INTRODUCTION
The working environment of Intensive Care Unit (ICU) is a constant source of stress for nurses working there. Critical care nurses practice in a complex assessment, high intensity therapies and continuous nursing vigilance (Norbeck 1985). Nurses con-stantly experience a stressful environment because of the complex nature of patient’s health problems requiring an extensive use of very sophisticated technology (Robinson & Lewis 1990). Nurses not only have to cope with the sophisticated technology but also regularly face ethical dilemmas con-cerning issues of patient care manage-ment. The changes in Health care delivery has also created new nursing roles and responsibilities and has also contributed to the source of stress (Erlen & Sereika 1997). Stress occurs when nurses try to manage patient’s nursing care within the scope of nursing. Stress also occurs when there is a constant desire to achieve only the best.
Types of work stressors
Several researchers have described ICU as a stressful environment (Robinson & Lewis 1990) and Youngner et al (1979) found that ICU environment itself creates stress for nurses. Studies have also shown that high level of stress can affect the com-petence and job performance of nurses (Taromina 2000). Hay & Oken (1972) identified the ICU environment and the psychological impact of working in an ICU as two factors contributing to the stress experienced by ICU nurses. However, a study done in Netherlands on 521 nurses did not agree with the idea that the work environment in ICU is more stressful than a non ICU (Boumans & Landeweerd 1994).
Some researchers have indicated issues related to death and dying of patients nursed closely with the hope of recovering as fully stressful for ICU nurses. Decision making is another factor that is a concern for ICU nurses. Previous research has also indicated that the source of stress among ICU nurses is more organizational in na-ture. Organizational stressors could be physical, psychological and social in nature (Duquette et al 1994). Nurses working in environments where verbal and physical aggression is prevalent are more likely to experience the effects of stress. The other determinants causing the stress in ICU nurses could be due to increased job de-mand, nursing shortage (Janseen et al 1999), overload of work, lack of social support from colleagues (Balker et al,2000), a lot of paperwork and high expectations from the superior, organiza-tion and next of kin of patients.
Effect of work stressors
According to Dunham (1984), response to stress can be divided into three categories i.e mental, physical and emotional. Emo-tional and mental responses to stress has been linked to outbursts of anger, unne-cessary worries and frequent mood changes whereas physical stress is asso-ciated with cardiac disorders, ulcer and skin rashes. Stress has also been found to be associated with mood changes which include tension, anxiety, fatigue and de-presssion (Cox & Ferguson 1991). Effect of burnout can range from a degree of dysfunction to exhaustion and loss of con-trol (Tavares 1994). Previous studies on stress among nurses have identified posi-tive relationships between work stress, mental distress (Tyler & Ashway 1992) and high incidences of stress. Little is known about the prevalence of stress and the factors influencing stress among the nurses in ICU in HUKM. This study thus aims to investigate the prevalence of stress among the critical care nurses, factors influencing the stress and to examine the relationship between stressors and nurses.
METHODS
A total of 70 critical care nurses working in ICU, Hospital Universiti Kebangsaan Ma-laysia (HUKM), were recruited in this cross-sectional study. The ICU of HUKM was chosen because of it being a referral center and a teaching hospital, its utilization of so-phisticated technology in the management of critical patients and also partly because patients here are managed by trained spe-cialists and anaesthetists. Questionnaires adapted from Cole (1992) were distributed to all nurses who were recruited, using a random universal method which means all nurses working in ICU, who meet the in-clusive criteria were recruited into this study. The inclusive criteria used in the recruitment of the samples are that they must be registered with the Nursing Board of Malaysia. The questionnaire was tested for validity and reliability through a pilot study conducted on 20 nurses working in the Intensive care unit of Hospital Tengku Ampuan Rahimah Klang. The results of the pilot study were not included in the actual study. Questionnaires consisted of four sections: section A on socio-demographic data, section B consisted of 25 stress in-ventory items divided into three subtopics: physical environment (9 items), psycholo-gical environment (10 items) and nurses responses towards stress in the past 12 months (6 items), section C are question-naires on the study variables influencing stress and section D on coping mechanism of stress. For the questions in relation to responses towards stress, nurses are just required to answer ‘Yes’ or ‘No’.
Data was coded and entered into SPSS version 10.0 (Statistical Package for Social Sciences) for descriptive analysis. Data were described by frequencies and percen-tages. A Chi square was performed to in-vestigate the relationship between factors influencing stress and socio-demographic data.
RESULTS
Description of the samples
Out of the 70 questionnaires distributed, only 67 sets were returned with full infor-mation whereas 3 sets were returned emp-ty. More than 70% of the nurses were 22-40 years old. Only 13% were between the age of 25-27 and an equal number of nurses between 28-30 years and over the age of 31. All the nurses had completed their secondary education and were regis-tered nurses. Majority of the nurses (80%) have a short working experience of less than three years. Out of the 67 nurses, only 10 (14.3%) nurses had undergone the post basic course in ICU. Based on the short working experience and not having a post basic course (87.5%), nurses may not have a strong foundation and knowledge in rela-tion to critical care nursing. In relation to marital status, 57 (81.4%) of the res-pondents were married and 16 (22.9%) were found to be living with families. Living on their own accounted for 20% and living with friends 57.1%.
Prevalence of stress
All (100%) of the nurses said they had experienced physical stress, psychological stress and changes in behaviour and indicated the symptoms of stress they ex-perienced in the past 12 months through the stress inventory.
Stress inventory
From the total number of 67 nurses, 66 (98.6%) experienced episodes of head-ache followed by abdominal pain (60%) and chest pain (57.1%). Sixty-five (97.1%) nurses were also taken ill with viral infection, experienced sleeping problems (84.3%) and weight loss (65.7%). However, loss of libido was experienced by only a minority (5.7%) of nurses (Table 1).
Nursing a critically ill patient
A total of 50 (71.4%) nurses indicated they feel stressful when nursing a critically ill patient compared to 53 (75.7%) when nursing patients who require resuscitation.
Nurse-patient ratio
Nurse-patient ratio was identified as a stress factor by 100 percent of the nurses. However, nurses who were given only one patient to care finds it less stressful compared to nursing two to three patients.
Environmental factor
The majority (67.1%) indicated that being in an environment with sophisticated machines as very stressful to handle as operating and fixing the machines requires a lot of knowledge and patience.
Interpersonal relationship
Thirty-one (44.9%) nurses finds it uncom-fortable working with other staff - doctors and nurse managers, whereas the other half finds it comfortable working together. Fifty-nine (85.5%) nurses find it uncom-fortable working in the presence of their head nurse around them and 49 (70%) finds it uncomfortable working in the pre-sence of doctors.
Relationship of stress with study variables (work stressors)
There is a significant difference between all the study variables with stress (Table 2). Findings indicated a significant difference between nurses with post basic and nurses without post basic training (p<0.05). Thus, it indicates that nurses working in ICU without post basic training find intensive care nursing stressful. Nurses with less years of working experience, experienced more stress compared to nurses with many years of working experience (p=0.0001). A significant difference between work envi-ronment, nurse patient ratio and nursing critically ill patients and stress was iden-tified among the nurses here. This indica-tes that nurses who work in a high tech environment(p=0.0011), a high nurse pa-tient ratio(p=0.0321), working relationship with staff/professionals (p=0.0021) and nur-sing critically ill patients (p=0.0011) are the main cause of stress for nurses working in ICU.
Coping mechanisms
The five coping mechanisms adopted by ICU nurses were identified. Prayers (100%) and relaxation (100%) methods were the common methods used in coping stress. Physical exercises were only used by some (35.7%) of the nurses whereas more than half (60%) of the nurses relieved stress by ventilating their feelings and sharing their problems with others. Some (35.7%) nurses were found to relieve their stress by taking rest in between work.
DISCUSSION
Findings of this study indicated that the prevalence of stress among nurses in ICU, HUKM is high, as symptoms of stress were experienced by 100% of the nurses. Three categories of stress symptoms investigated in this study comprising of physical, psy-chological and changes in behaviour re-vealed interesting findings. The common physical stress symptoms experienced by nurses in ICU were headache, being easily susceptible to viral infections, back pain, insomnia and weight loss. The psycho-logical stress symptoms experienced by many of the nurses is high which consisted of fatigue, anxiety, boredom, poor concen-tration at work, irritability, loss of interest in work and depression. However, the type of changes in behaviour experienced was committing errors at work and having frequent conflict with colleagues and other staff. The result was consistent with the study findings of Milazzo (1988) and Yip (2001). Stress at work did not indulge any of the ICU nurses to be involved in drugs and alcohol as strong spirituality and reli-gious background may have prevented the nurses from doing so.
Knowledge was found to have influenced the level of stress among ICU nurses as the majority (82.5%) of the nurses in this study did not have a post basic course but were posted to ICU to work. Lack of knowledge among ICU nurses was also identified as a main indicator of stress among ICU nurses (Steffen 1980). Find-ings also indicated that the majority of the nurses in this study experienced stress when nursing critically ill patients. This si-tuation was unavoidable as most patients in ICU were either critically ill or required resuscitation. A post basic course in ICU is necessary for nurses working in a special-ized unit like the ICU as it demands a high level of knowledge and skill in handling cri-tically ill patients (Kelly & Cross 1985; Sawatzk 1996)
The significant association between work stress with less experience concurs with previous findings (Huckabay & Jagia 1979; Oisen 1977; Stone et al. 1984). Huckabay & Jagia (1979) again investigated further the association between work stress and less working experience and concluded that “once the nurse has the knowledge and skill required, the degree of stress is reduced. However, Sawatzk (1996) con-cluded that nurses perceived inadequate knowledge as challenging. Pagana (1990) also reported that nursing students’ initial clinical experiences were perceived as sig-nificantly more challenging than threat-ening.
Nurses working in ICU are more often confronted with life sustaining treatment decisions and ethical issues concerning issues of patient care management. Death and dying are frequently encountered and this poses a high level of stress for the nurses working in ICU. This finding is con-sistent with the findings of Sawatzk (1996) and Bartz & Maloney (1986). Study findings among ICU nurses in Hong Kong also reported the causes of stress being nursing critically ill patients, shortage of nurses, increasing workload and interper-sonal relationship among the staff (Lau & Chan, 1995).
Nurses were found to have more than one patient under their care. Nurses find it very stressful when nursing two to three patients under their care. According to Coghlan (1984) shortage of nurses is the main factor causing nurses to care for two to three patients. The inability to meet the needs of patients is affected by the nurse’s workload and ultimately patients, and the nurses suffer. Nursing stress ultimately can have an impact on the patient and com-promise patient care (Gentry et al.1972; Rich & Rich 1987). However, according to Payne (2001), despite heavy workload being a frequently reported stressor, it is suggested that some stress may be necessary for optimum functioning. But, of course, heavy workload may lead to other negative consequences.
Maintaining a professional relationship among working colleagues is important as it results in a harmonious working environ-ment. Teamwork and collaboration need to be strong or else nurses will find difficulties in speaking about problems. They will not be able to resolve conflicts in a healthy manner and also may not be able to par-ticipate in clinical decisions. This is agreed by Cottrell (2000) that poor professional relationship may cause a stressful working environment. Therefore, specialized know-ledge and competency are required in or-der for nurses to communicate and colla-borate effectively which will thus improve patient care. In fact, both physicians and nurses find difficulty when confronted with inter-professional problem due to lack of ability and unwillingness to accept res-ponsibility (Maxfield 2005).
An unsafe environment may also cause a stressful environment for nurses. This find-ing is consistent with the findings of Briner (1999). The ICU work environment is phy-sically, cognitively and emotionally deman-ding. Stressful experiences may lead to work-related problems such as staff con-flicts, absenteeism, lowered morale de-creased productivity and ultimately burnout (Stechmiller & Yarandi 1993; Bailey 1980).
Stress can be alleviated by the avail-ability of coping resources such as social support. Nurses in this study were found to have utilized quite effective coping strate-gies such as prayers and relaxation. How-ever, nurses should be taught the appro-priate coping skills. A stress inoculation training could be implemented to prevent total burnout among ICU nurses (Payne 2001). Several studies, however, have identified “Painful problem solving” as the most frequent coping strategy being used by nurses in other countries (Payne 2001, Healy 2000; O’Brien & Delongis 1996).
RECOMMENDATIONS AND CONCLUSION
This study has important implications for critical care nursing practice and administration. Critical care nurses work in an environment that is highly stressful due to the increased responsibility in the management of patient care. ICU nurses are confronted not only by the increasing demand for quality care by patient’s family and the organization, but also by the demand for technological excellence. The origins of stress among ICU nurses in HUKM has now been identified and because stress has an impact on the health and well-being of critical care nurses, it is therefore important for organi-zations to take measures to relieve stress among ICU nurses. Recommendations like encouraging ICU nurses to take up post basic ICU courses and increase staff quota can help reduce stress levels among ICU nurses as nursing is regarded as a very potentially stressful occupation.