It Was Never about Resilience: The Structure of Stress in Nursing
How working conditions, and not personal weakness, continue to create chronic stress for hospital nurses.
I left my first job as a nurse in a 45-bed male ward after only nine months, a story I later explored more fully in my autoethnographic memoir. I experienced chronic stress and exhaustion, and I believed I simply couldn’t cope. I was wrong.
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.