Helping Nurses Manage Their Stress by Integrating Health Promotion : An Ecological Approach

In the United States registered nurses constitute the largest health care occupation; with about three out of five jobs being located in hospitals Everyday more and more nurses describe their profession as increasingly hectic and stressful. The purpose of this study is to design and implement how nurses at the Cayuga Community Health Network Center can reduce stress by using an Ecological Approach on health promotion programs. Two-hundred and seventy five nurses agreed to attend the Stress Management for Professional Caregivers workshop. All of the participants were female, with the majority being Caucasian. A majority of the nurses stated the workshop made them think about how they handle stress. Nearly all of the nurses stated that the information in the stress management workshop was valuable to them professionally. The success of this stress workshop demonstrates that implementing health promotion programs from an ecological perspective has the potential to reduce stress among nurses. © 2006 Californian Journal of Health Promotion. All rights reserved.


Introduction
Over the past 20 years, the proportion of women entering the nursing profession has risen steadily (Kane, 1996).Although women are entering the workforce at a steady rate they still remain one of the highest professions to experience burnout due to high levels of stress (Robinson-Kurpius, Keim, 1994).Whether in a nursing care facility, clinic, or hospital setting worksite health promotion activities can provide numerous benefits to both the employer and the nurses who experience stress.
Many health educators believe that in order to achieve the goals of Healthy People 2010 of increased quality of life, and job satisfaction especially among nurses, it is necessary for program interventions to be viewed from an ecological perspective.(U. S. Department of Health and Human Services, 2000).McLeroy, Bibeau, Steckler, and Glanz (1998) offered, "An Ecological Model on Health Promotion Programs," as a framework that identified multiple levels of influence (or factors) in the design, implementation, and evaluation of health promotion programs.The Ecological Model is described as a dynamic interaction between the individual and the environment.Intrapersonal factors consist of health education activities based on ones knowledge, attitudes and skills.The second level described by McLeroy et al. is interpersonal, which provides social identity, support, and role definition.Institutional factors are another level of influence which provides rules and regulations that help guide the group members within the organization.The fourth level consists of community factors where there is a connection among groups to protect, promote, and preserve the health of the entire community.The fifth and final level of influence includes policy such as changing laws at the national, state, and local levels.
An Ecological approach to address stress among nurses requires multi levels of influence.For example, nurses seeking opportunities for accurate health information from peer reviewed stress management journals and textbooks represent the intrapersonal emphasis.Group discussion seminars between nurses, stress management therapists, and faculty members who teach stress management courses represent the interpersonal emphasis.Administrators in hospitals and nursing homes who actively recruit and give incentives to nurses for participating in worksite health promotion programs reflect the institutional emphasis.Collaborating with community church initiatives and other organizations such as the American Institute of Stress represents the community emphasis.Finally, local, state and federal policies that provide rules and guidelines to follow (nursing code of ethics) reflect the policy emphasis.Since stress is so complex an ecological approach for nurses to reduce stress is far more effective than a single level influence.
The working environments of nurses (hospitals, nursing homes) serve as an important venue for influencing community and institutional factors of the ecological model.In the United States registered nurses constitute the largest health care occupation, with about three out of five jobs being located in hospitals (U. S. Department of Labor Bureau of Labor Statistics, 2006).The worksite has significant potential to influence and support health norms and values due to preexisting institutional and local structures (Reardon, 1998).Therefore, employee health promotion programs offer hospital administrators with opportunities for nurses to reduce their stress while they reduce their health care cost (Forouzesh, Ratzker, & Leslie, 1984).Therefore, when the faculty from the department of Health Promotion and Physical Education at Ithaca College was asked by the administration from the Finger Lakes Geriatric Education Center at Ithaca College to design a stress management program for the nurses at the Cayuga Community Health Network Center, the first priority was to design a program that uses an ecological framework.The purpose of this study is to design and implement how nurses at the Cayuga Community Health Network Center can reduce stress by using an Ecological Approach on health promotion programs.

Methods
The Cayuga Community Health Network Center consists of 340 nursing employees.Of this group 275 agreed to attend the Stress Management for Professional Caregivers workshop.All of the participants were female, with the majority (90%) being Caucasian.Levels of education varied among nurses.Approximately (22%) have a LPN degree, less than half (45%) have a RN in nursing, while (18%) have a Bachelor of Science in Nursing, and a little less than onequarter (15%) have a Master of Science in Nursing.
The administration from the Cayuga Community Health Network Center in Auburn, New York conducted a needs assessment with all of their nurses and provided employees the opportunity to participate in a workshop for professional caregivers to reduce stress.The timeline is presented in Table 1.

Table 1
A task development time line for nurses to participate in a stress management workshop.

Timeline Task January February March The administration from the Cayuga Community Health Network
Center distributed a needs assessment survey to their employees.

X
Employees returned needs assessments to Cayuga Community Health Network Center for data analysis.

X
Administration offered nurses at the Cayuga Community Health Network the opportunity to sign up for stress reduction workshop.

X
Faculty at Ithaca College presented a stress management workshop for nurses at the Cayuga Community Health Network.Nursing employees received relaxation technique CDs as an incentive for participation in the stress management workshop.

Results
Two hundred and seventy five of the three hundred and forty nursing employees agreed to participate in the stress management workshop which was facilitated by a faculty member in the Department of Health Promotion and Physical Education at Ithaca College.In this stress management workshop (see Table 2 for activities conducted by the Cayuga Community Health Network), nurses learned: 1) how to identify their stressors, 2) how stress can psychologically and physically impact the body, and 3) learned a variety of other relaxation techniques (e.g., diaphragmatic breathing and yoga).Most (84%) of the participating nurses stated they planned to share the workshop information with other nurses and family members.A majority (85%) said the workshop made them think about how they handled stress.Nearly all (97%) of the nurses stated that the information in the stress management workshop was valuable to them professionally.The nurses rated the workshops informative and excellent.

Table 2
Activities conducted by the Cayuga Community Health Network using concepts from the Ecological ModelSummaryThe success of this stress workshop for nurses was a result of the collaboration among and support of administration from the Finger Lakes Geriatric Education Center at Ithaca College, the Cayuga Community Health Network Center, and an assistant professor from the Department of Health Promotion and Physical Education at Ithaca College.Implementing health promotion programs from an ecological perspective have the potential to reduce stress for nurses and reduce health care cost for the employer.The idea that administrators have a shared vision, as their nurses and are willing to allocate recourses for nurses to reduce their stress shows that a multi-level ecological model is conducive to a worksite environment.