Workplace stress in nursing: a literature review

I N T E G R A T I V E L I T E R A T U R E R E V I E W S A N D M E T A - A N A L Y S E S
Workplace stress in nursing: a literature review
Andrew McVicar BSc PhD
Reader, School of Health Care Practice, Anglia Polytechnic University, Chelmsford, Essex, UK
Received for publication 19 June 2002
Accepted for publication 24 July 2003
Correspondence:
M c V I C A R A . ( 2 0 0 3 )
Journal of Advanced Nursing 44(6), 633–642
Andrew McVicar,
Workplace stress in nursing: a literature review
School of Health Care Practice,
Background. Stress perception is highly subjective, and so the complexity of nursing
Anglia Polytechnic University,
practice may result in variation between nurses in their identification of sources of
Chelmsford,
stress, especially when the workplace and roles of nurses are changing, as is cur-
Essex CM1 1SQ,
rently occurring in the United Kingdom health service. This could have implications
UK.
E-mail: a.j.mcvicar@apu.ac.uk
for measures being introduced to address problems of stress in nursing.
Aims. To identify nurses’ perceptions of workplace stress, consider the potential
effectiveness of initiatives to reduce distress, and identify directions for future
research.
Method. A literature search from January 1985 to April 2003 was conducted using
the key words nursing, stress, distress, stress management, job satisfaction, staff
turnover and coping to identify research on sources of stress in adult and child care
nursing. Recent (post-1997) United Kingdom Department of Health documents and
literature about the views of practitioners was also consulted.
Findings. Workload, leadership/management style, professional conflict and emo-
tional cost of caring have been the main sources of distress for nurses for many
years, but there is disagreement as to the magnitude of their impact. Lack of reward
and shiftworking may also now be displacing some of the other issues in order of
ranking. Organizational interventions are targeted at most but not all of these
sources, and their effectiveness is likely to be limited, at least in the short to medium
term. Individuals must be supported better, but this is hindered by lack of under-
standing of how sources of stress vary between different practice areas, lack of
predictive power of assessment tools, and a lack of understanding of how personal
and workplace factors interact.
Conclusions. Stress intervention measures should focus on stress prevention for
individuals as well as tackling organizational issues. Achieving this will require
further comparative studies, and new tools to evaluate the intensity of individual
distress.
Keywords: workplace stress, nursing recruitment and retention, stress management,
organizational change
(Lehrer & Woolfolk 1993, Rick & Perrewe 1995). The
Background
basic concept is that stress relates both to an individual’s
Stress is usually defined from a ‘demand-perception-
perception of the demands being made on them and to their
response’ perspective (see Bartlett 1998). Lazarus and
perception of their capability to meet those demands. A
Folkman (1984) integrated this view into a cognitive theory
mismatch will mean that an individual’s stress threshold is
of stress that has become the most widely applied theory in
exceeded, triggering a stress response (Clancy & McVicar
the study of occupational stress and stress management
2002).
Ó 2003 Blackwell Publishing Ltd
633

---

A. McVicar
An individual’s stress threshold, sometimes referred to as
Assessment is further complicated because the term
stress ‘hardiness’, is likely to be dependent upon their char-
‘stress’ is often used too simplistically. Negative connota-
acteristics, experiences and coping mechanisms, and also on
tions are usually ascribed to the term, yet some stress
the circumstances under which demands are being made. A
responses are of positive benefit (Bartlett 1998). ‘Eustress’ is
single event, therefore, may not necessarily constitute a
a term commonly applied to these more positive responses,
source of stress (i.e. be a ‘stressor’) for all nurses, or for a
whilst the term ‘distress’ appropriately describes negative
particular individual at all times, and may have a variable
aspects. ‘Stress’, therefore, should be viewed as a continuum
impact depending upon the extent of the mismatch (Lees &
along which an individual may pass, from feelings of
Ellis 1990). Assessing stress is likely to be very difficult in an
eustress to those of mild/moderate distress, to those of
occupation as diverse and challenging as health care, yet the
severe
distress.
Indicators
of
distress
are
recognized
effectiveness of organizational interventions to reduce or
(Table 1), but those of mild/moderate distress may not be
eliminate sources of stress depends upon a sound under-
observed collectively, or may have differing degrees of
standing of the stress phenomenon for nurses. This paper
severity, and so symptoms at this level of distress are likely
reviews the implications of the subjective aspects of stress
to vary between individuals. In contrast, severe and
perception for nurses who, with teachers and managers, are a
prolonged distress culminates in more consistently observed
professional group most likely to report very high levels of
symptoms of emotional ‘burnout’ and serious physiological
workplace stress (Smith et al. 2000).
disturbance.
Table 1 Psychological and physiological indicators of eustress and distress*
Eustress
Distress
Severe distress
Psychological
Fear/excitement
Unease
Burnout i.e.
Increased level of arousal,
Apprehension
(a) emotional exhaustion
and mental acuity
Sadness
(b) depersonalization
Depression
and disengagement
Pessimism
(c) decreased personal
Listlessness
accomplishment
Lack of self esteem
Negative attitudes
Short temper
Fatigue
Poor sleep
Increased smoking/alcohol
consumption
Physiological 
Autonomic arousal
Persistently elevated arterial
Clinical hypertension
(a) Increased arterial blood pressure
blood pressure
Coronary heart disease
(b) Increased heart rate
Indigestion
Gastric disorders
(c) Quicker reaction times
Constipation or diarrhoea
Menstrual problems
Release of metabolic hormones
Weight gain or loss
in women
especially cortisol
Increased asthma attacks in
(a) Increased metabolic rate
sufferers
(b) Mobilization of glucose,
fatty acids, amino acids
Impact
Adaptive:
Variable between individuals,
Variable between individuals
on the individual
Increased alertness
but usually maladaptive
but usually severely maladaptive,
Attention focused on the situation
possibly life threateningà
Individual more responsive to changing
situations
Fear, fight, flight preparation
for activity: ‘Energised’.
*The evidence that both cognitive and physiological responses occur simultaneously is debatable, except in extremely distressful situations, but it
is convenient to consider cognitive and physical responses separately. See Sarafino (2002) for further information.
 Physiological responses based on the General Adaptation Syndrome (Selye 1976).
àThe health impact may be compounded in nurses by health-risk behaviours, for example excessive smoking and alcohol abuse (Plant et al.
1992).
634
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642

---

Integrative literature reviews and meta-analyses
Workplace stress in nursing
It is the transition to severe distress that is likely to be most
A secondary question is:
detrimental for nurses, and is closely linked to staff absen-
• What should be the directions of further research on stress
teeism, poor staff retention, and ill-health (Healy & McKay
in nursing?
1999, McGowan 2001, Shader et al. 2001). If severe distress
is to be prevented, then it is important to understand what
Methods
factors promote the transition. Nursing provides a wide range
of potential workplace stressors as it is a profession that
The CINAHL, MEDLINE and COCHRANE databases were
requires a high level of skill, teamworking in a variety of
accessed using the key words nursing, stress, distress, stress
situations, provision of 24-hour delivery of care, and input of
management, job satisfaction, staff turnover, coping. It soon
what is often referred to as ‘emotional labour’ (Phillips
became clear that some generic issues, such as workload,
1996). French et al. (2000) identified nine sub-scales of
were identified by both mental health (psychiatric) and other
workplace stressors that might impact on nurses. In no
nurses, but there were also some specific differences, partic-
particular order, these are:
ularly in relation to the more frequent need for mental health
• conflict with physicians,
nurses to deal with aggression and violence (Carson et al.
• inadequate preparation,
1997). Accordingly, the search was restricted to adult and
• problems with peers,
child care nursing.
• problems with supervisor,
Not all studies identified the practice areas from which the
• discrimination,
study sample was drawn. Where this was stated, the sample
• workload,
came from a wide range of practice settings, and sometimes
• uncertainty concerning treatment,
an entire hospital. There was no consistency between studies
• dealing with death, and dying patients,
in this respect, but medical, surgical and high dependency (for
• patients/their families.
example, intensive care) units were prominent. No attempt
As the transition from eustress to distress will depend upon
was made in this review to establish comparisons between
an individual’s stress perceptions, it follows that variability
practice areas, although two empirical studies (Foxall et al.
between people in the identification of workplace stressors
1990, Tyler & Ellison 1994) did so. The findings from these
within these sub-scales might be expected. Additionally,
are referred to later in this paper.
temporal changes in the sources of stress might also be
The search was completed in April 2003 and was restricted
anticipated, as working conditions are not static. Indeed,
to papers published since 1985. It was supplemented by a
recent years have seen a number of changes in the structure of
manual search of current issues of periodicals, including
the United Kingdom (UK) National Health Service (NHS), in
major nursing and occupational health journals from the UK,
prioritizing of services, and in the roles of nurses, as detailed
United States of America, Australia and New Zealand, and
in policy documents published by the UK Department of
manual follow-up of other cited material, where appropriate.
Health (1998a, 1998b, 1998c, 1998d).
In all, over 100 papers and texts were consulted, of which 21
were primary research studies that detailed the main sources
of stress for nurses.
Review aims and research questions
United Kingdom Department of Health documents from
The UK Government has recognized the need to address
1998–2003 were also accessed for information on policy
sources of stress in health care, and in particular to reverse
directions in the context of the workplace for nurses, as were
the shortfall in nurse recruitment and retention, and to
bulletins and reports from the UK Royal College of Nursing
introduce a participative style of management (Department
and the UK Health and Safety Executive. A resultant litera-
of Health 2002a, 2002b). In view of the subjectivity of stress
ture trail was followed that identified practitioner views of
perception, it would be useful to ascertain the potential of
the likely impact of the policies.
recent organizational interventions to meet the needs of
nurses. This study is a integrative review that seeks to answer
Findings
the following research questions:
• Is there commonality of sources of workplace stress for
Collating the evidence from the literature led to the identi-
nurses?
fication of six main themes for the sources of workplace
• Are sources of workplace stress for nurses changing?
distress for nurses (Table 2). In line with findings of Williams
• Will recent organizational interventions introduced to
et al. (1998), this review indicates that most sources of stress,
reduce the sources of stress for nurses be effective?
that is workload, leadership/management issues, professional
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642
635

---

A. McVicar
Table 2 Major workplace stressors that
Stressor
References: 1985–1997
References: 1998–April 2003
impact on work satisfaction for staff nurses.
Those stressors that relate to the same
Workload/inadequate
Hipwell et al. (1989)
Healy and McKay (1999)
theme are collated, and presented pre- and
staff cover/time pressure
Baglioni et al. (1990)
Demerouti et al. (2000)
post-1997, that is before and after recent
Foxall et al. (1990)
McGowan (2001)
policy changes in the workplace (Depart-
Lees and Ellis (1990)
Stordeur et al. (2001)
ment of Health 1998a, 1998b, 1998c,
Tyler and Ellison (1994)
1998d). The stressors are not listed in order
Tyler and Cushway (1995)
of importance
Hillhouse and Adler (1997)
Relationship with other
Foxall et al. (1990)
Hope et al. (1998)
clinical staff
Lees and Ellis (1990)
Healy and McKay (1999)
Tyler and Ellison (1994)
Bratt et al. (2000)
Hillhouse and Adler (1997)
Stordeur et al. (2001)
Leadership and management
Constable and Russell (1986) Bratt et al. (2000)
style/poor locus of control/poor
Lucas et al. (1993)
Demerouti et al. (2000)
group cohesion/lack of adequate Tyler and Ellison (1994)
Schmitz et al. (2000)
supervisory support
Leveck and Jones (1996)
McGowan (2001)
Morrison et al. (1997)
Shader et al. (2001)
Stordeur et al. (2001)
Coping with emotional needs
Hare et al. (1988)
Bratt et al. (2000)
of patients and their families/
Hipwell et al. (1989)
poor patient diagnosis/death
Foxall et al. (1990)
and dying
Lees and Ellis (1990)
Tyler and Ellison (1994)
Shift working
Demerouti et al. (2000)
Healy and McKay (2000)
Lack of reward
Demerouti et al. (2000)
McGowan (2001)
conflict and emotional demands of caring, have been iden-
Stordeur et al. (2001) attempted to rank stressors in order
tified consistently by nurses for many years. Perhaps this
of severity of impact, the main ones being ranked as:
should not be surprising, as they relate to the main generic
• high workload,
characteristics of practice. Inexperienced nurses identified
• conflict with other nurses/physicians,
similar clinical sources of stress, but they also reported low
• experiencing a lack of clarity about tasks/goals,
levels of confidence in their clinical skills as a further source
• a head nurse who closely monitors the performance of staff
(Charnley 1999, Brown & Edelmann 2000).
in order to detect mistakes and to take corrective action.
Hillhouse and Adler (1997) suggest that it is the actual
Healy and McKay (2000) also found workload to be most
characteristics of the work environment, and workload,
significantly correlated with mood disturbance. However,
rather than any differences in practice requirements that are
Payne (2001) did not find a significant relationship between
important in evaluating sources of stress for nurses. How-
workload and burnout, although levels of burnout in her
ever, a small number of studies suggest that, whilst overall
study were lower than in related studies. The reasons for
reported stress levels may be similar, their ranking may vary
this variation are unclear, but seem likely to include differences
according to practice area. Foxall et al. (1990) found that
of stress ‘hardiness’ (Simoni & Paterson 1997), of coping
nurses working in intensive care ranked coping with ‘death
mechanisms (Payne 2001), of age and experience (McNeese-
and dying’ more highly as a source of distress than did those
Smith 2000) or of the level of social support in the workplace
in medical–surgical care, who ranked workload and staffing
(Ceslowitz 1989, Morano 1993, Healy & McKay 2000).
issues higher. Tyler and Ellison (1994) found that theatre
Inter- and intraprofessional conflict continues to be an
nurses ranked emotional aspects lower than did those work-
important source of stress for nurses. Interprofessional
ing in a liver unit, or in haematology or oncology. More such
conflict, particularly between nurses and physicians, appears
comparative studies are required, but from these few it
to be more of a problem (Hillhouse & Adler 1997, Bratt et al.
appears to be important that the NHS should consider that
2000, Ball et al. 2002). The impact of professional conflict as
nurses’ needs could differ between practice areas.
a source of distress is supported by findings that bullying is
636
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642

---

Integrative literature reviews and meta-analyses
Workplace stress in nursing
prevalent (Kivimaki et al. 2000). The recent ‘Working well’
et al. 2000), the data still suggest that perceptions vary
survey for the Royal College of Nursing (Ball et al. 2002)
considerably even between nurses working in the same area.
found that 30% of nurses on long-term sick leave reported
It is, therefore, too simplistic to suggest that any one, two
harassment and intimidation arising from sex/gender, age,
or even three sources of distress are the causal factors for all
race, sexuality or personal clashes as the main cause of their
nurses, or to consider that the transition of an individual
absence.
nurse from mild to severe distress can be predicted reliably at
Workplace stress is having a greater impact on today’s
present. This is also supported by the work of Foxall et al.
workforce (McGowan 2001, Shader et al. 2001). This
(1990), who found such variability between individuals that
suggests that stress intensity from the most frequently
they could not recommend generalization of their findings
recognised sources has increased, and/or additional sources
that sources of distress were ranked differently between
are contributing to the cumulative effects. In this respect it is
samples of nurses working in intensive care and medical/
interesting that some recent studies (Demerouti et al. 2000,
surgical care. Commonality of sources of distress, therefore,
McGowan 2001) also identified lack of reward and shift
cannot be assumed even for nurses within the same practice
working as major sources of distress, but these did not appear
area.
as significant stressors in earlier studies. These sources cannot
be considered as ‘new’, but rather they appear to have
Discussion: implications for the impact of
increased in relative significance. Interprofessional conflict
organizational interventions to reduce stress in
also appears to have increased in importance for many
nurses
nurses during the last 10 years or so (Ball et al. 2002). In
contrast, the emotional aspect of caring does not appear as
This section considers the review findings in light of
frequently in the recent literature as a source of distress as
interventions that have been introduced to reduce stress in
it did in earlier studies. The emotional costs of providing
nurses. It is perhaps noteworthy that until recently there has
care are unlikely to have reduced, and so it is possible that
been a scarcity of programmes to reduce work-related stress
the increased significance of sources such as reward have
for nurses in the UK (Jones & Johnston 2000).
assumed a greater significance for nurses. If this were so, then
it would suggest that the problem is becoming one of growing
Workload, leadership/management, professional conflict,
dissatisfaction with the terms and conditions of employment,
and ‘emotional labour’
rather than nursing per se.
In addition to identifying sources of distress, Demerouti
Workload, leadership/management, professional conflict, and
et al. (2000) sought to distinguish between the factors that
‘emotional labour’ have been the main collective sources of
were most likely to result in emotional exhaustion and (job)
distress for nurses for many years.
disengagement, the two main components of burnout arising
as a consequence of severe distress (see Table 1). They found
Workload
that job demands (viz. workload, time pressure, demanding
The most obvious means of reducing the workload of prac-
contacts with patients) were most associated with emotional
titioners is to ensure that staffing levels are adequate, inclu-
exhaustion, whereas job resources (viz. lack of participation
ding administrative staff who could reduce the paperwork
in decision-making, lack of reward) were most associated
burden on nurses (Finlayson et al. 2002). Recent funding
with disengagement from work. These findings extend
increases introduced by the Government promise improve-
understanding by distinguishing between the type of impact
ments in staff recruitment (Department of Health 2002a),
that major stressors may have, but in terms of their general
and the Department of Health (2003) has noted that there
meaning are in broad agreement with those of Stordeur et al.
has been ‘excellent progress’ in both recruitment and retent-
(2001) noted above. However, data from these two studies
ion of nurses during the past 2 years, even exceeding their
also identify that there are limitations to such attempts to
own forecasts. The document also looks forward to the
rank or categorize stressors. Thus, whilst Stordeur et al.
‘largest substantial increase in funding (of the NHS) of any
(2001) identify ‘workload’ as the most frequently reported
5-year period in its history’. However, Deeming and Harrison
stressor, even this made a relatively low contribution (22%)
(2002) and Finlayson et al. (2002) suggest that the rate of
to the variance in emotional exhaustion identified in that
increased recruitment cannot be sustained, as statistics have
study. Likewise, although the impact of the combinations of
been influenced by an initial large influx of employees from
stressors that contributed to exhaustion and disengagement
overseas and also by those returning to nursing after a
was much higher at 55% and 66% respectively (Demerouti
break in employment. Finlayson et al. also argue that
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642
637

---

A. McVicar
year-on-year increases in newly-trained nurses seem unlikely,
which development of a nurse–patient relationship is con-
as universities struggle to fill their student places. It will also
sidered essential (Williams 2001). Such ‘emotional labour’
be some time before a new initiative for Junior Scholarships
places considerable demands on those delivering health care
(Department of Health 2002c) to attract young people into
(Phillips 1996) and may reduce objectivity in caring (Wil-
nursing will make an impact. The Royal College of Nursing
liams 2001). Identification of the need to cope with sick
(RCN 2002) has identified that the NHS remains seriously
patients and their families as a source of distress for nurses,
understaffed, with an ageing staff profile, and so recruitment
therefore, is not surprising.
efforts perhaps should be seen as medium- to long-term
Smith and Gray (2001) suggest that new patterns in
measures that will produce little significant improvement in
learning to care are required to enable nurses to cope better
workload stress in the near future.
with the emotional demands of their work. Constructive
clinical supervision, mentorship and praeceptorship, under-
Leadership/management issues, and professional conflict
pinned by an effective leadership style, will have a signifi-
Introducing a participative strategy for management is at the
cant role to play here, especially for newly qualified nurses
heart of human resource proposals within the ‘NHS Plan’, a
(Charnley 1999, Gerrish 2000). However, the introduction of
long-term strategy for the delivery of health care in the UK
preceptorship schemes in the UK has been patchy (Charnley
(Department of Health 2002a, 2002b). Ensuring an inclusive
1999), and more effective mentorship is required to support
(i.e. ‘transformational’) leadership style would seem to be
nurses experiencing the emotional impacts of care (Smith &
crucial to improving staff retention. This style engenders
Gray 2001).
group cohesion and empowerment and has been found to be
inversely correlated with burnout in nurses, but a ‘transac-
Pay and shiftworking
tional’ leadership style that is interventionist and potentially
critical was positively associated with it (Stordeur et al.
Pay and shift work schedules seem to be becoming more
2001). The recent introduction of the Leading an Empowered
prominent as major sources of distress for nurses, to the extent
Organization training programme (LEO; developed by the
that they are displacing other sources in importance. Lack of
Centre for the Development of Nursing Policy and Practice,
reward is an increasing source of frustration (Ball et al. 2002)
University of Leeds, UK) for senior NHS staff is welcomed,
and contributes to role disengagement, a component of
together with proposals to extend the programme to more
burnout (Demerouti et al. 2000). There remains a disparity
junior nurses (RCN 2002).
of pay for newly qualified nurses when compared with that for
Improved leadership/management styles could also go some
police officers and teachers, two professional groups tradi-
way to reducing interprofessional and intraprofessional con-
tionally compared with nurses (Duffin 2001, Holyoake et al.
flict. Conflict with other professionals is a group cohesion/
2002), and nurses are especially aggrieved by governmental
management issue, and would seem to require a culture shift if
failure to address the issue of salaries (RCN 2002). Further-
the problem is to be eradicated. The Royal College of Nursing
more, proposals to remove clinical grades and to link pay to
(RCN 2002) has urged that this issue be addressed quickly, as
competency indicators through the ‘Agenda for Change’
harassment from doctors, supervisors, managers and col-
programme (Department of Health 1999) have not helped
leagues is an increasing cause of distress and absenteeism
to reduce anxieties over levels of pay (MacKenzie 2002).
amongst nurses (Kivimaki et al. 2000, Ball et al. 2002). The
Deeming and Harrison (2002) and Duffin (2002) suggest that
NHS now requires a commitment from managers to remove
improving pay is the only long-term answer to the UK’s nurse
harassment and discrimination (Department of Health
recruitment and retention difficulties. Improved funding of the
2002b). How and when moves towards a more inclusive style
NHS (Department of Health 2002a) may go some way to
of management will produce the culture shift required in
improving the situation, but it is questionable whether the
practice remains to be seen, but it may take some time before
anticipated pay awards will be sufficient recompense for the
the situation is sufficiently improved to have a significant
current level of workload (RCN 2002).
impact on stress reduction.
Shiftworking, particularly night shifts, traditionally attracts
pay enhancements but can have a significant effect on personal
‘Emotional labour’
and social life. Prolonged shiftwork, especially night shift-
Moves during the 1980s and 1990s to promote a more hol-
work, also has a health risk as it produces symptoms that
istic approach to care have altered the dynamic between
correspond closely to those of mild or moderate distress
nurses and patients, from one in which nurses might distance
(Efinger et al. 1995). Long-term night shiftworking has even
themselves from the emotional needs of patients to one in
been suggested to increase the risk of cardiovascular disease,
638
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642

---

Integrative literature reviews and meta-analyses
Workplace stress in nursing
although the data are inconclusive (Steenland 1996, Scott
Simoni & Paterson 1997), as do the levels of companionship
2000).
and social interaction at work (Ceslowitz 1989, Morano
There has to be equity in the allocation of shift schedules,
1993, Healy & McKay 2000). There will also be contribu-
and flexibility to reduce the social and personal impacts of
tions from sources outside the workplace. The study of Tyler
shift working. A possible reason for the recent appearance of
and Ellison (1994) provides an illustration of this, as it
shiftwork scheduling as a source of distress is that staff
identified that nurses living with a partner had fewer stress
shortages make it more difficult for nurses to choose when to
symptoms than those with no partner, and those with
work unsocial hours. This lack of choice runs contrary to
children experienced less stress from dealing with patients
NHS proposals (Department of Health 1998c). The situation
and relatives. The range of possible interactions between
will not be improved if prescriptive patterns of shiftworking
personal and workplace sources of distress is considerable,
for staff are introduced (Waters 2002). Indeed, the situation
but under-researched (Schaefer & Moos 1993, Jones &
may worsen if current pay modernization plans lead to
Johnston 2000).
reduced payments for working unsocial hours (Buchan
In view of the importance of personal factors in influencing
2002). The scheduling of shifts seems likely to remain a
the perception of stress, it is important for the NHS to
source of distress until the problems, exacerbated by staff
consider just how individual nurses might be supported,
shortages, are resolved satisfactorily. Difficulties with inter-
enabling them to utilize the most effective coping strategies
nal shift rotation are common reasons for nurses leaving the
that work for them as individuals, supported by colleagues
profession (Learthart 2000). An alternative 12-hour shift
and senior staff. Two principal coping strategies have been
pattern has been tried in some practice areas and in some
proposed: emotion-focused coping and problem-focused
studies has been found to be beneficial and popular, primarily
coping (Folkman et al. 1986). Research indicates that
because it can have social benefits (Reid et al. 1994, Gillespie
problem-focused coping, such as problem-solving, is the
& Curzio 1996, Bloodworth et al. 2001). However, other
more effective of the two at preventing burnout in nurses
studies suggest that fatigue levels and stress may be higher
(Ceslowitz 1989, Tyler & Cushway 1995, Simoni & Paterson
with 12-hour shifts (Fountain et al. 1996), possibly depend-
1997, Healy & McKay 2000, Payne 2001). An issue here is
ing upon the practitioner’s age (Reid & Dawson 2001).
the actual dimension that is employed (see Table 3). Thus,
Individual preferences appear to vary.
employing positive reappraisal or self-control (that is, posit-
ive emotion-focused dimensions) effectively decreases burn-
out (Ceslowitz 1989, Healy & McKay 2000, Payne 2001),
Individuality of stress perceptions
and so a combination of problem-focused coping with the
The preceding discussions suggest that organizational mea-
more positive emotion-focused dimensions ought to be most
sures to reduce stress for nurses are likely to have limi-
effective. Parkes (1986) refers to this combination as ‘direct
ted impact, at least in the short-term. This is partly because
coping’. The demand for organizational support and personal
of their limitations, but also because perceptions are not
consistent. An important finding from the current review is
Table 3 Dimensions within problem-focused and emotion-focused
that there is a lack of commonality between nurses’ percep-
coping strategies (derived from Folkman et al. 1986)*
tions of sources of stress, even where the main sources seem
Problem-focused coping
Emotion-focused coping
to be identified strongly by a sample (Demerouti et al. 2000,
Confrontative coping
Attempts at self control
Stordeur et al. 2001). Consequently, a collective evaluation of
Seeking social support
Distancing 
sources of distress for nurses in any given clinical area cannot
Planful problem-solving
Positive reappraisal
be predictive of ensuing distress in an individual. In addition,
Accepting responsibility
there is some evidence that different clinical areas may
Escape/avoidance, including
influence perceptions of which sources are the most import-
wishful thinking and short-term
ant (Foxall et al. 1990, Tyler & Ellison 1994). Measures
alleviating measures
such as smoking, drinking
introduced for the majority within a hospital, or even within
alcohol 
a single practice area, are therefore unlikely to meet the
needs of other staff. Variation between individuals in their
*‘Direct coping’ strategies are also recognized (Parkes 1986), which
utilize problem-focused dimensions with the more positive emotion-
perception of the workplace must be addressed.
focused ones.
The variation between individual perceptions is most likely
 These emotion-focused dimensions are typically viewed as being
to arise from differences in personal factors, as personal stress
negative and unhelpful, and have been associated with burnout
‘hardiness’ influences ability to cope (Boyle et al. 1991,
amongst nurses.
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642
639

---

A. McVicar
might be the development of biological stress tests based on
What is already known about this topic
evaluating changes in the secretion of biomarkers such as
• Stress is a subjective phenomenon based on individual
immunoglobulin-A in saliva (Ng et al. 1999).
perceptions, producing positive (eustress) and negative
(distress) perspectives.
Conclusions and directions for future research
• The workplace for nurses provides a multiplicity of
sources of stress.
Progression along the continuum from eustress to distress
• Recent organizational initiatives seek to reduce levels of
is subjective, depending upon the relationship between an
distress in nursing, particularly by addressing staffing/
individual and their environment. Thus, whilst there is recog-
workload, and leadership/management issues.
nition that workload, leadership style, professional relation-
ships, and emotional demands are the most frequently
reported major factors that cause workplace distress for
What this paper adds
staff, it is clear that their impact varies considerably. There
• The pattern of reported sources of stress for nurses may
are differences in the perceptions of nurses in different work-
be changing, with relatively greater emphasis on con-
places, and even between individuals in the same workplace.
ditions of employment, such as pay and shiftwork
The workplace is also not static: lack of reward and compli-
scheduling, which are likely to add to rather than
cations of shiftworking have been identified recently as
replace previously noted sources of stress.
further significant sources of distress for nurses.
• The effectiveness of organizational initiatives is likely to
Initiatives introduced by the NHS to address the problem of
be limited in the short to medium term, and may not
stress in nursing have the potential to go some way towards
resolve the issues for many nurses.
improving the situation, although more comparative studies
• Perceptions of nurses may differ between practice areas
are required to clarify how interventions might be directed at
but initiatives are not addressing this.
specific clinical areas. Improvements are most likely in
• Development of preventative strategies will be hindered
leadership/management styles and interprofessional conflict,
until employers enable individualized coping strategies,
but workload (i.e. staffing levels), emotional labour, pay and
and research enables understanding of personal and
shiftwork are likely to remain problems, at least for the
workplace interactions and provides a means of asses-
foreseeable future. Inadequate pay is increasingly a source of
sing the intensity of distress experienced by individuals.
distress, exacerbated by high workload and falling levels of
staffing. The UK Government and NHS are seeking to
improve the situation but, whilst initiatives will help, it is
training in stress management is clear: in a recent survey only
questionable whether they will remove the problem.
53% of nurses with significant signs of poor psychological
Distress arising from the workplace, therefore, will not be
health were receiving counselling or other supportive help
addressed overnight. If interventions that are targeted at
(Ball et al. 2002). The need for the NHS to provide further
sources of distress for the majority of nurses do not succeed,
stress management training is evident. However, there is
then what seems to be required is more support for nurses as
evidence that the coping dimensions employed by nurses vary
individuals. In order to identify how personal circumstances
with experience (Lees & Ellis 1990), and so the workplace
exacerbate workplace stress, and how they may be used to
may have to be flexible in facilitating coping amongst nurses
reduce stress, it is essential that personal/workplace interac-
of different levels of experience.
tions be researched. It is unreasonable to expect any indi-
Ensuring provision of professional, emotional and social
vidual to separate the workplace from their personal lives,
support in the workplace as part of stress management should
and more research is needed to identify how personal
be seen as being preventative. One of the main problems in
circumstances exacerbate workplace stress, and how they
this respect is that assessment tools are not predictive (Rick
may possibly be used to reduce stress.
et al. 2001). Until methods are improved, detection of distress
Support services should be preventative, so that health
in nurses is still only likely to identify clearly those who are
problems for nurses can be averted. This requires more
already showing symptoms associated with severe distress, as
research into identifying the most effective way of detecting
these are consistent and extreme (see Table 1). This is too
when individuals are experiencing early difficulties, and of
late. A means of accurately assessing an individual’s position
improving their stress management techniques so as to
on the stress continuum is urgently required. Better psycho-
prevent the transition to severe distress. Until the prediction
logical assessment tools are needed, but another possibility
of distress becomes possible, organizational initiatives to meet
640
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642

---

Integrative literature reviews and meta-analyses
Workplace stress in nursing
the needs of the majority remain the best starting point, but
Department of Health (1998b) The New NHS. Modern and
should not be expected to provide the answer for all nurses.
Dependable: A National Framework for Assessing Performance.
DH, London.
Department of Health (1998c) Working Together. Securing a Quality
Acknowledgements
Workforce for the NHS. DH, London.
Department of Health (1998d) A First Class Service. Quality in the
I would like to acknowledge the help of Sue Harrington,
New NHS. DH, London.
Research Administrator, in the preparation and proofreading
Department of Health (1999) Agenda for Change – Modernising the
of this article.
NHS Pay System. DH, London.
Department of Health (2002a) Human Resources and the NHS Plan:
A Consultation Document. DH, London.
References
Department of Health (2002b) Code of Conduct for NHS Managers.
DH, London.
Baglioni A.J. Jr, Cooper C.L. & Hingley P. (1990) Job stress, mental
Department of Health (2002c) Working Together – Learning
health and job satisfaction among UK senior nurses. Stress Medi-
Together. A Framework for Lifelong Learning for the NHS. DH,
cine 6, 9–20.
London.
Ball J., Pike G., Cuff C., Mellor-Clark J. & Connell J. (2002) RCN
Department of Health (2003) The NHS Plan – A Progress Report.
Working Well Survey. RCN Online, http://www.rcn.org.uk/pub-
DH, London.
lications/pdf/working_well_survey_inside1/pdf (last accessed May
Duffin C. (2001) Relatively speaking. Nursing Standard 15, 12–13.
2003).
Duffin C. (2002) On the pay treadmill. Nursing Standard 16, 12–13.
Bartlett D. (1998) Stress, Perspectives and Processes. Health psy-
Efinger J., Nelson L.C. & Starr J.M.W. (1995) Understanding
chology Series. Chapter 1. Stress and Health, OUP, Buckingham,
circadian rhythms: a holistic approach to nurse and shift work.
pp. 1–21.
Journal of Holistic Nursing 13, 306–322.
Bloodworth C., Lea A., Lane S. & Ginn R. (2001) Challenging the
Finlayson B., Dixon J., Meadows S. & Blair G. (2002) Mind the gap:
myth of the 12-hour shift: a pilot evaluation. Nursing Standard 15,
policy response to the NHS nursing shortage. British Medical
33–36.
Journal 325, 541–544.
Boyle A., Grap M.J., Younger J. & Thornby D. (1991) Personality
Folkman S., Lazarus R.S., Gruen R.J. & DeLongis A. (1986)
hardiness, ways of coping, social support and burnout in critical
Appraisal, coping, health status and psychological symptoms.
care nurses. Journal of Advanced Nursing 16, 850–857.
Journal of Personality and Social Psychology 50, 571–579.
Bratt M.M., Broome M., Kelber S. & Lostocco L. (2000) Influence of
Fountain I., Curzio J. & Hunt J. (1996) Issues involved in introducing
stress and nursing leadership on job satisfaction of paediatric
the 12-hour shift. NT-Research 1, 349–357.
intensive care unit nurses. American Journal of Critical Care 9, 307–
Foxall M.J., Zimmerman L., Standley R. & Bene B. (1990) A com-
317.
parison of frequency and sources of nursing job stress perceived by
Brown H. & Edelmann R. (2000) Project 2000: a study of expected
intensive care, hospice and medical-surgical nurses. Journal of
and experienced stressors and support reported by students and
Advanced Nursing 15, 577–584.
qualified nurses. Journal of Advanced Nursing 31, 857–864.
French S.E., Lenton R., Walters V. & Eyles J. (2000) An empirical
Buchan J. (2002) What’s it worth to work nights? Nursing Standard
evaluation of an expanded nursing stress scale. Journal of Nursing
16, 20–21.
Measurement 8, 161–178.
Carson J, Wood M., White H. & Thomas B. (1997) Stress in mental
Gerrish K. (2000) Still fumbling along? A comparative study of the
health nursing: findings from the Mental Health Care survey.
newly qualified nurses’ perception of the transition from stu-
Journal of Mental Health Care 1, 11–14.
dent to qualified nurse. Journal of Advanced Nursing 32, 473–
Ceslowitz S.B. (1989) Burnout and coping strategies among hospital
480.
staff nurses. Journal of Advanced Nursing 14, 553–557.
Gillespie A. & Curzio J. (1996) A comparison of 12-hour and 8-hour
Charnley E. (1999) Occupational stress in the newly qualified staff
shift system in similar medical wards. NT-Research 1, 358–365.
nurse. Nursing Standard 13, 33–36.
Hare J., Pratt C.C. & Andrews D. (1988) Predictors of burnout in
Clancy J. & McVicar A. (2002) Physiology and Anatomy: A
professional and paraprofessional nurses working in hospitals and
Homeostatic Approach, 2nd edn. Chapter 22: Stress., Arnold,
nursing homes. International Journal of Nursing Studies 25, 105–
London, pp. 611–633.
115.
Constable J.F. & Russell D.W. (1986) The effect of social support
Healy C. & McKay M.F. (1999) Identifying sources of stress and job
and the work environment upon burnout among nurses. Journal of
satisfaction in the nursing environment. Australian Journal of
Human Stress 12, 20–26.
Advanced Nursing 17, 30–35.
Deeming C. & Harrison T. (2002) The long view. Nursing Standard
Healy C. & McKay M.F. (2000) Nursing stress: the effect of coping
16, 12–13.
strategies and job satisfaction in a sample of Australian nurses.
Demerouti E., Bakker A., Nachreiner F. & Schaufeli W.B. (2000) A
Journal of Advanced Nursing 31, 681–688.
model of burnout and life satisfaction amongst nurses. Journal of
Hillhouse J.J. & Adler C.M. (1997) Investigating stress effect pat-
Advanced Nursing 32, 454–464.
terns in hospital staff nurses: result of cluster analysis. Social Sci-
Department of Health (1998a) The NHS Plan. DH, London.
ence and Medicine 45, 1781–1788.
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642
641

---

A. McVicar
Hipwell A.E., Tyler P.A. & Wilson C.M. (1989) Sources of stress and
RCN (2002) Royal College of Nursing Congress 2002 report sum-
dissatisfaction among nurses in four hospital environments. British
marised. Nursing Standard 16, 4–9.
Journal of Medical Psychology 62, 71–79.
Reid K. & Dawson D. (2001) Comparing performance on a simu-
Holyoake D., Singleton C. & Wheatley F. (2002) Answer the ques-
lated 12-hour shift rotation in young and older subjects. Occupa-
tion. Nursing Standard 174, 24.
tional & Environmental Medicine 58, 58–62.
Hope A., Kelleher C.C. & O’Connor M. (1998) Lifestyle practices
Reid N., Robinson G. & Todd C. (1994) The 12-hour shift: the views
and the health promoting environment of hospital nurses. Journal
of nurse educators and students. Journal of Advanced Nursing 19,
of Advanced Nursing 28, 438–447.
938–946.
Jones M.C. & Johnston D.W. (2000) A critical review of the
Rick C. & Perrewe P.L. (1995) Occupational Stress Handbook.
relationship between perception of the work environment, coping
Taylor & Francis, London.
and mental health in trained nurses and patient outcomes. Clinical
Rick J., Briner R.B., Daniels K., Perryman S. & Guppy A. (2001) A
Effectiveness in Nursing 4, 74–85.
Critical Review of Psychosocial Hazard Measures. HSE Books,
Kivimaki M., Elovainio M. & Vahteera J. (2000) Workplace
HMSO, Norwich. Also available at http://www.hse.gov.uk/
bullying and sickness absence in hospital staff. Occupational and
research/crr_pdf/2001/crr01356.pdf (last accessed May 2003).
Environmental Medicine 57, 656–660.
Sarafino E.P. (2002) Health Psychology. Biopsychosocial Interac-
Lazarus R.S. & Folkman S. (1984) Stress, Appraisal and Coping.
tions, 4th edn, Chapter 3. Stress – Its Meaning, Impact and
Springer Publishing, New York.
Sources. John Wiley & Sons, New York, pp. 70–96.
Learthart S. (2000) Health effects of internal rotation of shifts.
Schaefer J.A. & Moos R.H. (1993) Work stressors in health care:
Nursing Standard 14, 34–36.
context and outcomes. Journal of Community and Applied Social
Lees S. & Ellis N. (1990) The design of a stress-management pro-
Psychology 3, 235–242.
gramme for nursing personnel. Journal of Advanced Nursing 15,
Schmitz N., Neumann W. & Opperman R. (2000) Stress, burnout
946–961.
and locus of control in German nurses. International Journal of
Lehrer P.M. & Woolfolk R.L. (1993) Principles and Practice of
Nursing Studies 37, 95–99.
Stress Management. Guildford Press, London.
Scott A.J. (2000) Shift work and health. Primary Care; Clinics in
Leveck M.L. & Jones C.B. (1996) The nursing practice environment,
Office Practice 27, 1057–1078.
staff retention and quality of care. Research in Nursing and Health
Selye H. (1976) The Stress of Life. McGraw-Hill, New York.
19, 331–343.
Shader K., Broome M.E., West M.E. & Nash M. (2001) Factors
Lucas M.D., Atwood J.R. & Hagaman R. (1993) Replication and
influencing satisfaction and anticipated turnover for nurses in an
validation of anticipated turnover model for urban registered
academic medical center. Journal of Nursing Administration 31,
nurses. Nursing Research 42, 29–35.
210–216.
MacKenzie L. (2002) Lessons from the past. Nursing Standard 16,
Simoni P.S. & Paterson J.J. (1997) Hardiness, coping and burnout in
20–21.
the nursing workplace. Journal of Professional Nursing 13, 178–
McGowan B. (2001) Self-reported stress and its effects on nurses.
185.
Nursing Standard 15, 33–38.
Smith P. & Gray B. (2001) Reassessing the concept of emotional
McNeese-Smith D. (2000) Job stages of entry, mastery and disen-
labour in student nurse education: role of link lecturers and
gagement among nurses. Journal of Nursing Administration 30,
mentors in time of change. Nurse Education Today 21,
140–147.
230–237.
Morano J. (1993) The relationship of workplace social support to
Smith A., Brice C., Collins A., Mathews V. & McNamara R. (2000)
perceived work-related stress among staff nurses. Journal of Post
The Scale of Occupational Stress: A Further Analysis of the Input
Anaesthesia Nursing 8, 395–402.
of Demographic Factors and Type of Job. HSE Books, HMSO,
Morrison R.S., Jones L. & Fuller B. (1997) The relation between
Norwich.
Also
available
at
http://www.hse.gov.uk/research/
leadership style and empowerment on job satisfaction of nurses.
researchpublications (last accessed May 2003).
Journal of Nursing Administration 27, 27–34.
Steenland K. (1996) Epidemiology of occupation and coronary heart
Ng V., Koh D., Chan G., Ong H.Y., Chia S.E. & Ong C.N. (1999)
disease: research agenda. American Journal of Industrial Medicine
Are salivary immunoglobulin A and lysozyme biomarkers of stress
30, 495–499.
among nurses? Journal of Occupational & Environmental Medi-
Stordeur S., D’Hoore W. & Vandenberghe C. (2001) Leadership,
cine 41, 920–927.
organisational stress and emotional exhaustion among hospital
Parkes K.R. (1986) Coping in stressful episodes: the role of individual
nursing staff. Journal of Advanced Nursing 35, 533–542.
differences, environmental factors and situational characteristics.
Tyler P.A. & Cushway D. (1995) Stress in nurses: the effects of
Journal of Personality and Social Psychology 51, 1277–1292.
coping and social support. Stress Medicine 11, 243–251.
Payne N. (2001) Occupational stressors and coping as determinants
Tyler P.A. & Ellison R.N. (1994) Sources of stress and psychological
of burnout in female hospice nurses. Journal of Advanced Nursing
well-being in high-dependency nursing. Journal of Advanced
33, 396–405.
Nursing 19, 469–476.
Phillips S. (1996) Labouring the emotions: expanding the remit of
Waters A. (2002) Turns around the clock. Nursing Standard 16, 13.
nursing work? Journal of Advanced Nursing 24, 139–143.
Williams A. (2001) A literature review on the concept of intimacy in
Plant M.L., Plant M.A. & Foster J. (1992) Stress, alcohol, tobacco
nursing. Journal of Advanced Nursing 33, 660–667.
and illicit drug use amongst nurses: a Scottish study. Journal of
Williams S., Michie S. & Pattani S. (1998) Improving the Health of
Advanced Nursing 17, 1057–1067.
the NHS Workforce. The Nuffield Trust, London.
642
Ó 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 633–642

---