Work related stress in healthcare Setting

Stress may be defined as the physical and emotional response to excessive levels of mental or emotional pressure, which may arise from issues in both the working and personal life. Stress may cause emotional symptoms such as anxiety, depression, irritability or low self-esteem, or even manifest as physical symptoms including insomnia, headaches, loss of appetite and difficulties concentrating. Individuals experiencing high levels of stress may experience difficulty in controlling emotions such as anger, and may be more likely to experience illness or consume increased quantities of alcohol (NHS Choices, 2015). In the UK a survey undertaken by the Health and Safety Executive (HSE) has estimated that in the year 2013-2014, 487,000 of work related illnesses (39%) could be attributed to work-related stress, anxiety or depression (HSE, 2014). Additionally the survey found that as many as 11.3 million working days were lost in the year 2013-2014 as the direct result of work-related stress (HSE, 2014).

Studies have shown that healthcare professionals, particularly nurses and paramedics, are at an increased risk of work-related stress compared with other professionals (Sharma et al., 2014). This is likely to be due to the innate long hours and high pressure of maintaining quality care standards in the job, as well as pressures caused by staff shortages, high levels of patient demand, a lack of adequate managerial support as well as the risk of aggression or violence towards nurses from patients, relatives or even other staff (Royal College of Nursing (RCN), 2009). Indeed, a 2014 survey of nursing staff by the RCN showed that up to 71% of staff surveyed worked up to 4 hours more than their contracted hours a week, 80% felt that work-related stress lowered morale, and that 72% reported that understaffing occurred frequently in their workplace. As a result of these issues, 66% of respondents in the survey considered leaving the NHS or the nursing profession altogether (RCN, 2014b). A separate report by the RCN suggested that over 30% of absence due to illness was due to stress, which was estimated to cost the NHS up to £400 million every year (RCN, 2014a).

In addition to the physical and emotional symptoms of stress previously discussed, studies in this area have shown that nurses experiencing high levels of work-related stress were more likely to be obese and have low levels of physical exercise, factors which increased the likelihood of non-communicable diseases and co-morbidities such as hypertension and type 2 diabetes (Phiri et al., 2014).

Stress and staff absence

Chronic stress has been linked to “burnout”(Khamisa et al., 2015; Dalmolin et al., 2014), or a state of emotional exhaustion under extreme stress related to reduced professional fulfilment (Dalmolin et al., 2014) and “compassion fatigue”, where staff have experienced so many upsetting situations that they find it difficult to continue empathising with their patients (Wilkinson, 2014). As previously discussed, reducing staffing levels contribute to stress in nursing staff, and in this way chronic stress within the workplace launches a self-perpetuating cycle of understaffing; increased stress leads to increased illness, more staff absence and increased understaffing. In turn, these negative emotions also reduce job satisfaction and prompt many staff to consider leaving the nursing profession, further reducing staffing availability for services (Fitzpatrick and Wallace, 2011).

Reasons for work-related stress amongst healthcare professionals

Studies amongst nursing staff have also reported stress occurring as the result of poor and unsupportive management, poor communication skills amongst team members, institutional and organisational issues (e.g. outdated or restrictive hospital policies) or bullying and harassment (RCN, 2009). Even seemingly minor issues have been reported as exacerbating stress amongst nursing staff, for example a lack of common areas to take breaks in, changing shift patterns, and even difficulty and expense of car parking (Happell et al., 2013).

Work related stress can particularly affect student or newly qualified nurses, who often report higher expectations of job satisfaction from working in the profession, they have worked hard and aspired to join, and are therefore particularly prone to experiencing disappointment on discovering that they do not experience the job satisfaction that they presumed they would do whilst training. Student and newly qualified nurses may also have clear ideas from their recent training on how healthcare organisations should be run and how teams should be managed, and may then be disillusioned when they discover that the reality is that many departments could in fact benefit from improvements and further training for more experienced staff in these areas (Wojtowicz et al., 2014; Stanley and Matchett, 2014). Nursing staff are also likely to, on occasion, find themselves in a clinical situation that they feel unprepared for, or do not have the necessary knowledge to provide the best possible care for patients, and this may cause stress and anxiety (RCN, 2009). They may also be exposed to upsetting and traumatic situations, particularly in fields such as emergency or intensive care medicine (Wilkinson, 2014).

Moral distress can also cause strong feelings of stress amongst healthcare professionals. This psychological state occurs when a discrepancy occurs between the action that an individual takes, and the action that an individual feels they should have taken (Fitzpatrick and Wallace, 2011). This may occur if a nurse feels that a patient should receive an intervention in order to experience best possible care, but is unable to deliver it, for example due to organisational policy constraints, or a lack of support from other members of staff (Wojtowicz et al., 2014). For example, a nurse may be providing end of life care to a patient who has recently had an unplanned admission onto a general ward but is expected to die shortly. The nurse may feel that this patient would benefit from having a member of staff sitting with them until they died. However, due to a lack of available staffing this does not happen as the nurse must attend to other patients in urgent need of care. If the patient dies without someone with them, the nurse may experiences stress, anger, guilt and unhappiness over the situation as they made the moral judgement that the dying patient “should” have had a member of staff with them, but were unable to provide this without risking compromising the safety of other patients on the ward (Stanley and Matchett, 2014). One large scale questionnaire based study in the USA on moral distress amongst healthcare professionals has shown that moral distress is more common amongst nurses than other staff such as physicians or healthcare assistants. The authors suggested that this may be due to a discrepancy between the level of autonomy that a nurse has in making care decisions, (especially following disagreement with a doctor, who has a high level of autonomy), while experiencing a higher sense of responsibility for patient wellbeing than healthcare assistants, who were more likely to consider themselves to be following the instructions of the nurses than personally responsible for patient outcomes (Whitehead et al., 2015).

Recommendations for policies to address work related stress

It is acknowledged that many individuals find that being asked to perform tasks that they have not been adequately trained or prepared for can be very stressful. As such management teams should also try to ensure as far as possible that individuals are only assigned roles for which they have adequate training and abilities, and support employees with training to improve skills where necessary (RCN, 2009).

Surveys have frequently reported that organisational issues such as a lack of intuitive work patterns, overloading of workloads and an unpleasant working environment can all contribute to work related stress. Organisations can reduce the impact of these by developing programmes of working hours with working staff and adhering to them, making any necessary improvements to the environment (e.g. ensuring that malfunctioning air conditioning is fixed), and that incidents of understaffing are reduced as much as possible (RCN, 2009). Issues such as insomnia and difficulty in adapting to changing shift patterns can also be assisted by occupational health, for example by encouraging healthy eating and exercise (Blau, 2011; RCN, 2005). For example, in 2005 the RCN published an information booklet for nursing staff explaining the symptoms of stress, ways in which it can be managed e.g. relaxation through exercise or alternative therapies, and when help for dealing with stress should be sought (RCN, 2005). More recently, internet based resources are available from the NHS to help staff identify if they need assistance, and how and why it is important to access it (NHS Employers, 2015).

Witnessing or experiencing traumatic or upsetting events is an unavoidable aspect of nursing, and can even result in post-traumatic stress disorder (PTSD). However, there are ways in which staff can be encouraged by their management teams and organisations to deal with the emotions that these circumstances produce, limiting the negative and stressful consequences of these events. This may include measures such as counselling or even peer support programmes through the occupational health departments (Wilkinson, 2014). Staff should also be encouraged to use personal support networks e.g. family, as this can be an important and effective source of support, however studies have shown that support within the work place is most beneficial, particularly if this can be combined with a culture where healthcare professionals are encouraged to express their feelings (Lowery and Stokes, 2005).

One commonly cited reason for work related stress amongst nurses is the incompetence or unethical behaviours of colleagues, and a lack of opportunity to report dangerous or unethical practice without fear of reprisal. Therefore it is important that institutions and management teams ensure that there is an adequate care quality monitoring programme in place, and a culture where concerns can be reported for further investigation without fear of reprisal, particularly with respect to senior staff or doctors (Stanley and Matchett, 2014).

It has been reported that in the year 2012-2013, 1,458 assaults were reported against NHS staff (NHS Business Service Authority, 2013). Violence and abusive behaviour towards nursing staff is an acknowledged cause of stress and even PTSD, and staff have a right to provide care without fear (Nursing Standard News, 2015; Itzhaki et al., 2015). Institutions therefore have a responsibility towards their staff to provide security measures such as security staff, workplace design (e.g. locations of automatically locking doors) and policies for the treatment of potentially violent patients e.g. those with a history of violence or substance abuse issues (Gillespie et al., 2013).

As previously discussed, nurses are more likely than other healthcare professionals to experience moral distress as the result of a discrepancy between the actions they believe are correct and the actions they are able to perform (Whitehead et al., 2015). However there are policies that can be introduced into healthcare organisations to reduce its occurrence, and the severity with which it can affect nursing staff. Studies have shown that nurses who were encouraged to acknowledge and explore feelings of moral distress were able to process and overcome these in a less damaging manner than those who did not (Matzo and Sherman, 2009; Deady and McCarthy, 2010). Additionally, it is thought that moral distress is less frequent in institutions and teams that encourage staff to discuss ethical issues with a positive attitude (Whitehead et al., 2015). For example, institutions could employ a designated contact person for staff to discuss stressful ethical issues with, or set up the facility for informal and anonymous group discussion, for example on a restricted access internet-based discussion board (Matzo and Sherman, 2009)

Conclusion

Work related stress is responsible for significant costs to the NHS in terms of staffing availability and financial loss from staff absence from stress itself or co-morbidities that can be exacerbated by stress (RCN, 2009), for example hypertension and diabetes (Phiri et al., 2014; RCN, 2009, 2014a). The loss of valuable and qualified staff from the profession is also a significant cost to health services, and of course exacerbates the situation by increasing understaffing further, which in turn increases stress for the remaining staff (Hyrkas and Morton, 2013). It can also exert a significant cost to healthcare professionals who experience it, in terms of their ability to work, their personal health, effects on personal relationships (Augusto Landa et al., 2008) and job satisfaction (Fitzpatrick and Wallace, 2011). However, organisations can implement recommendations to reduce work related stress, for example by encouraging a positive and supportive culture for staff by offering interventions such as counselling (Wilkinson, 2014; RCN, 2005). Furthermore, interventions such as encouraging the reporting of unsafe or unethical practice – a commonly cited source of stress amongst nurses (RCN, 2009; Stanley and Matchett, 2014) – may also contribute to improving the quality of patient care.

References

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Dalmolin, G. de L., Lunardi, V. L., Lunardi, G. L., Barlem, E. L. D. and da Silveira, R. S. (2014). Moral distress and Burnout syndrome: are there relationships between these phenomena in nursing workers? Revista Latino-Americana de Enfermagem, 22 (1), p.35–42. [Online]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692014000100035

Deady, R. and McCarthy, J. (2010). A Study of the Situations, Features, and Coping Mechanisms Experienced by Irish Psychiatric Nurses Experiencing Moral Distress. Perspectives in Psychiatric Care, 46 (3), p.209–220. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20591128

Fitzpatrick, J. J. and Wallace, M. (2011). Encyclopedia of Nursing Research. 3rd ed. New York: Springer Publishing Company.

Gillespie, G., Gates, D. M. and Berry, P. (2013). Stressful Incidents of Physical Violence Against Emergency Nurses. OJIN: The Online Journal of Issues in Nursing, 18 (1). [Online]. Available at: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No1-Jan-2013/Stressful-Incidents-of-Physical-Violence-against-Emergency-Nurses.html

Happell, B., Dwyer, T., Reid-Searl, K., Burke, K. J., Caperchione, C. M. and Gaskin, C. J. (2013). Nurses and stress: recognizing causes and seeking solutions. Journal of Nursing Management, 21 (4), p.638–647. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23700980

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Question:

Explain the epidemiology of Alcoholism. Critically discuss the public policy options which are available to address this problem.

Introduction

According to Alcohol Concern Organisation (2015) more than 9 million people in England consume alcoholic beverages more than the recommended daily limits. In relation to this, the National Health Service (2015) actually recommends no more than 3 to 4 units of alcohol a day for men and 2 to 3 units a day for women. The large number of people consuming alcohol more than the recommended limits, highlights the reality that alcoholism is a major health concern in the UK which can lead to a multitude of serious health problems. Moss (2013) states that alcoholism and chronic use of alcohol are linked to various medical, psychiatric, social and family problems. To add to this, the Health and Social Care Information Centre (2014) reported that between 2012 and 2013, a total of 1,008,850 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary cause for hospital admission or a secondary diagnosis. This shows the detrimental impact of alcoholism on the health and overall wellbeing of millions of people in the UK. It is therefore vital to examine the aetiology of alcoholism in order to understand why so many people end up consuming excessive alcohol. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) (n.d.) supports this by stating that learning the natural history of a disorder will provide information essential for assessment and intervention and for the development of effective preventive measures. This essay will also look into the different public health policies that address the problem of alcoholism in the UK. A brief description of what alcoholism is will first be provided.

What is Alcoholism?

It is safe to declare that alcoholism is a lay term that simply means excessive intake of alcohol. It can be divided into two forms namely; alcohol misuse or abuse and alcohol dependence. Alcohol misuse simply means excessive intake of alcohol more than the recommended limits (National Health Service Choices 2013). A good example of this is binge drinking.

Alcohol dependence is worse because according to the National Institute for Health and Care Excellence (2011, n.p.) it “indicates craving, tolerance, a preoccupation with alcohol and continued drinking regardless of harmful consequences” (e.g. liver disease). Under the Diagnostic Statistical Manual of Mental Disorders (DSM)- 5, these two have been joined as one disorder called alcohol use disorder or AUD with mild, moderate and severe sub-classifications (NIAAA 2015).

Genetic Aetiologic Factor of Alcoholism

Alcoholism is a complex disorder with several factors leading to its development (NIAAA 2005). Genetics and other biological aspects can be considered as one factor involved in the development of alcohol abuse and dependence (NIAAA 2005). Other factors include cognitive, behavioural, temperament, psychological and sociocultural (NIAAA 2005).

According to Goodwin (1985) as far as the era of Aristotle and the Bible, alcoholism was believed to run in the families and thus could be inherited. To some extent, there is some basis that supports this ancient belief because in reality, alcoholic parents have about four to five times higher probability of having alcoholic children (Goodwin 1985). Today, this belief seems to lack substantially clear and direct research-based evidence. On the other hand, studies also do not deny the role of genetics in alcoholism. With this view, it is therefore safe to argue that genetics is considered still as an important aetiologic factor in alcoholism.

The current consensus simply indicates that there is more to a simple gene or two that triggers the predisposition of an individual to become an alcoholic. Scutti (2014) reports that although scientists have known for some time that genetics take an active role in alcoholism, they also propose that an individual’s inclination to be dependent on alcohol is more complicated than the simple presence or absence of any one gene. The National Institute on Alcohol Abuse and Alcoholism (2008) states that there is no one single gene that fully controls a person’s predisposition to alcoholism rather multiple genes play different roles in a person’s susceptibility in becoming an alcoholic. The NIAAA (2005) further claims that the evidence for a genetic factor in alcoholism lies mainly with studies that involve extended pedigree, those that involve identical and fraternal twins and those that include adopted individuals raised apart from their alcoholic parents.

For pedigree studies, it is believed that the risk of suffering from alcoholism is increased four to seven fold among first-degree relatives of an alcoholic (Cotton 1979; Merikangas 1990 cited in NIAAA, 2005.). First degree relatives naturally refer to parent-child relationships; hence, a child is therefore four to seven times at higher risk of becoming an alcoholic, if one or both of their parents are alcoholics. Moss (2013) supports this by stating that children whose parents are alcoholic are at higher risk of becoming alcoholics themselves when compared to children whose parents are non-alcoholics.

A study conducted by McGue, Pickens and Svikis (1992 cited in NIAAA 2005) revealed that identical twins generally have a higher concordance rate of alcoholism compared to fraternal twins or non-twin siblings. This basically means that a person who has an alcoholic identical twin, will have a higher risk of becoming an alcoholic himself when compared to if his alcoholic twin is merely a fraternal twin or a non-twin sibling. This study further proves the role of genetics in alcoholism because identical twins are genetically the same; hence, if one is alcoholic, the other must therefore also carry the alcoholic gene.

The genetic factor in alcoholism is further bolstered by studies conducted by Cloninger, Bohman and Sigvardsson 1981 cited in NIAAA 2005 and Cadoret, Cain and Grove (1980 cited in NIAAA 2005) involving adopted children wherein the aim was to separate the genetic factor from the environmental factor of alcoholism. In these studies, children of alcoholic parents were adopted and raised away from their alcoholic parents but despite this, some of these children still develop alcoholism as adults at a higher rate than those adopted children who did not have an alcoholic biological parent (Cloninger et al., 1981 cited in NIAAA 2005 and Cadoret et al., 1980 cited in NIAAA 2005).

One interesting fact about aetiologic genetic factor is that although there are genes that indeed increase the risk of alcoholism, there are also genes that protect an individual from becoming an alcoholic (NIAAA 2008). For example, some people of Asian ancestry carry a gene that modifies their rate of alcohol metabolism which causes them to manifest symptoms such as flushing, nausea and tachycardia and these generally lead them to avoid alcohol; thus, it can be said that this gene actually helps protect those who possess it from becoming alcoholic (NIAAA 2008).

Environment as an Aetiologic Factor of Alcoholism

Another clearly identifiable factor is environment, which involves the way an individual is raised and his or her exposure to different kinds of activities and opportunities. The National Institute on Alcohol Abuse and Alcoholism (2005) relates that the genetic factor and the environmental factor have a close relationship in triggering alcoholism in an individual. This can be explained by the simple fact that even if an individual is genetically predisposed to becoming an alcoholic, if he is not exposed to a particular kind of environment which triggers activities that lead to alcohol intake, the likelihood of his becoming an alcoholic will be remote.

There are certain aspects within the environment that makes it an important aetiologic factor. According to Alcohol Policy MD (2005) these aspects include acceptance by society, availability and public policies and enforcement.

Acceptance in this case refers to the idea that drinking alcoholic drinks even those that should be deemed excessive is somewhat encouraged through mass media, peer attitudes and behaviours, role models, and the overall view of society. Television series, films and music videos glorify drinking sprees and even drunken behaviour (Alcohol Policy MD 2005). TV and film actors and sports figures, peers and local role models also encourage a positive attitude towards alcohol consumption which overshadows the reality of what alcohol drinking can lead to (Alcohol Policy MD 2005). In relation to this, a review of different studies conducted by Grube (2004) revealed that mass media in the form of television shows for instance has an immense influence on the youth (age 11 to 18) when it comes to alcohol consumption. In films, portrayals regarding the negative impact of alcohol drinking are rare and often highlight the idea that alcohol drinking has no negative impact on a person’s overall wellbeing (Grube 2004). In support of these findings, a systematic review of longitudinal studies conducted by Anderson et al. (2009) revealed that the constant alcohol advertising in mass media can lead adolescents to start drinking or to increase their consumption for those who are already into it.

Availability of alcoholic drinks is another important environmental aetiologic factor of alcoholism simply because of the reality that no matter how predisposed an individual is to become an alcoholic, the risk for alcoholism will still be low if alcoholic drinks are not available. On the other hand, if alcoholic beverages are readily available as often are today, then the risk for alcoholism is increased not only for those who are genetically predisposed to alcoholism but even for those who do not carry the “alcoholic genes”. The more licensed liquor stores in an area, the more likely people are to drink (Alcohol Policy MD 2005). The cheaper its price, the more affordable it is for people to buy and consume it in excess (Alcohol Policy MD 2005).

Another crucial environmental aetiologic factor is the presence or absence of policies that regulate alcohol consumption and its strict or lax enforcement. It includes restricting alcohol consumption in specified areas, enacting stricter statutes concerning drunk driving and providing for penalties for those who sell to, buy for or serve to underage individuals (Alcohol Policy MD 2005). It is worthy to point out that in the UK, the drinking age is 18 and a person can be stopped, fined or even arrested by police if he or she is below this age and is seen drinking alcohol in public (Government UK 2015a). It is also against the law for someone to sell alcohol to an individual below 18; however, an individual age 16 or 17 when accompanied by an adult can actually drink but not buy alcohol in a pub or drink beer, wine or cider with a meal (Government UK 2015a).

Policies to Combat Alcoholism

One public health policy that can help address the problem on alcoholism is the mandatory code of practice for alcohol retailers which banned irresponsible alcohol promotions and competitions, and obliged retailers to provide free drinking water, compelled them to offer smaller measures and required them to have proof of age protocol. It can be argued that this policy addresses the problem of alcoholism by restricting the acceptance, availability and advertising of alcohol (Royal College of Nursing 2012). Another is the Police Reform and Social Responsibility Act 2011 which is a statute that enables local authorities to take a tougher stance on establishments which break licensing rules about alcohol sale (Royal Collage of Nursing 2012).

There is also the policy paper on harmful drinking which provides different strategies in addressing the problem of alcoholism. One such strategy is the advancement of the Change4Life campaign which promotes healthy lifestyle and therefore emphasises the recommended daily limit of alcohol intake for men and women (Government UK 2015b). Another strategy within this policy is the alcohol risk assessment as part of the NHS health check for adults ages 40 to 75 (Government UK 2015b). This policy aims to prevent rather than cure alcoholism which seems to be logical for after all, an ounce of prevention is better than a pound of cure.

Conclusion

Alcoholism which includes both alcohol misuse and alcohol dependence is a serious health problem which affects millions in the UK. Its aetiology is actually a combination of different factors. One vital factor is genetics wherein it can be argued that some people are predisposed to becoming an alcoholic. For example, an individual is at higher risk of becoming an alcoholic if he or she has a parent who is also alcoholic. When coupled with environmental factors, the risk of suffering from alcoholism becomes even greater. Environment refers to the acceptability and availability of alcohol and the presence or absence of policies that regulate alcohol sale and consumption. Vital health policies such as Harmful Drinking Policy Paper advocated by the government, are important preventive measures in reducing the incidence and prevalence of alcoholism in the UK.

References

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Anderson, P., de Brujin, A., Angus, K., Gordon, R. and Hastings, G. (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol and Alcoholism. 44(3):229-243.

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