Anxiety, stress and burnout in nursing

Anxiety, stress and burnout in nursing is a significant issue, which affects many nurses during their professional career (McVicar, 2003). Graduate nurses transitioning from university education to a hospital setting face additional causes of stress and new challenges at this time and require accommodating measures such as a supportive work environment (Chang & Hancock, 2003). At present the nation is experiencing a severe nursing shortage that is impacting greatly on the work conditions of nurses that remain (Chang & Hancock, 2003). In this critical appraisal stress and burnout will be defined, as will all major terms throughout this paper.

The author will discuss the critical nursing shortage and describe the symptoms of stress and burnout. Causes of burnout and stress will be discussed in relation to the graduate and experienced nurse. The author will present and discuss stress and burnout prevention strategies. Throughout this essay empirical evidence will be used to demonstrate validity of concepts. A literature search was conducted using computerized databases that were searched over the time period 2003-2008 and included Academic Search Premier, psycINFO, Psychology and Behavioral Sciences Collection, EJS E-Journals Database, Professional Development Collection, Medline, Health Source: Nursing/Academic Edition, Health Source: Consumer Edition and Cinahl.

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Key words searched included burnout, nursing, anxiety, stress, shortage, graduate, and strategies.

Stress is thought to be connected to an individual’s response to specific demands, if the individual assesses the demand as beyond their resources this generates a stress response (Clancy & McVicar, 2002, as cited in McVicar, 2003). Stress responses include variation in an individual’s biochemical, physiological and behavioural processes (Billter-Koponen & Freden, 2005).

According to McVicar (2003) the ability of the individual to handle the stress response is dependent on specific experiences, coping mechanisms and the environment where demands are produced. Stress is usually part of a larger problem and is noted as the first phase of a ‘chronic process’ (Gillespie & Melby, 2003). If severe stress and anxiety persist without interventions being implemented this may lead to burnout, which is typically characterized by emotional exhaustion, depersonalisation and reduced personal accomplishment (Maslach & Jackson, 1986 as cited in Chang & Hancock, 2003).

Chang, Daly & Hancock et al., (2006) suggests that stress from work reduces the quality of work environment, job satisfaction, psychological wellbeing and physical health on nurses. Since stress has been identified as prevalent in nursing there have been various research studies discussing the causes and impacts of stress (Billter-Koponen & Freden, 2005). As well as the effects of work place stress on nurses, there is the larger issue of the consequences for the health care system, with many nurses finding the only way to cure burnout is leaving the workforce, this is further impacting the serious shortage of nurses world wide (Chang et al., 2005; Edwards and Burnard, 2003 as cited in Chang, Bidwell & Huntington, 2007).

A literature review of stress in nursing by Chang, Hancock & Johnson et., 2005 commented that currently the severe shortage of nurses in Australia is the largest since World War II and reports that by 2010, there will be a shortage of approximately 40, 000 nurses (RMIT University, 2003 as cited in Chang, Hancock & Johnson et al., 2005). A report by AIHW (2005), found that the nursing work force has persisted to age, with the average age of nurses increasing from 42.2 years old in 2001 to 45.1 years old in 2005 and the amount of working nurses aged over 50 years has increased from 24.4% to 35.8%. The older population of nurses will eventually be leaving the profession in years to come when the shortage of nurses is at its worst, this will further compound the issue (Janiszewski Goodin, 2003).

The Australian government has responded to the issue of an aging workforce by encouraging older nurses to continue with further study and actively discouraging them from retiring (Wickett, McCutcheon & Long, 2003). After many years of decline of enrolments to tertiary nursing courses there has been a considerable influx of applicants, this is thought to be created by the governments increasing media campaigns to generate interest in nursing as a career, however, the boost in enrolments does not necessarily solve the nursing shortage as the larger issues of why retention of nurses has not been successful have not been addressed and media campaigns could almost been seen as a ‘band-aid’ covering up the larger problems (Wickett, McCutcheon & Long, 2003). The nursing shortage has seen many ‘unskilled’ workers entering the aged care sector as a ‘substitution’ of registered nurses; currently the aged care system is overwhelmed with demand and ‘patient complexity’ (Wickett, McCutcheon & Long, 2003). Duffield & O’Brien-Pallas (2002, as cited in Wickett, McCutcheon & Long, 2003) suggest three main reasons for the growing nursing shortage, these include, personal issues that pertain to stress, burnout and an inadequacy of balance in their personal lives.

Secondly Duffield & O’Brien-Pallas (2002, as cited in (Wickett, McCutcheon & Long, 2003) cite organizational and management issues, which relate to workplace violence, either verbal or physical between patients or staff, as issues of concern in retention of nurses as well as professional issues with dissatisfaction stemming from the ability of the nurse to provide quality of care in circumstances of high demand (Chang, Hancock & Johnson, 2005; Wickett, McCutcheon & Long, 2003). These unresolved problems contributing to the nursing shortage emphasize the urgency of studying the nursing profession and environment so that the sustainability of the health care system can continue (Chang, Hancock & Johnson, 2005).

There are multiple symptoms of anxiety and burnout, as noted, prolonged stress and anxiety can result in burnout. Physical effects of stress include persistently elevated arterial blood pressure, indigestion, constipation or diarrhoea and weight gain or loss (McVicar, 2003). In cases of severe prolonged stress physical effects can progress to clinical hypertension, gastric disorders, nausea, fatigue, headaches and exacerbated symptoms of asthma (McVicar, 2003; Billter-Koponen & Freden, 2005). The possible cause of fatigue in severe stress and anxiety is high levels of cortisol, which is a hormone that can be produced in excess when a person is stressed leading to cortisol affecting sleep patterns and resulting in sleep difficulties (Billter-Koponen & Freden, 2005). According to Hugo (2002, as cited from Billter-Koponen & Freden, 2005) symptoms of stress in European countries are rising, in 2003 over 5,000 nurses in Sweden were sick for over 30 days with approximately 40% of the diagnosis for the long-term absence from work being emotional exhaustion (burnout), the 2003 statistics were reported to have increased by 20% from the previous year.

Billter-Koponen & Freden (2005) suggests that the larger proportion of demands for nurses are psychologically related and in turn this creates more psychological disturbances than physical symptoms. The three core elements of burnout; emotional exhaustion, depersonalisation and reduced personal accomplishment can produce various psychological effects. Emotional exhaustion may occur when the nurse experiences the inability to function professionally at a psychological level, the symptoms may include depression, sleep disturbances and the inability to control emotions (Maslach et al., 1996 p.4 as cited in Gillespie & Melby, 2003; Patrick & Lavery, 2007). A nurse who develops depersonalization may have feelings of irritability, anger and a general negative attitude towards clients, according to Leiter (1993, as cited in Patrick & Lavery, 2007) depersonalization transpires from a need to create distance from the work that is emotionally draining (Maslach et al 1996 p.4. as cited in Patrick & Lavery, 2007; Chang & Hancock, 2003). Reduced personal accomplishment can create feelings of inadequacy, self-doubt, low self-esteem and the predisposition to view their level of skill and care negatively (Chang & Hancock, 2003; Patrick & Lavery, 2007).

These symptoms are especially worrying as they can reduce quality of care and decrease patient satisfaction (Janssen et al ., 1999; Garrett & McDaniel, 2001 as cited in Chang & Hancock, 2003). It is generally accepted that nurses who are excessively stressed or experiencing burnout typically have poor job satisfaction, high absenteeism rates and many nurses contemplate leaving the profession altogether (Larson, 1987; Callaghan & Field, 1991 as cited in Chang & Hancock, 2003). A qualitative study by Billter-Koponen & Freden (2005) interviewed nurses about their own experiences regarding work place anxiety, stress and burnout, the nurses commented they felt ‘powerless’ to avoid burnout and had inadequate time or energy to take on patient demands.

The nursing profession involves demands beyond clinical technical skills, teamwork and constant care of patients; the role of nursing requires a high level of ‘emotional labour’, which can lead to many complex causes of stress and burnout (Phillips, 1996 as cited in McVicar, 2003).

Gillespie & Melby (2003) found that the length of shifts and shift patterns, which included night duty contributed to emotional exhaustion, personal relationship problems, difficulty concentrating and fatigue. Similarly, Efinger et al., (1995 as cited in McVicar, 2003) reported shift work as having a negative influence on social and personal aspects of the nurses’ lives, it was also mentioned that night shift work was particularly draining in terms of physical health and disrupted family life. Furthermore a study by Chang, Daly & Hancock et al., (2006) consisting of 320 randomly selected Australian registered nurses who were listed on the New South Wales registration board database found that workload was the most common source of stress with indications that high workload negatively affected the mental health of nurses. Chang, Daly & Hancock et al., (2006) also comment on the legal requirements of providing a safe work place in which workers are not under excessive stress, which is affecting their mental health.

However, a study by Patrick & Lavery ( 2007) based on a random sample of 574 division 1 Victorian Australian Nursing Federation members were surveyed on burnout in nursing stated that hours worked by nurses have a weak correlation with emotional exhaustion. Yet it could be argued that these results are not a true indication of full-time nurses feelings as 65.73% of the participants worked part-time or casual nursing roles with the average amount of hours that nurses worked in this study being 32.17 hours, which amounts to a ‘lower average’ than full time work (Patrick & Lavery, 2007). A cross-sectional study by Spooner-Lane & Patton (2007) found that nurses who worked full-time experienced higher levels of emotional exhaustion compared to part-time or casually working nurses. Increases in workload exist in other areas such as recent updating of technology, extra responsibilities, paper work and increasing staff shortages (Chang & Hancock, 2003).

A study by Gillespie & Melby (2003) that consisted of a triangulated research design, which incorporates both qualitative and quantitative methods as well as using questionnaires, focus groups and interviews found that staff shortages were cited numerous times as a significant cause of anxiety and stress. The nurses specifically identified the use of agency staff as a concern as many nurses expressed the issue of spending valuable time assisting agency staff in locating equipment and explaining the way that particular ward operated (Gillespie & Melby, 2003). A nurse that was interviewed in Billter-Koponen & Freden’s (2005) study reported trying to bridge the gap of time lost from extra demands by coming in early, working through meal breaks, and staying back to work longer. Nurses interviewed in Gillespie & Melby’s (2003) study also stated that ‘junior nurses’ were forced to take on roles beyond their experience. A focus group by the Australian Government further reports levels of growth in turnover and the increased amount of more acute patients as a source of stress due to staff levels remaining stagnant while demands escalate (Chang & Hancock, 2003).

Considering levels of demand are high and staff levels are not increasing as well as substituting agency staff or pressuring junior staff to meet senior roles these pressures would certainly contribute to anxiety, stress and potentially, burnout. Role ambiguity can be described as insufficient information about specific responsibilities and roles that a nurse must undertake (Chang & Hancock, 2003). Role ambiguity can occur in the form of objective ambiguity, which arises from ‘lack’ of information for that particular role, and subjective ambiguity, which is associated with the ‘social’ and ‘psychological’ features of ‘role performance’ (Kahn et al., 1964, as cited in Chang & Hancock, 2003).

Chang & Hancock (2003) conducted a qualitative study of 110 tertiary nursing graduates from 13 institutions across New South Wales, Australia who work in one of four teaching hospitals about role stress in graduate nurses, the participants were surveyed during 2-3 months of working and then again between 10-11 months. Chang & Hancock (2003) reported the graduates experienced role ambiguity within the first few months of working and this continued throughout the 12 months as well as being a contributor to lower job satisfaction. However, Chang & Hancock’s (2003) study was limited due to the use of self-reporting by the graduates, which is subjective and not objective data. Patrick & Lavery (2007) suggests role ambiguity is an extra stressor as graduates endeavor to fulfill their expected roles whilst experiencing new challenges.

Role overload typically occurs whilst graduates are learning time management skills and learning new roles (McVicar, 2003). Chang & Daly (2001, as cited in Chang & Hancock, 2003) identify that role overload can intensify the effects of role ambiguity. Chang & Hancock (2003) found that role overload became a larger contributor to stress than role ambiguity in nursing graduates after 10-11 months of working.

Gillespie & Melby (2003) notes a significant difficulty for graduate nurses as they transition into a hospital environment as opposed to learning at university, this ‘gap’ between skills learned in theory within university education and the ability of realistic demands within the hospital environment could present additional stress on the graduate nurse. Madjar et al., (1997 as cited in Chang & Hancock, 2003) describes this as the ‘theory-practice gap’, which causes a clash between personal standards and own values (Jasper, 1996; Reutter et al., 1997 as cited in Chang & Hancock, 2003). Patrick & Lavery’s (2007) study supports this ‘theory-practice gap’ and goes on to further state that nurses who acquired their nursing degree at a university have higher levels of emotional exhaustion and depersonalization than hospital-trained nurses.

Graduate nurses also report low levels of confidence, lack of support, unrealistic expectations of other clinical staff, unexpected work situations, adjusting to shift work and the increase in responsibility as added sources of stress (Chang & Hancock, 2003; Kelly, 1998 as cited in Chang, Hancock & Johnson et al., 2005; Patrick & Lavery, 2007). Allenach & Jennings (1990, as cited in Chang & Hancock, 2003) explain that stress from these new challenges includes anxiety. It could be assumed that normal stressors that affect all nurses regardless of age and experience affect graduate nurses as well as other specific experience- related stressors. Patrick & Lavery (2007) found that age and experience was negatively associated with burnout, suggesting that young and inexperienced nurses have a higher rate of burnout compared to older and more experienced workers. This finding is consistent with Spooner-Lane & Patton’s (2007) study of 273 nursing staff, which reported age as a significant indicator of burnout.

Jackson et al., (2002, as cited in Chang, Hancock & Johnson et al., 2005) suggest nurses are at risk of workplace violence in the forms of verbal or physical violence from their patients, relatives and staff. Participants from Chang, Daly & Hancock’s et al., (2006) study completed four different questionnaires regarding workplace stressors and findings suggested workplace conflict between nurses and physicians was a significant cause of stress. According to Ball et al., (2002, as cited in McVicar, 2003) conflict between staff has become a more important issue throughout the previous 10 years. Due to the nature of nurses’ work where patients’ emotions are highly sensitive, as they may be scared or have a higher expectation of required care than they are receiving, nurses can be venerable to violence and research by Carter (2000, as cited in Chang, Hancock & Johnson et al., 2005) comments workplace assault is more common for nurses than any other health professionals. The consequences of workplace violence are increased levels of anxiety, high levels of sick leave, lower levels of job satisfaction, burnout and lower retention rates (Jackson et al., 2002 as cited in Chang, Hancock & Johnson et al., 2005; RCN, 2000 as cited in Gelsema & Van Der Doef et al., 2006).

The flexibility of working hours and shift patterns was a significant cause of stress for nurses, it would be safe to assume that greater flexibility in working hours could possibly reduce stress, assist nurses in achieving a more balanced life as they contend with family and other personal pressures. Strategies to achieve greater flexibility in working hours will require a concentrated effort by management and staff to achieve ‘equity’ when allocating shifts and empowering nursing staff to have preferences regarding overtime and in particular, night shift (McVicar, 2003).

The workload of nursing is consistently reported to lead to an increase in anxiety, stress and burnout, therefore lowering workload would be a reasonable intervention, however workload is a complex issue which includes determinants that can be influenced by the individual or organization in which they work (Gelsema & Van Der Doef et al., 2006). The main issue that needs to be addressed is to ensure staffing levels are sufficient for that particular setting, this would greatly reduce pressures relating to patient care and reduce the incidence of staff working outside of their roles (McVicar, 2003). Other measures such as time management skills and delegation skills may further assist in reducing workload pressures. Hayhurst, Saylor & Stuenkel (2005) recommends further research into workload pressures that are associated with specific specialty areas so that programs can be implemented to target the needs of that specialty.

In Chang & Hancock’s (2003) study of role stress and role ambiguity in Australian nursing graduates it was noted that graduates experienced a high level of role ambiguity in their transition from university to the workplace. A study by Mrayyan & Acorn (2004) assessed nursing students to determine causes of burnout and invited students to suggest solutions to stressors affecting burnout. The nursing students highlighted role ambiguity as a contributor to stress and suggested a comprehensive update of job descriptions that included the scope of practice, skills and experience needed, explanation of knowledge required and a regular assessment if changes of the job expectations change. Greenwood (2000. as cited in Chang, Hancock & Johnson et al., 2005) reported that preceptor programs, orientation programs, ‘open communication’, and staff development considerably aids graduates transition and experience of role ambiguity throughout the year.

Violence in the workplace in the form of verbal abuse from other colleagues is a negative experience for nurses and is the cause of significant amounts of anxiety and stress Chang, Daly & Hancock et al., 2006). McVicar (2003) suggests that conflict with staff is the responsibility of management, nurses and all other professionals. Tourangeau & Cranley (2006) advise that relationships with co-workers have a potential influence on the retention of nurses and suggests further strategies, which include praise and recognition of co-workers as well as team building strategies that increase social interaction.

A qualitative study by Abuairub (2004) surveyed 303 nurses from various locations throughout the world on the effect of social support from co-workers in which, participants who ‘perceived’ having additional social support from co-workers reported lower levels of stress. Abuairub (2004) comments that extra social support from co-workers may assist in creating a more friendly and pleasurable working environment as well as nurses feeling they could call on co-workers for assistance. Graduate nurses would benefit from social support as they are constantly challenged and require guidance from all staff. Chang, Daly & Hancock et al., (2006) further support the notion of social support by reporting that a positive social climate can decrease levels of stress and ‘prevent’ burnout. The leaders of the work environment need to foster a more socially supportive culture by demonstrating co-operation, encouraging teamwork, social equality, supportive attitudes and education about stress education and helpful coping mechanisms (Abuairub, 2004; Hayhurst, Saylor & Stuenkel, 2005).

Coping strategies can be defined as psychological and ‘behavioural efforts’ to control demands that are considered as “exceeding the resources of the person” and are either problem focused which attempts to deal with or alter the problem that is the source of the stress or emotionally focused which attempts to ease ‘emotional distress’ (Lazarus and Folkman 1984, p. 141 as cited in Chang, Daly & Hancock et al., 2006). Chang, Daly & Hancock et al., (2006) comment that many studies suggest problem-focused coping to be more effective in preventing burnout than emotion-focused coping. It would be beneficial to address coping strategies with nursing staff to educate them about different methods and to assist them in recognizing coping methods that are unhelpful so that they may employ personal control to their responses of stress (Chang, Bidwell & Huntington, 2007).

These strategies would greatly assist nurses in reducing stress and burnout as well as providing graduate nurses with a firm foundation of clear guidelines and support.

In conclusion, the nursing profession is under high demand as our population is growing older and the acuity of patients is increasing. To ensure sustainability of the nursing profession it is essential that graduate nurses are supported in their transition from university to a hospital environment so they continue to remain in the profession. To retain more experienced nurses there must be change within nursing environments and organizations to create a more flexible and supportive workplace. The main causes of anxiety, stress and burnout have been well documented, and it is the implementation of strategies that is lacking. Further investigation into the effectiveness of prevention strategies for burnout should be explored, as better working environments will encourage more people and ex-nurses into the profession and therefore lessening the staff shortages that directly contribute to anxiety, stress and burnout.