The intent of this position statement is to promote self-care activities for the Registered Professional nurse and to emphasize the Nurses Code of Ethics provision five (5) that states “The nurse owes the same duties to self as to others, including the responsibility to preserve . . [personal] safety, to maintain competence, and to continue personal and professional growth” (ANA, 2015).
POSITION
It is the position of the New York State Nurses Association that:
- The profession of nursing contains multiple sources of stressors regardless of workplace setting.
- Nurses should pay as much attention to taking care of themselves as they do their patients.
- Health care organizations are responsible for assessing what causes stress and for creating a climate in which nurses aren't working unmanageable patient assignments.
- Responsibility for assessing and reducing workplace stressors is on the management team.
- There is a relationship between a nurses’ ability to care for self and their ability to provide effective patient care.
- There is a positive correlation between the impact of safe, secure and healthy working environments on both nursing staff and patient outcomes.
- Health care employers must make a commitment to consult and communicate with employees on matters relating to healthy working environments and employment practices.
- Health care employers must make a commitment to continuously improve the working environment by monitoring and evaluating the impact of initiatives on working conditions.
BACKGROUND
Stress is a condition of tension experienced by individuals when they are subjected to extraordinary physical and psychological demands (Anderson & Pulich, 2001). This complex phenomenon can be either positive or negative, depending upon the individual’s perception. Workplace stressors are defined by many variables (Olin,2012), among them:
ü Avoidance or dread of working with certain patients;
ü Reduced ability to feel empathy;
ü Frequent use of sick days;
ü Physical symptoms including headaches, digestive problems, sleep disturbances, and muscle tension, to name a few; and
ü Emotional symptoms including, but not limited to, mood swings, restlessness, irritability, oversensitivity, anger, depression and anxiety.
Nursing is an extremely fulfilling yet highly stressful profession. Not only is it fast-paced with a heavy workload, but nurses must also cope with difficult issues, such as ethical dilemmas, moral distress, and their own emotions over interacting with people who are ill and suffering. When nurses allow the stress level to deplete their energies, they are no longer able to give quality care to others. Additionally, exhausted and stressed nurses are more likely to make medication and patient care errors.
When nurses choose between the risk to their patients while working ill, and the risks of decreasing nurse-to-patient ratio, continuity of care, and their reputation as a team player, the decision is not so clear. Many nurses will over-extend themselves and, although fatigued or sick, will show up to work. The literature indicates the following reasons for working while sick:
- Not wanting to let colleagues down
- Staffing concerns
- Not wanting to let patients down
- Fear of ostracism by colleagues
- Concerns about continuity of care
- Difficulty finding coverage
- Strong cultural norm to come to work unless remarkably ill
- Ambiguity about what constitutes “too sick to work
Stress in the workplace today is a key problem for many organizations, and the workplace for nurses provides a multiplicity of sources of stress. Some of the identified stressors are unrealistic workload due to inadequate staffing and excessive paperwork; fluctuating schedules associated with changing shifts; mandatory overtime; floating without appropriate orientation; moral and ethical dilemmas, and interpersonal conflicts with physician colleagues. Additionally, the care of patients and families experiencing progressive illness, death and bereavement can increase nurses’ awareness of their own losses and vulnerabilities and heighten their fear of death, thereby raising anxiety and stress levels (Sherman, 2004).
Consequences of untreated cumulative workplace stress can result in: somatic complaints such as changes in eating habits, gastrointestinal distress, headache, fatigue, and sleep disorders; change in work habits such as tardiness and absenteeism; mental and emotional difficulties such as memory disturbances, anger, self-doubt, and isolation; impaired judgment and reasoning, and burn out and accidents. Recent laboratory studies showed a correlation between mental stress and higher rates of adverse ischemic events (Shep, et al, 2002). Long term effects of ineffective stress management can result in post-traumatic stress disorder (Oster & Doyle, 2000). In addition to the negative consequences of stress upon the nurse, when nurses fail to care for themselves in the face of loss and grief, the care they provide may be compromised.
Responsible health care employers respect the needs of all staff to balance work life with life outside work. These compassionate employers will go above and beyond the legal minimum in terms of meeting their health and safety statutes, rules, and regulations. The more enlightened and progressive employer understands that equal access to modern working arrangements leads to a committed and motivated workforce and a healthy and safe working environment in which teamwork and patients alike flourish (Royal College of Nursing, 2015).
While treating patients and clients with dignity is mandated in nursing practice by the Nurses Code of Ethics, in order to do this effectively, nursing staff must also be treated with dignity and respect by their employers, managers and colleagues. Employers who value their employees will reap the benefits of a more motivated, harmonious, willing and loyal workforce. Promoting dignity at work is likely to reduce stress-related health problems and absenteeism and also likely to attract staff from a wider pool of job applicants which can deliver a greater range of talent and experience (Royal College of Nursing, 2015).
Although workplace stress cannot be eliminated altogether, the negative stressors can be reduced when nurses make caring for themselves a priority. Most nurses are not taught the correlation between self-care and the delivery of quality patient care as part of their basic nursing education. Self-care is noted in the literature as a form of protection against stress. It is the self-initiated behavior that people choose to incorporate to promote good health and general well-being (Sherman, 2004).
As suggested by Sherman Wright, self-care begins with each individual. Rather than the tendency to look for external solutions to problems, Wright challenges nurses to pay attention to their inner thoughts, feelings and actions (Sherman, 2004) and exercise personal power by establishing routines and an individualized stress-reduction plan. Creating the plan can be modeled on the nursing process (Carlson, 2017):
- Do a self-care assessment: First, conduct an assessment of how you care for yourself.
- Exercise/physical needs
- Emotional needs
- Spiritual needs
- Play time
- Diagnose a self-care deficit: Admit that you may have a problem.
- Level of burnout
- Amount of exhaustion you experience
- Take stock of how often you engage in self-care activities
- Plan a course of action:
- Exercise
- Counseling/psychotherapy
- Nutrition/hydration
- Vacation
- Yoga, meditation, Tai Chi, Qigong, etc.
- Implement the plan:
- Formulate a plan with measurable and achievable goals
- Set specific timing for the actions you plan to take
- Make the plan specific, measurable, achievable, action-oriented, and time-sensitive.
- Evaluate your progress: Assess how you’re doing overall.
- Make adjustments
- Were goals too lofty or hard to reach
- Can you manage to do more for yourself
RECOMMENDATIONS
The New York State Nurses Association recommends:
- Employers properly staff each unit to ensure nurses to take their at work breaks and don’t regularly work over their scheduled hours or work in a climate in which nurses are working unmanageable patient assignments.
- Employers proactively monitor absences for hot spots and trends and staff to meet these trends.
- Employers have policies that promote dignity, value, and worth of all nurses.
- Employers provide staff with opportunities at work to maintain and improve their health.
- Build basic principles of self-care into nursing education curricula.
- Nurses utilize personal stress management strategies such as relaxation, meditation, exercise, group therapy, guided imagery, massage and humor.
- Advocating for work environments that are healing and nurturing for staff and patients, through: improved communication, collaboration, empowerment, and accountability; and use of debriefing and support groups.
- Further research to determine the relationship between nurses who practice self-care and the benefits to the patients for whom they care.
- Nurses engage in collective bargaining, legislative, regulatory and administrative agency supports to decrease workplace stress related to staffing, mandatory overtime, floating and unexpected shift rotation.
Approved by the NYSNA Board of Directors March 19, 1992.
Reviewed and revised by the Expanded Council on Nursing Practice on July 22, 2005.
Approved by the NYSNA Board of Directors August 30, 2005.
*Formerly titled- The Role of the Professional Nurse in Stress Management
References
American Nurses Association. (2015). Code of ethics with interpretative statements. Silver Spring, MD: Author.
Anderson, P., & Pulich, M. (2001). Managing workplace stress in a dynamic environment. Health Care Manager, 19(3), 1-10.
Carlson, K. (February 24, 2017). 5 Simple self-care practices for busy nurses. We're not talking a spa day. Retrieved March 19, 2017 from https://nurse.org/articles/5-steps-to-nursing-wellness/.
McVicar, A. (2003). Workplace stress in nursing: a literature review. Journal of Advanced Nursing, 44(6), 633-642.
Olin, J. (2012). Compassion Fatigue: Nurses Need To Take Care of Themselves As Well As Others. RN Central. Retrieved March 8, 2018 from http://www.rncentral.com/blog/2012/compassion-fatigue-nurses-need-to-take-care-of-themselves-as-well-as-others/.
Oster, N. S., & Doyle, C. J. (2000). Critical incident stress and challenges for the emergency workplace. Emergency Medicine Clinics of North America, 18(2), 339-350.
Royal College of Nursing. (2015). Healthy workplace toolkit. Retrieved March 19, 2018 from file:///C:/Users/cesposito/Downloads/004964.pdf.
Shepp, D. S., McMahon, R. P., Becker, L. et al. (2002). Mental stress induced ischemia and all-cause mortality in patients with coronary artery disease. Circulation, 1780-1784.
Sherman, D. W. (2004). Nurses’ stress & burnout. American Journal of Nursing, 104(5), 48-55.
