Journal of Nursing Management, 2013, 21, 638647

Nurses and stress: recognizing causes and seeking solutions

BRENDA HAPPELL R N , R P N , B A ( H o n s ) , D i p E d , B E d , M E d , P h D 1, TRUDY DWYER R N , P h D 2,

KERRY REID-SEARL R N , R M , B H l t h S c , M C l i n E d , M R C N A 3, KARENA J. BURKE B A ( H o n s ) P h D 4,
CRISTINA M. CAPERCHIONE B H M , P h D 5,6 and CADEYRN J. GASKIN B B S ( H o n s ) , M B S , P h D 7
1
Engaged Research Chair, Director, Professor, Central Queensland University, Institute for Health and Social
Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Qld,
2
Associate Professor, 3Professor, Central Queensland University, Institute for Health and Social Sciences Research
and School of Nursing and Midwifery, Qld, 4Research Fellow, Senior Lecturer, Central Queensland University,
Institute for Health and Social Science Research and School of Health and Human Services, Qld, 5Research
Fellow, Central Queensland University, Institute of Health and Social Science Research, Qld, Australia, 6Assistant
Professor, School of Health and Exercise Sciences, University of British Columbia, BC, Canada and 7Research
Fellow, Central Queensland University, Institute for Health and Social Sciences Research and School of Nursing
and Midwifery, Queensland, Australia

Correspondence HAPPELL B., DWYER T., REID-SEARL K., BURKE K.J., CAPERCHIONE C.M. & GASKIN C.J. (2013)
Brenda Happell Journal of Nursing Management 21, 638647
School of Nursing and Midwifery Nurses and stress: recognizing causes and seeking solutions
Central Queensland University
Bruce Hwy Aims To identify, from the perspectives of nurses, occupational stressors and
Rockhampton, ways in which they may be reduced.
Queensland 4702 Background Nurses commonly experience high levels of occupational stress, with
Australia negative consequences for their physical and psychological health, health-care
E-mail: b.happell@cqu.edu.au
organisations and community. There is minimal research on reducing
occupational stress.
Method Six focus groups were conducted with 38 registered nurses using a
qualitative exploratory approach. Participants were asked to identify sources of
occupational stress and possible workplace initiatives to reduce stress.
Findings Sources of occupational stress were: high workloads, unavailability of
doctors, unsupportive management, human resource issues, interpersonal issues,
patients relatives, shift work, car parking, handover procedures, no common area
for nurses, not progressing at work and patient mental health. Suggestions for
reduction included: workload modification, non-ward-based initiatives, changing
shift hours, forwarding suggestions for change, music, special events,
organisational development, ensuring nurses get breaks, massage therapists,
acknowledgement from management and leadership within wards.
Conclusion The findings highlight the need to understand local perspectives and the
importance of involving nurses in identifying initiatives to reduce occupational stress.
Implications for nursing management Health-care environments can be enhanced
through local understanding of the occupational stressors and productively engaging
nurses in developing stress reduction initiatives. Nurse managers must facilitate such
processes.
Keywords: nursing, occupational support, strategies, stress

Accepted for publication: 4 October 2012

DOI: 10.1111/jonm.12037
638 2013 Blackwell Publishing Ltd
 Nurses and occupational stress

poor patient diagnosis/death and dying; (5) shift work-

Introduction
ing; and (6) lack of reward. Although there is a large
Occupational stress in nursing is of global concern and growing body of knowledge of the stressors that
(Lambert & Lambert 2001, Wong et al. 2006, Gonge nurses experience, these findings suggest stressors have
& Buus 2011, Hamdan-Mansour et al. 2011, Ward changed over time. Specifically, shift working (Hayes
2011, Happell et al. 2012). In one Australian study, for et al. 2006, Lavoie-Tremblay et al. 2008, Barker &
example, almost three-quarters of the private and pub- Nussbaum 2011) and lack of reward seemed to have
lic sector nurses surveyed reported their stress levels to gained greater prominence as sources of stress. Further,
be extremely high or quite high (Hegney et al. 2006). there is evidence that stressors may differ between
Empirical evidence shows that occupational stress can practice areas (Tyler & Ellison 1994). These findings
be reduced (Richardson & Rothstein 2008), meaning suggest that it may be important to clarify the sources
health-care organisations may be in a position to ensure of stress for nurses as a precursor to designing and
that work-related stress is minimized. An initial step implementing interventions that target stress levels.
towards reducing occupational stress is to understand The occupational stressors nurses experience can dif-
the stressors present in health-care environments and fer between countries (Burnard et al. 2008, Glazer &
ways in which they may be reduced. Gyurak 2008), between jurisdictions within the same
Occupational stress can have an adverse effect on country (Glazer & Gyurak 2008, Lim et al. 2010) and
nurses physical and psychological health (Laposa between urban and rural areas (Gonge & Buus 2011).
et al. 2003, Chang et al. 2007, McKinney 2011), the Such differences may be attributed to variations in
health-care organisations for which they work (Davey factors such as cultural values (e.g. collectivism versus
et al. 2009, Foglia et al. 2010) and the general com- individualism), education and training, health-care
munity (Safe Work Australia 2010). Although most of policy, geopolitics (e.g. nursing wounded soldiers from
the research involves correlational analyses (meaning the IsraelPalestine conflict), national economic pros-
that claims about causation cannot be made), there is perity, nurse-to-patient ratios and the availability of
a growing body of work suggesting that workplace other health-care professionals (Glazer & Gyurak
stress is associated with poor health outcomes, such as 2008). In Australia, where the present study was
physical illness (Callaghan et al. 2001, Weyers et al. based, systematic review evidence suggests that nurses
2006, Chang et al. 2007), diminished mental health commonly experience several stressors, including heavy
(Chang et al. 2006, 2007, Ward 2011), symptoms of workloads, conflicts between colleagues, working with
depression (Lin et al. 2010) and post-traumatic stress inadequately prepared or inexperienced staff, aggres-
disorder (Laposa et al. 2003). Organisational conse- sive patients and relatives, role ambiguity and shift
quences of nurses stress include staff turnover (Lavoie- work (Lim et al. 2010). The implication of these
Tremblay et al. 2008, Foglia et al. 2010), significant findings is that health-care administrators who wish to
levels of staff intending to leave (Laposa et al. 2003, implement programmes to reduce nurse stress should
Coomber & Barriball 2007) and absenteeism (Davey better understand local stressors before embarking on
et al. 2009). In addition to the significant financial change initiatives. This implication is particularly
burden of replacing staff when they are absent or pertinent as most research examining stress in nursing
resign, the education and training of new nurses and has been conducted in metropolitan areas and may
the compensation paid to those with work-related therefore not be reflective of specifically regional
health conditions is also costly (Marine et al. 2006). In issues.
Australia, for example, nursing has one of the highest During the last decade, there has been increased
rates of workers compensation claims for work- focus on reducing occupational stress in nursing
related mental disorders associated with mental stress (McVicar 2003). One way to conceptualize workplace
(Safe Work Australia 2010). stress management interventions, in general, is to
A comprehensive review of the literature has identi- group them into primary, secondary, and tertiary
fied six main stressors of nurses in relation to adult and prevention strategies (Landy & Conte 2010). Primary
child care nursing (McVicar 2003). These stressors prevention strategies aim to modify or eliminate stres-
are: (1) workload/inadequate staff cover/time pressure; sors (e.g. work design, cognitive restructuring), second-
(2) relationships with other clinical staff; (3) leadership ary strategies target responses to the inevitable
and management style/poor locus of control/poor group stressors (e.g. relaxation techniques, social support)
cohesion/lack of adequate supervisory support; (4) cop- and tertiary strategies promote healing from the
ing with emotional needs of patients and their families/ negative effects of stressors (e.g. employee assistance

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Journal of Nursing Management, 2013, 21, 638647 639
B. Happell et al.

programmes). Generally, primary and secondary strat- Setting and participants

egies (focused on limiting the experience of stress) are
The study was conducted in a acute care hospital in
preferred over tertiary strategies (Quick et al. 1997).
regional Queensland. The participants were 38 nurses
This framework of organising stress management inter-
who worked at different levels within the nursing hier-
ventions could be useful for reflecting on the strategies
archy, including nursing directors (NDs, n = 4), nurse
that nurses suggest as potentially helpful.
unit mangers (NUMs, n = 13) and registered nurses
Research on the effectiveness of interventions to
(RNs, n = 21) from paediatric, surgical and medical
reduce occupational stress in nurses (Galbraith &
wards. The participants worked in the following areas:
Brown 2011), specifically, and in health-care workers
day surgery rehabilitation, cancer and palliative care,
(Marine et al. 2006) and diverse occupational settings
intensive care, cardiac services, hospital in the home,
(Richardson & Rothstein 2008), generally, has pro-
emergency department, surgical wards, mental health
duced mixed results. Research with student nurses,
wards, medical wards, outpatient department, educa-
for example, has shown that effective ways of reduc-
tion and mental health, perioperative care, as well as
ing stress include relaxation, cognitive restructuring
nursing administration. The decision to include nurses
and reducing the intensity and number of stressors
from different levels of the hierarchy is consistent with
(Galbraith & Brown 2011). Generally, however, there
other research (Hamdan-Mansour et al. 2011) that has
are few high-quality investigations into person- or
shown that the inclusion of multiple perspectives can
work-directed initiatives to reduce stress (Marine et al.
enhance the richness of the material collected.
2006), especially with respect to organisational inter-
ventions (Richardson & Rothstein 2008). As it is
important for local health-care organisations to clar- Interview guide
ify stressors that nurses are experiencing, there may
Two open-ended interview questions were generated
also be advantages in seeking their opinions about
to guide the initial discussion: What are the sources
strategies that could help reduce stress levels.
of stress for you in your nursing roles at this hospital?
The study presented in this paper represents the first
and What could be introduced into your workplace
phase of a multi-strategy project designed to promote
that would make a difference to the stress levels you
the physical and psychosocial wellbeing of nurses in a
experience?. These questions provided the broad
regional Queensland hospital. Specifically, we sought to
focus for the commencement of the interviews. The
identify, from the perspectives of nurses, (1) nurse
subsequent discussions were influenced by the
occupational stressors and (2) ways in which the
responses of participants.
organisation may be able to help reduce nurse occupa-
tion-related stress.
Ethical issues

Method Ethics approval was obtained from the human

research ethics committees of the Health Service Dis-
Design trict within which the hospital is located and from the
A qualitative exploratory method was used to conduct University responsible for this project. All participants
this research. This approach is particularly relevant received a consent form and an information letter
where the aim is to explore the phenomenon under advising them of the voluntary and confidential nature
question from the perspectives of those with opinions of the study and of their right to withdraw from the
and experiences of relevance to contribute (Stebbins study at any stage. Confidentiality of participants was
2001). assured. The study was conducted in accordance with
Six focus group interviews were conducted with the requirements of the National Health and Medical
registered nurses. Focus groups were chosen as the Research Council of Australia.
data collection method to facilitate in-depth explora-
tion of the topic through group interaction (Krueger
Procedure
& Casey 2000). Two members of the research team
facilitated these focus groups, which included pro- Following ethical approval, two members of the research
viding the initial questions to generate discussion, team conducted the focus groups. For the convenience
seeking clarification as required and recording field of participants, the focus groups were held at the hospi-
notes. tal study site. Interviews were audio-recorded and tran-

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 Nurses and occupational stress

scribed verbatim. The interview transcripts and field Unavailability of doctors

notes were used as the material for the analysis. Participants found it stressful when they could not get
doctors to see patients. They were sometimes unable
to get doctors from other units when there were no
Analysis
doctors rostered on to their wards:
To provide a rich description of participants experi-
One of the main things was not having a ward
ences, inductive content analysis was used (Skinner
call doctor at night time, to deal with the night
et al. 2003, Braun & Clarke 2006). Each research
duties and that loaded our stress up really
team member received a copy of the transcripts and
high. And you really need that ward call doctor
independently read them as a whole to obtain a feel
during the night shift, to help us through the
for the content. Emerging statements and passages
night.
that captured sources of stressors and ways in which
the organisation could help to reduce stress were (RN)
extracted and subsequently coded. Following this
initial process, the codes were then grouped to form Unsupportive management
conceptual themes. The research team met to discuss, A number of participants reported stress being exacer-
compare and revise identified themes until consensus bated by limited support from those in senior manage-
on relevance was reached. ment positions:
I personally dont feel that were very well
supported by management, or listened to even.
Findings None of our concerns that we raise ever go any-
where. Were not told were doing a good job.
Sources of stress
(RN)
Twelve sources of stress emerged from the material of
the six focus groups: high workloads, unavailability of However, these perceptions were not shared by all
physicians (referred to by participants as doctors), of the nurses, with several mentioning they felt that
unsupportive management, human resource issues, their managers supported them well; some expressed
interpersonal issues, relatives of patients, shift work, empathy toward their managers and the work pres-
car parking, handover, no common space for nurses, sures that they may be experiencing.
not progressing at work and patient mental health.
Human resource issues
Each subtheme is briefly discussed and textual exemp-
Several focus group participants reported experiencing
lars are coded according to whether the respondent
issues with the human resources functions of their
was a ND, NUM or RN.
workplaces. Two issues that came to the fore were the
deletion of staff from casual employment lists and
High workloads incorrect payments. Nurses who worked periodically
Nurses reported experiencing stress because of high were automatically deleted from the casual employment
workloads resulting from inadequate skill mixes list if they did not work for several months. These dele-
(imbalances of nursing staff with low and high levels tions meant that nurses had to complete an employment
of skills and experience), staff shortages, too many starter pack again, which discouraged some nurses
patients, patient acuity, using specialized equipment from working for the organisation. The underpayment
and having to perform activities other than direct of staff was reported to be a common occurrence:
patient care (e.g. organising travel forms). High work-
But the frustrating side of that as well is the
loads also resulted in nurses missing scheduled breaks:
pay. The staff, they work the shifts, and then
Its the staffing shortages and the skill mix their pays are wrong. Week after week their pays
shortages people still keep coming in the are incorrect.
doors, irrespective of what [the] workload is
(NUM)
Theres very little downtime for nursing staff
anymore. Its fast paced activity. So thats a
Interpersonal issues
major stressor.
The nurses identified three interpersonal issues that
(ND) caused them stress: bullying, communication prob-
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Journal of Nursing Management, 2013, 21, 638647 641
B. Happell et al.

lems and conflict between nurses. Some participants stressor for some nurses, leaving them feeling tired,
stated that bullying was still present in health-care especially when their family lives prevented them from
workplaces. With regard to communication, nurses obtaining adequate sleep:
perceived that not all information regarding the care
Well, its crap. Like its not normal working
of patients was being properly documented. With
night shift and you know you work a couple of
several clinicians (sometimes from different wards)
night shifts and then youll have one or two days
involved in the care process missed communications
off. And come back exhausted still from the
affected the care of patients and contributed to the
night shift.
stress of nurses:
(RN)
I find that on [the] day surgery pre-admission
clinic because we deal with a lot of doctors and Car parking
allied health. So you might think the patient is The site hospital where the participants work does not
progressing this way and someone else will come provide designated parking areas for staff. As a result,
in and say no, this has got to happen first. But if some nurses mentioned that car parking caused them
its documented and not communicated, it gets stress. They often had to park some distance from the
missed so I think communication is one of the hospital, and reported using lunch breaks to move
biggest issues. their cars closer to work for safer access when they
(NUM) finished their shifts. Knowing they needed to find a
car park often resulted in nurses feeling stressed before
Some nurses stated that conflicts arose between they even commenced work:
nurses because of demanding workloads. For example,
nurses starting a shift sometimes came into conflict Im thinking, Oh, where am I going to go to
with the nurses finishing their shifts when work had try and find a park today? Should I try here first
not been completed because of workload pressures or should I try down there? and, so Im already
during that shift. stressed by the time I get in, cause Im going,
Oh, Ive got three minutes to get in.
Relatives of patients (RN)
Some nurses described feeling stressed because of the
demands placed on them by relatives of patients. Handover procedures
These demands can be exacerbated if the relatives take Several nurses discussed how the handover procedures
their concerns to others in the health-care organisation in their ward made them feel stressed. Handovers
(e.g. going to the liaison officer to get permission to occurred at the bedside and the nurses reported feeling
be with the patient outside of visiting hours). The uncomfortable discussing personal matters within
nurses indicated that some relatives could be quite earshot of other patients and relatives:
unreasonable in their requests:
and some confidentiality stuff, it shouldnt be
It happens all the time. The family ring up, we mentioned in the handover at the at the bed-
dont want him back until hes well. Well, side.
whats well and how long is it going to take?
(RN)
Where is he going to go in the meantime? Were
not designed for that but unfortunately were No common area for nurses
being forced into a corner where we are now A stressor consistently mentioned was the lack of ded-
having to put these people weve had people icated common areas for nurses to relax during their
on this ward for 11 months because the families breaks (e.g. tea rooms). Nurses reported having to
jump up and down. stay predominantly in and around their work areas
(RN) throughout the day, which resulted in them not feeling
that they were able to talk and informally debrief with
other staff:
Shift work
Having to work shifts was a stress in the working people dont leave their work area previ-
lives of several participants. Shift work was a physical ously everyone would go down to an area and

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 Nurses and occupational stress

catch up and have a bitch and off youd go and Table 1

Initiatives that could reduce nurse stress
everyone would feel better. Whereas now you
stay in that work area. Primary Secondary
prevention prevention Tertiary prevention
(NUM) strategies strategies strategies

Workload Massage therapists

Not progressing at work modification on the wards
Some nurses reported feeling stressed because they Changing Music in wards
were not progressing career-wise within their jobs and shift hours
Forwarding Special events
felt that management did not recognize their efforts:
suggestions
not getting where you want to get at work, for change
Ensuring Organisational
like not seeing the results of all your effort. nurses get development
breaks
(RN) Leadership Acknowledgement
within the ward from management
Mental health issues Non-ward-based
Some nurses stated that they experienced stress when initiatives

having to care for patients with mental health issues.

These nurses perceived that they were inadequately
trained to care for patients with such comorbidities: disagreement between focus group participants, with
some nurses perceiving that more staff may encourage
Having situations where were in were deal-
absenteeism:
ing for patients that we dont actually feel
trained to deal with, like the mental health It might bring relief at the moment, but then
patients, but trying as hard as we can as a ward, people will start thinking, oh such and such will
and then having our professionalism questioned. do my work today, Ill just call in sick, I dont
need to work today.
(RN)
(RN)

Initiatives to reduce stress Changing shift hours. Some nurses perceived that
Eleven initiatives (including groupings of initiatives) modifying the hours that nurses worked would relieve
to reduce stress were apparent in the material from stress. Apparently, this strategy had been tried (suc-
the six focus groups and included: workload modifi- cessfully) in the past, but abandoned:
cation, non-ward-based initiatives, changing shift We did a pilot for 8 hours and it got better, but
hours, forwarding suggestions for change, music in we had to do the pilot for maybe 6 months
wards, special events, organisational development, before you could actually see the difference,
ensuring that nurses get breaks, massage therapists rather than 2 months.
on the wards, acknowledgement from management
and leadership within the ward. These initiatives (RN)
are identified in Table 1 as primary, secondary or
tertiary strategies and are described in the following Forwarding suggestions for change. Some nurses indi-
sections. cated that they had developed solutions to issues expe-
rienced in their wards, but these ideas were
Primary strategies infrequently used to change practice or the ward envi-
ronment. They argued there should be a clear process
Workload modification. Ways of modifying (mainly for making suggestions to change ward environments
reducing) workloads was a common topic that partici- or nurse practice:
pants discussed. Specific initiatives to reduce work-
Most of us can identify things on the ward
loads for nurses included the appointment of shift
every day that we actually could probably find a
coordinators without patient loads, rostering on more
solution for. But where do you take it and noth-
staff on occasions to allow nurses to perform activi-
ing gets done if you did take it somewhere.
ties other than direct patient care and improving staff-
to-patient ratios. On this last initiative, there was (RN)

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B. Happell et al.

Ensuring that nurses get breaks. Some nurses men- ties were effective in relieving stress, but occurred
tioned how they seldom got breaks when they were infrequently:
on their wards. Having these breaks was proposed as
Well, our unit has just started the ball rolling
a way of managing their stress levels:
with the whole social outing thing just last week
Another benefit, I suppose, is making sure that actually because we have been so under pressure
people get their time out. Thats not always the and so stressed and all that sort of thing and
case. We dont always say, okay, go. Because someone said, Look we need to band together
theyve got the old Catholic guilt that nurses get and be a bit more of a team, which we are. We
embedded into them as part of the military train- are a good team but you can tell that the stress
ing we go through. You will look after the is getting to us sort of thing and so we said,
patient, no matter what. If the patient dies, its Well once a month why dont we get out and
your fault and your fault only and youre the do the whole bonding session thing and get out
one to blame. Versus okay, well sometimes they and do something?. I think I noticed Saturday
need to step back. morning straight after the dinner that everyone
was probably a little bit more relaxed and had a
(ND)
bit of down time sort of thing to get out and actu-
Leadership within the ward. The ND argued that the ally do something rather than just go to work, go
leaders within a ward have a significant role in man- home, go to work, go home sort of thing.
aging the stress levels of their staff. If nurse leaders (RN)
can effectively control the work that is going on in
wards, then stress levels too are likely to be managed:
Secondary strategies
One individual in the unit, the shift coordinator,
who starts spinning, causes the whole unit to Music. Several nurses suggested that the playing of
spin out of control and become highly stressed. music in their wards would help to relieve stress:
The same goes for a nurse unit manager. A nurse Do you know, if you go into the medical unit,
unit manager who enters that unit and goes hang
theyve got the radio cranked way up in the
on, its okay, everybody calm, take a breath, we
treatment room? You go in there. Oh my god.
can do this, the whole unit de-escalates in their
But theyre all jiving [dancing] in there and
stress and just gets on and does the job. But if
whatever. Good on them.
that one key person isnt within the unit, going
thats okay, its alright, then they just they feed (RN)
off each other into a very stressed and frenzied
kind of practice. Special events. The holding of simple special events
was suggested as one way of boosting morale and
(DN) reducing stress. Events that the nurses mentioned
included acknowledging birthdays and crazy shirt
Non-ward-based initiatives. Nurses mentioned several
days.
initiatives for relieving stress that related to things
other than the care of patients. Although these are
Organisational development. The NDs described an
identified within a single subtheme, many of these ini-
organisational development philosophy that could be
tiatives can be classed as either primary or secondary
employed within wards to reduce nurse stress levels.
strategies. The initiatives the participants identified
Independently of this discussion, however, nurses
included providing opportunities for exercise (e.g. pro-
seemed sceptical of the value of team building.
viding changing facilities for those who cycle or run
to work, or running Tai Chi or yoga classes for Team building stuff doesnt [work]. I mean, Ive
nurses), childcare facilities, places for nurses to take been through it in units in [another city], it was
time out from busy wards (e.g. tearooms), bar facili- actually flagged as a unit at risk and we did the
ties, car parking improvements, designated smoking big bonding thing and I guess Im a little bit neg-
areas and social events. With regard to the last of ative about it because it actually just proved
these initiatives, the nurses indicated that social activi- exactly what we said was the case. Abusers were

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the abusers and everybody said, Oh rah, rah, perceived social support for nurses (Gaynor et al.
we had a bonding day, that was good, wasnt it 1995). Research findings suggest that nurses value
and you think, no, it actually just proved that positive team interaction within the working environ-
harassment is alive and well. ment (Day et al. 2007b) and consider it crucial to
enhance morale in the nursing workforce (Day et al.
(RN)
2007a). Addressing the need for team interaction
through organisational change and enlightened leader-
Acknowledgement from management. A theme that
emerged consistently throughout the focus group dis- ship has been identified in the research literature
(Chiok Foong Loke 2001, Greco et al. 2006, Giallo-
cussions was how nurses felt that their managers
nardo et al. 2010). There may, however, be more
under-appreciated the work they did. A simple thank
practical strategies to reduce stress levels, such as pro-
you was perceived as one way that they would feel
viding common space for nurses. This approach would
more acknowledged:
have the additional benefit of empowering nurses to
I think just better communication. A bit of recognize their own stress and work together in a col-
respect, a bit of acknowledgment. legiate fashion to reduce stress where possible.
Some stressors apparent in the Australian literature
(NUM)
(e.g. working with inadequately prepared or inexperi-
Tertiary strategies enced staff, aggressive patients and relatives, and role
ambiguity; Lim et al. 2010) were not mentioned in
Massage therapists on the wards. Several nurse man- this study. Given the evidence that nurse stressors can
agers suggested that having massage therapists come differ between jurisdictions within the same country
to the wards would be an effective way of reducing (Glazer & Gyurak 2008, Lim et al. 2010), and
stress. Independently, however, some nurses argued between urban and rural areas (Gonge & Buus 2011),
that massage therapists would be dealing with the the presence of both commonly shared, as well as
symptoms of stress and not actually addressing the unique local stressors should not come as a surprise.
stressors present within the ward. As such, this initia- However, the finding, does reinforce the need to inves-
tive is better represented as a tertiary strategy: tigate stressors in local settings before embarking on
stress reduction initiatives.
A colleague was just telling me about some Almost all initiatives that nurses suggested could
work that shed come across at another regional help reduce stress can be classified as either primary
hospital where they actually did have a massage or secondary prevention strategies (Landy & Conte
person come on one day a week. That person 2010). One theme that emerged through the focus
would go to each ward and everyone was there group material (non-ward-based initiatives) was classi-
and given like a 5-minute head and neck. Some- fied under two headings because it contained both
thing like that, would that be something, you primary and secondary prevention strategies. Only
know?. one initiative (massage therapists on the wards) could
(ND) be classified as a tertiary prevention strategy. These
findings seem positive because the nurses suggestions
were predominantly aimed at reducing stressors or
Discussion
improving their responses to stressors, rather than
Although many of the stressors the nurse participants dealing with the consequences of stress.
described in this study are commonly found in the Nurses serve to gain greatest benefit if interventions
nursing literature (e.g. heavy workloads, interpersonal include both personal-directed intervention, such as
issues, unsupportive management, shift work; McVic- coping skills training, and work-directed intervention,
ar 2003, Lim et al. 2010), several of the issues raised such as reducing workloads (G unus en & Ust un
in the focus groups seemed to be localized (e.g. car 2009). Although person-directed interventions,
parking, handover procedures, no common area for adapted for nurses working in hospital, can be effec-
nurses). The majority of participants in this research tive in reducing the levels of emotional exhaustion,
suggested the need for a space for nurses to meet and the outcomes demonstrate a short-term effect that
interact. This point has not previously been raised needs to be repeated on regular basis.
through research about nursing stress. However, com- The findings of this study support the importance
mon space, has been identified as a way to increase of managers understanding nurse stressors in their

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Journal of Nursing Management, 2013, 21, 638647 645
B. Happell et al.

particular organisations. There is now a large body of findings presented in this paper highlight the impor-
research literature describing the manifestations of, tance that nursing stressors are contextualized and
and contributing factors to stress in nurses (for promote the importance of involving nurses in the
reviews, see McVicar 2003, Lim et al. 2010). This lit- identification of solutions. The literature has been
erature can be informative for managers. However, a much more effective in emphasizing the problems than
sound understanding of the experiences of nurses in in identifying the solutions, and to avoid this cycle
their own organisations would appear to be a prere- continuing a greater focus must be placed on moving
quisite for addressing nurse stress issues. Implementing from discussion to action. The more nurses can be
mechanisms to facilitate two-way communication with involved in this process, the more positive the out-
nursing staff is likely to enhance the perception of comes are likely to be.
nurses that they have organisational support, and
therefore reduce one of the major stressors frequently
Acknowledgements
identified in the literature (Chiok Foong Loke 2001,
McVicar 2003, Gelsema et al. 2005). The authors extend their thanks to the Queensland
By establishing mechanisms for effective communi- Nursing Council for providing the funding for this
cation, nurses at all levels across specific health-care research and to the nurse participants who gave so
settings can contribute to the reduction of stress and freely of their time. Thanks also to those who assisted
the enhancement of job satisfaction at both individual with the conducting of this research, including
and systemic levels. Not only would this assist with Matthew Johnson, Lynn Jamieson, Sue Williams,
the identification of strategies relevant to the specific Christina Hunt and Jodie Morris.
service, it would contribute to nurses sense of
empowerment. Being empowered in itself is likely to
Source of funding
have positive benefits in reducing the impact of stres-
sors associated with nursing work (Greco et al. 2006). The project was funded by Queensland Nursing Council.
The findings of the current study suggest that, given
opportunities, nurses are able to identify strategies
Ethical approval
that would create more positive working environ-
ments. Not all strategies may be easily implemented Ethics approval was obtained from Central Queens-
or financially viable, but the active involvement of land Universitys Human Research Ethics Committee
nurses in the identification and implementation of (EC00158) and Queensland Healths Research Ethics
strategies is an important starting point. Committee (EC00334).
Conducting this research in a rural setting is a par-
ticular strength of this work. Most research on this
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