Virginia Nurses Today - August 2022

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Page 20 | August, September, October 2022 Virginia Nurses Today | www.VirginiaNurses.com Occupational Stress: Definition, Impact, and Strategic Mitigation Richard Ridge, PhD, RN, NEA-BC, CNL Commissioner of Workforce Virginia Nurses Association Occupational stress is well known as a health risk for a wide range of psychological, behavioral, and medical disorders and diseases. The National Institute for Occupational Safety and Health (NIOSH) established a national priority agenda for policy and research 20 years ago that still guides efforts to better understand occupational stress in general and to mitigate its impact on the U.S. workforce across industries. 1 The recent Covid-19 pandemic has uncovered and exacerbated numerous sources of occupational stress within healthcare, including nursing. This article will define occupational stress within a nursing context, describe the impact of this stress on nurses as individuals and as a workforce, and identify several strategies to mitigate its impact. Occupational stress, like all forms of stress, may not be inherently destructive or harmful. One of occupational health’s foundational principles is that the response to stress is a normal and naturally occurring reaction to stress of all types, including stress caused by work-related factors. 2 The epidemiology of stress recognizes that the stress response manifests differently depending on a wide variety of variables that may serve as protective or as additional individual risk factors. Simply put, work is stressful to a harmful extent when demands exceed the individual’s resources to effectively adapt. Why is this important? Two years into the Covid-19 pandemic, the nursing workforce supply is under extreme threat. In a recent analysis, Auerbach and colleagues identified an alarming decrease of 100,000 RNs in 2021, the greatest drop in a single year over the past four decades. 3 Especially distressing is that the decrease stemmed primarily from nurses younger than age 35. The overall reduction in supply was due primarily to losses of hospital-employed RNs. This loss of younger RNs will be felt for a generation in contrast to the attrition of nurses at retirement age. The loss of frontline hospital RNs will not only mean a labor disruption for hospitals, but also for many other care settings that depend on experienced hospital nurses for specialty settings and practices. What we know about nurses’ stress and their ability to adapt and function. Several major recent surveys of nurses provide some insight into the recent exodus of younger nurses and to understanding occupational stress from an actionable perspective. The American Nurses Association Second Year Covid-19 Impact Assessment Survey received responses from 11,964 nurses in January 2022. 4 This survey built upon previous surveys and included questions on mental health, well-being, financial impact, perceived organizational support and intent to leave their current position. The responses to many items seem to reflect opposing opinions. For example, for the question regarding intent to leave your position within six months, 52% answered yes or maybe, and 48% replied no. In another example, 30% of nurses rated their emotional health as not or not at all healthy, and 37% rated theirs as emotionally healthy or very healthy. While this survey identified numerous activities to strengthen wellbeing, a similar distribution is seen in regard to nurses’ perceptions of their organizations’ caring with respect to well-being. 43% of nurses disagreed or strongly disagreed that their organizations cared about their well-being, as compared to 32% who agreed or strongly agreed. Staffing shortages not surprisingly were reported by 89% of acute care nurses, predominately at a moderate or highly serious level. The majority of acute care nurses experienced bullying and incivility from patients and families. And 20-25% experienced incivility and bullying from colleagues, managers, and supervisors. The ANA’s Mental Health and Wellness Survey compiled responses from 9,572 nurses in the early Fall of 2021. 5 On a scale of 1-10 rating the ability of nurses to recover or adjust to the impact of Covid-19 on their well-being, the average score was 6.2. But again, the survey showed high levels of responses to items at each end of the spectrum with 42% of nurses reporting having had an extremely stressful, disturbing, or traumatic experience due to COVID-19, and 52% reporting they had not experienced this. Thus, the impact of the trauma of work during the pandemic was perceived differently, as one would expect from the epidemiology of stress and its impact on health. The third survey, undertaken by AMN Healthcare in Spring 2021, reported data received from 6,562 active and practicing nurses who had provided direct care within the previous year. 6 Focused on understanding nurses’ perspectives during the pandemic, they reported the findings relative to whether they had Covid, and whether they cared for Covid-19 patients. Over 50% of nurses reported feeling burnt out to some degree, feeling emotionally drained, and that their job was adversely impacting their health. Almost 40% felt misunderstood by their employer, and over half reported not getting what they wanted from their job. Many of these findings were worse for nurses who either had Covid-19 or who cared for Covid-19 patients. Thus, based on the findings from these three surveys it is reasonable to conclude, within the limitations of these individual studies, that many nurses are adapting and coping well, while many are not. In terms of the nursing workforce, it is not an overstatement to say that each nurse who leaves the profession is one too many. System solutions must be strengthened where already in place and introduced where they are missing. Strategic Mitigation (Taking Action) Recognizing occupational stress in nursing as a public health issue can frame a comprehensive and systematic approach to address immediate, midrange, and long-term needs. Effective mitigation of occupational stress for nurses requires three levels of interventions: primary, secondary, and tertiary. Primary interventions aim to prevent occupational stress harm before it occurs. Secondary prevention aims to reduce the impact of stress once harm has occurred, and tertiary prevention aims to lessen the long-term impact of nurses who experience persistent harmful effects. Each of these three levels of prevention must be addressed in a systematic way at all levels, including the policy and population level, organization level, and by the individual nurses. At a fundamental policy level, as envisioned in the FON report, major changes are needed in payment systems to healthcare organizations that shift away from incorporating nurses in the room rate. Such mechanisms incentivize minimization of nurse resources, rather than recognizing and paying for the value that nursing contributes to healthcare. The current pay for performance structures may be a good beginning, but they are insufficient to fully incentivize organizations to optimize rather than minimize nurse resources. This should have a positive influence on nurse workload. Other policies, with associated Inova Fair Oaks Hospital is Hiring! Experienced Labor and Delivery Nurses – Full Time & Part time Sign-On Bonus/Relocation Bonus for qualified candidates! The Labor and Delivery unit at Inova Fair Oaks Hospital located in Fairfax, Virginia has recently undergone a beautiful renovation. Our unit consists of thirteen private labor and delivery rooms, an eight-bed triage/PACU area, and three operating rooms. Our nurse to patient ratio is 1:2. Inova Fair Oaks Hospital has earned a High-Performing rating for the first edition of Best Hospitals for Maternity by U.S. News & World Report. U.S. News rates hospitals in this category by evaluating key indicators of maternal and newborn health data.
www.VirginiaNurses.com | Virginia Nurses Today August, September, October 2022 | Page 21 regulatory requirements, could strengthen and make more consistent, organization-level programs to promote healthy workplaces and reduce the threats from workplace violence and lateral incivility. Increased funding provided through national and state level policy change would help support organization-level efforts. Organizations should implement programs that address the three levels of prevention to help those nurses not yet affected, those nurses in the early stages of harm, and those nurses who have incurred chronic adverse effects. One example of this is the Stress First Aid (SFA) program, initially developed by the U.S. military, and now available through the Schwartz Center for Compassionate Healthcare. This program helps leaders and staff create customized implementation plans. As seen from the nurse survey data, programs are needed to address bullying, lateral incivility, and workplace violence. Organizations can adapt programs and toolkits already in place. For example, the recently published VHHA Workplace Violence Prevention Toolkit, developed with input from the VNA, provides information about applicable state laws, background information, and detailed guidelines to support organizations in developing, implementing, evaluating, and sustaining workplace violence prevention programs. Another example of an adaptable toolkit is the PACERS program, funded by the Robert Wood Johnson Foundation. This toolkit provides a systematic and multi-level approach to create care environments of respect and civility; both issues are specifically identified as highly problematic in the recent nurse surveys. Organizational guidance for developing resiliency to prevent nurse burnout is available from many sources. The Joint Commission published a guide for healthcare leaders in 2019 that guides leaders to empower employees’ ability to access resources, information, and support needed to perform their work and to gain the opportunity to develop. 7 Inadequate staffing is a major source of occupational stress for nurses, which was exacerbated by the pandemic. Minimum staff ratios are seen as a solution by some and by others as a solution with many unintended and negative consequences for patients, nurses, and other employees. But from an occupational stress perspective, appropriate and effective nurse staffing is a prerequisite for addressing occupational stress. At a minimum, nurse-led groups should create unitlevel staffing plans based on a patient population’s acuity and needs, and matched with staff’s skills and experience. (ANA, https://www.nursingworld. org/practice-policy/nurse-staffing/nurse-staffingadvocacy/) While building resilience and promoting adaptive coping skills are important for individual nurses, the burden and responsibility cannot be borne solely by the nurse. Effective occupational stress mitigation must occur at the policy and organizational level for individual nurses to be successful. However, several evidence-based key strategies for nurses to prevent stress injury emerge from the occupational stress literature: • Identify and understand your own vulnerabilities and the specific sources of your job stress. • Regularly assess stress-levels and the presence of stress injury signs and symptoms using an established scale such as the Stress First Aid framework. • Be aware that stress injury may manifest as medical condition, psychological distress, or as tobacco abuse, alcohol and drug abuse, aggression, and violence. • Identify support resources available through a professional organization, other peer groups, your organization, or through your health plan. • Identify and implement individual stress management strategies. • Develop and use social support, at work and at home. (Being part of a cohesive health workgroup and networks have significant protective impact.) • If injury has occurred, emphasis must be first placed on healing in the short-term. Discontinuing employment in the current setting may be indicated. Use support networks in making any critical decisions about your employment, career, or personal life. nurses, the profession, and to the overall healthcare system. Occupational stress has become more pronounced during the Covid-19 pandemic but the underlying causes are not new and are generally well-known. Systematic mitigation is required to address underlying causes, prevent stress injury from occurring, minimize the extent of harm to individual nurses and the profession, and to help nurses with significant stress injury recover and return fully to the healthcare workforce. 1 Sauter, S.L. et al., (NORA Organization of Work Team Members). (2002). The Changing organization of work and the safety and health of working people: Knowledge gaps and directions. National Institute for Occupational Safety and Health. 2 Quick, J.C. & Henderson, D.F. (2016). Occupational stress: Preventing suffering, enhancing wellbeing. International Journal of Environmental Research and Public Health, 13(4):1-11. doi:10.3390/ijerph13050459 ✓ 3 Auerbach, D.I., Buerhaus, P.I., Donelan, K. & Staiger, D.O. (2022). A worrisome drop in the number of young nurses. Health Affairs Forefront. https://w w w.healthaffairs.org/do/10.1377/ forefront.20220412.311784/ 4 American Nurses Foundation. (2022). COVID-19 Two- Year Impact Assessment. American Nurses Foundation & Joslin Insight. 5 American Nurses Foundation. (2021). Mental Health and Wellness Survey Report. American Nurses Foundation & Joslin. 6 AMN Healthcare. (2021). Nursing and the nation: Extreme challenges, extraordinary impact. 2021 Survey of Registered Nurses. AMN Healthcare. https://www. amnhealthcare.com/siteassets/amn-insights/surveys/ amn-healthcare_2021-rn-survey.pdf 7 The Schwartz Center for Compassionate Healthcare. Stress First Aid. Accessed 6/22/22, https://www. theschwartzcenter.org/stress-first-aid-private/ The Joint Commission (2019). Developing resilience to combat nurse burnout. Quick Safety, Issue 50. The Joint Commission, Division of Healthcare Improvement. RNs, GET YOUR MSN Two starts per year (Jan., Aug.) Online format with two clinical courses FROM SENTARA COLLEGE WITH THIS ONLINE, PART-TIME PROGRAM Clinical Nurse Leader (Master of Science in Nursing) For RNs with their BSN who wish to become advanced practitioners Part-time curriculum for busy RNs Accreditations & Certifications: 2 No preadmissions test Finish in only two years Certified by SCH EV to operate in Virginia, accredited by ABHES & approved by NC-SARA. In summary, occupational stress is an emerging public health issue that poses a significant threat to
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