The relationship between nurses’ stress and nurse staffing factors in a hospital setting

The relationship between nurses’ stress and nurse staffing factors in a hospital setting

STACEY R. PURCELL R N , M S N 1, MARY KUTASH A R N P , M S N 2 and SARAH COBB P h D , R N 3

1Research, College of Nursing, University of South Florida, Tampa, Florida, USA, 2Nurse Specialist, Tampa General Hospital, Tampa, Florida, USA and 3Former Associate Professor, Florida Mental Health Institute, Tampa, Florida, USA

Introduction

Nurses have many job-related stressors including stress

as a result of dealing with death and dying (Hoffman &

Scott 2003), emotional exhaustion (Vahey et al. 2004),

stress owing to working conditions (Golubic et al.

2009) and less than adequate staffing mixes or abilities

(Brooks & Anderson 2004, Donaldson et al. 2005).

Although there are notable research studies related to

stress and nurse burnout (Blythe et al. 2008, Sasaki

et al. 2009) and job satisfaction related to burnout

(Aiken et al. 2002), there is a lack of research relating

job stressors to specific nurse staffing and such realities

in practice as: days of week worked, presence of unto-

ward events during a shift and nurses� ages. The present study will add to the body of knowledge

about the relationships between nursing stress and

staffing factors. It was hypothesized that staffing factors

such as shift length, days of week worked and cumu-

lative nursing work hours will increase nursing stress. It

was anticipated that the findings of the present study

could be used toward planning and improving the

Correspondence

Stacey R. Purcell

103 Bennetts Creek Landing

Suffolk, VA 23435

USA

E-mail: sboutili@health.usf.edu

P U R C E L L S . R . , K U T A S H M . & C O B B S . (2011) Journal of Nursing Management 19, 714–720

The relationship between nurses’ stress and nurse staffing factors in a hospital setting

Aim The present study objective was to examine the relationships between nurses� stress and nurse staffing in a hospital setting. Background Nurses have many job-related stressors. There is a lack of research

exploring the relationship between job stressors to staffing and day of week worked.

Methods The sample consisted of registered nurses (RNs) (N = 197) providing

direct patient care. Data were collected via electronic software. Variables included

demographic information, work setting information, Perceived Stress Scale (PSS)

scores and Nursing Stress Scale (NSS) scores. Data analysis included descriptive

statistics, correlations and analysis of variance.

Results Among respondents, a positive correlation (r = 0.363, P < 0.05) was found

between the NSS and PSS and between age and patient work load (i.e. number of

patients the nurse cared for) (r = 0.218, P < 0.05). A negative correlation

(r = )0.142, P < 0.05) existed between NSS and respondents� age. Analysis of variance showed that younger nurses had more nursing stress than older nurses

(F1,195 = 4.283, P < 0.05).

Conclusions Age, patient work load and day of the week worked are important

factors affecting nurses� stress levels. Implications for Nursing Management Nurse managers should consider scheduling

as a potential stressor for nurses.

Keywords: acute care stress, job stress, nursing stress, staffing patterns

Accepted for publication: 28 February 2011

Journal of Nursing Management, 2011, 19, 714–720

DOI: 10.1111/j.1365-2834.2011.01262.x 714 ª 2011 Blackwell Publishing Ltd

 

 

nursing workplace. The aim was to examine the rela-

tionships between nurses� stress and nurse staffing in one hospital setting.

Literature review

According to the (American Hospital Association,

2006), there were 118 000 registered nurse (RN)

vacancies as of December 2005. By 2020 the RN

vacancy rate is anticipated to reach 1 000 000 nurses

(American Hospital Association 2006). There were over

19 000 RN vacancies in long-term nursing care posi-

tions (American Health Care Association 2008). The

nursing shortage has had a significant impact in the

United States, including job stresses for nurses. Many

qualified entry-level bachelor�s nursing students have been turned away from nursing schools owing to a lack

of faculty and resources (Staffing Watch 2010). Al-

though nursing shortages and stressors exist for nurses

in other countries, the literature review in the present

study focuses on describing a series of recent studies

published in the United States and highlights the key

points from more recent international publications.

Staffing, burnout and patient outcomes in the USA

In their classic research about nursing staffing, burnout

and patient outcomes, Aiken et al. (2002) performed a

cross-sectional study within the state of Pennsylvania

(N = 210 hospitals). Emotional exhaustion and job

satisfaction were risk adjusted to patient mortality and

nurses� burnout. Aiken et al. (2002) reported that among hospitals with the highest patient work load (i.e.

number of patients the nurse cared for), surgical pa-

tients had higher risk adjusted mortality and nurses had

higher burnout than those nurses with less of a work

load. This previous study sparked nationwide interest

in relationships between nursing staffing patterns and

patient outcomes.

The following year, Aiken et al. (2003) conducted a

cross-sectional study from the acute care hospitals

within the state of Pennsylvania (N = 168 hospitals;

N = 234 342 surgical patients). Nursing work factors

(nurses� highest levels of credentials, nurses� workload and mean years of experience) and hospital character-

istics (size, teaching status and technological abilities)

were the focus of interest with outcomes such as mor-

tality and failure to rescue (i.e. deaths in surgical pa-

tients with serious complications). Aiken et al. (2003)

found that each 10% increase in the proportion of

nurses with higher educational degrees decreased

the risk of mortality and of failure to rescue by 5%.

Although this previous study did not directly measure

nursing stressors, the findings illuminated the relation-

ships between nurses� education and workload to patient outcomes.

That same year, Hoffman and Scott (2003) per-

formed a descriptive cross-sectional study among staff

nurses working in the state of Michigan (N = 208). The

focus of interest were the nursing work shifts (8- vs.

12-hours shift), the nursing stress [measured using the

Nursing Stress Scale (NSS)], work satisfaction and

career satisfaction. Hoffman and Scott (2003) found a

linear relationship between stress and career satisfaction

and an inverse relationship between stress and satis-

faction. They also found that less-experienced nurses

were remarkably more stressed than experienced

nurses.

In the same year, Staten et al. (2003) conducted

research among staff nurses in the state of California

(N = 248) with the purpose of identifying factors

related to job satisfaction and retention. Staten et al.

(2003) specifically focused on the perceptions among

RNs with different ethnic backgrounds, age groups and

the work environment. The researchers found no sta-

tistical differences amongst age groups in perceptions of

the work environment (e.g. goals, relationships and

system changes). A difference was noted between the

perceptions of managerial control over the work envi-

ronment (Staten et al. 2003).

The following year, Brooks and Anderson (2004)

conducted an exploratory study among staff RNs

working in the hospital setting (N = 341) across the

state of Illinois. Their purpose was to explore the way

acute care nurses rated their quality of work life. Several

problems were reported by nurses, including feelings of

overwhelming stress. Nurses indicated a lack of per-

ceived support to decrease burnout. Other problems

included being exhausted with little energy left after

work, having insufficient or inadequate help from

unlicensed assistive personnel (UAPs) and being nega-

tively affected by rotating shift schedules.

In the same year, Dr Aiken was involved in two

studies using nationwide sampling of nurses. Rogers

et al. (2004) specifically examined shift patterns and

sleep/wake patterns to determine their impact on mak-

ing errors during a shift (coded as a binary �yes� or �no� response). Rogers et al. (2004) found that fewer than

20% of nurses were able to leave work at the end of the

scheduled time; many worked longer shifts and many

stayed later to finish up work not completed during the

shift. The longest shift reported by this nationwide

sample (N = 393) was 23 hours and 40 minutes.

Rogers et al. (2004) also found that 30–32% of nurses

Nurse stress

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reported having made an error or a near miss error.

Nurses were three times more likely to make an error if

they had worked more than 12.5 hours.

In the second nationwide study, Vahey et al. (2004)

performed cross-sectional surveys of hospitals in the

United States (N = 20 hospitals). A measure developed

from the Nursing Work Index (NWI-R) was used to

study environmental characteristics (i.e. staffing ade-

quacy, administrative support and nurse–physician

relationships). The other focuses of interest were such

characteristics as: the hospital and unit size, staffing

ratio and skill mix. The Maslach Burnout Inventory

(MBI) was used to study nurses� burnout. The researchers also surveyed the nurses� intentions to leave, patient satisfaction and nurse/patient characteristics.

Vahey et al. (2004) found that nurses reporting good

working environments (e.g. adequate staffing, admin-

istrative support and better relationships between nur-

ses and physicians) were less likely to experience

burnout, emotional exhaustion, depersonalization and

intent to leave within the year.

The following year, Donaldson et al. (2005) used a

convenience sample of hospitals from California to

examine the impact of mandated nurse-to-patient ratios

on staffing and patient outcomes. The patient outcomes

were based on national quality indicators of fall rates,

pressure ulcer rates and restraint rates. Donaldson et al.

(2005) found no statistical difference in patient out-

comes with the improved nursing–patient ratio man-

dated in California. While Donaldson et al. (2005) did

not directly study stressors, the authors studied patient

outcomes relative to RN nursing care hours. Another

study on this topic was published in 2010 and had

different results. Aiken et al. (2010) found that staff

ratios mandated in California did impact patient care

and predictors of nursing outcomes, such as turnover

and burnout. It was noted that lower nursing–patient

ratios decreased mortality.

Nursing stress in the international research

More recently, there has been an increase also in

international studies on the topic of nursing stress. A

study of nursing work demands on sleep was published

by Winwood and Lushington (2006) from Australia. A

large sample (N = 760) of nurses reported data on work

demands, sleep quality, fatigue and recovery between

shifts. It was found that a rapid work pace increased

psychological strain on work demand, effected sleep

quality and impaired recovery between nursing shifts.

Further, a study from Japan was conducted to assess

the effects of a web-based assertion training programme

on hospital nurses. Nurses completed the training pro-

gramme and data were collected post-training and

1 month later. Results indicated increased assertion

knowledge and a decreased mental workload with

regards to job stress (Yamagishi et al. 2007).

Another Japanese study found that job-related stress

factors are unique per hospital department. Full-time

nurses at four acute care hospitals completed ques-

tionnaires regarding stress factors, psychological

symptoms and somatic symptoms. Notable relation-

ships included nurses working in the operating room

with fatigue, the intensive care unit with anxiety and

surgery–internal medicine with anxiety and depression

(Kawano 2008).

A Chinese study indicated that workload was the

most frequent workplace stressor among intensive care

nurses. The most commonly reported coping strategy

was planning. Various relationships were identified

between workplace stressors, coping strategies, job

satisfaction factors and demographic characteristics. (Li

& Lambert 2008).

A study of Italian mental health nurses found that

empowerment (structural and global) was related to job

satisfaction. Empowerment was also found to have a

negative relationship with job stress. Nurses who were

part of the study worked in hospital wards and health

agencies. Data were collected via questionnaires and

nursing stress was assessed via a five-point scale (Lautizi

et al. 2009).

In summary of the recent literature, multiple reasons

are contributing to nursing stress. Nurses have higher

error rates when overworked (Rogers et al. 2004); they

are emotionally exhausted (Aiken et al. 2002, Brooks &

Anderson 2004, Vahey et al. 2004); they perceive dif-

ferences in work control based on their ethnicity (Staten

et al. 2003); they perceive more stress with longer work

shifts (Hoffman & Scott 2003); they see worse patient

outcomes related to work load (Aiken et al. 2002) but

they do not see improvement with mandated staffing

ratios in California (Donaldson et al. 2005). And fi-

nally, it appears as although the nursing shortage is

projected to increase exponentially as the baby boomer

generation of nurses mature into senior citizens

(American Hospital Association 2006).

Methods

The study design was a descriptive (cross-sectional),

correlational study that utilized self-reported survey

data. Data were collected from a convenience sample of

1300 staff nurses from multiple patient care areas of a

large teaching hospital in the Southeastern United

S. R. Purcell et al.

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States. The data were collected in 2008. Historical

analyses of earlier studies from the hospital indicated

that an average response rate of 30% was commonly

achieved in this organization. Software for electronic

data collection via the internet was used to allow for an

ample number of responses and convenience of the

nurses completing the survey. After institutional review

board (IRB) approval was obtained, recruitment flyers

were placed in nursing stations and the responding

nurses initiated their password protected survey on

Survey Monkey�. Completion of the survey indicated

informed consent as stated in the introductory page of

the questionnaire.

Inclusion criteria were RNs who provided direct pa-

tient care, were able to read and write in English and

willing to complete the survey. Nurses were excluded

from the study if they worked in non-patient care units,

were not employed by the hospital, were in leadership/

administrative positions, had not worked directly in

patient care within the previous 7 days, or were not

licensed as RNs.

Instruments

Instruments used in the present study included the

Nurse Stress Scale (NSS) (Gray-Toft & Anderson 1981)

and the Perceived Stress Scale (PSS-14) (Cohen et al.

1983). The NSS is a 34-item questionnaire designed to

measure job-related stress for nurses. The NSS is a

summated Likert-type instrument with each item scored

0 (never), 1 (occasionally), 2 (frequently) to 3 (very

frequently). The seven subscales of the NSS are work-

load (Six items), death and dying (Seven items), inade-

quate preparation (Three items), lack of support

(3 items), uncertainty concerning treatment (5 items),

conflict with physicians (Five items) and conflict with

other nurses (Five items). Initial tests of internal con-

sistency produced a coefficient of 0.89 (Gray-Toft &

Anderson 1981).

The PSS-14 is a 14-item questionnaire used to mea-

sure the situations in the nurse�s life that are deemed stressful. The PSS is a summated Likert-type instrument

with each item scored 0 (never), 1 (almost never), 2

(sometimes), 3 (fairly often) to 4 (very often). Initial

evaluation of the instrument revealed a test–retest cor-

relation of 0.85. Cronbach�s alpha was 0.84, 0.85 and 0.86 in the three samples (Cohen et al. 1983).

The total scores of NSS (range: 0–102) and PSS

(range: 0–56) are the sums of the individual items with

higher scores indicating higher levels of stress. Other

study variables reported by the subjects included shift

length (i.e. 8- or 12-hours shift), nursing work hours

(i.e. number of hours worked during the last shift), day

of week worked (i.e. days within the previous week that

the nurse worked) and patient work load (i.e. number of

patients the nurse cared for).

Data analysis

Data were analysed using PA SW 1 7 (SPSS, Inc., Chicago,

IL, USA). Measures of central tendency were conducted

for descriptive statistics of the sample including mean,

standard deviation (SD) and variance. Pearson�s corre- lation coefficients were analysed to determine the

strength of the relationship between nursing stress and

other study variables. Analysis of variance (A N O V A) tests

were used to determine differences between nursing

stress and age of the nurse. The significance level was set

a priori at P < 0.05.

Results

There were 321 surveys returned, although many

respondents completed the demographic portion of the

surveys without completing the stress scales. Missing

data points left 197 surveys with complete data. The

response rate of the completed surveys was 15%.

Demographic results from the respondents (N = 197)

were female (92.4%), with an average age of

38.7 years, average of 10.5 years of nursing experience

and an average of 38 hours worked weekly. The

majority of nurses were married (54.3%), about half

(50.3%) had no children living with them and 7.6%

lived with their parents. The most frequent educational

level reported was a Bachelor�s degree (43.7%). The majority (45.7%) worked day shifts, most frequently on

Monday and Tuesday. The respondents� background characteristics are shown in Tables 1 and 2.

Overall, the results of the stress scales were NSS

(mean = 89.6, SD = 21.5) and PSS (mean = 36.6,

SD = 8.0). Nurses were categorized as younger or older

via a median split which occurred at the age of 37 years.

Older nurses (mean = 48.0, SD = 7.1) reported caring

for a greater number of patients than younger nurses

(mean = 29.6, SD = 4.6), especially with a patient load

of greater than six patients. NSS scores for older nurses

(mean = 86.4, SD = 21.6) were lower than those of

younger nurses (mean = 92.7, SD = 21.0). PSS scores for

older nurses (mean = 35.7, SD = 8.3) were also lower

than those of younger nurses (mean = 37.4, SD = 7.7).

Although these differences were not statistically signifi-

cant, they are notable. Stress scale scores are in Table 3.

Among the respondents a moderately strong and

statistically significant positive correlation (r = 0.363,

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P < 0.05) was found between the total scores of NSS

and PSS as well as between age and the highest number

of patients assigned during the respondents� last shift (r = 0.218, P < 0.05). A significant, but weak negative

correlation (r = )0.142, P < 0.05) existed between NSS and respondents� age. No significant correlations were noted between PSS and the average weekly

worked hours. There was a weak, but significant posi-

tive correlation between age and the total number of

patients cared for during the last shift worked

(r = 0.193, P < 0.05). Correlation coefficients are

shown in Table 4.

Analysis of variance showed that younger nurses had

significantly more nursing stress than the older nurses

(F1,195 = 4.283, P < 0.05). Variability in PSS and NSS

scores were significantly affected by the age of the nurse

and working the weekend (Friday, Saturday and Sun-

day) using a one-way A N O V A. A N O V A results are shown

in Table 5.

Discussion

Key limitations of the present study were the overall

response rate and the number of respondents with

complete surveys on the stress scales. At the time of this

Table 1 Respondents� background characteristics

n %

Gender Male 14 7.1 Female 182 92.4

Marital status Married 107 54.3 Divorced 37 18.8 Single (never married) 49 24.9 Separated 2 1.0 Widowed 2 1.0

Education level Diploma (nursing) 12 6.1 Associate�s degree (nursing) 74 37.6 Bachelor�s degree (nursing) 86 43.7 Graduate school (nursing) 6 3.0 Associate�s degree (non-nursing) 1 0.5 Bachelor�s degree (non-nursing) 15 7.6 Graduate school (non-nursing) 3 1.5

Shift worked, hours 07.00–15.00 8 4.1 15.00–23.00 7 3.6 23.00–07.00 5 2.5 07.00–19.00 90 45.7 19.00–07.00 71 36.0 Other 14 7.1

Day of week worked Monday 106 53.8 Tuesday 105 53.3 Wednesday 104 52.8 Thursday 99 50.3 Friday 92 46.7 Saturday 86 43.7 Sunday 78 39.6

Table 2 Respondents� background

Variable N Min Max Mean SD

Age 197 21 68 38.65 10.99 RN years 188 0 48 10.53 10.16 Weekly work hours 191 3 80 38.32 8.30 Parents at home 193 0 4 0.10 0.42 Children at home 194 0 5 0.89 1.06

SD, standard deviation; RN, registered nurse.

Table 3 Respondent data

Variable n Min Max Mean SD

Overall NSS 197 40 154 89.60 21.50 Overall PSS 197 16 57 36.56 8.04 Age: older nurses* 97 38 68 48.02 7.08 Age: younger nurses 100 21 37 29.56 4.57 NSS: older nurses* 97 40 152 86.41 21.65 NSS: younger nurses 100 55 154 92.70 20.99 PSS: older nurses* 97 16 54 35.67 8.32 PSS: younger nurses 100 19 57 37.42 7.70

NSS, Nurse Stress Scale; PSS, Perceived Stress Scale. *Older nurses are >37 years.

Table 5 Analysis of variance

Predictor variable Dependent variable F P

Older nurses* NSS 4.283 0.040 PSS 2.349 0.127

Weekend work� NSS 7.606 0.006 PSS 6.164 0.014

Weekend work�, age NSS 6.004 0.003 PSS 4.783 0.009

Weekday work�, age NSS 4.570 0.011 PSS 3.018 0.051

*Older nurses are >37 years. �Weekend work includes Friday, Saturday and Sunday.

Table 4 Correlations between Nurse Stress Scale (NSS), Perceived Stress Scale (PSS) and background variables

Variables 1 2 3 4 5

PSS NSS 0.363* Age )0.126 )0.142* Work hours )0.063 )0.099 0.168* Total patients )0.029 )0.108 0.193* 0.003 Highest no. 0.007 )0.088 0.218* 0.024 0.813*

Total number of patients cared for on the last shift worked. Highest number of patients cared for on the last shift worked. *A significant correlation at the 0.05 level.

S. R. Purcell et al.

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study, the institution had recently implemented a new

system for email for all nursing staff. It is possible that

the response rate may have been higher had the survey

been disseminated after nurses became more comfort-

able with this method of communication.

The results indicate that age and the day of the week

worked are important factors affecting nurses� stress levels. Nurses reported higher stress levels when they

worked the weekend. This may be due to several fac-

tors. Anecdotal knowledge of the hospital shows that

many of the nurses work primarily on weekends and

therefore may not be as engaged in the culture of the

unit. In addition, several of the nursing staff that serve

in managerial/supportive roles and provide resources to

staff (clinicians, nurse mangers, advanced practice

nurses and educators) do not routinely work weekends.

Also, the staffing level of medical residents is lower on

weekend days. The present study adds to the body of

knowledge of the nurse–stress relationship within acute

care. Further research is needed to understand the

intricacies of various stresses that nurses encounter to-

day and their potential clinical consequences.

An interesting finding of the present study was the

positive correlation between age and the total number

of patients cared for. Older nurses reported greater

numbers of patients (mean = 4.75, SD = 2.67) cared for

than younger nurses (mean = 3.89, SD = 2.23). There-

fore, older nurses had a higher patient work load.

Younger nurses reported greater nursing stress than did

older nurses. There may be various reasons for this

finding. The immediate and surrounding areas of the

study site include urban, suburban and rural locations.

Almost 20% of the population of this area is between

the ages of 18–34 years. The high number of young

adults in the area lends toward many unique social

opportunities. It may be speculated that younger nurses

have greater nursing stress than the older nurses as a

result of activities outside of the hospital, especially

when working the weekends.

The stress levels reported by the nurses may also be

affected by the length of time in which the nurses have

been working. A recent study noted that as nurses

�progress in expertise� in their nursing roles they func- tion more appropriately with patient care situations

such as organization, interruptions, anticipating patient

care needs, communication and integration of nursing

roles (Burger et al. 2010). Staff development pro-

grammes may assist in nurses transitioning from

the novice role to that of the expert (Haag-Heitman

2008).

Findings that nurses of various ages report multiple

causes of stress can be supported by previous research.

Blythe et al. (2008) found that nurses of diverse gen-

erations have different career commitment, job satis-

faction, stress and emotional exhaustion. Moreover,

Golubic et al. (2009) noted that older age was a pre-

dictor related with low work ability. More research is

needed on the topic of age-related nursing stressors in

acute care institutions to assist management with

proper staffing.

Other causes of nursing stress include the area

worked and patient work load. Mrayyan (2009) con-

cluded that stressors were higher in intensive care units

(ICUs) than in wards. Furthermore, the shift worked

was a predictor of nursing job stressors in the ICUs and

wards. Once these stressors have been identified, inter-

ventions are essential to decrease or assist nurses with

coping techniques. The value of strategies needed to

prevent hospital nursing stress from becoming chronic

and leading to burnout have been documented (Sasaki

et al. 2009).

Implications for Nursing Management

The importance of the nursing workforce to patient

outcomes has been documented. The projected RN

vacancy rate has significant implications for healthcare

and poses a challenge for hospital administration re-

lated to quality and cost of care. For example, a recent

study has demonstrated that increased work hours,

work stress and poor collaboration among staff are

related to hospital-acquired infections among those

patients (Virtanen et al. 2009). Therefore, actions of the

staff, in addition to patient care, can affect the health of

the patient.

It has been reported that the turnover cost to replace

an RN ranges from $12 000 to $67 000 (Jones 2004,

2005). It is also possible to assume that these costs will

be increasing because of to the decreasing workforce in

the very near future. As nurse managers continually

struggle to maintain adequate staffing levels, the burden

of stress among nurses who provide direct patient care

cannot be understated. An imperative step in addressing

this well-documented issue is to identify the sources of

nursing stress related to staffing. A greater under-

standing of those stressors will lead to appropriate

strategies for nursing stress reduction and coping which

may result in a healthier, more satisfied and effective

nursing workforce.

Conclusions

Job-related stress remains an issue in the nursing

workforce. The effects of stress experienced by the

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nurse impact job satisfaction and retention. Recogniz-

ing and understanding the job-related stressors of nurses

can help nurse leaders to implement strategies that are

more efficiently aimed at reducing nurse�s stress and subsequently improve patient outcomes. Although pa-

tient work load and day of week worked are important

factors within nursing, age is a significant factor

affecting nurses� stress levels. More research that in- cludes nurses within a variety of practice settings is

needed to further explore these findings.

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