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Mary Hurley describes how nursing managers can adciress workpiace stress in their staff by strategies involving complementary alternative therapies
NURSE MANAGERS are responsible for the satisfaction of both patients and staff. At first glance, this statement may seem both reasonable and attainable yet, for many years, achieving staff satisfaction has been elusive. One of the main reasons for staff dissatisfaction is said to be stress (Ma et al 2003, Ruggiero 2005) and, although many writers on the subject argue that some stress in workplaces is desirable, it is most often viewed as an outcome of undesirable events. This view leads us to focus on how to eliminate stress from our lives, and much time and money is spent on identifying and addressing its sources, both in general and specifically in relation to work. By thinking of stress as something that exists outside the realms of 'good' and 'bad' however, we can understand the experience of stress, in any of its contexts, as 'natural' and identify strategies for nurses to experience it without damaging their health. This article analyses such strategies and the role of complementary alternative therapies in reducing stress in the workplace. A different approach to understanding workplace stress is possible if stress is defined as an experience of change (Hurley 2005), based on Rogers' (1994) theory of a mutual relationship between humans and their environments, and of Barrett's theory of power as 'knowing participation in change' (Caroselli 1998). By defining stress as a function of change in this way, the need to identify and eliminate stressors disappears, and an opportunity arises to identify healthy ways of experiencing it.

Self care
The term 'self care' can refer to nurses' participation in the healing of others and an awareness of ways of caring for oneself. By learning to self care, nurses can care better for others, so that self care and the development of caring relationships become intertwined (McElligott ef a/2003). Self care can address stresses of any kind by incorporating complementary alternative therapies and, because nurses are often role models for patients, the better able they are to understand and evaluate the use of alternative therapies, the better they can serve their patients. McNeese-Smith and Crook (2003) suggest that people's priorities are value driven and that their satisfaction decreases if these values are compromised. Nurses can benefit from a knowledge of self care therefore by developing a better understanding of their own value systems and what they need in order to experience satisfaction in their work and personal lives. This approach leaves open possibilities for interventions that are outside the realm of traditional healthcare practices.

Stress as an experience of change

McElligott et al (2003) state that stress is a form of anxiety, while Carey (1997) sees it as 'a state of mind, a way of interpreting the world, and a pattern of behavior'. Me Vicar (2003) meanwhile sees stress as a continuum from eustress to distress and suggests that, if distress is prolonged, symptoms of disease can develop. Several authors agree that stress is a naturally occurring phenomenon in society. Maurer (2002) proposes for example that it is a kind of fear, similar to the 'fight or flight' response felt by people when they are challenged, which can ultimately have negative consequences. These perspectives suggest that an inability to experience stress in ways that maximise our quality of life can be more problematic than stress itself.

Suggested strategies
The healthy experience of stress, as well as its reduction, is a goal worthy of investment of time and money. Creative and innovative strategies for doing so are available moreover but, until recently, these have received little attention from nurse managers.

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n the workD ace

Yet nurse managers are crucial links in the ultimate success of any organisational endeavour and are in ideal positions to implement strategies to decrease any sense of being overwhelmed by change, or stress, among nurses. Such strategies include: B Addressing common workplace stressors H Providing educational opportunities B Offering access to complementary alternative therapies, as well as influencing construction and renovation projects in which such therapeutic strategies are considered. Common workplace stressors While there has been some progress in addressing workplace stress (Buerhaus et a/ 2005), there is little likelihood of it being addressed to universal satisfaction. Common work related stressors of nurses, such as failure to meet patients' needs or self expectations, and workload and personnel issues (Hall 2004, Jasper 2005, Reineck and Eurino 2005), have changed little over the years, and they are unlikely to ever disappear completely. Everyone who has experienced these stressors has their own perspective on them and such personal perceptions influence nurses' levels of satisfaction (McVicar 2003). Organisational change can also be a stressor, sometimes to an overwhelming extent, but it can also offer creative opportunities for dealing with the stress that accompanies it (McDermott 2002). Workplace stress and personal stress are not mutually exclusive phenomena. Each has direct and indirect effects on the other, and, while ways to address stress in each environment differ, they can also overlap.
Educational opportunties

Education can be addressed in terms of its effect on both day-to-day nursing practice and self care. In the first case, self imposed standards, especially those of new graduates, can be self defeating, so managers must advocate 'realistic, appropriate, and evidence or research based standards in the orientation of graduate or newly hired nurses' (Hall 2004). In the second case, although the concept of self care is a worthy one, achieving it can be elusive and may require education. Managers can therefore advocate that self care learning activities are incorporated into nurses' educational programmes to help them achieve a balance between their personal and professional lives. As employees are offered educational opportunities, often in partnership with local colleges and universities, they can begin to understand themselves better, and can identify strategies that help them care for others, and themselves, more successfully.

Meditation can be beneficicii to nurses' wellbeing-

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Access to complementary alternative therapies Complementary alternative therapies are rarely regarded as having a role in therapeutic healthcare environments but, as staff become exposed to them, they may regard them as beneficial to their wellbeing and, in exercising their power to choose them, may alleviate their stress. McElligott et al (2003) for example describe the study of a 'touch therapy' course intended to reduce anxiety among staff that was undertaken by 20 nurses in the cardiovascular and thoracic department of a United States hospital, while Cohen and Bumbaugh (2004) describe a course of 'dream work', in which six nurses at a US cancer centre underwent a form of group therapy that focused on their dreams to help 'increase their self understanding and problem solving abilities in both their personal and professional lives'. While neither study produced conclusive results, participants generally reported that their feelings of stress and anxiety had reduced after they had completed the studies. Other forms of complementary alternative therapies are listed in Box 1. . of eompiemenlary
ra|i9ern:'ative Iher^pLei S
n Aromatherapy a 'Guided imagery' a Massage Q Music therapy n Ref Iexology n 'Dream work' n Light therapy D Meditation nSpirituai nurture DTherapeutic touch
j

Nurse managers need not provide these programmes or services but they can help others to access them and can support research that examines them. Alternatively, they can introduce employee benefit programmes in which businesses are contracted to offer such services to employees, either freely or at reduced rates. Employees who take up this option require sufficient time and reimbursement to pursue these initiatives however.

Conclusion
Meeting the needs of nurses and their organisations has been a goal of nurse managers for many years. A lack of understanding of stress however, and a failure to take account of the accelerating rate of change in healthcare services, has hindered researchers from identifying interventions that can assist nurse managers in meeting this objective. By acknowledging that stress is as an experience of change however, individuals can identify strategies to help them to respond healthily to stress in the workplace, and complementary alternative therapy strategies are an excellent starting point for managers and staff to explore how they can best work under stress Mary Hurley PhD, RN, CNAA, BC is a nursing administrator at the Overlook Hospital, Summit, New Jersey

References
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