Stress in the clinical setting

The nature of clinical nursing is changing at whirlwind speed. Job stress creates a threat to bedside nurses and, over time, their organizations. The difficulties nurses experience may be temporary or enduring. There may be factors caused by work or outside of work. No one is immune to stress and it can affect individuals at all levels. Nurses face many stressors such as inadequate staffing, lack of support dealing with death, interpersonal conflicts, unresponsive to leadership, and physical inefficiencies. This paper will examine the meaning of stress using the Walker and Avant method of concept analysis and explain the factors influencing stress and nurses in the clinical setting.

This concept analysis will have eight parts. Using Walker and Avant, as based on the work of Wilson, “method of concept analysis provides a clear, concise method for exploring and clarifying a concept that has been used extensively” (Glaister, 2001, p.63). The steps of the process are: 1. choosing concept; 2. definition of concept and critical attributes; 3. example of model, contrary, borderline, related, and illegitimate cases; 4. proposition/statement for the concept; 5. list antecedents and consequences; 6. clinical examples of how concept would be used in practice; 7. definition of empirical referents; 8. conclusion: including how nursing theory can be an advantage or disadvantage in daily practice.

Concept Analysis of Stress

“Stress, like beauty, is in the eye of the beholder. An event that may cause you major concern could be a mere minor irritation to another” (Kowalski, 2001). Dr. Hans Selye borrowed the term stress from the field of engineering (where it refers to external mechanical forces, strains, and tensions) and implied it to the human body (The principles of stress, n. d.). “His experiments on rats in 1936 showed that various stressors such as cold, heat, infection, trauma, hemorrhage, fear and the injection of noxious substances, all produced the same effect” (The principles of stress, n.d.). He later called the theory ‘general adaptation syndrome’ (or G.A.S.). Since the stress theory was developed in 1930’s, numerous definitions have resulted through the years.

Defining Attributes of Stress

Through literature review and research, it is important to see the defining characteristics of the concept of stress. “According to Walker and Avant the method of concept analysis, the most used characteristics for describing a concept become the defining or critical attributes” (Glaister, 2001, p. 64). Clinical nurses encounter four critical attributes of stress in their daily practices. These defining attributes are physical, emotional, social, and spiritual being.

The physical level, “repeated exposure to stressful conditions can precipitate tension and fatigue” (Engel, 2004, p. 4). Stress is natural and unavoidable. Humans were built to cope with stress on a short term basis. However, prolong periods of stress also called chronic stress, causes a combination of physical and emotional consequences leading to disease (Carvalho, Muller, Bachion, & Melo, 2005, p.187).

The second defining attribute of stress is emotions. Engel (2004) stated “Psychologically this can cause us to harbor emotions such as anxiety, depression, fear, and anger” (p. 4). On the other hand, individuals may find themselves slowing down, feeling flat, apathetic, depressed, sad, or blue (Sylvia, Bauer, Brighton, Johnson, & Stringer, 1998, p.294). Internalizing these emotions can result in the increase risk of disease such as: high blood pressure, increased susceptibility to substance abuse, less resistance to disease, and depression.

Social or behavioral changes are the third critical attribute in defining the concept of stress. In response to these feelings of emotional stress, “healthy behaviors are inhibited and behaviors such as overeating, alcohol consumption and smoking are utilized to cope with the stress” (Engel, 2004, p. 4). The fourth defining attribute of stress is spiritual stress. Everything in the world is comprised of energy. Therefore, every thought or action affects not only each individual but the universe as well. Spiritual stress is composed of “negative thoughts produce negative energy and positive thoughts produce positive energy” (Engel, 2004, p. 5). As stated by Engel (2004) “Stress can cause a disconnection with one’s soul/sole purpose” (p. 4).

Within the nursing literature, many researchers have coined their own definitions of stress. The most common definition of stress is “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Engel, 2004, p. 4). Short term stress is effective for completing tasks. However, long term stress causes poor health, burnout, and even death. Depending on the context, the definition of stress has several meanings unrelated to the critical attributes of its concept. However, clarifying the other definitions is important for this paper. Merriam-Webster Online Dictionary (n. d.) defines stress as:

1: constraining force or influence a: a force exerted when one body or body part presses on, pulls on, pushes against, or tends to compress or twist another body or body part; especially : the intensity of this mutual force commonly expressed in pounds per square inch b: the deformation caused in a body by such a force c: a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation d: a state resulting from a stress; especially : one of bodily or mental tension resulting from factors that tend to alter an existent equilibrium e: strain, pressure 2: emphasis, weight 3: archaic: intense effort or exertion 4: intensity of utterance given to speech sound, syllable, or word producing relative loudness 5: a: relative force or prominence of sound in verse b: a syllable having relative force or prominence 6: accent.

Each of the definitions has different meanings and briefly describes varying aspects of the concept of stress. The concept of stress has been poorly defined in the nursing profession and the ultimate goal is to develop a working definition that can be used by nurses in the clinical setting. The explanation of the four critical attributes: physical, emotional, social and spiritual stress will assist in creating this statement.

Case Examples Model case

A model case of a concept includes all its defining attributes and none of the others. The following case is an example of the concept of stress. Nurse T arrives 10 minutes before her 12 hour day shift. She is exhausted because she worked a 12 hour shift the night before. After receiving report from the night nurse, Nurse T goes in to assess Patient A and Patient B. One hour later, Patient A cardiac arrests. The fatigued nurse calls the code and begins CPR. However, minimal staff arrives because they are short staffed that day.

The patient dies after 50 minutes of resuscitation. Nurse T is very upset because this death was unexpected. This patient was supposed to be transferred to the floor later that day. The physician calls the family to explain the unfortunate event and the family comes to the hospital to see their loved one. The patient is young and Nurse T is having a hard time dealing with the death. However, Nurse T attempts to put her feelings aside and provide the angry and tearful family with support but, cannot do it. She is saddened by the fact this is her fourth patient that has died this month. A few colleagues asked Nurse T to go to dinner. However, she declined and after her long shift went home and drank 2 bottles of wine to forget about her day and help her sleep.

The model case example provides all the defining attributes for the concept of stress. Nurse T is experiencing fatigue from her rotating shifts. She is depressed about several of her patients dying during the month and as a result, turns to alcohol for comfort. Nurse T is also showing signs of disconnection with her friends by refusing their invitation to dinner and drinking alone at home. Contrary case A contrary case is constructed to reflect none of the defining attributes of stress. This allows the reader to see the opposite of the concept. Avant (2000) states “the opposite method can also be helpful” (p. 5).

Nurse K arrives 20 minutes prior to her shift. She feels refreshed because she has been off the previous three days. This intensive care has a scheduling rule nurses rotate on a two week or monthly basis depending on the nurse’s preference. Nurse K receives report from the night shift nurse and begins her day assessing her patients and attending grand rounds. Nurse K takes an hour lunch off the unit because there is adequate staff. At the end of the day, Nurse K reports her assessment to the oncoming RN. After work, she goes to dinner with friends and goes immediately home to get some sleep.

Nurse K is an example of a contrary case because it does not illustrate any of the defining attributes of stress. However, this case is highly unlikely in the nursing profession. Nurse K exemplifies the opposite of stress by stating she is well rested before coming to work, has power over her work schedule, is able to take a long lunch with friends, and does not exhibit maladaptive behaviors. Borderline case A borderline case is another example that reveals which factors are important to the concept and which are not (Avant, 2000, p.6). Several of the defining attributes are excluded deliberately.

The night shift charge nurse, John, makes the patients assignments for the day shift staff at six o’clock in the morning. At 6:15 a.m. he receives two sick calls for day shift which begins at seven o’clock. John calls the in house agency, but is unable to replace the two sick calls. At the last minute, one of the nurses who were scheduled committee work for the day was reassigned to do clinical nursing and a night shift nurse decided to stay 4 extra hours.

This example of a borderline case reveals a few defining attributes. The cut off time for sick calls is 5:00 a.m. However, John received two sick calls at 6:15 a.m. causing some emotional and physical stress. John called the in-house agency, but was not able to replace the two sick calls. His heart began to beat faster and he felt nervous because there was not a solution. After taking a look at the day shift roster, he realized he could pull the nurse doing committee work and have her take patients and one of the night shift staff decided to staff four extra hours. Although this resolution is temporary, it will resolve the problem.

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