Work-related stress is a significant problem in contemporary nursing. The emotional, cognitive, and physical demands of nursing have taken a toll on the physical and psychological well-being of its practitioners. Work stressors in nursing have been shown to be related to high levels of tension and psychosomatic symptoms, low job satisfaction, high absenteeism, and the inclination to change jobs (Livingston & Livingston, 1984; Norbeck, 1985; Vachon, Lyall, & Freeman, 1978).
In addition to affecting the well-being of nurses, stress can adversely affect the quality of nursing care delivery. Jamal (1984) found a negative linear relationship between work stress and job performance, motivation, and patient care in a large sample of nurses. Clearly, prolonged occupational stress in nursing can be costly for nurses themselves, to the patients in their care, and to the hospitals in which they work.
Outcome studies of stress management programs designed to help practicing nurses cope with work-related stress generally have shown those programs to be effective in reducing: perceived stress (Zinder-Wernet, Bailey, Walker, & Hölzerner, 1980), depression (Donovan, 1981), anxiety (Von Bayer & Krause, 1983), somatization, obsessive compulsive qualities, feelings of interpersonal anxiety, and hostility (Randolph, Price, & Collins, 1986).
While numerous descriptive and experimental reports related to stress management training have focused on practicing nurses, comparatively little attention has been paid to the teaching of coping skills during baccalaureate educational programs. Two studies reported positive effects of stress management skills programs taught in the context of undergraduate nursing education. Charlesworth, Murphy, and Beutler (1981), who administered a 10-session program focusing on methods of relaxation, found that trait and state anxiety in experimental subjects were reduced, while there was a rise in state anxiety in the control subjects. Similarly, Lantican (1980) found that those who participated in a stress management program performed better than a control group in both behavioral and taskoriented challenges during a simulated stressful situation.
Since there is some evidence that stress management programs for student nurses are effective, it would seem that proactive, prevention-oriented approaches to teaching nursing students to cope effectively with future workrelated stressors would be incorporated into nursing school curricula. To what extent are such stress management training efforts included in nursing education? To date, there has been no attempt to assess nursing school curricula related to stress management content. The following questions were posed: In baccalaureate nursing programs: a) To what extent are general courses in stress management offered, and what content typically is included in such courses? b) In relationship to specific work-related stressors, what methods of stress management are most often incorporated into courses and instructional units? c) What work-related stressors receive the most instructional time?
SAMPLE - Questionnaires were sent to the curriculum chairs of all 452 National League for Nursing-accredited baccalaureate schools of nursing. A one-month follow-up mailing was sent to those not responding to the initial request. A total of 276 returned questionnaires were usable; this represents 61% of the total population of NLNaccredited baccalaureate programs. The respondents consisted of curriculum committee chairs and/or coordinators, curriculum committee members, faculty members with teaching responsibilities related to stress management content, and administrators (e.g., department chairs, deans or directors of baccalaureate nursing programs). Fifty-seven percent of the schools were public institutions, 35% were private religious schools, and 8% were classified as private secular schools. The median category reflecting range for undergraduate enrollment was 150 to 200 students. Eighty-six percent of the schools offered a generic baccalaureate program, while 14% were RN completion programs only. Forty percent of the programs also offered a master's degree, and 6% awarded a doctorate in nursing.
INSTRUMENT - The questionnaire was comprised of three major segments. The first segment consisted of demographic data related to the respondent's position and characteristics of the respondent's institution. The second segment focused on the existence and nature of a general course in stress management. In the final and largest segment, respondents were asked to indicate instructional units and/or courses designed to help students cope with specific work stressors related to nursing. The stressors identified on the questionnaire were those that appeared most consistently in the empirical literature on sources of stress in nursing: interpersonal stressors, direct patient care stressors, physical work environment stressors, physical and mental fatigue, and time stressors. Internal stressors, though not mentioned specifically in the empirical literature in nursing, was an added category since contemporary conceptualizations of stress emphasize the importance of the interaction of internal processes with external events.
COURSE IN STRESS MANAGEMENT- Roughly 10% of the sample indicated that they offer a separate course in stress management (N= 28). Twenty offer the course as an elective, and six require the course of all undergraduates. (The remaining two did not respond to this question. ) Of the 20 schools that offer the course as an elective, 15 indicated that their course is offered to all students on campus, three offer the program to nursing students only, and two indicated it is a graduate level course available to nursing school undergraduates. The majority of the courses were worth three credit hours; however, four offered one-credit courses, and one offered a two-credit course.
Respondents were asked to list stress management topics that were offered in the course and to indicate the clock hours devoted to each topic. All indicated that they addressed symptoms of stress, 85% included instructional units on communication skills, assertion skills, and muscle relaxation, and 81% had instructional units on time management, breathing exercises, and imagery. Topics included in over half of the stress management courses were values clarification, exercise, nutrition, biofeedback, conflict management, meditation, coping with difficult people, establishing support groups, and cognitive restructuring. Autogenic training, self-hypnosis, and stress inoculation were indicated in less than one-third of the programs. The greatest number of clock hours were devoted to communication skills (M=4.5 hours). This was followed by values clarification (4.23 hours) and time management (3.7 hours).
COURSES FOCUSING ON A SPECIFIC ASPECT OF STRESS MANAGEMENT- Many programs included required or elective courses on a specific stress management method. These were not stress management courses, being broader in scope and typically having objectives that included more than a stress-and-coping focus. Results on the prevalence of such courses are shown on Table 1. Nutrition was the single course topic most often in the curricula, followed in order by communication skills, death awareness, group processes, and values clarification.
INSTRUCTIONAL UNITS RELATED TO MANAGING WORK-RELATED STRESSORS- Respondents were asked to identify instructional content related to managing specific work-related stressors. They also were asked how many clock hours were devoted to these instructional units. As can be seen on Table 2, a variety of stress management techniques were identified for each of the six stressors.
A variety of interpersonal skills instruction (communication skills, group process skills, crisis intervention, conflict management, assertion skills) were offered by many of the schools.
Other content areas mentioned by at least 80% of the respondents included: death awareness, change strategies, values clarification, recognizing stress, organizational skills, time management, and problem solving. Of these, only on problem solving did the instructional units average more than seven clock hours.
Stress management techniques, such as meditation, biofeedback, autogenic training, exercise, stress inoculation, cognitive restructuring, and rational-emotive therapy, often were not included and, if they were, typically less than two clock hours of instruction time were expended.
THE PREVALENCE OF COURSES FOCUSING ON A SPECIFIC ASPECT OF STRESS MANAGEMENT
Few baccalaureate programs in nursing offer a course in stress management as part of the curriculum. Less than 2% require such a course of undergraduates. This number is surprisingly low, given the fact that nursing is a career prone to high levels of stress.
There may be several reasons, however, for the absence of stress management courses in nursing curricula. Faculty may be opting for the inclusion of stress management content in several courses, rather than in one course specifically designed for such content. Indeed, there is evidence from this survey that virtually all nursing programs include instructional units on stress management. This "integrated" approach to teaching stress control methods may be preferred by a majority of programs. Another approach that may explain the dearth of general stress management courses is one that integrates such content throughout the curricula but adds courses on specific aspects of stress management (such as communication skills or time management). This may not be as prevalent as an "integrated" approach, but it is apparently an option chosen by some programs. A final reason may be that baccalaureate nursing curricula are too "full" of nursing content and other important material to allow room for a course devoted to stress reduction techniques. Such a course simply may not have high enough priority to be included.
Clearly, however, nursing curricula include stress management content. What methods are most often taught? The most instructional time was devoted to teaching students how to cope with interpersonal stressors. These stressors involve conflictuel or problematic relationships nurses encounter in the work environment, such as communication problems or lack of respect from other team members. Nearly all programs offer instructional units on communication skills as a method of coping with interpersonal stressors. The mean number of hours offered in communication skill building was the highest of all instructional units across all categories of stressors. Instructional units on group process also were offered by most of the programs. A strong curriculum emphasis on communication skills, as well as group process, is not surprising since these are basic competencies required of all graduate nurses. While these skills are a necessary part of effective nursing practice, they also are skills that are effective in minimizing stress that might arise from difficult interpersonal encounters.
In view of the fact that interpersonal conflict has been ranked as the number one stressor of nurses (Bailey & Bargagliotti, 1983), it is gratifying to note that a large majority of the programs surveyed offer some content on conflict management and instruction on assertion skill building. On the other hand, barely half of the programs offered content related to establishing support groups. This is a particularly disappointing finding since there is evidence that social support has the capacity to ameliorate the effects of stress in the work setting (e.g., Parkes, 1982).
The general categories of physical and mental fatigue stressors received the second highest instructional clock hours. Fatigue is often the consequence of working under highly stressful conditions; it is, therefore, not only a reaction to stress, but it has the potential to be a stressor in and of itself. All but 15% of the schools provide units of instruction pertaining to the recognition of these physical and mental signs of stress. Of the variety of methods available to induce physical relaxation, progressive muscle relaxation was the method most offered by the programs (67%).
Techniques such as progressive muscle relaxation, breathing exercises, imagery, meditation, autogenic training, biofeedback, self-hypnosis, and exercise provide nursing students with skills in decreasing their own autonomic reactivity, as well as helping clients manage pain and stress. Considering that physical and mental stressors were repeatedly noted as top stressors in several studies (Caldwell & Weiner, 1981), it is appropriate that this content receive emphasis. Nutrition units were included as relevant content under this category of stressors. No doubt, the emphasis received is due to the fact that adequate nutrition has long been an important aspect of nursing practice. While instruction in adequate nutrition was more likely aimed at patient nutritional needs, this obviously does not discount the personal benefit that might be received by students.
Direct patient care stressors include situations such as working with critically ill patients and their families, dying patients, emergency situations, and ethical issues such as machine-aided prolongation of life. Most programs offered instructional units dealing with crisis intervention, death awareness, and values clarification. The latter two units, no doubt, help students increase their understanding of themselves, their personal values, beliefs, and attitudes surrounding stressful patient and family encounters. It was interesting to note that 25 schools offer separate courses in death awareness; only three of the programs, however, require such a course. Crisis intervention units are likely designed to provide students with skills in helping clients cope with crises surrounding serious illness or injury. Being prepared with this relatively structured intervention in these situations could serve to decrease stress in nurses by increasing their sense of competence in such interactions.
INSTRUCTIONAL UNITS DESIGNED TO HELP NURSING STUDENTS COPE WITH SPECIFIC WORK-RELATED STRESSORS
It was not surprising to see a small number of programs using stress inoculation as a method of managing patient care stressors. This is a relatively new methodology, involving the rehearsal of cognitive and behavioral coping skills in the presence of simulated stressors prior to. confronting actual stressors. Application of this technique in an undergraduate program has been described by Manderino and Yonkman (1985).
Physical work environment stressors pertain to elements in the work environment that are stressful. For example, noise levels, poor lighting, eversive odors and sights, malfunctioning or inefficient equipment, and limited work space. Problem solving and change strategies were both emphasized strongly as methods of coping with physical environment stressors. Both of these techniques would appear to be antidotes to the powerlessness over important aspects of their work environment as described by Hay and Oken (1972).
Multiple work demands to be accomplished within a limited amount of time may lead to stress. It makes sense that most programs offer instruction on time management as well as organizational skills.
Internal stressors are those that have to do with stressproducing thinking patterns or attitudes. For example, catastrophization (enlarging events, or the consequences of events, out of proportion), perfectionistic standards, and extremes of self-criticism are internal stressors. This category of stressors received the least emphasis from the responding programs. Techniques such as cognitive restructuring, rational emotive methods, and use of humor are all strategies that emphasize the importance of the content and structure of thought on the subsequent experience of stress. Since cognitive strategies are designed to help individuals identify and change stress-producing thinking patterns, they might be quite useful to the beginning nurse in controlling her/his own internal reactions to inevitable external stressors. The fact that cognitive strategies are one of the more recently developed methods of stress management may explain the low frequency of these offerings in nursing programs.
We obviously are not at a point where we can make informed recommendations about what kind of stress management content should be offered and how such content should be structured in curricula. It is important at this time to conduct outcome studies of a longitudinal nature to test the long-term effects of stress management instruction in baccalaureate programs. A list of possible questions might include:
1. What stress management methods are most effective in decreasing or preventing affective, physiological, behavior manifestation of stress in the work setting?
2. What is the most efficacious method of structuring stress management content (general course, integrated stress management curriculum, a combination, etc.)?
3. What is the optimal point(s) in time for stress management instruction (e.g., at the beginning of the educational program, throughout, just prior to graduation)? and
4. What basic conditioning factors in the student influence the effects of stress management instruction?
Given the impact of stressors on nurses' career satisfaction, emotional well-being, and the ability to provide quality care, it is important for nursing educators to carefully examine what and how stress management methods are taught. Researchers should investigate the efficacy of various teaching approaches so that educators can make more informed decisions about the content and structure of stress management in baccalaureate nursing curricula.
- Bailey, J.T. & Bargagliotti, L.A. (1983). Stress and critical care nursing. In W. Hölzerner (Ed.), Review of research in nursing education (pp. 108-122). Thorofare, NJ: Slack.
- Caldwell, T. & Weiner, M.F. (1981). Stresses and coping in ICU nursing I - A review. General Hospital Psychiatry, 3, 119-127.
- Charlesworth, E.Q., Murphy, S., & Beutler, L.E. (1981). Stress management skill for nursing students. Journal of Clinical Psychology, 37(2), 284-290.
- Donovan, M.I. (1981). Study of the impact of relaxation with guided imagery on stress among cancer nurses. Cancer Nursing, 4(2), 121-125.
- Hay, D. & Oken, D. (1972). The psychological stresses of intensive care unit nursing. Psychosomatic Medicine, 34, 109-118.
- Jamal, M. (1984). Job stress and job performance controversy: An empirical assessment. Organizational Behavior and Human Performance, 33, 1-21.
- Lantican, L.S. (1980). Effects of coping skills training on nursing students' reaction to a stressful situation. The Anphi Papers, 15(3), 2-20.
- Livingston, M. & Livingston, H. (1984). Emotional distress in nurses at work. British Journal of Medical Psychology, 57, 292-294.
- Manderino, M.A. & Yonkman, C. (1985). Stress inoculation: A method of helping nursing students cope with anxiety related to clinical performance. Journal of Nursing Education, 24(3), 115-118.
- Norbeck, J.S. (1985). Perceived job stress, job satisfaction, and psychological symptoms in critical care nursing. Research in Nursing and Health, 8, 253-259.
- Parkes, K.R. (1982). Occupational stress among student nurses: A natural experiment. Journal of Applied Psychology, 67, 785-796.
- Randolph, G., Price, J., & Collins, J. (1986). The effects of burnout prevention training on burnout symptoms in nursing. Journal of Continuing Education in Nursing, 17(2), 43-49.
- Vachon, M., Lyall, W., & Freeman, S. (1978). Measurement and management of stress in health professionals working with advanced cancer patients. Death Education, 1, 365-377.
- VonBayer, C. & Krause, L. (1983). Effectiveness of stress management training for nurses working in a burn treatment unit. International Journal of Psychiatry in Medicine, 13, 113-126.
- Zinder-Wernet, P., Bailey, J.T., Walker, D., & Hölzerner, W.L. (1980). Personalogical measures to assess program effects: A case study. Journal of Nursing Education, 19(6), 38-42.
THE PREVALENCE OF COURSES FOCUSING ON A SPECIFIC ASPECT OF STRESS MANAGEMENT
INSTRUCTIONAL UNITS DESIGNED TO HELP NURSING STUDENTS COPE WITH SPECIFIC WORK-RELATED STRESSORS