|Image of a nurse by Oleg Leonidovich Lomakin
Courtesy of via Wikimedia Commons
Victorina T. Malones, RN,
Iloilo City, Philippines
Some years ago I wanted to work as the best hospital nurse I could possibly be. I worked hard to become a staff nurse. I passed the board exam, had a successful interview, and after months of gaining experience by volunteering, I was hired. After I got the job and experienced nursing beyond textbooks I realized ... and still ask myself sometimes ... what did I get myself into? In reality, many nurses from different parts of the world feel the same. There are so many stressors in the hospital that it is too much for one nurse to handle. And this is not just my experience, but many others. There are several studies about nursing stressors and how they affect nurse’s job satisfaction and performance. ,
1) Long work hours
As a nurse, it is inevitable that you will have to work longer than you expected. There will always be unforeseen circumstances that you just cannot end the shift on time because of code blue, intubation, stat operation, etc. However, according to research, shifts lasting ten hours or longer were associated with a greater level of job dissatisfaction, higher possibility to leave the job, and nurses most likely to experience burnout. 
Burnout is typically conceptualized as a syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment.  There are other studies enumerated by Reese that needle-stick injury, drowsy driving, and risk for musculoskeletal disorders are also significantly increased due to long working hours in the hospital. That is quite alarming! 
2) Interpersonal conflicts
Interpersonal conflict is experienced by nurses worldwide. There is a study that shows nurses who are experiencing conflicts express their willingness to quit their job.  According to Moustaka & Constantinidis there are two primary sources of stress in this field.  The first is conflicts with co-workers. Second, the lack of social support from colleagues and superiors and less satisfaction with the head nurses, contributed significantly to the appearance of stress.
3) Heavy workload and understaffing
One night, while we were busy finishing our charting, a relative of one of our patients walked to the nurse’s station and complained that nurses were doing paperwork instead of attending to the patients. Most patients and their families do not realize the tug-of-war responsibilities we balance between our clerical responsibilities and providing for our patients.
Nurses work beyond their job description .We regularly change patients’ television channels, adjust the temperature of their air conditioners, collect food trays, transport via wheelchair or stretcher, and other ancillary services. Perhaps, for this reason hospital administrators are not likely to hire more nurses and ancillary workers because they think one nurse can do everything! Nonetheless, the amount of pressure from all the workload contributes to the stress of nurses who are understaffed and overworked.
Research by Carayon & Gurses shows that a heavy nursing workload adversely affects patient safety.  It negatively affects nursing job satisfaction and contributes to high turnover and to the nursing shortage.W Work system factors and expectations also contribute to the nurses’ workload. Nursing workload definitely affects the time that a nurse can allot to various tasks. With a heavy workload, nurses may not have sufficient time to perform tasks thathave a direct effect on patient safety. A heavy nursing workload can influence the care provider’s decision to perform various procedures. Workload can be a factor leadingleading to errors.
According to a paper released by UCLA School of Public Health, patient mortality rises when nurses are understaffed.  When there is a high patient turnover, such as admissions, discharges and transfers during the shift, the risk for mortality of patients is 4% higher. Now, if you think that hiring fewer nurses is cost-effective, think again! It might cost you not only assets, but also patients’ lives.
4) Poor leadership and management
A nurse leader can either lessen the stress or become the source of stress. Zangaro, et al. have shown that toxic nurse managers or supervisors are detrimental to organizations, diminish staff morale, thwart creativity, and create unnecessary job stress.  Toxic nurse managers affect staff absenteeism, decrease job satisfaction and critical thinking, increaseincrease staff turnover, and complicating innovation, decision making, and problem solving. John Maxwell once said: leaders become great not because of their power, but because of their ability to empower others.
McVicar emphasized that individuals need better support, but this is hindered by a lack of understanding of how sources of stress vary between different practice areas, lack of predictive power of assessment tools, and a lack of understanding of how personal and workplace factors interact.  But this should not be an excuse. Mitt Romney expressed that “leadership is about taking responsibility, not making excuses.”
5) Workplace bullying
The laboratory results are back. My colleague found some abnormal findings so he phoned the resident doctor on duty. The doctor answered with her drowsy voice, seems like she just woke up from her sleep. He started to make his referral and at the end of the call, the doctor asked, “What I am supposed to do with that?” The doctor started to question the nurse sarcastically and slammed the phone. When the attending physician made rounds, he started berating the nurses for not referring his patient’s laboratory results.
The Journal of Nursing Administration released a study about workplace bullying and the results are:
- 3% of the nurses had experienced workplace bullying in the last six months.
- Most respondents who had been bullied stated that they were bullied by their managers or charge nurses.
- Workplace bullying was significantly associated with intent to leave one's current job and nursing. 
6) Poor reward system
Nursing is not all about making money but good compensation is integral to the profession onon account of the risks and challenges of the job. A study by Terera & Ngirande shows that employee rewards lead to employee retention but do not result in job satisfaction.  The study concludes that employee rewards and job satisfaction are very importantfactors when it comes to employee retention. This means that compensation is a major factor that employees consider when making the decision to leave or remain in an organization. Employees also consider their happiness when making the decision to stay with an organization.
Manojlovich stated that powerless nurses are less satisfied with their jobs and more susceptible to burnout and depersonalization. Lack of nursing power may also contribute to poorer patient outcomes. 
Nurses become insecure if they are not empowered. Institutions that allowed their staff autonomy over their own practice and active participation in decision making about patient care issues were the most successful in recruiting and retaining nurses.
There are many circumstances that make me consider leaving my job as a nurse, but the truth is that this is what I want to do. I love to care for the sick. I care for my profession. All I wantis for management to care for us as well.
 American Holistic Nurses Association. (2016). The Reality of Stress in the Nursing Workplace. Retrieved from http://www.ahna.org/Resources/Stress-Management
 Jennings BM. Work Stress and Burnout Among Nurses: Role of the Work Environment and Working Conditions. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 26. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2668/
 Reese, S. (2016). Evidence-Based Nursing: 10 ways to practice evidence-based staffing and scheduling. Lippincott Nursing Center. Wolters Kluwer. Retrieved from http://www.nursingcenter.com/journalarticle?Article_ID=1239110
 Bousari, M., Ebrahimi, H., Ahmadi, F., Abedi, H., & Kennedy, N. (2009). The Process of Nurses Interpersonal Conflict: Qualitative Study. Research Journal of Biological Sciences. Vol. 4 Issue 2, pp. 236-243
 Moustaka, E & Constantinidis, T (2016). Sources and effects of work-related stress in nursing. Health Science Journal. Retrieved from http://www.hsj.gr/medicine/sources-and-effects-of-workrelated-stress-in-nursing.php?aid=3575
 Carayon P, Gurses AP. Nursing Workload and Patient Safety—A Human Factors Engineering Perspective. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 30. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2657/
 UCLA School of Public Health (2011). Nurse Understaffing Linked to Increased Risk of Patient Mortality. Retrieved from http://ph.ucla.edu/sites/default/files/downloads/magazine/sph.june11.research.pdf
 Zangaro, G., Yager, K., & Proulx, J. (2015). Recognizing and Overcoming Toxic Leadership. RNJorunal. Retrieved from http://rnjournal.com/journal-of-nursing/recognizing-and-overcoming-toxic-leadership
 McVicar, A. (2003, July 24). Workplace stress in nursing: a literature review. School of Health Care Practice, Anglia Polytechnic University, Chelmsford, Essex, UK. Retrieved from https://www.researchgate.net/publication/8979126_Workplace_Stress_in_Nursing_A_Literature_Review
 Johnson, S. & Rea, Ruth (2009). Workplace Bullying: Concerns for Nurse Leaders. Vol. 39. Issue 2. pp 84-90. doi: 10.1097/NNA.0b013e318195a5fc
 Terera, S. & Ngirande, H. (2014). The Impact of Rewards on Job Satisfaction and Employee Retention. Mediterranean Journal of Social Sciences. MCSER Publishing, Rome-Italy. Doi:10.5901/mjss.2014.v5n1p481
 Manojlovich, M. (January 31, 2007). "Power and Empowerment in Nursing: Looking Backward to Inform the Future". OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 1, Manuscript 1. DOI: 10.3912/OJIN.Vol12No01Man01
Victorina Malones is a critical care nurse at The Medical City Iloilo in Iloilo City in the Philippines.