Research papers and studies by domestic and foreign authors show that the incidence of work-related disorders of the musculoskeletal system, nervous and mental disorders is constantly increasing.
Musculoskeletal disorders are the most common work-related problem in Europe. Almost 24% of EU employees report suffering from back pain and 22% complain of muscle pain. Both problems occur more frequently in the new member states, 39% in new and 36% in old member states. (European Agency for Safety and Health at Work, 2007)
Work-related stress is one of the biggest occupational safety and health challenges we face in Europe. It affects approximately one in four workers and studies show that it is associated with 50–60% of all lost working days. This represents enormous costs not only in terms of human suffering but also in terms of weakened economic performance. In 2005, stress was the second most frequently reported work-related problem, affecting 22% of employees in the EU (European Agency for Safety and Health at Work, 2007)
Many shortcomings in the occupational safety and health of healthcare workers in the Slovak Republic related to excessive load were also highlighted by the results of a trade union inspection report in 2006. As the report states, one of the shortcomings was the exceeding of set limits on overtime work of nurses and doctors, caused by the current situation in healthcare facilities – the constant reduction in the number of healthcare employees, as well as their departure abroad or to other economic activities.
While previous research has focused mainly on specifying the degree of load and energy demands of work for individual categories of healthcare workers, in the present paper we focused on assessing the theoretical knowledge and practical skills of nurses needed to eliminate excessive physical load and on the use of effective strategies for coping with nurses' psychological load when providing nursing care. Our aim was primarily to contribute to the prevention, support and protection of nurses' health.
PHYSICAL LOAD
Physical Work and Load in Nursing Care
Workload is determined by the degree of balance between a person's performance capacity on the one hand and the task requirements and conditions under which it is performed on the other. If both components are in balance, the workload is adequate. If an imbalance occurs, it is an inadequate load, referred to as overload of performance capacity, or an excessive load.
Heavy physical work in nursing care, especially associated with handling patients and loads, can lead to some health problems for the nurse, particularly in the area of the musculoskeletal system. During daily and repeated handling of immobile patients and patients with reduced mobility, it is often not possible to respect the recommended limits for weight and load handling (including human load).
One of the basic prerequisites for preventing damage to the nurse's musculoskeletal system is mastering safe patient handling techniques. The current trend in nursing is to focus on minimizing tasks associated with simple vertical lifting and carrying of patients and on applying correct handling techniques together with the use of technical aids for handling.
NEUROPSYCHIC LOAD
Psychological Load and Strategies for Coping with Psychological Load in Nursing Care
Nursing care is work with and for people, typically the ill, and is demanding both physically and psychologically. In daily practice, the nurse addresses and experiences problems associated with suffering, pain, illness and death of patients, which represents a great psychological load and a risk of developing burnout syndrome. If nurses acquire the skills and abilities to effectively cope with stressful situations at work and in their lives, they can better assess the difficulty of the patient's stressful situations and can help the patient, their relatives and others in coping with difficult life situations associated with hospitalization, changes in health status, therapy or death.
Stress management helps the nurse find the right balance between energy and creativity on the one hand and symptoms of excessive stress (fatigue, feeling of inadequacy in fulfilling roles) on the other. This kind of balance is individual for each person and the way it is acquired and maintained represents a learning process. For this reason, the nurse needs to learn to identify her own sources of stress, recognize stressors and symptoms of stress, and acquire skills and abilities for stress management.
For stress management, she can use three main approaches: 1. implement basic stress management (knowing what to do when stress suddenly appears), 2 manage the influence of stressors and 3 create a balanced lifestyle.
Basic stress management includes: problem solving, dealing with feelings, using available social support, and reducing physiological reactions induced by stress.
RESEARCH
Definition of the Research Problem and Research Objectives
In order to comprehensively understand and find solutions to the issue of managing professional load in nurses, we decided to conduct research in which we examined the specifics of this area in healthcare facilities in Slovakia.
The aim of the research was to determine: a.) nurses' knowledge of prevention of risks from excessive physical and psychological load, b.) nurses' knowledge of ways of coping with physical load, as well as c.) nurses' strategies for coping with psychological load.
We monitored these aspects in nurses providing nursing care within inpatient healthcare in our conditions, focusing mainly on possible differences related to varying load (1) in different clinical nursing specialties and (2) during the development of the nurse's professional career.
Research Method
The first part of the research – the study of physical load – was based on theoretical assumptions stated in theories about human potential for behavioral change – social-cognitive theories explaining health-related behavior (the theory of reasoned action by Fishbein and Ajzen, according to Křivohlavý, 1994, or the theory of planned behavior by Ajzen and Madden, according to Ogden, 1998). In this sense, we examined nurses' knowledge, performance prerequisites (skills) and environmental conditions on the one hand, and the implementation of healthy behavior on the other. The second part of the research project was based on verifying theoretical assumptions about the effects of psychological load/stress in providing nursing care in relation to coping strategies, self-image and social contexts of work, depending on clinical specialties, age and length of nursing practice.
In terms of methods used, scale questions in the original questionnaire, standardized questionnaires and original psychosemantic scales were employed. In the second part of the research, a qualitative approach was also used in the form of open-ended questions in the questionnaire.
Sample
The sample in the first part of the research consisted of 55 nurses. In the second part of the research project, the research sample consisted of 257 nurses. The most represented age category was the category of nurses aged 27 to 29 years. The largest group consisted of nurses with clinical practice length of up to 20 years, 34.9%.
Results Regarding Physical Load and Their Interpretation
According to the research results, we can state that the most significant deficiencies in nurses' knowledge and skills are in the area of kinesiology (89.1%) and in the use of technical equipment to facilitate work with excessive load (89.1%). Relatively milder (though still significant) deficiencies are in nurses' knowledge of the mechanics of their own body and the application possibilities of the principles of leverage, friction and inertia when performing patient handling and transfers (70.9%). Finally, the most positive findings relate to working in pairs when handling patients (61.8%), which, however, unfortunately does not apply during night shifts, where this collaboration is practically excluded by the systemic absence of additional nurses, assistants and orderlies on the ward. This is confirmed by the fact that up to 96.4% reported frequent back pain related to excessive physical load during nursing care and 72.7% of nurses reported frequent swelling and pain in the lower extremities. The above-described deficiencies in nurses' knowledge and skills take on high significance as potential causal factors of health risks in the professional performance of nursing care.
Results Regarding Psychological Load and Their Interpretation
Our finding of the degree of burnout in nurses (mean value 3.1, corresponding in nominal classification to the level of 'presence of burnout signals'; N=255) is consistent with the conclusions of other works on the degree of burnout in nurses (e.g. Lejková, Baumgartner, 2006, Final Report of the Ministry of Health of the Slovak Republic, 1999). Possible health risks for nurses arising from excessive psychological load in providing nursing care are indicated not only by this average value, but also by the fact that 12% of nurses are in the zone of presence of burnout syndrome and in 2.4% we found a 'critical state' of psychological exhaustion..
We consider it important that in oncology/palliative medicine departments, the linear relationship between the intensity of burnout and age/length of practice, indicating a 'cumulation' of psychological load over the course of practice or with advancing age, in the form of increasing burnout levels, did not manifest. It can be assumed, in agreement with Martin (1990), that nurses with longer practice and experience (and who meet other prerequisites such as a mature personality, appropriate character traits, self-control and patience, together with social support) demonstrate a greater ability to cope with psychological load despite a high degree of emotional exhaustion when caring for patients in the terminal stage of illness.
The results of examining nurses' choice of coping strategies in managing professional load showed practically the same mean score for the use of effective problem-focused strategies (2.52), ineffective emotion-focused strategies (2.49) and mental disengagement strategy (2.13).
In the context of considering the process of acquiring individual coping strategies, we should also mention the finding that the assumption about the relationship between the length of clinical practice and a higher degree of active coping and use of effective strategies was not confirmed. A surprising significant relationship appeared, on the one hand, with increasing age of nurses and, on the other hand, with a reduced use of mental disengagement strategy and also with a reduced use of escape through humor (F=2.214, sig.=0.068; F=3.380, sig=0.010) and also, on the one hand, with increasing length of practice of nurses and, on the other hand, with a reduced use of mental disengagement strategy and a reduced use of escape through humor (F=4.267, sig.=0.006; F=3.547, sig=0.015), which could perhaps be interpreted as a gradual 'unlearning' of ineffective strategies. That, in addition to having effective coping strategies, such a decline in the use of ineffective strategies may also be a significant benefit for nurses, follows from the finding that the degree of burnout in nurses is directly proportional (r=0.346, p=0.000) to the degree of use of the ineffective mental disengagement strategy.
Indirectly, all these findings point to the absence of targeted training in the use of active coping, effective strategies for managing professional load – i.e., problem-focused strategies; in the preparation of nurses for the profession and in continuous lifelong education.
The significance of social contexts of work in relation to nurses' psychological load was demonstrated by the finding that the lower the nurse's participation in decision-making, the less appreciation the nurse perceives (from superiors and from patients), and the worse she evaluates the quality of relationships in the workplace, the higher her degree of burnout. This statistical relationship between burnout and the degree of non/participation in decision-making is relatively the 'weakest' (sig. 0.045 = *); the other relationships are significant at the 0.000-0.01 level (***-**).
Suggestions and Recommendations
1. Regarding Physical Load
Based on the knowledge gained from the research, many years of personal experience with the issue of managing physical load and from our own pedagogical practice, we recommend for the area of education (A), for nursing practice (B) and for the area of nursing care management (C): A: In the preparation of nurses for the profession, pay attention to the issue of targeted prevention and protection of nurses' health from excessive physical load and introduce it into the content of educational programs of undergraduate and specialization studies as well as into continuing education of nurses. B: When amending the Decree of the Ministry of Health of the Slovak Republic No. 428/2006 Coll. on minimum requirements for staffing and material-technical equipment of individual types of healthcare facilities, we recommend supplementing the minimum material-technical equipment of wards with: - hydraulic equipment facilitating lifting, handling and transfer of immobile patients, - ergonomic equipment of wards in line with the prevention of excessive physical load of healthcare workers and equipping especially patient hygiene facilities with aids and technical equipment facilitating locomotion for people with limited and reduced mobility. C: In nursing practice, as a prerequisite for targeted prevention and protection of nurses' health, we recommend that nurses in managerial positions actively participate in creating safe working conditions in accordance with applicable legislation.
We prepare nurses through education for nursing practice. If a nurse is to provide nursing care to patients in a qualitatively humane and highly professional manner, she should be in good physical and psychological condition. When a nurse is unwell, something is also lacking in what she does for others. Therefore, self-care is just as important as caring for others.
2. Regarding Psychological Load
Based on the knowledge gained from the research, we recommend for the area of education (A) and for nursing practice, for the area of nursing care management (B): A: In the area of education, we propose the creation of an educational module and its inclusion in the educational program with content focused on effectively managing excessive psychological load and minimizing the psychological exhaustion of the nurse in providing nursing care: B: In practice, we propose: implementing systematic assistance – so-called supervision – in solving professional problems in a non-threatening atmosphere that allows understanding of the personal, especially emotional, contribution of the nurse to the professional problem. Regular, professionally conducted supervision by an experienced trained nurse is one of the best preventive measures against the development of burnout syndrome.
CONCLUSION
Just as physical health, psychological health does not exist and function independently. It manifests, strengthens and develops only in coordination with other conditions. In terms of the causes of nurses' load, we found that they have significant deficiencies particularly in knowledge and skills in the area of kinesiology and in the use of technical equipment to facilitate work with excessive load, but also in knowledge of the mechanics of their own body and the application possibilities of the principles of leverage, friction and inertia when performing patient handling and transfers. In terms of psychological load, it was shown that alongside the average degree of burnout, which is at the level of presence of burnout signals, 12% of nurses are in the zone of presence of burnout syndrome and in 2.4% we found a critical state of psychological exhaustion. However, it is noteworthy that the generally known linear increase of burnout with age/length of practice did not manifest in oncology departments or palliative care departments, which may indicate that nurses working there have specific personal prerequisites (mature personality, appropriate character traits, self-control and patience, together with social support).
In terms of coping strategies, nurses use effective and ineffective strategies equally often – the latter are focused on emotions and their processing and on mental disengagement. Unlike burnout, which shows a cumulative effect due to age/length of practice, the use of effective coping strategies was not higher in nurses with longer clinical practice. However, increasing age or length of practice in nurses are predictors of decreased use of less adaptive strategies of mental disengagement and escape through humor, thus representing an effect of a kind of gradual 'unlearning' of ineffective strategies.
We also found a determining role of social contexts of work in relation to nurses' psychological load – authentic responsibility for work is apparently a significant predictor of lower burnout levels. The lower the nurse's participation in decision-making, the less appreciation the nurse perceived from both superiors and patients, and the worse she evaluated the quality of relationships in the workplace, the higher her degree of burnout.
Our findings point to a 'spontaneous' development of psychological load, burnout and coping strategies in nurses, respectively confirm the absence of targeted training in the use of active coping and effective strategies for managing professional load, as well as the absence of systematic use of social contexts of nurses' work by healthcare management.
SUMMARY
The paper presents the issue of nurses' workload in nursing with a focus on prevention, protection and support of nurses' health.
We provide an overview of knowledge on physical load and preventive procedures protecting the nurse from excessive physical load in providing nursing care, and we address knowledge on psychological load, its management, stress and the risk of developing burnout syndrome in nurses.
In the empirical part, we assessed: a.) nurses' knowledge of prevention of risks from excessive physical and psychological load, b.) nurses' knowledge of ways of coping with physical load, as well as c.) nurses' strategies for coping with psychological load in relation to their degree of burnout, some characteristics of self-image and social contexts of work.
We monitored these aspects in nursing practice in various healthcare facilities in the Slovak Republic, focusing mainly on possible differences related to varying load (1) in different clinical nursing specialties and (2) during the development of the nurse's professional career.
We found a lack of technical equipment facilitating nursing care and supporting the prevention and protection of nurses' health during excessive physical load. We also found a lack of knowledge and absence of practical skills of nurses in managing physical load when handling immobile patients.
In the area of psychological load, we confirmed the presence of burnout signals and health risks for nurses resulting from excessive psychological load in providing nursing care. When examining nurses' choice of strategies for managing professional load, practically the same mean score was found for the use of effective problem-focused strategies as well as ineffective emotion-focused strategies and mental disengagement strategy.
Furthermore, we pointed out that to improve the quality of nurses' professional lives, it is not enough to only increase their individual professional, psychological and social competence, but it is also necessary to optimize the social conditions of work.
SUMMARY
The paper outlines the problems of work load in nursing. The theoretical part presents an overview of knowledge on physical load in nursing care, as well as a summary of relevant information in the area of psychic load, stress, coping and burnout processes in nurses.
In the empirical part, the focus was on assessment of the nurses´ a) knowledge about prevention of risk due to psychic and physical load, b) knowledge about ways of coping with physical load, and c) strategies of coping with psychic load, as related to: their burnout, self-concept, and social context of their work. These measures were evaluated in a variety of clinical specializations and in nurses along their professional career.
The most important findings concern: shortage of technical equipment alleviating the work of a nurse, knowledge deficit and absence of practical skills of nurses concerning the lifting of immobile patients. Concerning the psychic load, symptoms of burnout and signal of possible health risks resulting from excessive psychic load from nursing practice were identified. The examination of coping strategies has revealed that nurses use equally both effective strategies (focusing on problem solving) and non-effective strategies (emotional and psychic avoidance). Improvement of professional life of nurses requires - along with increasing their professional, psychological and social competencies – optimising work-conditions in nursing.
Autor: Dagmar Komačeková
REFERENCES
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The paper was presented at the 5th annual conference entitled 'Psychology of Health 2010', held on May 19, 2010 in Bratislava. The conference was organized by the Health Psychology Section of the Slovak Psychological Society at the Slovak Academy of Sciences in cooperation with the Health Section of the Ministry of Health of the Slovak Republic. The following also participated in the preparation of the event: the National Institute of Cardiovascular Diseases in Bratislava, St. Elizabeth University of Health and Social Sciences in Bratislava, the WHO Office in Slovakia, KISH Košice, the Department of Psychology of the Faculty of Arts of the Catholic University in Ružomberok and the Department of Psychology of the Faculty of Arts of the University of Trnava.
The proceedings of the 5th Conference on Health Psychology, Bratislava, 2010 were published only in electronic form Availability: http://www.prohuman.sk/psychologia/zbornik-prispevkov-z-konferencie-psychologia-zdravia-2010