Difficulties with Stress Management Faced by Nurse Managers : A Survey of Nurse Managers at a University Hospital

C l i n M e d International Library Citation: Kaneko M, Kakehi R (2015) Difficulties with Stress Management Faced by Nurse Managers: A Survey of Nurse Managers at a University Hospital. Int Arch Nurs Health Care 1:021 Received: November 11, 2015: Accepted: December 19, 2015: Published: December 24, 2015 Copyright: © 2015 Kaneko M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Kaneko and Kakehi. Int Arch Nurs Health Care 2015, 1:1 ISSN: 2469-5823


Background
The current shortage of nurses has been implicated in the emergence of overwork and stress [3].
Employees in the health care service are at a high risk of developing mental health problems.This affects their work performance, compromising the quality of care they can provide [4].
Common mental disorders can have negative impacts such as decreasing work function and increasing the number of absences because of illness [2,[5][6][7].Nurse managers are under increased stress because of excessive workloads and hospital restructuring; however, few stress management seminars are conducted for their benefit [2].A search of the electronic database EBSCO host CINAHL plus with Full Text and MEDLINE with Full Text for documents that had the keywords 'mental support for nurse' yielded 73 search results from the past five years (2010)(2011)(2012)(2013)(2014)(2015).There were one study regarding support for nurse managers among these results, and at present, the training of people in these positions is not being adequately conducted in Japan.
Nursing management indicates the need for a work environment that enables high job control and good managerial support for both first-line nurse managers and registered nurses [8].Independent of the inevitable work-related stress associated with a nurse manager's role, social support provided to current and aspiring nurse managers is thought to assist with coping and thriving in the work environment [9].

The Study Aim
The aim of the present study was to investigate the management of stress with regard to nurse managers who provide guidance to staff.

Introduction
Nurse leaders experience significant job stress [1][2].It is important for nurse managers to consider mental health support systems for nurses, in order to enable them to provide patient care while in a good mental and physical state.However, the state of

Data collection
This study was conducted from July to August 2010, with a sample of nurse managers.The researcher created the questionnaire regarding nurse manager's recognition of staff stress management and staff support, the measures used to manage stress and stress management needs.Nurse managers were asked to freely describe the following three items in the form of answering a survey: (1) everyday thoughts and difficulties of nurse managers with regard to staff stress management; (2) measures taken for staff stress management; and (3) nurse managers' stress management needs.
The basic attributes recorded of the subjects investigated were sex and age.

Ethical considerations
The researcher drew up written explanations of the purpose of this study and distributed these during a meeting held with the nurse managers.
The target group voluntarily participated in this study.
The survey was anonymous, and return of the survey was considered to indicate consent.
The ethics committee of Tokyo Women's Medical University approved this study in June 2010.

Data analysis
Basic demographic data of subjects included sex, age and mean age.The survey data of the nurse managers' descriptions of difficulties with staff stress management were conducted content analysis.Following this, common details were grouped from the sub categories, from which categories were created.With regard to the nurse managers' descriptions of the measures used and stress management needs, similar types of information were categorized.

Basic attributes of subjects
In total, 28 questionnaires were returned (response rate = 100%).
The subjects were all women.The average age of the respondents was 48.1.
The administrative organizational structure of the nursing department of the target institution comprised one director as the overall manager of the nursing department, four deputy directors as assistants to the director in charge of hospital training and management and 28 nurse managers below these positions.The role of a nurse manager was to manage the wards and the nurses belonging to each ward.Each nurse manager was in charge of a ward or one to two outpatient departments.Nurse managers reported to and consulted with the deputy nursing directors.The descriptions given by nurse managers regarding stress management are described below:

Difficulties with staff stress management and psychological support
Difficulties were classified into three categories as follows: Understanding and supporting staff members: The following two subcategories were created for this category: (1) Understanding and supporting self-centred staff members and those who cause accidents Nurse managers struggled to understand and support highly assertive staff members who lacked consideration for others and those who unknowingly caused stress to others.
(2) Managing the group dynamics of ward teams Nurse managers were concerned about how to provide psychological follow-up to novice nurses within the team and how to completely change the team.

Difficulty with Staff training:
The following three subcategories were created for this category: (1) Young staff members must become leaders themselves Nurse managers elucidated the challenge of training young staff (comprising the ward staff), who would inevitably have to become leaders themselves.
(2) The decline in perseverance, thinking power and management skills in nurses and the struggle to deal with this Nurse managers cited difficulties in coping with the social phenomenon of the decline in perseverance and thinking power in young individuals whose values are diversifying, as well as the decline in self-care in such aspects as managing work and private life and controlling emotions.

Dealing with the worries and dilemmas of individual staff members:
The following two sub-subcategories were created for this subcategory: (1) Stress experienced when a stressed staff member quits halfway through.
This pertains to the stress placed on the nurse manager when the staff member could not adapt to the job.
(2) Difficulties faced by a staff member in managing dilemmas related to patients Managers described the difficulties they experienced in managing dilemmas that staff members faced with regard to terminal patients.
(3) The content of staff stress management and support provided by managers The following six subcategories were created for this category: 1) Observation of staff members and support Changes in staff members' behaviours were observed at an early stage by their facial expressions and utterances.
Young nurses who could not express their own thoughts or feelings well and who would not express their difficulties were observed carefully.Nurse managers also tried to support staff members who expressed their difficulties but also pretended to be alright.
2) Ensuring that levels of stress placed on staff members are not very high Nurse managers ensured that levels of stress placed on staff members were not too high, and they worked toward relieving it so that staff members maintained their motivation.

3) Maintaining communication and early intervention
Nurse managers maintained constant communication with staff members and ensured that they understood staffs concerns about their work and personal life.They also obtained information from nursing staff and advised the respective nurses regarding both their work and private life.

4) Identifying the positive aspects of staff members and providing feedback
Nurse managers took an interest in staff members, and if they identified any positive aspects, they acknowledged them.

The support system and administration issues
The following two subcategories were created for this category: 1) Inadequate support for managers Some nurse managers knew that their institution was aware of the need for psychological support for staff members but did not Nurse managers expressed needs regarding general knowledge, such as the perception of stress and communication, as well as for the need for training on empirical knowledge and support.This included joint empirical initiatives with veteran nurse managers and measures to deal with staff stress management.
2) The need for a system to support staff members in managing stress Nurse managers expressed that the need for supporting and managing staff members' stress was extremely high.
Nurse managers who manage two or more wards have ineffective communication with staff members.The need to secure human resources for factoring in time for training and the insufficient manpower of nursing staff were cited as issues.
Nurse managers gave their opinions on whether staff members could overcome stress with the aid of a support system.Nurse managers also considered it to be a good idea to have a system that allowed the objective exchange of opinions or a consultation service that offered a support system for nurse managers to improve selfmanagement skills.It was also important for both nurse managers and staff members to discuss their stress in a timely manner.
They outlined the need for a system measuring stress catharsis and recording feelings.They also expressed the need for a consultation system when managers themselves are under stress, for a system to improve managers' self-management skills and for a response system to intervene at the stage before managers become depressed.Some nurse managers expressed the need for anonymous consultation methods such as consultations by phone or via e-mail.

Subjects' attributes
The target institution was a large-scale 1,300-bed university hospital in Tokyo that offered highly advanced medical care.The average length of a patient's stay was 14 days.
The role and organizational position of the nurse managers in the present study were staff administration and the management of staff and health care professionals in each of the wards in their charge.However, because nurse managers were managed by the nursing director and assistant nursing directors, the authority to run and manage the hospital was not delegated well, giving the nurse managers the role of middle managers.

Staff stress management by nurse managers
Based on the categorization of the study results, nurse managers were required to not only understand, support and train staff but also to take up a wide range of management roles such as reviewing the system and dealing with their own challenges.In addition, because many ward nurses worked in teams, the group dynamics of a ward team was an important factor affecting the overall motivation and administration of the ward.
In the category related to understanding and supporting staff members, it was found that nurse managers faced difficulties in understanding and supporting self-centred nurses, as well as those who caused accidents.However, nurse managers dealt with these difficulties overall by observing staff members, maintaining constant communication with them and providing them with feedback on positive aspects of their performance.Because of the lack of a selfsupporting system, nurse managers expressed a strong need for such a system.The nurse managers in the present study were placed in a situation in which they did not have time to communicate properly with staff members, because they were managing two or more wards and were burdened with insufficient nursing manpower.In addition, they had no time for themselves.With regard to stress management support for them, the need was cited for a system immediately offering psychiatric liaison nurses in times of stress, as well as group seminars for stress management.
The results of the present study revealed a very strong need for a stress management system measuring stress catharsis and recording feelings.Many managers also described the need for feasible countermeasures, such as consultations via telephone and e-mail.This suggested that a care system for stress management, including that for nurse managers, was required.
Nurse managers exposed to high job demands had significantly increased odds for low self-rated health.It was also found that having less support from a professional network, the job, their social network, or personal relationships showed increased odds for low self-rated health, which was independent of age, gender and education [10].
Effectively dealing with work stressors by helping to increase hardiness may better equip managers (and their staff) to prevent or reduce negative effects of stress, such as physical and psychological illnesses [11].
Empowered work environments were associated with a lower nurse manager burnout rate and better physical and mental health [12].
To provide patients with better care, it is important to enhance the stress management support system for nurses who provide care and the nurse managers who support them.

Limitations
A limitation of this study was that nurse managers with years of experience were not included, which prevented determining whether difficulties and coping mechanisms of nurse managers differed with experience.In addition, this study did not investigate differences in the scope of management of nurse managers and nursing directors, indicating that the features of the scope of management and the corresponding support methods still need to be investigated.
If it is considered that nurse managers, nurses (who are the main care providers) and patients are part of a single system, then maintaining mental and physical health of the care providers may in turn result in better patient care.Henceforth, it will be necessary to examine a care system supporting nurse managers who in turn support nurses.

Conclusion
The aim of the present study was to investigate the current state and challenges of stress management for nurse managers and their staff.
Based on the categorization of the study results, nurse managers not only understand, support and train staff but also, along with dealing with their own challenges, take on a wide range of management roles such as patient support, coordinating with doctors and reviewing the system.

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convenience sample, targeting facilities that were obtained with the consent of the top manager of the nursing department.