ORIGINAL RESEARCH

Stress – realities experienced by nurses working in an Intensive Care Unit

Armando dos Santos Trettene^I; Rosana Bonete da Costa^II; Priscila Capelato Prado^III; Maria de Lourdes Merighi Tabaquim^IV; Ana Paula Ribeiro Razera^V

^I Nurse. PhD. Professor. Craniofacial Anomalies Rehabilitation Hospital of University of São Paulo. Bauru, São Paulo, Brazil. E-mail: armandotrettene@usp.br
^II Nurse. Graduated. University Paulista. Bauru, São Paulo, Brazil. E-mail: rosana_bonete@hotmail.com
^III Nurse. PhD. Craniofacial Anomalies Rehabilitation Hospital of University of São Paulo. Bauru, São Paulo, Brazil. E-mail: priprado@usp.br
^IV Neuropsychologist. Professor. Bauru Dentistry College of University of São Paulo. Bauru, São Paulo, Brazil. E-mail: malu.tabaquim@usp.br
^V Nurse. PhD. Lecturer at University Paulista and Faculdades Integradas de Jaú. Bauru, São Paulo, Brazil. E-mail: anapaularazera@gmail.com

DOI: https://doi.org/10.12957/reuerj.2018.17523

ABSTRACT

Objective: to investigate the level of stress in nurses of an intensive care unit (ICU). Method: quantitative, descriptive study of a sample of 26 nurses in the ICU of a public hospital. The project was approved by the research ethics committee (Protocol E-016/10). Data were collected through two instruments: the Nursing Stress Inventory and a sociodemographic questionnaire. Statistical analysis included Student's t-test, Pearson's correlation and Variance Analysis, to a 5% significance level. Results: a significant association was observed between longer time working in the area and higher stress levels. Conclusion: the training time of less than ten years with a career that is still on the rise, linked to a context that allows stressful challenges, may have favored facilitatory and compensatory coping mechanisms with lower degrees of impact on the organism.

Descriptors: intensive care units; nursing; physiological stress; psychological stress.

INTRODUCTION

Work-related stress, also referred to as occupational stress, is a problem to be considered nowadays, as the rates of temporary incapacitation, absenteeism, early retirement, among others are alarming. However, the stress and risk of health problems arise when the demands of the job do not fit the worker's needs, expectations, or abilities.¹

In the health area, professional stress is frequent, and, among professionals, nurses are the most likely to develop a high level of stress, which directly affects their job satisfaction and the quality of care provided, including patient safety.^2-5

Within the hospital context, intensive care units (ICUs) are environments for the care of critically ill patients, who require permanent and specialized medical and nursing care. They are characterized by demanding routines and the need for fast and effective decision-making, as well as high technology equipment, an environment with a lot of noise, most of the time without natural light, and high possibility of death and pain, which makes this environment naturally stressful.^2,3

The work of ICU nurses has special characteristics due to the activities in the direct assistance to patients and their families, as well as the managerial and administrative activities, which include all the necessary resources for the functioning of the unit. They are also responsible for activities with a high degree of difficulty and responsibility, which effectively contribute to the development of psychosocial factors that condition the presence of stress at work, encompassing physical, psychological and moral stress.⁶

Another important aspect related to the nurses' performance is the approach to family members of the patients, who are usually at a high level of anxiety and stress, especially when the family member's prognosis is reserved. Authors have pointed out that family members of intensive care patients are more likely to develop psychological symptoms, including stress, anxiety and depression. Another factor considered as highly stressful for nurses working in ICU is to mediate frequent conflicts between professionals and family members about treatment plans.⁷ A humanization-based approach, especially in relation to reserved prognosis of critical patients, is advocated for resulting in emotional support and comfort to the family.⁸

In short, working at the ICU means investing intensively in the health care of critical patients, with the help of differentiated technologies and trained professionals who work as a team, in a suitable and specific physical space. It is also associated with the difficulty to deal with death, frequent in this sector.⁶

In this context, it is essential to identify the level of stress of nurses working in the ICU. We believe that, through a situational diagnosis, it is possible and feasible to propose interventions that minimize this phenomenon, contributing to the quality of care, patient and professional safety, worker health and cost reduction.

Thus, the objective of this study was to investigate the level of stress in nurses working in an Intensive Care Unit (ICU).

THEORETICAL REFERENCE

Stress can be defined as a break in internal homeostasis, that is, the stress reaction is elicited by a stressor that consists of any event or situation in the environment that breaks internal homeostasis, requiring an adaptation effort.⁹ In this way, stress is a normal mechanism; If it is well understood and controlled it is beneficial for a person because it causes the human being to react to situations of risk. However, the lack of control and chronicity, cause constant pressure to end in damage, both intellectually and physically. The stimulus that could be beneficial is replaced by fatigue, which can lead to the susceptibility of both physical and mental illness.¹⁰

Stress can be divided into three phases: alert phase (considered the positive phase – the human being is energized through the production of adrenaline, where survival is preserved and a sense of fullness is often achieved), resistance phase (the person automatically tries to deal with its stressors in order to maintain its internal homeostasis) and exhaustion phase (when serious diseases can occur in the most vulnerable organs, such as infarction, ulcers, depression, among others).⁹

However, one study has identified a four phases stress model called near-exhaustion (when stressors persist in frequency or intensity, resulting in a breakdown in the person's resistance), which is between the stages of resistance and exhaustion.¹¹

Stress as an intense reaction of the organism can arise when an individual is confronted with situations that irritate, frighten, excite, confuse or even those that make him immensely happy, due to the interpretation given to the challenging event or due to inherently negative stressors. ¹² Changes in people's lifestyles are leaving them debilitated and thus vulnerable to stress, which has assumed the status of disease. In Brazil, people are increasingly stressed, since the great majority do not know how to deal with their sources of tension.¹³

Thus, it can be observed that studies about stress in the nursing team and its correlation with work can help in the better understanding and possible elucidation of some of the problems faced by nurses. Since these professionals have different attributions and specific responsibilities, depending on the field in which they operate, adding the internal and external charges and having variable intensities.¹⁴

METHODOLOGY

This is a quantitative approach descriptive study carried out in the ICU of a large public hospital, located in São Paulo state countryside. The sample consisted of 26 nurses, both genders, in the age group from 31 to 50 years old, who worked in the ICU, performing care and coordination activities. Participants accounted for 93% of the workforce in the ICU.

The inclusion criterion was to work in the ICU in a period of more than six months, because it was considered as adaptive and independent of performing administrative or care functions. Nurses who were on vacation or on health leave were excluded.

The ICU had 37 beds: 12 Adult ICU, 12 Pediatric ICU, 9 Coronary ICU and 4 Burned ICU. The nursing team, per unit, was composed of a coordinating nurse, two nurse assistants in the morning, an attendance nurse in the afternoon, even and odd evenings, as well as a professional covering the days of each shift, nursing technician for every two beds per period. Multidisciplinary care included nursing staff, physicians, nutritionists, physiotherapists, social workers, speech therapists and psychologists. Patients with clinical and/or surgical conditions, including neurological, cardiovascular, pulmonary, metabolic, orthopedic, gastrointestinal and renal dysfunction were attended.

Two instruments were used to collect the data: Nurses Stress Inventory (IEE)¹⁵ and the Sociodemographic Questionnaire proposed for this study. The IEE is composed of 44 questions that are inherent to the nurses' work, scored in four levels, varying from never to always, categorized into four domains (interpersonal relations, career stressors, intrinsic work factors, organizational structure and culture). For the classification of stress level, the following criteria were used: final score between 44 and 88 points - low stress, between 89 and 132 - intermediate stress, between 133 and 220 - high stress.

The socio-demographic questionnaire sought to identify the following variables: gender, age, marital status, number of children, time in the area, specialization course in the area, work shift, weekly workload and number of employments, so that they are associated with the level of stress later.

The data collection took place in October 2010, in a single moment, in the counter shift of working hours, at a previously agreed place and time. For the statistical analysis, T-Student Test, Pearson's Correlation and Variance Analysis were used, all with a significance level of 5% (p≤0.05).

The research began after approval of the Research Ethics Committee involving Human Beings¹⁶, by means of protocol E-016/10 on 09/08/2010. The participants formalized their adhesion with the signing of the Informed Consent Form.

RESULTS AND DISCUSSION

To characterize the sample, from the 26 participating nurses, 4 (15.38%) had administrative and managerial functions and 22 (84.62%) had administrative and care functions. There was a prevalence of 24 (92%) female nurses, 17 (65%) comprising between 20-30 years old, 13 (50%) were married, 16 (62%) had no children, 23 (88%) had 1-10 years of graduation, 16 (62%) had 1-10 years of work time, 17 (65%) were specialists, 13 (50%) worked in the morning shift, 16 (62%) worked 36 hours weekly and 16 (62%) had a single employment agreement.

Regarding the IEE score according to domains, standard deviation and confidence interval: 1-interpersonal relationships (average 29.4 points, SD 6.1), 2-career stressors (average 31.4 points, SD 7.5), 3-factors intrinsic to work (average 30.5 points, SD 7, 3) and 4-structure and organizational culture (average 32 points, SD 7.4), organizational structure and culture domain prevailed as shown in Figure 1.

FIGURE 1: Distribution of the participants according to the score of the Nurses Stress Inventory, according to the domains: 1-interpersonal relationships, 2-career stressors roles, 3-factors intrinsic to work and 4-organizational structure and culture, and the confidence interval. Bauru, 2010.

Statistical significance (p=0.017), were associated with the sociodemographic variables in the stress domains, noting that the longer the activity time in the area (>5 years), the higher the level of stress. In the other variables there was no significant correlation.

Regarding the classification of the participants on the level of stress, the intermediate group had the highest number of participants (16), with a percentage of 62% of the sample (Figure 2). It was considered representative that 35% (n=9) of the participants showed a high stress level and only 3% (1 participant) with a low rating.

FIGURE 2: General percentages of participants according to stress levels: low, intermediate and high, according to the Nurses Stress Inventory. Bauru, 2010.

To identify the prevalent situations in relation to the categorization of stress, Table 1 presents the distribution of participants' responses in relation to the structure and organizational culture domain, evidenced as a more intermediate stressor. There was a higher score in the activities "administering or supervising the work of other people", "restriction of professional autonomy" and "interference of institutional policy in the workplace", each with 82 points. The less-punctuated activities were related to "responding to more than one function in this job" (61), "keeping up to date" (69) and "the specialty in which I work" (69).

TABLE 1: Distribution of the participants' responses, according to the questions belonging to the domain: structure and organizational culture. Bauru, 2010.

Regarding the sociodemographic characterization, the predominance of the female gender was observed. Nursing, from its earliest stages, is exercised mainly by women, although a recent progression of the masculine gender in the profession has been observed recently. The woman, by exercising multiple activities besides her job, like domestic activities and the care with the children, it can be inferred that the level of stress could be greater in this gender; however, this relationship was not observed in the present study, a result consistent with the literature, in which there is no difference in genders regarding stressors.¹⁷

In relation to the age group, it was predominant that it comprises between 20 and 30 years old, that is, the nurses working in the ICU were young. This profile of nurses is indicated as ideal for the ICU due to the openness and ease of technology, as well as the motivation to aid critical patients, aiming at professional growth. Nurses over 40 years old, due to their professional experience, usually hold administrative positions or teaching-related activities.¹⁷ In the present study there was no association between age and stress level, corroborating another study. ¹⁸

Regarding the marital status, it was observed a predominance of married people, which did not influence on the level of stress. On the other hand, another study showed that most of the nurses were single, and the level of stress was higher between divorced and married people.¹⁸

Most participants reported that they did not have children. It is understood that the greater the number of children, the greater the responsibilities and consequently the greater the stress; however, this relationship was not observed in the present study.

Regarding training time, those trained between 1 and 10 years prevailed, and this result did not influence the level of stress. However, one study evidenced stress in most nursing students, and one third of them are in the phase of exhaustion, given that this is the most worrying phase, in which there is a higher propensity to become ill.¹⁹ Systematic training programs for nurses newly admitted to intensive care have been developed with positive results, and this practice is recommended for patient safety and reduction of stresses.²⁰

As for the time of ICU performance, more than five years predominated, and this result influenced the level of stress, i.e., the higher the professional experience, the higher the stress level, corroborating with the literature.¹⁷ This result was associated to the nurse's exposure to stressful situations, commonly experienced in ICUs, including: overload of work, turnover, overcrowding, inadequate physical space, direct and indirect assistance to severely ill patients with imminent death, excessive levels of noise, unpreparedness and professional dissatisfaction, among others.^6-8

On the other hand, another study observed that the longer the performance time, the lower the stress level, relating the result to the acquired professional experience.¹⁸ A study carried out with senior nurses who began their activities in ICU concluded that they presented satisfactory adaptation, with capacity to cope well with the inherent complexity of the unit, associating this result to the stages as students in this area.²¹

When questioned about having a course of specialization in ICU, most of the participants reported having it, but this variable did not influence the level of stress, corroborating with the literature.¹⁸ In order to act in the ICU, it is necessary to have a significant theoretical and practical knowledge, due to the complexity of the patients, the technologies required for care, as well as fast and effective decision making, which explains the nurses' demand for specialization courses.

In relation to the work shift, morning and night were predominant. Although the night period is indicated as the most influential work shift on the level of stress due to sleep deprivation, the results of the present study did not indicate its influence on stress. However, night work and shifts in relation to the work shift have been reported as interfering directly in the functioning of the body, causing headache, irritability, sleep disturbances and stress.²²

Regarding the workload, the majority reported working 36 hours a week and this variable did not influence the level of stress. It is worth mentioning that in the ICU where the present study was carried out, the care nurses had a weekly workload of 36 hours, while the administrative staff had a workload of 40 hours a week. The prevalence of care nurses may justify this result. Long working hours are pointed out as an important factor in the development of stress and burnout, and can be detrimental to family time, rest and leisure.²³

In relation to the number of employment agreements, the majority reported having a single agreement; however, this result did not influence the level of stress. It is assumed that nurses who have multiple employment relationships, with all the inherent responsibilities, are more likely to develop stress.

When assessing the level of stress of nurses working in the ICU, the prevalence of the intermediate stress level linked to the structure and organizational culture domain was observed, implying situations related to the administration or supervision of the work of others, restriction of professional autonomy and interference institutional policy at work. These data corroborate with the findings in the literature.^6,24

Coping with criticism, crises among managers, subordinates and colleagues, difficulties in decision making, discrepancies between tasks, lack of professional recognition, and difficulties related to patient and family care are pointed out as more stressful factors.¹⁸ The psychic charges are related to the object of human work, which demands situations generating stress, suffering, fatigue, tension, and to the forms of organization of this work, marked by routine, lack of autonomy and by forms of supervision and control.²⁴ Communication difficulties, inappropriate working conditions and unworthy remuneration are destabilizing factors of the interprofessional relationship.

Nurses recognize the difficulties in relation to the leadership and organization of work, especially when reflecting on how the team relates and articulates with the demands. The condition of articulating the individual, relational and organizational dimensions necessary for the exercise of leadership makes its practice complex, which clarifies the difficulty faced in the nursing work routine.²⁶

It is worthy highlighting that the working conditions related to the stressors of the profession, aspects of the organization and administration of ICU, supervision of team work and professional autonomy are inherent functions of the nurse. Studies indicate that responsibilities of this type can be one of the main causes of occupational stress among nurses, because they lead to lack and/or failure in communication, which make decisions difficult and compromise care, generating more suffering than pleasure at work.^4,27

A study carried out with the objective of identifying the factors influencing nurses working in pediatric ICU to leave their jobs concluded that the main reason was the work stress, influenced by the nature of the work, the lack of resources and the lack of recognition by the managers.²⁸

It is important to note that although many researches on stress in nurses have been developed in recent times, there is a shortage of proposals and interventions that seek to minimize or facilitate the coping of stressors, since they are inherent to work and to the critical units.

The study allowed to identify, therefore, the necessity of carrying out multicentric studies, which allow to increase the sampling, as well as researches that allow comparing the level of stress of nurses, according to the profile of patients attended. Studies that propose interventions on occupational stress have been little contemplated in the literature and it is pertinent as a necessary contribution to the advancement of science in this challenging theme.

CONCLUSION

The nurses working in the ICU presented an intermediate level of stress, related to the difficulties regarding supervision, professional autonomy and influence of institutional policy. The training time of less than ten years, with a career still on the rise, coupled with a context that allows challenges considered as stressful, may have favored facilitating coping mechanisms, with lower degrees of impact on the body.

Although the present study contemplated almost the entire ICU population participating, the sample size of nurses in intensive care units may be referred to as a limitation. Another limiting factor is the fact that the sample includes nurses working in pediatrics, which may have influenced the result in some way, believing that these professionals are exposed to a greater number of stressors.

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