Friday, 28 July 2017

Resilience as a Buffer of Stress in Nurses

Julie J. Lanz & Valentina Bruk-Lee

Lanz, J. J. and Bruk-Lee, V. (2017), Resilience as a Moderator of the Indirect Effects of Conflict and Workload on Job Outcomes among Nurses

Where have all the nurses gone? According to Lafer (2005), “the stress, danger, exhaustion, and frustration that have become built into the normal daily routine of hospital nurses constitute [the] single biggest factor driving nurses out of the industry” (p. 36). This is important because researchers have projected that there will be a significant shortage of 300,000 to 1 million registered nurses in the U.S. by 2020 (Juraschek et al, 2012). Indeed, the World Health Organization (WHO, 2016) reports that there is a global shortage of healthcare workers, and this shortage is reaching a crisis level in 57 countries.

Urban, rural, and student nurses all report similar stressors:
  • Caring for the dying 
  • Conflict with patients, families, and staff 
  • Workload 
  • Inadequate nursing staff 
  • Feeling unprepared to meet the emotional needs of patients 
  • Fear of failure 

These stressors are frequent – enough so that nurses are burnt out, getting injured, and even leaving the profession altogether. The two most frequently reported negative workplace events among a sample of Oregon nurses were interpersonal conflict at work and work role demands such as workload (Sinclair et al., 2009). One report estimated that U.S. employees spend 2.8 hours every week dealing with workplace conflict (Hayes, 2008). Thus, there is a critical need to investigate the effects of conflict and workload on job outcomes, as well as explore factors like resilience that may mitigate this stressful work environment.

A framework by which we can understand the stress process in nurses is the Emotion-Centered Model of Occupational Stress, which theorizes a causal flow from job conditions such as job-related stressors to job outcomes (i.e., strains, or reactions to a stressor; Spector & Goh, 2001). According to this model, a job stressor is a situation or condition that prompts a negative affective (i.e., emotional) response like frustration or anger. These negative emotions serve as a mechanism through which conflict and workload exert their influence on the experience of job outcomes (i.e., burnout, turnover intent, and injuries). Some variables, such as resilience, have previously been found to moderate the relationship between stressors and emotions (see Figure 1). In other words, highly resilient individuals under high levels of stress don’t experience as many negative emotions.

Figure 1. The Proposed Role of Resilience in the Emotion-Centered Model of Occupational Stress

The first objective of this study was to assess the relative effects of conflict and workload on burnout, turnover intentions, and injuries. Second, the mediating role of negative affect in the relationships between stressors and job outcomes was tested. Last, the study assessed resilience as a condition to the indirect effects of stressors on outcomes through the experience of negative emotional states. This study used a quantitative self-report two-wave design whereby 97 nurses were surveyed two weeks apart was used. Data from Time 1 and 2 were matched.

We found that conflict predicted turnover intentions and burnout; workload predicted injuries. Second, emotions were a mediating mechanism for most of the studied relationships consistent with Emotion-Centered Model of Occupational Stress, but not for workload and injuries, for which a direct relationship was found. Finally, resilience moderated the indirect effects of conflict on job outcomes via job-related negative affect. This effect was not found for the stressor workload, however.

Conflict is a social stressor that leads to negative outcomes, and it is likely that resilient nurses use positive emotions to deflect the negative effects of conflict. Resilience interventions may be a promising avenue to ameliorate the negative effects of conflict on nurses' job attitudes and well-being. This pattern was not seen for workload, so using a human factors (i.e., ergonomic) approach to understanding the negative effects of workload might be more valuable (Holden et al., 2011). For organizations seeking to reduce costs associated with injuries, reducing nurse workload and increasing support for safe patient handling are critical factors.

Dr Julie Lanz
Department of Psychology
University of Nebraska at Kearney

Dr Valentina Bruk-Lee
Department of Psychology
Florida International University

Hayes, J. (2008). Workplace conflict and how businesses can harness it to thrive [WWW document]

Holden, R.J., Scanlon, M.C., Patel, N.R., Kaushal, R., Escoto, K.H., Brown, R.L. ... & Karsh, B.T. (2011). A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ Quality & Safety, 20, 15–24. doi:10.1136/bmjqs.2008.028381

Juraschek, S.P., Zhang, X., Ranganathan, V., & Lin, V.W. (2012). United States registered nurse workforce report card and shortage forecast. American Journal of Medical Quality, 27, 241–249. doi:10.1177/1062860611416634

Lafer, G. (2005). Hospital speedups and the fiction of a nursing shortage. Labor Studies Journal, 30, 27–46. doi:10.1177/0160449X0503000103

Lanz, J. J. and Bruk-Lee, V. (2017), Resilience as a Moderator of the Indirect Effects of Conflict and Workload on Job Outcomes among Nurses. Journal of Advanced Nursing. doi:10.1111/jan.13383

Sinclair, R.R., Mohr, C.P., Davidson, S., Sears, L.E., Deese, M.N., Wright, R.R. … Cadiz, D. (2009). The Oregon Nurse Retention Project: Final Report to the Northwest Health Foundation [WWW document].

Spector, P. E., & Goh, A. (2001). The role of emotions in the occupational stress process. In P. L. Perrewé & D. C. Ganster (Eds.), Exploring theoretical mechanisms and perspectives (pp. 195–232). Bingley: Emerald Group Publishing Limited.

World Health Organization (2016). Health worker occupational health. Retrieved from


This study was funded by CDC/NIOSH through the Sunshine Education and Research Center (ERC) at USF (5T42OH008438-09). The opinions expressed are those of the authors and do not represent either NIOSH or USF.

Thursday, 27 July 2017

Prevention and management of patient and visitor aggression in general hospitals

Nurse managers: Determinants and behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study

Birgit Heckemann

Patient and visitor aggression (PVA) in general hospitals is internationally recognized as a problem that requires urgent attention. A large international body of research has to date investigated the perception and experiences of nursing staff with PVA (Lanctôt & Guay, 2014). However, little is known about how nurse managers experience and manage PVA, although the link between leadership, workplace safety, job satisfaction and quality of care has been recognised (Farrell, Touran, & Siew-Pang, 2014; Feather, Ebright, & Bakas, 2015).

This qualitative descriptive interview and focus group study explored nurse managers' behaviours, attitudes, perceived social norms, and behavioural control in the prevention and management of patient and visitor aggression in general hospitals. The study is part of a sequential mixed methods research project aimed at obtaining an international overview of PVA from a managers' perspective (Hahn et al., 2016).

Using the Reasoned Action Approach (Fishbein & Ajzen, 2010) as a theoretical underpinning for data collection and content analysis of 13 interviews and five focus groups, we identified three main themes: (1) Background factors: ‘Patient and visitor aggression is perceived through different lenses’; (2) Determinants and intention: ‘Good intentions competing with harsh organizational reality’; (3) Behaviours: ‘Preventing and managing aggressive behaviour, and relentlessly striving to create low-aggression work environments’.

Our key findings were:
  • Managers' behaviours depend on whether patient and visitor aggression is perceived from a situational and/or organizational perspective.
  • Existing communication channels between nursing staff and managers should be strengthened. Particularly formal incident reporting is underutilized as a tool to document and communicate aggressive incidents within the organization.
  • Nurse managers face substantial challenges in addressing patient and visitor aggression at an organizational level. This is due to a lack of financial resources and awareness within the organization.
Addressing patient and visitor aggression is challenging for nurse managers due to lack of coordination between the situational management of individual aggressive incidents and organizational feedback loops, protocols and procedures. Further challenges include a scarcity of financial resources and lack of interest in the topic across the organization. Being able to present patient and visitor aggression as a quality issue and business case might help to raise awareness and support within the organisation. Furthermore, clear communication about expectations, needs and available resources between staff and nurse managers could facilitate adequate support provision for

Birgit Heckemann
RN, MSc, PhD student
CAPHRI, Maastricht University


Farrell, G., Touran, S., & Siew-Pang, C. (2014). Patient and visitor assault on nurses and midwives: An exploratory study of employer ‘protective’ factors. International Journal of Mental Health Nursing, 23(1), 88–96. doi:10.1111/inm.12002

Feather, R., Ebright, P., & Bakas, T. (2015). Nurse manager behaviors that RNs perceive to affect their job satisfaction. Nurs Forum, 50(2), 125-136. doi:10.1111/nuf.12086.

Fishbein, M., & Ajzen, I. (2010). Predicting and Changing Behavior: The Reasoned Action Approach. New York: Taylor & Francis.

Hahn, S., Heckemann, B., Gerdtz, M., Hamilton, B., Riahi, S., Thomson, G., . . . De Santo Iennaco, J. (2016). PERoPA – the nursing managers’ perspective. Retrieved from Research Project Information: PERoPA – the nursing managers’ perspective website:

Heckemann B, Peter KA, Halfens RJG, Schols JMGA, Kok G, Hahn S. Nurse managers: Determinants and behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study. J Adv Nurs. 2017;00:1–11.

Lanctôt, N., & Guay, S. (2014). The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggress Violent Beh., 19(5), 492-501. doi:

Friday, 21 July 2017

How do we evaluate nursing care?

Roger Watson, Editor-in-Chief

As long as I can remember we have been looking for ways to measure nursing care. These parallel discussions for definitions of  nursing and they come and go. Now they have definitely come back. Resources for medical and nursing care are limited worldwide, professional boundaries are becoming blurred and roles are beginning to change. Nurses nearly always work as parts of a multidisciplinary team and it is not always easy to decide what happens as a results of nursing. 

The issue of indicators is the subject of an article from Canada by Dubois et al. (2017) titled: 'Which priority indicators to use to evaluate nursing care performance? A discussion paper' and published in JAN. The aim of the article was: '(a) discussion of an optimal set of indicators that can be used on a priority basis to assess the performance of nursing care'.

By reviewing previous work the authors arrived at a list of 12 indicators which I will not list here; refer to Table 3 of the article. Some of the 'usual suspects' such as pressure ulcers and falls are there but also team composition and length of continuous work. The key references are provided and the evidence is summarised.

You can listen to this as a podcast


Dubois, C.-A., D'Amour, D., Brault, I., Dallaire, C., Déry, J., Duhoux, A., Lavoie-Tremblay, M., Mathieu, L., Karemere, H. and Zufferey, A. (2017), Which priority indicators to use to evaluate nursing care performance? A discussion paper. J Adv Nurs. doi:10.1111/jan.13373

Pressure sores are painful

Roger Watson, Editor-in-Chief

I am well aware the we no longer refer to 'pressure sores' and even the term 'pressure ulcer' has been replaced by 'pressure injury' - and a good thing too because that is exactly what skin breakdown due to pressure is: a pressure injury. However, the original term 'sore' reminds us also that pressure injury is painful as explained in this article from UK and Australia by Jackson et al (2017) titled: 'Pain associated with pressure injury: a qualitative study of community based, home-dwelling individuals' and published in JAN.

The aim of the study was 'to provide deep insights into the pain associated with pressure injuries' and towards that end 12 people experiencing or who had experienced pressure injury were interviewed. One person said: 'You tend to think that pain is a question of mind over matter, but it isn’t. There’s nothing, apart from taking the pain killers. You are at its mercy. And pressure sores are relentless. . . . the pressure ulcer is there 24 hours. And it doesn’t matter where you sit, where you lie, where you turn, it’s there, there’s no getting away from it.' Another person was more specific: 'Like there’s glass in it, that’s what that feels like. All the time, like I’ve got glass in my foot. It just rubs all the time. It’s horrible. Stings as well as rubs and they just cover it up.' The unbearable nature of the pain was expressed by someone who said: 'The one thing that’s consuming me at the moment is the pressure sore. Everything else fades into insignificance, the fact that your heart might stop at any moment doesn’t worry me as much as the pressure sore. It’s consumed me in the last two to three weeks. . .'

The authors concluded: 'Our findings suggest that both the assessment of pain and the subsequent
management of the pain were not well managed in this patient group' and '(t)here is clearly a need for revised nursing policy and practices with better assessment and recognition of risk to reduce (pressuse injury) developing, strong patient advocacy and involvement to ensure optimal pain management strategies are in place and adhered to.

You can listen to this as a podcast


Jackson, D., Durrant, L., Bishop, E., Walthall, H., Betteridge, R., Gardner, S., Coulton, W., Hutchinson, M., Neville, S., Davidson, P. M. and Usher, K. (2017), Pain associated with pressure injury: a qualitative study of community based, home-dwelling individuals. J Adv Nurs. doi:10.1111/jan.13370

Friday, 30 June 2017

How Much More Evidence Do We Need about Nurses’ Work Environments?

Ann-Marie Urban

Over three decades of research, monies, attention and recommendations highlight how the working conditions influence nurse turnover, retention, cost and more recently as highlighted in the recent virtual issue on nurses’ health. Gallagher and Pickler note the importance of healthy diets and stress management as part of improving nurses’ health, however, it is important to recognize the problematic work environment that continues to influence nurses’ health and their work. The realities of many work environments do not allow nurses to practise in a safe and caring way much of the time. Unfortunately, it requires nurses to be productive, expedite discharge, manage increasing complex patients and practise within a traditional hierarchical structure. Sadly, this disconnect has created nurses who are increasingly sick, stressed, bullied, burned out and morally fatigued.

What will the conditions be like in another decade? While nurses know that they work in the adverse conditions of acute care, they may not understand how they contribute to and are organized to meet institutional demands. Increasing patient acuity, budget constraints, a chronic shortage of staff, and overcrowding are routine in hospitals, yet no one discusses how this influences nurses’ work except when discussing nurses as stressed, fatigued or comprising patient care. Nurses are placed in situations where they lack the time, the resources and, in some cases, even the knowledge to care for patients. Because of these problems every year nurses suffer mental and physical injuries which are largely preventable. And sadly but not widely acknowledged, because the majority of nurses are women, this work is expected. Patriarchal underpinning and gendered assumptions situate nurses and their work in a quagmire of persistent problems with strategies focusing on nurses rather than on the system. While the nurse and nurses’ work have been widely studied, a focus on gender related to nurses’ physical and mental health is lacking. Understanding the realities and acknowledging the actualities of nurses’ work in hospitals are key to change. However, before a new reality will be realized, embedded assumptions about nurses and their work must be acknowledged by government, hospital managers and nurses. Similarly, nurses’ work must be understood within the context of the moving political and economic agendas. Further attention must be directed to the nurse’s work environment and how this influences patient care and the health of nurses.

Although efforts to improve the conditions in hospitals have been attempted, few strategies effectively support nurses’ health in their efforts towards patient care in the context of today’s hospitals. What has to change for hospital administrators, governments, professional associations, unions and researchers to notice and make changes? Is it not enough that nurses’ illness and injuries continue to be a problem, and that patient care is compromised? The existing traditional structure must be challenged to embark on another way. Supporting nurses’ health is vitally important for their overall well being for the care of patients.

A new structure would recognize nurses’ work by shifting their participation to a collaborative decision-making team. Different models of care delivery would move nurses to autonomous roles such as patient education, admission and discharge coordinators and patient advocates or to a model that incorporates an expanded role for nurses. Nurses and their work must also be understood within a broader sociopolitical context. Creating a collective awareness about the influencing powers could provide the space for discussion and possibilities for change. The gendered aspect of nursing must also be acknowledged as well as how nurses actively participate in maintaining their place in the hospital. Nurses, too, must realize other possibilities; they must realize that they do not have to become injured, stressed or leave the profession because of the patriarchal and political ruling. Untangling power will take time; however, if we begin to recognize and name it, nurses’ work has the potential to change.

Ann-Marie Urban, RN, RPN
Associate Professor
Faculty of Nursing, University of Regina,

Wednesday, 28 June 2017

Should residents in care homes have sex?

Roger Watson, Editor-in-Chief

My answer to the question that heads this entry is 'why not?' However, this entry covers an article from New Zealand by Cook et al. (2017) titled: 'Ethics, intimacy and sexuality in aged care' and published in JAN. The study on which the article is based aimed to: 'analyse the accounts of staff, family and residents to advance ethical insights into intimacy and sexuality in residential care.' Four  people, including a resident, were involved and interviewed.

With regard to the possibility of intimacy, the resident said: 'No. Couldn’t do anything here because if the door opened and somebody like [manager] walked in I’d be mortified. There are no locks on the door, as you notice. . .So there really is no privacy here at all . . .. I don’t feel like I’m home.' A care assistant expressed uncertainty about what to do with regard to sexuality: 'It [sexuality-related issues] does happen, I’ve seen it happen and nobody talks about it and, we’ve got to make a judgement call, which I have done on a few occasions. . ..and you just don’t know which is the right way . . ..'  The Registered Nurse was aware that some older people may be exploited but said: 'As long as they’re not being taken advantage of and I think for some it can open up new relationships, new caring. Again, when we talk about this everybody thinks of [penetrative] sex. . .but sometimes just to sit, cuddle, kiss, stroke, whatever, that’s more than enough for a lot of them.'

In conclusion, the authors said: 'The topic is complex: too often ageism shapes assumptions about older people’s entitlement to be intimate; where there is cognitive impairment, the debate about upholding the preferences of the “then” self or the well-being of the “now” self may result in conflict among decision-makers; proxy decision-makers may have limited knowledge of the resident’s lifetime of sexual preferences. Education and policies upholding rights may increase staff awareness beyond their own moral code. However, rigid policies may work against residents’ wellbeing. Instead, flexible responses that focus on person-centred wellbeing rather than a risk management approach are desirable.'

You can listen to this as a podcast


Cook, C., Schouten, V., Henrickson, M. and Mcdonald, S. (2017), Ethics, intimacy and sexuality in aged care. J Adv Nurs. doi:10.1111/jan.13361