A new contribution to the classification of stressors affecting nursing professionals

Objective: to identify and classify the most important occupational stressors affecting nursing professionals in the medical units within a hospital. Method: quantitative-qualitative, descriptive and prospective study performed with Delphi technique in the medical units of a general university hospital, with a sample of 30 nursing professionals. Results: the stressors were work overload, frequent interruptions in the accomplishment of their tasks, night working, simultaneity of performing different tasks, not having enough time to give emotional support to the patient or lack of time for some patients who need it, among others. Conclusion: the most consensual stressors were ranked as work overload, frequent interruptions in the accomplishment of their tasks, night working and, finally, simultaneity of performing different tasks. These results can be used as a tool in the clinical management of hospital units, aiming to improve the quality of life of nursing professionals, organizational models and, in addition, continuous improvement in clinical treatment.


Introduction
There is an increasing interest in recent years on the study of work stress (1)(2)(3) and the stressors in the work place due to their impact on the health of workers (3)(4)(5)(6)(7)(8) . Among the negative effects of work stress on the individual, several disorders can be mentioned both physical and psychological or behavioral. These, in turn, can lead to corporate problems, such as increased work absenteeism, reduced quality of work, reduced productivity, job dissatisfaction, work-related accidents, frequent changes of job and abandonment of the profession (7)(8)(9)(10)(11) , with possible undesirable effects on clinical management and patient care. In the sphere of Health Sciences, according to current studies such as RN4CAST (12) , nursing is considered a stressful profession.
In general, the identification of the main occupational stressors in nursing is related to specific units or contexts, such as Intensive Care Units (ICU), Emergency Services, Specialized Services or Primary Care. However, in medical units of general hospitals, there has been an increasing interest in finding out the specific occupational stressors of these units (13) . It can be stated that there are currently several levels of stress exposure depending on the different medical specialties, areas or services of the hospital, and there is also no international consensus on the choice of method for stress assessment (14) .
In previous related studies in other hospitals, it was observed that the main stressors are related to physical environment, demands of the work itself, work content, performance of the job, components of the organizational structure or work environment (15) .
Stress is considered as an emerging occupational pathology, with a special incidence on the services sector and a greater risk in activities that require personalized dedication (16) . It is understood as a stress factor or stressor, any stimulus capable of eliciting a stress response, with stress being the same response or reaction to a stressor (17) . To reinforce this theoretical model, there is the continuous contribution of several authors, from W. Cannon to JM. Peiró, passing by H. Seyle, Lazarus and Folkman or Ivansevich and Matteson, among others. These are based both on the socio-cognitive theory of the ego, the theory of social interchange and the organizational theory, as well as on the structural theory, in which a concept is developed from a physical point of view to a more holistic model, including psychological and social factors, and internal and external agents (18)(19) .
Currently, since the collapse of one of the world's largest investment banks, Lehman Brothers Holdings Inc. in 2008, which triggered the current economic slowdown in the industrial world, it has been observed the intensification of occupational stress. Thus, it seems relevant conducting related research, which may be important in the clinical management.
The general objective of the study is to identify and classify the main occupational stressors affecting the Nursing Professionals (NP) of the hospital medical units.

Method
Quantitative-qualitative, descriptive and prospective study developed with Delphi methodology. The Delphi technique is validated as a reliable consensus tool used in studies that require consensus from experts (20) .

Selection criteria for their inclusion:
Nurses who perform clinical nursing in the units mentioned before, for at least 3 years in the medical units and were active during the study.

Exclusion criteria
Nurses less than 5 years away to reach retirement; pregnant nurses; staff who did not voluntarily accept to participate in the study.

Losses
Nurses who were absent from the job during the study due to medical leave; refusal to continue participating at any time.
Data collection was performed in three stages. The procedure to obtain the answers was carried out by e-mail or mail (sealed envelope), according to the participant's preference. The stages were as follows:

Results
The sample is mostly female (83.33%) and there is  Firstly, a document with empty writing spaces was elaborated within each of the headings of the chosen classifier of stressor (21) , so that, in each section, the participants filled with the stressors that they considered as most important. The second part consisted of a new writing space in order to contribute with comments. Secondary variables (age, sex, level of education, hospital, hospital unit, length of service in the medical units, work schedule, and ratio of nurses per patient) were also collected. It was given a period of three weeks to answer the forms, and two weeks to data collection and analysis, preparation of a new form and participants' rest.
After obtaining the stressors, a list was drawn up grouping them according to the statements (21) .
Subsequently, a new form with 108 stressors mentioned by the participants was prepared for their assessment on a scale of 1 to 5 (from no stress to much stress).

Second stage
A form with 108 stressors was given to each participant for their assessment.
After completing and collecting all the forms, the analysis of the results (mean and median) was performed.  *Nursing professionals who met the inclusion and exclusion criteria †Nursing professionals who agreed to participate in the study ‡Response rate

Second stage
Of the 12 professionals who initially participated,

Third Stage
The total number in the third stage, which turned out to be the last due to the high level of consensus, began with 10 participants, of whom 7 replied. Therefore, the response rate was 70%. The results of the stage that turned out to be the last one due to the high consensus level are shown in Table 2.

Discussion
The inauguration of the hospital took place in January 2005, which evidences the length of service of participants.
While some have no more than 3 years of service in the same unit, others have 3 or more years of service in the same hospital medical units, or in the same hospital.
Therefore, they have experience in working with these particular types of patients.
In qualitative studies with Delphi methodology, the greater the number of participants, the better the conclusions obtained (22) (8,(13)(14) .
According to the classifier considered (21) , it was Therefore, the results of this study corroborate other studies that presented organizational problems as their results (12,(25)(26)(27)(28) .
When these results are compared with those of a previous study (15) , it is observed that they are coincident  (31) . However, there are other studies that point out the importance of stressors such as work overload, emotional demands or the conflicting relationship between doctors and nurses (32)(33) .
The geographic region of this study is restricted to an autonomous community, whereas it would be desirable to increase the studies in different autonomous communities aiming at making comparisons and carrying out improvement actions.

Conclusion
It can be stated that the main stressors, ordered