Impact of stress on nurses working in the district nursing service

District nursing (DN) is a field of nursing that specialises in providing care to individuals living in the community (NHS, 2019). DN teams are led by district nurses who have completed the Specialist Practitioner Qualification in district nursing and supported by registered general nurses and healthcare assistants. DN has had to develop in order to accommodate an ageing population with increasingly complex health needs (NHS, 2019). Staff working within these teams are often a lifeline for patients, helping them to maintain independence (King's Fund, 2016a; 2016b). Nurses working in DN services are central in providing empowerment and high-quality, holistic care to people living in the community while reducing costs in the long term within the NHS (Queen's Nursing Institute (QNI), 2015). The NHS (2019) Long Term Plan identifies the importance of DN services as well as the challenges faced due to insufficient staffing levels, leading to lack of capacity to meet the rising patient need and complexity within the community setting. The QNI and Royal College of Nursing (RCN) (2019) undertook a report that provided an overview of DN, in order to identify the elements that are required to deliver an excellent DN service. The report found that the number of district nurses working within the NHS in England has reduced by 43%. Challenges within district nursing are often not recognised, with media attention focusing on care within hospitals (QNI, 2016a). Middleton (2016) described DN as an overlooked field of nursing, an invisible glue that is holding the health service together.

The QNI (2016b) reassessed its 2020 vision on the future of district nursing 5 years after the document was first published. Their report found respondents were experiencing low morale within district nursing due to the following (QNI, 2016b):

• Continuous change
• Poor referrals
• Heavy workload
• Lack of capacity to cover absence/sickness
• Career uncertainty
• Blame culture with zero tolerance
• Poor management
• Lack of support from seniors
• Unpaid hours
• Cuts to staffing levels
• No limit in caseload capacity.

The report established that district nurses were experiencing stress and, as a result, sickness, early retirement and resignation were on the rise (QNI, 2016b).

Employers have a legal duty to protect their employees from stress (Health Service Executive, 2019). Despite this, district nurses are required to meet the high demand for their services with limited resources, relying on their resilience. When the demand for services exceeds the capacity of the DN team, it is significant to consider how this might be impacting on nurses and patient care (Duncan, 2019). Hall (2016) described the negative impact of chronic work stress as a modern epidemic. Nursing has always been a highly stressful occupation, but the number of nurses and health visitors absent from work due to depression, anxiety, stress or other mental health disorders has increased progressively over the last 7 years (King's Fund, 2019). Hall (2016) suggested that managing stress in district nursing should be prioritised to ensure that community nurses feel valued and cared for by the NHS, creating a happy workforce rather than losing nurses due to burnout.

The present study describes a literature review undertaken to identify the consequence of nurses working within a highly stressful environment. The review focused on the experiences of nurses as individuals. The existing literature on the topic was critically appraised with the intention of answering the focus question: ‘What is the impact of stress on nurses working within the DN service?’

Methodology

The PICOT tool was used to aid in formation of the research question (Aveyard, 2019). Systematic searches were conducted in six databases: British Nursing Index (BNI), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Internurse, PubMed, Health Management Information Consortium (HMIC) and Medline. Over a 2-week period, each database was searched using the following key words and alternative terminology: district nurses; community nurses; primary care nurses; impact; effect; influence; stress; occupational stress; workplace stress; pressure; burnout; anxiety. Inclusion and exclusion criteria were identified and applied to ensure the appropriate articles were selected (Table 1) (Garg, 2016).

Six primary research studies were identified via the databases. Snowballing was used to acquire a further four studies. Kreis et al (2012) stated that databases often do not provide all journal articles, and snowballing overcomes this limitation and strengthens the search strategy (Figure 1).

Figure 1. PRISMA flow diagram of study selection

The strengths and limitations of each paper were analysed using the CASP (2018) critical appraisal tool for qualitative research. Quantitative research was appraised using a stepwise guide derived by Coughlan et al (2007). Thematic analysis was used to synthesise the findings by identifying common themes within the research (Clarke and Braun, 2017).

Results

Multiple themes were presented in each study, so the overarching theme was selected for consideration, namely, burnout and compassion fatigue, reduced job satisfaction and emotional injury. These three themes were explored to draw conclusions about the impact that stress can have on nurses working within DN services.

Compassion fatigue and burnout

A quantitative study by Durkin et al (2015) sought to analyse associations between burnout, wellbeing, and compassion fatigue in community nurses. The study had a small sample of 37 registered nurse participants who complete standardised psychometric questionnaires. According to their findings, nurses who presented with more self-compassion were less likely to suffer from burnout and compassion fatigue and had increased resilience to occupational stress (Durkin et al, 2015). In contrast, nurses who neglected their own emotional wellbeing and who were self-critical were prone to experiencing burnout and compassion fatigue, a finding that highlighted the need for self-care among community nurses. Durkin et al (2015) concluded that the development of self-compassion could be beneficial for community nurses, since it can be linked to lower levels of burnout, thus improving wellbeing.

A qualitative study by Tunnah et al (2012) used semi-structured interviews with seven participants to explore the wellbeing of hospice-at-home nurses who were caring for patients who were dying; compassion fatigue and burnout were highlighted as consequences of the psychologically demanding specialty of palliative care. The themes identified from the interviews were job satisfaction, stressors, coping strategies and support. A predominant comment from the nurses was that the job was ‘mentally draining’ and the nurses had a need to ‘switch off’ after work. Again, self-care was identified as an important factor to combat burnout and manage stress, along with appropriate support from colleagues and coping strategies, such as time management (Tunnah et al, 2012).

Similarly, in a qualitative study conducted by Terry et al (2015), the phrase ‘compassion fatigue’ was reported to have been used by multiple nurses during their semi-structured interviews when describing the impact of caring for palliative patients. Although the main purpose of the study was to investigate the impact of health and safety issues for community nurses, one of the themes derived from the semi-structured interviews was burnout and work-related stress. The nurses interviewed spoke about the challenges they encounter daily, such as death and heavy workloads, which contribute to them experiencing burnout (Terry et al, 2015). The study was conducted in Australia, so the findings may not necessarily represent UK district nurses; however, it is evident from UK studies that there are similarities. Terry et al (2015) discussed the trustworthiness of their study, explaining that processes were in place to ensure the findings were transferable, reinforcing the validity of the paper (Moule and Hek, 2011). The authors concluded that a proactive approach rather than a reactive approach is imperative in maintaining the health of nurses providing care in the community (Terry et al, 2015).

Reduced job satisfaction

Reduced job satisfaction and retention have emerged as a result of stress for nurses working in DN teams. Ball et al (2014) conducted a quantitative study with 2438 survey responses from community nurses. Among the key findings were:

• 40% of nurses working in DN services reported that they would leave their current job if they could
• 69% reported no limits for referrals and long working hours
• 50% mentioned poor staffing levels due to sickness, poor recruitment and retention
• Many of the nurses raised concerns about providing poor quality of care to patients because of lack of time and increasing pressure to meet demands (Ball et al, 2014).

The researchers did not explain how the data were analysed and did not mention the limitations or strengths of their study. However, the study was published by the Royal College of Nursing (RCN), which is the largest nursing union and professional body in the world, so the trustworthiness of the study might be assumed (RCN, 2020). However, this could also present funding bias, where the findings reported support the interests of the RCN.

Addressing the same theme of reduced job satisfaction and retention, Samia et al (2012) used observations and interviews to describe 29 home care nurses' experience of job stress. They used blinding to conceal agency selection and triangulation to reduce systematic bias, both of which increased the validity of the study (Mullane and Williams, 2013). Thematic analysis was used to analyse the findings, and the themes that emerged, namely, loss/lack of control, role conflict and role overload, were reported to contribute to increased stress and reduced job satisfaction. The authors emphasised the importance of effective organisational support and system changes to support nurses, whereby a positive working environment could be created to attract and retain them (Samia et al, 2012). Solutions included effective recruitment, adequate resources to do the job efficiently, regular clinical supervision and a supportive team leader. Despite the small number of participants, this explorative study provided vital information to support more robust future research (Hallingberg et al, 2018).

Begic et al (2019) investigated how burnout among community nurses might impact their intention to leave the profession. The study used qualitative data collected through in-depth interviews and quantitative data collected through surveys with a small number of participants (n=27), of which only six were nurses, which was a limitation of the study. The qualitative data found that home visitors often experienced secondary traumatic stress but were unsupported with this by supervisors, which resulted in withdrawal and self-isolation. Contemplating leaving their job due to high levels of stress was a frequent occurrence, and flexible working was an important factor in maintaining a good work–life balance. Further, the use of humour was reported as an important coping mechanism when dealing with stress (Begic et al, 2019). The authors reported the findings without separating the participants into their different roles, to ensure that anonymity was not compromised. However, this posed an additional study limitation, as the findings are not necessarily representative of nurses' experiences. The key findings from the quantitative data were supported by the qualitative data, adding depth, but it is difficult to apply these findings to nurses working within the community because other professionals will have different experiences.

Emotional injury

Emotional labour, emotional exhaustion, emotional dissonance and psychological distress were all frequently used to describe the impact of stress on nurses working within the DN service. Therefore, the umbrella term ‘emotional injury’ was used to incorporate the various emotional responses reported in the literature. Emotional injury is the consequence of stress that can render an individual emotionally scarred and/or emotionally unfit (Fineman, 2003). A quantitative study by Karimi et al (2014) used surveys with 312 participants to investigate the relationships between the variables emotional labour and emotional intelligence in relation to wellbeing and job stress. The authors found statistically significant results to support both their hypotheses (nurses who have higher levels of emotional intelligence have a higher level of wellbeing and experience less job stress and nurses experiencing more emotional injury have lower wellbeing and greater job stress). The authors concluded that community nurses have emotionally demanding roles that, consequently, put them at risk of the adverse effects of emotional injury (Karimi et al, 2014).

Emotional injury was also a theme within Haycock-Stuart et al's (2010) qualitative study, which investigated emotional labour in community nursing leadership through interviews with 12 nurse leaders. The study used thematic analysis, and the themes that emerged were emotion and decision-making, managing emotions at work, feeling unsupported and emotional injury (Haycock-Stuart et al, 2010). Many of the participants described various emotional injuries related to pressure at work that resulted in illness. Work–life balance was highlighted as an important factor affecting resilience and coping with stress. Haycock-Stuart et al (2010) recommended additional support via coaching and ongoing emotional support rather than only providing access to this when the nurses became unwell.

In contrast, a quantitative study by Opie et al (2011) compared the levels of stress and psychological wellbeing between hospital-based nurses and nurses working within the community. Some 612 nurses completed questionnaires, with the results indicating that high levels of stress in both groups of nurses affected their psychological wellbeing. Opie et al (2011) concluded that the levels of stress are extremely high in both community and hospital-based nursing and have an impact on the psychological wellbeing of nurses. The authors highlighted that longitudinal studies would reinforce the links made in this study to stress and emotional injury (Opie et al, 2011). Quantitative research by Karimi et al (2017), in the form of a survey conducted among 312 community nurses, examined how workplace organisational factors can impact on emotional withdrawal. The authors hypothesised that emotional dissonance is linked to withdrawal behaviours and that workplace organisational factors can mediate the link between emotional dissonance and withdrawal. Their findings supported the hypothesis, and the authors concluded that emotional injury could lead to withdrawal behaviour, such as job neglect, and that withdrawal behaviours could negatively impact on patient care and reduce the quality of care being provided (Karimi et al, 2017). Creating a positive working environment could alleviate stress for community nurses and prevent the negative impact of emotional dissonance (Karimi et al, 2017).

Discussion

Burnout and compassion fatigue have emerged as significant repercussions of stress for nurses working within the community setting. The phrase ‘compassion fatigue’ was developed by Figley (2013), who described it as the manifestation of yielding to the demands of patient care over self-care. Compassion is a key attribute of a nurse, but providing emotional support for patients every day could impact the wellbeing of nurses themselves (Cross, 2016). Similarly, burnout is the result of becoming emotionally and physically exhausted from coping with high levels of stress (Nursing Times, 2019).

Nurses who neglected their own emotional wellbeing suffered with compassion fatigue and burnout, while nurses with higher levels of self-compassion showed increased resilience towards occupational stress (Durkin et al, 2015). This is supported by Neville and Cole (2013), who also found associations between compassion fatigue, burnout and compassion satisfaction and concluded that promotion of positive health behaviours among nurses can improve their wellbeing and counteract the negative impacts of stress. Both Tunnah et al (2012) and Terry et al (2015) found links between compassion fatigue and burnout and caring for palliative patients. A study by Slotum-Gori et al (2011) made the same correlations, suggesting that institutional programmes are required to support nurses and reduce the emotional toll of caring for palliative patients. Nyatanga (2012) stated that, motivated by wanting to provide the best quality of care for their patients, nurses will often ignore signs of stress in caring for people at the end of life because they do not want to let the patient down.

Nurses' health and wellbeing has been an important consideration, with all the studies in this review reporting a variation of emotional injury as a result of stress. As demonstrated by Karimi et al (2017), emotional labour can lead to withdrawal behaviour that is detrimental to the wellbeing of nurses and could negatively impact on patient care. This is supported in research conducted by Delgado et al (2017), who found that, although emotional labour is an issue across all fields of nursing, resilience can protect nurses from its negative implications. Resilience is highlighted as significant in combatting emotional injury (Delgado et al, 2017). Karimi et al's (2014) research found that the ability of an individual to manage their own emotions, known as emotional intelligence, is vital in managing stress. Furthermore, research by Por et al (2011) found that nurses who were in control of their emotions and were emotionally competent effectively coped with their stress, which subsequently enhanced their wellbeing.

It is clear that coaching in skills such as emotional resilience and emotional intelligence is imperative. However, according to a report by the King's Fund (2017), DN services are under severe financial strain due to structural differences between primary and acute care, resulting in unequal levels of pressure. Finding funding for additional training or coaching could be a challenge, unless there is enough evidence to suggest the training would be beneficial in the long term. There is currently a lack of up-to-date evidence that focuses on the impact that stress can have on nurses working within the DN service.

Reduced job satisfaction and retention were often cited as consequences of stress. Samia et al (2012) and Ball et al (2014) both concluded that positive work environments, system changes and addressing concerns regarding staff wellbeing would assist in attracting and retaining nurses. Research conducted by McVicar (2015) reinforced the connection between stress and job satisfaction, with the results of the research indicating that increased job stress causes a decrease in job satisfaction. Additionally, Kumar et al (2015) described job satisfaction and job stress as key components in maintaining quality of care provided to patients. Their research concluded that timely and appropriate interventions must be in place to improve stress levels of nurses, maintain job satisfaction and enhance quality of care being provided (Kumar et al, 2015). Begic et al (2019) highlighted that nurses reported using coping strategies, such as the use of humour and being able to switch off from work, as a useful way of managing work-related stress. Manomenidis et al (2016) suggested that, although mentally disengaging after a shift can be difficult and strategies individuals use to do this can vary, this strategy when done effectively could increase resilience and improve wellbeing.

Further, a study conducted by Williams et al (2018) sought to investigate the relationship between job stress, job satisfaction and nurses' health-promoting behaviours. The study found that high levels of health-promoting behaviour resulted in increased job satisfaction, thus strengthening the need for interventions that reduce stress levels for nurses (Williams et al, 2018). In addition, improving workplace conditions and reducing pressure by managing caseloads effectively could assist in retaining nurses and improving job satisfaction (King's Fund, 2016a; 2016b). As DN caseloads have no limits, this could be a challenge. However, effectively triaging referrals, using other services and having an efficient skill mix of staff will contribute to achieving this (QNI, 2016a).

Additonally, on a corporate level, NHS Improvement's (2018) resource for DN indicates that increasing demand on the DN service requires further deliberation in order to shape a financially and operationally safe and sustainable service. Difficulties in recruitment are a significant factor affecting staffing levels. Turnbull (2017) stated that policies created to reduce costs by recruiting less qualified staff and not filling vacancies also affect staffing levels. Furthermore, a lack of nursing staff applying for DN roles is an issue (Turnbull, 2017). Thus, promotion of the DN service must be addressed.

The present study had some limitations. There was a lack of up-to-date, primary research addressing this topic. Additionally, not all the studies reviewed here were conducted in the UK, and therefore, they present results from different healthcare systems. However, this could be viewed as an advantage, as it presents an overview of nurses' experiences within various healthcare systems. Some of the studies had a small number of participants, so theire findings might not necessarily be representative of larger populations.

Conclusion and recommendations

This review provided essential answers in addressing the question, ‘What is the impact of stress on nurses working within the district nursing service?’ Evidence shows that there are a variety of negative implications of high levels of stress among community nurses. The evidence presented identifies gaps in health care that need addressing. Focusing on these gaps will provide the basis for future research, with the goal of reducing and managing stress among nurses where possible.

Self-care and organisational support are imperative in counteracting compassion fatigue and burnout. Being proactive rather than reactive is essential; thus, it is recommended that organisations promote healthy behaviours, coping strategies and self-care through support and training.

Emotional injury was identified as an issue in DN. Emotional resilience and emotional intelligence appear to be key aspects of managing emotional injury in community nursing. Thus, the final recommendation for practice is for coaching in these skills to be provided to all nurses within the DN service.

Finally, stress leads district nurses to become dissatisfied with their jobs and leaving DN services. To improve job satisfaction and retention, an additional recommendation for practice is to reassess how caseloads are managed in correlation with staffing levels to enable staff to take protected breaks and not work overtime due to workplace pressure.

KEY POINTS

• Burnout, compassion fatigue and reduced job satisfaction have emerged as significant repercussions of stress for nurses working in district nursing (DN) teams
• Self-care and organisational support are imperative in counteracting compassion fatigue and burnout, and high levels of health-promoting behaviour can result in increased job satisfaction
• Emotional labour can lead to withdrawal behaviour that is detrimental to the wellbeing of nurses and could negatively impact on patient care
• Organisations should invest in training and support to improve resilience and encourage coping strategies among district nurses

CPD REFLECTIVE QUESTIONS

• Have you ever experienced burnout, compassion fatigue, emotional injury or reduced job satisfaction? What were the causes?
• How do you manage work-related stress?
• Can you think of ways in which your organisation can better support you in coping with or managing stress?