Stress among nurses is well documented, and in the midst of the coronavirus disease 2019 pandemic, it has reached record highs.
Under normal conditions, nurse managers and frontline nurses face stressors that come with the territory of their profession, but the coronavirus disease 2019 pandemic has greatly added to their burden. Nurse managers are being called not only to help their organizations manage the crisis operationally, but also to help the nurses they supervise mentally, emotionally, and even ethically.
This article provides recommendations for how nurse managers can use the American Association of Critical-Care Nurses Healthy Work Environment standards and make the experience of stress more productive.
Stress comes with the territory in nursing, but nurses can work together to make stress their ally and not their enemy. The real enemies are coronavirus disease 2019, burnout, and the aftermath of uncontrolled stress. When nurses keep stress in perspective and focus on what they can control, they contribute to developing healthier work environments.
Stress in nursing is well documented, and in the midst of the coronavirus disease 2019 (COVID-19) pandemic, stress levels have reached record highs. Under normal conditions, workplace factors such as work overload, time pressures, long hours, risk of exposure to infection, exposure to work-related incivility, violence, sleep deprivation, understaffing, and a perceived lack of support can all be drivers of stress in nursing.1,2 The COVID-19 pandemic adds to that list: separation from family, fear of bringing home this potentially life-threatening virus, fear of being unprepared to care for patients with COVID-19, and a new feeling of helplessness as we learn to cope with this unfamiliar disease.3
These drivers of stress also continue to challenge nurses, especially nurse managers, when it comes to establishing and sustaining healthy work environments (HWEs). Nurse managers have been handed the burden of managing the crisis not only operationally, but also mentally, emotionally, and even ethically. Unfortunately, nurse managers may not be trained or prepared to take on this additional burden. In addition to handling their regular responsibilities, nurse managers’ most important duty is to look out for frontline staff. To meet these increased demands, nurse managers need specialized training to develop their emotional intelligence.4,5 In this article, we offer evidence-based guidance for nurse managers who are ready to accept this new set of responsibilities, build from the American Association of Critical-Care Nurses (AACN) HWE standards, tap into their own humanity, and make the experience of stress more productive as they lead frontline nurses during this crisis and beyond.
A nurse manager’s support of a safe and respectful work environment that promotes communication, collaboration, decision-making, appropriate staffing, and meaningful recognition is central to promoting and sustaining a healthy work environment.
Healthy Work Environments
The AACN Standards for Establishing and Sustaining Healthy Work Environments identify 6 essential standards for HWEs: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.6 These standards provide an evidence-based framework for all nurses to use to establish work environments that encourage and empower nurses “to practice to their utmost potential, ensuring optimal patient outcomes, and professional fulfillment.”6(p1)
The AACN HWE standards shine a light on the dimensions of HWEs that are often overlooked. Essentially, these dimensions constitute the human factor. Healthy work environments support the tenets of the “quadruple aim” of health care: improve patient outcomes, improve the health of populations, decrease costs, and support health care providers in finding joy in their work.7 But we cannot forget that HWEs start with the well-being of individual nurses.8 Nurse managers set the standards for an HWE for frontline staff, which in turn provides for high-quality outcomes for patients and the institution as a whole. A nurse manager’s ability to value and foster an HWE depends on their own sense of health and well-being. Human attributes of the nurse manager, such as patience, compassion, and forgiveness, cannot be overestimated when creating an HWE, as they are integral factors that value individual nurses’ well-being and foster self-care.9 Engaged and satisfied nurses report higher overall job satisfaction, improved patient outcomes, and enhanced patient experiences of health care.10,11 A nurse manager’s support of a safe and respectful work environment that promotes communication, collaboration, decision-making, appropriate staffing, and meaningful recognition is central to promoting and sustaining the 6 standards of an HWE.12 In short, a culture that embraces the human factor can help to mitigate stress among nurse managers and frontline staff.
Stress: From Management to Mindfulness
Stress is a natural psychological and physiological response to caring for those who are ill and in distress, which means that nursing, as a profession, is inherently stressful.9 Consequently, any strategy that purports to completely eliminate stress is not likely to work in the nursing environment. Therefore, rather than aiming to eliminate or suppress natural feelings of stress, we would be wiser to recognize and respond to these feelings in a mindful way. Nurses and nurse managers need tools to mitigate their stress—particularly now, with the COVID-19 pandemic adding to the baseline level of stress.
Nurse managers can help frontline nurses deal with stress by sharing techniques for focusing on what they can control: their response to stress. The COVID-19 pandemic has introduced stressors far outside anyone’s experiences or expectations. These stressors include the huge numbers of admissions, quick deterioration of patients’ physical status, patients dying without family members at their bedside, and fears of having to care for patients while the unit is understaffed or lifesaving personal protective equipment is not available. These examples are only some of the conditions caused by COVID-19, and they lead to increased stress for nurses. Although the recent rollout of vaccines is positive and gives us hope, as we can now see a light at the end of the tunnel, it will be several months before frontline nurses feel its positive effects on the ground.
The COVID-19 pandemic has revealed many insufficiencies in the ability of the US health system to respond to this crisis.8 The severity of these insufficiencies has risen to disaster-like proportions. For this reason, we suggest that throughout the COVID-19 pandemic, nursing be recognized as disaster nursing during a public health emergency. Such recognition of the work that essential health care workers have been doing for months gives us an opportunity to reframe the challenges nurses face. Because disasters are traumatic events, we recognize stress as an expected hazard of disaster response. The pandemic has exposed leaders and frontline staff to their patients’ and their own experiences in an “in-depth and intimate way.”8(p1) Given the crushing demands of the pandemic, even nurse managers may become overwhelmed with stress, thus risking the loss of their staff ’s trust.8,13 Nurse managers need to understand that during times of crisis, without effective mitigation strategies, stress can paralyze the entire team. Nurse managers who acknowledge stress levels and support staff by modeling stress relief or stress management behaviors can greatly help their teams maintain healthy work habits. Managers must acknowledge the stress levels within their teams and teach stress management techniques.
The ability to acknowledge stress levels often comes, in part, as a learned experience through the development of emotional intelligence. Using emotional intelligence, leaders are able to screen their own feelings and emotions and use that screening process to ensure that it guides their actions toward and their influence on their teams, especially during highly stressful situations (Table 1). Prezerakos4 stated that emotionally intelligent managers have the capability to inspire emotions, manage fears, and turn frustration into motivation in order to achieve goals that at the time may seem unattainable. Furthermore, leaders who embody good emotional intelligence also exhibit good emotional management, which helps to promote not only personal well-being, but also collective well-being in the workplace. Once the leader has addressed their own self-care issues, it becomes important for them to lead by example and establish ways in which all staff can engage in both physical and psychological self-care practices.16
Leaders can help support recovery and provide effective stress management for most staff in 2 main ways: by ensuring that staff know their leaders are looking out for their best interests, that leaders have their backs, and that what is important to them is also important to their managers; and by moving forward in a routine and disciplined manner.8 Nurse managers can do much to support their teams during disasters such as the COVID-19 pandemic. Evidence suggests that clear communication at regular intervals and leader visibility are key to helping teams feel supported.17 Ensuring that both the team and the leader have access to and use resources to meet their physiological and psychological safety needs is paramount; some such resources are listed in Table 2. It is also important for nurse managers to seek support for themselves in order to build their capacity to support others and to become role models for good self-care.18,19 With this in mind, nurse managers should ask themselves 4 questions13 :
How can we create a mindset to embrace stress as normal and a driver for productive action?
How can we allow stress to provide focused energy and strengthen relationships?
How can we increase our ability to learn from stressful situations?
How can we see stress as opportunity and as a path for growth?
The Science of Stress
Stress is an essential part of our lives. Understanding the science of stress and becoming more self-aware of our personal stress level is key to management and recovery.
The human stress system reacts to threats in the environment. Acute stress is a response to a single event such as providing immediate urgent care to save a patient’s life. Chronic stress is a continual, but usually less acute, response, for example, in a nurse on whom numerous patients depend for long-term care. It is clear that nurses experience both acute and chronic stress, and both types of stress can have negative consequences on health and well-being.19
When it comes to supporting nurses, the goal should be to help them maintain optimal stress levels—levels that allow them to care for their patients and themselves most effectively. Nurses, however, experience elevated levels of stress—particularly during a pandemic, but also under conditions of chronic understaffing and excessive demands—that have consequences for their performance and their health. Acute stressors can, in the worst case, lead to symptoms of posttraumatic stress disorder or secondary traumatic stress. But acute stress can also interfere with a nurse’s ability to think and act in a coordinated and precise way.20 Consequences can include potentially serious errors, disengagement, and incivility; all of which negatively impact patient care.
Chronic stress occurs when the body’s stress system is activated continuously. Chronic stress has many negative consequences. Sapolsky21 and LeDoux22 have presented the argument that the human stress system is largely the same as that in other mammals: it is designed to respond to occasional predation. The big difference in the modern human context is that the stress system can be activated by much more than the threat of predation. An angry boss, a mistake on the job, too many demands, and not enough time are just some of the events that can activate hormonal changes that trigger a stress response.
Chronic activation of the stress system has serious consequences for the body, mainly because of the effects of stress hormones. These hormones are well adapted to responding quickly and urgently, such as when running from a predator. When they are triggered frequently, however, these adaptive responses can become problematic. For example, stress responses interfere with digestive function. When one must use all available resources to escape a stressful situation, redirecting the energy that would be devoted to digestion could make escape more likely. But if digestion is interfered with frequently, the stomach lining can become vulnerable to gastric acid.23 This difference between the stress to which our bodies are well adapted and the stress that is common in the modern world causes a particular issue for those in professions like nursing, where chronic stress is likely to be a feature of the job.
One of the likely results of this continued activation of the stress system is burnout. Nurses can experience burnout when their physical and psychological systems no longer respond to the stress they experience. Symptoms of burnout can have important effects on a nurse’s ability to effectively provide quality patient care.24,25 These symptoms generally include exhaustion, cynicism, inefficacy, and disengagement, among others.26
In general, burnout is characterized by the depletion of energy and internal resources, which makes it an important factor in the process of health impairment. Burnout is also associated with susceptibility to other negative consequences of stress, including posttraumatic stress disorder and compassion fatigue, an occupational hazard representing the psychological cost of healing others. All of these symptoms can lead to errors, reduced quality of care, lack of engagement, and decreased satisfaction at work, thereby perpetuating unhealthy work environments.24,27
How we as humans acknowledge and respond to stress has important biological and cognitive consequences. Research suggests that how we think about and respond to stress matters. If we can reframe our perspective to focus on the productive side of stress, our performance will improve and we can mitigate many of the physiological effects of stress, such as sleeplessness and feelings of fear and anxiety. In fact, research indicates that changing our minds about stress can actually make us more resilient.28
Moving Toward Nurse-Centered Stress Care
Managing stress is not a one-size-fits-all proposition. Just as health care has moved toward individualized patient-centered care, which has led to improved patient health, awareness of the individual needs of each nurse can lead to better stress management. Nurses are a diverse group and have various stress responses and stress-relief needs. Centering the individual nurse as part of stress management will allow for a multitude of individual stress-relief strategies. The nurse manager does not necessarily have to adopt or even know each nurse’s stress-relief strategy; rather, they must allow room for a diversity of responses and strategies, which makes it more likely that each individual nurse will identify and use the strategy that best suits their needs. For example, rather than recommending that everyone engage in deep breathing or offering therapeutic meditation sessions to all nurses, nurse managers must respect the diversity of the nurses in their unit, provide educational opportunities for nurses to learn about new stress-relief strategies, give them the space to decide which stress management strategy is most effective for them, and, most importantly, give them permission to engage in these strategies as needed. Although a diversity of strategies is key, nurse managers should be aware that too many choices might be overwhelming. The best approach may be to offer a menu of choices that changes every few months so that nurses can select what makes sense for them given their schedule, and do so during a time when they are not overwhelmed by other decisions.
In addition, nurse managers should emphasize that nurses are encouraged to engage in stress-relief strategies. It is not enough simply to offer stress management training and talk about “self-care.” Many nurses are not able to take advantage of these opportunities. For example, nurses working the night shift may have a hard time attending activities provided during the day. In addition, when units are short-staffed, nurse managers often call nurses at home, on their days off, with offers of overtime and monetary incentives to help their coworkers. Nurses may feel pressured to give up their downtime to help their coworkers, managers, and patients. So, nurse managers should consider how they can create a culture in which frontline nurses do not feel judged for not working overtime, stress-relief strategies are part of an ongoing conversation, and everyone truly values stress management.
Nurse-centered stress management means discussing job stressors with colleagues and being honest about how the pandemic is affecting our work.
Finally, nurse-centered stress management means discussing job stress with colleagues and being honest (with ourselves and others) about how the pandemic is affecting our work. During such discussions, staff and nurse managers work together to identify both the causes of and solutions to stress, and to discuss the mental health resources provided at their workplace; nurse managers should then give staff explicit instructions about how to access those resources.29
In addition to these common stress management techniques, research into disaster response recommends that responders look closely at how their work contributes to their stress levels and implement actions that can shield them against the most distressing factors of the job. The Institute for Healthcare Improvement has several resources for staff that can help them learn to make stress less of an enemy and more of an ally.30,31 These resources are intended to start conversations between nurse managers and staff:
Gather information from colleagues and discuss problem-solving strategies to protect everyone’s mental health.
Look at the COVID-19 crisis as an opportunity to reassess rules, adjust those that are not working, and brainstorm better systems.
Empower everyone to contribute to a discussion about solutions for immediate and future needs.
Encourage everyone to look for joy, even in tough moments. Cultivate healthy relationships and HWEs that support teamwork and personal development while reducing current and future stress.
In using these resources and similar resources from other organizations (Table 3), managers of frontline nurses are encouraged to find creative opportunities to bring up stress management with their staff; chatting during shift-change huddles, encouraging mental health breaks, and sharing quick stress-relief techniques are a few good ways to acknowledge the pressure all nurses are experiencing during— and will experience beyond— the COVID-19 crisis.
Work overload, time pressures, long hours, risk of exposure to infection, exposure to work-related incivility, violence, sleep deprivation, understaffing, and perceived lack of support all drive stress in nursing. The unique stressors of the COVID-19 pandemic exacerbate these issues, increasing the potential for nurses to experience professional burnout and to lack joy in their work. Evidence-based recommendations such as understanding emotional intelligence (Table 1), “psychological PPE” (protection and support for the mental health and well-being of staff18 ; Table 2), and additional resources for coping with stress and building resilience (Table 3) can serve as lifelines to support staff who are providing care during the COVID-19 pandemic. We also recommend that nurse managers consider how these resources can be adapted in order to reenvision stress management beyond the current crisis.
Stress comes with the territory in nursing. But we can work together to make stress more productive. Our enemies are COVID-19, burnout, and the aftermath of uncontrolled stress. When we keep stress in perspective and focus on what we can control, we all contribute to creating HWEs.
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To learn more about healthy work environments, read “Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community” by Epstein et al in AACN Advanced Critical Care, 2020;31(2):146–157. Available at www.aacnacconline.org.