That was 1979. What I experienced was not a personal failure; it was a reflection of the physical environment where I worked and how the work itself was structured. At the time, we lacked the evidence to fully understand these experiences differently. Decades later, we continue to frame these experiences as issues of individual resilience rather than system-driven problems. Given the evidence we have now, that’s a mistake and one that will continue to drive nurses out of the profession.

April is recognized as National Stress Awareness Month, but for nurses, stress is not something that appears once a year. It is embedded in the structure of daily work. My posts this month have focused on how chronic stress is experienced by nurses in hospital settings. What becomes clear across these frameworks and studies is that nurse stress is not incidental; it is structurally produced. There are many tools that have been devised over the years to measure occupational stress, but very few have been validated beyond small sample sizes.

However, there is one scale that has been well documented since 1989. It was created in partnership with the International Labor Organization (ILO) and the World Health Organization (WHO). I especially appreciate this tool since it focuses on system-driven stresses rather than those originating with an individual.

This scale has 25 items that are organized around 7 segments of labor activity: organizational climate, organization structure, leader influence, lack of cohesion, territory, technology, and group support. https://www.scribd.com/document/956387090/ILO-WHO-WORKPLACE-STRESS-QUESTIONNAIRE. A recent study reported this to be a reliable and valid scale for a population of workers in the Canary Islands. https://pmc.ncbi.nlm.nih.gov/articles/PMC9324391/#_ad93

The WHO defines occupational health as an area of work in public health that promotes and maintains the highest degree of physical, mental, and social well-being of workers in all occupations. https://www.who.int/health-topics/occupational-health. This definition clearly goes beyond the mere absence of disease.

In the WHO Guidelines for Mental Health at Work, psychosocial risks to mental health at work include the following ten risk factors. I’ve added my thoughts about how each is reflected and experienced by nurses in the hospital work setting.

1. Work content/Task design: For nurses, this would include fragmented work assignments

2. Workload and work pace: Nurses are being assigned too many high-acuity patients and experience significant pressure to complete tasks in a timely manner.

3. Work schedule: Inflexible work schedules with long hours and rotating shifts.

4. Control: Nurses often have little control over workload and decision-making.

5. Environment and equipment: Excessive noise on units, along with poor lighting and industrial spaces where nurses can take a break.

6. Organizational culture and function: As complex organizations, health systems often have complicated bureaucracies, which make problem-solving and organizational change difficult.

7. Interpersonal relationships at work: bullying, harassment, and microaggressions have been documented in the literature, with a lack of perceived or actual social support.

8. Role in organization: Nursing leadership is often under pressure from central administration to achieve certain goals. This can, on occasion, result in role ambiguity and/or conflict.

9. Career development: Although nursing has encouraged staff nurses to advance in their education, working conditions are rarely modified to meet educational goals without adding more stress.

10. Home-work interface: Nurses often experience conflicting demands of work and home, and when forced to choose one over the other, work is usually the default choice, leading to more stress.
https://www.who.int/publications/i/item/9789240053052

Additional references that are especially relevant for nurses were cited to support these findings. Across systematic reviews and meta-analyses, consistent associations emerge between system-driven workplace stressors and depression, medication use, exposure to violence, and burnout. This reinforces that these are not isolated experiences, but rather, patterned outcomes as evidenced in the following:

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data.
https://pubmed.ncbi.nlm.nih.gov/28122650/

Workplace bullying and mental health: a meta-analysis on cross-sectional and longitudinal data. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135225

Work-related exposure to violence or threats and risk of mental disorders and symptoms: a systematic review and meta-analysis. https://pmc.ncbi.nlm.nih.gov/articles/PMC8506313/

Long working hours and depressive symptoms: systematic review and meta-analysis of published studies and unpublished individual participant data. https://pubmed.ncbi.nlm.nih.gov/29423526/

Exposure to work stress and use of psychotropic medications: a systematic review and meta-analysis. https://pubmed.ncbi.nlm.nih.gov/30914444/

In their recommendations, the authors of this report state that these risk factors are universal and can be applied to any workforce or work setting, beginning with an assessment. Furthermore, this assessment should be an ongoing process, with careful monitoring of protocols or any changes that may be implemented that could impact mental health.

These are not risk factors that are exclusive to the US or any specific country. Similar risks can be found in many regions of the world, as noted in the following:

Denmark
Psychological Well-Being Among Nursing Staff in an Emergency Department: A Mixed-Methods Study. https://pubmed.ncbi.nlm.nih.gov/39614856/

South Korea
Emotional Labor, Burnout, Medical Error, and Turnover Intention among South Korean Nursing Staff in a University Hospital Setting. https://pubmed.ncbi.nlm.nih.gov/34639412/

Germany
Health status, health behavior and perceived stress of nursing staff in Germany: a scoping review
https://pubmed.ncbi.nlm.nih.gov/41514235/

Australia
Understanding the Experience of Workplace Violence in Hospitals as Documented by Nursing Staff. https://pubmed.ncbi.nlm.nih.gov/39540452/

Any interventions designed to minimize risk to mental health should also be careful to integrate cultural differences, acknowledging that workers from diverse socioeconomic backgrounds may be disproportionately impacted.

Nurses have described these stress-producing experiences for decades. These are not new observations. Rather, the latest analyses show a pattern in workload, expectations, and the quiet erosion of control over one’s work. This growing body of evidence is now validating what nurses have been saying all along.

Perhaps the question is no longer whether hospital nurses are experiencing stress in their workplace. Continuing to measure stress without meaningfully reducing it does little to address the conditions that produce it. The urgent question now is whether we are willing to look closely at the system-driven stresses that sustain it and what it would take to change them. The focus must shift from individual resilience to organizational responsibility.

The evidence is already here. The question now is whether we are prepared to act on it.

There is a significant amount of research linking the physical environment to chronic stress. We often sense that when a space feels calm, it can create a sense of peace. And the opposite is also true. But how can this understanding be translated into action within a hospital unit?

I’ll begin by stepping back in time to the ancient Greeks, well before there were hospitals as we know them today. Asclepieia were public healing centers that were considered sacred spaces for restoration and care. They were usually located in idyllic settings, surrounded by nature, with relaxing views, and some even included thermal springs. The Greeks also had an appreciation for the healing effect of music, which was incorporated along with poetry in designing an Asclepieion. These healing centers numbered over 300, not only in ancient Greece but throughout the Mediterranean region. A short but very interesting article on the origins of this approach can be found here ( Pavli &. Maltezou, 2024).

During the medieval and Renaissance periods, hospitals were largely run by church-based monasteries. The focus continued to be on locations close to nature, rather than in towns where there was more crowding, dirt, and noise. This approach continued until the 16th century, when many of these hospitals were taken over by secular institutions either at the local or state level. It’s easy to forget that modern hospitals, as we know them now, didn’t begin to take shape until the mid-19th century, when doctors became professionalized and began to take an active role in how these facilities were organized and operated.

But it wasn’t until the brilliant statistical work of Florence Nightingale during the Crimean War that a deeper appreciation for the role of the environment helped move hospitals from places of death and dying to places of health and healing. Although many of her findings related to sanitation were applauded and implemented, there was significant resistance to her recommendations related to noise, light, and ventilation, primarily from the medical establishment whose focus was increasingly on efficiency and cost-effectiveness, much like today.

Fast forward to the present, and a kind of renaissance in thinking is taking place around the impact of the environment on health. Two specific specialties within the field of architecture are receiving increased attention: Biophilic Design and Neuroarchitecture.

“Biophilic design as a discipline refers to an innate human connection to nature and natural processes, and the fulfilment of this connection promotes health and well-being in the environment we inhabit” (Tekin, B. H., Corcoran, R., & Gutiérrez, R. U. (2023).

Neuroarchitecture also explores how spaces impact health, more specifically, psycho-neurological health. For example, research conducted at the University of California, Davis found that amber-toned lighting can significantly reduce stress. Interestingly, this is the color most often found in sunrises and sunsets.

Revisiting the work of Nightingale, we can find evidence of her thinking along many of these same lines in her Notes on Nursing – from 1863!

“Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect”.

“Second only to air is light as an essential for growth, health, and recovery from sickness — not only daylight, but sunlight — and indeed fresh air must be sun-warmed, sun-penetrated air”.

“It is the unqualified result of all my experience with the sick that, second only to their need of fresh air, is their need of light; that, after a close room, what hurts them most is a dark room and that it is not only light but direct sunlight they want”.

When I think back on the hospital ward I describe in my YouTube video, I can see that at least some of the stress I experienced was shaped by the physical environment itself. It was grey and dreary, with very little natural light. There was constant noise, especially around the nurses’ station, where many students and residents would gather. We charted in a small, narrow space, no bigger than a walk-in closet by today’s standards. There were no desks, only a narrow counter. There were many charts strewn throughout the main desk and charting space, and in neither were there any windows. Ventilation was poor.

The environment in most hospitals today has improved, but continues to carry some resistance to Nightingale’s teaching. Much of the lighting remains harsh. There is reliance on hospital-wide systems to provide adequate ventilation since windows cannot be opened, at least not in most US hospitals. This is different in many European hospitals, where windows are able to open at least enough to provide fresh air.

In their research, Tekin et al. (2023) reviewed nine studies to identify which biophilic elements were most important in clinical environments, considering both patient and staff perspectives. Both groups identified the use of natural materials, natural colors, fresh airflow, and access to natural light as important elements in a therapeutic environment. Staff, in particular, emphasized the importance of having a window in break rooms:

“When I had a window, it made all the difference in the quality of my day, being able to look out and see what was going on, I think the access to a view or to daylight and to the changing of the time of the day and the seasons is critical to the mental health and well-being of the staff.” (Tekin et al. 2023)

Obviously, it would be difficult to make these structural changes in an established setting. But there are ways to improve existing environments that may help reduce stress for both patients and staff. Consider the physical space that nurses go to for a break, lunch, or unit meetings.

What type of lighting is used?
Are there any elements that reflect or represent nature?
Does it feel industrial, or is there a sense of calm?
Are there persistent or unpleasant odors?
This is a space that nurses have some control over on their unit.

These same questions can also be applied to patient spaces. In the discussion on LinkedIn, one issue that emerged involved patients and families who were perceived as demanding. With an understanding that patients are also feeling the impact of a stress-inducing physical environment, it’s not surprising. The truth is: happy patient, happy nurse!

Florence Nightingale said it plainly:

“Bad sanitary, bad architectural, and bad administrative arrangements make it impossible to nurse.”

I hope this has provided some food for thought. If you are currently working in a hospital setting, take a moment to look around and consider what small changes in the physical environment might help reduce stress—for both you and your patients. Discuss this with colleagues, and consider how you might collectively take back some control of these spaces.

If this resonates with you, I continue to explore these ideas through my videos and reflections. You’re always welcome to explore them here:
https://nursingprofessor.com/link-hub

If this piece spoke to you and you’d like to support my work, a cup of coffee is always appreciated, so I can continue to share these reflections.
https://buymeacoffee.com/nursingprofessor

Thank you for being here.

I’m Nonna Nurse—sharing a little warmth and wisdom. Pass it on.

REFERENCES

UC Davis (July 28, 2025). The Color lab uncovers the soothing effect of light. https://www.ucdavis.edu/health/news/color-lab-amber-light-eases-stress-anxiety

Kellert, SR & Calabrese, EF. (2015). The Practice of Biophilic Design. www.biophilic-design.com

Pavli, A., & Maltezou, H. C. (2024). Asclepieia in ancient Greece: pilgrimage and healing destinations, the forerunner of medical tourism. Le infezioni in medicina, 32(1), 113–115. https://doi.org/10.53854/liim-3201-15

Rs Barcelona (n.d.). Neuroarchitecture: How spaces shape the way we work. https://rsbarcelona.com/en/blogs/news/neuroarchitecture-how-spaces-shape-the-way-we-work?srsltid=AfmBOoqkSO7NPnWhGo29JQ2e1a_dTGXuBiKsUHHKlxHxn7NrxZk0XHJo

Tekin, B. H., Corcoran, R., & Gutiérrez, R. U. (2023). A systematic review and conceptual framework of Biophilic Design parameters in clinical environments. HERD, 16(1), 233–250. https://doi.org/10.1177/19375867221118675

So, I had to stop and ask myself: What would I really be contributing?

As a practitioner, when I sit with someone who is clearly under a great deal of stress, I don’t begin with pathways or hormones. I begin by acknowledging what is right in front of me. And then, gently, I begin to ask: What is causing this?

In my first article, I named what so many nurses are experiencing: chronic stress.
But naming something is only the beginning. Now, I want to take a deeper look at the causes, with a focus on hospital-based nurses.

The literature has quite a lot to say about this.
And yet… I noticed something strange in the way stress was being addressed in this context. When I looked at several studies from outside the United States, the language is direct, clear, and unapologetic. Researchers use terms like stress and occupational stress without hesitation. But when I turned to studies from within the U.S., something seemed to shift.
What nurses are experiencing is no longer called stress. It’s called burnout.

Both sets of articles were addressing the same experiences that we all know too well:
* Challenging working conditions with insufficient staffing ratios, nurse shortages, physical exhaustion, and even the risk of violence.
* An organizational climate that too often results in incivility and bullying, as well as ageism and other forms of discrimination.
* Moral distress and emotional exhaustion from the daily exposure to suffering, death, and how these are managed.

So why is there a difference in the language we use to describe the same experiences?
Is there a difference between stress and burnout? Or are they the same?

Let’s dive a little deeper – and spoiler alert, they are NOT the same! Let’s look at the evidence.

The International Classification of Diseases (ICD) is an international coding system for the classification of diseases. It’s created by the World Health Organization (WHO). In 2018, an 11^th edition was released, becoming effective in 2022. As of 2025, more than 60 countries have adopted it (WHO, n.d.).

This is NOT the same ICD coding structure that is currently used in the US, expressly for the billing of health services, although the ICD-11 is under review (Feinstein et al., 2023). However, countries such as Norway, Canada, the Netherlands, Finland, and Thailand are leading adopters in using it not only for public health reporting but also for clinical reimbursement.

The ICD-11 helps us to better understand the difference between stress and burnout. It defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” (WHO, May 28, 2019).

And there it is! Chronic stress in the workplace is a CAUSE of burnout. These two words are very different.

The ICD-11 goes on to describe the symptoms of burnout as being characterized by three dimensions:
* feelings of energy depletion or exhaustion;
* increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
* reduced professional efficacy.

Understanding this difference now leads to the next question:

Why has burnout become the language we focus on in the US, while many other countries directly address its cause?

Perhaps the answer lies in the fact that burnout describes what the nurse is experiencing internally. It’s very personal. Chronic workplace stress, on the other hand, describes the conditions in the work setting that lead to burnout. The ICD-11 defines burnout not as a disease, but as an occupational hazard caused by a system that creates a stressful environment. If the focus is placed on this environment, it becomes the system’s responsibility to address it.

It comes down to the difference between personal and institutional responsibility. The US has a very complex health care system that focuses on outcomes, so it makes sense that burnout, as an outcome, is its immediate concern. This is especially relevant since the research points to burnout as directly impacting patient outcomes (Li et al., 2024). An additional benefit to the institution when focusing on burnout is to then shift the responsibility for managing it to the nurse.

Words have meaning. Meaning develops into beliefs. Beliefs shape behavior and actions. Putting the focus on burnout leads to the belief that nurses need to address this personal issue. They are encouraged to become more resilient. Perhaps they need to seek help, counseling. There is movement now to encourage self-care among nurses. The American Nurses Association has a free, ongoing initiative to support nurses’ well-being called Healthy Nurses, Healthy Nation (HNHN, n.d.). It’s organized around six domains: physical activity, rest, nutrition, quality of life, safety, and mental health. This is a wonderful endeavor, but these are health-promoting practices that benefit everyone!

So why do nurses need to be especially targeted? To mitigate burnout.

This underscores again that the responsibility lies largely with the nurse and not the institution where she/he works. In their 2025 report for this initiative, I found very little that addressed the workplace environment that creates chronic stress leading to burnout. The only hint can be found in these two sentences: “Advocate for healthy work environments. Collaborate with colleagues to identify and suggest improvements and speak up for policies that support well-being” (ANA, 2025). But even this does not address systemic factors creating chronic stress and leading to burnout. Meanwhile, the system keeps functioning with the same factors that created nurse burnout.

Let’s be clear. The primary cause of chronic stress experienced by hospital-based nurses is not their inability to cope or poor life-work balance. Chronic stress is caused by a work environment that invests time in quickly improving outcomes, while lacking a true understanding and appreciation for the root causes of burnout. This is amplified by a culture outside the institution that urges increasing financial and material gain at the expense of individual well-being.

Now that I’ve shared my views on the real causes of chronic stress and burnout among acute care nurses, I will add that none of this is entirely new. I had my first job in 1974 in a 45-bed male ward in New York City. Check out this and my other acute care nursing stories here.

RESOURCES
The following are some very helpful videos that are easy to understand and will help get you up to speed in understanding the stress response.

2-Minute Neuroscience: HPA Axis
These are created by a professor at Penn State who clearly loves his work . He has other well-done videos as well, so check them out!

Hypothalamic Pituitary Ovarian Axis | Female Reproductive System
These videos are created by Dr. Matt and Dr. Mike – two award-winning university professors who cover a whole range of topics in physiology and pathophysiology in very easy-to-understand ways. A great resource!
If this piece spoke to you, and you’d like to support my work, you can buy me a coffee. Thank you for being here.

REFERENCES
ANA (2025). Healthy Nurses, Healthy Nation. 2025 Report. https://www.healthynursehealthynation.org/globalassets/2025-hnhn-report.pdf

Feinstein, J. A., Gill, P. J., & Anderson, B. R. (2023). Preparing for the International Classification of Diseases, 11th Revision (ICD-11) in the US Health Care System. JAMA Health Forum, 4(7), e232253. https://doi.org/10.1001/jamahealthforum.2023.2253

HNHN (n.d.) Healthy Nurse, Healthy Nation. https://www.healthynursehealthynation.org/

Li, L. Z., Yang, P., Singer, S. J., Pfeffer, J., Mathur, M. B., & Shanafelt, T. (2024). Nurse burnout and patient safety, satisfaction, and quality of care: A systematic review and meta-analysis. JAMA Network Open, 7(11), e2443059. https://doi.org/10.1001/jamanetworkopen.2024.43059

WHO (n.d.). International classification of diseases and related health problems. https://www.who.int/standards/classifications/classification-of-diseases

WHO (May 28, 2019). Burn-out an “occupational phenomenon”: International Classification of Diseases. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

On the nursing student juggling work, family, and school?

On the nursing faculty member, trying to adapt to institutional pressures, while something in their gut says, this doesn’t feel right?

On the person living with multiple symptoms that no one has been able to diagnose… or help manage?

Our bodies are designed with specific mechanisms to deal with acute stress. We would never have been able to survive as a species without it! It’s a built-in safety mechanism—one that signals danger and prepares the body to respond.

Some of us already know how acute stress affects the body, but even if we don’t know the exact science, we feel it.

This might be someone who is physically threatening you, but more often, it’s simpler, just as powerful. It might be the stress of trying to keep an appointment while driving in terrible traffic. Or maybe it’s a disagreement that turns into an argument with a friend or family member.

Let’s take a moment to quickly review what happens when our body perceives danger – an episode that triggers acute stress.

When a threat is perceived, your body releases hormones like cortisol, along with adrenaline and noradrenaline.

Your heart rate increases. This helps your blood to flow to vital organs and power the muscles needed to respond.
Breathing becomes more efficient, maximizing oxygen intake. In some people, this can trigger underlying conditions like asthma.

Glucose and fats are released into your bloodstream to provide immediate energy, while cortisol helps maintain those elevated levels, something that can be especially significant if you have diabetes.

At the same time, some systems are temporarily shut down because they aren’t needed for your survival in this situation.

Your gastrointestinal system slows or becomes disrupted, leading to symptoms like constipation or diarrhea.
Your reproductive system is affected, sometimes changing menstrual cycles or impacting fertility.
And your immune system becomes less responsive, making your body more vulnerable to infection.
This is acute stress.
It’s time-limited, usually lasting only a few days or at most a few weeks. It resolves. Your body returns to baseline, or what we call homeostasis.

But what happens when it doesn’t?
What happens when the stress isn’t limited to a brief period of time but rather becomes a part of our daily lives?
That is where chronic stress begins.

And that is where the story changes.

So what is chronic stress?
Chronic stress is not a single event. It’s stress that is ongoing and doesn’t resolve.
Your body remains in that state every day, sometimes for months or even years.
And over time, that begins to change how your body functions.

Normally, with acute stress, there is what we call a feedback mechanism that signals various systems that the threat is over, and everything can now go back to normal.

However, when there is chronic stress, that message is not received. Everything doesn’t go back to normal. And the system that protected you during acute stress is no longer functioning. Some people might refer to this as adrenal fatigue even though that’s not recognized as a medical diagnosis.

During chronic stress, your cardiovascular system remains at high alert.
Your heart rate and blood pressure may stay elevated, increasing the risk for long-term complications.

The metabolic system is also affected.
When your cortisol levels remain elevated, it can contribute to insulin resistance, weight changes, and worsening control in conditions like diabetes.

The gastrointestinal system does not fully recover.
Symptoms such as bloating, constipation, diarrhea, and changes in appetite are no longer occasional disturbances but rather ongoing issues that can impact the quality of life.

The immune system becomes dysregulated.
There may be increased susceptibility to infection, as well as a shift towards chronic inflammation, setting up your physiology for chronic illnesses.

Your nervous system adapts to a constant state of alertness.
Sleep becomes disrupted. Focus becomes more difficult. Your body may begin to interpret even minor stressors as significant threats. And this is when we see more depression and anxiety as well.

Most importantly—chronic stress is not always recognized.
It’s often normalized.

For the nursing student, it can look like constant exhaustion, difficulty concentrating, and the feeling of never quite catching up.

For nursing faculty, it may be expressed as increased anxiety due to work that never seems to end and expectations that are often impossible to meet.

For individuals with complex or undefined illnesses, chronic stress can both contribute to symptoms and complicate the process of being heard, diagnosed, and treated.

Over time, the line between cause and effect becomes less clear.
Is the stress driving the symptoms?
Or are the symptoms driving the stress?

Often, it’s both.
This is why chronic stress matters.
It’s not simply a concept, but rather something that lives in your body, across systems, over time. Something that can increase the risk of chronic illnesses and significantly impact your quality of life.

In the end, the important question is this:
Is it worth these risks?

We often tell ourselves that we don’t have a choice. This is life.
Or perhaps we say it’s temporary.
So, we keep pushing through.

As someone who has lived on this path, I encourage you to pause for a moment and consider your options. Over two decades ago, I didn’t, and I continue to live with the consequences. If you’d like to hear more, I share a bit of my own experience with chronic stress in a brief video.

In the next post, I’ll explore what happens when stress begins to shape your symptoms—and why health professionals so often miss those symptoms. This is also where nurses, and especially nurse practitioners, can make a significant difference.

If you’re a nurse, student, or simply someone trying to make sense of health and illness in all its human complexity, you’re welcome here.

Pull up a chair.

Subscribe now

Subscribe now