Introduction: Nurses in hospitals have most of work stress due to workload, leadership style, professional conflict, emotional, lack of appreciation and shift work. It results in absenteeism, high error rates, and decreased work performance lead to patient safety threat. Effectiveness work stress management is needed to minimize the work stress of nurses. The objective is identified nurse work stress management. Method: Design using scoping review, inclusion criteria randomized control trial design, experimental design, and a cross-sectional survey. The process using PRISMA-SR via the Sciencedirect, Scopus and Pubmed databases was published from 2019 to 2023. A total of 810 articles were obtained from Pubmed (53 articles), Scopus (83 articles), Sciencedirect (674 articles). 6 full articles were obtained based on the objectives. Result: Six articles from a scoping review showing that smartphone-based stress management is effective in rectifying depression. Listening music during the afternoon shift shows 432Hz music more effectively than 440Hz and free activities. Restorative yoga for female nurses working night shifts has been shown effective in reducing work stress compared to conventional stress relief methods. The medical material management system app uses the shift check application; the workload of nurses is reduced effectively. Effective delegating behaviour and developing resilience effectively reduce stress. Rose aromatherapy has a positive effect compared to placebo. Conclusion: Stress management is effective in reducing nurses work stress; smartphone-based stress management, listening to 432 hz frequency music, restorative yoga, medical material management system app. effective delegation behaviour, develop resilience and rose aromatherapy.
Nurse profession has high risk that lead to work stress [1]. Their work is one of the factors can cause stress, workload and the environment become stressor that trigger stress [2].
Work stress is a condition of human interaction with work in the form of tension causing physical and psychological imbalance. Work stress affects the emotions, thought processes, and conditions of an employee. Work stress affects productivity and the work environment and can interfere with individuals [3].
Two hundred Saudi nurses worked at government health centre, majority female (68,0%) thirty percent has severe stress [4]. 199 nurses worked in ICU at one of hospital in Taiwan shows 29,4% suffered acute stress after their patients die [5]. Result of study during pandemic covid 19, one of primary healthcare centre in Semarang with 156 respondent, the nurse suffered work stress around 68.7 % [6].
The impact of work stress results in disruption of physical health, psychological health, decreased work performance, and affects employees in decision making [3]. In nursing practice, work stress causes absenteeism, high error rates, and decreased work performance lead to a deadly threat to patient safety [7]. Lack of stress management skills at work causes difficulties in dealing with stress. [8].
Work stress management is the ability to use resources effectively to deal with mental and emotional disorders that arise. Work stress management’s objective is to prevent stress, accommodate the physiological effects of stress, improve quality of life for the better and prevent the development of short-term stress into long-term stress. [3].
Work as a nurse has a strenuous stressor. It needs effective work stress management to minimize the occurrence of work stress for nurses. Based on the review of work stress management for nurses, the researchers are interested in reviewing work stress management for nurses in hospitals. The objective of this scoping review is to identify work stress management for nurses in hospitals.
Article review uses the Arksey and O'Malley methods [9] in conducting a scoping review analysis through five stages consisting of identifying research questions according to the topic, identifying research that is relevant to the topic taken, selecting research related to the topic, conducting analysis using a data matrix, and interpreting the findings. The article contains review questions: "What are the types of management to deal with work stress for nurses in hospitals?"
Article collected through online database Sciencedirect, Scopus dan Pubmed. The articles used were published between 2019 and 2023. Searching the article uses Boolean operator method "DAN", the key word is "Management" DAN "Nurse work stress" DAN "Hospital".
The inclusion criteria in this study involved all types of work stress management for nurses in hospitals around the world, using randomized control trial designs, experimental designs, and a cross-sectional survey, nurse respondents, nurse work stress management interventions, stress measuring instruments and research conducted in the hospital.
Chosen data with deleting duplication, article publish before last 5 year, and not complete treks of article. Most important in the selection of this research is the management of overcoming or reducing the work stress of nurses [9].
Assessment scoping review, literature search using reliable data based. Articles be analysed to find the necessary data, and analysed for similarities and differences. Titles, abstracts, and articles are reviewed according to inclusion and exclusion criteria. The data used in each of the articles found are full text, year of study, type of intervention, population and results. Figure 1 illustrates the process of searching and selecting articles using the Preferred Reporting Item Systematic Review and Meta-analysis for Scoping Review (PRISMA-SR)[10].
Figure 1: The PRISMA Flow Diagram of the Literature Review
Data Analysis/Synthesis
A total of 810 articles were obtained as literature sources from Pubmed (53 articles), Scopus (83 articles), Sciencedirect (674 articles). There is 1 same article based on excluded data and the remaining 809 articles. Furthermore, out of 809 articles, 794 articles were excluded because they only contained theory and discussion, not in English, the articles were not related to the topic and were not original articles. The results of the article screening obtained 15 articles. Furthermore, from 15 full text articles, 11 articles and 5 articles were excluded because they did not match the research objectives. Completeness of the articles obtained 6 articles analysed discussing the work stress management of nurses in hospitals.
Based on the results of the 6 articles, the analysis of work stress management for nurses in hospitals is shown in Table 1.
Scoping review gave benefit in managing effective nurses work stress. Based on analysis from scoping review obtained is below discussed.
Smartphone Based Stress Management Programs
iCBT program is effective to reduce depression of nurses in the hospital at Vietnam. Application smartphone stress management program-based includes behavioural activation, cognitive restructuring, problem solving, assertiveness, compassion and crafting. Other function of iCBT program is self-assessment of work-related stress and emotional states. Computerized CBT via the internet (iCBT) is very promising because the method is cost effective, can be accessed directly by workers more effectively for location and time, accessed by larger groups, privacy is maintained.
One randomized controlled trial (RCT) reported that a web-based stress management program, including cognitive behavioural techniques, was effective in reducing work-related stress among nurses in the USA. [8]. Another study showed that stress management program-based smartphones significantly increased the performance of nurses in Vietnam [11].
Listening Music
Listening music on 432 Hz is low-cost intervention and brief, be a source of managing anxiety and stress. Music tempo has direct correlation to changing of heart rate, respiratory rate and blood pressure. The effect depend on music speed then the style or subject music preference [12].
Other study show music intervention to cancer patient compare to standard care, has beneficial effect to anxiety, depression, hope, pain, and fatigue in adults with cancer [13].
Restorative Yoga
There is no significant changing in the vital sign before and after yoga sessions, and no weight changing after 4 weeks practices at home. Questionnaire score “means” for "psychological and physical stress reactions" significantly reduce after yoga sessions. The mean scores were significantly lower after 4 weeks at-home exercise than before or after yoga, or after 4 weeks of regular stress relief methods. These findings indicate that restorative yoga is effective in reducing work stress among female nurses working night shifts.
Yoga is defined in an environment that is predominantly spiritual and meditation. Movement in yoga, exercises of aerobic and anaerobic to improve musculoskeletal structure, insulin circuits, hormone systems, and metabolism. The benefits achieved help relaxation, self-awareness, increase cognitive flexibility, increase attention, acceptance and control of emotional reactions [20].
Other research states that work stress could impact to decreased work satisfaction, poor performance and overall health impacts. Activities based on yoga exercises are effective in reducing stress at work place [21].
Table 1: Summary of Included Article kind of management the nurse works stress in hospital | ||||
|---|---|---|---|---|
| Author(s), Year of Publication, Origin/ Country of Origin | Aims/purpose, Study Population and size (if applicable) | Methodology/Methods, Intervention Type, Comparator and Details of these (e.g. duration of intervention) (if applicable) | Outcomes and details of these (e.g. how measure) (if applicable) | Key Findings that relate to scoping review question/s |
| [14] /Vietnam | The universal prevention effect test of two types of smartphone-based iCBT stress management programs (i.e., free choice sequence and fixed sequence) compared to the control group in improving symptoms of depression and anxiety in hospital nurses in Hanoi Vietnam | Method of a three-arm randomized controlled trial. Intervention of two types of programs (free choice and fixed order) from a smartphone-based stress management program. Participants were randomly allocated to Program A (free choice, multimodule stress management), Program B (fixed sequence, internet cognitive behavioral therapy, iCBT), and control group (medication as usual). Program Module A (Free choice) 1. Behavioral Activation 2. Cognitive Restructuring 3. Troubleshooting 4. Assertive / Firmness 5. Respect yourself 6. Initiative and proactive in work Program Module B (Sequential) 1. Transactional module and coping mechanism 2. The self-case formula is based on a cognitive behavioral model 3. Behavioral Activation 4. Cognitive Restructuring part 1 5. Cognitive Restructuring part 2 and Relaxation 6. Troubleshooting | Program B showed a significant effect on improving depressive symptoms at month 3 (p = 0.048), but not at month 7 (p = 0.92); D Cohen − 0.18 (95% CI − 0.34 to − 0.02) and 0.03 (95% CI − 1.00 to 1.05), respectively. Program A failed to show a significant effect at either 3 or 7 (months) follow-up (p > 0.05). Although the effect was small, the iCBT program was effective in reducing nurses' depression. Instrument: 1. Depression Anxiety and Stress Scales (DASS 21) 2. iCBT software Smartphone | Smartphone based stress management program B iCBT is effective in reducing nurse work stress |
| [15] / Italy | Knowing the effect of listening to music during breaks compared to regular breaks (without listening to music) on the anxiety level and vital parameters of the nurse on duty in the operating room. | Methods using Randomized, controlled, three-arm, double-blind, single-center clinical study. The intervention group was divided into 3 groups: Group 1: listening to 440Hz music; Group 2: listening to 432Hz music; Group 3: free activity. The study was conducted during the afternoon shift. | Results: 54 health workers; 32 women (59.3%); mean age 39.64 years (SD ±9.94); the total measurements were 83. The median STAI X1 value decreased in all 3 groups from T0 to T1 Group 1: 34.5 vs 32, p=0.000; Group 2: 34 vs 29, p=0.001; Group 3 : 33 vs. 31, p=0.028). Group 2 decreased mean respiratory rate and systolic blood pressure at T1 (-2.714/min, p=0.000 and -3.821 mmHg, p=0.031, respectively). Conclusion: Low-cost, brief listening to 432 Hz music effectively manages anxiety and stress. Instruments: State-Trait Anxiety Inventory – (STAIX1), heart rate (HR), respiratory rate (RR), systolic/diastolic blood pressure, pain and productivity. The Likert scale was measured at the start (T0) and at the end of the exposure (T1). | Listening to music on 432hz frequency is effective in reducing nurse work stress |
| [16] / Japan | Determine whether restorative yoga methods are effective in relieving nurses' work stress. Participants were 20 female nurses in their 20s to 30s who work night shifts in Japanese hospitals | The method uses a randomized crossover trial. Intervention duration of 1-hour yoga session followed by 4 weeks of home exercises and 4 weeks of regular stress relief methods. | Results: Before to after the yoga session; Vital signs showed no significant change, there was no change in body weight after 4 weeks of practicing at home. The mean questionnaire score for "psychological and physical stress reactions" was significantly reduced after the yoga session. The mean scores were significantly lower after 4 weeks of home exercise than before or after yoga, or after 4 weeks of regular stress relief methods. This shows that restorative yoga is effective in reducing work stress for female nurses working the night shift Instrument: The level of stress was assessed by the Brief work Stress Questionnaire of the Ministry of Health | Restorative Yoga is effective in reducing nurse work stress
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[17] / Taiwan | Develop clinical medical device management applications for nurses to reduce workload and increase the efficacy of medical device management. The subjects were 57 nurses in ICU of a hospital in Hsinchu | The single-group pre- and post-test experimental design was adopted. The results were analysed using SPSS, APP Inventor, and data mining modelling to determine the effect of the application. Structured questionnaire research tools, including open-ended questions covering aspects of nurses' workload, stress, and intentions to receive information, as well as demographic questionnaires, collect basic personal data, including gender, age, years of service, education level, level of nursing ability, ability to use IT products, and the unit type. Research time starts November 2019 to March 2020 | After using the Shift Check Application, the average workload of nurses is effectively reduced, the reduction in the workload of nursing ability level N1 is greater than that of N2. This IT helps manage medical devices in clinical practice to have a significant effect on reducing nurse workload and increasing satisfaction. | Medical material management system app is effective in reducing nurse work stress
|
[18] / United Arab Emirates.
| Check management stress behaviours of nurses work during pandemic COVID-19 in UEA. 64 nnurses worked at isolation and ICU | a cross-sectional survey Participants completed Google Form survey from two validated instruments: 10-items scale measuring perceived stress levels and 15-items stress management inventory. | 78.1% of respondents reported moderate stress levels (Mean=18.03 and SD=5.33). Four elements stress management behavior (stress relief, developing resilience, using short-term coping, and effective delegation) and mean and SD were 17.62 ± 2.6, 17.42 ± 3.3, 8.88, respectively ± 1.47, and 23.98 ± 3.54. There is a significant positive correlation between the four elements of stress management inventory (p = 0.00). The findings show a significant inverse correlation between perceived stress scores, effective delegation and developing resilience are effective stress management behaviors among nurses. | Stress Management Behaviors effective delegation and resilience development is effectice to reduce work stress |
[19] / Iran
| Test and comparations the effect of lavender and rose essential oil aromatherapy on nurses’ work stress. Sample of 118 nurses divided into three groups, lavender(n=39), rose(n=40), and sesame seeds as placebo (n=39) | Method Randomized controlled trial. Descriptive and inferential statistical tests. The level of statistical significance was set at p < 0.05. Nurses received lavender and rose scents for two hours a day for four weeks
| There was a statistically significant difference between the groups at the end of the fourth week (p < 0.003). Rose aromatherapy has a positive effect on nurses' work stress at the end of the fourth week compared to placebo (p = 0.002). Rose aromatherapy is a safe and non-pharmacological method that is effective in increasing self-comfort at work, can reduce dependence on drugs, effectively relieves work stress. Measurement Tool Nursing Stress Scale (NSS) | Rose scent aromatherapy is effective to reduce work stress |
Medical Material Management System App
Application Shift Check is management medical device application for nurses shows that the average workload of nurses is effectively reduced, especially the reduction in the workload of nursing ability level N1 is greater than N2. Utilization of information technology products has a significant effect on reducing nurse workload and increasing satisfaction.
Management medical inventory affects the quality of care. Routine counting of medical devices is an important job in nursing activities. Nurses need to check and register items before the shift starts and ensure the number of tools and the condition of the tools.
Shift check application is smartphone-based as medical device accessories. Model M2M (machine to machine), data uploaded through internet, Bluetooth, radio frequency identification (RFID), and other technology, while medical staff makes judgment according to recorded data. All the job documented, if any property missing during the sift, nurses must pay [17].
Other study shows using technology helps quality management of nursing, it has a significant effect on reducing nurses burden and increase head nurse satisfaction [22].
Stress Management Behaviours
Effective delegation and developing resilience are effective in stress management behaviours among nurses.
Delegation is an activity of one-person responsibility, completed by other, and accepts responsibility for completing appropriate activities. Delegation concept based on authority, responsibility, and good relations between those involved. Personal responsibility and professional of nurses to delegates the activities and ensure that delegates are educated, competent and experienced to be performed ensuring patient safety [23].
Result of other study An Integrative Review of Team Nursing and Delegation: Implications for Nurse Staffing during COVID-19 show delegating education is very important for the nursing team, and evidence show improve knowledge, decision making, and nurse competency [24]. Many benefits have been reported from implementing delegation, including service efficiency and improved patient care [25].
Resiliency is rapid recovery of mental health during periods of exposure to a stressor, from potentially traumatic events, challenging life circumstances, critical life transition phases, or physical illness. [26].
Resilience significant to reduce fatigue and prevent mental health disorders. Biologically, uncontrolled stress affects the cognitive function of the brain, leading to compromise logical thinking [27].
How to develop resiliency: feel the works is meaningful and contribute the good, feel supported by family, friends, co-workers, enough sleep and eat, exercise at least 15 minutes a day, foster positive emotions, be grateful, feel sorry for yourself and other people, sharing stories, listening to music, spending time with religious practices or beliefs [28].
Aromatherapy
Aromatherapy with rose scent is one of the safest methods and non-pharmacological that can be use by nurse to increase self-comfort in workplace. This can reduce the dependence of nurses on medicines to relieve symptoms of work stress.
Work stress can stimulate nerve sympatric system and hormones such as adrenalin, cortisol, which results in symptoms of stress. Nursing science identify non-pharmacological therapy Aromatherapy is more effective, cheap, simple and low risk. Aromatherapy as non-pharmacological, complemented therapy and alternative, oil essential from nature for relaxing and mind control and body through aromatic essential oil lead to neurology effect and physiology, have been proven in so many countries and shows the effective of aromatherapy used increase in stress management [29].
Other studies have shown that essential oils are concentrated volatile aromatic liquids, extracted from natural plants with different chemical compositions, obtained by physical and chemical methods such as distillation and pressing. Essential oils exert neuropharmacological effects through the blood circulation or the olfactory system. Clinical studies show that aromatherapy can improve sleep quality, relieve preoperative and postoperative anxiety, relieve gynaecological pain [30].
Finding through scoping review there are 6 types of nurse work stress management effective in reducing nurse work stress: stress management smartphone based, listening music, restorative yoga, medical material management system app, stress management behaviours and aromatherapy.
Acknowledgment
Thank you to the education’s staff of Department of Nursing Science, Faculty of Medicine, Diponegoro University, especially to the organizer of manuscript camp event, thereby supporting the completion of this manuscript.
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