Stress in nurses’ caring for stroke patients and families: a mixed-method study [version 1; peer review: awaiting peer review]

Background: Within nursing, caring for stroke patients and helping them with the recovery of their abilities can be strenuous; even more so when considering the nurse’s scope of practice includes the patient and predicts a supportive role to the caregivers. This type of rehabilitative nursing care can be demanding, and nurses may experience increased levels of stress. Despite the extensive literature about the nursing workload and its connection to occupational stress, very little research has been conducted particularly about stress levels experienced by nurses working with stroke patients, who may experience particularly high stress. The rationale for this research emerged from the scarcity of studies worldwide and especially in Irish stroke units. Methods: Nurses from stroke and medical wards (n=100) were distributed the Perceived Stress Scale and requested to complete it from the perspective of their workplace. A convenience sample of these nurses were interviewed about their experience of stress. Results: Of 48 survey respondents, 68% reported ‘moderate’ levels of stress, with higher mean levels in nurses working in medical wards (M=20.10, SD=5.42) than nurses in stroke units (M=16.17, SD=4.41; t(46)=2.757, p<0.01). In interviews with nurses on stroke units (n=11), sources of stress included work performance anxiety (e.g. fear of errors), workload burden/conflicting demands, and family/physician interactions. Coping mechanisms included brief “time outs”, direct problem-solving, and peer support. Conclusions: The participants’ experiences of stress may help other nurses working with stroke patients to cope better with work-related stress, and provide guidance to managers in improving the Open Peer Review Reviewer Status AWAITING PEER REVIEW Any reports and responses or comments on the article can be found at the end of the article. HRB Open Research Page 1 of 9 HRB Open Research 2020, 3:51 Last updated: 05 AUG 2020


Introduction
Nursing is known to be a stressful profession and this problem is frequently addressed in the literature (Eslami Akbar et al., 2017;Lee & Kim, 2020;Lim et al., 2010;Roberts & Grubb, 2014;Ruotsalainen et al., 2015). Multiple European and international studies have acknowledged the increase demands in the nursing profession leading to an intention to quit their jobs and high turnover rate (Austin et al., 2017;Bordignon & Monteiro, 2019;Heinen et al., 2013;Holland et al., 2019;Kovner et al., 2014;Lee & Kim, 2020;Leineweber et al., 2016;Moloney et al., 2018). Most of the available research identifies nurses as experiencing increased stress levels compared to other healthcare professionals (Geuens et al., 2015;Han et al., 2015;Joice et al., 2012;Müller et al., 2011). However, experiences of stress among nurses working specifically in stroke units remains a relatively unexplored area. Indeed, there is abundant literature on the impact of stress among informal caregivers, but less about the nurses caring for those with stroke (Joice et al., 2012).
Providing rehabilitation nursing care can be exhausting and demanding, as stroke survivors are often confronted with multiple losses. Caring for stroke patients and helping them with the recovery of their abilities can be strenuous; especially given that the nurse's scope of practice includes not just the patient, but also a supportive role to the person's family. Many clinical guidelines highlight the importance of supporting stroke caregivers emotionally and of encouraging them to be involved in the stroke care (Intercollegiate Stroke Working Party, 2016; National Institute for Health and Care Excellence (NICE), 2013; Scottish Intercollegiate Guidelines Network (SIGN), 2010). Facilitating such involvement can be demanding as conflicts may arise from this interaction and, within a rehabilitation environment, nurses appear to experience more of these conflicts which leads to a high level of stress (Creasy, et al., 2015;Joice et al., 2012;Lee & Kim, 2020;Lehto et al., 2019;Rochette et al., 2014).
The rationale for this research emerges from the scarcity of studies in stroke units worldwide and especially in Irish stroke units, cognizant that nurse stress could negatively impact the patient rehabilitation process (Douglas et al., 2017;Rejnö et al., 2013;UNISON, 2014). This study used a mixed-method approach to address this gap in the literature by exploring nurses' experiences of stress when supporting stroke patients and their families in two acute stroke units, where the median length of stay of 3 weeks includes early rehabilitation for severe strokes (before transfer to off-site rehabilitation), and the full period of in-patient rehabilitation for patients with minor strokes.
The specific objectives of the study are: to determine the levels of stress experienced by nurses in stroke units compared to nurses working on general medical wards; to explore nurses' understanding and views regarding stress in stroke units; and to identify how these nurses manage stress. From this, we aimed to make recommendations for nursing practice.
The research question was "What are nurses experiences of stress when dealing with stroke patients and their families?".

Design
A non-sequential mixed methodology was used, using surveys and face-to-face interviews. Data were collected from two wards, the stroke unit and the immediately adjacent medical ward, in each of the two hospitals in Cork city with acute stroke units (Hospital X and Hospital Y).

Ethics
Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (reference: ECM 3 (o) 10/01/18). All participants were given an invitation letter, an information leaflet and a consent form to be read prior to participating in the study. The documents provided to the participants defined their participation in the study as voluntary and clearly stated the risks and benefits of the study, and the option to refuse to participate in the study or withdraw from the study at any time without prejudice.

Sample
Surveys. In each hospital, there were 25-35 eligible nurses per ward, and 25 surveys were allocated to each study ward (n=100 total distributed), along with information leaflets (See extended data (Saramago, 2020)). These survey packs were provided to the Clinical Nurse Manager (CNM) 2 of each ward who were instructed to distribute them amongst their staff. Reminders were given through weekly visits over 4-5 weeks by the researcher.
Inclusion criteria were: permanent registered nurses and strokes pecialist nurses (i.e. graduate education in stroke and working solely with stroke patients), working on the ward/unit (whether part-time or full-time). Exclusion criteria were: relief or agency nurses, and student nurses.
Interviews. In total, 11 nurses working in the stroke units were invited to participate in interviews, using convenience sampling within the eligible cohort. Inclusion criteria were: registered nurses and stroke clinical nurse specialists working in the stroke unit for at least 3 years.

Instruments
The survey used was the Perceived Stress Scale (PSS), originally designed by Sheldon Cohen in 1983(Cohen et al., 1983 and later shortened to a 10-item version. The PSS is one of the most widely used stress scales and it has been validated in several populations, including college students and workers. The internal consistency and test-retest reliability of the 10-item version are both >0.70, with 12 studies evaluating the former and four studies the later (Lee, 2012). The PSS is frequently used to measure stress in healthcare workers. In this current study, the survey participants were specifically directed to answer the questions in relation to their current workplace. The scale items were not modified in any way.
The survey consists of ten direct questions, and for each question there are five possible answers, on a 5-point Likert scale ranging from 0 ("never") to 4 ("very often"). The total score per participant can thus range from 0 to 40. For scores between 0 and 13, the participant is considered to have low stress levels. Scores between 14 and 26 correspond to moderate levels of stress, and scores ranging from 27 to 40 indicate perceived high levels of stress.
Face to face semi-structured interviews were performed individually in a private office, using an interview guide adapted from King and Horrocks in 2010 ( Figure 1). The interview guide consisted of eight open-ended questions, with another three optional 'prompts' in case clarification was required. The focus was on stroke nurses' experiences in dealing with stroke patients and their families.

Data collection
Surveys. The surveys were distributed by the ward manager to eligible nurses; the managers indicated that all available surveys were distributed. Gentle reminders to complete the surveys were given through weekly visits by the researcher over the subsequent 4-5 weeks (noting that the surveys were anonymous, so there was no pressure placed on any one individual to complete a survey, but rather a general reminder to the overall nursing staff).
Interviews. For the realization of the interviews, the Senior Clinical Nurse Managers of the two stroke units were contacted in advance, to discuss the times and dates that would be most convenient for staff. They briefed the ward nurses on the planned interviews. On the agreed days, the nurses on duty were approached and eligibility confirmed, and if interested, they were given an information leaflet to read. They had time to consider this information before the interview slots later that day (at the quietest times on the ward), and could choose to proceed, refuse, or take more time to consider it further (contacting the researcher to ask more questions or to arrange another date). The interviews generally lasted between 25-30 minutes each (one lasted 10 minutes only) and were audio recorded on a digital voice recorder stored in a locked drawer when not in use. The audio files were destroyed after transcription was completed. A consent form was read and signed by the participants. The total number of interviews was decided at the point when data saturation was reached.

Data analysis
Data retrieved from the surveys was analysed using Statistical Package for the Social Sciences version 25. As the data met the assumptions for normality, an independent samples t-test analysis was conducted to compare the total PSS scores between stroke units and medical wards. Interview data was analysed using Thematic Content Analysis as per the Newell and Burnard (2011) model. The author followed this six stage process by: 1 -transcribing data via 'intelligent verbatim' and making relevant side notes; 2 -reviewing transcripts and side notes to identify general themes; 3 -summarising extensive sentences into important topics; 4 -screening for similar codes and regrouping them into a list of category coloured codes; 5 -reviewing transcribed interviews and colour coding appropriate sentences; 6 -writing up a report using data extracts. All transcripts were coded by the researcher who conducted the interviews, with a second senior researcher reviewing this coding in one-third of the sample.
An initial nine interviews were performed and analysed. Data saturation appeared to be reached, so a further two interviews were performed and analysed, with no new themes emerging, confirming data saturation.

Surveys
In total, there were 48 surveys completed, representing a 48% response rate if all surveys were distributed, as we were told by the ward managers. There was a bias in response rates between the two hospitals, with 77% of the 48 respondents being from Hospital X. However, there were fairly even proportions of total participants from the medical wards versus the stroke units (n=20 and n=28, respectively, in total). Most respondents (94%) were aged between 25 and 45 and 75% of respondents had a minimum of 3 years' experience (see Table 1 for sample characteristics (Saramago, 2020)). Table 2 shows the means and standard deviations for the PSS scores for the total sample and sub-samples (Saramago, 2020). The mean PSS score for the total group was 17.81, i.e. 'moderate' stress levels. Table 3 and Table 4 show the means and standard deviations for the PSS scores for years of experience and age range

Interviews
The interview data from the eleven participating nurses (6 from hospital X and 5 from hospital Y) was coded into five initial themes. These initial five themes were then collapsed into three final higher-order themes ( Figure 2): Nurses' experiences of work-related stress in stroke wards; Factors contributing to work-related stress in stroke wards; Nurses' coping mechanisms in the stroke environment.

Nurses' experiences of work-related stress in stroke units.
All of the nurses interviewed reported experiencing workrelated stress. The majority of experiences were related to psychological stress. The participants often described themselves as feeling "frustrated", "overwhelmed", "disappointed", "anxious", "nervous", "worried" and "upset" during their work.

Figure 2. Development process of category codes as per Newell and Burnard (2011).
Participants also felt they were unable to cope with the workload and these feelings could lead to a heightened sense of job responsibility. Two participants commented: In both hospitals, issues with the work environment and job performance were also seen as factors leading to work-related stress in the stroke wards. In terms of job performance, one participant also reported the administration of unfamiliar medication as a stressful factor. As per participant G:

Discussion
In the present study, the rate of 'moderate stress' levels in nurses working on stroke units was 68%, although the mean PSS score was lower than in the nurses working in the adjacent medical ward. In contrast, the available literature suggests that nurses working in a rehabilitation setting have a higher risk of experiencing burnout than nurses working in other clinical areas (Tay et al., 2014). However, the available literature is very scarce and lacks direct comparison of stress levels between stroke nurses and their peers. The following references are examples of this ambiguity. An Irish study (McCarthy et al., 2010) analysed perceived stress levels using the nursing stress scale (M= 47.9, SD= 12.8) for nurses working in medical areas but failed to disclose the characteristics of the patient population in those areas. A recent study focusing only on nurses caring for stroke patients in Chinese neurology wards reported a nursing burnout rate of 90% (Jiang et al., 2016). Similarly, another study had only looked at stress levels in nurses working in medical units (Geuens et al., 2015); in this study, medical nurses reported low stress levels, a mean of PSS score of 9.1. One explanation for these differences may be the use of different instruments to measure stress levels across these studies, for example the Maslach Burnout Inventory, Profession Quality of Life Scale, Revised Nursing Work Index, etc.
Nevertheless, in the current study the majority of nurses working on stroke units reported being stressed, and a further qualitative analysis explored the experience, influence and coping methods related to this stress. Multiple stressors were cited; with common issues including the workload and multi-tasking requirements. There appeared to be hospital-specific issues also, i.e. family involvement in one hospital, and communication issues with doctors in the other, larger hospital. This is somewhat supported in the available literature which demonstrates that in smaller hospitals, nurses and physicians have greater communication levels when compared to larger hospitals (Hailu et al., 2016). This may influence the relationship between families and staff in multiple ways. Apart from the obvious possibility that a smaller unit fosters more personal relationships between staff and families, it is possible that larger units foster more family-to-family peer support, which may lead to negative comparisons of care, or alleviate the need for seeking information from the nursing staff (Kessler et al., 2014;Morris & Morris, 2012). Staff having time to build a relationship with families may also influence these relations, and this may have differed between the two units.
The stressful experiences expressed by the nurses in the present study have also been reported in previous studies. Specifically, feelings of anxiety and frustration and issues with lack of time, increase in the workload and lack of adequate nursing staff ratios are common to the available literature (Barreca & Wilkins, 2008;Joice et al., 2012;Lee & Kim, 2020;Sveinsdottir et al., 2006;Theofanidis & Gibbon, 2016). Family involvement and communication issues with medical teams are also cited in several studies (Barreca & Wilkins, 2008;Joice et al., 2012;Lee & Kim, 2020;Sveinsdottir et al., 2006;Theofanidis & Gibbon, 2016).
When nurses were asked to reflect on their coping mechanisms, a variety of strategies were identified in the current study, including seeking some "time-out", seeing a problem as a solvable challenge, and peer support. Taking a break from a stressful situation, more training opportunities, and relying on support from colleagues and managers were also mentioned in the literature (Barreca & Wilkins, 2008;Joice et al., 2012;Lee & Kim, 2020;Sveinsdottir et al., 2006;Theofanidis & Gibbon, 2016).

Limitations and recommendations
A number of limitations exist in the present study. This study was based in two hospitals in a single city. The response rate at 48% was adequate given the reliance on the ward manager to distribute the surveys. A convenience sampling technique was chosen for study interviews, but may have allowed selection bias. The sample size for the interviews is relatively small, but data saturation was reached. Findings may not be generalizable to other nurse populations who work with patients with stroke in acute or rehabilitation settings. Another limitation is the subjective nature of the measurement instrument. However, stress is a subjective experience and bias was somewhat mitigated through the use of a validated quantitative scale.
Finally, performing repeat assessments of stress levels, as part of a longitudinal design, would be useful to help explore effectively how work experience may affect the stress experiences and coping mechanisms over time of nurses working with stroke patients. Occupational stress in stroke rehabilitation units remains a relatively unexplored area of research. Therefore, it's important that future researchers concentrate their efforts in this field.

Conclusion
Chronic stress in nursing staff is an ongoing issue and has been widely investigated under the umbrella term 'burnout'. The present study adds to available literature with the majority of participants expressing levels of 'moderate stress', and mean stress levels higher in nurses working on medical wards than those working on stroke units. A variety of reasons for stress were identified during interviews, with the most frequent issues being family involvement, medical team communication, the work environment and their job performance.
Suggestions to alleviate stress experienced by rehabilitation nurses include: • Improve communication between staff, particularly between members of the multidisciplinary team, by communication training and the use of appropriate feedback tools to ensure a closed loop in the communication process; • Educate families about stroke and its complications to enable relatives to participate appropriately in the rehabilitation process; • Improve access to and uptake of formal counselling for stroke nurses to ensure stressful events are dealt with in a timely and confidential manner; • Encourage and provide ongoing training to stroke nurses as well as the other members of the multidisciplinary team to ensure all members work towards the same goals.

Data availability
Underlying data Interview data. The interview transcripts will not be stored in an open access repository, due to their potentially identifiable nature. However the anonymous and retracted (i.e. de-identified) transcripts can be made available upon email request to the first author, with a valid reason for the request provided, such as completion of secondary analysis.