aggression as a Stress Factor
Dean, Gibbon, McDermott, Davidson, and Scott (2010) studied nurses and other health professionals who were exposed to aggression in child and adolescent mental health settings in Queensland. Half of the participants were nurses. Both nonclinical and clinical voluntary staff (N=33) were consented and interviewed by a nurse. The methodology was conducted by an interview questionnaire with replying ‘yes’ or ‘no’ answers, generated by professionals. Results indicated higher rates of aggressiveness and increased emotional stress in the staff. However, limitations included small sample sizing, external stress factors and measurements of the “dose of aggression exposure” (Dean et al., 2010, p. 22). Because of aggressive confrontations, the staff experienced stress due to the fear of being attacked, and this concluded that patients’ aggression causes stress.
Furthermore, Drury et al. (2014) conducted a qualitative and quantitative study, containing two phases to explore “compassion fatigue” (Cragun, April, & Thaxton, 2016, p. 730) and distress in Australian nurses. A total of 132 nurses in part one and 10 nurses in part two participated. The sample was obtained by a survey (part 1) and was followed by face-to-face or telephone interviews (part 2). The study was conducted in Australian Capital Territory (ACT), involving acute tertiary hospitals and excluding outpatient oncology areas. The method consisted of a questionnaire interview guide and further data analysis, utilising a "thematic analysis method" (Braun & Clarke, 2006, p. 77). Results suggest that "skill deficits, family issues and patient-related issues, such as aggression and dying patients" were the common factors (Drury et al., 2014, p. 525). However, limitations included acute care hospitals and small sample size, which would not represent the Australian nursing cohort. This study concluded the common stressors and how Australian nurses implement coping strategies in a clinical workplace.
Mindfulness as a Resilience
Foureur et al. (2013) researched two teaching hospitals in New South Wales (NSW), conducting qualitative and quantitative studies. In the study, 20 midwives and 20 nurses participated in a one day workshop, receiving “mindfulness-based stress reduction” (Schlieter, 2017, p. 447), practising meditation up to eight weeks daily, and completing pre and post measures of interventions. Foureur et al. (2013, p. 114) found that the quantitative results included substantial advances in the “general health questionnaire, sense of coherence and the stress subscale of the depression, anxiety and stress scale”, resulting in significant improvements in stress management. Also, Foureur et al. (2013, p. 114) found that qualitative data helped the suitability and acceptability of the study while indicating further “randomised controlled trials”. However, this study was limited to less heterogeneous samples, reducing the total effect on the organisational culture. The study strongly adds weight to the major aim of the paper, indicating that the well-organised coping strategies could reduce the impact of stressors in Australian nurses.
Social Support as a Resilience
Cope, Jones, and Hendricks (2016) conducted a qualitative study, involving registered nurses (N=9) from aged care, educational and acute care settings, located in Western Australia (WA). Nurses were interviewed and voice recorded with consent. An interview guide was used to meet objectives, expanding the elucidation of resilience in a long-term practice, and the cause of remaining in nursing. Data consisted of "field notes, memos and gesture drawings interviews" (Cope et al., 2016, p. 89), gathering individual stories which were presented as narrative portraitures. Results indicate that nurses manage stressors with the support of co-workers, acquaintances and family. Sample size and settings were disseminated in a limited range, and results were highly subjective and not applicable to a greater population. The findings sustain the objectives, concluding that social assistance is a form of resilience.
Emotional Distance as a Resilience
Hayward and Tuckey (2011) researched qualitatively on emotional regulation to improve resilience. The study was conducted in two South Australian (SA) metropolitan public hospitals. Nurses (N=90) were invited by letters and emails, and 12 nurses were participated, ranging from 24-52 years old and 14 months to 33 years of experience. Contrarily to Cope et al. (2016), this study implemented a “cognitive interview format” (Centofanti & Reece, 2006, p. 669) to retrieve possibly true stored memories from their work, exploring the coping strategies of their emotions with fewer errors. Structured interviews were used, but they presented with higher errors. Results depict that emotional distance between clients enhanced nurses’ performance. However, the backdated verbal communication data and the strategies were limited. The study reinforces the objective of the literature review by scrutinising emotional barriers as a coping strategy.