RESEARCH ARTICLES

The stress of nursing workers: study in different units of a university hospital

Celia Caldeira Fonseca Kestenberg^I; Ingryd Cunha Ventura Felipe^II; Felipe de Oliveira Rossone^III; Livia Moreira Delphim ^IV; Michele Costa Teotonio^V

^I Enfermeira e Psicóloga Clínica. Doutora em Psicologia Social. Professora Adjunta da Faculdade de Enfermagem e Pós-Graduação Latto Sensu de Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil E-mail: celiaprofuerj@gmail.com
^II Doutora em Enfermagem pela Universidade do Estado do Rio de Janeiro. Especialista em Enfermagem do Trabalho pela Universidade Gama Filho. Enfermeira do Trabalho, Farmanguinhos/Fundação Oswaldo Cruz. Rio de Janeiro, Brasil. E-mail: ingrydventura@hotmail.com
^III Enfermeiro. Especialista em Enfermagem do Trabalho pela Universidade do Estado do Rio de Janeiro. Enfermeiro do Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (Hemorio). Rio de Janeiro, Brasil. E-mail: feliperossone@hotmail.com
^IV Enfermeira Graduada pela Universidade do Estado do Rio de Janeiro. Especialista em Oncologia pela Universidade Federal Fluminense. Enfermeira do Hospital Municipal Dr. Nelson de Sá Earp. Rio de Janeiro, Brasil. E-mail: livia.delphim@gmail.com
^V Enfermeira Graduada pela Universidade do Estado do Rio de Janeiro. Enfermeira do Hospital Municipal Rocha Maia. Rio de Janeiro, Brasil. E-mail: micheleteotonio94@msn.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.11487

ABSTRACT

This descriptive research, with quantitative approach aims at discussing the stress level in three nursing teams' from a university hospital in Rio de Janeiro, RJ, Brazil. Eighty-five professionals were part of the study, conducted from January to December, 2011. The nurses were staffed at the central clinic, at the general intensive care unit, and at two wards in the hospital's medical clinic. The stress evaluation was held by Lipp's Inventory of Stress Symptoms (ISSL) and the measurement of the exposure to labor's environment stress factors through Inventory of Stressors Subjective Evaluation of Factors (IAFES). 56.5% (fifty-six point five percent) of the participants were found to be stressed and 49.4 % (forty-nine point four percent) were in resistance phase. 68.5 % (sixty-eight point five percent) of the participants were found to be exposed to medium or high levels of labor stress factors. The need for actions seeking the decrease in factors subject to labor intervention as well as the need for research approaching the theme was identified.

Keywords: Nursing team; physiological stress; psychological stress; occupational health.

INTRODUCTION

Stress is a large-scope issue that has some concepts and derivations. Widely discussed in popular discussion topics, the subject has come to occupy a prominent place in the media, becoming the object of interest of researchers in various areas^1,2.

Stress can appear when an individual is confronted with situations that irritate, scare, excite, confuse or even those that do her or him immensely happy, because of the interpretation given to the challenging event or due to stressors inherently negatives³.

Numerous studies have linked stress to the work, which demonstrates the close relationship between the themes, and therefore the concern about the negative impact on health and well-being of workers, being able to cause damage to the functioning and effectiveness of institutions⁴.

The hospital is an institution that is configured as a possibly stressful workplace due toits peculiar characteristics. "In general, it is recognized as an unhealthy, painful and dangerous environment for those who work there"^{5: 518}. Included in this scenario, are nursing professionals whose health has deserved a special care¹.

Observing different sectors inside the same hospital, one realizes that these professionals have several tasks and specific responsibilities, depending on the field where they work. Therefore, the external and internal results demand may have varying intensities. In this context the following question arises: which nursing teams working in different units of a university hospital have a higher level of stress?

It was defined as a general goal: to discuss the level of stress coming from nursing professionals' work. And the following specific objectives: to compare the stress level of the acting nursing teams in three sectors of a University Hospital; evaluate the effect of stressors arising from the work context in the stress level of the nursing staff.

It is important to emphasize the importance of this study for nursing care, since it is related to the quality of life of the professional, that when compromised, it influences the assistance provided by it. Regarding education, this study will assist in the formation of criticaland concerned professionals about their own health in the work environment and know how to identify the factors causing higher levels of stress. The search result will facilitate a broader view and greater understanding of stress and its implications in the workplace, family and socialenvironment.

LITERATURE REVIEW

Stress was first defined as non-specific response of the body to any situation that threatens the homeostasis of the individual, creating the need to mobilize to face the event which caused the imbalance biopsychosocial⁶. It is the psychophysiological reaction characterized as imbalance between what is charged to a person by the social environment and her ability to correspond to such charge.

Common sense often thinks of the stress as something bad, which is not always the case, as there are two types: eustress used to designate the good stress that motivates humans to act in the world and that is natural and necessary in the dynamics of lifetime; on the other hand the distress related to bad stress, characterized by mild discomfort to the extreme one, and may cause physical and mental exhaustion⁷

Stress can be divided into four phases⁸: Alert - phase in which the individual needs more strength and energy to respond to what is demanding a greater effort⁹; resistance - it is the constant search for balance, which may cause widespread feeling like apparent tiring without shown cause and difficulties in memory¹⁰apud³; near-exhaustion - when defenses begin to run out and the person cannot restore the inner homeostasis. The appearance of some diseases, common in this phase, shows that the resistance is not as effective³; and the fourth stage is named exhaustion - resistance is completely broken, and some symptoms similar to the alarm phase appear again, however, in greater extent. Despite the intense gravity of this phase, it is not necessarily irreversible³.

Discussions about stress are entering the world of work because although it fulfills other needs of man and family and is one way to reach self-realization, work can also be a source of illness for workers^1.11.

Current trends in promoting safety at work include not only the risks of working environments, but also the multiple psychosocial factors inherent in the working environment and how these factors influence the employee's health condition¹². These risks are the least studied but inattention to the same does not minimize its potential to cause occupational diseases or work-related ones, such as stress¹³.

The stress experienced in the occupational setting can influence on the quality and the level of commitment to the work, and also influence the level of personal satisfaction and the work environment itself, including the relationship with colleagues and supervisors. Sick workers inevitably diminish productivity at work, they are more vulnerable to absenteeism and long-term absences from work environment, which may lead to losses for organizations ¹³. What can be inferred is that it is installed a vicious cycle in which the worker and the institution enter a situation in which both lose. It then becomes necessary to think of strategies to deal with these demands of the working world.

From the analysis of several studies, we found some components known as threatening to the nurse's stability: the lack of a clear recognition among the general public, about who the nurse is, the political situation in which we are immersed, with the shrinking of wages, labor market tightening and unemployment. All these components are aggravating factors to professionals who are required to act in more than one workplace, exerting extremely long monthly working hours¹⁴.

Historically the nurse tries to build their professional identity and gain recognition. Difficulties experienced by and are not only historical, but also situational. The activities performed by these professionals make them especially susceptible to occupational stress phenomenon. Based on these statements, studies on stress in nursing cannot lose sight of its dimension¹⁴.

In research carried out with operating room nurses it was elucidated the need to conduct a comparative study between the different units of these professionals. Other comparative studies have been conducted and it was attempted to set a stress effect model in occupational activity of nursing. However, the various theoretical and practical and methodological frameworks hinder this design².

Thus, it is noted that research on the stress of the nursing team and its correlation with the work can improve the understanding and possible elucidation of some of the problems faced by category. Interventions and solutions are possible when there is a better understanding of these processes¹⁴.

METHODOLOGY

The study is descriptive, with quantitative approach. The research field was a University Hospital located in the city of Rio de Janeiro and its selected units were the intensive care unit (ICU) general; two medical wards; and the outpatient clinic. The choice of these units was justified because they are scenarios where nursing care varies according to the complexity of care provided to the patient assisted, which enabled the implementation of the objectives of the study.

The population was composed of all professionals of the nursing team: nurses, residents, technicians and nursing assistants who made up the existing workforce in the sectors surveyed. The samples were 19 at wards, 25 at ICU and 41 at outpatient clinic.

The including criteria were used: professionals working for at least one month in the selected units; all professionals who were exercising their work activities in the period of headcount data collection or temporary contract. Those who were on leave or vacation regime, which refused to participate in the study, and even the professionals were inaccessible were excluded.

The research was approved by the Research Ethics Committee of the Hospital, with the registration number 3005/2011, on August 9, 2011, because it is a study involving human subjects. Still in line with the law, all participants who signed the informed consent containing the goals and all information about the research, safeguarding the ethical principles and ensuring the right of workers to participate or not in the study without financial or professional losses¹⁵.

Data collection took place between August and September 2011. Two instruments were used for data collection: Inventory of Stress Symptoms for Adults (ISSL) ⁸; and other inventory prepared by the researchers called Inventory Assessment of Factors stressors Subjective (IAFES) that was based on two validated instruments: the Job Stress Scale (JSS)¹⁶ and the Inventory of Stress for Nurses (IEE)¹⁷.

The ISSL allowsidentifying the presence of stress in adults and at what stage the person is (alarm, resistance, near-exhaustion and exhaustion) and the prevalence of physical and /or psychological symptoms at each stage. It consists of 56 items with 37 somatic, physical and 19 psychological. The instrument consists of three tables: the first relates to the symptoms in the last 24 hours - alert phase; the second identifies the symptoms experienced in the last week - resistance levels and near-exhaustion; and the third refers to symptoms in the last month - burnout stage⁸.

IAFES consists of 19 items that consist of statements about attitudes of nurses in the workplace. It is a Likert scale in which the answers can range from never to always; as were only used direct items, if the respondent agrees with the sentences she/he will have higher and vice versa scores. Those individuals who obtained the figures above the sum of the average of the total scores, and less exposed below averagewere considered more exposed to the risk factors. The sum of the scores can range from 20 to 100.

The data from the IAFES were analyzed by frequency distribution of scores for each subject. Were determined by quartiles and guided by mean scores. The average was 51.32 points for the level of exposure to stressors in the workplace, and the standard deviation 10.98.

In addition, the power of discrimination of the items using the Student t test Studant was calculated and the result showed that all values were significant for 19 at items (p <0.05) and were accepted. Only item 13 did not reach significant (p> 0.05) and then was rejected. It is inferred that this item, described as follows: I do night shifts in this unit, was rejected because it consists of a fact and not an attitude. It is emphasized that this assertion was removed.

The data analysis techniques belonging to the descriptive statistics which was used to describe and summarize the data, and performed statistical calculations to estimate the parameters 18 with the support of Microsoft Office Excel 2007 software.

RESULTS AND DISCUSSION

From the purpose of this study, data emerged which enlarged our understanding of the importance of this topic in the field of nursing practice. According to the analysis of the collected material, the phase of stress in which professionals are is represented according to the sectors in which they operate, in Table 1.

TABLE 1: Stress level of nursing professionals by units. Rio de Janeiro, 2011

In the evaluation of stress, it is observed that the total number of professionals who participated in the study, the majority, 48 (56.5%) had some level of stress. Although only 4 (4.7%) of the sample are on the stage of near exhaustion and exhaustion, this data is relevant, since the phase almost exhaustion initiates the disease process and the organs at highest risk are now affected by stress⁸.

Comparing the level of stress among nursing staff working in the units studied, it is observed that almost half 42 (49.4%), the professional is in the resistance phase. These data corroborate previous studies: one that evaluated the stress level of workers from a health unit of the family, whose results showed that, for the most part, were in the resistance phase¹⁹. Another, whose objective was to evaluate the degree of stress in nursing students from the inventory Lipp, showed that most students, corresponding to 146 (68.5%) have some degree of stress. Here, 115 (54%) are in phase II, resistance, suggesting that undergraduate students possibly need great effort to manage stress²⁰.

Elucidating the findings, studies have found that stress affects negatively the performance of work activities of nursing professionals¹. This can be stated, since these workers feel overworked physically and emotionally, discouraged, with frequent irritation, in bad mood, frustrated, with muscle pain; signs and symptoms typical of stress "^1:701.

Another relevant aspect when it comes to resistance phase is to think that it is characterized by increased production of cortisol causing the person to greater vulnerability to diseases⁸. It is the moment in which may arise somatization.

The correlation between the level of stress with the positions held by survey participants indicates that, nurse assistants, the majority - 24 (51.1%) - has no stress. However, a significant percentage, 18 (38.3%), is in the resistance phase, followed by 3 (6.4%) in the near-exhaustion phase. These data are presented in Table 2.

TABLE 2: Stress level by position held. Rio de janeiro, 2011

In addition to those at different stages, it is evident the high number of professionals under stress effect corresponding to 22 (46.8%). As for nursing home residents, most, 5 (62.5%), is the phase of resistance. Among the nurses surveyed, it was found that 10 (35.7%) did not show any stress level, 1 (3.6%) is in the alerting phase, and the most, a total of 17 (60.7%) is in resistance stage. See Table 2.

The data show that the presence of stress in the resistance stage is not directly related to the position held by the professional, since the four categories surveyed, all had a significant percentage of individuals that stage.

From the findings of this study and previous researches, one can see that, regardless of position, all nursing professionals experience situations that promote very similar stress. Some events experienced by these professionals include: the feeling of helplessness in the face of pain and death; the exaggerated charge from the management, other workers and patients; and the lack of time for leisure and rest 5. In response to these developments, the idealization of the profession arises as a way to address the stressors and avoid suffering⁵.

The classification of occupational exposure was determined by first quartile (less than or equal to 45), the second quartile (46 to 50), the third quartile (51 to 55), and the fourth quartile (greater than or equal to 56). Therefore, the analysis of results highlighted: 31 (36.5%) participants are not exposed to stress factors; 13 (15.3%) were considered average exposure; 19 (22.3%) with medium-high exposure and 22 (25.9%) with high exposure, as shown in Table 3.

TABLE 3: Level of exposure to stressors by work unit of the participants Rio de Janeiro, 2011

About the level of exposure to stressors of professionals by work units, the majority, 54 (63.5%), is in average, medium-high or high exposure to stressors from work. The wards had the highest percentage of workers in high exposure, totaling 8 (42.1%). See Table 3.

There is a line between these data and those shown in Table 1, since the participants in all units are in phase of resistance, near-exhaustion and exhaustion - 46 (54.1%). Then, it can be inferred that the stressors present in the work activity may have direct influence with altered levels of stress of professionals, especially for the ones from the wards.

Among the participants of this study are nursing residents. Here, the research was conducted with these professionals pointed out that all 16 (100%) participants feel stressed because of the pressure in relation to the comprehensive workload. When it comes to professional training up process, it is important to take into consideration the inexperience to face newand unforeseen situations²¹.

In order to do not reach the extremes of illness and maintain their protected healthit is necessary that these employees develop, in relation to experienced stressors, more effective confrontation mechanisms to ease the psychological and somatic impact of stress and thus increase in frequency and intensity positive emotional states, which interfere directly and indirectly in the physical health of these professionals²².

Authors say it is important the investment in occupational stress management programs in order to intervene in these groups of workers, promoting health and safety, maintaining ideal levels of productivity and also reducing the costs of organizations with possible illnesses¹¹.

Previous studies show some strategies to face stress by health professionals^12,23,24. A study of the strategies used by nurses working in oncology obtained as the most relevant strategies, the ones focused on emotion, essentially positive reappraisal, in which the individual revisits the events in order to find positive aspects in the experience and to talk things for himself with intention of easing the stressful situation. Another strategy was focused coping problem, aiming to resolve this²³.

Previous studies show some strategies to face stress by professional saúde^12,23,24. A study of coping strategies used by nurses working in oncology obtained as the most relevant strategies the ones focused on emotion, essentially positive reappraisal, in which the individual revisits the events in order to find positives in the experience and talk things for himself in order to ease the stressful situation. Another strategy was focused coping problem, aiming to resolve this²³.

Still on used strategies, a study conducted with nursing staff, which operates in the emergency room of a health center school, points avoidance strategies, direct confrontation (search for information, talk about it and negotiate alternatives) and indirect (linked to religious activities and sports practice) facing the stress²². There was also a strategy carried out by the service, common to all teams, which include weekly meetings with exposure of problem situations and / or population's needs, as well as solutions to the daily life of their work¹².

Although professionals use the various strategies in the face of occupational stressors, work aimed at identifying and directly minimize the causes of stress in the workplace is necessary because these coping strategies, even providing a temporary relaxation, do not change the creating stress situation ²².

CONCLUSION

For this research, some limitations have been faced and may be highlighted in a special way the difficulty of finding professionals available to answer the questionnaires, as many times they were busy. Even that way, it was possible to do quality work and results that deserve attention, as they relate to workers' health.

From this study it was found that the nursing staff, working in the different units studied showed no differences in the level of stress. However, it became clear that the stressors arising from the work context interfere in the stress level of the teams.

Despite the lack of a significant percentage, it is noteworthy that some participants are in the highest stages of stress, beyond resistance. In this context, we see the need to think of intervention strategies that can reduce not only the labor stressors, but also its effects on workers.

Some situations in the workplace are hard to change in short time, perhaps in a medium term, so in that time, you need to take care of workers. To do so, we suggest training in stress management and conflict, training in social skills and creating support groups to the worker. These strategies can lead to the strengthening of internal resources and help them learn to manage stress, changing the way you perceive and deal with the stressful situation presented.

REFERENCES

1.Hanzelmann RS, Passos JP. Imagens e representações da enfermagem acerca do stress e sua influência na atividade laboral. Rev esc enferm USP. 2010; 44: 694-701.

2.Bianchi ERF. Enfermeiro hospitalar e o stress. Rev esc enferm USP. 2000; 34: 390-4

3.Lipp MEN. O modelo quadrifásico do stress. In: Lipp MEN, organizadora. Mecanismos neuropsicofisiológicos do stress: teoria e aplicações clínicas. São Paulo: Casa do Psicólogo; 2003. p. 17-21.

4.Hökerberg YHM. Demanda e controle no trabalho e hipertensão arterial: validade dimensional e meta-análise [tese de doutorado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2010.

5.Elias MA, Navarro VL. A relação entre o trabalho, a saúde e as condições de vida: negatividade e positividade no trabalho das profissionais de enfermagem de um hospital escola. Rev Latino-Am Enfermagem. [Internet]. 2006 [cited on 25 mar 2014];14:517-25. Available from: http://www.facenf.uerj.br/v19n1/v19n1a23.pdf

6.Selye H. Stress: a tensão da vida. São Paulo: Ibrasa; 1959.

7.Ribeiro MAP, Ribeiro LTF. Estresse: conhecer para superar. Petrópolis: Vozes; 2005.

8.Lipp MEN. Inventário de sintomas de stress para adultos de Lipp (ISSL). São Paulo: Casa do Psicólogo; 2000.

9.Margis R, Picon P, Cosner AF, Silveira ROS. Relação entre estressores, estresse e ansiedade. Rev Psiquiat. [Internet]. 2003 [cited on 21 apr 2014];25(1):65-74. Available from: http://www.scielo.br/pdf/rprs/v25s1/a08v25s1.pdf.

10.Lipp MEN, Malagris LEN. Manejo do estresse. In: Range B, organizador. Psicoterapia comportamental e cognitiva: pesquisa, aplicações e problemas. Campinas (SP): Editorial Psy; 1995. p. 17-21.

11.Murta SG, Tróccoli BT. Avaliação de intervenção em estresse ocupacional. Psicol Teor Pesq. 2004; 20(1): 39-47.

12.Camelo SHH, Angerami ELS. Riscos psicossociais no trabalho que podem levar ao estresse: uma análise da literatura. Ciênc Cuid Saúd. [Internet]. 2008 [cited on 24 may 2014];7:232-40. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/5010/3246

13.Guimarães LAM. Fatores psicossociais de risco no trabalho. In: Anais do 2^o Congresso Internacional sobre Saúde Mental no Trabalho: 2006; Goiânia Brasil. Goiânia (GO): [s.e.]; 2006, p. 99-110.

14.Stacciarini JMR, Tróccoli BT. O estresse na atividade ocupacional do enfermeiro. Rev Latino-Am Enfermagem. 2001; 9(2): 17-25.

15.Ministério da Saúde (Br). Normas de pesquisa envolvendo seres humanos. Brasília (DF): Ministério da Saúde; 1996.

16.Alves MGM, Chor D, Faerstein E, Lopes CS, Werneck GL. Versão resumida da "job stress scale": adaptação para o português. Rev Saude Publica. [Internet] 2004; [cited on 10 apr 2014];38:164-71. Available from: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0034-89102004000200003&lng=en&nrm=iso

17.Stacciarini JMR, Trócolli BT. Instrumento para mensurar o estresse ocupacional: inventário de estresse em enfermeiros (IEE). Rev Latino-Am Enferm [Internet]. 2000 [cited on 18 apr 2014]; 8(6):40-9. Available from: http://www.scielo.br/pdf/rlae/v8n6/12347.pdf.

18.Polit D, Beck CT, Hungler B. Fundamentos de pesquisa em enfermagem. Porto Alegre (RS): Artmed; 2004.

19.Camelo SHH, Angerami ELS. Sintomas de estresse nos trabalhadores atuantes em cinco núcleos de saúde da família. Rev Latino-Am Enfermagem. [Internet] 2004 [cited on 05 nov 2014];12(1): 14-21. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692004000100003&lng=en&nrm=iso

20.Kestenberg CCF, Silva AV, Fabri JMG, Silva NABS, Rosa BMS, Branco LM. Estresse em graduando de enfermagem: técnicas de relaxamento para lidar com fatores estressores. Rev Interagir. 2014; (17): 37-43.

21.Oliveira EB, Souza NVM, Chagas SCS, Lima LSV, CRA. Esforço e recompensa no trabalho do enfermeiro residente em unidades especializadas, Rev enferm UERJ [Internet] 2013 [cited on 28 jan 2015]; 21(2):173-8. Available from: http://www.facenf.uerj.br/v19n1/v19n1a23.pdf

22.Steffy BD, Jones JW, Noe AW. The impact of health habits and life-style on the stressor-strain relationship: an evaluation of three industries. Journal of Occupational Psychology. 1990; 63: 217-29.

23.Calderero ARL, Miasso AI.; Corradi-Webster CM. Estresse e estratégias de enfrentamento em uma equipe de enfermagem de pronto atendimento. Rev Eletr Enf. [Internet]. 2008 [cited on 13 apr 2014];10(1):51-62. Available from: http://www.fen.ufg.br/revista/v10/n1/v10n1a05.htm

24.Rodrigues AB, Chaves EC. Fatores estressantes e estratégias de coping dos enfermeiros atuantes em oncologia. Rev Latino-Am Enfermagem. [Internet] 2008 [cited on 23 may 2014];16(1):24-8. Available from: http://www.scielo.br/pdf/rlae/v16n1/pt_03.pdf.