Essay: Stress in Healthcare

Stress in Healthcare
Individuals working in the field of healthcare perceive high levels of work-related stress.  The negative effect of stressful situations can vary among individual based on such characteristics as personality type, gender as well as job roles, design, and environment.  Healthcare workers should have adequate knowledge regarding the impact of stress on themselves and their patients. As a result of this knowledge, they can better develop successful stress management strategies.  Healthcare professionals responsible for employee safety, satisfaction, and job design should seek opportunities to implement necessary changes to reduce the harmful effects of stress on both healthcare workers and patients.
Stress Explored
According to Butler (1993), there are several ways to define stress, including the following:  1) stimulus-based stress, 2) response-based stress, and 3) stress as a process.
Stimulus-based stress
An understanding of stimulus-based stress focuses on the concepts of pressure and strain; when an object or individual experiences too much pressure from the stimulus, a collapse will occur (Butler, 1993).  A stimulus-based perspective is limited because it does not take into account that while two individuals may experience that same stressful situation, their individual responses may differ.
Response-based stress
Another way to examine stress is as a response to negative stimuli as proposed by Hans Selye (Butler, 1993).  Han Selye’s (1976; cited from Krohn, 2002) research in the area of stress responses in animals laid the foundation for development and application of General Adaptation Syndrome.  He (Selye, 1976; cited from Krohn, 2002) found that when animals were exposed to numerous stimuli, such as cold, heat and poison, for long time periods, the animal responded in the following a common cycle 1) an alarm reaction manifesting in increased adrenaline and counter shock resulting in increased adrenocortical activity; 2) a resistance stage during which animals adapted to negative stimuli but resistance to negative stimuli increases; and 3) an exhaustion stage during which the animals’ abilities to adapt to negative stimuli is exhausted, resulting in irreversible tissue damage, and eventually death.
While Seyle’s research focused on animal responses to negative stimuli, other studies have shown that men and women who experience prolonged stress also experience prolonged negative biological responses correlated with negative health outcomes. For example, Kischman, Pirke, and Hellhammer (1993) used the Trier Social Stress Test to study the effects of psychological stress and physical changes.  Individuals gave a speech and completed mental mathematical problems in front of an audience. These individuals experienced significant increases in adrenocorticotropic hormone, cortisol levels as well as increased heart rate.
While human persons experience physical responses to negative stimuli (stress) and may have negative health outcome due to prolonged exposure to stress, this understanding of stress is also limited in that it does not take into account both external and internal circumstances such as personal characteristics, cognitive factors including thoughts, attitudes, perceptions, and beliefs (Butler, 1993).
Stress as a process
Butler posited that the process theory of stress, also known as the transactional-cognitive process theory of stress (Lazarus & Folkman, 1994), provides a better framework for examining stress than both stimuli-based and response-based definitions (Butler, 1993). According to Lazarus and Folkman (1994), stress can be defined as “a particular relationship between the person and the environment that is appraised by the person as taxing and exceeding his or her resources and endangering his or her well-being” (p. 19).  This theory focuses on one’s assessment (called appraisals) of the environment and perceived demands, including physical demands, task demands and role demands, and interpersonal demands (Borwkowski, 2001, p. 233-234). Physical demands include climate and air quality, temperature, and noise; task demands include the type of job, job uncertainty, and work overload; role demands include role conflict or uncertainty and work/life balance; and interpersonal demands include status, team pressure, diversity, and leadership styles (Lazarus, 1991; cited in Borwkowski, 2001).  These demand appraisals are assessed by the individual in light of the material, personal, social resources available (Lazarus, 1991; cited in Borwkowski, 2001). Based on one’s assessment of the demands and the resources available, an individual will perceive the situation as a challenge, threat, or harm or loss and based on the type of coping strategies (reactionary, anticipatory, preventive, or proactive) utilized and then experience behavioral, psychological, and/or physical consequences (Lazarus, 1991; cited in Borwkowski, 2001). The transactional-cognitive process theory of stress provides an explanation of why individuals may responds to the same situation differently based on their perception of the demands of the situation; resources available to them, perception of the situation as a challenge, threat, or harm; and their chosen coping strategies.
Individual Factors which Influence Stress
As highlighted by the transactional-cognitive process theory of stress, the effect of stress experienced by individuals can vary based on individual differences and characteristics.  While a variety of individual factors influence perceptions of stress, this section focuses on research surrounding personality type and gender.
Personality Type. An individual’s personality type may influence how one perceives and responds to stressful circumstances.  For example, Tyssen et al., (2007) explored how personality types and characteristics may predict medical school stress. 236 Norwegian medical students participated in a six year study to explore if personality types and characteristics could predict stress experienced in medical school (Tyssen et al., 2007).  Researchers found that individuals scoring high on traits of neuroticism and conscientiously as well as extroversion reported significantly higher levels stress throughout the six years than their counterparts (Tyssen et al., 2007). When controlling for gender, they (Tyssen et al., 2007) discovered that female students reported higher levels of stress at the mid-point of their education (year 3) but not upon graduation, which indicated that class education was more stressful for females but that hands-on (clinical) education was not as stressful.
Type D Personality, a disposition towards negative affect, social inhibition, and suppression of emotional distress, has been found to be a predictor of mortality in for those individuals with coronary heart disease  (Denollet et al., 1996). Expanding upon this general research of the impact of Type D personality and negative health outcomes, researchers Kim et al. (2016) specifically explored the impact of Type D personality relating to job stress and job satisfaction on clinical nurses.  875 clinical nurses working hospitals in South Korea completed that Type D personality scale (DS 14) which measures negative affectivity and social inhibition; the Professional Quality of Life Scale which measures compassion fatigue, burnout, and compassion satisfaction; the Korean Occupational Stress Scale measuring such items as job related items, including demands, lack of control, or rewards, climate, organizational system; and the Job Satisfaction Scale to ascertain job satisfaction (Kim, et al., 2016).  Individuals who had high Type D personality characteristics reported significantly higher rates of compassion fatigue, burnout, stress as well as less compassion and job satisfaction than their fellow nurses with low Type D personality characteristics (Kim et al., 2016).
Closing sentence
Gender.  Research suggests that in general women are more likely to assess situations as stressful than their male counterparts.  Karkoulian, Srour, & Sinan (2016) explored the relationship between one’s ability to control circumstances or and outcomes (external vs. internal) focus of control, perceived level of stress, work interference with personal life (WIPL) and personal interference with work (PLIW) for 160 female and 160 male bank employees. The researchers (Karkoulian, Srour, & Sinan, 2016) found that both men and women who had a internal locus of control perceived less stress due to WIPL and PLIW.  Women, regardless of their locus of control, perceived higher levels of stress due to WIPL and WPLW than men.
Madhysastha, Latha, & Kamath (2014) explored the differences between stress, coping, and gender in 94 medical students based responses from the Professional Student Stress Survey and Carver’s Brief COPE survey.  They found while all the students reported stress (most to a moderate degree) female students perceived higher levels of academic stress than their male counterparts. The female medical students were more likely to utilize problem-focused and emotion-focused coping strategies while the male students employed humor, positive-emotion focused and self-blame, and maladaptive strategies.  Closing sentence on section? sure
The Stressful Environment of Healthcare
While it is clear that individual differences such as personality traits and gender can influence  perception of stress, according to the transactional-cognitive process theory, one’s work conditions, tasks, and other environmental factors may also contribute to the amount of stress perceived.  In 2008, the Department of Health and Human Services reported that negative workplace factors, poor organizational design and leadership factors, financial and economic factors, tension involving work/life balance, and lack of opportunity for advancement contribute to job stress (Cite booklet). Healthcare workplace places characteristics such as insufficient staff, long hours, undefined roles, and exposure to harmful substances also contribute to the high levels of stress perceived by healthcare workers (Cite booklet).  Nurses experience higher levels of stress due to such factors work overload, lack of time to complete tasks, workplace violence, conflict among co-workers as well as difficult and ill patients (Cite booklet). Increased stress among doctors is associated with long hours, work overload, interpersonal conflicts, as well as the death of patients, meeting patient demands, and fear of malpractice claims. While all these factors contribute to the stressful environment of healthcare, this section will limit the focus to factor role factors, workplace violence, and leadership style.
Sources of Workplace Stress
Factors Surrounding Role and Design.  Studies have shown that role demands, design and organizational factors are contributing components in job stress perception.  Yeboah and Ansong (2014) conducted an empirical analysis on factors contributing to workplace stress among 453 healthcare professional at a teaching hospital in Ghana.  As part of the research, participants completed a questionnaire regarding such factors as work demands (workload, patterns, and environment); control regarding how their own work is performed; support such as encouragement, mentorship, and resources; role (understanding of job role and job role conflicts); and change (small or large changes within the organization) as well as survey regarding perception of stress (Yeboah and Ansong, 2014). Significantly higher perceptions of stress were correlated high workload, lack of understanding regarding roles, duties, and conflicting role demands, poor relationships with both colleagues and managers, as well as rapid change and lack of communication regarding change (Yeboah and Ansong, 2014). Factors that mitigated perceptions of work-related stress included a supportive environment, involvement in decision-making, and respect of managers (Yeboah and Ansong, 2014).
In another study, Terry and Curzio (2017) explored the experience of newly certified nurses during this first year of work.  Data for this study was obtained from 374 nurse who participated in the study completed the Nursing Stress Scale as well as individuals doesn’t make sense!!(Terry & Curzio, 2017).  Results showed that high workload due to insufficient staffing, competing priorities in task completion and roles as well as incivility among staff and patients were identified as significant stressors (Terry & Curzio, 2017).  Factors that resulted in less perceived stress included a good team environment characterized by collaboration, successful communication, and a supportive environment (Terry & Curzio, 2017).
Workplace Violence and Bullying.  Workplace violence in the healthcare has been shown to have a significant contribution to perceptions of stress.  Over the course of six years, researcher Magnatvita (2014) studied the correlation between work-related stress and violence at work.  698 healthcare workers completed self-assessment regarding their experience of workplace stress and incidences of aggression each year of the study.  Over the course of the study, 24% reported at least one act of physical aggression and 52% reported at least one act of nonphysical aggression (Magnatvita, 2014).  The experience of workplace violence, both physical and nonphysical, correlated with significantly higher levels of stress, anxiety, and depression as well as lower levels of job satisfaction (Magnatvita, 2014).
In a recent study, Beattie, Innes, Griffiths, and Morphet (2018) examined neurobiological responses of healthcare workers after experience workplace violence (WPV) due to patient actions.  Researchers (Beattie et al., 2018) interviewed 99 healthcare workers who worked in a broad range of positions such as managers, directors, and nurses participated in interviews regarding their responses to workplace violence (Beattie et al., 2018) the following: 1) daily experience of WPV lead to feelings of disconnectedness (freeze response); 2) unpredictable patient behaviors lead to hypervigilance and fight or flight response; 3) threats to staff lead to fight for protection and flight for safety; and 4) cumulative trauma result in increased use of sick leave, burnout, and resignation of staff, showing an avoidance response.  Formal and informal peer support resulting in the positive mobilization of staff (fight response) and social engagement and functional training resulted in recognizing one’s default neurobiological responses to stressors (Beattie et al., 2018).
Yang, Stone, Petrini, and Morris (2018) conducted a cross-sectional survey on mental health nurses regarding  the effect of workplace violence. Of the 245 participants, 94.6% reported at least one experience of workplace violence; 92.1% experienced verbal aggression; 63.1 % experiences sexual harassment, and 81.9% experienced a physical attack (Yang, et al., 2018). Experiences of workplace violence significantly correlated with feelings of injustice, depression, or anger; reduced engagement in work; anxiety, insomnia, and fear; and a desire to leave the profession (Yang, et al., 2018). Nurses also identified patient characteristics such as irritability and aggressiveness, reduced impulse control, and lack of insight and adherence to treatment plans; hospital characteristics such as understaffing and inadequate aggressive management; and societal characteristics such as patient distrust of healthcare services and cost of services as contributing factors of workplace violence (Yang, et al., 2018).
Discussion
Stress among healthcare workers has been shown to have a negative impact on patient safety.  In a study spanning 18 months of 185 physicians, Dollarhide et al. (2014) found that medication events (the wrong medication given) were significantly associated with higher workloads, emotional distress, and lack of sleep.  In another study (Park and Kim, 2013), high levels of job stress due to shift work, job instability, cognitive failure, and lack of autonomy were highly correlated with increased patient safety instances. In a qualitative study (Berland, Natvig, & Gundersen, 2007) involving critical care nurses, researchers found that competing workplace demands, lack of control, and lack of social support resulted in higher stress levels which negatively impacted patient safety.  Since the stress of healthcare providers negatively impacts quality of patient care, it is important for utilize both individual and organizational strategies to reduce work-related stress among healthcare providers. This section will focus on XX organizational strategies