Critical care nurses ’ perceptions of stress and stress-related situations in the workplace

Critical care nurses (CCNs) experience stressful situations in their daily working environments. A qualitative research approach (exploratory, descriptive and contextual) was used to explore and describe the stressful situations experienced by critical care nurses in the Tshwane metropolitan are of South Africa. Focus group interviews were conducted with critical care nurses. Data was generated by means of focus group interviews. The results revealed CCNs' perceptions and experiences about stressful events, factors contributing to stress in the critical care environment, as well as their needs for support systems.Critical care nurses experience stressful situations in their daily working environments. The question arises for nurses: are there adequate support systems in the critical care environment and what are critical care nurses doing to maintain their own health and well-being? Facilitating conscious awareness among critical care nurses could enhance their resiliency and their hardiness, strengthening their coping capacities in stressful working situations. The contextual framework adopted for this research was the Neuman Systems Model. A qualitative research approach (exploratory, descriptive and contextual) was used to explore and describe the stress experienced by critical care nurses. Focus group interviews were conducted with critical care nurses and individual interviews with nurse managers. The results revealed their perceptions and experiences about the effects of stress in the critical care environment, as well as some of their coping strategies. The recommendations include that stress management programmes should be implemented and evaluated; debriefing services should be available to CCNs, in-service education programmes should address raising CCNs' consciousness awareness and enhance their resiliency skills. Effective communication systems should be established between managers and CCNs to address inconsistencies as they arise, including critical shortages of staff and equipment.


Introduction
Owing to the highly technical nature of the critical care environment in which CCNs work, and the critical incidents which they encounter, large numbers of critical care nurses might be in danger of developing p o st-trau m atic stress disorder.This makes it imperative that they develop conscious awareness as a basic prerequisite for stress management and enhanced resilience behaviour.Conscious awareness is gained when an inner sense of behaviour enhances selfcontrol and perso n al autonom y is regained through behaviour modification (Taylor, 1999: 321).The aim of conscious awareness is to achieve self-awareness of present thoughts and feelings, to accept those feelings experienced and to own them (Muller, 1998:33).Developing resilience is one process which could assist CCNs to attain and m aintain desirable levels of conscious awareness.Realistic conscious aw areness is a significant aspect in coping with and adapting to change w ithin the self (Muller 1998:33).
Stressful events are an inevitable part of life.Many people are able to cope with stresses depending on the severity of the stress.However the severity of the stress does not alw ays predict a resultant adjustment disorder.Most people under stress do not develop mental disorders, though possibly a vulnerability to them.Stresses d iffer in degree, quantity, duration, reversibility, environment and personal context.Stress that is chronic and ongoing may result in a chronic disorder.Nurses who work in highly stressful situations are constantly under pressure and are vulnerable to a variety of symptoms in reaction to the stress.Over time the exposure to stress and trauma may induce both physical and emotional signs described as "burnout" (Cudmore, 1996:20).

Background information
Professional burnout is a phenomenon that can occur in the life of a critical care nurse (CCN).Internal and external stresses are inherent in the critical care environment.This environment involves stressful critical situations relating to role conflict, role ambiguity, qualitative and q u an titativ e w ork o v erload, rapid decision making and a speedy delivery of care.CCNs experience suffering as affecting their integrity and wholeness, and th eir ab ility to carry out their perceived roles.They practise in the face of moral incongruity on a daily basis.Thus CCNs might have difficulty in meeting their obligations to themselves as w ell as to their patients.These persistent difficulties could evolve into distress.The starting point for growth is knowledge about the present situation.CCNs must become aware of how they see them selves and how they act on those perceptions (B osek De Wolf, 1999:12-13).Bailey (1985:47) points out that CCNs who reach the limits of their adaptive capabilities are unable to cope with posttraum atic stress and often leave the critical care environment.The focus of this article is that CCNs need to confront the different situations in which they find themselves.Effective coping entails accurate p ercep tio n s, know ledge, courage and cognitive appraisals.The critica l care environm ent m ust be effectively assessed in order to establish a starting point for promoting coping resources.A m ajor part o f this assessment must be directed at the CCN, who must recognise signs and symptoms before any type of intervention can be implemented.CCNs can identify signs and symptoms of post-traumatic stress by becom ing attentive to signals of physiological arousal, but they might hide u n d erly in g stress responses (Muldary, 1983:124-126).Not all CCNs exposed to stressful situations suffer from burnout, presumably because some might be more resilient to stresses than others.
Deliberate self-monitoring of physical signs, thoughts and emotions enhances conscious awareness.Self-monitoring entails observational skills, which are applied inward to the "se lf' (Muldary, 1983:127) to help develop greater resilience.

Problem statement
While it is generally acknowledged that the c ritic a l care environm ent encompasses stresses, the precise jobrelated stresses encountered by critical care nurses need to be identified.Once these stresses have been acknowledged and addressed, rem edies to address stressful situations could be identified and implemented to enhance the coping skills of critical care nurses, to improve the quality of patient care rendered and reduce the turnover rates among CCNs.

Research questions
The follow ing research questions guided the study:

Purpose of the research
The purpose o f this research was to identify C C N s' stressful job-related experiences, their coping strategies to address these stresses and to recommend ways in which these coping strategies could be enhanced.

Assumptions
The assum ptions underly in g this research included that CCNs

Objectives of the study
The objectives of this study were to: • describe CCNs' experiences stressful incidents • identify the coping strategies used by CCNs • recommend ways in which CCNs' coping strategies could be enhanced.

Definitions of terms used in the context of this study
The definitions explain the way in which the following term s are used in the context of this study:

Adaptation
Monsen, Floyd and Brookman (1992:28) describe adaptation as the modification of behaviour to elim inate the stress experience and maintain balance and integrity.A daptation m aintains the balance between perceived demands and coping.Ineffective adaptation causes internal disorganisation.

Burnout
The

Compassion fatigue
Pfifferling and Gilley (2000:39) describe a form of burnout as "compassion fatigue", a deep physical, emotional and spiritual ex h au stio n acco m panied by acute em otional pain.Com passion fatigue takes a toll, not on the health-care professionals only, but also on the w o rk p lace, cau sin g a decrease in productivity, increased absenteeism and increased rates of staff turnover.

Conscious awareness
C onscious aw aren ess is a process w hereby hum an beings gain an awareness of their internal psychological p rocesses (thinking, reasoning and feeling), obtaining access to their internal worlds and acquiring insight into their feelings and em otions.C onscious aw areness req u ires the ow ning of thoughts and feelings in dealing with conflicting or distressing situations (Pollard 1994:727).

Coping
Coping is viewed as the process through w hich the in d iv id u al m anages the demands of the person/environm ent re la tio n sh ip th at are appraised as  etal., 1996:xiii).

Post-traumatic Stress Disorder (PTSD)
S hould stress resp o n ses becom e prolonged, signs and symptoms of PTSD could occur.These include constant flash b ack s, unw anted thought intrusions, m oodiness, difficulty in concentrating, avoidance behaviour and restlessness, fatigue, sleep disturbances, anxiety and dep ressio n .If these disturbances continue, the person's ability to function will be adversely affected (Bell, 1995:37).
Resilience Striimpher (1995:87) defines resilience as a pattern of psychological activity which includes a need or m otivation to be strong in the face o f ad v ersity or inordinate demands, especially stressful and traumatic experiences.

Stress
Although there are numerous definitions o f stress, this study accep ted the definition of the Concise Oxford Handy Dictionary (1991:903) as demands on physical or mental energy that cause tension.Neuman (1995:22) defines stressors as tension-producing stimuli which result in disequilibrium within the internal, external and created environments.The effect of the stressor in any type of environment is mitigated by the number, nature and intensity of stressors; and the timing, occurrence, and conditions of well-being and adaptive ability of human beings w ithin the environm en t.The environmental stressors include intra-, inter-and extrapersonal stressors:

•
Intrapersonal stressors would be those within the CCN him/ herself, such as adverse emotions.
• Interpersonal stressors would be forces that exist outside the boundaries of the CCN, for example, interpersonal relationships with ether health care workers, with patients and their families/friends.
• Extrapersonal stressors may be experienced by the CCN due to adverse factors in the environment, such as respirators which malfunction or interruptions in the electricity supply.

Significance of this research
Descriptive research about the use of techniques that facilitate reflection, co n scio u s aw areness, re silien c e techniques, debriefing and counseling may enhance nurses' coping skills in clinical areas (W ilkinson 1999:39).Enhanced coping skills of CCNs might help to reduce the turnover rates among this group of specialised nurses, reducing healthcare costs and im proving the quality of care rendered to critically ill patients.
The researchers departed from a point of reference of not knowing, and thus used exploratory methods to gain information through focus groups (M o u to n & Marais, 1990:43).A descriptive study is structured and organised according to saturated themes which will provide relevant information (Bums & Grove, 1999:411).This research aim ed at identifying ways in which CCNs' levels of coping skills could be enhanced in order to reduce the potential impact of stressful job-related experiences on the

Data analysis Data analyses
The data obtained by a descriptive approach were analysed, by using a computer package for the analyses of qualitative non numerical unstructured data indexing searching and theorising (NUD*IST 4).The participants' verbatim statem ents, as transcribed from the audiotapes, were analysed.In cases of uncertainty, the statements on the video recordings were correlated with those from the audiotapes.Data within the same category were then grouped and sub categories were developed.The data were organised by identifying meaningful units which were categorised or coded (Cresswell, 1994:1).Data were validated by moving backwards and forwards between the raw data and the categorised data in NUD*ST 4. Data were then compared in order to identify common and unique themes and patterns (Bums & Grove, 1999:24).
Two nurse researchers independently developed the categories and sub ca te g o ries.T h ereafte r these tw o re searc h ers jo in tly decided w hich categories and sub-categories to accept and which to combine.A summary of the m ajor categories, sub-categories and sub-sub categories is provided in table 2

It m u st co m e out, b u r s t o r b re a k out.....you r behaviour must show that you are having these feelings. You d o n 't know w h o 's where anymore and you have to keep you r head and not f o r g e t anything, p le a s e d o n 't fo r g e t anything.
Appleton (1994:25) reported that CCNs experienced critical and em ergency situ atio n s in m any d iffe ren t w ays.Emotional reactions to stress include fear, anger, an x iety and d ep ressio n .If stressors are concerned with anger, then irritability, aggressive outbursts and Curationis June 2008 withdrawal from others are experienced.Involuntary cognitive responses include memory and concentration difficulties (Baum, 1990:653).

Personality type
The p artic ip a n ts in d icated th at personality types influenced C C N s' reactions to and coping strategies with stressful events.Rutter (1985:598) reported that personality traits such as hardiness, self-esteem, extroversion, a sense of coherence and maintaining an internal (versus an external) centre of control, impacted positively on persons' abilities to cope with stressful situations.The following statements indicate that CCNs' personality types might have impacted negatively on their coping capacities I withdraw totally, I lock m yself in my room or in my home, see nothing, do nothing, alm ost a type o f escape.

The inability to function as a result of stress levels
The inability to function generated inadequate direction and support.There's other colleagues, there's patients that are waiting, screaming ... but if you scream you cause a lot of stress to other people, nobody understands what you need.

The burnout period, i t 's only the ashes th at's left and now to try and fix a person ... they fir s t w ait and see that you 're burnt out and then want to fix things.
These statements indicate that CCNs may be affected em otionally and physiologically, leading to decreased performance (Orasao & Bacher 1996:115) and increased risk of suffering from burnout (Keijsersetal 1995:513).CCNs' inability to function might be increased by repeated stressful events.Herman (1992:10) explained that while the victim of a single traumatic event .may say she is not herself since the event, the victim of chronic trauma may lose the sense that she has a self'.Such chronic exposures to stressful job-related events, are portrayed in the following statement:

It doesn 't m atter how much you try avoiding it...tom orrow it will be there, there will be a shortage o f staff, there w ill be very sick patients, incapable staff... you have to handle this.
Critical care nurses' experiences of stress C C N s' ex p erien ces o f stress w ere grouped in to the follow ing subcategories: critical care environment (physical and psychological), frequency intervals o f pressure, inevitability, circumstances and role uncertainty.

Critical care environm ent
Stressful experiences in a critical care environm ent called for im m ediate attention and decision making.Conflict and disintegration resulted from an u n supportive physical and psychological environment, as revealed in the following statements:

For me why must the stress be so bad at work? The place is too big, i t 's an open venue.
There is stress in a six bed unit as well as with sick people.You've got no time to g et to every individual

I f there isn 't support, i f the sisters d o n 't work together and help each other it becomes very stressful, especially with very sick patients.
However, positive experiences were also reported:

Fortunately I can say... sh e's a positive person, she's an approachable person, you don't battle to work with her and that made me fe e l so good.
Much stress was experienced when the CCN s had to w ork w ith unskilled personnel who lacked knowledge about various procedures and protocols.This resulted in work overload and additional stress for permanent CCNs, as indicated by the following quotations:

There's no time, I 'm dealing with an em ergency situation, I cannot teach you... I think the whole problem here is we have too little perm an en t trained s ta ff or permanent sta ff with experience. ... every time i t 's a different agency nurse, which also frustrates the doctors.
Goll-McGee (1999:8) describe the critical care unit as a challenge to every CCN within which to care for acutely ill patients while coping with stressful fast-paced and demanding clinical events.This description aptly summarises the experiences revealed by the CCNs who participated in this study's focus group interviews.
The frequency of stressful job-related experiences CCN's reported the frequency of stressful events in the workplace to be causing a steady build-up of stress, as stated:

The inevitability of stress
The inevitability of stress was attributed to changes that occur momentarily, are u n p red ictab le and in ev itab le.The circu m stan ces m entio n ed were absenteeism, the expectation that CCNs must cope in spite of staff shortages, that time is limited while the demands are numerous.

.... if you've got no staff, you know, y o u 've
been told or been taught to cope...

Circumstances under which CCNs work
The focus group participants raised concerns about the circumstances under which CCNS are expected to render expert services to critically ill patients.There are days when you feel you cannot cope and this is not only because you yourself do not have confidence or knowledge, it is the circumstances.

Role uncertainty
CCNs have a multitude of roles to fulfil.Role uncertainty is experienced when student CCNs have to cope with the theoretical and practical environment.Work/family roles and role overload was the result of conflict.

The needs of CCNs
The needs of CCNs include operational (including the en v iro n m e n t) and emotional support systems.

Operational support systems
The critical care environment is one with long working hours and a shortage of personnel, with num erous potential stressful in cid en ts.C C N s, who participated in the focus group interviews did not portray a supportive work culture nor a collaborative work environment.They don't see me as a human being.... there was no one who supported me...

I took care o f a man who w as in an accident... he literally bled to death in my hands, there was nobody to support me.
If you admit a critically ill patient and there are veryfew seniors, too fe w hands, that is also very stressful.

You fin d yo u rself looking after a sick patient or a difficult patien t and th ere's no one to co m e a n d h elp w ith admissions.
I think the whole problem is we have too little perm an en t tra in ed s ta ff or permanent sta ff with experience.Cudmore (1996:122) describes the critical care en v iro n m en t as d ea lin g w ith situations that range beyond usual human experience.Much stress was generated by n u rses who lacked know ledge about p ro c ed u re s and protocols, p articu larly about those concerning electrocardiograms (ECGs), an ti-clo ttin g tim e p ro c ed u re s and medications.

Emotional support systems
These support systems encompass the needs for criticial stress debriefing, supportive in te rre la tio n sh ip s, com m unication, asse rtiv e n e ss and teamwork.

Critical incident stress debriefing
Most p artic ip a n ts ag reed th at no emotional support was given and felt that in ter-p ro fessio n al co llab o ratio n depended on sp ec ific su p p o rtiv e strategies.There are no systems in place to support, say listen, hmm, you must go and talk to such a person who does p ro p er counselling.

When I had a problem they told me i t 's my problem, i t 's not the unit, i t 's not the workload, i t 's me, myself.
Berk (1998:20) states that it is not the work environment, nor the individual, but their interaction, which is responsible for the type of stress experienced by workers in a specific situation.D ebriefing and defusing support system s for CCNs should be accessible 24 hours per day (Everly & Latting 1995:131) to help resolve critical incident stress, and cumulative prolonged stress reactions.This author also m aintains that the integration of professional and peer interventions improves identification and clarification of emotions.

Supportive interrelationships
Team w ork involves the sharing o f experiences which lead to reflective co n sc io u sn e ss, "n o rm a lisin g " experiences and alleviating emotional reactions to stress (Ivey, Ivey & Simek-M organ, 1997:197).
S upportive programmes are offered irregularly in some hospitals.Professional support groups are perceived as a stress reducer.A few participants described supportive en v iro n m e n ts and supportive interrelationships.

Communication
C om m u n icatio n and good hum an relations are important for coping in stre ssfu l situ atio n s.P a rtic ip a n ts experienced vulnerability by often having to cope without showing any emotion, tension or pressure.

Assertiveness
A few participants stated that they were not able to be assertive in the work environment because of victimisation.They tell you at a later stage that you said this and this, and you did this and this and in the end it is taken completely out of context.So, you learn to rather keep quiet, to hold back more and more and put it away and you don't even try to cope with it.

Teamwork
CCNs described a lack of teamwork and supportive interrelationships.

It always comes back to teamwork.... People will not help you o f their own free w ill... you have to beg her and say, please do this fo r me.... "
Patient profiles affect the demands made upon the nurses and the physical and psychological well being of the CCN.

Yes in the unit where we work...there are a lot o f factors, sick patients their age groups and the p a tie n t's families.
Most participants experienced physical exhaustion, emotional, cognitive and behavioural changes, due to a heavy workload.

I f e e l d ra in ed . You b u ild on, i t 's snowballing and...no one copes.
A diversity of emotions were experienced concerning the demands and the coping efforts needed for working in a critical care environment....You only have two hands!Absenteeism from work was the only way out for some participants who could not cope, a low morale and self-esteem p ressu red an avoidance type o f behaviour as their only option.H o w ever th ere w ere also p o sitiv e comments:

When th e re is a h ig h e r le v e l o f competence involved there is a better relationship with the doctors.
Solutions for enhancing critical care nurses' coping skills Debriefing and counselling could help CCNs to cope better with their stressful jo b -re la te d situ atio n s.P roviding debriefing sessions at regular intervals, but specifically after the death of a patient, could enhance CCNs resilience and coping abilities.
Adequate numbers of knowledgeable nurses in these units would decrease the CCN s stresses.
S upport and acknowledgement from nurse managers and from doctors would also ameliorate some stresses.
the stress home.They were prepared to listen to it, five months, six months, these things are carrying on fo r years.So the moment you start talking about it, you hear ' ju st shut up please, because we 're fe d up '.The doctors place a heck o f a lot more stress on us.
that I can n ot make it, I 'm sic k ..... / cannot, you know, take it.........You know your people do not turn up f o r work.Families of patients become secondary victims of stress as they observe their fam ily members suffer.The lack of com m unication and respect was a frequently cited concern of most CCNs.You are there with the p a tie n t, the nursing staff, 24 hours, so I mean you are very important.The key factor o f that whole situation is respect.
GOLL-McGEE, B 1999: The role of the clinical forensic nurse in critical care.Nursing Quarterly.22(1):8-18.ORASANO, JM & BACHER, PI 1996: Stress in military performance in Stress and human performance edited by JE Driskell & E Salas.Mahwah: Lawrence Erlbaum.GUBA, EG & LIN CLO LN , YS 1985: Naturalistic inquiry.London: Sage.H E R M A N , J L 1992: T raum a and recovery: from d o m estic abuse to political terror.London: Harper Collins.IVEY, AE; IV EY , M B & S IM E K -M ORGAN, L 1997: Counseling and psychotherapy: a m u ltic u ltu ra l perspective.4th edition.Boston: Allan & Bacon.LAZARUS, RS & FOLKMAN, S 1984: Stress, appraisal and coping.New York: Springer.LAWS, T & HAWKINS, C 1995: Critical incident stress.A ustralian Nursing Journal 2(7): 17-18; 32-33.MASLACH, C & SCH AUFELI, WB 1993: H isto rical and co n cep tu al developm ent o f b u rn o u t: re cen t developments in theory and research edited by WB Schaufeli, C Maslach & T Marek.Washington DC: Taylor & Francis.M O N SE N , R B ; F L O Y D , RB & BROOKMAN, J C 1992: Stress-Coping-A daptation: co n cep ts fo r nursing.Nursing Forum.27(4):28.MOUTON, J & M ARAIS, HC 1990: Basic concepts in the methodology of the social sciences.Pretoria: Human Sciences Research Council.MULDARY, TW 1983: Burnout and health professionals: manifestations and management.Connecticut: Appleton-Century-Crofts. N EU M A N , B 1995: The N eum an Systems Model.3rd edition.Norwalk: Appleton & Lange.PARAHOO, K 1997: Nursing research: principles, process and issues.London: MacMillan.PFIFFERLING, JH & GILLEY, K 2000: Overcoming compassion fatigue: mental fatigue.Journal of Medicine Practice.
1985: Resilience in the face o f adversity .B ritish Jo u rn a l o f Psychology.147:598-611.SELYE, H 1974: Stress without distress.Philadelphia: JB Lippincott.STRAUSS, A & C O R BIN , J .1990: Basics of qualitative research: grounded theory procedures and techniques.London: Sage.STRUM PHER, D J W 1995: The origins o f h ea lth and stren g th from "salutogenisis" to "fortigenesis".South A frican Jo u rn al o f P sychology.25(2):2,19,65 81-89.T A Y L O R , G 1999: T he race for co n sc io u sn e ss: a B rad fo rd book.Massachusets: MIT Press.VAN SERV ELLEN, G & LEAK E, B. 1993: B urnout in hospital nurses: a c o m p ariso n o f acquired im m u n o deficiency syndrome, oncology, general medical and intensive care unit samples.Journal of Professional Nursing.9(3): 169-177.W ILK IN SO N , J 1999: Implementing reflective practice.Nursing Standard.13(21): 37-39.

Tablel: Measures for ensuring trustworthiness STRATEGY CRITERIA
meaning".The focus group interviews attempted to obtain information about CCNs' stressful experiences in CCUs.A context is a particular set of conditions within w hich the action/interaction strategies are taken (Strauss & Corbin 1990:29).This study was contextual in Participants had to meet the following criteria:• They had to be employed full time or part time as CCNs in one • The final questions, asked at the end of the focus group discussion, were: Is there a need for stress management programmes in your hospital?How do you think CCNs could be helped to cope with stress in the critical care environment?

you keep going. I think bad stress is what comes out in you physically, you know you scream at people, you are irritable.
Eustress versus distressParticipants vaguely described eustress as good stress implying the ability to cope and distress as bad stress and being unable to cope in stating: ... fo r me that stress is a good stress I live on that stress, on that adrenaline.I think there is a difference between good s tr e s s a n d b a d s tr e s s , yo u keep deadlines,

You get a tolerance f o r yo u r stress level and you must try not to exceed that... so d o n 't think that stress is the problem , but the amount. Ongoing stress can be a problem.
Due to the stress... there's ten times more friction ... people are at each oth ers' throats, and th at's the worst because you hurt a person because o f the frustrations y o u 've got inside o f you, not that youhave anything against the person....... ... you damage your own persons around y o u ...