Commentary on Su SF, Boore J, Jenkins M, Liu PE & Yang MJ (2009) Nurses’ perception of environmental pressure in relation to their occupational stress. Journal of Clinical Nursing 18, 3172–3180


Stina Fransson Sellgren, Deputy Director of Nursing, Karolinska University Hospital, SE 12067, Stockholm, Sweden. Telephone: +46 851775849.

How nurses feel at work influences their ability to give high-quality care and also the intention to stay in the current workplace. The nature of nursing in critical care, where you deal with life and death every day, makes it impossible to exactly know what is going to happen the next minute, the next hour or the next shift. To be able to work as a nurse during those circumstances, place demands on the nurses to be flexible and resistant to stress. Although the nurse is stress resistant, environmental issues such as nurse shortages, increased workload and conflicts between staff can put strain on the individual, decrease job satisfaction and result in negative stress symptoms.

In their paper, Su et al. (2009) explored stress experiences of the critical care nurses (CCN) and analysed key factors that can be seen as stressors. They also relate their study to the current situation in Taiwan, with a decreased budget for care from the National Health Insurance and demands for accreditation. In-depth interviews were used based on a grounded theory methodology.

In-depth interviews are not usually used to explore occupational stress. More common is the use of validated questionnaires such as the Nursing Stress Scale (Gray-Toft & Anderson 1981), the Source of Occupational Stress Scale (Sveinsdotir et al. 2006) or the Personal Strain Questionnaire used among hospital nurses in China (Wu et al. 2010). The authors have not discussed why they choose in-depth interviews, and it would have been interesting to know the rational for the choice. It would have been interesting to compare the results from the CCN in Taiwan with results from other studies and countries if the same methods had been used.

When conducting research on stress, a definition of the phenomenon is helpful. In the present paper, unfortunately, no such definition of stress is described. Stress is a subjective perception and therefore hard to define. What is stressful for one person may be stimulating for another. Stress is related to both external factors including environment and internal factors that determine your body’s ability to respond to and deal with the external stress-inducing factors. Stress is not always harmful. There is also healthy stress that gives you extra energy, and this must be considered when studying stress (Selye 1975). Occupational stress is stress at work. Negative stress occurs when there is a discrepancy between the demands of the environment/workplace and an individual’s ability to meet these demands (Jonge et al. 2005). In this paper, the authors focus on factors in the environment that cause negative stress.

Two major occupational stressors were identified by Su et al. (2009)– first, the trend of hospital re-organisation and second, the cultural burden of nurse’s role. Decreased budget for health care is not only a problem in Taiwan but is a universal problem resulting in limited hospital finances. The reason is often an ageing population within the same amount of tax revenue. This unbalance often results in an increased workload – more work per nurse. Increased workload and growing occupational stress among nurses have been identified in many countries and result in declining job satisfaction (Blegen 1993, Sellgren et al. 2009) and an increased turnover rate (Shader et al. 2001). With insufficient manpower, there is a high risk for decreased quality of care and patient safety (Bailit & Blanchard 2004, Sochalski 2004). Understaffing can result in more hospital deaths (Aiken et al. 2002). Extended work shifts and overtime are also escalating in nursing as a result of staff shortages (Rogers et al. 2004), which can also cause increased workplace stress among nurses (Park et al. 2010).

The perceived stressor of coping with hospital accreditation is also a worldwide phenomenon. In almost every country, there is some form of accreditation or quality comparison between hospitals often linked to money. To be able to cope with this, the manager has to involve nursing staff in the process. Teamwork within interdisciplinary teams is essential for the success, and negative stress could be avoided or at least reduced by ensuring this happens (Sellgren et al. 2009).

The second stressor, the cultural burden of nurse’s role is also a universal problem although its impact on nurses today certainly varies between countries and continents. The nursing role is often placed lower down the hierarchy in health care settings. Chinese nurses may neither have had the opportunity to self-select nursing as their profession nor to discuss dissatisfaction with their work (Li & Lambert 2008). Su et al. (2009) discuss the Taiwanese nurse’s role as an extension of the traditional subservient role including sacrificing oneself for the patient. Role insufficiency was also one of the two major factors associated with stress in a Chinese study (Wu et al. 2010). Professional status is therefore important for one’s self esteem and the feeling of being valued.

Organisational changes with increased workload, no or little influence on decisions and a difficult professional role were identified as stressors in this study and in others. If nurses have opportunity to take part in the change process, it will be easier to motivate and less frustrating. Decisions makers all over the world need to take into account that adequate and well-educated nursing staff are necessary to achieve patient safety.