Assignment: Concept Analysis

Role stress amongst nurses at the workplace: concept analysis

SANAZ RIAHI R N , B S c N , M S N

Clinical Education Leader, Professional Practice, Ontario Shores Centre for Mental Health Science, Whitby, ON, Canada

Introduction

�Nursing is, by its very nature, an occupation subject to a high degree of stress. Every day the nurse confronts

stark suffering, grief, and death as few other people do.

Many nursing tasks are mundane and unrewarding.

Many are, by normal standards, distasteful, even dis-

gusting, others are often degrading; some are simply

frightening� (Mcgrath et al. 2003, p. 555). According to the United Nations and World Health Organization,

job stress has become a worldwide epidemic (Collins

2006) and there is a growing body of research docu-

menting the stressful nature of the nursing role in pa-

tient care settings. The concept of stress, in general, and

role stress more specifically, lacks consensus and may

vary depending on the academic background of the

researcher (Mulhall 1996, Clegg 2001).

The health care systems, both in Canada and USA,

have encountered many challenges throughout the

years. In the early 1990s, cuts to the Canadian health

Correspondence

Sanaz Riahi

Professional Practice

Ontario Shores Centre for Mental

Health Science

700 Gordon Street

Whitby, ON L1N 5S9

Canada

E-mail: [email protected]

R I A H I S . (2011) Journal of Nursing Management 19, 721–731

Role stress amongst nurses at the workplace: concept analysis

Aim The present study explicates the concept of role stress amongst nurses through an analysis adopted from Walker and Avant; Strategies for Theory Construction in Nursing, 4th edn, Prentice Hall, New Jersey, NY. Background Role stress has become a significant problem amongst nurses and has

created much distress leading to burnout among many in the nursing profession. It

is significant to analyse the concept of role stress and its relative attributes and

consequences, in order to recognize the necessary antecedents needed to create

better conditions for nurses at the workplace.

Evaluation A modified method developed by Walker and Avant was used for this

concept analysis.

Key issues A model representing the concept of role stress was developed through

careful consideration of the attributes, consequences, antecedents and empirical

referents of role stress.

Conclusion The concept analysis of role stress among nurses at the workplace

recognized the vulnerability of the nursing discipline towards burnout and distress

in general.

Implications for Nursing Management It is critical to be aware of the current state

of health care and note the increased workload created for nurses. Nurses are at a

greater vulnerability for role stress, making it imperative for health care organiza-

tions to critically evaluate and establish preventative measures for the concept of

role stress.

Keywords: burnout, hardiness, nursing, role stress, stress

Accepted for publication: 19 Januray 2011

Journal of Nursing Management, 2011, 19, 721–731

DOI: 10.1111/j.1365-2834.2011.01235.x ª 2011 Blackwell Publishing Ltd 721

care budget led to the elimination of nursing positions

in several provinces. This was mainly attributed to the

significant reductions in transfer payments and budget

deficits from the Federal government (Armstrong-Stas-

sen et al. 2001). The US health care system experienced

higher economical pressure on hospitals as a result of

growing price competition and tightening of payments

for Medicare and Medicaid throughout the 1990s. This

pressure produced an increase in the severity of inpa-

tient illnesses with reduced hospital stay (Buerhaus &

Needleman 2000). It has also been noted that job dis-

satisfaction in nursing has been mainly related to the

quality of care provided and labour shortage, resulting

in an increased workload (Wright et al. 2006). The

current state of health care, both in Canada and USA,

continues to see the residual effects of the challenges

faced in the 1990s which have created negative effects

within the nursing profession.

The purpose of the present study was to define a

concept of role stress amongst nurses in the workplace,

to raise awareness of this important professional issue

and to support development of future research and

education in this area. Also, it is hoped that this concept

analysis will act as a useful tool for health care orga-

nizations in creating a supportive environment to enable

nurses to continue to provide an optimum quality of

care. This concept analysis has been developed utilizing

the method recommended by Walker and Avant (2005).

Role stress is discussed according to the framework

which specifies the use of defining attributes, anteced-

ents, consequences and empirical referents. In the

present study the method has been modified by only

providing a model case to illustrate the concept of role

stress. This analysis will apply these guidelines to ex-

plore the concept of role stress amongst nurses in the

work setting, one of the most destructive problems

facing the profession today.

Methodology

In order to complete this analysis, a literature search

was performed on various databases such as: EBSCO-

host Online Research Databases, Electronic Journal

Center (EJC) and Proquest. The terms used for search

were �role stress and nursing�, �nursing stress and workplace�, �workplace stress and nursing�, �stress and nursing�, �stress and workplace�, �burnout and nursing�, �coping and nursing�, �hardiness and nursing� and �feedback and nursing�. It was noted through the process of the literature search that literature regarding the

attributes and the concept of role stress are understud-

ied within the nursing discipline. The search was

restricted to publications since 1996 with the exception

of two publications in 1966 and 1991 which were both

reoccurring references in other literature reviewed. The

literature search was initiated with a basic broad search

allowing the discovery of the components involved in

the concept. This lead to an advanced search once

greater understanding of the concept was achieved and

inclusion and exclusion criteria were developed as a

result of the intersections of various descriptors within

the literature. The total sample included 39 documents

consisting of a variety of sources such as primary search

studies, professional journal articles and reference

publications, all published in the English language. The

method used for the sample selection was achieved

through a thorough review of each publication by the

author(s). The inclusion criteria were very broad as a

result of the limited studies available and included

qualitative and quantitative studies, as well as, any

systematic reviews and analysis on the topics of the

search terms stated above. The exclusion criteria for the

selection of literature were those studies that were not

related to healthcare, nursing or psychology.

Definition

Focusing on role stress amongst nurses at their work-

place, the definitions of stress, role stress and occupa-

tion stress are necessary to define and are also seen as

being related. The concept of role stress is not found in

the dictionary; therefore, the term stress will be used as

the initial starting point for this analysis. The term

�stress� is commonly used in modern-day vocabulary by individuals. Its meaning is vague by multiple usages and

references. Monat and Lazarus (1991) insisted that the

reason for a lack of agreement on a general definition

for �stress� is because of the inability to accurately evaluate response patterns. For example, observing in-

creased physiological activity as an indicator of stress

may also arise from different stimulus conditions such

as extensive fear or exercising. This creates the com-

plexity of forming an agreed-upon definition.

In the 1930s, Hans Seyle described stress as any living

organisms experiencing some form of strain (Olofsson

et al. 2003). Lazarus (1966) acknowledged the incon-

sistency and confusion of the terminology of �stress� and provided a broad description. Stating �stress, as a uni- versal human and animal phenomenon, results in an

intense and distressing experience and appears to be of

tremendous influence in behaviour� (Lazarus 1966, p. 2). Some literatures cite the terms �distress� and �eustress�, where eustress refers to the positive responses towards stress, whereas distress describes the negative

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reactions (McVicar 2003). Distress and eustress are

viewed on a continuum, where an individual may move

along the continuum during different situations

(McVicar 2003). For the purposes of the present study,

it is critical to acknowledge the term �stress� as a dis- tressful experience regarding the role of an individual.

More focused within the nursing profession, Lambert

et al. (2003) suggest stress occurs when demands that

are placed upon a person exceed the available resources

the individual encompasses in order to manage. Con-

sistent with this idea, Mulhall (1996) reported that a

number of nursing models conceptualize stress as an

�imbalance�. Clegg (2001) proposed the definition of occupation stress as being �any force that pushes a psychological or physical factor beyond its range of

ability, producing strain within an individual� (p. 102). The Merriam-Webster�s Online Dictionary (2007) defines role as �a character assigned or assumed; and a socially expected behaviour pattern usually determined

by an individual�s status in a particular society�. Role stress, then, is viewed as the consequence of a discrep-

ancy between the individual�s perception of the traits within a specific role, and what in actuality is being

accomplished by the individual currently functioning in

that role (Chang et al. 2005). For example, nurses ex-

pect to provide quality patient care, however, the

experience of being overwhelmed as a result of an in-

crease in workload and insufficient time may lead to the

perception that the quality of care provided was not at

an optimum level. When the loss of quality in care is

perceived owing to uncontrollable factors, it creates

role stress. Therefore, when the situation is perceived as

exceeding the nurse�s resources, role stress occurs.

Literature review

A literature review has been completed to allow for

greater understanding of the attributes contributing to

the concept of role stress. These attributes will be dis-

cussed in detail to create a better understanding of role

stress amongst nurses at the workplace.

Literature identifies perceptual incongruence as a

contributing factor to the concept of role stress. Per-

ceptual incongruence is the individual�s perception of discrepancy between what is needed to meet a specific

task as compared with what is available; this discrep-

ancy triggers a stress response (McVicar 2003, Lambert

et al. 2004a,b). The majority of papers identified

workload, interpersonal relationships, patient care,

knowledge of nursing and nursing skills, limited re-

sources and bureaucratic-political constraints as central

to the concept of role stress amongst nurses (Clegg

2001, Happell et al. 2003, Mcgrath et al. 2003,

McVicar 2003, Lambert et al. 2004a,b, Chang et al.

2005, Xianyu & Lambert 2006). These present results

were consistent for various nursing positions, as well as

cross-culturally (Lambert et al. 2004a,b). For example,

Lambert et al. (2004a,b) determined in their study that

nurses in UK, Japan, Thailand, South Korea, and the

USA shared the same mentioned stress factors influ-

encing role stress. A lack of autonomy and confidence in

practice ability is also reported as stressful in some

previous studies, demonstrating a wide range of aspects

causing perceptual incongruence in the nursing role

(Mcgrath et al. 2003, Olofsson et al. 2003).

Appraising is another attribute identified in literature

and it has been described as consisting of two compo-

nents. Primary appraising examines the process of

evaluating the relevancy of the individual�s current sit- uation to their values, goal commitments and beliefs

(Lazarus 2000). Secondary appraising focuses on the

construction of tasks that need to be done regarding a

troubled person–environment relationship. Lazarus

(2000) also explains the key appraisal variants of psy-

chological stress to be harm, loss, threat or challenge.

Overall, appraising allows an individual to judge whe-

ther their current situation is worthy of attention and

action.

Role stress is multidimensional, consisting of physi-

ological and psychological effects. Physiological effects

refer to how role stress physically disturbs the individ-

ual. McVicar (2003) discusses the idea of �eustress� and �distress� along a stress continuum in which an individ- ual moves along. Some of the physiological facets

influenced by the concept of role stress can be very

damaging to a nurse and vary in severity depending on

whether the experience is �eustress� or �severe distress�. Numerous physiological problems have been linked to

role stress, varying from issues such as high blood

pressure, increase in heart rate, weight gain or loss,

indigestion, coronary heart disease and gastric disor-

ders, dependent on where the individual�s experience is on the stress continuum. The psychological component

as a result of role stress may have extremely negative

impacts on an individual. These impacts may range

from increased arousal, feeling of uneasiness, emotional

exhaustion, depression, fatigue and burnout depending

on the individual�s position on the continuum (McVicar 2003).

It is crucial to recognize the degree to which role

stress influences nurses in a multidimensional manner,

affecting the whole person. Having an understanding

that physiological and psychological responses may

become severe as a result of a prolonged experience of

Role stress

ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 721–731 723

role stress, reiterates the significance of attempting to

resolve role stress amongst nurses.

Evidence-based research has also identified interac-

tional feedback as another attribute contributing to the

concept of role stress for nurses. Interactional feedback

describes the acknowledgement and communication

from colleagues at the workplace, as experienced by an

individual affected by role stress. A study evaluating

nurses� experiences and emotions regarding stress at work revealed that one main deficiency expressed by

nurses was a lack of acknowledgement for performed

work and absence of sensitivity by supervisors towards

stress signals (Olofsson et al. 2003). Mcgrath et al.

(2003) mentioned that the absence of positive or other

forms of constructive feedback from the senior staff in

the nursing profession creates stress at the workplace.

In a previous study, participants who identified with

having more social support from their colleagues, sta-

ted that they encountered less job stress (AbuAlRub

2004). AbuAlRub�s (2004, p. 77) study revealed that �nurses who believe that they are supported by their colleagues (1) like their work environment and thus

excel in their work and perform better than do those

with less support; and (2) feel comfortable asking for

help from their coworkers with regards to certain un-

clear nursing tasks, thus decreasing error and enhanc-

ing performance�. A comparative study of �burnout� indicates a lack of

support from colleagues to be critical for nurses suf-

fering from burnout and an inadequate leadership and

management style leading to an increase in stress at the

workplace (Gillespie & Melby 2003). Demerouti et al.

(2000) indicated nursing job demands become more

stressful when a social network, to discuss and improve

patient�s quality of life, is unavailable. Thus, a recom- mendation made within their study was to train

supervisors to implement a leadership style which

would provide adequate feedback to nurses. As well, a

concept analysis of burnout discusses �positive climate factor� linking to decreased stress scores for nurses on a variety of nursing units (Raiger 2005). From the liter-

ature it is evident that role stress amongst nurses may

decrease if interactional feedback such as social support

and task and/or emotional acknowledgement from

coworkers would be of greater existence.

A response pattern is another attribute of role stress

evident in literature. A response pattern describes the

coping mechanism an individual who is experiencing

role stress utilizes. Coping is identified as a process of

response to role stress in nursing. Keil (2004) recognizes

that coping must encompass altering or eliminating

factors while recognizing that success or failure is not

fundamental to coping and all responses are a form of

coping. The manner in which the individual perceives

and evaluates a circumstance establishes which coping

method they will use (Healy & Mckay 2000). Chang

et al. (2006, p. 31) defined coping as �constantly changing cognitive and behavioural efforts to manage

specific external and/or internal demands that are ap-

praised as taxing or exceeding the resources of the

person�. Coping methods may be either internally or externally focused. Internal coping is problem-centred;

it concentrates on managing or changing issues causing

the stress, such as problem solving or inquiring infor-

mation. External coping focuses on trying to lessen the

emotional distress, which may involve behaviours such

as seeking others� company, denial of the actual situa- tion and thinking optimistically (Chang et al. 2006).

Healy and Mckay (2000) found the most useful

coping strategy used by nurses was problem-focused

coping. There have been some debates in accordance to

the use of internal or external coping methods. Some

researchers believe the use of internal coping may pre-

vent burnout and ultimately have positive effects;

whereas external coping may lead to a negative

behaviour of avoidance (Chang et al. 2006). McVicar

(2003) and Keil (2004) within their studies concluded

that a �direct coping�, which refers to the utilization of both internal and external focused coping, with a more

positive external (emotion-centred) coping method to-

wards role stress, is the most effective. As well, it is

important to recognize that Lazarus (2000) describes

secondary appraising to be the �essential cognitive underpinning� of coping actions. This illustrates that once an individual experiences role stress through its

multidimensional components, it is the response pattern

of coping that plays a key component in managing role

stress at the workplace.

Hardiness is another attribute of role stress identified

in the literature. Hutchings (1997) describes hardiness

as a personality trait coined by Kobasa in the 1970s.

This terminology of hardiness consists of three ele-

ments: commitment, control and challenge. Klag and

Bradley (2004, p. 138) explain that Kobasa �introduced the hardiness concept, arguing that it plays a leading

role in protecting people from the deleterious effects of

stress on health�. These three components are viewed to aid in the ability to rise to stressful challenges and in

turn viewed as opportunities for growth and develop-

ment of authenticity and when combined, form a stress-

resistant personality style (Ford-Gilboe & Cohen 2000).

Lambert et al. (2003) further explains hardy personality

style as an encouraging transformational coping, con-

sisting of a combination of cognition, emotion and

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action methods for the purpose of survival and

enhancement of life through growth.

Commitment, being one of the components of har-

diness, refers to being goal oriented and actively in-

volved in life, as opposed to a passive lifestyle.

Individuals with high hardy for commitment tend to not

give up as easily in stressful situations and have greater

involvement with their tasks and others (Judkins &

Rind 2005). The component of control describes �the tendency to believe and act in a way that influences life�s events rather than feeling helpless when confronted

with adversity� (Lambert et al. 2003, p. 182). Lower levels of stress and greater job satisfaction amongst

nurses have been reported when there has been a high

sense of control (Judkins & Rind 2005). The last

component, challenge, describes change to be a neces-

sary factor in life, as opposed to stability, because it

generates growth and enhances maturity (Lambert et al.

2003). Individuals who are hardy tend to find excite-

ment and opportunity in change, where less hardy

individuals feel threatened (Judkins & Rind 2005).

Judkins and Rind (2005) stated that �hardiness seems to alter appraisal of stressors and transforms events as less

overwhelming and less undesirable� (p. 114). As illustrated, hardiness is a result of positive coping

mechanisms which will allow nurses to view role stress

in a constructive manner to enable knowledge and

growth development within their roles as nurses and

individuals. The utilization of a hardy style for the

management of role stress should be a goal for nurses to

set in order to cope with everyday stress encountered at

the workplace. The presence of role stress experienced

by nurses is evident in current practice. The elimination

of role stress is unlikely because of many factors, one

main contributing factor being the nursing shortage,

which faces the nursing discipline today. Therefore, it is

imperative for nurses to develop positive mechanisms to

manage stress.

The term �burnout� is the last attribute identified in the literature within the concept of role stress. A great

deal of the nursing literature utilizes the term burnout

interchangeably with stress. It is important to distin-

guish between the two terms as burnout is a negative

result of role stress. Gillespie and Melby (2003) defines

burnout as a depletion of an individual�s energy where personal resources seem diminished, resulting in

vulnerable and negative feelings. The majority of the

literature describes characteristics of burnout as emo-

tional exhaustion, depersonalization, reduced feelings

of accomplishment and feelings of cynicism and disen-

gagement (Demerouti et al. 2000, Chang et al. 2006,

Leiter & Maslach 2009).

According to a European epidemiological study,

burnout has impacted approximately 25% of all nurses

(Demerouti et al. 2000). The literature indicates that

high workload and negative social climate at the work-

place leads to role strain and gives rise to the possibility

for burnout amongst nurses (Chang et al. 2006). Ekstedt

and Fagerberg (2005) explain burnout to be a result of

long-term involvement in highly stressful situations and

�ineffective� coping with persistent stress. It was identi- fied that organizational dynamics, role conflict and role

ambiguity were factors which play a role in burnout

(Ekstedt & Fagerberg 2005). Within the literature, some

argue that the stressful role characteristics of nursing

may not be the only matter resulting in burnout; sug-

gesting an individual�s characteristics or personality type may leave them at a greater risk to the effects of stress

and burnout (Gillespie & Melby 2003). Early works of

Lazarus (1966) also suggest that stress cannot solely be

defined by the situation because a stress reaction also

depends on the characteristics of the individual in rela-

tion to the situation. �Research has identified six key areas of worklife, in which incongruities, or mismatches

between the person and the job, are predictive of burn-

out: workload, control, reward, community, fairness

and values� (Leiter & Maslach 2009, p. 332). The outcome of burnout can be very detrimental to

the physical and psychological health of an individual.

It is significant for those experiencing burnout to at-

tempt to change coping mechanisms to a more positive

direction to regain balance and reduce role stress. The

methods to accomplish this will be discussed within

antecedents to illustrate preventative and supportive

methods for those nurses experiencing role stress.

Role stress and attributes

For the purposes of this analysis, role stress is defined as

any physical or psychological strain experienced by an

individual, who needs greater abilities or resources than

available, in order to perform the role which has re-

vealed disparity to the expected role currently being

practiced, through an appraisal. As a result of the lit-

erature review conducted, contributing attributes to

role stress have been identified. Walker and Avant

(2005) describe attributes to be common characteristics

of a concept which aid in recognizing the occurrence of

a specific phenomenon. The attributes of role stress

established for this concept analysis are defined below:

• Perceptual incongruence and appraising defines how an individual perceives role demand in relation to

capabilities or resources; and the evaluation of the

Role stress

ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 721–731 725

relevancy of the situation to the person and the op-

tions available in dealing with the constraints.

• Multidimensionality consists of physiological and psychological effects on a person.

• Interactional feedback is the experienced acknowl- edgement/validation communicated by others during

stressful situations at a workplace.

• Response pattern describes the coping mechanisms used by an individual experiencing role stress.

• Hardiness is an element of positive coping style used by individuals to rise in stressful situations in order to

manage more effectively.

• Burnout describes a negative method of responding to stress. This method may be detrimental to an

individual.

Antecedent

According to Walker and Avant (2005), antecedents are

incidents that should occur preceding the occurrence of

the concept. Within the concept of role stress amongst

nurses it is recognized that there is a very broad spec-

trum of events/incidents that may occur before role

stress and it is very individualized for nurses. As the

antecedents are broad and individualized based on the

nurses� perception, literature focuses the antecedents of role stress from the preventative methods perspective.

Three preventative methods have been identified. These

are primary, secondary and tertiary prevention which

are aimed to create a �healthy organization� to reduce role stress and workplace stress (Cooper & Cartwright

1997, Clegg 2001). Each level of prevention addresses

various stages in the process of role stress. It is crucial to

prioritize managing work and role stress for all health

care workers. It is also significant to recognize that role

stress within the workplace will not only affect the

health of those experiencing role stresses but also the

quality of care provided for clients.

The purpose of primary prevention is to modify or

eliminate the source of stress. This level of prevention is

aimed to reduce the negative impact on individuals at

the workplace (Cooper & Cartwright 1997). Chang

et al. (2005) recommend preparing nurses more

appropriately to better suite the needs of the increas-

ingly sicker clients with greater turnovers. Nurses

should be educated at a more �wholistic� level, meaning curriculums should be focused on a variety of para-

digms of nursing rather than mainly focusing on path-

ophysiological aspects of nursing. The nursing

education�s focus on more theory and less on patho- physiology would encourage nurses to embrace and

cope better with environmental and organizational

stressors which arise within practice. Olofsson et al.

(2003) suggests having motivated and committed lead-

ers in an organization to create better work environ-

ments for nurses. Collins (2006) strongly believes �the responsibility for initiating strategy for workplace stress

rests clearly within the remit of senior managers� (p. 311). In their previous study of management style,

Shabbrook and Fenton (2002 cited in VanOyen Force

2005) found a positive impact on nursing retention with

the existence of high leader visibility and a shared

decision-making process. The characteristics of a leader

will have significant effects on the workplace and so if

leaders can create an atmosphere where there is a sense

of pride, determination, enjoyment at work and moti-

vation amongst co-workers, this could encourage the

employees to become more involved and positively

influence their workplace (Olofsson et al. 2003).

AbuAlRub and Al-Zaru (2008) found in their previ-

ous study that nurses who received more recognition for

their performance and achievements experienced less

job stress. In specific, the supportive behaviour of

managers created greater intentions for nurses to stay at

work (AbuAlRub & Al-Zaru 2008). One common

leadership trait identified to lead to job satisfaction and

nurse retention is a transformational leadership style

(VanOyen Force 2005). Characteristics within this

leadership style have been classified as three character-

istics: charisma, individualized consideration and intel-

lectual stimulation (VanOyen Force 2005). These

characteristics describe the nurse managers� roles and responsibility to enhance job satisfaction which in turn

will impact role stress amongst nurses at the workplace.

Charisma will allow leaders to develop relationships

with individual staff to enhance their engagement of

work. Individual consideration provides individualized

support for staff by having the leader identify strengths

and weaknesses of staff. Last, intellectual stimulation is

for leaders to build on their problem awareness and

problem-solving skills through pursuing graduate edu-

cation and mentoring of nurse managers (VanOyen

Force 2005). Therefore, primary prevention involves

creating an environment with the least amount of

stressors which may include antecedents such as healthy

work environments, leadership support and effective-

ness, and re-assessment of the nursing curriculum.

Secondary preventions are mainly concerned with

detecting the stress and attempting to manage the stress

experienced. This may be done by increasing awareness

and improving stress management skills through

greater education and training (Cooper & Cartwright

1997, Clegg 2001). Cooper and Cartwright (1997)

believe that the purpose of secondary preventions is to

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�limit the damage� by focusing interventions on the consequences of stress and not the sources, as this is

primary prevention. AbuAlRub and Al-Zaru (2008)

recognize that even although literature describes stress

management programes as secondary preventions that

produce short-term effects, their importance still re-

mains as it aids in buffering the negative effects of stress

and possibly promote effective coping mechanisms

which can be helpful in the long run. Chang et al.

(2005) states hiring more staff to reduce the workload

for nurses would be an ideal secondary prevention. This

is believed to be the most obvious, but also the most

difficult strategy given the shortage in nursing and

economic resources. Health care organizations will

need to create environments and systems which pro-

mote and support healthy workplaces through various

organizational strategies such as wellness programmes

and education, to ensure that the well-being of nurses is

embedded within the culture and climate of the orga-

nization (RNAO 2008).

Tertiary preventions are focused on treatment, reha-

bilitation and recovery processes for those who are

experiencing serious health issues as a result of stress,

such as burnout. Counselling services are believed to be

a very effective tertiary prevention method for the well-

being of an individual (Cooper & Cartwright 1997).

The aim of tertiary prevention is to help the individual

regain coping mechanisms that would be most optimal

to improve health and support the individual experi-

encing role stress at the workplace. The focus will be on

gradual return to work with increased level of support

from leadership to ensure well-being.

Consequences

Walker and Avant (2005) describe consequences to be

the outcome of the concept, or the incidents that take

place as a result of the occurrence of the concept. The

concept of role stress amongst nurses at the workplace

has numerous intertwining consequences. The literature

illustrates absenteeism, high staff turnovers resulting in

poor nursing retention, ill health, decreased quality and

quantity of care, increases in costs of health care and

decreased job satisfaction to be the most common

consequences of role stress for nurses at the workplace

(McVicar 2003, AbuAlRub 2004). Stress is identified as

one of the main causes to why nurses fail to practice at

their optimal level of effectiveness (Happell et al. 2003).

Stress has a physical and mental affect on nurses, as well

as, an economical effect on the community. Some

researchers have tried to estimate the effect of job stress

through economical consequences. Salmond and Ropis

(2005, p. 302) stated that �stress has been estimated to cause half of workplace absenteeism and 40% of

turnover, which is projected to cost the U.S. economy

$200–$500 billion annually�. Hans Seyle who has developed the General Adapta-

tion Syndrome theory, discussing the concept of stress

and bodily responses, has stated that the nursing

profession is one of the most stressful occupations

(AbuAlRub 2004). Literature illustrates nurse turnover

to be influenced by factors related to workload,

empowerment and autonomy, management style, pro-

motion opportunities and flexibility in scheduling

(Registered Nurses of Ontario 2008). Within research,

it has also been noted that nurses who experienced a

greater level of autonomy, work empowerment and

accessibility to resources in conjunction with strong

leadership present at work, will be more likely to be

satisfied with their current position (Registered Nurses

of Ontario 2008). This highlights the essential charac-

teristics health care organizations should focus on in

order to influence their recruitment and retention of

nurses which has great probability to be influenced by

role stress amongst nurses.

Empirical referent

Empirical referents �are classes or categories of actual phenomena that by their existence or presence demon-

strate the occurrence of the concept itself. [They] are

extremely useful in instrument development because

they are clearly linked to the theoretical base of the

concept� (Walker & Avant 2005, p. 73). The most common tool used in the reviewed studies within the

literature to assess the concept of role stress was the

Nursing Stress Scale (NSS). The NSS is a 34-item

questionnaire which requires Likert-type responses. The

items in the questionnaire assess potentially stressful

situations in the nursing workplace which are rated; the

higher the score indicating the greater the level of stress

(Happell et al. 2003). McVicar (2003) discusses the

need for improved methods of measuring and detecting

distress in nurses. McVicar (2003) argued that the

current assessment tools are only likely to identify

clearly those who have visible symptoms related to

distress, believing that the main problem with the

assessment tools is that they are not predictive. The

assessment tools are therefore useful once symptoms are

present (McVicar 2003). It is then recommended that

within the nursing discipline, improved assessment tools

for the measurement of stress be generated to contribute

to primary preventions, allowing the evaluation of

the sources of stress. Currently, the assessment tools

Role stress

ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 721–731 727

measure the consequences of distress, which are part of

secondary preventions.

Model development

A model of role stress (Appendix 1) has been developed

to represent the reviewed literature best describing the

concept. The depiction of this model was done through

careful consideration of the attributes, consequences,

antecedents and empirical referents of role stress. The

model illustrates perceptual incongruence and apprais-

ing which allow for recognizing role stress and leading

to a response pattern of coping. As shown, coping is

influenced by interactional feedback, which ultimately

results in hardiness or burnout. These two attributes are

dependant on the coping mechanism the nurse utilizes.

As well, alongside this process, the antecedents of pri-

mary, secondary and tertiary preventions are repre-

sented at the different stages of role stress. This model

of role stress is created to better enhance the reader�s understanding of this concept analysis of role stress

amongst nurses at the workplace.

Model case

According to Walker and Avant (2005), a model case is

an example using the concept which incorporates all the

defining attributes of the concept. The model case be-

low is an example of role stress comprised of all its

defining attributes.

Nurse Sarah and nurse Joe have been working on the

medical–surgical unit for the past 5 years. In the past

couple of months the unit has experienced an increase

in staffing shortage which has greatly impacted the

workload of the nursing staff working on the unit.

Sarah and Joe are challenged with finding enough time

within their shift to provide the quality of care for their

patients that they feel necessary.

Sometimes during work Sarah experiences heart pal-

pitations and has difficulty focusing. She rarely sees her

manager supporting the nurses during busy times,

which causes Sarah great frustration. In fact, Sarah has

not had any form of interaction with her manager for

weeks. She finds that when she is not at work she is

constantly dreading her return to work, knowing the

workload she will encounter. Hoping that her manager

is planning to hire more nurses, she tries to ignore her

thoughts about work and tries to concentrate on her

hobby of reading during her days off.

On the other hand, even although Joe has been

overwhelmed at times during his shift, he views the

increased workload as an opportunity to gain more

knowledge and experience. He prioritizes his tasks and

reminds himself that as long as his patients� main con- cerns and issues are cared for, the rest of the tasks will

eventually get completed and his patients will receive

the care expected and needed. During the most chal-

lenging and busy times, Joe takes deep breaths and fo-

cuses on one task at a time to decrease his stress level.

This case study demonstrates the main source of

stress within the nursing workplace, which is an in-

crease in workload. As illustrated, nurses Sarah and Joe

perceive their roles in two different manners. Sarah

experiences physical, psychological and social stresses

through heart palpitations in a stressful situation,

inability to focus at work and spending her free time

worrying about returning to work. With the absence of

interactional feedback and a negative stress response,

her coping mechanism of avoidance is leading her down

a path towards burnout. Trying to forget about the

situation at her work place does not solve any problems

for Sarah. This will be very detrimental to her and she

will need tertiary prevention methods, such as a support

group or counselling to help her move towards a more

positive way of coping. Nurse Joe�s positive response pattern allows him to develop a hardy style of coping

management which allows him to grow and improve as

a nurse.

Implications and conclusion

Research findings illustrate various environmental fac-

tors which contribute to role stress, such as a decrease in

control and ambiguity with in the nursing role, increased

job demands and limited support from supervisors and

colleagues (Lambert et al. 2004a,b). It is significant to

note that this concept has many attributing factors which

structure the process of role stress nurses experience at

work. The nursing profession encounters varying stres-

sors as a reflection of the current state of health care

resulting in high levels of job frustration and dissatis-

faction. Issues such as staffing shortage, an increase in

workload and greater acuity of patients, create role stress

to a greater extent. In many developed economies

healthcare organizations are experiencing unprece-

dented shortages of registered nurses (Rondeau et al.

2009). There is limited literature on the concept of role

stress inhibiting an opportunity in variability within

findings. The heterogeneity of primary studies within the

literature review also creates variability in the findings,

as there are many factors that may affect the attributes

and the concept.

Implications from this concept analysis point to the

importance of individual actions taken by nurses,

S. Riahi

728 ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 721–731

responsibilities of employers and policy changes. It is

essential for nurses to be educated on the concept of

role stress to heighten their awareness regarding coping

strategies and consequences. It is recommended for

nurses to self-reflect regarding their perceived role and

available resources; develop and maintain hardiness

through positive coping styles; and embrace and accept

the various forms of prevention to aid in reducing and/

or preventing role stress. These are key elements for

nurses in order to establish and sustain a healthy work

life.

Leaders within an organization need to prioritize

continual support of nurses through recognition of job

performance, inclusion of nurses for decision-making

processes and meaningful engagement with individual

staff to enhance and support job satisfaction and allow

for reduced role stress. This can be very challenging for

management as their role is greatly occupied with

implementation and assessment of corporate initiatives

and time-consuming task-oriented duties such as

scheduling and payroll. It is recommended for man-

agement to conduct an assessment of the current state of

their nurses practicing within their setting to initially

understand their current position related to role stress

and develop an action plan to address detected role

stress.

There needs to be greater research within the field of

role stress and nursing, specifically in the development

of scales or tools to assist in the identification of stress

amongst nurses. Further research focusing on role stress

amongst nurses would benefit from utilizing Betty

Neuman�s Systems Model as a conceptual framework to guide in developing greater understanding of this con-

cept and viewing the dynamic components effecting role

stress. Neuman�s Systems Model looks at humans from a wholistic perspective, with the multidimensional lay-

ers in a constant dynamic interaction with the envi-

ronment and other humans, including nurses. The two

main components this framework focuses on is stress

reaction and systemic feedback loops which would be

useful in guiding future research in understanding and

preventing role stress (Neuman & Fawcett 2002).

It is also highly recommended for nursing education

to create some focus on the current challenges

encountered by the discipline and teach strategies

regarding coping and prevention to nursing students.

This early awareness will support prevention of burnout

and the various consequences seen in literature and

allow new graduate nurses to be better prepared for

the realities of the profession.

Noting some of the negative outcomes illustrated in

literature as a result of the shortage, the concept of role

stress amongst nurses needs to become a priority on

healthcare organizations� agenda or the nursing pro- fession will continue to suffer and diminish in size

which will directly affect the quality of care given to

clients. It is evident that greater value and support is

needed among nurses and healthcare organizations to

develop wellness programmes for nurses to provide

support and promote care for the profession. This may

allow improvements in retention rates of nurses and

help recruit future nurses who are desperately needed by

the profession.

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Appendix 1

Model of role stress in nurses within the workplace

Role stress ▪ Physical, psychological

Interactional feedback ▪ Presence of feedback

Response pattern (+) coping

▪ Internally or externally

Response pattern (–) coping

▪ Avoidance

Hardiness ▪ Commitment, control

and challenge

Burnout ▪ Emotional exhaustion and

depersonalization

Tertiary prevention

Secondary prevention

Primary prevention Primary prevention

Secondary prevention

Consequences ▪ Absenteeism ▪ High staff turnovers and poor nursing retention ▪ Ill-health ▪ Decreased quality and quantity of care ▪ Increase in costs of health care ▪ Decreased job satisfaction

Perceptual incongruence and appraising

▪ Objective or subjective ▪ Evaluate situation

Legend

Attributes

Antecedents

Role stress

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