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Review

Why nurses need to unwind from work

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Failing to find time to unwind once work is over can cause long-term ill health in nurses

In this article…

  • Why workers are currently more vulnerable to stress
  • The effects of not unwinding after work
  • Barriers to recovering after work

 

5 key points

  1. Work-related stress is a reaction to harmful aspects of work
  2. Greater demands for flexibility and efficiency at work is linked to stress
  3. Being away from the work environment does not necessarily result in recovery from work
  4. Up to 30% of workers in Europe are affected by chronic work-related fatigue
  5. Work-related fatigue among nurses can lead to medication errors and increase the risk of work-related injuries

Authors

Dawn Querstret is an MSc student, and Mark Cropley is a reader in health psychology, both at the University of Surrey.

Abstract

Querstret D, Cropley M (2011) Why nurses need to unwind from work. Nursing Times: 107: 10, early on-line publication.

With increased pressures in the workplace, more people are at risk of poor health. Individuals frequently take stress home with them and ruminate on problems, which can prevent them from recovering from work. More research is needed to identify and understand what factors can enhance or prevent nurses from effectively unwinding after a shift.

Keywords: Work-related stress, Fatigue, Shift work, Ill-health

  • This article has been double-blind peer reviewed

 

Nurses have a demanding role in fast-paced and varied work environments. It is well known employees in these types of environments are at greater risk of developing poor health and wellbeing (Devereux, 2003). The working world is continually evolving, and has become a more demanding, complex environment - characterised by drawn-out decision making, increased uncertainty, and high levels of responsibility. There is also greater demand for employees to be more flexible. Many researchers have suggested a relationship between work-related stress and this change in the way work is organised.

Work-related stress has been defined as an emotional and psycho-physiological reaction to aversive and harmful aspects of work, work environments and work organizations (Levi and Levi, 2000), and is characterised by high levels of stimulation and distress and often by feelings of “not coping”. Schnall et al (2000) suggested there was a higher incidence of cardiovascular disease associated with increased psychological work demands, while Kaminski (2001) found evidence that the increasingly high demand for flexibility and efficiency is linked to an increase in workers’ vulnerability to stress. Given the economic climate and resultant increase in redundancies, it is common for the remaining workers to take on extra responsibilities. This can result in extra stress, which they take home with them when they finish their shift. For example, fewer nursing staff on shift may result in their experiencing more stress because they still have to care for the same number of patients. Redundant posts being filled with agency staff may also lead to increased stress because permanent team members still need to manage their own workload as well as supporting the agency staff.

Ultimately, this increase in stress, if unrelenting, can lead to ill-health, and this can have a huge economic and social impact. For example, in 2005 the cost of staff absence to the UK economy rose to more than £13 billion (Berry, 2006). The National Institute of Occupational Health and Safety (2002) found a strong relationship between employee wellbeing and the changing nature of work, suggesting the stress employees experience at work is increasing, which could adversely affect their health. The NIOSH has called for new research, tools and methods to evaluate the impact of the changing demands of work on employees’ health and safety.

Work-related ‘recovery’

A critical factor underlying the relationship between work and ill-health is inadequate psychological and physical recovery. The Employment of Britain Survey (1992) interviewed over 3,000 workers and found that 70% of them found it difficult to unwind after work (Gallie et al, 1998). People invest mental and physical resources to deal with work-related demands, and are tired when they leave work because their resources have been depleted. This can only be resolved by successfully unwinding (Sluiter et al, 1999). It might be assumed that “recovery” outside of work is an automatic process - after all, the demands of work are no longer present. However, research has shown that simply being away from the work environment and having enough time between work periods does not necessarily result in an individual adequately recovering (Sluiter et al, 2003).

Consequences of inadequate recovery

Healthcare settings and schools are known to be particularly demanding environments. Studies have shown that people who work in them find it difficult to unwind when the working day is done (Gorter, 2005). However, working in demanding environments does not automatically mean health and wellbeing will be compromised. People seem able to cope with the stress of work as long as they can achieve a consistent level of recovery between periods of work activity (Sluiter et al, 2003). In fact research has shown that intermittent demands or stress followed by complete recovery builds physiological “toughness” (Winwood et al, 2007). It is prolonged or repeated stress exposure with sustained stimulation that results in detrimental health effects.If employees cannot adequately recover in periods between work, they will be operating with reduced resources and maintaining their work performance will require more effort. As a result they will have an even greater need for recovery, resulting in “recovery debt” and fatigue (Geurts and Sonnetag, 2006).

Research suggests that 11-30% of workers in Europe are affected by chronic work-related fatigue (Akerstedt et al, 2002). Fatigue in nurses has been implicated in medication errors and can lead to decreased productivity, cognitive impairment and increased risk of work-related injuries (Kunert et al, 2007). Insufficient recovery is also thought to be a significant factor in some health problems experienced by people who are chronically stressed. Prospective research studies have highlighted the importance of successful recovery - individuals with an insufficient recovery have been shown to be at increased risk for cardiovascular death in the following 25 years (Kivimäki et al, 2006), while inadequate recovery outside of work has also been associated with other poor health outcomes including:  sleep problems and fatigue (Nylen et al, 2007), increased risk of cardiovascular disease (Suadicani et al, 1993), and negative mood (Pravettoni et al, 2007).

The impact of shift-work

Not only do nurses work in extremely demanding environments, many also need to adapt to rotating shift patterns. Research has shown that shift-work is particularly bad for health (Kantermann et al, 2010). While some of its effects are acute and short-lived, such as disturbed sleep and digestive problems, others lead to long-term health problems that persist well into retirement, for example, diabetes mellitus, increased body mass index/obesity, elevated triglycerides and cholesterol levels. The risk of breast, colorectal, prostrate, and endometrial tumours also correlates with the number of years people have worked night shifts. These health problems in shift workers are well known, but the reasons why are poorly understood. In addition to these physiological symptoms, shift workers may also experience psychosocial problems their work makes it difficult to maintain stable social lives.

Despite its potential negative effects, we should not assume that shift work is intolerable for everyone. Many people enjoy it and do not experience health difficulties. Why is this?

People’s natural sleep-waking patterns vary hugely.We each have a “chronotype” – which reflects at what time of the day our physical functions, such as hormone level, body temperature, cognitive faculties, eating and sleeping, are active, change or reach a certain level.  Our chronotype is largely governed by genetics through the circadian (biological) clock. The distribution of chronotypes in the population ranges from extreme “early types” (who prefer to get up early and go to bed early) to extreme “late types” (who would rather get up late and go to bed late), with most people falling somewhere in between. While social schedules such as school and work can interfere with people’s sleep, short-term disturbance to preferred sleep-waking timing is not harmful. The difference between those who develop ill-health while working shifts and those who do not may lie in what people do when they are not at work. For nurses and other shift workers, adequate recovery between shifts is imperative. So, what are the barriers to adequate recovery when not at work?

Work-related rumination

Something people may do when they are not at work that may interfere with their ability to adequately unwind or recover, is to ruminate on work-related issues and events. Some think about tasks they have left uncompleted, some ruminate about a problem that needs to be solved, and others dwell on relationship issues with colleagues or negative events at work. This rumination may include upcoming events or expected demands and issues as well as those that have already happened.

Ruminating about work does not need to be a negative experience – in fact it can often help people to develop solutions for problems, which in turn make the next shift easier to manage. The problem with rumination (whether for positive or negative reasons) is that it prevents people from taking adequate time to recover between shifts. If they are not properly recovered they must work even harder to cope with the same level of demand in their next shift, and if this continues they can develop fatigue and can experience other health problems. Research has suggested that rumination may provide a vehicle for work-stress to disrupt sleep (Cropley et al, 2006) - and sleep is one of the most important restorative processes we have.

Do we all ruminate?

Of the 3,000 workers interviewed for the Employment of Britain Survey (1992), 72% reported worrying about their job at some time after work and 22% described themselves as regular worriers, with 11% stating they worried about their job after work much of the time (Gallie et al, 1998). Rumination is not a new idea. Research in this area has been dominated by clinical or health psychology. Rumination is thought to be implicated in the aetiology of a number of psychological disorders, including depression and anxiety, and is associated with increased physical symptom reporting, negative self-evaluations, diminished feelings of control and of helplessness. Laboratory studies have also shown prolonged physiological stimulation and delayed recovery in people who ruminate (Roger and Jamieson, 1988).

In the clinical context, rumination is thought of as a trait, and it may also be true that people who ruminate in the work context are displaying a general tendency for rumination. However, not everyone ruminates, and those who do, do not ruminate all the time. This suggests that some rumination is driven by certain situations. It may be that people who are experiencing high levels of stress at work are more likely to ruminate when they leave work, and research has shown an association between work-related stress and rumination (Cropley and Millward Purvis, 2003).

Is rumination harmful?

Literature on the subject tends to regard rumination as a negative process, and the majority of research focuses on repetitive thinking about negative experiences. However, not all rumination is harmful.

The difference between positive and negative rumination may reflect its focus and purpose. Rumination is thought to be problematic when it prolongs the psychological and physiological response to work demands. This is because recovery cannot occur in the presence of this constant psycho-physiological response. But not all forms of ruminations result in this continued response. Ruminating about the positive aspects of a job, or about something done well at work can be a rewarding experience resulting in increased feelings of wellbeing.

Even if you are reflecting on negative aspects of your job, if your focus is on solving a problem, and a solution presents itself, this could be a positive experience. What can be problematic is emotion-focused (or affective) rumination - becoming stuck in a repetitive cycle of thinking about things that went wrong at work, perhaps an argument with a colleague, or something that happened when dealing with a difficult patient. With this type of rumination, people remain in a high state of psychological and physiological stimulation, even though they are no longer at work, which can be problematic. Even though the positive and/or problem-solving reflection may appear more beneficial in the short-term, ruminating about work when they need recovery this could lead to employees developing long-term health problems. This is because such thoughts continue to drain their energy resources, interfering with sleep and other recovery processes, when they should be giving themselves time to recharge.

To ruminate or not to ruminate?

So, why is it that some people ruminate and others do not? It may be that high and low ruminators see their work in different ways. Recently, we conducted interviews with high and low ruminators about how they unwind after work, and found qualitative differences in the way these two groups viewed work (Cropley and Millward, 2009). It appears that for people who ruminate a lot, their sense of identity is entwined with their role at work, the boundary between work and home is blurred and work-related thinking consumes a lot of their time, irrespective of the context they find themselves in. Low ruminators on the other hand have clearly established boundaries and regarded their work and home lives as different domains.

This is not to suggest that low ruminators are any less committed to their work than high ruminators - they simply see a much clearer distinction between home and work and actively work to maintain this when not at work. It may be the nature of an individual’s role that either helps or inhibits “switching off” after work. Recent research with surgical nurses showed low levels of rumination when not at work (Mackintosh, 2007). Mackintosh suggested this may be because these nurses were able to hand over to the oncoming shift, who they knew would complete any unfinished work. However, because of the lack of research in this area, we do not know if these findings apply to other nurse specialties.

The importance of research

With an ever-changing working world, it is essential to identify and understand the factors that enhance or prevent nurses from effectively unwinding from work. Nurses represent a unique sub-population of the workforce and are under-represented in research looking at recovery from work. Given the health implications of inadequate recovery between shifts for both nurses and patients it is important we understand the factors interfering with recovery.

Work and health survey

We are inviting nurses to participate in our research. Log on to the link below to complete our web-based survey, which should take approximately 20 minutes.

There are no difficult or highly personal questions, and you can get a personalised report showing how you compare with nurses in general if you wish.

This research is important to us and will help to develop interventions designed to aid the unwinding process.

Please click here to complete the questionnaire.

We thank you in advance for completing the survey.

If you have any questions or comments, or if you would prefer to complete a paper copy of the questionnaire, contact Dawn Querstret: dq00007@surrey.ac.uk.

 

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