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

Introduction
Occupational stress in nursing is of global concern
(Lambert & Lambert 2001, Wong et al. 2006, Gonge
& Buus 2011, Hamdan-Mansour et al. 2011, Ward
2011, Happell et al. 2012). In one Australian study, for
example, almost three-quarters of the private and pub-
lic sector nurses surveyed reported their stress levels to
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
be reduced (Richardson & Rothstein 2008), meaning
health-care organisations may be in a position to ensure
that work-related stress is minimized. An initial step
towards reducing occupational stress is to understand
the stressors present in health-care environments and
ways in which they may be reduced.
Occupational stress can have an adverse effect on
nurses physical and psychological health (Laposa
et al. 2003, Chang et al. 2007, McKinney 2011), the
health-care organisations for which they work (Davey
et al. 2009, Foglia et al. 2010) and the general com-
munity (Safe Work Australia 2010). Although most of
the research involves correlational analyses (meaning
that claims about causation cannot be made), there is
a growing body of work suggesting that workplace
stress is associated with poor health outcomes, such as
physical illness (Callaghan et al. 2001, Weyers et al.
2006, Chang et al. 2007), diminished mental health
(Chang et al. 2006, 2007, Ward 2011), symptoms of
depression (Lin et al. 2010) and post-traumatic stress
disorder (Laposa et al. 2003). Organisational conse-
quences of nurses stress include staff turnover (Lavoie-
Tremblay et al. 2008, Foglia et al. 2010), significant
levels of staff intending to leave (Laposa et al. 2003,
Coomber & Barriball 2007) and absenteeism (Davey
et al. 2009). In addition to the significant financial
burden of replacing staff when they are absent or
resign, the education and training of new nurses and
the compensation paid to those with work-related
health conditions is also costly (Marine et al. 2006). In
Australia, for example, nursing has one of the highest
rates of workers compensation claims for work-
related mental disorders associated with mental stress
(Safe Work Australia 2010).
A comprehensive review of the literature has identi-
fied six main stressors of nurses in relation to adult and
child care nursing (McVicar 2003). These stressors
are: (1) workload/inadequate staff cover/time pressure;
(2) relationships with other clinical staff; (3) leadership
and management style/poor locus of control/poor group
cohesion/lack of adequate supervisory support; (4) cop-
ing with emotional needs of patients and their families/
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Journal of Nursing Management, 2013, 21, 638647
Nurses and occupational stress
poor patient diagnosis/death and dying; (5) shift work-
ing; and (6) lack of reward. Although there is a large
and growing body of knowledge of the stressors that
nurses experience, these findings suggest stressors have
changed over time. Specifically, shift working (Hayes
et al. 2006, Lavoie-Tremblay et al. 2008, Barker &
Nussbaum 2011) and lack of reward seemed to have
gained greater prominence as sources of stress. Further,
practice areas (Tyler & Ellison 1994). These findings
suggest that it may be important to clarify the sources
of stress for nurses as a precursor to designing and
implementing interventions that target stress levels.
The occupational stressors nurses experience can dif-
fer between countries (Burnard et al. 2008, Glazer &
Gyurak 2008), between jurisdictions within the same
country (Glazer & Gyurak 2008, Lim et al. 2010) and
between urban and rural areas (Gonge & Buus 2011).
Such differences may be attributed to variations in
factors such as cultural values (e.g. collectivism versus
individualism), education and training, health-care
policy, geopolitics (e.g. nursing wounded soldiers from
the IsraelPalestine conflict), national economic pros-
perity, nurse-to-patient ratios and the availability of
other health-care professionals (Glazer & Gyurak
2008). In Australia, where the present study was
based, systematic review evidence suggests that nurses
commonly experience several stressors, including heavy
workloads, conflicts between colleagues, working with
inadequately prepared or inexperienced staff, aggres-
sive patients and relatives, role ambiguity and shift
work (Lim et al. 2010). The implication of these
findings is that health-care administrators who wish to
implement programmes to reduce nurse stress should
better understand local stressors before embarking on
change initiatives. This implication is particularly
pertinent as most research examining stress in nursing
has been conducted in metropolitan areas and may
therefore not be reflective of specifically regional
issues.
During the last decade, there has been increased
focus on reducing occupational stress in nursing
(McVicar 2003). One way to conceptualize workplace
stress management interventions, in general, is to
group them into primary, secondary, and tertiary
prevention strategies (Landy & Conte 2010). Primary
prevention strategies aim to modify or eliminate stres-
sors (e.g. work design, cognitive restructuring), second-
ary strategies target responses to the inevitable
stressors (e.g. relaxation techniques, social support)
and tertiary strategies promote healing from the
negative effects of stressors (e.g. employee assistance
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

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

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640 Journal of Nursing Management, 2013, 21, 638647

scribed verbatim. The interview transcripts and field
notes were used as the material for the analysis.
Analysis
To provide a rich description of participants experi-
ences, inductive content analysis was used (Skinner
et al. 2003, Braun & Clarke 2006). Each research
team member received a copy of the transcripts and
independently read them as a whole to obtain a feel
for the content. Emerging statements and passages
that captured sources of stressors and ways in which
the organisation could help to reduce stress were
extracted and subsequently coded. Following this
initial process, the codes were then grouped to form
conceptual themes. The research team met to discuss,
compare and revise identified themes until consensus
on relevance was reached.
Findings
Sources of stress
Twelve sources of stress emerged from the material of
the six focus groups: high workloads, unavailability of
physicians (referred to by participants as doctors),
unsupportive management, human resource issues,
interpersonal issues, relatives of patients, shift work,
car parking, handover, no common space for nurses,
not progressing at work and patient mental health.
Each subtheme is briefly discussed and textual exemp-
lars are coded according to whether the respondent
was a ND, NUM or RN.
High workloads
Nurses reported experiencing stress because of high
workloads resulting from inadequate skill mixes
(imbalances of nursing staff with low and high levels
of skills and experience), staff shortages, too many
patients, patient acuity, using specialized equipment
and having to perform activities other than direct
patient care (e.g. organising travel forms). High work-
loads also resulted in nurses missing scheduled breaks:
Its the staffing shortages and the skill mix
shortages people still keep coming in the
doors, irrespective of what [the] workload is
Theres very little downtime for nursing staff
anymore. Its fast paced activity. So thats a
major stressor.
(ND)
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Nurses and occupational stress
Unavailability of doctors
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
doctors rostered on to their wards:
One of the main things was not having a ward
call doctor at night time, to deal with the night
duties and that loaded our stress up really
high. And you really need that ward call doctor
during the night shift, to help us through the
night.
(RN)
Unsupportive management
A number of participants reported stress being exacer-
bated by limited support from those in senior manage-
ment positions:
I personally dont feel that were very well
supported by management, or listened to even.
None of our concerns that we raise ever go any-
where. Were not told were doing a good job.
(RN)
However, these perceptions were not shared by all
of the nurses, with several mentioning they felt that
their managers supported them well; some expressed
empathy toward their managers and the work pres-
sures that they may be experiencing.
Human resource issues
Several focus group participants reported experiencing
issues with the human resources functions of their
workplaces. Two issues that came to the fore were the
deletion of staff from casual employment lists and
incorrect payments. Nurses who worked periodically
were automatically deleted from the casual employment
list if they did not work for several months. These dele-
tions meant that nurses had to complete an employment
starter pack again, which discouraged some nurses
from working for the organisation. The underpayment
of staff was reported to be a common occurrence:
But the frustrating side of that as well is the
pay. The staff, they work the shifts, and then
their pays are wrong. Week after week their pays
are incorrect.
(NUM)
Interpersonal issues
The nurses identified three interpersonal issues that
caused them stress: bullying, communication prob-
641
B. Happell et al.
lems and conflict between nurses. Some participants
stated that bullying was still present in health-care
workplaces. With regard to communication, nurses
perceived that not all information regarding the care
of patients was being properly documented. With
several clinicians (sometimes from different wards)
involved in the care process missed communications
affected the care of patients and contributed to the
stress of nurses:
I find that on [the] day surgery pre-admission
clinic because we deal with a lot of doctors and
allied health. So you might think the patient is
progressing this way and someone else will come
in and say no, this has got to happen first. But if
its documented and not communicated, it gets
missed so I think communication is one of the
biggest issues.
(NUM)
Some nurses stated that conflicts arose between
nurses because of demanding workloads. For example,
nurses starting a shift sometimes came into conflict
with the nurses finishing their shifts when work had
not been completed because of workload pressures
during that shift.
Relatives of patients
Some nurses described feeling stressed because of the
demands placed on them by relatives of patients.
These demands can be exacerbated if the relatives take
their concerns to others in the health-care organisation
(e.g. going to the liaison officer to get permission to
be with the patient outside of visiting hours). The
nurses indicated that some relatives could be quite
unreasonable in their requests:
It happens all the time. The family ring up, we
dont want him back until hes well. Well,
whats well and how long is it going to take?
Where is he going to go in the meantime? Were
not designed for that but unfortunately were
being forced into a corner where we are now
having to put these people weve had people
on this ward for 11 months because the families
jump up and down.
(RN)
Shift work
Having to work shifts was a stress in the working
lives of several participants. Shift work was a physical
642
stressor for some nurses, leaving them feeling tired,
especially when their family lives prevented them from
obtaining adequate sleep:
Well, its crap. Like its not normal working
night shift and you know you work a couple of
night shifts and then youll have one or two days
off. And come back exhausted still from the
night shift.
(RN)
Car parking
The site hospital where the participants work does not
provide designated parking areas for staff. As a result,
some nurses mentioned that car parking caused them
stress. They often had to park some distance from the
hospital, and reported using lunch breaks to move
their cars closer to work for safer access when they
finished their shifts. Knowing they needed to find a
car park often resulted in nurses feeling stressed before
they even commenced work:
Im thinking, Oh, where am I going to go to
try and find a park today? Should I try here first
or should I try down there? and, so Im already
stressed by the time I get in, cause Im going,
Oh, Ive got three minutes to get in.
(RN)
Handover procedures
Several nurses discussed how the handover procedures
in their ward made them feel stressed. Handovers
occurred at the bedside and the nurses reported feeling
uncomfortable discussing personal matters within
earshot of other patients and relatives:
and some confidentiality stuff, it shouldnt be
mentioned in the handover at the at the bed-
side.
(RN)
No common area for nurses
A stressor consistently mentioned was the lack of ded-
icated common areas for nurses to relax during their
breaks (e.g. tea rooms). Nurses reported having to
stay predominantly in and around their work areas
throughout the day, which resulted in them not feeling
that they were able to talk and informally debrief with
other staff:
people dont leave their work area previ-
ously everyone would go down to an area and
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Journal of Nursing Management, 2013, 21, 638647
 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:
Having situations where were in were deal-
ing for patients that we dont actually feel
trained to deal with, like the mental health
patients, but trying as hard as we can as a ward,
and then having our professionalism questioned.
(RN)
disagreement between focus group participants, with
some nurses perceiving that more staff may encourage
absenteeism:
It might bring relief at the moment, but then
people will start thinking, oh such and such will
do my work today, Ill just call in sick, I dont
need to work today.
(RN)

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

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Journal of Nursing Management, 2013, 21, 638647 643
B. Happell et al.
Ensuring that nurses get breaks. Some nurses men-
tioned how they seldom got breaks when they were
on their wards. Having these breaks was proposed as
a way of managing their stress levels:
Another benefit, I suppose, is making sure that
people get their time out. Thats not always the
case. We dont always say, okay, go. Because
theyve got the old Catholic guilt that nurses get
embedded into them as part of the military train-
ing we go through. You will look after the
patient, no matter what. If the patient dies, its
your fault and your fault only and youre the
one to blame. Versus okay, well sometimes they
need to step back.
(ND)
Leadership within the ward. The ND argued that the
leaders within a ward have a significant role in man-
aging the stress levels of their staff. If nurse leaders
can effectively control the work that is going on in
wards, then stress levels too are likely to be managed:
One individual in the unit, the shift coordinator,
who starts spinning, causes the whole unit to
spin out of control and become highly stressed.
The same goes for a nurse unit manager. A nurse
unit manager who enters that unit and goes hang
on, its okay, everybody calm, take a breath, we
can do this, the whole unit de-escalates in their
stress and just gets on and does the job. But if
that one key person isnt within the unit, going
thats okay, its alright, then they just they feed
off each other into a very stressed and frenzied
kind of practice.
(DN)
Non-ward-based initiatives. Nurses mentioned several
initiatives for relieving stress that related to things
other than the care of patients. Although these are
identified within a single subtheme, many of these ini-
tiatives can be classed as either primary or secondary
strategies. The initiatives the participants identified
included providing opportunities for exercise (e.g. pro-
viding changing facilities for those who cycle or run
to work, or running Tai Chi or yoga classes for
nurses), childcare facilities, places for nurses to take
time out from busy wards (e.g. tearooms), bar facili-
ties, car parking improvements, designated smoking
areas and social events. With regard to the last of
these initiatives, the nurses indicated that social activi-
644
ties were effective in relieving stress, but occurred
infrequently:
Well, our unit has just started the ball rolling
with the whole social outing thing just last week
actually because we have been so under pressure
and so stressed and all that sort of thing and
someone said, Look we need to band together
and be a bit more of a team, which we are. We
are a good team but you can tell that the stress
is getting to us sort of thing and so we said,
Well once a month why dont we get out and
do the whole bonding session thing and get out
and do something?. I think I noticed Saturday
morning straight after the dinner that everyone
was probably a little bit more relaxed and had a
bit of down time sort of thing to get out and actu-
ally do something rather than just go to work, go
home, go to work, go home sort of thing.
(RN)
Secondary strategies
Music. Several nurses suggested that the playing of
music in their wards would help to relieve stress:
Do you know, if you go into the medical unit,
theyve got the radio cranked way up in the
treatment room? You go in there. Oh my god.
But theyre all jiving [dancing] in there and
whatever. Good on them.
(RN)
Special events. The holding of simple special events
was suggested as one way of boosting morale and
reducing stress. Events that the nurses mentioned
included acknowledging birthdays and crazy shirt
days.
Organisational development. The NDs described an
organisational development philosophy that could be
employed within wards to reduce nurse stress levels.
Independently of this discussion, however, nurses
seemed sceptical of the value of team building.
Team building stuff doesnt [work]. I mean, Ive
been through it in units in [another city], it was
actually flagged as a unit at risk and we did the
big bonding thing and I guess Im a little bit neg-
ative about it because it actually just proved
exactly what we said was the case. Abusers were
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Journal of Nursing Management, 2013, 21, 638647

the abusers and everybody said, Oh rah, rah,
we had a bonding day, that was good, wasnt it
and you think, no, it actually just proved that
harassment is alive and well.
(RN)
Acknowledgement from management. A theme that
emerged consistently throughout the focus group dis-
cussions was how nurses felt that their managers
under-appreciated the work they did. A simple thank
you was perceived as one way that they would feel
more acknowledged:
I think just better communication. A bit of
respect, a bit of acknowledgment.
(NUM)
Tertiary strategies
Massage therapists on the wards. Several nurse man-
agers suggested that having massage therapists come
to the wards would be an effective way of reducing
stress. Independently, however, some nurses argued
that massage therapists would be dealing with the
symptoms of stress and not actually addressing the
stressors present within the ward. As such, this initia-
tive is better represented as a tertiary strategy:
A colleague was just telling me about some
work that shed come across at another regional
hospital where they actually did have a massage
person come on one day a week. That person
would go to each ward and everyone was there
and given like a 5-minute head and neck. Some-
thing like that, would that be something, you
know?.
(ND)
Discussion
Although many of the stressors the nurse participants
described in this study are commonly found in the
nursing literature (e.g. heavy workloads, interpersonal
issues, unsupportive management, shift work; McVic-
ar 2003, Lim et al. 2010), several of the issues raised
in the focus groups seemed to be localized (e.g. car
parking, handover procedures, no common area for
nurses). The majority of participants in this research
suggested the need for a space for nurses to meet and
interact. This point has not previously been raised
through research about nursing stress. However, com-
mon space, has been identified as a way to increase
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Journal of Nursing Management, 2013, 21, 638647
Nurses and occupational stress
perceived social support for nurses (Gaynor et al.
1995). Research findings suggest that nurses value
positive team interaction within the working environ-
ment (Day et al. 2007b) and consider it crucial to
enhance morale in the nursing workforce (Day et al.
2007a). Addressing the need for team interaction
through organisational change and enlightened leader-
ship has been identified in the research literature
(Chiok Foong Loke 2001, Greco et al. 2006, Giallo-
nardo et al. 2010). There may, however, be more
practical strategies to reduce stress levels, such as pro-
viding common space for nurses. This approach would
have the additional benefit of empowering nurses to
recognize their own stress and work together in a col-
legiate fashion to reduce stress where possible.
Some stressors apparent in the Australian literature
(e.g. working with inadequately prepared or inexperi-
enced staff, aggressive patients and relatives, and role
ambiguity; Lim et al. 2010) were not mentioned in
this study. Given the evidence that nurse stressors can
differ between jurisdictions within the same country
(Glazer & Gyurak 2008, Lim et al. 2010), and
between urban and rural areas (Gonge & Buus 2011),
the presence of both commonly shared, as well as
unique local stressors should not come as a surprise.
However, the finding, does reinforce the need to inves-
tigate stressors in local settings before embarking on
stress reduction initiatives.
Almost all initiatives that nurses suggested could
help reduce stress can be classified as either primary
or secondary prevention strategies (Landy & Conte
2010). One theme that emerged through the focus
group material (non-ward-based initiatives) was classi-
fied under two headings because it contained both
primary and secondary prevention strategies. Only
one initiative (massage therapists on the wards) could
be classified as a tertiary prevention strategy. These
findings seem positive because the nurses suggestions
were predominantly aimed at reducing stressors or
improving their responses to stressors, rather than
dealing with the consequences of stress.
Nurses serve to gain greatest benefit if interventions
include both personal-directed intervention, such as
coping skills training, and work-directed intervention,
such as reducing workloads (G unus en & Ust un
2009). Although person-directed interventions,
adapted for nurses working in hospital, can be effec-
tive in reducing the levels of emotional exhaustion,
the outcomes demonstrate a short-term effect that
needs to be repeated on regular basis.
The findings of this study support the importance
of managers understanding nurse stressors in their
645
B. Happell et al.
particular organisations. There is now a large body of
research literature describing the manifestations of,
and contributing factors to stress in nurses (for
reviews, see McVicar 2003, Lim et al. 2010). This lit-
erature can be informative for managers. However, a
sound understanding of the experiences of nurses in
their own organisations would appear to be a prere-
quisite for addressing nurse stress issues. Implementing
mechanisms to facilitate two-way communication with
nursing staff is likely to enhance the perception of
nurses that they have organisational support, and
therefore reduce one of the major stressors frequently
identified in the literature (Chiok Foong Loke 2001,
McVicar 2003, Gelsema et al. 2005).
By establishing mechanisms for effective communi-
cation, nurses at all levels across specific health-care
settings can contribute to the reduction of stress and
the enhancement of job satisfaction at both individual
and systemic levels. Not only would this assist with
the identification of strategies relevant to the specific
service, it would contribute to nurses sense of
empowerment. Being empowered in itself is likely to
have positive benefits in reducing the impact of stres-
sors associated with nursing work (Greco et al. 2006).
The findings of the current study suggest that, given
opportunities, nurses are able to identify strategies
that would create more positive working environ-
ments. Not all strategies may be easily implemented
or financially viable, but the active involvement of
nurses in the identification and implementation of
strategies is an important starting point.
Conducting this research in a rural setting is a par-
ticular strength of this work. Most research on this
topic has been conducted in metropolitan settings and
is likely to have missed important factors that may be
specific to a rural environment.
Limitations
The qualitative nature of this research limits the
extent to which these findings may be generalized to
broader settings, particularly given that the research
setting was located in a regional area. Further research
should focus on a broader range of geographical
settings to increase the understanding of environmen-
tal factors on nursing stress.
Conclusions and implications for nursing
management
The stress associated with nursing work has been
extensively documented over several decades. The
646
findings presented in this paper highlight the impor-
tance that nursing stressors are contextualized and
promote the importance of involving nurses in the
identification of solutions. The literature has been
much more effective in emphasizing the problems than
in identifying the solutions, and to avoid this cycle
continuing a greater focus must be placed on moving
from discussion to action. The more nurses can be
involved in this process, the more positive the out-
comes are likely to be.
Acknowledgements
The authors extend their thanks to the Queensland
Nursing Council for providing the funding for this
research and to the nurse participants who gave so
freely of their time. Thanks also to those who assisted
with the conducting of this research, including
Matthew Johnson, Lynn Jamieson, Sue Williams,
Christina Hunt and Jodie Morris.
Source of funding
The project was funded by Queensland Nursing Council.
Ethical approval
Ethics approval was obtained from Central Queens-
land Universitys Human Research Ethics Committee
(EC00158) and Queensland Healths Research Ethics
Committee (EC00334).
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