Work-Related Stress in Healthcare

Chapter 1 Introduction

Work-related stress is predominant across all the occupations, but it is significantly higher among the professionals in the healthcare sector. By definition, work-related stress refers to any harmful reaction resulting from undue demand and pressures placed in the workplace (Buckley, 2016). HSE (2017) defined work-related stress as any form of cognitive, emotional, psychological and behavioural reactions exhibited in the workplace with the intent of affecting any employee. Stressors are almost invariably encountered in every workplace, and both the employers and employees can contribute the occurrence of stressful conditions in the workplace (Anisman, 2015). Regardless of the place of origin, the workplace stressors have enormous ramifications on human health and wellbeing. Work environment as defined in the study by Munnangi et. al., (2018) refers to the physical, psychological and social characteristics of the workplace setting and is an important predictor of stress, burnouts as well as job satisfaction among the nurses. The current study utilises an extended literature review to investigate the methods that the nurses use to manage work-related stress. The section is categorised in four sections. The introduction part offers background information and rationale for the study. The methodology section provides information on the procedure used to select articles. The results section arranges the articles thematically while the discussion section compares current findings with existing literature.

Background Information, Rationale and Focus of the Study

Several studies and reports reveal high incidences of work-related stress. For instance, the report by House and Safety Executive (2018) stated 595,000 cases of work-related stress across all occupations with 2,760 cases out of 100,000 workers reported related to nursing and midwifery. A cross-sectional study by Weigl et, al., (2016) reported that, a third of new cases of ill health among the health care employees, especially the nurses, were as a result of work-related stress especially high emotional exhaustion and depression. Work-related stress also resulted in loss of 31 working days among nurses as nurses took time to recover from occupational stress (Cope, Jones, and Hendricks, 2016). HSE (2018) also reported that, the occurrence of anxiety, stress, and depression among healthcare workers resulted in the loss of £12.8 million. Work-related stress can result in psychological distress, physical and mental illness resulting in global and national recessions, job insecurity, work intensity, and disruption in children mental strength due to disrupted parenting, all resulting in interpersonal conflicts and greater workloads. Various factors contribute to work stress with any clinical settings, although low nurse to patient ratio is a key facilitator of stress among nurses (Anisman 2015). Other factors include difficulty in building interpersonal relationships with physicians (Trépanier, Fernet, and Austin, 2013), violence and abuse among patients (AbuAlRub and Al-Asmar, 2014), relatively high workload especially for nurses in the intensive care unit (van Mol et al., 2018), emotional exhaustion and lack of social support (Adriaenssens, De Gucht, and Maes, 2015), and poor patient outcomes such as death (Ko and Kiser-Larson, 2016). Since most studies on work-related stress among nurses focus on factors influencing the occurrence of stress (Zhang et al., 2018), and impacts of occupational stress among the stress on the nurses (Blomberg et al., 2016), there is proper need for the formulation and implementation of the most effective approaches, which can be used for the prevention and management of the already identified workplace stressors. Assessing stress among the nurses, the first step towards eliminating the sources of stress (Zúñiga et al., 2015). The International Labour Organisation considers stress as a harmful emotional or physical response which occurs due to disparities between perceived available resources and demands and the inability of an individual to cope with such demands (Burton et al., 2017). For that matter, the occupational stress is in the most cases determined by the work environment, work design, labour relations and mostly develops in a situation whereby job demands fail to match or exceed available resources, capabilities or overall needs of employees.

The number of trained nurses leaving the profession in the UK has been increasing in recent years. During 2016-2017, 29000 (5%) nurses and midwives left the nursing profession as compared to 21,000 (3.6%) in 2012 (House of Commons Health Committee 2019). 33 % of nurses leaving NHS cited work-related stressors such as increased workload, psychological and physical assaults from the patients and their families, poor management of nursing welfare (House of Commons Health Committee, 2018). Due to the increasing cases of occupational stress among the nurses, and health care providers Duncan et al., (2001) observed that, the problem could not be ignored by the National Health Service (NHS) which spends approximately £300 million and £400 million every year. Since complete eradication of work-related stress is impossible in the workplace, as indicated by Tee et al., (2016), methods which can manage work-related stress based on available empirical evidence should be explored. The Health Education England (HEE) has proposed that, there is a need for the government to improve the quality of working condition of the nurses in order to reduce the turnover cases. However, government healthcare policies focus on formulating and implementing strategies that can help in increasing the number of new nurses (Buchan et al., 2019). For that matter, it is justifiable to note that the current approaches used by the government may help in addressing the medium and long-term nursing shortage, but cannot act as immediate strategies for addressing work-related stress. As an approach of preventing and managing different forms of occupational stressors among the nurses, Royal College of Nursing (2013) developed proper guidelines for work-related stress. The strategies are vital tools to help employers, employees and their representatives in assessing and identifying potential causes of stress. Royal College of Nursing (2013) stress management standards address six elements including control, demand, social support, role clarity, interpersonal performance and involvement in the organisational change. Currently, the nurses in the United Kingdom experience occupational stress on a higher frequency compared to other professionals in the United Kingdom (House of Commons Health Committee, 2018). Particularly, their wellbeing, associated with job demands and changes in the workplace are low, hence a clear indication that there is need for urgent actions to be taken in order to address such issues. Hospital environments are a major source of work-related stress, which affects several facets of quality healthcare including job satisfaction nurse’s health and patients welfare (Koinis et al., 2015). However, studying how nurses manage work-related stress offers insights on how to advert its associated consequences Various studies on occupational stress among nurses have largely been based on a quantitative approach(Hayes, Douglas, and Bonner, 2015; Harzer and Ruch, 2015), although use of such positivist methods and questionnaire approach has been criticised for presenting inadequate examples based on answer keys and checklists (Berjot and Gillet, 2011). Thus, qualitative narrating approaches provide the best alternative for assessing such factors. In this case, the study utilises a qualitative approach in form of an extended literature review to investigate how nurses cope with work-related stress.

Chapter 2 Methodology Review

In this section, a critical analysis of the collected evidence from the selected studies was conducted. An extended literature review (ELR) is a methodological approach, which is used to extract and analyse the data. Aveyard (2011) defined ELR as the process of conducting a comprehensive study and interpreting literature which share a close relationship with a particular question. The first step in conducting an ELR is identification of the research question followed by a methodological process of answering the question. Appraising and analysing relevant literature via a systematic approach is the last stage. Siu and Comerasamy, (2013)observed that ELR is a comprehensive search process that utilises numerous available resources in a methodological and structured style to identify appropriate data for answering the formulated clinical questions. Available evidence in the first section indicated that, occupational stress is rampant among nurses and negatively affects clinical outcomes for patients and healthcare professionals. Therefore, the main reason for using an ELR as a methodological approach for the current study is to identify factors which promote the occurrence of occupational stress among the nurses and suggest approaches used to prevent or manage such factors. Performing an ELR in a rigorous manner and systematic fashion ensures transparency, reliability, validity of data and reduces bias. In order to minimise bias, an inclusion and exclusion criteria were used for the study selection process based on Nursing Midwifery Council 2018 CODE of quality care (NMC, 2018).

2.1 Formulating the Question

The Population Intervention Comparison and Outcome (PICO) approach is a common approach, used to investigate quantitative articles. For qualitative studies, PEO format which addresses the population, exposure, and outcome is commonly utilised. Use of either PICO or PEO format is dependent on the research question under investigation. Since, the qualitative studies largely lack an intervention and comparison where the data could be compared to, the PEO format which addresses three key elements including the exposure is used. In the above case, the population under investigation is composed of nurses, exposure is varying types of occupational stress, and the outcome is coping or management of stress as summarised by Table 1 below. Thus, the question under investigation will be: What strategies are used by nurses (P) to cope with various forms of occupational stress (E) in hospital settings (O)?

2.2 Keywords and Boolean Operators

The use of keywords during the search process helps in the identification of the most appropriate research studies with comprehensive data for answering the research question (Stannard, 2012a). Since the databases are often composed of studies explaining different concepts, using keywords is necessary for the selection of studies that would meet the conditions of the inclusion criteria. In order to increase the chances of obtaining large number of studies with appropriate information, Aveyard (2019) explained that, there is need for the researchers also to consider using the synonyms of the selected keywords. Specific to this study, the following keywords were used; nurses, stress, burnout, and stress management. Furthermore, different types of Boolean operators were used for combining two or more keywords during the search process. Aveyard (2019) encouraged, the use of Boolean operators such as ‘AND,’ ‘OR’ among others to act as linking words. In this study, the Boolean operators were used to link two keywords. For example, nurses AND stress, work-related stress OR occupational stress, burnout OR fatigue, Stress AND burnout were used during the search process as indicated in Table Furthermore, truncation symbol (*) was used during the location of alternative word endings or stems. Based on the fact that the use of such symbol led to the production of limited number of studies hence use of that symbol was discontinued.

2.3 Online Electronic Database

Electronic search process was conducted on different databases with the aim of selecting relevant articles to be reviewed in order to help in answering the research question. Based on the information presented by Polit and Beck, (2009) and Aveyard (2019), it is justifiable to note that, the collection of online resources from the electronic databases allow for the identification of specific journals hence providing the researchers and reviewers with the opportunity of systematically searching for the most relevant studies. Because, there are very many databases, which host studies about the nursing and work-related stress, assessing the authenticity and reputability of those databases before conducting article search process on them was important for ensuring that the final studies were of the right quality. Polit and Beck (2018) stated that, the researchers must employ broad and critical thinking skills during the formulation of the inclusion and exclusion criteria that will be used for the selection of the studies to be reviewed. The selected research studies were obtained from the following databases; CINAHL, PubMed and British Nursing Index. In a situation, whereby the selected studies did not have readily available subscriptions, the reviewer made sent the request to the management of Royal College of Nursing (RCN) Library and Heritage Centre for the provision of such studies. Furthermore, Google Scholar search engine was used for obtaining the full texts of the studies which were not readily available on the selected electronic databases. Table 2 below shows a detailed description of the rationale that led to the selection of the databases used in the search process.

2.4 Inclusion and Exclusion Criteria

The criterions was important for ensuring that only studies with relevant data that could answer the research question were considered for review. Polit and Beck (2009) and Aveyard (2019) supported, the use of inclusion and exclusion criteria during the selection of the studies to be used in the ELR as the approach provides the reviewers with the opportunity of developing appropriate strategy to be employed in searching for the literature related to the research question while at the same time omitting those studies with no relevancy to the focus question. On the other hand, LoBiondo-Wood and Haber, (2014) and Glasper and Rees (2012) noted that, the use of inclusion criteria together with the exclusion criteria provides the researchers with the opportunity of making up the selection or eligibility criteria to be employed during the process of ruling in or out of the targeted population and articles for the research study. Furthermore, the inclusion and exclusion criteria strategy is an important auditing tool, which is used for promoting transparency during the search process for the purpose of increasing the chances of the reviewers to obtain studies with high-quality data that can provide appropriate answers to the research question.

2.5 Justification for the Inclusion and Exclusion Criteria

2.5. 1 Inclusion criteria

The review included studies which were published between 2015 and 2019. As a result of the increasing number of studies being conducted concerning work-related stress among the nurses, there was need to include studies published not more than five years from now. Palfreyman (2012) and Burke (2011) explained that, including recently published studies during the development of literature review is important as it allows the researcher to incorporate the current trends about the subject matter; hence leading to the production of updated study. Since the present study did not incorporate the use of translation services, only those studies which were published in UK-English language were included with reference to the use of translation services. Hewitt-Taylor (2017) argued that, there are some important points which might be misinterpreted during the process. Based on the fact that, there are very studies which have been conducted on the occupational stress management among UK nurses, studies from the other countries were also considered. Furthermore, the studies must be openly accessible and available in full text. The other inclusion criterion employed was that, the main focus of the studies must be to explain the strategies for work-related stress management, specifically among the nurses. For that matter, nurse was the population of interest. Among the health care practitioners, nurses are the most affected by work-related stress (Campbell, 2010), hence performing a study to determine the strategies that can be used for the management of such issues is important for promoting the quality of nursing services. In order to increase the chances of obtaining high quality and comprehensive data about occupational stress management among nurses, both the qualitative and quantitative research studies were included.

2.5.2 Exclusion criteria

The review excluded the studies, which focused on determining the management of work-related stress among health care professionals other than the nurses. Excluding such studies ensured no deviation from the main aim of the study. The studies which were published prior to 2015 were also excluded in order to increase the chances of the researcher to obtained high quality and up-to-date information about the area of interest. Furthermore, the studies which included the nurses as their population but focused on determining the impacts and factors associated with the development of occupational stress were excluded. With reference to the information presented byBurns et al., (2009) and Mabbott, (2013) all the studies which have deviating information from the main focus of the present research should be excluded as their inclusion can lead to the production of contradicting results hence compromising the overall quality and authenticity of the study. Table 3 below shows the criteria used during the search process of the articles.

2.6 Article Selection

Before starting the selection process of the articles, all of the three databases (CINAHL, PubMed, and British Nursing Index) were independently searched. During the search process, a total of 1855 articles, 2553 articles, and 2177 articles were obtained from the initial search on the CINAHL, PubMed and British Nursing Index respectively. In order to ensure that, only those studies which would lead to the production of high-quality results were finally selected, the inclusion and exclusion criteria (as previously described) were employed. With reference to the information from the studies by Kamienski et al., (2013), Williamson and Whittaker, (2017) and Gough et al., (2012), it is justifiable to note that, the researchers should use both the inclusion and exclusion criteria for selecting of the preferred articles in order to eliminate bias and unfairness during such process. For that matter, all of the studies were subjected through the same inclusion and exclusion criteria irrespective of the database from which they were obtained. After applying the criteria, only six studies were finally selected and thereafter reviewed. Table 4 below shows the summary of the article searching process.

2.7 Appraising Evidence

Assessing the quality of the articles considered to be reliable and valid for review allow ensures internal validity by only focusing on research questions of interest. Different studies are classified based on the type of evidence presented based on an existing hierarchy of evidence. Gough, Oliver, and Thomas (2012) explained that hierarchy of evidence allows the researchers to determine the quality of evidence per study, which is further used for classification and interpretation of results. Since, the above study utilised an ELR methodology, the traditional hierarchy of evidence was used during the evidence selection process. A detailed description of that hierarchical distribution of evidence is provided in appendix 3. Additionally, the Caldwell critiquing tool was used for critical appraises identified studies, a process which involved identification of the strengths and weakness of each study. Gough, Oliver, and Thomas (2012) noted that, the use of Caldwell critiquing tool has increased in the last few years as a result of its ability to assess the credibility of studies regardless of their methodological approach and its ability to appraise studies without introducing any form of bias.

3.0 Results

3.1 Study Types

Among the six studies, five studies used a qualitative methodological approach including Imani et al., (2018), Mcdonald et al., (2016), Akbar et al., (2017), Akbar et al., (2015) and Bayuo and Agbenorku, (2018), hence; only one study involved the collection and analysis of quantitative data (Lu et al. 2015). Furthermore, each of the study employed a particular research design during analysis of the data. For example, Imani et al. (2018) was based on the Husserlian descriptive phenomenology, McDonald et al. (2016) employed descriptive and case study based approach, Akbar et al. (2015) used content analysis approach, Akbar et al. (2017) used grounded theory approach, Bayuo, and Agbenorku, (2018) employed an exploratory descriptive approach while the study by Luet al. (2015) used inductive research approach that involved data collection through the use of occupational stress source questionnaire and coping strategies questionnaire. Further classification of the studies indicated that five articles, McDonald et al. (2016), Akbar et al. (2017), Bayuo and Agbenorku (2018), Imani et al. (2018) and (Akbar et al. 2015), were cross-sectional studies while the remaining study by Lu et al. (2015) was the only research that used randomised control trial approach. A summary of all articles is indicated in Appendix 1.

3.2 Level of Evidence

The level of evidence in qualitative studies is categorised in four classes; generalisable studies which form the highest levels of evidence, followed by conceptual studies, descriptive studies, and single cases studies in the aforementioned order. The study by Akbar et al. (2017) falls under a single case study since the study focused on interviewing a very small number of individuals to provide insights regarding managing work-related stress. Also, most accounts were moving and contain numerous emotional accounts of personal experience aimed at arousing sympathy. Bayuo and Agbenorku (2018) study was classified under a descriptive level while the studies conducted by Akbar et al. (2017) and Imani et al. (2018) were classified as under the conceptual level. Bayuo and Agbenorku (2018) was a theoretical in nature, and the sample was selected from a specific group or setting without any form of diversification. For instance, the study by Bayuo and Agbenorku, (2018) used purposive sampling to recruit 13 nurses working in the same intensive care unit and utilised face to face semi-structured interviewed followed up by another interview before generating the required themes. Thus, the entire sample size utilised in the entire study came from the same place. Akbar et al., (2017) and Imani et al., (2018) included some form of diversity in the sampling process and was based on an existing theoretical concept, and thus the studies were classified under the theoretical level. For instance, Akbar et al. (2017) utilised the purposive sampling and identified 18 nurses and was analyzed through unstructured face to face interviews. Imani et al. (2018) also utilised the participants from different hospitals associated with Hamadan University of Medical Sciences in Iran. The study by McDonald et al. (2016) was classified under the highest level since the sampling utilized focused on existing literature and theory, and the analysis extended to capture the diversity of experience. The hierarchy of evidence is indicated in Appendix 3.

3.3 Critical Appraisal Using Caldwell Tool

All titles by the different six authors were informative and indicated the focus of the study. Keywords such as coping strategies and managing workplace adversity dominated the titles making it easy to identify and interpret the content of the study. Some headings indicated the qualitative approach (Akbar et al., 2017, Imani et al., 2018), type of research (Akbar et al. 2015, Bayuo and Agbenorku 2018), clinical research unit (Bayuo and Agbenorku, 2018)and country where the studied was carried out (Lu et al., 2015). All the researchers held appropriate academic qualifications and were linked to relevant professional bodies in different countries across the globe. All the abstracts, provided for analysis, were structured and provided information regarding the aim, outline of the methodology, findings and conclusion. All the six studies indicated that work-related stress significantly affected clinical outcomes for both the nurses and patients. Akbar et al. (2017) reported that, the use of the grounded approach in investigating coping strategies among nurses was based on the limitations associated with quantitative studies. Akbar et al., (2015) noted that, qualitative studies grounded in qualitative studies go deeper and explore behaviours and thoughts of nurses based on stressful conditions in a clearer approach. These above sentiments were supported by the study, conducted by Akbar et al., (2017), which observed that, qualitative studies which use open-ended question help in the identification of real strategies for work-related stress. The study by Imani et al., (2018) focused on the gap between intelligence and emotional resilience which had been previously linked to better outcomes while the study by Mcdonald et al., (2016) focused on the gap between thriving and resilience. Bayuo and Agbenorku, (2018) and Lu et al., (2015) addressed the existing gap regarding the intensity of work-related stress while serving in an intensive clinical unit within the hospital such as the emergency department and intensive care unit. Most selected studies had a low sample size which significantly affected the validity and reliability of the result. For instance, Bayuo and Agbenorku, (2018) used a sample size of 18 while Akbar et al., (2017) used a sample size of 17. The remaining studies utilised lesser sample sizes. Large sample size increase the variability of responses in qualitative studies and provide more themes; thus, allowing proper analysis of the research question. The literature review utilised in most studies was up to date, although most papers cited in all papers traced back past the five years. Specific reason why the specific studies selected grounded or phenomenological studies were also provided. The study by Akbar et al. (2015) reported that, ethical approval was provided for the study, but no details regarding ethical considerations were provided. However, the study by Akbar et al., (2017) indicated ethical compliance issues as well as various procedures including informing the participants on the objective of the study and research objectives and insisting on the confidentiality of information presented by participants throughout the entire study. Imani et al. (2018) also observed ethical issues indicated by Akbar et al. (2017) and also included voluntary participation in the study. All the remaining three studies adhered to the above-mentioned ethical principles. Five of the selected studies utilised a qualitative approach, while one utilised a quantitative approach. Akbar et al., (2015) reported that, a qualitative approach especially one formulated in the grounded approach explores deeper behaviours and thoughts of nurses in unique stressful conditions. Akbar et al., (2017) observed that, a qualitative approach in a narrative approach and open-ended approach revealed more information compared to the use of quantitative studies which rely on close-ended questions and interviews. Imani et al., (2018) explained that, the use of a phonological approach allowed nurses to study phenomena which occur on a daily basis based on personal experiences while the approach utilized by Bayuo and Agbenorku, (2018) observed that qualitative studies allowed researchers to experience their phenomena of the interest while collecting data until the saturation point is achieved. Mcdonald et al., (2016) provided no rationale on why a qualitative approach was utilized while the quantitative study by Lu et al., (2015) examined the commonly utilised strategies for coping with stress. Qualitative studies were based on purposive sampling while the quantitative study was based on cross-sectional design. Data collection was largely collected through the use of unstructured interviews for qualitative studies which allowed nurses to express their views regarding coping strategies. Only the qualitative study by Lu et al. (2015) utilised a structured questionnaire to assess the views of the nurses regarding the most effective coping strategies used in managing work-related stress. Akbar et al., (2015) presented studies containing excerpts from the nurses with no form of structural organisation per topic while Akbar et al., (2017) categorised the responses into several relevant themes. The study by Imani et al., (2018) also categorised response into several themes with excerpts examples. The remaining studies were also arranged thematically with results being generalised. The results in most studies were compared to existing findings. Some of the key limitations associated with the various studies include the low sample size used in the analysis by all studies, self-sampling as evident in the study conducted by Akbar et al.,( 2015), failure to include other types of nurses working in specialised settings and private settings (Bayuo and Agbenork , 2018) , thus failing to generalise studies ( Akbar et al., 2017), The critiquing tool is indicated in Appendix 2.

Each of the different studies provided information on a number of different themes. Some studies structured the themes while others failed to indicate themes. For instance, Bayuo and Agbenork (2018) identified three key themes and subthemes including support from colleagues, dissociating with the patient and use of recreation. Imamiet al., (2018) observed a number of themes including situational self-control, wisdom and patience, reverence, and appealing to religiosity with subthemes such as distancing oneself from any displacing staff causing stress, stressful situations, and nurses trust in God, patients and family. Akbar et al., (2015) reported several themes including seeking help, situational control of conditions, escaping the situation, self-control, spiritual coping and preventive monitoring of conditions. Akbar et al., (2017) only outlined one approach for managing stress categorised as comprehensive approaches of calming down. Mcdonald et al., (2016) identified three themes including personal characteristics, support networks and personal resilience as key factors for managing occupational stress while Lu et al., (2015) identified cause of occupational stress. The theme in individual studies was then characterised into two major themes; personal coping strategies and organisational strategies.

3.4 Themes

After the quality of the selected studies was assessed, thematic analysis was conducted to identify common themes concerning the management of occupational stress among the nurses. Based on the information provided in the research study by Moorley and Cathala (2019), it is justifiable to note that thematic analysis is an important research methodology that is used analysing data to identify relevant themes, which can help in addressing the research or contribute an important point towards on the subject matter. Thematic analysis approach that was used in this research study was adopted from that demonstrated by Moorley and Cathala, (2019) whereby every theme was individually explained in a comprehensive manner. The term “theme” can be used to describe an abstract entity which is imperative to the data being analysed and has the ability to represent similar responses. For that matter, the reviewer thoroughly reads through selected studies more than three times, highlighting key points, themes or words which have direct relationship with the research question. After reviewing all of the studies, Moorley and Cathala (2019) noted that, there is need for the reviewer to identify the possible research gaps, recommendations as well as areas that can be researched in future. Specific to this research study, a total of six articles, previously selected from the search process, were reviewed with the aim of identifying the various types of occupational stress management strategies employed by the nurses. After the review process, three important themes were identified, and they include types of occupational stress, personal coping strategies and organizational support for stress management.

3.4.1 Types of occupational stress

Over the past years, different research studies have identified various types of occupational stress affecting health care professionals, especially nurses. All of the six selected studies contained information that could be used to identify types of occupational stresses affecting nurses. Nevertheless, three main types of occupational stress; physical stress (Akbar et al., 2016; Akbar et al., 2017), emotional stress (Imani et al. 2018; Lu et al. 2015; McDonald et al. 2016; Akbar et al. 2016), and psychological stress (Bayuo and Agbenorku, 2018; McDonald et al., 2016; Akbar et al., 2017) were identified in the studies. All studies indicated that the various types of studies interfere with the productivity of the nurses as well as the quality of health care services provided to patients. According to Akbar et al. (2015) and Akbar et al. (2017), important stressors in the nursing workplace comprise of tension factors caused by work pressure and increased work demands in the nursing career. Akbar et al. (2015) also explained that, the nursing shortage forced the available nurses to work for long hours, some combining day and night shift to meet the demand of the patients. The nurses in low cadres also face different threats in their respective workplaces compared to experienced nurses. Despite the fact that nurses are often focused on improving the tranquillity and recovery among the patients, McDonald et al. (2016), Imani et al. (2018) and Akbar et al. (2017) noted that, the nurses are on the other hand facing stressful situations as well as experiencing high levels of stress and that both the occupational and emotional stress can lead to the occurrence of job burnouts, increased absenteeism cases, and low job satisfaction rates. The reviewed studies also determined that occupational stress has the ability to interfere with quality of care services offered to patients. Occupational emotional and psychological stress has been determined to be severe among nurses (Imani et al., 2018). Furthermore, the most important factor that led to the occurrence of occupational stress was determined to be increased workload in the nursing environment hence requiring the nurses to work for long hours or attend to many patients concurrently (Akbar et al., 2016; Akbar et al., 2017). For that matter, Akbar et al. (2017) and McDonald et al. (2016) proposed that the nurse managers should ensure that the schedule used in assigning nursing duties is effective and unbiased in order to increase resilience among the nurses.

3.4. 2 Personal coping strategies

Personal coping strategies were identified as the second theme in the selected studies. All studies reviewed highlighted different forms of personal coping strategies used to manage occupational stress. In the study by Akbar et al. (2015) personal coping strategies or situational control of the stressful conditions that were identified included; undertaking immediate action in order to control acute conditions of the patients, taking immediate action to prevent the occurrence of professional errors, proper time management, and effective collaboration among the nursing team among others. On the other hand, the study by Akbar et al. (2017) identified personal coping strategies including situational control and preventive monitoring of stressors, seeking help from other colleagues, practicing self-control, avoiding stressful situations, and seeking spiritual intervention. With reference to the information from the study by Bayuo and Agbenorku (2018), the process of providing care to the patients could expose the nurses to occupational stress. Bayuo and Agbenorku (2018) indicated several strategies including seeking and obtaining support from their colleagues as an approach of preventing or reducing the severity of the occupational stress. Distancing oneself from stressful conditions is another important personal coping strategy highlighted in the study. Even though Imani et al. (2018) also identified the strategies such as seeking support and distancing oneself from the stressful conditions, there are other new personal coping strategies which were highlighted in this study such as patience and wisdom, reverence, having peace, and appealing to religiosity. Similar to the other four studies, Lu et al. (2015) mentioned that seeking for help, effective nursing collaboration and avoiding or distancing oneself from stressors some of the most important and effective personal coping strategies that nurses could employ during the management of occupational stress. Additionally, McDonald et al. (2016) noted various personal characteristics for resilience, such as self-care, self-motivation and distancing oneself from stressful conditions, as effective personal coping strategies that could be used by nurses in the management of occupational stress. Akbar et al. (2017) and McDonald et al. (2016) observed that increasing professional capacity and influencing the personality traits on coping with work-related stress are effective coping strategies. Lu et al. (2015) argued that effects of motivation, interest on coping and support from colleagues and families play a role in improving the quality of personal coping strategies for work-related stress. With reference to the information provided in the study by Imani et al. (2018) and Bayuo and Agbenorku (2018), distancing oneself from the stressful situations is considered as the easiest and most effective approach of coping with work-related stress. For example, in situations where nurses develop a problem with a specific patient, nurses could opt to delegate roles to other nurses in handling the nurses. In such cases, nurses become protected from emotional and psychological stress associated with unfriendly patient care environment. Collegial support and networks are effective in improving the quality of personal coping strategies for occupational stress (McDonald et al., 2016). Therefore, there is need for effective cooperation among the nursing team in order to allow for the creation of supportive work environment.

3.4.3 Organisational support for stress management

Even though personal coping strategies have been identified by most studies analysing stress management among nurses, studies indicated that organisational policies aimed at reducing work-related stress promote better outcomes. Three studies including McDonald et al. (2016), Akbar et al. (2016) and Bayuo and Agbenorku (2018) identified the role of organisational support in managing work-related stress. According to McDonald et al. (2016), the hospital management is responsible for providing nurses with support networks that promote resilience, interpersonal support within the nursing workplace and promoting workplace diversity to prevent any form of social discrimination. Concurrently, Akbar et al. (2016) observed that, hospital management has an important part in promoting effective management and prevention of work-related stress among nurses. In the study, the authors noted that there is need for the human nursing resource to always consult all members of the nursing team prior to the formulation of work schedules in order to eliminate possible burnouts that could lead to stress. Workplace diversity was also mentioned as an effective approach to managing work-related stress, especially in multicultural settings. Although seeking help is largely considered as a personal coping strategy for occupational stress, Bayuo and Agbenorku (2018) noted that hospital managements have the responsibility of providing an enabling environment in the nursing workplace. Bayuo and Agbenorku (2018) further noted that nurses often enjoyed different forms of recreational activities, especially during their off-duty periods. Despite the fact that collegial support is an important approach of personal stress management strategy, it can also be classified under the theme of organisational support for stress management. Participants in the studies conducted byBayuo and Agbenorku (2018) and McDonald et al. (2016) admitted that collegial support was very important in the nursing environment as it served as a source of support for nurses during tough times. Therefore, nurse managers have the responsibility of ensuring that appropriate environments that support interpersonal relationships and teamwork which serve as the foundation collegial support are developed. Bayuo and Agbenorku (2018) supported the above view by indicating that hospital management was involved in the building of a conductive atmosphere that would help in promoting positive communication within the work environment. On the other hand, McDonald et al. (2016) highlighted that the workplace should allow for easy collaboration and communication among the members in order to allow the members share their personal and work-related problems which could lead to the occurrence of occupational stress. External support was another significant approach that promoted the occurrence of a sense of resilience among the participants included in the study by (McDonald et al., 2016). Participants strongly believe that, the external support such as working with partners, families, and friends, increases emotional security and sustains a positive self-concept when dealing in adverse environments. Nevertheless, the success of those approaches largely depends on the types of structures and policies put in place by the hospital management.

4.0 Discussion

In this section, the results obtained from the thematic analysis process would be discussed in order to allow for effective interpretation of the collected data. For that matter, the reasons behind the use of specific strategies for occupational stress management among the nurses would be discussed. With reference to the conducted thematic analysis, three important themes, such as types of occupational stress, personal coping strategies, and organisational support for stress management, were identified. Occupational stress is one of the most important problems affecting nurses (Luet al. 2015). At the individual level, work-related stress has negative impacts on nurse’s health and wellbeing (McDonaldet al., 2016), affects the health care organisation in terms of increased rates of absenteeism and turnover hence having direct impacts on the quality of care provided to the patients (Akbar et al., 2017). The analysis of the selected studies led to the identification of three main forms of occupational stress; the physical stress, emotional stress, and psychological stress. Therefore, the obtained data are in agreement with those included in the previous studies by Hayes et al., (2015) and Burtonet al. (2017) which noted that, there are different manifestation of the occupational stress side effects on the nurses such as the emotional form which is characterised by anxiety, overreaction and frustration, psychological form which leads to forgetfulness, lack of concentration and withdrawal, and physical form which is characterised by the occurrence of fatigue, insomnia, high blood pressure and fatigue. Although prevention and management of occupational stress among the nurses can be managed at the personal intervention, the present study indicated the need for organisational structures in managing work-related stress in hospital settings. For example, the research study by Bayuo and Agbenorku (2018) determined that, the nurse management policies, such as biased work schedule and discrimination of nurses from specific ethnical orientations could result in occupational stress. The same arguments were also provided in the research study by Burton et al., (2017) which observed that, nursing workplace which was not highly diversified were associated with occupational stress. Furthermore, a study by Starc (2018) also observed that, least stressing factors in nursing environments included diversity of work, social security in the workplace and allowing nurses to work based on their abilities. Thus, it is the role of the hospital management to ensure that the workplace is diversified in terms of gender, race, and age among others in order to prevent the occurrence of minority groups within such workplaces. All of the reviewed studies indicated that the occurrence of various factors such as inadequate motivation, handling of large number of patients alone (Akbar et al. 2016), poor or inadequate staffing levels, lack of break periods during the nursing shifts (McDonald et al., 2016), and nursing difficulties because of patients behaviorsas well as lack of opportunities for promotion or professional grow as those involved in the increased cases of occupational among the nurses (Luet al. 2015). Similar occupational stressor reported in the above studies has been identified in other studies. Starc (2018) noted common stressors like physical or psychological abuse by patients and colleagues in the workplace, family confrontations after the death of patients, staffing shortages, working at night, poor working conditions, low pay and poor work organisation as some of the common stressors. Since occupational stressors differ per clinical setting based on resource availability and organisational structures, other stressors not mentioned in the above study also exist. Jetha et al., (2017) reported that, job insecurity and poor management of nursing schedule and shift programmed as the most common occupational stressors for nurses. Moreland and Apker (2016) also reported that the use of exclusionary communication especially the use of unsupportive and non-satisfactory messages significantly contributes to conflict and stress within the workplace. Nurses also tend to mismanage stress and conflict using disrespectful means, and as a result such communication patterns prohibit any positive change. Communicative conflicts could be managed if organizational decisions support development of interpersonal relationships.

Collegial support was determined to be another important approach that the nurses use in order to manage workplace adversities (Akbar et al. 2017; McDonaldet al.2016; Imani et al. 2018). The findings are supported by a study conducted by Weigl et al., (2016) which identified collegial support as an essential element of workplace resilience and occupational stress management. Weigl et al., (2016) identified a three-way interaction where depression and emotional exhaustion were strongest factors for low supervisor support and high work overload while nurses who had low work overload, as well as supervisor support, was associated with depression and emotional exhaustion. Leader behaviours and organisational characteristics with nursing settings empower nurses to use their behaviours, knowledge as well as skills in improving organizational commitment, quality of care, increase in trust in the management and reducing burnout levels. Empowering leaders who lead by example by showing concern for other leaders serve to reduce nurses feelings of depersonalization and emotional exhaustion (Mudallal, Othman, and Al Hassan, 2017). Social support aids in stress management by managing uncertainty, increasing one’s perception of their personal control over different life experiences and assisting one in achieving the goal. Social support shows positive correlation with improved health outcomes, lowered job strain, preventing psychiatric symptoms associated with emotional exhaustion and enhances a protective function against suicidal ideations (Mikkola, Suutala, and Parviainen, 2018). Thus, organisations should focus on developing support and collegiate systems that reduce incidences of occupational stress. Olsen et al., (2017) added that, the occurrence of such supportive networks provided the nurses with the opportunity of easily navigate through the organisational hierarchy, reducing organizational burdens as and enhancing greater nursing satisfying career. While explaining the importance of collegial support as an approach of managing occupational stress among the nurses, McDonald et al. (2016) noted that the technique is important as it allows for the development of sense of belonging among the nurses hence positively influencing their commitment towards work and the members of the workplaces as well as to increase the overall quality of care services they provide to the patients. Imani et al. (2018) also observed a positive association between hope and sense of among the nurses and the quality of care services they provide to their clients. Additionally, the present study also determined that the collegial support was very important in resolving the negative self-judgment among the nurses as well as the loss of confidence as a result of the increased occurrence of clinical errors which could cause adverse effects on the patients. Similar arguments were also provided in the study by Edward et al., (2017) noted that collegial support within the nursing workplace was essential as it helped the nurses to overcome both the personal and workplace-related stressor hence increasing the quality of their care services.

Personal practices, which promote self-care and motivation, were also identified to play an essential role in managing occupational stress. The previous study by Zúñiga et al. (2015) presented the advantages of having optimism and flexibility among the nurses working in large hospitals. Among the reviewed studies, three studies (Akbar et al. 2016; McDonald et al., 2016; Bayuo and Agbenorku 2018) acknowledged the importance of self-care and motivation in the promotion of resilience among the nurses. For example, McDonald et al. (2016) highlighted that, the involved participants presented pro-activeness and high level of commitment in order to help in ensuring that they did become overwhelmed as they also developed their own strategies that they could use for the management or disconnect themselves from the potential stressors in the workplace. Thus, there is need to continuously encourage and support the nurses to formulate, implement and maintain strategies that they can use for improving the quality of their psycho-social health and wellbeing. Despite the fact that self-care and motivation were identified by McDonald et al. (2016) as the most essential strategies for improving the quality of mental health among the nurses, Hayes, Douglas and Bonner (2015) argued that, a wide range of resilient personal characteristics including flexibility, optimism, life balance, emotional insight, and hardiness. Furthermore, the present research has helped in expanding the concept of self-care as temporary and a pleasurable approach that could help in destructing the workplace stressors as well as to boost the energy levels among the nurses. Furthermore, it is important to note that the habitual maintenance of emotional and physical health and wellbeing is also another strategy that can be used of promotion personal and professional resilience.

4.1 Recommendation

The current study identified numerous work stressors in hospital settings and reported the adverse effects of occupational stress on the nurse’s health and patient outcomes. Thus, there is a need to effect strategies which significantly reduce occupational stress within clinical settings in various ways. First, clinical or hospital settings should formulate organisational policies aimed at eliminating occupational stressors through different approaches. Some available options include providing adequate information on the available stress management strategies for nurses, and motivational packages which appreciate role of nurses in hospital settings. Others include nurse managers and leaders implementing better and friendly working environments for nurses, establishing mentoring programmes for the nurses, and creating socialising rooms both within the workplace and off clinical settings. Secondly, hospital settings can also increase the number of nurses in the workplace, introduce people management skills for supervisors, and encourage aspects such as teamwork and cooperation within the workplace. The organisations should also introduce stress management programmes for nursing students in college to equip nurses with the requisite skills required in any busy nursing environment. Nurses should also be offered professional counselling to sharpen skill on how to manage any form of occupational stress. Generally, improving the working conditions of nurses within clinical settings significantly improves nurse’s output and reduces incidences of occupational stress.

4.2 Implication to Practice and Policy

The current study indicates that occupational stress is still a major problem affecting nurses in clinical settings. Considering that the number of nurses has been on a decline in the United Kingdom and other parts of the world, it is essential to implement strategies that reduce incidences of occupational stress within clinical settings. Although nurses are faced with occupational pressures at the individual level, the overall effect is magnified on health outcomes. Therefore, there is need for clinical settings to establish guidelines that deal with stress within the nursing environment. The standard should be implemented across hospital settings to reduce occupational stress nationally. Also, a course of stress management should be made mandatory for all nurses with refresher courses being provided on an annual basis. Furthermore, at the individual level hospitals should identify methods of dealing with occupational stress such encouraging teamwork, open communication and development of interpersonal relationships among all staff members. Guidelines should also be in place on how to deal with violent patients and protective measures against any form of psychological abuse should be enacted.

4.3 Limitation of Study

Although the above study illustrated some of the existing coping strategies used by nurses to manage occupational stress in hospital settings, it has several limitations. First, the study was conducted in a hospital and public settings and thus does not fully provide information on occupational stress levels in private clinics due to different working conditions. Private and specialised nurses could be included in future studies. Another limitation is the small number of studies included in the analysis, with only six studies being analysed. Use of a few studies risks leaving out various strategies used by different nurses across hospitals. Also, some studies included self-reported measures during interviews increasing risks of bias in the findings. Lastly, only one study investigated occupational stress in intensive care units. Nonetheless, the methodological study used in the above study is rigorous in nature and the findings reported were consistent across board.

5.0 Conclusion

Occupational stress remains a major issue within the UK with the number of nurses leaving the NHS increasing on an annual basis. The nurses have also reported poor health outcomes due to occupational stress which significantly affects their ability to provide quality care to patients. Since, the occupational stress cannot be completely eliminated within the workplace; the available approach is to identify short-term and long-term strategies used to manage work-related stress. The current approach, which identified a total of six studies, reported that, the nurses utilise various personal strategies to manage occupational stress. Such strategies ranged from delegating functions to other nurses, calmly dealing with situations associated with stress, preventive monitoring of situations resulting in work-related stress, seeking help from other colleagues, practicing self-control, avoiding stressful situations, and seeking spiritual intervention. Apart from the personal strategies, nurses also relied on organisational strategies such as collegiate support in dealing with difficult patients, moderating the working hours for nurses within clinical setting and encouraging aspects such as open communication, teamwork, and developing interpersonal relationship. There is need to conduct wider studies on coping strategies for occupational stress using more articles, including private and specialised nurses as well as nurses working in intensive units. The findings of the above study act to provide a blueprint which can be used to address issues related to occupational stress among nurses and improve both nurses and patient health outcomes.

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