Stress and Coping 1

Running head: Stress and Coping in New Nurses

Stress and Coping Mechanisms in New Nurses

Jordan Harris

Florida Atlantic University

 Stress and Coping 2

Nursing in general has always been a stressful field, but new nurses particularly both feel

the stress of nursing and are susceptible to it. For many new nurses if the stress load becomes

too intense this can lead to burnout and eventually perhaps leaving the profession as well as

critical errors in patient care. As the nursing field is experiencing a shortage of nurses it is

important to retain every nurse; especially if they leave because they are not provided with a few

tools to help them cope with stress. In addition to providing opportunities to learn coping

mechanisms, nursing leaders can also institute organizational changes to improve stress levels

not only for new nurses but also for all nurses under their management. New nurses themselves

can be proactive in learning these coping mechanisms and exploring ways they can protect

themselves from excessive stress. The consequences of not dealing with stress in the nursing

industry will lead to nurse burnout, decrease in quality of patient care, patient accidents such

as medication errors, and ultimately nurses leaving the profession.

DEFINITION OF STRESS

Nurses are in general a group vulnerable to stress as they deal with patients’ and

relatives’ suffering, a high level of physical exhaustion, a quickly changing healthcare field and

understaffing (Campos de Carvalho 205). The National Institute of Occupational Safety and

Health defines job stress as “the harmful physical and emotional responses that occur when the

requirements of the job do not match the capabilities, resources, or needs of the worker”

(Wellker-Hood 2006 p.104). Nursing has historically been a stressful field and likely always

will be. Florence Nightingale’s experience during the Crimean war in the barracks of Scutari

were stressful as they were in a situation with too few funds, supplies and trained personnel to
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care for the hundreds of young soldiers dying from battle wounds and infections (Milliken &

Tillman 2007). Things have not changed too much since that time as hospitals today still find

themselves short on funds and trained personnel on a daily basis. Nurses find that they have a

shorter period of time to provide complete patient care to the “sicker” and to do so “quicker”

(Milliken & Tillman 2007). However, stress itself is not necessarily damaging. Some stress is

good and in fact necessary- for example the stress and adrenaline that kicks in during a Code

Blue. Positive stress is referred to as eustress and can heighten and focus attention as well as

increasing mental acuity (Wellker-Hood 2006). However, at some point the level of stress

becomes too high and then no longer improves a person’s performance but rather starts to impair

their ability to meet the challenges their job presents (Wellker-Hood 2006). Stress has also been

described as a type of anxiety or as an experience of change (Hurley 2007). No matter how it is

described it is clear that while things can be done to ameliorate the experience of stress it is not

something than can ever be banished and so consequently it must be coped with instead.

Stress causes the sympathetic nervous system to flood the body with cortisol and

adrenaline; this constant triggering of the sympathetic nervous system can exhaust the body and

lead to health problems (Milliken & Tillman 2007). These high levels of stress can lead to a

myriad of physical symptoms: heart disease, migraines, hypertension, irritable bowel syndrome,

muscle tension, back and joint pain and duodenal ulcers (Milliken & Tillman 2007). High levels

of stress can also lead to mental health problems: depression, insomnia, anxiety and feelings of

inadequacy (Milliken & Tillman 2007). Chronic high levels of stress can lead to a depressed

immune system, decreased cognitive functioning and ultimately even degenerative changes to

the brain structures responsible for storing new information (Pipe, Bortz, Dueck, Pendergast,

Buchda & Summers 2009). In fact chronic stress appears to affect cellular aging by shortening
 Stress and Coping 4

telomeres, which is a biological indicator of age. Ultimately these degenerative changes, which

are linked to high levels of stress perception, translate to an average loss of 10 years of life (Pipe

et al 2009). Stress particularly affects high-level cognitive skills such as attention and memory,

which are critical components in quality nursing care (Pipe et al 2009). High levels of stress can

lead to the phenomenon of burnout. Burnout is a feeling of being overworked, emotionally

drained, and leads to lower productivity in both work and home life (Davies 2008). Nurses find

this syndrome of burnout to be a pervasive source of distress (Leiter & Laschinger 2006).

Nurses who become burnout can also become cynical and exhausted leading to lack of patient

care (Laschinger & Wong 2006). Burnout is particularly common in the health care professions

because of the emotional intensity of the relationships with their patients. Physical symptoms of

burnout include headaches, dizziness, insomnia, skin problems and gastrointestinal distress

(Sardiwalla, Vandenberg & Love 2007).

New graduates nurses are eager to join the workforce, but they are especially vulnerable

to the stressors that exist in the current workplace. New nurses are statistically more likely to

leave their first nursing position within 1 year and can cost $40,000-$100,00 to replace

(Winfield, Melo & Myrick 2009). They experience a transition from school to the reality of

professional nursing that can be shocking when they realize there are gaps between their

knowledge and what they are expected to know as new nurses (Winfield et al 2009). Stressors

that are particularly common to new nurses include: lack of confidence/competence in their

skills, worry about making errors and fear of new situations and procedures (Winfield et al

2009). New nurses have this set of stressors as well as the ones that are common to all nurses:

critical nature of their work, staffing shortages, working more shifts, inadequate rest, potential

for lawsuits, working with potentially deadly communicable disease, aches and pains from lifting
 Stress and Coping 5

patients, watching people suffer, job layoffs or insecurities and difficulties with co-workers or

supervisors (Winfield et al 2009). The question then becomes what are the consequences of

stress and ultimately burnout on nurses, the economy and patients?

CONSEQUENCES OF STRESS

The most serious consequence of overstressed or burnt out nurses is adverse incidents

with patients. Medication errors are one of the most common and most serious adverse events

that can befall a patient in the hospital; research studies have shown a clear correlation between

stressed and unfocused nurses leading to medication and other patient care errors (Wellker-Hood

2006). Nurse focused research has found work overload was the most perceived stressor among

nurses (Hays, Mannahan & Wallace 2006). A study by Aiken et al examined the association

between staffing and patient mortality. This study found each additional patient resulted in a 7%

increase in odds of failure to rescue, and 7% increase in 30-day mortality (Garrett 2008). This

study also found that each additional patient increased odds of burnout 23% and job

dissatisfaction by 15% (Garrett 2008). Not only does an overload of patients increase nurses’

stress but also directly affects the patients’ care and outcomes. Many nurses list excessive work

hours and overtime shifts as significant sources of stress. A study by Whitman et al found that

the higher the amount of hours worked the higher the likelihood that patients would have more

falls, nurses would more often place patients in restraints, and that nurses would make

medication errors (Garrett 2008). Lower staffing rates were also shown to directly relate to the

rate at which patients in the hospital acquired pneumonia and the study found that by adding only

half an hour of RN staffing per patient they could reduce the rate by 4% (Garrett 2008). Often

times when understaffing leads to stressed or tired nurses making critical errors in medication,
 Stress and Coping 6

assessments, or overall care the nurse is blamed (Wellker-Hood 2006). Blaming the nurse can

start a vicious cycle as it leads to more stress and ultimately doesn’t address the underlying cause

of the error caused by understaffing or other stressors (Garrett 2008).

Excessive stress can cause a plethora of somatic symptoms in nurses such as: headaches,

nausea, dizziness, insomnia, skin problems, gastrointestinal symptoms, heart disease, irritable

bowel syndrome, back and joint pain and a myriad of mental health problems. These physical

and mental problems become issues not only on a personal level but an administrative level as it

leads to absenteeism and therefore requires administration to use expensive replacement staff or

mandatory overtime (Milliken et al 2007). Mandatory overtime can then also cyclically lead to

nurses feeling overworked and burnt out. Nurses often cope with stress and the physical

symptoms of stress by calling out sick; when nurses call out sick, especially if they cannot be

replaced, patient care and safety is compromised (Garrett 2008). The estimated national cost of

health care worker stress is about $250 to $300 billion annually (Milliken et al 2007). This

estimate takes into account: dollar effects of reductions in operating effectiveness, poor decision

making, medical expenses and staff attrition due to overwork (Milliken et al 2007).

Burnout is a major consequence of excessive stress and is a particular problem in the

nursing field (Leiter & Laschinger 2006). Burnout is a syndrome characterized by emotional

exhaustion, depersonalization and feeling a lack of personal accomplishment that occurs after a

period of chronic and unrelieved job related stress (Barnard et al 2006). One way to measure

burnout is the Maslach Burnout Inventory (MBI). This inventory consists of 22 items with 3

subscales: emotional exhaustion, depersonalization and lack of personal accomplishment

(Sardiwalla et al 2007). Nurses score high on the burnout scale with younger nurses reporting

even higher levels of emotional exhaustion. Close to 53% of nurses surveyed in this study were
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in the severe burnout category according to the MBI scale (Laschinger & Wong 2006). Heavy

workload is the strongest predictor of nurses’ emotional exhaustion and ultimately burnout

(Laschinger & Wong 2006).

Stress can lead to nurses, particularly new nurses, deciding to leave the nursing field

entirely. Currently 1 in 5 nurses plan to leave the profession within the next 5 years and almost

50% think about leaving often (Letvak & Buck 2008). This is a negative trend as our nurse

workforce is currently aging and an influx of new nurses is needed. About 1/3 of the current

workforce is over the age of 50 and possibly approaching retirement age (Milliken et al 2007).

The average age of nursing faculty is also on the rise and is currently approximately 49 years of

age (Milliken et al 2007). Ultimately, as many as 20% of nurses will leave the industry, citing

stress or burnout as their reason (Milliken et al 2007). Nurse turnover, which is often caused by

burnout, ranges annually between 18-26% and averages a cost of $62,100-$67,000 per incident

of turnover (Milliken et al 2007). In addition we currently have a predicted nursing shortfall of

36% by 2020 so it is important to retain the new nurses who come into the profession (Letvak &

Buck 2008). A current nurse shortfall nationally of 8.5-14% is affecting patient safety and

quality of care and leading to overwork and stress of the nurses currently in the field (Letvak &

Buck 2008).

COPING MECHANISMS

Identifying strategies to help nurses deal with stress can be problematic as often the staff

is unaware of the extent that stress is building up and affecting not only them but their ability to

care for patients (Repar & Patton 2007). Anna Halprin, an esteemed author in the area of

expressive arts theories states; “the inability to relax is often so enmeshed in emotional blocks
 Stress and Coping 8

that we are unaware of making relaxation the most difficult skill to achieve” (Repar & Patton

2007 p.182) The front line of defense for nurses, and new nurses in particular, against stress is to

use coping mechanisms to help them deal with the stress they feel on a daily basis. Coping is

defined as “the cognitive and behavioral efforts exerted to manage external and/or internal

demands. Which were perceived as taxing to an individual. The function of coping was to

manage or alter demands that occur externally in the environment or internally within oneself”

(Hays et al 2006 p.185). It was through the framework of scientists like Freud, Menninger, Haan

and Erikson that we as a society were first introduced to strategies for individuals to reduce their

level of stress (Hays et al 2006). Coping mechanisms such as planful problem solving and the

seeking of social support are the most frequently reported coping mechanisms. Planful problem

solving includes delegating work, rationalizing the situation and speaking with someone who can

do something concrete about the problem (Hays et al 2006). Social support can be within the

workplace such as coworkers or outside the workplace with friends, families, or other supportive

environments such as church groups (Hays et al 2006). Peer support can reinforce “feelings of

competence and successful achievement of one’s work with people” which can lead ultimately to

lower rates of burnout (Barnard et al 2006 p.343). New nurses in particular benefit from more

peer support from experienced nurses (Barnard et al 2006). Patricia Repar believes that nurses

“who wish to have effective and enjoyable working careers should consider integrating into their

every day self-care, some practices designed to identify and overcome stress, chronic grief, and

compassion fatigue” (Repar & Patton 2007 p.183).

Some of the main somatic symptoms of stress are muscular tension, headaches and

general pain and tension in the neck, arms and the shoulders. One way to treat both the muscle

tension and the underlying stress is massage, which has been cited in numerous studies as a
 Stress and Coping 9

specific and effective way of reducing not only the effects of stress but also the stress itself and

thereby ultimately improving the overall health of the massagee (Repar & Patton 2007). In a

meta-analysis of 37 studies on massage therapy, which included 1802 participants, those that

received the massage therapy showed lower levels of anxiety, blood pressure and heart rate

(Repar & Patton 2007). While massage can be an expensive therapy it may be worth pursuing to

see if it is covered under a nurses’ health benefits as it is sometimes covered when it is done

through a chiropractic or physical therapy practice. One nurse who participated commented

before the massage that she felt “overwhelmed, rushed very stressed, tired” and afterward stated

“I feel like I’ll be more able to manage my assignment” (Repar et al 2007 p. 185). Another

massage participant stated “as I was getting massaged and my body began to relax I envisioned

entering a patient’s room with that sense of calm and peace which in turn can be transferred to

my patients. I have a much deeper understanding of the importance of self –care today than I

think I ever had” (Repar et al 2007 p.185) Overall massage therapy provides a tool that can

stimulate full body relaxation and when combined with other therapies or coping mechanisms

can help nurses stay ahead of the stressors of their jobs (Repar et al 2007). It can be hard to

convince nurses to participate in massage or other therapies as they often think they are too busy

to take the time or that it is too expensive (Repar et al 2007). Another idea is that perhaps

hospital administration could arrange for a massage therapist to visit each floor once a month and

cover the cost. It could very well be more than worth the cost if it decreased absenteeism and

worker’s comp claims. If nurses found it beneficial they may then seek out more massage

therapy using their own time and money, which might ultimately also benefit the hospital.

Exercise is another coping mechanism/therapy that can help reduce stress. Exercise, in

addition to its obvious health benefits, can also help trigger the relaxation response, which is a
 Stress and Coping 10

“state of deep rest that changes the physical and emotional response to stress” (Billingsley et al

2007 p.50). Exercises, which can be done in the hospital such as stretching or deep breathing,

can provide immediate relief from stress buildup (Billingsley et al 2007). Many larger hospitals

have added gyms to their buildings or allowed employees access to gyms used for physical

therapy. Almost any hospital can encourage exercise either through a physical gym on location,

or a discount program to a local gym.

Another coping strategy nurses can use to deal with stress is called Mindful Meditation.

This type of meditation is based on the ancient contemplative tradition of Vipassana and is a type

of cognitive exercise that “enhances the experience of the quiet mind and teaches recognition and

control of intrusive thoughts” (Davies 2008 p.33). Regularly practicing meditation can help

increase mental clarity, concentration, and the ability to deal with stress. (Davies 2008).

Meditation, unlike massage, is not something that brings about an immediate drop in stress.

However, long term it can help practitioners gain perspective on life events and better ways to

cope with them (Davies 2008). Most programs that teach Mindful Meditation are 8 weeks long,

but research has shown that even brief amounts of training can have a positive correlation with

improving levels of stress and negative emotions (Davies 2008). While the length of training is

not essential it is actually after the training how often the person practices meditation that has the

most impact on their stress level (Davies 2008). Meditation teaches the practitioner to reduce

extraneous thoughts and improve cognition. As nurses are often faced with situations where they

must sort through many conflicting messages meditation can help them sort the information and

prioritize therefore ultimately saving time, money and patients’ lives (Davies 2008). One study

found that after an 8-week meditation program, which consisted of 90% nurses, those

participants reported increases in self-acceptance, self-compassion, self-awareness, self-care, and

 Stress and Coping 11

self-confidence (Davies 2008). Other than Vipassana another types of Mindful Meditation is

Hatha Yoga, which is a type of yoga that uses physical poses along with breathing exercises to

develop strength, flexibility and balance (Davies 2008). Yoga “allows one to become aware of

the sensations that arise as one places one’s body in various positions or postures….yoga is done

without striving or forcing the body to do something, so while practicing yoga, one learns to

work within the body’s limits all the while focusing on being mindful of what sensations,

feelings, and thoughts occur (Davies 2008 p.35) . Nurses tend to live compartmentalized lives

and practices like meditation or yoga provide the potential to link all their experiences and offer

them a means to see their true selves without those barriers (Davies 2008). Yoga classes can be

found not only at private yoga studios, but today most community centers offer the classes for a

small fee. Since most yoga classes only require an empty room, a qualified teacher and a mat it

would even be possible for hospitals to provide yoga classes to its employees for a minimal cost

which could be either absorbed by the hospital or passed on to their employees. Other

alternative therapies that have been shown to reduce stress are aromatherapy, guided imagery,

music therapy, reflexology, dream work, light therapy and therapeutic touch (Hurley 1007).

Some of these alternative stress therapies, such as aromatherapy or music therapy, can be

accessed through a trip to the library and a small investment in materials.

One set of stressors that is unique to new nurses is the expectation from their employers

that they can hit the ground running. However, many studies show that this expectation is not

really feasible and that programs to help orient and preceptor new nurses can do a lot to lessen

the stress of their transition from school to practice (Winfield et al 2009). It is financially

important for hospitals to retain new nurses as the cost is estimated at between $20,000-$50,000

to replace them (Winfield et al 2009). Therefore it is to both the hospitals’ and the new nurses’
 Stress and Coping 12

benefit to have a nurse internship or residency program to ease that transition. There are many

programs out there of varying lengths that offer new nurses an internship or residency period. It

has been shown that despite some differences in length and program content that as a whole

these programs provide their hospitals a lower rate of staff turnover and an improved

commitment to the hospital from those nurses who completed these programs (Winfield et al

2009). While these programs differ they do have a few common characteristics: a commitment

to build competence and confidence in the new nurse, a longer than average orientation period

and the opportunities for new nurses to become involved in interdisciplinary collaborations

(Winfield et al 2009). A study of a one year internship pilot program at Children’s Hospital in

Los Angeles found that retention of new graduates went from 63% to 86% and that there was a

67.3% return on the investment in this internship program (Winfield et al 2009). In addition to

better retention, graduates of internship programs show better interpersonal skills, problem

solving and critical thinking skills (Winfield et al 2009). As there is currently a nursing shortage

in many parts of the country new graduates can be perceived as “an immediate solution to

staffing shortages” and so orientation periods may be shortened instead of lengthened (Winfield

et al 2009 p.E12). If more hospital administrators see the financial rewards of having new nurse

residency or internship programs they may become more amenable to implementing them in

their hospitals. New nurses themselves should speak up if their orientation period comes to an

end and they don’t feel prepared. If this occurs they should speak to their nurse administrator

about possibly extending their orientation period.

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CONCLUSION

Nursing is not going to get less stressful in the near future and as the nursing shortage

increases it is likely to get more stressful. Therefore new nurses need to seize the reins and be

proactive in their knowledge of work stress, ways they can personally deal with stress, and

programs they can encourage their hospital or place of work to implement. By understanding

how stressful a new nurses’ transition can be it prepares him/her to deal with it and perhaps

experience less shock. There are many coping mechanisms out there that can help head off

stress before it gets to the level of burnout. Some, like massage, may seem like a pipe dream due

to expense and time, but it is important for the new nurse to try it to see if it helps them and then

pursue whether their health insurance might cover it. If it doesn’t cover it there are many places

that provide mini massages for under $15 that may provide some relief from both muscle tension

and stress. Other strategies may simply entail a little research and some small startup costs such

as aromatherapy. By raising a new nurses’ level of stress awareness in the workplace it may be

possible to decrease stress and head off burnout. However, it is important for nurses to seek

counseling or talk therapy if they feel they need it . It is also important that hospitals provide

employee assistance programs or mental health benefits in their benefits package as well as

encouraging employees to make use of them as they are needed. Co-workers and administrators

should not place any stigma on hospital staff that chooses to use these mental health benefits.

Administrators, even those with modest budgets, can do much to alleviate stress in their

hospitals. They can make break rooms warm and inviting places for nurses to get away from the

stress of their jobs. They can provide comfortable seating and adequate facilities within the

break rooms while keeping postings to a minimum or keeping the tone of those postings
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encouraging rather than harsh. If incentives are offered for any reason it is a great opportunity

to make those rewards ones that can help alleviate employees’ stress levels such as massage gift

certificates, gym memberships or paid time off. Another idea is to bring in professionals to

educate on stress and stress management techniques; this may cost a bit more but research shows

that the investment pays itself off in many ways. New nurses are entering a stressful and volatile

career field, but with adequate education and coping mechanisms they can keep their stress level

down and avoid burnout.

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REFERNCES

Barnard, D., Street, A. & Love, A.W. (2006). Relationships between stressors, work
supports, and burnout among cancer nurses. Cancer Nursing, 29, 338-345.

Billingsley, S.K., Collins, A.M. & Miller, M. (2007). Healthy student, healthy nurse a
stress management workshop. Nurse Educator, 32, 49-51.

Campos de Carvalho, E., Muller, M., Bachion de Carvalho, P. & de Souza Melo, A.
(2005). Stress in the professional practice of oncology nurses. Cancer Nursing, 28,
187-192.

Davies, W. R. (2008). Mindful meditation: healing burnout in critical care nursing.

Holistic Nursing Practice, 22, 32-36.

Garrett, C. (2008). The effect of nursing staffing patterns on medical errors. AORN
Journal, 87, 1191-1204.

Hays, M.A., Mannahan, C., & Wallace, D. (2006). Reported stressors and ways of
coping utilized by intensive care unit nurses. Dimensions of Critical Care Nursing,

Hurley, M. (2007). Managing. Nursing Management, 14, 16-18.

Laschinger, H.K. & Wong, C.A. (2006). The impact of staff nurse empowerment on
person-job fit and work engagement/burnout. Nursing Administration Quarterly, 30,
358-367.

Leiter, M.P. & Laschinger, H.K. (2006). Relationships of work and practice environment
to professional burnout. Nursing Research, 55, 137-146.

Letvak, S. & Buck, R. (2008). Factors Influencing work productivity and intent to stay in
nursing. Nursing Economics, 26, 159-165.

Milliken, T.F., Clements, P.T. & Tillman, H.J. (2007). The impact of stress management
on nurse productivity and retention. Nursing Economics, 25, 203-210.

Pipe, T.B., Bortz, J.J., Dueck, A., Pendergast, D., Buchda, V. & Summers, J. (2009).
Nurse leaders mindfulness meditation program for stress management. The Journal of
Nursing Administration, 39, 130-137.

Repar, P.A. & Patton, D. (2007). Stress reduction for nurses through arts-in-medicine at
the university of new mexico hospitals. Holistic Nursing Practice, 21, 182-186.

Sardiwalla, N., VandenBerg, H. & Esterhuyse, K.G.F. (2007). The role of stressors and
coping strategies in the burnout experienced by hospice workers. Cancer Nursing, 30,
488-497.
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Wellker-Hood, K. (2006). Does workplace stress lead to accident or error.

American Journal of Nursing, 106, 104.

Winfield, C., Melo, K. & Myrick, F. (2009) Meeting the challenge of new graduate role
transition. Journal for Nurses in Staff Development, 25, E7-E13.