40 June 2015 • Nursing Management


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Mentalforhealth tips nurse managers By Dennis Sherrod, EdD, RN, and Lenora R. Campbell, PhD, RN


ealthcare grows increasingly complex as policy, economic, organizational, and patent care landscapes merge to create more accessible, affordable, safe, and quality models of healthcare delivery. Demand for rapid responses in increasingly larger, integrated, human-focused systems requires nurse managers to anticipate, initiate, and lead intensive change—and then rapidly prepare for the next initiative. Increased scrutiny through regulation, litigation, and public focus on transparency and patient outcomes provides additional healthcare management challenges. Leading in healthcare delivery workplaces can be stressful. So, as a nurse manager, how can you deal with work, home, and life stressors? What can you do to best maintain your mental health? Fortunately,


stress is a well-researched topic; strategies such as maintaining a healthy lifestyle, strengthening hardiness factors, boosting emotional intelligence, establishing supportive relationships, appraising and limiting engagement, and clarifying competing priorities can be helpful for managing personal and work stressors. Learning to manage stress can assist personal goal accomplishment, enhance success, and influence nurse manager health and mental well-being.

Stressed out Patient care responsibilities place high levels of stress on nurses and even higher stress levels on nurse leaders as they manage groups of providers delivering care in complex, rapidly changing systems.1-5 Although the organizational goal may be to prioritize and address critical issues, your personal goal may be to maintain sanity, and not allow a mental

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Mental health tips for nurse managers

meltdown to occur as you address administration, staff, and patient needs. Work-related stress is inevitable. There are invariably competing demands, anticipated and unanticipated deadlines, fiscal challenges, and interpersonal conflicts, among others. How you handle stressors is central to your effectiveness and longevity. Ineffective stress management can accelerate the onset of health conditions such as cardiovascular disease.6 Moreover, research

It can affect job performance and personal well-being. Effective stress management, on the other hand, lessens the negative impact on emotional and physical health and has the potential, not only to create a high-achieving work environment, but also to contribute to one’s personal and professional growth.7

Healthy lifestyles One of the best ways to promote mental health is to maintain physical health. A nutritious diet,

How you handle stressors is central to your effectiveness and longevity.

demonstrates that long-term stress increases BP, even in employees who report they feel little or no job pressure.7 Job stress can cause emotional exhaustion, negative attitudes toward others, decreased selfesteem, and, if not resolved, it can cause burnout.8 Burnout can lead to depression, which can precipitate a variety of other physical and emotional conditions, such as eating disorders, obesity, diabetes, and other chronic diseases. Long-term or chronic depression can reduce immunity to other types of illnesses, and can even contribute to premature death. Stress can reduce energy for getting things done, decrease decisionmaking abilities, lower sensitivity to others and the environment, and even increase aggressive behaviors.

adequate rest, and exercise are essential for effective management of stress. A poor diet can stress the body by decreasing its immune system response. Unhealthy food choices or eating at irregular intervals can starve the body of nutrients needed for normal processes. Inadequate or irregular nourishment of the brain can decrease cognitive activity and the body’s ability to deal with emotional stress. Similarly, inadequate physical activity and lack of sleep can further stress the body. Adequate physical activity and sleep promote a feeling of well-being and help a person cope with stress.9 Sleep deprivation can decrease assessment skills, decision-making abilities, and response time.10 Integrating a proper diet, adequate rest, and exercise into one’s daily regimen provides the

42 June 2015 • Nursing Management

foundation for effectively dealing with challenges and opportunities during the work day. Although competing priorities demand your attention, you must make time for you. Including “energizing” activities in your schedule boosts productivity. Participate in at least 30 uninterrupted minutes of exercise four to five times weekly. You may be thinking, “I spend much of my day on my feet” but you’ll want to make sure you have periods of at least 30 consecutive minutes of exercise to promote cardiac health. Consider participating in yoga classes, which can provide both physical and meditative benefits. Make sure you know your family history, which will allow you to monitor for high-risk diseases related to your genetic makeup, and complete regular checkups, screenings, and immunizations. Eat plenty of fruits/vegetables and fewer processed foods, avoid tobacco, and go easy on the caffeine.11 Physical health is a vital component to mental health.

Strengthen your hardiness factor One of the personality variables found to influence stress levels among nurse managers is hardiness.8 Hardy individuals transform stressful life events into opportunities for personal growth.8 In other words, it’s not what happens to you, but what you do with it. Hardiness has received much attention as a strategy for decreasing psychological distress in individuals experiencing high levels of stress. Hardiness, evidenced by commitment, control, and challenge, has been found to protect against stress by improving stress perceptions and mobilizing effective coping strategies.12 Within the course of a given day, anticipated and www.nursingmanagement.com

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unanticipated events occur, all of which may impact your effectiveness as a manager. How you think about those occurrences (your attitude toward them) determines their impact. Important questions to ask are: What do I think about this, and is this the only way to think about it? How do I feel about this, and is this the only way to feel about it? What impact, if any, does this have on what’s occurring in my sphere of leadership influence? Is it something I need to handle now and, if so, do I need to address it in its entirety or take care of one or more of its most urgent components? If it can be handled later, how can I integrate it into my current list of priorities, or is it something that can be delegated? Taking control of events rather than reacting to them allows proper cognitive processing of events, effective appraisal, and sound decision making. This approach enables events to be perceived in the most beneficial light and managed appropriately, leading to continued growth, rather than spiraling out of control, managing by creating unhealthy responses, interfering with performance and job satisfaction, and leading to long-standing physical and emotional health problems. Hardiness can be learned, and hardiness training has been found to be beneficial, but the focus is to perceive stressful issues and events as challenges requiring decisions to control outcomes to which you and your staff are committed, such as improving patient care.13 A mainstay of hardiness is taking control, demonstrating commitment, and rising to address the challenge.14 For nurse managers, hardiness reportedly decreases the need for sick leave.15 Research also shows that hardiness decreases perceptions of stress, improves mental www.nursingmanagement.com

and physical health, and increases happiness.16 Engage the hardiness factors within you. Rather than allowing a drop in patient satisfaction scores to cause fear and stress in you and your unit, establish a task force of nurses with patient satisfaction strengths, set a timeline, and charge them to develop patient satisfaction improvement strategies. In the first group meeting, demonstrate your support and commitment to the initiative and assure the team that talent is available to address this unit challenge. Remind unit staff that team members are committed to quality patient care

passion can be harnessed to coach, create vision, and energize teams.18,19 Look for opportunities to develop leadership skills in yourself and in your staff. Strengthening emotional intelligence skills related to organizational awareness, collaboration, respect, open communication, building relationships, team work, developing others, and visionary leadership can influence how staff members feel about accomplishing unit goals and patient outcomes.20 Remind nurses in staff meetings of your organization’s commitment to safe and quality patient care. Encourage them to

A mainstay of hardiness is taking control, demonstrating commitment, and rising to address the challenge.

and this is yet another challenge that allows unit nurses and staff to demonstrate their expertise and collectively develop solutions to evolving patient care issues.

Flex your emotional intelligence Exercise self-awareness. Set aside time to reflect on the human capital and personal assets you bring to problem solving on your unit. Assess your strengths honestly and develop your ability to access inner resources, such as attention to details, creativity, and follow through to ensure goal accomplishment.17 Realize how your feelings and emotions influence your thoughts, actions, reactions, and your workplace. Emotion, motivation, and

be action-oriented and empower them to identify solutions to patient challenges as they arise. Know the strengths and abilities of fellow nurse managers, as well as the nurses and staff on your units. Your colleagues may have already dealt with an issue similar to one occurring on your unit and can provide insight on possible solutions. Look for opportunities to delegate projects to your staff who demonstrate the skillsets needed to accomplish project and unit goals. As you review your abilities, strengths, and expertise; consider your rank on the novice-to-expert nurse manager continuum. If you’re a new nurse manager on the novice end of the continuum, you may

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Mental health tips for nurse managers

want to identify one or more nurse manager mentors with whom you can consult and confide as you address new nurse management issues. If a formal nurse manager mentoring program isn’t available in your health system, look for experienced nurse managers who demonstrate qualities that you admire. Invite them for coffee and ask if they’d be willing to serve as a mentor and resource. If you’re toward the expert end of the continuum, be willing to share

tions and reactions. Understand what excites you about your work and how you boost your energy when needed. If there’s a work responsibility that really drains your energy, such as budget planning, schedule short periods of time to work on that challenge. Know your most productive time of day. Are you a morning or evening person? Schedule major tasks that require attention to detail during the most productive part of your day. Exercise social awareness. Your goal isn’t to be a matchmaker, but

Nurse leaders who demonstrate high levels of self-awareness reveal greater emotional intelligence, interpersonal control, personal efficiency, and self-confidence. your expertise with less-experienced nurse managers and discuss “lessons learned” as well as what has worked, or not worked, in your management experiences. Know what stresses you and understand how you react to different stressors. Recognize and validate the meaning of body language and nonverbal cues. Use humor as a stress reliever and resolve conflict quickly and positively. Nurse leaders who demonstrate high levels of selfawareness reveal greater emotional intelligence, including interpersonal control, personal efficiency, and selfconfidence.21 Exercise self-management. Studies have shown that emotional intelligence assists nurse leaders to buffer stress, improve their mood, and develop more positive interpretations of the work environment.22,23 Consider how you manage your emo-

remain aware of how staff members are feeling and if they collaborate successfully with team members and other disciplines. Understand that you don’t control relationships, but, in many instances, early intervention as a mediator or social facilitator can be helpful in establishing productive work relationships.

Establish supportive relationships Individuals able to ask for and receive emotional support have lower stress levels and better outcomes than those who are without emotional support.7 Relationships that offer unconditional opportunities to share and reflect on experiences, and encourage introspection for continual selfassessment and growth, serve to mitigate the adverse reactions

44 June 2015 • Nursing Management

of stress on one’s health and performance. Develop a social support network. Include one or more fellow nurse managers who are nonjudgmental, trustworthy, and good listeners with whom you can test new ideas or discuss strategy sessions. Network with one or more manager colleagues who don’t work in your health system and can provide you with unbiased responses to issues and proposals. Include individuals in your social network who know your strengths and weaknesses, but support you anyway, and are willing to hold you accountable when needed.

Appraise and limit engagement Advances in communication technologies make it possible for job responsibilities to creep into every facet of life. However, staying plugged into the job, even when away, can be stressful. A study examining the impact of frequently checking e-mails on health found that people felt less stressed when they checked their e-mails less often.24 Continual engagement (whether face-to-face or electronic) can be insidious and although it isn’t always recognized as stressful, it has been determined to have an adverse reaction on a person’s health. Some professions have built in traditions to protect their members from overextending themselves. For example, in many religious traditions, it’s mandated that pastors take at least 1 day a week to recuperate or disengage. Although it’s challenging for nurse managers to disengage, decreasing the amount of time spent responding to e-mails at work or remotely may be an effective strategy for managing stress. One suggestion is to deal with e-mail at planned times instead of constantly checking and responding to messages. Another suggestion is to www.nursingmanagement.com

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develop a schedule with fellow nurse mangers to “cover” unit responsibilities for each other to allow for “unit disengagement” for a day or so.

Take time for you Role overload can be a major source of stress among nurse managers. This isn’t only the actual gap between time available to complete work and the amount of work expected, but also one’s perception of the difference between the two.25 Whether role overload is actual or perceived, it’s important to recognize that perception is reality. The link between role overload and stress is real and warrants efforts to minimize its adverse stress effects. Having crucial conversations with one’s supervisor regarding the list of priorities, the amount of time required to complete tasks, and competing priorities or conflict is important to effectively manage role-related stress.26 As nurse managers are being asked to include larger numbers of units, nurses, staff personnel, and patients under their span of control, discussions of realistic management responsibilities must be a part of the conversation. The goal is to create the right balance of work assigned, organizational resources, and the efficiency of nurse managers; given the unique set of priorities. The ability to have an effective crucial conversation about work that must be completed, however, is contingent on having a clear awareness of the priorities and how they relate to your organizational mission. Nurse managers should communicate with supervisors and those they lead to identify a clear set of priorities. Although stress is an inevitable part of the nurse manager role, stress management is a learned behavior, and you can develop skills that allow you to harness its positive effects. Maintaining a healthy lifestyle, www.nursingmanagement.com

strengthening hardiness factors, boosting emotional intelligence, establishing supportive relationships, gauging and limiting engagement, and clarifying competing priorities can help you thrive—not just survive—in your environment. NM REFERENCES 1. Harrisson M, Loiselle CG, Duquette A, Semenic SE. Hardiness, work support and psychological distress among nursing assistants and registered nurses in Quebec. J Adv Nurs. 2002;38(6):584-591. 2. Kath LM, Stichler JF, Ehrhart MG. Moderators of the negative outcomes of nurse manager stress. J Nurs Adm. 2012;42(4):215-221. 3. Shirey MR, McDaniel AM, Ebright PR, Fisher ML, Doebbeling BN. Understanding nurse manager stress and work complexity: factors that make a difference. J Nurs Adm. 2010;40(2):82-91. 4. Stichler JF, Kath L, Ehrhart M, Gates MG. Predictors of nurse manager workplace stress. Communicating Nursing Research. 2011;44:309. 5. Udod SA, Care WD. Nurse managers’ work stressors and coping experiences: unravelling the evidence. Nurs Leadersh (Tor Ont). 2011;24(3):57-72. 6. Steptoe A, Kivimäki M. Stress and cardiovascular disease. Nat Rev Cardiol. 2012; 9(6):360-370. 7. American Psychological Association. Stress in America: paying with our health. Report from the American Psychological Association (APA). http://www.apa.org/news/press/releases/ stress/2014/stress-report.pdf. 8. Judkins SK. Stress among nurse managers: can anything help? Nurse Res. 2004;12(2): 58-70. 9. Larzelere MM, Jones GN. Stress and health. Prim Care. 2008;35(4):839-856. 10. Killgore WD, Balkin TJ, Wesensten NJ. Impaired decision making following 49 h of sleep deprivation. J Sleep Res. 2006;15(1): 7-13. 11. Santa J, Lipman M, Avitzur O, Mosquera J. You asked and our doctors answered. Consum Rep. 2011;76(9):12. 12. Kobasa SC, Maddi SR, Kahn S. Hardiness and health: a prospective study. J Pers Soc Psychol. 1982;42(1):168-177. 13. Judkins S, Reid B, Furlow L. Hardiness training among nurse managers: building a healthy workplace. J Contin Educ Nurs. 2006;37(5):202-207. 14. Judkins S, Furlow L, Kendricks T. Developing hardiness in nurse managers. Nurs Manag (Harrow). 2007;14(7):19-23.

15. Judkins S, Massey C, Huff B. Hardiness, stress, and use of ill-time among nurse managers: is there a connection? Nurs Econ. 2006;24(4):187-192. 16. Abdollahi A, Abu Talib M, Yaacob SN, Ismail Z. Hardiness as a mediator between perceived stress and happiness in nurses. J Psychiatr Ment Health Nurs. 2014;21(9): 789-796. 17. Akerjordet K, Severinsson E. Emotional intelligence: a review of the literature with specific focus on empirical and epistemological perspectives. J Clin Nurs. 2007;16(8): 1405-1416. 18. Cummings G, Hayduk L, Estabrooks C. Mitigating the impact of hospital restructuring on nurses: the responsibility of emotionally intelligent leadership. Nurs Res. 2005;54(1):2-12. 19. Watson L. Self-leadership: becoming an exceptional leader. Radiol Technol. 2004; 75(6):457-470. 20. Yoder DM. Organizational climate and emotional intelligence: an appreciative inquiry into a “leaderful” community college. Community College Journal of Research and Practice. 2005;29:45-62. 21. Akerjordet K, Severinsson E. Emotionally intelligent nurse leadership: a literature review study. J Nurs Manag. 2008;16(5): 565-577. 22. Brown RF, Schutte NS. Direct and indirect relationships between emotional intelligence and subjective fatigue in university students. J Psychosom Res. 2006;60(6):585-593. 23. Carr A. Positive Psychology: The Science of Happiness and Human Strengths. New York, NY: Brunner-Routledge Taylor & Francis Group; 2004. 24. Kostadin K, Dunn EW. Checking email less frequently reduces stress. Computers in Human Behavior. 2015;43:220-228. 25. Kath LM, Stichler JF, Ehrhart MG, Sievers A. Predictors of nurse manager stress: a dominance analysis of potential work environment stressors. Int J Nurs Stud. 2013;50(11):1474-1480. 26. Patterson K, Grenny J, McMillan R, Switler A. Critical Conversations: Tools for Talking When the Stakes are High. New York, NY: McGraw Hill; 2012. In addition to serving as a Nursing Management editorial board member, Dennis Sherrod is a Forsyth Medical Endowed Chair of Recruitment and Retention at Winston-Salem State University, N.C., and Lenora R. Campbell is an associate dean and professor of Nursing. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000465399.44170.5e

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Mental health tips for nurse managers.

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