Stress is the body's and mind's response to demands (stressors) that are perceived as challenging or threatening. Eustress is positive, motivating stress; distress is harmful stress that exceeds coping ability.
Job (occupational) stress arises when job demands do not match the worker's resources, abilities, or needs. Nursing is a high-stress occupation: heavy workloads, shift work, life-and-death decisions, exposure to suffering and death, and conflict with clients, families, and co-workers.
Burnout is defined by the World Health Organization in ICD-11 as a syndrome resulting from chronic workplace stress that has not been successfully managed. It has three dimensions:
- Feelings of energy depletion or exhaustion
- Increased mental distance from one's job, or negativism or cynicism about it
- Reduced professional efficacy
WHO classifies burnout as an occupational phenomenon, not a medical condition, and applies the term only to the work context. Maslach's Burnout Inventory describes the same three dimensions as emotional exhaustion, depersonalization, and reduced personal accomplishment.
Related concepts:
- Compassion fatigue: the emotional cost of caring for people who suffer; it combines secondary traumatic stress (absorbing others' trauma) with burnout, and its onset can be sudden
- Moral distress: knowing the ethically right action but being unable to take it because of institutional or other constraints
- Resilience: the ability to adapt, recover, and grow in the face of adversity; it can be strengthened by both individual skills and a supportive organization
Selye's General Adaptation Syndrome
- Alarm — fight-or-flight response; sympathetic activation, cortisol release
- Resistance — the body adapts and tries to cope
- Exhaustion — resources are depleted; illness and burnout become likely
Lazarus and Folkman's transactional model
- Primary appraisal: "Is this situation a threat, harm, or challenge to me?"
- Secondary appraisal: "Do I have the resources and ability to cope?" A sense of losing control reflects a negative secondary appraisal.
- Coping: problem-focused (changing the situation — reorganizing work, seeking information, asking for help) or emotion-focused (managing the feelings — relaxation, venting, reframing, prayer).
Karasek's job demand–control model
| Low control | High control |
|---|
| High demands | High-strain job (highest stress risk) | Active job (challenging but motivating) |
| Low demands | Passive job | Low-strain job |
Johnson later added social support: high demand, low control, and low support ("iso-strain") is the most harmful combination. A new nurse facing heavy workload with little skill or decision latitude is in a high-strain position.
Siegrist's effort–reward imbalance: stress rises when high effort is met with low reward (pay, esteem, job security, career opportunity).
Sources of stress in nursing
| Category | Examples |
|---|
| Job content / workload | High client load, understaffing, time pressure, overtime, documentation burden |
| Role-related | Role conflict (incompatible demands), role ambiguity (unclear expectations), role overload |
| Interpersonal | Conflict with co-workers or physicians, verbal abuse or violence from clients and families, bullying |
| Organizational | Rigid policies, low participation in decisions, poor pay, limited promotion, frequent change |
| Work schedule | Rotating and night shifts disrupting sleep and family life |
| Emotional | Death of clients, suffering, ethical dilemmas |
| Personal | Family responsibilities, financial pressure |
Stress responses
- Physiologic: fatigue, headache, muscle tension, sleep disturbance, gastrointestinal upset, frequent illness
- Emotional: irritability, anxiety, anger, depressed mood
- Cognitive: poor concentration, forgetfulness, indecision, more errors
- Behavioral (observable by the manager): lateness, absenteeism, withdrawal from colleagues, conflict, increased errors and incidents, substance use, resignation
Consequences: individual (health problems, burnout), organizational (turnover, absenteeism, errors, lower quality of care), and social (strained family and social relationships).
Individual strategies
- Recognize personal warning signs early.
- Protect sleep, especially with night shifts; eat regularly; exercise.
- Use relaxation methods: deep breathing, progressive muscle relaxation, mindfulness, prayer or reflection.
- Seek social support from colleagues, family, and peer groups.
- Set boundaries: assertively decline excessive extra duties, take breaks and leave.
- Use problem-focused coping for controllable stressors (improve work organization, learn new skills) and emotion-focused coping for uncontrollable ones.
- Seek professional help for persistent low mood, anxiety, or thoughts of self-harm.
Organizational (manager) strategies — the most effective prevention addresses root causes in the work environment.
- Adequate staffing and fair scheduling; limit consecutive night shifts and mandatory overtime where possible.
- Job redesign: reduce unnecessary tasks, clarify roles, increase staff control over how work is done.
- Participation in decisions (shared governance, unit councils).
- Recognition and fair rewards.
- Orientation, preceptorship, and mentoring for new nurses.
- Debriefing after critical incidents such as a code, a violent event, or the death of a child.
- Zero tolerance for violence and bullying, with a clear reporting system.
- Access to counseling or an employee assistance program; a psychologically safe climate where staff can ask for help without stigma.
Stress prevention works at three levels: primary (removing stressors — job redesign, staffing), secondary (building coping skills and detecting stress early — training, screening, peer support), and tertiary (treatment and return-to-work support for those already affected).
Philippine workplace rules
- The Mental Health Act (RA 11036) and the Occupational Safety and Health Law (RA 11058) are the basis of DOLE Department Order No. 208, series of 2020, which requires private-sector workplaces to adopt a Mental Health Workplace Policy and Program: raising awareness, preventing stigma and discrimination, supporting workers at risk or with mental health conditions, and facilitating access to services. Implementation runs through the workplace occupational safety and health committee.
- For private-sector workers, RA 11058 (Section 6) gives the right to refuse work without reprisal when DOLE determines that an imminent danger exists and the employer has not corrected it. RA 11058 does not cover the public sector (Section 2).
- Government nurses (DOH and other public hospitals, rural health units) follow Civil Service Commission rules; the public-sector mental health counterpart of DO 208 is CSC Memorandum Circular No. 04, series of 2020 (Mental Health Program in the Public Sector), issued under RA 11036.
- For public health workers, the Magna Carta of Public Health Workers (RA 7305) sets normal hours at not more than 8 hours a day or 40 hours a week and provides hazard allowance for hazardous assignments.
- Monitor one's own stress and fitness for duty; a nurse who is impaired by exhaustion must inform the supervisor, because fatigue increases errors.
- Support colleagues: notice changes, listen, and encourage help-seeking.
- Report violence, bullying, and unsafe conditions through official channels.
- The nurse manager identifies stressors on the unit (surveys of role conflict, role ambiguity, and workload), watches for behavioral signs (absenteeism, lateness, errors, withdrawal), and plans organizational interventions.
- Managers model healthy behavior: taking breaks, respecting days off, and treating errors as system-learning opportunities.
- Confidentiality: information about a worker's mental health is sensitive personal information; disclose it only with consent or as allowed by law (Data Privacy Act, RA 10173). DO 208 also aims to prevent stigma and discrimination.
- Non-discrimination: a worker must not be dismissed or penalized solely for seeking help for a mental health condition.
- Patient safety: an exhausted or impaired nurse has an ethical duty to protect clients by reporting unfitness; the organization has a duty to provide safe staffing.
- Occupational safety: employers must provide a safe workplace, including protection from workplace violence and hazards.
- The Code of Ethics for Registered Nurses requires competence and safe care, which includes the nurse's attention to personal health.
Case 1. A nurse on rotating shifts complains of constant tiredness and headaches and notices she is snapping at clients. Which stress responses are present?
Answer: Physiologic (fatigue, headache) and emotional (irritability). The manager should also watch for behavioral signs and help her address sleep and workload.
Case 2. A new graduate on a busy surgical ward has a heavy client load, little say in her schedule, and frequent criticism. Using Karasek's model, what is her stress risk?
Answer: High-strain — high demands with low control; low support makes it worse. Preceptor support, graduated assignments, and involvement in scheduling reduce the risk.
Case 3. A nurse manager wants the most effective organizational-level intervention for unit-wide stress caused by unclear roles and excessive paperwork. What should she choose?
Answer: Job redesign — clarify roles and streamline documentation. It removes the stressor rather than only teaching staff to cope with it.
Case 4. An experienced nurse says, "I feel nothing anymore when patients die. I just do my tasks and go home. I don't think I help anyone." What is this?
Answer: Burnout — exhaustion, mental distance (cynicism/depersonalization), and reduced professional efficacy. She needs support, workload review, and referral for counseling.
- Calling burnout a psychiatric diagnosis. WHO classifies it as an occupational phenomenon.
- Confusing primary appraisal (is it a threat?) with secondary appraisal (can I cope?).
- Labeling relaxation techniques as problem-focused coping. They are emotion-focused; problem-focused coping changes the stressor.
- Choosing only individual stress-management training when the question asks for an organizational-level strategy. Job redesign and staffing are organizational.
- Treating role conflict and role ambiguity as the same. Conflict = incompatible demands; ambiguity = unclear expectations.
- Assuming high demand alone causes the most strain. In Karasek's model, high demand combined with low control is the key.
- Eustress motivates; distress harms.
- Selye: alarm → resistance → exhaustion.
- Lazarus and Folkman: primary appraisal (threat?), secondary appraisal (resources?), problem- vs emotion-focused coping.
- Karasek: high demand + low control = high strain; low support worsens it.
- Burnout (ICD-11): exhaustion, mental distance or cynicism, reduced professional efficacy; occupational phenomenon.
- Role stressors: role conflict, role ambiguity, role overload.
- Behavioral signs the manager can observe: absenteeism, lateness, errors, withdrawal.
- Organizational prevention (job redesign, staffing, participation) targets root causes.
- Primary, secondary, and tertiary levels of stress prevention.
- DOLE DO 208 s. 2020 (under RA 11036 and RA 11058) requires workplace mental health policies in the private sector; CSC MC No. 04 s. 2020 covers the public sector.
- Compassion fatigue = secondary traumatic stress + burnout.
- RA 7305: public health workers' normal hours not more than 40 per week; hazard allowance.