Original Research

Journal of Intensive Care Medicine

1-12
Effects of Stress on Critical Care Nurses: ª The Author(s) 2017
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A National Cross-Sectional Study DOI: 10.1177/0885066617696853
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Amir Vahedian-Azimi, PhD, RN1, Mohammadreza Hajiesmaeili, MD2,

Mari Kangasniemi, PhD3, Joana Fornés-Vives, PhD4, Rita L. Hunsucker, DNP5,
Farshid Rahimibashar, MD6, Mohammad A. Pourhoseingholi, PhD7,
Leily Farrokhvar, PhD8, Andrew C. Miller, MD5,
for the MORZAK Collaborative

Abstract
Background: Health care is a demanding field, with a high level of responsibility and exposure to emotional and physical danger.
High levels of stress may result in depression, anxiety, burnout syndrome, and in extreme cases, post-traumatic stress disorder.
The aim of this study was to determine which personal, professional, and organizational variables are associated with greater
perceived stress among critical care nurses for purposes of developing integrative solutions to decrease stress in the future.
Methods: We conducted a correlation research survey using a cross-sectional design and an in-person survey method. The
questionnaire consisted of 2 parts: (1) socioeconomic, professional, and institutional variables and (2) work stressors. Surveys
were conducted between January 1, 2011, and December 1, 2015. Multistage cluster random sampling was utilized for data
collection. Inclusion criteria were (1) age 18 years, (2) registered nurse, (3) works in the intensive care unit (ICU), and (4) willing
and able to complete the survey. Results: We surveyed 21 767 ICU nurses in Iran and found that male sex, lower levels of peer
collaboration, working with a supervisor in the unit, nurse–patient ratios, and working in a surgical ICU were positively associated
with greater stress levels. Increasing age and married status were negatively associated with stress. Intensive care unit type (semi-
closed vs open), ICU bed number, shift time, working on holidays, education level, and demographic factors including body mass
index, and number of children were not significantly associated with stress levels. Conclusion: As the largest study of its kind,
these findings support those found in various European, North, and South American studies. Efforts to decrease workplace stress
of ICU nurses by focusing on facilitating peer collaboration, improving resource availability, and staffing ratios are likely to show
the greatest impact on stress levels.

1
Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical
Keywords Sciences, Tehran, Iran
stress, burnout syndrome, PTSD, critical care, nursing 2
Anesthesia and Critical Care Department, Anesthesiology Research Center,
Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences,
Tehran, Iran
3
Department of Nursing Science, University of Eastern Finland, Kuopio,
Background Finland
4
Department of Nursing and Physiotherapy, University of the Balearic Islands,
The nursing profession is among the largest workforce in most
Palma, Spain
industrialized countries.1 Globally, we are experiencing a wor- 5
Department of Emergency Medicine, J.W. Ruby Memorial Hospital, West
sening nursing shortage. Based on 2014 census data, Iran (pop- Virginia University, Morgantown, WV, USA
6
ulation 75 million) requires a nursing labor force of Department of Anesthesiology and Critical Care, School of Medicine,
approximately 240 000; however, currently it has only 100 Hamedan University of Medical Sciences, Hamedan, Iran
7
Gastroenterology and Liver Diseases Research Center, Research Institute for
000 nurses.2 As more nurses exit the profession, the individual
Gastroenterology and Liver diseases, Shahid Beheshti University of Medical
workload of remaining nurse’s increases, patient safety is jeo- Sciences, Tehran, Iran
pardized, job satisfaction decreases, and employer costs 8
Department of Industrial and Management Systems Engineering, Benjamin M.
increase to replace those nurses.2 Statler College of Engineering and Mineral Resources, West Virginia University,
Not all drivers of the global shortage can be mitigated. As in Morgantown, WV, USA
most industrialized nations, the elderly population is among Received December 30, 2016. Received revised February 2, 2017.
Iran’s fastest growing populations. 2,3 Communicable and Accepted for publication February 8, 2017.
chronic diseases are an increasing burden. 3 Other factors
include underinvestment in human resources (HRs), inadequate Corresponding Author:
Andrew C. Miller, Department of Emergency Medicine, J.W. Ruby Memorial
HR planning and management, migration, and high attrition. Hospital, West Virginia University School of Medicine, 1 Medical Center Drive,
Attrition occurs due to poor work environments, low satisfac- Morgantown, WV 26506, USA.
tion, inadequate salary, and high stress.1,2 Stress has a negative Email: taqwa1@gmail.com
2 Journal of Intensive Care Medicine XX(X)
impact on nurses and patient outcomes; however, those practi-
cing in critical care settings experience high levels of
burnout.4,5
The aim of this study was to determine which personal
sociodemographic, professional, and organizational variables
are associated with greater perceived stress among critical care
nurses in Iran for the purposes of developing integrative solu-
tions to decrease stress in the future.
Methods
Study Design
We conducted a correlation research survey using a cross-
sectional design and an in-person survey method. The study
was approved by the investigative review board at Baqiya-
tallah University of Medical Sciences (Tehran, Iran). Since
the research presented no more than minimal risk of harm to
participants and involved no procedures for which written
consent is normally required outside the research context,
the principle of implied consent was employed. Namely,
that by completion of the survey instrument, the participant
demonstrated their willful consent to participate. In accor-
dance with institutional review board (IRB) requirements,
the investigator provided participants with a written
informed consent statement regarding the research.
Although Iranian medical ethics laws (http://mehr.tums.a
c.ir/Codes.aspx) do not specifically address this topic, it is
in accordance with other international ethics codes and laws
including the US Federal Code of Regulations (45 CFR
46.117c). All parts of the study were reviewed according
to the Strengthening the Reporting of Observational Studies
in Epidemiology statement. 6 Surveys were conducted
between January 1, 2011, and December 1, 2015. Multistage
cluster random sampling was utilized for data collection. In
the first step, 31 cities in Iran were selected. From each city,
10 hospitals were selected through cluster random sampling
with replacement to decrease selection bias, once in the first
and second steps, respectively. In the second step, 5 hospi-
tals with more than 100 working nurses in critical care units
(CCUs) were selected through cluster random sampling. In
5 cities, all hospitals had fewer than 100 critical care nurses,
in which case all 10 hospitals were selected. Participant
inclusion criteria were (1) age 18 years, (2) registered
nurse, (3) works in the intensive care unit (ICU), and (4)
willing and able to complete the survey.
Following the baseline stress measurement, a stress
intervention was performed during which a 90-minute edu-
cational presentation on stress management was adminis-
tered, followed by posting of educational stress
management flyers in the clinical area (main ingress/egress
ICU doors, nursing station, clinical work tables, library
room door, call room door, rest room door). The poster
remained up for 1 month. Repeat stress measurements were
then performed at 15 days, 3 months, and 6 months
postintervention.
Sample Size
The sample size was calculated based upon the results of the
pilot study.7 In the pilot study, an odds ratio (OR) of 0.90 was
observed for the association between years of experience and
stress levels.7 By considering this OR, with proportion of stress
of 0.50, 95% confidence level, and 90% power, sample size
was calculated as 21 767 nurses. Sample size calculation was
performed using G-Power 3.1.2 software (available at http://
www.gpower.hhu.de/).8 Considering a 20% dropout rate, the
final sample size reached a total of 17 414 nurses.
Data Collection
Investigators hand-delivered sealed envelopes containing a
project summary letter and the questionnaire to certified criti-
cal care nurses in the clinical environment. If the nurse con-
sented to participate, the charge nurse arranged for coverage of
clinical duties while the survey was completed (usually 10-15
minutes). Upon completion, the form was returned to the
researcher in a sealed envelope provided in the initial packet.
Each de-identified questionnaire was then evaluated by a panel
of 3 investigators to determine suitability for inclusion based
upon data completeness and nurse certification status. The
survey was administered at 3 time points: (1) baseline
preintervention, (2) 15 days postintervention (3) 3 months post-
intervention, and (4) 6 months postintervention. All question-
naires were de-identified, labeled with a unique patient
identifier, and confidentiality maintained. Participants were
provided a unique identifier by a person not involved in survey
administration or statistical analysis. The key containing
patient names and identifiers was kept in a secure location
separate from surveys or data files.
Research Instrument
The questionnaire consisted of 2 parts: (1) socioeconomic, pro-
fessional, and institutional variables and (2) work stressors.
The utilized questionnaire was previously derived and vali-
dated using a 3 classic round Delphi technique.7 The surveyed
variables are socioeconomic (age, gender, marital status, num-
ber of children, body mass index [BMI]), professional (educa-
tion level and years of critical care nursing experience), and
institutional (shift schedule, frequency of working holidays,
city, hospital, ICU bed number, nurse–patient ratio, degree of
nursing collaboration type of CCU, ICU system, and having a
supportive supervisor). Collaboration was measured using a 5-
domain Likert-type scale (very low, low, moderate, high, and
very high). The presence of a supportive supervisor was mea-
sured using a yes/no scale. Part 2 of the questionnaire consisted
of a 22-item inventory of work stressors (Table 1) as previously
reported.7 The questionnaire items fell into 3 categories: inter-
active and communicative (questions 1, 2, 4, 11, 20, and 21),
managerial and administrative (questions 3, 9, 10, 12, 14, 15,
16, 19, and 22), and exclusive and situational (questions 5, 6, 7,
8, 13, 17, and 18). The respondents were asked to rate the work
Vahedian-Azimi et al 3

Table 1. Stressful Situations Instrument With 22 Items. items (slides 2-23), an invitation for open discussion of other
stressors (slide 24), and conclusion (slide 25). The poster was
1. Dealing with patient’s pain and suffering
2. Family presence
100  100 cm and contained the same content as the power
3. Heavy workload point presentation.
4. Relatives reaction
5. Time pressure Statistical Analysis
6. Communicating bad news
7. The necessity of having continual readiness for emergency Hierarchical logistic regression modeling was used to iden-
procedures tify those factors exerting a statistically significant effect on
8. Death & dying the nurse’s perceived stress levels. All statistical analyses
9. Staff shortage were performed using MLwiN software version 2.31. A
10. Non nursing tasks
11. Patients’ reactions
3-level model including nurse, hospital, and city data was
12. Physician not available constructed to reduce the total variation within the model.
13. Instability of patient’s clinical condition Forward selection was used to select the significant vari-
14. Lack of resources ables in the final model.
15. Working extra hours
16. Physicians’ demands
17. Decision making Results
18. Unpleasant tasks
19. Shift rotation Altogether 790 CCUs at 180 educational and private hospitals
20. Poor cooperation in dialysis, CCU, and ICU were involved, including ICUs (n ¼ 370), coronary care units
21. Poor cooperation & communication in other depts. (n ¼ 240), and dialysis units (n ¼ 180; Table 2). A total of
22. Disproportionate between salary and job hardness 21 767 participants were administered the survey, and 18 127
Abbreviations: CCU, critical care unit; ICU, intensive care unit. returned the survey, with 17 414 returning usable surveys. The
response rate of useful questionnaires was 80%. Sociodemo-
graphic and clinical features are summarized in Table 3. The
stressors on a 5-point Likert-type scale ranging from “causes mean age was 29 years with a female predominance (69%) and
me no stress” to “causes me extreme stress.” The minimum and a baccalaureate degree (74%) level of education. Most were
maximum scores of the instrument were 22 and 110, respec- married (89%) with children (79%). The average BMI was
tively. Based upon the results of the pilot study, the threshold 28.5. The average nurse-to-patient ratio was 2.78, and the mean
for significant stress was set at 67, with values higher than this years of clinical experience was 20. The mean ICU bed number
being indicative of significant stress.7 This cutoff was derived was 10.69. Sixty percent reported low or moderate levels of
using both quantitative and qualitative assessments. The quan- collaboration, and most were working in rotation shift (39%) or
titative portion was achieved by receiver operating character- evening shift (21%). The total stress score, mean (standard
istic curve analysis. The qualitative portion was accomplished deviation [SD]) measured was 69 (3). Using the threshold value
by the expert panel consisting of psychiatric nurses (n ¼ 5), of 67 determined in the pilot study,7 the incidence of stress in
psychologist (n ¼ 1), psychiatrist (n ¼ 1), ICU nurses (n ¼ 5), Iranian nurses was 71%.
CCU nurses (n ¼ 5), dialysis unit nurses (n ¼ 5), intensivists (n The association of stress and sociodemographic and clinical
¼ 3), cardiologists (n ¼ 3), nephrologists (n ¼ 3), and ICU features was analyzed using a hierarchical logistic regression
administrators (n ¼ 5). After the 2 sessions, the k agreement model (Table 4), with a univariate model as the crude OR and a
coefficient test was .89. backward selection model as the adjusted OR. In this hierarch-
ical logistic regression model, the estimated variance for level
of cities was 0.13 with standard error (SE) ¼ 0.014 (P < .001)
Intervention and the estimated variance for hospital type or level was 0.007
Following the baseline stress measurement, a stress interven- with SE ¼ 0.003 (P ¼ .019). Male gender was positively asso-
tion was performed during which a 90-minute educational ciated with increased stress in both crude (OR: 1.22; P < .001)
presentation on stress management was administered, fol- and adjusted models (OR: 1.19; P < .001). Increasing age had a
lowed by 1 month of posting educational stress management weak negative association with stress in the multivariate model
flyers in the clinical area (main ingress/egress ICU doors, (OR: 0.95; P < .001), as did years of clinical ICU experience
nursing station, clinical work tables, library room door, call (OR ¼ 1.04, P < .001). Marriage also displayed a negative
room door, rest room door). Repeat stress measurements were association with stress on both crude (OR ¼ 0.87, P ¼ .029)
then performed at 15 days, 3 months, and 6 months postinter- and adjusted analysis (OR ¼ 0.72, P ¼ .017). Lower levels of
vention. Presentation and flyer content were developed using collaboration (multivariate OR: 1.36, P < .001), working with a
the 3 classic round Delphi technique as previously described, supervisor on the unit (crude OR: 1.18; P < .001), and nurse–
with the previously described questionnaire items serving as patient ratios (multivariate OR: 1.17; P ¼ .05) were all
the primary content. The presentation was 25 slides including positively associated with greater stress levels. Working in a
an introduction (slide 1), a discussion of the questionnaire surgical ICU was associated with greater stress in the univariate
4 Journal of Intensive Care Medicine XX(X)

Table 2. The Number of Samples and Hospitals in Each Province of Iran.

No. of Selected No. of Nurses Given No. of Surveys No. of Unusable No. of Usable
Province Hospitals Surveys Returned Surveys Surveys

Ardabil 5 619 502 2 500

Esfahan 5 895 758 18 740
Alborz 5 497 402 2 400
Illam 10 489 403 3 400
Azarbaijan Sharghi 5 873 724 13 711
Azarbaijan Gharbi 5 650 513 13 500
Bushehr 5 690 524 24 500
Tehran 5 1155 966 10 956
Chaharmahal Bakhtiari 10 477 421 21 400
Khorasan Jonobi 5 664 514 14 500
Razavi Khorasan 5 1045 945 25 920
Khorasan Shomali 5 596 509 9 500
Khuzestan 10 768 618 18 600
Zanjan 5 562 432 32 400
Semnan 5 653 526 26 500
Sistan and Baluchestan 5 793 615 15 600
Fars 5 1082 919 17 902
Qazvin 5 507 411 11 400
Gom 10 481 334 43 301
Kordestan 5 663 558 24 534
Kerman 5 765 704 13 691
Kermanshah 5 659 549 49 500
Kohgiluyeh and Boyer- 10 593 476 76 400
Ahmad
Golestan 5 682 534 34 500
Gilan 5 674 521 21 500
Lorestan 5 597 519 19 500
Mazandaran 5 654 543 33 500
Markazi 5 776 708 24 684
Hormozgan 5 596 532 32 500
Hamadan 5 662 549 49 500
Yazd 5 950 898 23 875
Total 180 21 767 18 127 713 17 414

but not multivariate model. The ICU type (semi-closed vs open)
was not associated with stress in both models. No closed ICUs
were surveyed. Intensive care unit bed number, shift time, work-
ing on holidays, education level, and demographic factors
including BMI, and number of children were not significantly
associated with stress in univariate or multivariate models.
Baseline scores on the stress questionnaire were 94.7 (6.7).
Following the stress education intervention, mean scores were
71.7 (4.8) at 15 days postintervention, 64.9 (4.9) at 3 months
postintervention, and 57.1 + 5.4 at 6 months postintervention.
Stress scores decreased during the study overall, as well as
within both the lower (score 67) and higher (score >67) stress
subgroups (Table 5). Differences between subgroups were not
significant at baseline or measurements 2 or 3, reaching sig-
nificance only at measurement 4. Improvements were seen in
each of the 3 categories: interactive and communicative, man-
agerial and administrative, and exclusive and situational. The
observed attrition rate for completed and returned question-
naires from baseline to measurement 2 was 1828, from mea-
surement 2 to 3 was 1611, and from measurement 3 to
measurement 4 was 914.
Discussion
In the 1930s and 1940s, Hans Selye approached the conceptua-
lization of stress from the response end, viewing stress as a
dependent variable, “a response to disturbing or threatening
stimuli.”9 Conversely, stimulus-based definitions consider
stress to be an independent variable (generally environmental)
that causes an individual to respond. Modern definitions take
both into account. In the occupational stress literature, a stres-
sor is regarded as any work-related characteristic, situation, or
event that might initiate stress, while strain refers to the work-
er’s psychological or physiological reaction to stress.10
Stressors may be categorized into 6 broad domains: (1)
intrinsic job characteristics, (2) organizational roles, (3) work
relationships, (4) career growth issues, (5) organizational fac-
tors including climate, structure, and culture, and (6) the home–
work interface.9 Social support may mediate the relationship
between stressors and strain and may serve as a buffer between
occupational stressors and adverse effects on health.11 A stress
response is triggered when ones perceived demands exceed the
resources available to manage the stressor.12,13
Vahedian-Azimi et al 5

Table 3. Demographic Factors of Iranian Working Nurses in Critical The concept of BOS, as first described by Freudenberger in
Care Units. 1974, refers to a protracted course of distress in which one is
Variables Value
unable to cope with stressors over an extended period of time,
leading to depletion of the body’s defenses and ultimately
Age, yearsa 29.4 physical and emotional exhaustion.15-18 In 1996, this concept
BMIa 28.5 was further refined and BOS was defined as a syndrome of
Clinical experience, yearsa 19.9 emotional exhaustion, depersonalization, and reduced personal
Nurse–patient ratioa 2.8
achievement.19
ICU bed numbera 10.7
Gender (male; %) 31.1 In extreme cases, providers may develop signs and symp-
Education (%) toms of posttraumatic stress disorder (PTSD). Posttraumatic
Associate 14.8 stress disorder is caused by exposure to real or threatened
Baccalaureate 73.7 death, serious injury, or sexual violence through direct experi-
Master 11.3 ence or observation. Individuals may experience repeated inva-
Doctorate 0.2 sive distressing memories, dreams, or dissociative events
Marital status (married; %) 88.5
related to the traumatic event, psychological distress when
Shift schedule (%)
Rotation 39.2 exposed to similar experiences, or pronounced psychological
Morning 19.7 reactions to internal or external cues resembling the event. In
Evening 20.9 PTSD, individuals attempt to avoid distressing memories,
Night 20.0 thoughts, emotions, and external reminders of the incident.
Collaboration (low or moderate, %) 60.2 Patients may demonstrate amnesia, negative attitudes toward
Supervisor available in field (No, %) 36.7 self or others, self-blame, decreased participation in previously
Work holidays during study period (No, %) 95.2
enjoyed activities, or persistent negative emotions. Arousal and
Children living with them (%)
No (unmarried) 6.1 reactivity are affected and can present as irritability, aggres-
No (married) 14.5 sion, self-destructive behaviors, hypervigilance, concentration
Yes (unmarried) 0 difficulties, and sleep disturbances.20 Posttraumatic stress dis-
Yes (married) 79.4 order can be acute or chronic in nature and negatively affect
ICU type (%) work and home life. Nurses working in acute care environ-
Surgical 20.1 ments (emergency department or ICU) are at particular risk for
Cardiac 19.5
developing compassion fatigue, secondary traumatic stress,
Dialysis 20.4
Others (including medical) 39.9 and PTSD.21 This increased risk is due in part to cumulative
Adult mixed 8.0 exposure to direct and indirect traumatic events at work.22
Medical 8.0 Moreover, workplace bullying has been identified as a signif-
Neurology 8.0 icant predictor of PTSD among both experienced and novice
Trauma 8.0 nurses.22
Pediatric 3.0
Neonatal 2.9
Pediatric mixed 1.1 Coping With Stress
Toxicology 1.0
ICU system (%) Coping refers to any cognitive or behavioral strategies used to
Open 69 interpret and change environmental conditions (problem-
Closedb 0 focused or instrumental coping) or manage the negative emo-
Semi-closed 31 tions associated with a stressor (emotion-focused coping).
Abbreviations: BMI, body mass index; ICU, intensive care unit.
Problem-focused coping is used when the individual views the
a
Mean. stressor to be within their control to change, whereas emotion-
b
Generally speaking, the Iranian health-care system does not have closed ICUs. focused coping is implemented when the stressor is viewed as
something to be endured (Table 6).23 The evaluation of coping
outcomes is largely subjective and difficult to measure.24
Stress is experienced on a continuum from eustress to burn- Nurses coping mechanisms may vary based upon the situa-
out syndrome (BOS). Eustress is a term that is associated with tion, age, and geography.25-28 Escape avoidance, denial, and
the positive benefits of stress. In eustress, psychologic symp- distancing may be used to cope with emotional situations. Prac-
toms are excitement, increased mental acuity, and arousal. tically speaking, they may seek to avoid work, patients’ fam-
Individuals function effectively while managing resources to ilies, or patient assignments that cause distress or conflict.29-31
meet demands.12 This response is intended to be immediate but Moreover, they may not express their feelings due to fears of
limited. Frequent, chronic, or excessive stress exposure, how- being judged or creating conflict or a bad work atmosphere.32
ever, may result in maladaptive psychological and physical Regarding generational differences, baby boomers tend to use
effects.14 Distress occurs when the stress response becomes self-controlling behaviors, while escape avoidance behaviors
maladaptive or negative effects are experienced.12 are used more often by Generation Y.26
6 Journal of Intensive Care Medicine XX(X)

Table 4. Factors Associated With Stress in Critical Care Nurses in Iran.

Variable Crude OR (95% CI) P Value Adjusted OR (95% CI) P Value

Gender (male) 1.22 (1.11-1.33) <.001 1.19 (1.08-1.31) <.001

Age 1.0 (0.99-1.00) .32 0.95 (0.94-0.96) <.001
BMI 1.0 (0.99-1.01) .80
Marital status (married) 0.87 (0.77-0.99) .03 0.71 (0.56-0.95) .02
Married (no), children (no) Base
Married (no), children (yes) 0 NA
Married (yes), children (no) 0.90 (0.74-1.08) .26
Married (yes), children (yes) 0.85 (0.72-1.00) .06
Education
Associate 0.29 (0.07-1.21) .09
Baccalaureate 0.30 (0.07-1.28) .10
Masters 0.31 (0.07-1.31) .11
Clinical experience 1.01 (1.0-1.01) .10 1.04 (1.03-1.06) <.001
Shift
Morning 1.01 (0.91-1.13) .81
Evening 0.94 (0.85-1.04) .22
Night 1.0 (0.90-1.11) .95
Collaboration
Low or moderate 1.39 (1.29-1.50) <.001 1.36 (1.25-1.47) <.001
Work holidays 1.02 (0.85-1.22) .84
ICU bed number 1.00 (0.99-1.01) .87
Supervisor 1.18 (1.08-1.28) <.001
Nurse-to-patient ratio 0.96 (0.89-1.03) .28 1.17 (1.00-1.38) .05
ICU type
Surgical 0.90 (0.81-1.0) .05
Coronary 0.93 (0.84-1.03) .16
Dialysis 0.92 (0.83-1.02) .11
ICU system
Open Base
Closed 0 NA
Semi-closed 0.96 (0.88-1.04) .283
Abbreviations: BMI, body mass index; CI, confidence interval; ICU, intensive care unit; NA, not applicable; OR, odds ratio.

Table 5. Trends in Stress Scores.

Lower Stress Higher Stress P Value Within P Value Within P Value Between
Total (<67) (>67) P Value Lower Stress Higher Stress Groups

Baseline 71.7 + 4.79 64.8 + 2.22 73.31 + 3.67 .47a <.0001b <.0001b <.0001b
Postintervention 1 65.06 + 4.88 58.16 + 2.42 66.67 + 3.77 .60a
Postintervention 2 60.25 + 5.03 53.37 + 2.75 61.86 + 3.97 .57a
Postintervention 3 53.63 + 5.72 46.68 + 3.80 55.26 + 4.80 <.0001a
a
According to the independent sample t test.
b
According to the repeated-measures analysis of variance (RANOVA).

Geographical differences in utilized coping strategies high-
light the influences of culture and variations in health systems.
In a survey of 1554 hospital-based nurses, the most utilized
coping strategies were problem focused for those from the
United States, whereas emotion-focused strategies were most
common for nurses from Asian countries: self-control (Japan,
Thailand) and positive reappraisal (South Korea).27 A smaller
subsequent US-based survey of 135 ICU nurses reported the
most frequently used coping strategies to be a mixture of
problem-focused (confrontive coping, 60%; planful problem
solving, 59.2%) and emotion-focused coping strategies (escape
avoidance, 62.2%; seeking social support, 49.5%).33 This var-
iation highlights the difficulty in studying such problems and
why stress reduction interventions must be designed and tar-
geted for individual populations.
Individual personality traits also impact coping ability and
associated work efficacy. High levels of conscientiousness are
associated with active coping and planning with increased abil-
ity to address stressors, improved stress management, and
decreased stress related to perceived competence, confidence,
and time demands.34,35 The use of problem-focused coping
strategies and lowered levels of stress are also associated with
Vahedian-Azimi et al 7

Table 6. Stress-Coping Strategies. Conditions that contribute to the achievement of emotional

Coping
Coping Style Strategies Description
Problem focused Active approach focused on
altering, controlling, or
mastering the situation
Planful problem Analyzing the situation,
solving developing, and implementing
a solution
Confrontive Direct, assertive action without
coping hostility or anger
Emotional focused Approach focused on
controlling negative feelings
rather than altering the
source
Avoidance Mental withdrawal
Escape Neutralizes stress through
avoidance or escape from the
stressor. Examples are drugs,
alcohol, or exercise
Humor Used to release tension
Positive Minimizing the emotions related
reappraisal to the stressor by focusing on
personal growth
Seeking social Turning to friends, family, and
support others for emotional or
informational support
Distancing Acknowledging a stressor but
emotionally eliminating the
impact, detaching, or
depersonalizing
Denial Not acknowledging a stressor
exist
Self-controlling Gaining control over one’s
emotions
the traits of openness, extroversion, and agreeableness.35 Indi-
viduals with these traits report less stress related to dealing with
difficult patients and less reduction in professional efficacy. In
contrast, individuals with high levels of neuroticism utilize
more emotion-focused coping strategies, such as venting, and
reported increased role conflict and work overload.35 Neuroti-
cism, role conflict, and work overload have been reported to
predict reduced professional efficacy, emotional exhaustion,
and depersonalization in all dimensions of BOS.36
Resilience, a trait that allows an individual to succeed while
enduring hardship, can be learned. A decrease in symptoms of
stress, PTSD, BOS, anxiety, and depression is associated with
resilience. Hardiness, a trait defined as the incorporation of the
elements of commitment, control, and challenge that prepare
an individual to handle problematic life events, has been
reported to result in increased optimism and flexibility when
addressing problems. When addressing stressful situations,
hardy individuals use rational-oriented, rather than
emotional-oriented, coping styles. Increased hardiness is nega-
tively associated with perceived stress and positively associ-
ated with an approaching style of coping.37
well-being in the ICU are achieving best care for the patient’s
family, autonomy, achieving goals, and teamwork. In ICU
nurses, emotional well-being leading to happiness and personal
satisfaction is closely associated with providing the highest
quality of care to both the patient and the family and is tied
to a continued career working in the ICU.38 Perceived failure
results in distress and reduced emotional well-being. Nurses
value the ability to practice autonomously within the ICU,
including patient assessments, care plan development, and
inclusion in the physicians’ decision-making processes. When
teamwork is lacking, anxiety and unhappiness are reported.38
Stress in Nursing
Health care is a demanding field, and nurses are at a high risk of
occupational stress-related problems.39,40 In this series, 71% of
nurses reported being stressed. Moreover, nursing is one pro-
fession in which a link between employee well-being and orga-
nizational performance has been consistently demonstrated.
Organizational stressors include inadequate pay41,42 and lack
of appreciation.30 In Iran (2008), 48.8% of nurses reported
income below the poverty line of 3 million rials (US$300) per
month.42 Frequent interruptions41 and equipment in need of
repair cause moderate to high stress.43 Inadequate staffing is
one of the most commonly cited stressors and likely has a
compounding effect on perceived excessive work-
load.5,12,21,29,33,41,42,44-47 Similar to prior studies, we found that
nurse–patient ratios were positively associated with increased
stress levels in a multivariate analysis (OR: 1.17; P ¼ .05).
Nurses feel distressed when staffing ratios are perceived as
unsafe46,48 and when nursing assistant competency, support
personnel, and nonlicensed personnel were inadequate for the
patients’ demands.46 Nurses may feel incompetent and that
patient safety is jeopardized.49 Floating to other units may
also be a significant stressor.16 Although we found no asso-
ciation between shift (morning, evening, night) and stress
levels, shift rotation has been reported to positively associ-
ate with increased stress levels.5,30 Furthermore, this may be
exacerbated by acquired sleep deficits.33 Distressed nurses
may be more sensitive to noise, and auditory stimulation
may contribute to concentration difficulties and increased
irritability, stress, and fatigue.43,47,50,51 The mean ICU noise
level (71.9 decibels) surpasses the World Health Organiza-
tion recommended level of 30 decibels, with peaks no
greater than 40.52
The quality of work relationships with patients, patients’
family members, physicians, and charge nurses are significant
stressors.12,18,33,44,47 As previously mentioned, social support
may mediate the relationship between stressors and strain and
may serve as a buffer between occupational stressors and
adverse effects on health.11 Thus, social support is a key aspect
of a nurse’s life and ability to continue in a job.53 The absence
of social support significantly influences job turnover; conver-
sely, nurses who have social support are more likely to stay in
their job.53 As reported in prior studies, our study confirmed
8 Journal of Intensive Care Medicine XX(X)
that lower levels of supervisor collaboration and support and
worse communication with supervisors positively correlated
with increased stress.42,43 Nurses tend to seek emotional sup-
port from nursing colleagues before taking problems home,30,31
although our study did find that married status correlated with
lower stress levels. Support is sought from physician col-
leagues last.30,31
Stress may arise from the physician–nurse relationship
when the physician is not available in an emergency,33,43,47
uncertainty regarding treatments or transparency of physician
disclosure,12,31,33,44 treatments violating the patient’s wishes
(eg, cardiopulmonary resuscitation or prolonged mechanical
ventilation),31,54 when asked by physicians not to disclose
information to the patient,53,54 or if they believe the physician
to be incompetent.31,48 Additionally, they report significant
stress when they feel that unnecessarily painful procedures are
performed on patients for medical student’s education31,55 or
when asked to assist with a procedure without first acquiring
informed consent.55
Due to the complex nature of working in critical care, nurses
in the ICU encounter more ethical dilemmas than general ward
nurses.41 Nurses form bonds with patients and family members
and develop a sense of being responsible for patients’ out-
comes.41,45 A consistently reported stressor is dealing with
death and dying.18,30,41,43,44,45,47 This may be worse when the
nurse relates the distress from a patient’s situation with one in
his/her own personal life,38 when moral distress results from
perceived inappropriate treatment, futile care,31,48,55 patient
suffering from prolongation of the dying process,31,55 or when
they feel ignored or not engaged in the decision-making pro-
cesses.31 Nurses who participate in end-of-life family confer-
ences report less distress.48
Dealing with difficult patients is a frequently cited cause of
stress for nurses.18,41,44 Receiving threats from patients or fam-
ily members does not necessarily result in job turnover but does
correlate with avoidance in the form of increased job absentee-
ism.53 Emotional abuse correlates with increased intent of turn-
over.56 An increase in emotional abuse is associated with
unexpected changes in patient acuity and results in increased
time to perform tasks.57 Violence has been correlated with an
increase in the supply–demand ratio for nursing care, the num-
ber of incomplete nursing tasks at the end of each shift,
increased admissions, unexpected changes in patient acuity,
falls in medication errors, and delayed medication administra-
tion.57 The perception of physical violence decreased with an
increased proportion of bachelor’s degree nurses and more
complete skill mix, a finding not assessed in the current
study.57 Positive nurse–physician relationships seem to offer
a protective factor, as 1 study found this is inversely correlated
with a threat of violence.57
Although most threats, violence, and emotional abuse are
perpetrated by patients and families, studies report coworkers
are also responsible for a portion.56-58 Nursing has a hierarch-
ical power structure with a deep-rooted history of victimizing
the young and less experienced in the profession.59-61 During
the process of becoming a nurse, the experience of being
bullied is commonplace and psychologically damaging.59 In
a survey of 156 Israeli ICU nurses, 29% report experiencing
bullying and 4% report at least 5 incidents over a week’s
time.58 The most frequently reported method of bullying was
“exposed to unmanageable workload.”58 Lateral violence (also
known as horizontal violence) is another source of stress that is
similar to bullying and classified as workplace violence.62,63,70
Examples of lateral violence are gossiping, isolating, scape-
goating, verbal aggression, angry outbursts, sabotaging, humi-
liating, and inequalities in work assignments. This problem is
wide spread, with bullying rates reported as: Australia (15%-
22%), Brazil (40%), Canada (19%), Italy (22%-30%), Turkey
(21%), and United Kingdom (44%), United States (23%-
27%).63,70 Lateral hostility is negatively associated with peer
relationships and job satisfaction, and the consequences
include symptoms similar to other workplace stressors.64
Nurses who are victims of lateral hostilities frequently request
transfers, and many consider leaving the profession.62,65-67
Each of the aforementioned may promote increased absen-
teeism, turnover, health claims, and injuries, resulting in
increased hospital expenditures.42 A negative correlation exists
between subjective stress and job performance.68,69 Work
absenteeism may be associated with physical work demand,
autonomy, and physical and psychological aggression from
patients and patient’s family members.53 In a quantitative,
cross-sectional study of 461 ICU nurses in the Netherlands,
30% intended to leave their job, with significant associations
with night shift (P < .001), age (P < .001), perceived lack of
professional development (P < .001), and lack of social support
(P < .001).53 The financial implications of replacing an ICU
nurse is US$145 000.70
Consequences of Stress on Acute Care Providers
The impact of stress can manifest as a variety of physical and
psychiatric disorders, with 59% of nurses experiencing a psy-
chiatric disorder.71 Social dysfunction is the most prevalent
psychiatric disorder (71%).71 Depression and anxiety are com-
mon71; however, BOS and PTSD are of particular concern for
nurses in the emergency department and the ICU.
Those experiencing burnout have drained their physical and
emotional resources in attempting to cope with the stressors
present in the work environment.72 Burnout syndrome is the
inability to cope with stressors over an extended period of
time18 where the body’s defense system is depleted leading
to exhaustion.17,73 Burnout syndrome has 3 key characteristics
including emotional exhaustion, depersonalization, and feel-
ings of failure. Burnout syndrome symptoms may fall into the
following categories: affective (eg, depression, emotional
instability), cognitive (eg, reduced attention and concentra-
tion), physical (eg, fatigue, sleep disturbance, eating problems,
headaches), behavioral (eg, reduced job performance), motiva-
tional (eg, diminished idealism), interpersonal (eg, irritability,
relationship rigidity, indifference), and organizational (eg, job
turnover).18 Studies have reported a burnout incidence of 28%
to 33% among ICU nurses18,32 and is associated with younger
Vahedian-Azimi et al
age,18,41 organizational factors such as quality of relationships
and perceived conflicts, and receiving requested vacation
days.18 Moreover, burnout is positively associated with higher
fast-food consumption, infrequent exercise, higher alcohol
consumption, and more frequent painkiller use.74
Somatic and sleep complaints are highly prevalent (60.7%).71
Sleep disturbance is common, often associated with work-
related concerns (14.8%), affects quality and quantity, occurs
on 25.9% of days (regardless of shift status), and plays a role
in the development of physical and mental exhaustion.5,75,76
Physical and mental exhaustion have been reported during
42% and 39% of shifts, respectively, with exhaustion, stress, and
hypersomnia occurring in one-third of shifts.76 Post-shift acci-
dents and near accidents have been positively associated with
exhaustion, struggling to stay awake, and the number of consec-
utive shifts worked.76 Moreover, it has been reported that stress
is related to increased musculoskeletal, gastrointestinal, and car-
diovascular symptoms.75 Muscle cramps and spasms, arthralgia,
and back and neck pain are associated with job demands, social
support, job strain, overcommitment, and higher stress.75,77
Posttraumatic stress disorder is reportedly experienced at a
higher rates in ICU nurses. Manifestations of PTSD are sleep
disturbances, irritability, agitation, annoyance, anger, and mus-
cle tension. In a survey of US-based nurses comparing 140 ICU
nurses to 121 medical–surgical nurses, 29% of ICU nurses expe-
rienced PTSD as compared to 14% of medical–surgical nurses.
In a qualitative study of 744 ICU nurses using the Posttraumatic
Diagnostic Scale, 21% had a diagnosis of PTSD originating from
a workplace traumatic event.21 Of those nurses experiencing
PTSD, 70% reported experiencing symptoms for at least 3
months.21 The inciting events leading to PTSD were reported
as inability to rescue a patient (50%), experiencing verbal abuse
by patient family members (39%), performing futile care (36%),
and observing a patient expire (29%).21
Provider Stress and Patient Outcomes
Job stress indicators were found to correlate with increased
patient safety incidents.4 Burnout has been associated with
medical errors and inadequate patient safety.74,78 Medical
errors, cognitive errors, and decreased safety compliance are
associated with increased stress, long work hours, high patient
demand, and fatigue with struggling to stay awake.4,76,79,80
Nurses experiencing lack of autonomy, job instability, and
relationship conflict also reported increases in patient safety
incidents.4 In addition to long work hours,79 working overtime,
nights, and rotating shifts have been reported to associate with
increased fatigue and risk of medical errors or near errors.76,79
To illustrate the impact of patient demand on patient safety, an
increase of 1 patient in the nurses’ workload results in a 7%
increase in patient mortality.81
Interventions
A number of stress reduction interventions have been purposed
and studied in ICU nurses. Given the previously discussed
9
variation in coping mechanisms used by region and cul-
ture,27,33 on-site professional resources offered through an
institutional employee assistance program or other entity may
be beneficial. This may include employee wellness programs;
employee health screenings; adequate staffing; interdisciplin-
ary debriefing following difficult cases; and role model, pre-
ceptor, or mentor programs.82
Educational programs may also plan an important role in
promoting staff wellness. These may include education about
nursing care of the dying (ie, ELNEC courses) or other experi-
ences aimed at fostering skill development in coping, adapta-
tion, and emotional self-care. Due to the scope of the project
and number of study sites, our study employed a combination
of an educational lecture followed by visual stimuli posted in
the workplace to remind the nurse of lecture material. Lastly,
the serial questionnaire assessments also likely reminded par-
ticipants of content they may have forgotten or not focused on
previously. Some have advocated for instructed mindfulness-
based stress reduction to decrease stress and burnout.83-86
Lastly, specialized retreats may play a role as well.
Limitations
There are some aspects of the Iranian health-care system that
limit the generalizability of the findings. For example, most
academic and tertiary care ICUs in the United States are closed
ICUs; however, ICUs in Iran are generally semi-closed or open.
We did not collect data on individual nurse’s psychiatric symp-
toms or diagnoses. We also did not collect data on workplace
violence or lateral hostilities.
Conclusion
Health care is a demanding field, with a high level of respon-
sibility and exposure to emotional and physical danger. In this
national survey of 21 767 ICU nurses in Iran, we found that
male gender, lower levels of peer collaboration, working with a
supervisor on the unit, nurse–patient ratios, and working in a
surgical ICU were positively associated with greater stress lev-
els. Increasing age and married status were negatively associ-
ated with stress. Intensive care unit type (semi-closed vs open),
ICU bed number, shift time, working on holidays, education
level, and demographic factors including BMI, and number of
children were not significantly associated with stress levels. As
the largest study of its kind, these findings support those found
in various European, North, and South American studies.
Efforts to decrease workplace stress of ICU nurses by focusing
on facilitating peer collaboration, improving resource avail-
ability, and staffing ratios are likely to show the greatest impact
on stress levels.
Authors’ Note
Substantial contributions to conception and design, or acquisition, or
analysis of data are credited to Amir Vahedian-Azimi, Mohamma-
dreza Hajiesmaeili, Mari Kangasniemi, Joana Fornés-Vives, Farshid
Rahimibashar, Mohammad A. Pourhoseingholi, Leily Farrokhvar, and
10
Andrew C. Miller. Manuscript drafting and revision was performed by
Andrew C. Miller, Rita L. Hunsucker, and Amir Vahedian-Azimi.
Ethical Approval and Consent to Participate: The investigative
review board Baqiyatallah University of Medical Sciences (Tehran,
Iran) approved the study. Study participation was optional for respon-
dents. Since the research presented no more than minimal risk of harm
to participants and involved no procedures for which written consent
is normally required outside the research context, the principle of
implied consent was employed. Namely, that by completion of the
survey instrument, the participant demonstrated their willful consent
to participate. In accordance with IRB requirements, the investigator
provided participants with a written informed consent statement
regarding the research. Whereas Iranian medical ethics laws (http://
mehr.tums.ac.ir/Codes.aspx) do not specifically address this topic, it is
in accordance with other international ethics codes and laws including
the US Federal Code of Regulations (45 CFR 46.117c). Consent for
Publication: Based on the informed consent statement, implied con-
sent allowed for both study participation and publication of de-
identified aggregate results. There is no data contained within the
manuscript from which individual patients or participants may be
identified. Availability of Supporting Data: The data sets used and/
or analyzed during the current study are available from the corre-
sponding author on reasonable request.
Acknowledgments
The authors thank the Loghman Clinical Research Development Cen-
ter, Loghman Hakim Hospital, and Shahid Beheshti University of
Medical Sciences (Tehran, Iran) for methodological, logistical, and
financial support.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: Logistical
and limited financial support was provided by the Loghman Clinical
Research Development Center, Loghman Hakim Hospital, and Shahid
Beheshti University of Medical Sciences in Tehran, Iran. These enti-
ties had no role in the collection, analysis, or interpretation of data and
in writing of the manuscript.
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