5.5 STRESS
5.5.1 Introduction
At a 1986 symposium on 10 leading work-related diseases and injuries, NIOSH investigators presented a draft national strategy for the prevention of psychological disorders (ASPH/NIOSH 1988). The strategy identified the following clinical disorders as attributable to job stress:
Estimates based on data obtained from the National Institute of Mental Health indicate that about 25% of the Americans aged 25 to 55 (the prime working age) suffered psychological disorders (ASPH/NIOSH 1988).
Hospital work often requires coping with some of the most stressful situations found in any workplace. Hospital workers must deal with life-threatening injuries and illnesses complicated by overwork, understaffing, tight schedules, paperwork, intricate or malfunctioning equipment, complex hierarchies of authority and skills, dependent and demanding patients, and patient deaths; all of these contribute to stress. In addition, the increasing size and bureaucracy of many hospitals may depersonalize the environment and leave many workers feeling isolated, fatigued, angry, powerless and frustrated. The brunt of these feelings may be borne by other workers patients, or the worker’s family. These feelings may also be expressed as apathy, loss of self-confidence, withdrawal, or absenteeism. Failure to recognize and treat the sources of stress results in workers who suffer "burnout" (i.e., those who remain on the job but cease to function effectively).
In 1977 NIOSH investigators published a study of hospital admissions for mental health disorders among 130 major occupational categories. Of the 22 occupations with the highest admission rates for mental disorders, six were health care occupations—health technologists, practical nurses, LPN, clinical laboratory technicians, nurses’ aides, health aides registered nurses, and dental assistants (Colligan et al. 1977). Another study reported that the proportional mortality ratio (PMR) for suicide was elevated for male dentists, physicians, medical and dental technologists, and female nurses. The PMR for suicide was also elevated among chiropractors and veterinarians (NIOSH 1983c).
Hoiberg (1982) examined occupational stress and illness among white male enlisted Navy personnel and found that mess management specialists and hospital corpsmen were more frequently hospitalized for stress-related illnesses than Navy personnel in other occupational groups. She also reported that the rate of hospitalization increased with tenure; those in their second enlistment period had hospitalization rates for stress-related illnesses that were nearly five times the rates for personnel in their first enlistment period. Those in their third decade of service were hospitalized twice as frequently as personnel in their second decade of service. Hospitalization rates for neuroses, transient situational disturbances, hypertension, and ulcers exceeded the rates for six other stress-related causes of hospitalization. Hoiberg (1982) reported that the following factors contributed to the stress experienced by mess management specialists and corpsmen:
This study Hoiberg (1982) reinforces existing information on stress among nurses and other occupational groups involved in direct patient care; it also indicates that hospital food service work should be considered a high-stress occupation.
5.5.2 Hospital Locations Associated with Stress
Workers are most likely to encounter severe stress in intensive care units, burn units, emergency rooms, and operating rooms.
5.5.2.1 Intensive Care Unit
One of the most stressful areas of the hospital is the intensive care unit ICU. Several studies of ICU nurses indicate that the following factors also lead to stress (Huckabay and Jagla 1979; Bailey et al. 1980; Gribbins and Marshall 1982):
5.5.2.2 Neonatal Intensive Care Unit
Gribbins and Marshall (1982) also examined stress among nurses in the neonatal intensive care unit (NICU). Over several years of employment, nurses progressed through various stages of stress. Initially the nurses were concerned about their competence in the new job. Later they raised questions about the job itself (e.g. they questioned the quality of life for NICU survivors). Still later they felt they had mastered the job and were indifferent because they did not receive enough positive rewards for their work. Those still in the unit after 3 years had developed a number of coping mechanisms such as humor and tolerance.
5.5.2.3 Burn Units
Koran et al. (1983) explored the problems of 37 health care workers in the burn unit of a 425-bed county general hospital to determine how their job stresses affected morale and patient care. Koran et al described the following emotional stressors of these workers:
5.5.3 Potential Health Effects
Stress has been associated with loss of appetite, ulcers, mental disorder, migraines, difficulty in sleeping emotional instability, disruption of social and family life, and the increased use of cigarettes, alcohol, and drugs. Stress can also affect worker attitudes and behavior. Some frequently reported consequences of stress among hospital workers are difficulties in communicating with very ill patients, maintaining pleasant relations with coworkers, and judging the seriousness of a potential emergency.
5.5.4 Causes of Stress
Factors commonly mentioned as causes of stress by all categories of hospital workers are as follows (NIOSH 1978c; Huckabay and Jagla 1979; Bailey 1980; Gribbins et al. 1982; Koran et al. 1983):
Other important stress factors include job specialization, discrimination, concerns about money, lack of autonomy, work schedules, ergonomic factors, and technological changes. These factors are discussed briefly in the following subsections.
5.5.4.1 Job Specialization
Increased job specialization has made it more difficult for workers to move to higher positions in the hospital. Specialized jobs are stressful and involve a higher rate of occupational injuries such as back strain and dermatitis.
5.5.4.2 Discrimination
Despite recent trends to the contrary, women and minorities still tend to be clustered in lower-level hospital positions.
5.5.4.3 Concerns about Money
Money matters are a significant source of stress for many hospital workers. Although hospital workers’ wages have increased over the past decade, the difference between the higher- and lower-paying hospital positions has also increased. Meeting financial obligations and facing the threat of possible unemployment can be real sources of stress, especially for workers who are the sole support of a family.
5.5.4.4 Lack of Autonomy
Frustration over the frequent lack of decision-making power is a significant stressor. Nurses sometimes feel demeaned when their observations and recommendations for patient care are ignored or overruled.
5.5.4.5 Work Schedule
The effects of stress can be made worse by shift work, especially rotating shift work. A NIOSH study of the effects of rotating shifts indicated that about 25% of the 1,219 nurses in the study regularly worked rotating shifts These nurses reported visiting clinics for medical problems significantly more often than those working regular shifts (NIOSH 1978a). More nurses on rotating shifts stated that they stayed away from work because of acute respiratory infections, upper and lower gastrointestinal symptoms, headaches, colds, and influenza. The nurses on rotating shifts also visited clinics more because of these complaints and complaints of otitis, pharyngitis, gastritis, menstrual disorders, dermatitis, nervous symptoms, sprains and strains, contusions, and crushed body parts (NIOSH 1978a).
5.5.4.6 Ergonomic Factors
Stress can also result from ergonomic factors such as the poor design of furniture, lighting, and equipment and the need to lift heavy patients.
5.5.4.7 Technological Changes
Technological changes have contributed increasingly to the stress of hospital workers in the past 5 years. The introduction of VDT's at ward desks, the rapid change in medication protocols, and the development of new procedures and equipment may all frustrate staff when they are not given adequate training and time to incorporate these changes into their work patterns.
5.5.5 Methods for Coping with Stress
Some of the methods that have successfully reduced hospital worker stress and dissatisfaction area as follows (Huckabay and Jagla 1979; Bailey et al. 1980; Koran et al. 1983):
Koran et al. (1983) attempted to improve the work environment in a burn unit by providing the nursing staff with feedback about their work setting and by helping the staff use that information to formulate and implement changes. Using survey results and a series of meetings between the staff and a psychiatrist, substantial improvements in staff morale were observed and the quality of patient care seemed to be improved. Koran et al. (1983) believed that these improvements were realized because:
