Stressed out! Strategies for enhancing performance

Bright, Deborah EdD; Crockett, Anita B. PhD, RN

Nursing Management:
doi: 10.1097/01.NUMA.0000405230.91377.a5
Department: Career Scope: Pacific Mountain
Author Information

Deborah Bright has disclosed that she is the president of Bright Enterprises in Tucson, Ariz. Anita B. Crockett is the director for Nursing Research at the University of Arizona Medical Center in Tuscon, Ariz, and has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this article.

The authors would like to acknowledge Veronica Hoffman for her assistance in researching articles and noting references, and Mayur Raghavan, whose organization collected and analyzed the data.

Article Outline

Workplace stress and its effects on job performance are major concerns from both a human and economic perspective.1 The typical day for healthcare providers is inherently stressful.2–4 The consequences for having to work long hours and deal with high case loads, shortages of resources, time pressures, and high performance expectations greatly impact a nurse's job retention, satisfaction, and performance.5

Although much research on stress has been conducted, little is known about the specific behaviors and cognitive skills associated with the effective and ineffective management of stress and performance.6 According to one researcher, the main reason there has been little attention given to job performance in occupational stress research is that job performance is a complex variable.7

The aim of this experimental pilot study was to examine individual outcomes that have a more direct effect on job performance, targeting issues such as role ambiguity, relationships at work, and personal self-management. In particular, specific behavioral and cognitive skills used in the workplace to enhance performance while simultaneously mitigating the negative effects of stress were examined.

Back to Top | Article Outline


The aim of the Strategies for Enhancing Performance (SfEP) Initiative was to identify, isolate, test, and measure the effectiveness of specific performance control practices (behavioral and cognitive skills) used in the workforce. Thirty-six nurses and nurse managers from University of Arizona Medical Center in Tucson, Ariz., a 487-bed hospital with a Level I trauma center, were randomly divided into experimental and control groups. A total of 32 University of Arizona Medical Center nurses and nurse managers completed all the requirements of the study from September 2007 to December 2007. The dropout rate for the control group was approximately 17% (4 out of 18); there was a 0% dropout rate for the experimental group. The majority of participants reported having a 4-year college degree or higher, with ages ranging from 35 to 54. A majority had 0 to 3 children under the age of 18 at home. The sample groups were instructed not to talk about the study with one another during its duration.

The experimental group attended a 4-hour SfEP program. In a highly interactive session, nurses were introduced to the 10 most effective performance control practices. At the conclusion of training, they completed a performance control plan—an individualized form that provided participants with an opportunity to develop their own roadmap for enhancing their performance by incorporating specific behavioral and cognitive skills introduced in the 4-hour classroom training experience. Three to 4 weeks later, the experimental group engaged in an individually scheduled 30-minute telecoaching call. Test measures were gathered before the training and then again 9 to 10 weeks later. The experimental group also completed a pre- and postperformance control plan in which they noted their progress, along with the identification of those skills and techniques that were most effective.

What separated the personal development learning program from other stress and performance development programs, which often approach the acquisition of skills as "one-size-fits-all," was the emphasis placed on how to actually deal with a variety of everyday stressful workplace situations, as opposed to addressing the factors related to stress and the effects of stress. Attendees learned what they could do to effectively turn their stress into positive energy when using specific behavioral and cognitive skills. Emphasis was placed on the implementation of these specific skills and techniques, as opposed to simply learning about them. The telecoaching call 3 to 4 weeks following the classroom training session focused on, but wasn't limited to, what participants identified on their performance control plans.

A performance strategy index pretest and posttest design was used to investigate if SfEP would enhance job performance and satisfaction while simultaneously mitigating the negative effects of stress. The research hypothesis was as follows: Nurses who learn SfEP will have a perceived increase in job performance and a perceived decrease in the negative effects of stress compared with nurses who didn't learn SfEP. Both the experimental and control groups completed the pre- and posttest, which included the Job Stress Inventory, an instrument designed to assess a core set of 30 generic job-related stressor events that are encountered by men and women in many different occupations and work environments to determine the amount of variance in job stress and burnout levels predicted by demographic characteristics.8 The job stress-related events and their frequency were subjectively measured using a 1- to 9-point Likert scale, where 1 equalled low stress and 9 equalled high stress, using an assigned midpoint severity rating of 5.

Personal and demographic data were collected relating to the experimental and control group participants' age, gender, education level, and general health condition as part of the Performance Strategy Inventory (PSI), a measure that was developed specifically for this study. The measure was purposely designed to be simple to complete and factored in the penetration of technology available to most workers in the United States. The PSI instrument was designed to collect subjective data on the participants' effectiveness at handling typical work-related stressful situations, in addition to recording how stress impacted their day-to-day effectiveness.

Responses were collected using a 5-point Likert scale ranging from not effective to very effective or from no effect to great effect. The stems included 13 typical work-related stressful situations in which perceived effectiveness in handling the situations was measured. Additional questions assessed perceived stress and the effects of stress on job performance. Content validity of the test measures was established by a panel of experts from education, research, and practice in stress and job performance as well as survey design. The overall internal consistency reliability was determined to be 0.81 using Cronbach's alpha.

Back to Top | Article Outline


When examining the execution and completion of work, significance at the 0.05 level was found for the experimental group in their ability to more effectively deal with changing priorities (see Figure 1) and tight deadlines (see Figure 2). Closely related to these findings, experimental group participants also indicated they were more effective at handling more tasks and responsibilities than having the time to do them (see Figure 3). No significant difference was found between the experimental and control groups in their effectiveness at turning around assignments so they meet the expectations of others (bosses, peers, patients). Also, no significant difference was found between experimental and control group participants in their overall ability to handle everyday stressful situations at work. When examining how experimental group nurses handled situations that involved negativity, significant differences were found at the 0.05 level for rebounding from mistakes, setbacks, and disappointments (see Figure 4); being criticized (see Figure 5); and having to give others criticism (see Figure 6).

When taking a close-up look at the negative effects of stress on an individual's ability to function effectively while engaging with others or working on tasks, significance was found for the experimental group in their ability to: (1) identify solutions for issues that positively impacted the work to be done; (2) attentively listen to what's being said in meetings; (3) articulate ideas clearly and concisely; and (4) recall vital information when in meetings. No significance was found between experimental and control groups in their ability to concentrate when working on assignments ands completing a task to one's level of expectation. Experimental group participants reported a significant difference in their overall ability to keep stress from negatively affecting their performance (see Figure 7).

What did the experimental group do to address stress and performance? First, they readily picked up an understanding of how to make control manageable in their lives, both on and off the job. With the use of stress reduction techniques, the experimental group was able to demonstrate greater self-control over their thoughts and emotions. Second, nurses reported dramatic differences in their ability to rebound from setbacks, mistakes, and disappointments. Their ability to utilize control was also apparent when on the receiving end of criticism. With the use of another skill set introduced in the program, the experimental group was effective at quickly assessing the parameters of control in a stressful situation, determining desired results, and subsequently directing their actions in a more productive way.

Using these newly learned approaches helped the experimental group effectively handle being on the receiving end of criticism from patients, peers, and physicians. Before using these methods, many tried to approach the situation by making sure the facts were correct, but placing emphasis on facts often derailed the conversation. However, when viewing the situation from the perspective of desired results, they readily recognized that directing their energy to identify and clarify the needed corrective action on which all parties could agree was more important. The experimental group realized that they could always go back at a later time to discuss facts and, when necessary, "set the record straight." The desired result was to be able to quickly address what was wrong or unacceptable while at the same time keeping the conversation from becoming personal and defensive.

There are a number of limitations with this study. Most obvious is the small sample size and the fact that results were obtained from only one hospital environment. Another limitation is the variability in measurement of job performance. There are a number of stressors that impact job performance and, in time, the beneficial results identified in this study may not be sustainable. There are concerns about whether participants who engage in this learning experience will continue to utilize the skills and concepts introduced, although the initial results are positive.

Replication in other hospital settings using larger nurse samples and other professionals to conduct the classroom training experience and coaching would be valuable. Another recommendation is to consider at what point in a nurse's career the results are likely to benefit the most. Given the similar ages of the study participants, it would be interesting to know whether a new graduate or a more seasoned nurse reaps more benefits. Also, broadening the initiative to include multidisciplinary healthcare workers would be a response to the growing focus on interprofessional education.

Back to Top | Article Outline

Proven practices to help nurses perform optimally

Administrators and higher-level management may be assuming incorrectly that nurses are equipped with a repertoire of skills that are effective for managing themselves and interacting with others. The positive changes noted in the experimental group when compared with the control group suggest that nurse managers can expect improved performance when they equip their staff members with specific behavioral and cognitive skills for managing workplace stress. The positive posttest findings in specific aspects of work performance levels indicate the experimental group found that the learned behavioral and cognitive skills in this study were easy and nondisruptive to use given their heavy workload. Therefore, it's important for the hospital's human resources department to examine whether they're placing enough emphasis on self-management and the use of interpersonal on-the-job skills in their training curriculum.

Back to Top | Article Outline


1. Noblet A, LaMontagne AD. The role of workplace health promotion in addressing job stress. Health Promot Int. 2006;21(4):346–353.
2. Firth-Cozens J. Doctors, their wellbeing, and their stress. BMJ. 2003;326(7391):670–671.
3. Lee I, Wang HH. Perceived occupational stress and related factors in public health nurses. J Nurs Res. 2002;10(4):253–260.
4. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880–2889.
5. Rutledge T, Stucky E, Dollarhide A, et al. A real-time assessment of work stress in physicians and nurses. Health Psychol. 2009;28(2):194–200.
6. Lewis R, Yarker J, Donaldson-Feilder E, Flaxman P, Munir F. Using a competency-based approach to identify the management behaviours required to manage workplace stress in nursing: a critical incident study. Int J Nurs Stud. 2010;47(3):307–313.
7. Jex SM. Stress and Job Performance: Theory, Research and Implications for Managerial Practice. Thousand Oaks, CA: Sage Publications; 1998.
8. Vagg P, Spielberger C, Wasala C. Effects of organizational level and gender on stress in the workplace. Int J Stress Manage. 2002;9(4):243–261.
© 2011 by Lippincott Williams & Wilkins, Inc.