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Rev. esc. enferm. USP vol.43 no.4 São Paulo Dec. 2009
Stress among nurses who work at the intensive care unit
El estrés entre enfermeros que actúan en las Unidades de Terapia Intensiva
Vivian Aline PretoI; Luiz Jorge PedrãoII
INurse. Faculty at Centro Universitário
Católico Unisalesiano Auxilium. Araçatuba, SP, Brazil. email@example.com
IINurse. Ph.D. Professor at University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
Stress has been observed among various professionals, including intensive care unit (ICU) nurses, due to their close contact with patients in distress and at the risk of death. This situation becomes worse due to the need for direct and intensive care. This study was performed to characterize nurses working at ICU and verify the presence of stress among them. A total of 21 ICU nurses from five hospitals located in the state of São Paulo answered a series of questions about the ICU and completed the Nurse Stress Inventory. Study results showed that 57.1% of nurses consider the ICU a stressful place, and 23.8% achieved a high score, indicating the presence of stress. Stress continues to affect these professionals, and institutions do not offer any special care for nurses in the sense of promoting comprehensive health care.
Key words: Stress. Nursing. Intensive Care Units.
La presencia de estrés ha sido verificada en diferentes profesionales y también entre enfermeros de UTIs, debido al hecho de su gran proximidad con los pacientes en sufrimiento y con riesgo de muerte. Ese hecho se agrava debido a la necesidad de prestar cuidados directos e intensivos. Este estudio, siguiendo una metodología cuantitativa, objetivó caracterizar los enfermeros que desarrollan sus actividades en la UTI y verificar la presencia de estrés entre ellos. Para esto, veintiún enfermeros de UTIs de cinco hospitales del interior del estado de São Paulo respondieron un cuestionario de preguntas dirigidas a su caracterización y al Inventario del Estrés en Enfermeros. Los resultados mostraron que 57,1% de los enfermeros estudiados consideraron la UTI un local causador de estrés y 23,8% de ellos presentaron un puntaje elevado, indicando la presencia de estrés. Este hecho demuestra que el estrés, inclusive siendo discutido desde hace mucho tiempo, todavía acomete a esos profesionales, y las instituciones todavía no ofrecen atención especial a los enfermeros en el sentido de promover su salud integral.
Descriptores: Estrés. Enfermería. Unidades de Terapia Intensiva.
The term stress has been commonly applied these days, being associated with sensations of discomfort; the number of people who define themselves as stressed, or who consider others in varied situations as stressed, increases day after day. Different situations, depending on the individual standpoint, can unleash several types of emotional reactions. Most people commonly qualify unpleasant circumstances as stressing ones. Thus, the understanding and the assessment of stress are not always relevant to the individual's life status, but may be related to the perception the person has of everyday situations when applying his psychological process and his understanding of the facts.
Stress is deemed as the the evil of the century, a type of epidemic similar to those of the Middle Ages that struck millions down. In the healthcare field, this dissemination power has been overstated, since professionals are so involved in caring for their patients that many times they are not able to recognized their own vulnerability to the referred evil(1).
The concept of stress is understood as an assessment that individuals make of the situations to which they are exposed as being more or less affecting, that is, something that in their work is identified as a negative situation, or an adversity that is hard to face(2).
These days, labor seems to be a critical stress generator. It is important to learn how to cope with it within labor environments in order to positively transform it, thus bringing about individual and collective benefits(3). Whenever professionals are able to pinpoint personal stressing factors, they are somehow more capable of dealing with disturbing issues and improving their work and life quality.
Nursing is a stressful occupation and this fact is related directly to the work with people who suffer and who require abundant attention, compassion, and sympathy. Whenever nurses face situations like these, they may eventually become irritable, depressed, and disappointed. Such feelings can be considered as paradoxically incompatible with their professional performance, generating guilt and increasing anxiety(4).
In the last decades, the quest for improved quality of care for patients, among other health actions, has stimulated technological innovations and the modernization of health institutions; bearing that in mind, the present study focused on the work performed in an ICU, aiming at providing contribution to the development of further better qualified nursing assistance, even though this research subject has been explored widely by academic studies lately.
The objective of Intensive Care Units is to assist patients to duly recover, surrounded by an adequate physical and psychological environment where each professional is skilled to apply and use to advantage existing techniques, being ready to perform complex activities that involve a heavy work schedule, and demanding a fine practical, and theoretical, physical and mental preparation, since these units are environments used by patients who need direct and intensive care due to serious injuries or illnesses that put their lives at risk(5).
The presence of the nursing professional in the ICU is, thus, an imperative. The nurse performs managerial and assistance-based activities, and plays an essential role in the preservation of patients' physical and psychosocial integrity. Nursing professionals must be trained in order to perform complex activities, for which the theoretical foundation, allied to leadership, discernment, responsibility, and practice, are decisive ingredients.
ICUs are the backgrounds for extremely stressful situations that result from the regular expectation of emergencies, high technological complexity, and concentration of severely injured patients subject to sudden changes in their general health status. Thus, this work environment is characterized as stressful and the basis of an emotionally risky scenario, both for professionals and for patients and their family members(6).
Some studies reveal that nurses who work with critical care patients are more predisposed to stress(7), while others emphasize that the work overload and interpersonal relationship problems are the most evident stressing factors in the organizational environment of ICU nurses(8).
It is highly important to understand the reality experienced by multiprofessional teams that provide intensive care. This comprehension requires, among other things, the identification of aspects that hamper their performance and that can contribute to the lack of personalization of care of the patient and his family, thus generating distance, stress, and team suffering. The ICU environment is extremely stressful, and the group that works in this environment demands special attention, since the results of their work depend upon the team as a whole (9).
The emotional profile of ICU nurses undergoes alterations during their work shift, and that can be related to the weariness and stress of the activity of caregiving, above all in these units, where high level skills and immediate responses to emergencies are demanded(10).
Other variables that can influence the ICU nurses are: an excessively dry, refrigerated, sealed, and artificially lit environment; continuous and uninterrupted internal noise; steady inter-relationships between the same persons of the team all through the shift; as well as the excessive security, respect, and responsibility demands of the suffering patient experiencing pain and possibly imminent death, in order to safeguard the quality of care. These indicators certainly bring about an exhaustive, tense work environment, generating discouragement, conflicts among team members, group stress, and especially work stress(11).
Another series of factors that trigger stress within the ICU are the difficulty of accepting death, scarcity of material resources (beds and equipments) and human resources, and tense decision-making processes related to the selection of patients who will be assisted. These are some of the ethical and professional dilemmas intensive care multiprofessional teams face every day. Such situations generate tension among professionals, and in general negatively influence the quality of care rendered to clients(9).
According to the above-mentioned facts, it is crucially important that the professionals who work in ICUs receive special attention; hence, we believe that this study can be considered as decisively valuable for the Nursing field as a whole, bearing in mind the need for favorable means that provide these workers with integral health. Studies on the manifestation of occupational stress among nurses, mostly those who work in ICUs, can bring a better understanding of the problems faced by these professionals, and allow for intervention proposals and a search for solutions.
Characterize the nurses who work in ICUs and verify the presence of stress among them.
This is a quantitative study, mostly based upon a numeric language, applying a measuring instrument that is capable of offering direct responses to its objectives.
Eight hospitals in the countryside of Sao Paulo were required to authorize the implementation of the research; however, only five agreed to participate. In order to avoid eventual identification of subjects, the research chose not to disclose the name of cities and hospitals that agreed to participate in the study, since some of them had presented only two or three nurses willing to participate. Thus, aiming at a simple characterization process, we decided to name the hospitals as A, B, C, D, and F.
Hospitals A and B are philanthropic institutions, classified as midrange entities; their ICUs have 10 beds and the nursing personnel who works at the units is comprised of 4 and 5 professionals, respectively. Hospitals C and D are also philanthropic institutions, classified as large-sized entities and their ICUs have, respectively, 11 and 13 beds; hospital C has seven nursing professionals and hospital D, ten. Hospital F is a private hospital, classified as a small-sized entitiy; its ICU has five beds and the nursing personnel includes three professionals. All ICUs included in the study aimed at assisting both clinical and surgical patients.
At hospital A, two nurses participated in the research; at B, three; at C, five; at D, nive; and at F, 2 nurses. The total number of possible subjects was 29; however, as shown above, only 21 participants were included in the research due to the following reasons: three were on vacations; one was on maternity leave; and four were working in the ICU for less than one year, and were not included as they were considered as being in the initial stages of development in such an environment, and therefore, still undergoing an adaptation process; consequently, they represented a high risk of skweing the data of the applied data collection instruments.
Data collection procedures
This research complied with the norms of Resolution 196/96 of the Ministry of Health and was appreciated and approved by the Ethics Committee in Research Involving Human Beings of the Nursing School of Ribeirao Preto, University of Sao Paulo, under approval protocol number 0693/2006. Nurses who decided to take part in the study signed the Term of Free Consent.
After the previously described approvals related to the ethical proceedings, the subjects were contacted and officially invited to participate in the research; they also received the study materials concerning the data collection process. The material was comprised of:
a) Question naire on the subject's personal characteristics that could allow for an assessment of their profiles;
b) Inventory of Nursing Stress (INS), adapted and standardized for the Brazilian population, which investigates the major stressors of the nursing practice (12). The referred instrument is comprised of items that approach several aspects directed to common situations in the nursing practice that can be perceived as sources of tension or stress. These items are composed of factors that evaluate interpersonal relations, the stressful career roles, and all other intrinsic work-related stressors, as well as isolated items that compliment the assessment. The inventory is comprised of three specific factors, namely: Factor 1 Interpersonal relations; Factor 2 Stressing career roles; and Factor 3 The intrinsic aspects of the nursing practice. All through the factorial analysis, the authors identified six non-common items: numbers 1; 18; 19; 20; 32; and 44; however, these items were kept in the inventory because, after extracting the alphas, it was observed that it was possible to have acceptable magnitudes up to this amount of factors. Results indicated reliability. The authors establish that all values above 145 are strong indicators that professionals perceive their work environment as being stressing (Annex).
Nursing is a predominantly female occupation, and subjects in the present study ratified this predominance. Female participants constituted 90.5% of the entire researched group.
The percentage of participating nurses who were between 24 and 30 years old reached 47.6%, and those between 31 and 40 years old reached 42.8%; this allows us to affirm that 90.4% are between 24 and 40 years of age. Participating nurses who were over 40 comprised only the small index of 9.6%.
As for the experience of these professionals in ICUs, 42.8% had from 1 to 4 years of experience, and 38% showed between 5 and 8 years. A small percentage had experience of over 10 years, which means a percentage of 59.2% of nurses with over 5 years of experience. Table 1 shows us these results.
The table clearly indicates that 57.1% of the researched nurses work, on average, 36 hours weekly with critical patients, for a daily average of six hours. It can also be learned that 66.6% of these professionals have a different job in another healthcare institution.
We highlight the fact that 14 professionals, or 66.6%, who took part in the study had specialization courses; of these, 11 had specific post-graduation courses in intensive care (ICU) nursing.
When asked about their workplace, 12 subjects (57.1%) define their work unit as a source of stress (Figure1).
Charter 1 shows the nurses' responses to the INS.
Table 1 shows that women, while performing their nursing role, represent the majority healthcare providers in the hospital environment, an aspect that reflects a cultural tradition, highlighting that the gender issue is associated, in a general perspective, with task distribution and roles, particularly in the occupation of nursing(13).
As for the subjects' age, the fact that the majority of the researched professionals were located in the age group between 24 and 40 years old, and therefore a period of strong productivity, ensures a wide access road to high complexity know-how, self-improvement, and specializations. These findings were similar to those found in another study performed in ICUs, where 87.4% of nurses were located in the age group between 20 and 40 years old(14), leading to the conclusion that the younger nurses are those who get more involved in high complexity healthcare fields, perhaps in a search for a challenging professional experience. A considerable reduction in the amount of nurses over 40 years of age working in ICUs can be related to the fact that these professionals, when they come to this age, are absorbed in other areas, looking for administrative positions, educational positions, or even quitting the occupation(15).
Regarding the professional experience length of time, results can be understood as favorable towards a balance of a good professional performance related to the development of the occupation's general procedures. Thus, less experienced professionals always have the opportunity to discuss their difficulties with those who have been in the field for longer periods, with whom they share the same space in the same time span. If we match this to the stress factor, we come to a general conclusion, as the longer the graduation time, the less the stress level, as the professionals have more chances of gaining greater technical security, and consequently more appropriate skills to control situations, particularly the critical ones(16).
The fact that many nurses work in more than one place indicated by the study is probably a result of the wages of this professional class that, according to the Union of Nurses in the State of Sao Paulo (SEESP), presents a base of around R$ 1,248,00 (one thousand, two hundred and forty eight reais) or US$ 585.91 (five hundred and eighty-five dollars and ninety-one cents) for those who render services in the countryside of the referred state. Hence, we suppose that if the professional nurse must work in more than one place with all the responsibilities that are inherent in the job, the chance of developing stress is much higher.
Nurses working in more than one job is certainly necessary, mostly due to the low wages paid in the profession, causing them to search for new income sources. Thus, coping with more than one job is a factor that strongly contributes, in several aspects, to the presence of stress and quality of life(17).
The number of specialized professionals indicates that the high complexity job market demands better professional qualification. It is believed that when the professional is better prepared to deal with critical patients, it facilitates a broader adaptation to the sector, thus relieving stress factors; this could be observed in this study where nurses with no post-graduation education showed a higher level of stress than nurses with at least one specialization(15).
As for the work units (ICUs) themselves, a high percentage of subjects indicated them as generator of stress; this can be attributed to the prolonged exposure to difficult situations, to the excessive work load, and to the intense contact with critical patients. A study performed with 100 nurses showed that 90% of them mentioned that working in ICUs is stressful, wearying, and tiring(11).
Although a high percentage of nurses considered the ICUs they work in as stressful environments, it was observed that the INS scores indicated that there was an adaptation response, as only 5 nurses (N5, N6, N9, N18, and N19) presented a perception index of elevated stress, that is, above 145. These results match the findings obtained in another study with 42 ICU nurses, where results revealed that 62% of them did not present stress(13).
We highlight that two of the five nurses that displayed indexes indicative of stress are nursing professionals who are just beginning their careers, developing their experience in an extremely complex care unit, with a high monthly work load, and are on the night shift. Additionally, there is a lack of proper preparation, leading to the understanding that these nurses compliment their technical/scientific preparation process at the work place itself, with probably little chance for any sort of supervision. At first glance, such characteristics for quite a young professional may not seem to be meaningful in terms of stress promoting factors; however, as times goes by, a search for improvement and for alternatives can bring about relief for the conflicts provoked by an exhaustive and tense work environment. Otherwise, we can infer that the professional will develop pathologic profiles, among them stress, which will sure put his quality of life at risk.
As per the other three nurses who also presented perceived indexes of elevated stress, the research observed that they had been working at the unit for a longer period: 2, 3, and 7 years, respectively. The fact that two of them were not specialized in the field, and one was a post-graduate in Public Healthcare draws our attention. We can observe that two of them had two jobs, ratifying that the professional qualification, the financial condition, and the work environment are aspects that strongly impact the development of stress profiles.
This research allowed us to affirm that nursing professionals in the studied ICUs are, in their vast majority, women, and that the age group of participants was located between 24 and 40 years old, leading us to the conclusion that younger nurses are the ones who most intensely desire to work in these units to develop their professional skills. It is also possible to deduce that younger professionals often work in more than one job in an effort to compliment their wages.
These professionals pointed out their awareness of the need and importance of keeping up-to-date, and that specialization courses relieve the burdens imposed by work environments.
The INS revealed to be an effective instrument to assess stress in ICU nurses. It constitutes an easily applicable, all-embracing instrument toward the aspects it is set to evaluate. The relatively small amount of nurses in fact, an extremely relevant number - who indicated the professional care as a source of stress made possible the conclusion that in a healthy work environment the number of nursing professionals affected by stress could dramatically drop.
Despite the limitations of the study, which presented a small sample of nurses, it should be considered as a valuable tool for drawing attention to the fact that, in spite of the discussion and studies on stress performed by several researchers throughout the years, these professionals have not yet received from institutions the special attention that would empower them to face their sources of stress.
In conclusion, we believe that all the investments applied toward the search for healthy environments and better work conditions would inevitably be reflected in professional and service quality improvements to be rendered to clients, thus contributing to the diminishment of admittance time and making possible a faster recovery process, even for ICU cases, thus generating less expenses to the healthcare institution
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Received: 03/11/2008 INVENTÁRIO DE ESTRESSE EM ENFERMEIROS Leia cuidadosamente cada uma das sentenças
abaixo, que apontam situações comuns à atuação
do(a) enfermeiro(a). Considerando o ambiente de trabalho onde se encontra no
momento, indique se nos ultimos seis meses elas representaram para você
fontes de tensão ou estresse, de acordo com as seguintes escalas:
INVENTÁRIO DE ESTRESSE EM ENFERMEIROS
Leia cuidadosamente cada uma das sentenças abaixo, que apontam situações comuns à atuação do(a) enfermeiro(a). Considerando o ambiente de trabalho onde se encontra no momento, indique se nos ultimos seis meses elas representaram para você fontes de tensão ou estresse, de acordo com as seguintes escalas: