Several research studies focusing on nursing staff in acute care settings have attempted to identify a wide range of factors associated with stress. They include overwhelming workload, limited facilities and space, inadequate help, too much responsibility, too little continuing education, poor organization, excessive paperwork, inadequate communication with physicians, intrastaff tensions, and many other variables. Lack of recognition and lack of administrative support and leadership also can lead to stress. Although RNs frequently reported in testimony and during the committee's site visits that low staffing levels cause stress, empirical evidence does not corroborate their perception, although it clearly can exacerbate other stressful circumstances, as discussed below.
Some early studies of stress found that critical care nurses and intensive care nurses experience more stress than do staff in other units, but research has not consistently validated this finding (MacNeil and Weisz, 1987; Yu et al., 1989; Foxall et al., 1990). A survey of emergency room RNs, identified inadequate staffing and other resources, too many nonnursing tasks, changing trends in emergency department use, and patient transfer problems as causes of stress. They also described shortages of nursing staff during busy periods and at night, and the use of untrained relief staff, as other important factors in stress (Hawley, 1992).
One specific source of stress among health care workers is shift work. According to a 1991 review of 16 studies conducted by the Office of Technology Assessment (OTA, 1991), rotating nurses reported higher levels of stress, had more sleep disturbances, had significantly higher personal health problems, and suffered more injuries and accidents related to lack of sleep than fixed-shift nurses. Other research studies on shift work also reported adverse effects on performance, workers' health, performance, and mental and physical fitness (Gold et al., 1992).
Nursing personnel who work with the elderly confront many complex and potentially stressful situations in nursing homes where the work is highly demanding and labor intensive. Nursing personnel who work with patients with Alzheimer's disease are especially vulnerable to the effects of stress and burnout. These patients present many difficult care and management problems because of their progressive cognitive, functional, and psychosocial deterioration, which can result in bizarre and combative behaviors, emotional outbursts, and wandering. Moreover, nursing home staff are often poorly trained to cope with the disruptive behaviors of residents and are, therefore, repeatedly frustrated by their inability to manage recurrent problems (Stolley et al., 1991). Many nursing homes are also not equipped with environmental structures or the support and service systems required to care appropriately for the person with Alzheimer's disease (Peppard, 1984).
One recent study, using a quasi-experimental design with repeated measures, examined whether staff who cared for patients with Alzheimer's disease on a