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The Effects of an Intervention Program (MEDI) on Reducing Occupational Stress in Emergency Department Nurses

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Wo Oi Kwok
Abstract:
Given the taut and demanding working milieu of emergency nurses, the efficacy of a new stress reduction program (Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Relationship, MEDI) was evaluated. The sample from Prince of Wales Hospital consisted of 47 (70% response rate) emergency department (ED) nurses of whom 89.4% worked full time and 10.6% part-time. All completed the Taiwan version of the Medical Personnel Stress Scale-Revised (MPSS-R) which assessed their occupational difficulties, job dissatisfaction, negative patient attitude, and somatic problems. When compared to the Taiwan sample, Hong Kong ED nurses exhibited significantly higher levels of occupational stress with the major strains being heavy workload, insufficient personnel, and conflicts with patients and relatives. A total of 19 emergency department nurses participated the MEDI program (ns = 6 in intervention group and 13 controls). The results of nonparametric statistical analyses of MPSS-R scales showed that the two groups did not change differentially over time. However, with respect to the job satisfaction scale, while those in the intervention and control conditions showed significant improvements ( p <.01), intervention participants ended the study at a marginally higher satisfaction level than controls (p <.06). Similar results were found on self-acceptance scale with those receiving treatments having higher posttest scores than the nontreated participants (p <.06). While the efficacy of the MEDI program was not established, it is important for medical personnel at all levels to systemically and regularly evaluate stress among professionals and support staff. If this is found, then appropriate remedies must be initiated. In this regard, prevention is always the best strategy. Therefore, consideration of ways to avert occupational encumbrance and create more efficacious treatment programs for emergency department practitioners is recommended. Once stress reduction interventions are operationalized, then empirical validation studies must be undertaken. Keywords : Occupational stress, stress management program, emergency department nurses

Table of Contents

Page

Dedication …………………………………….……………… ……… ……… …….. .

iv

Acknowle dgemen ts………………………………………… ……………… ……. ….

v

List of Tables …………………………………………………… ………… … ………

ix

List of Figures……………………………………… ………. ………………… ……

x

I: Introduction ………………………………………………………………………

1

Statement of the Problem ……………………………………………………… …….

1

Literature review …………………………………… ……………………… ……. ….

3

The MEDI Program ……………………………………… …….. ……………………

13

Objectives and Hypotheses ……………………………… ……. …………………….

18

II: Method …………………………………………………………………………...

20

Study Design and Setting …………………… ……. …………………………………

20

Participants ……………………………………… ……. ………………… …………..

20

Measures …………………………………………… …….. ………………………….

21

Procedures …………………………………………… ……. …………………………

23

EVALUATION OF THE MEDI PROGRAM

viii

Page

Data Analysis …………………………………………… ……. ……………………...

III: Results …………………………………………………………………………...

30

Participants‟ Demographic Characteristics … ……. ……………… …………………..

…………………………… ……. ……………………………...

………………………………… ……. …………………………..

………………………………… ……. …………………………...

VI: Discussion ………………………………………………………………………..

48

Conclusion ……… …… …………………………………………………………… …

References …………… …… …………………………………………………………

Appendix A:

Consent ……… …… …………………………………………………..

Appendix

B: Participants‟ Checklist …

………………………………………

Appendix C:

Recruitment Poster …………………… …… …………………………

Appendix D:

Research Subject Infor mation Sheet … …… …………………………..

Appendix

E:

Ethical Approval ………………… …… ……………… ………………

Appendix

F:

Measurement Scales ………………… …… ……………… ……... ……

EVALUATION OF THE MEDI PROGRAM

ix

List of Tables

Page

Table 1:

Overall Structure of the

MEDI Program …………… …….. ……………….

25

Table 2: Account of Mindfu lness Skills Module ……………… …….. ……………...

2 6

Table 3: Account of Emotion Regulation Module …………… ……. ……………….

26

Table 4: Account of Distress Tolerance Module ……………… …… ……………...

27

Table 5: Account of Interpersonal Effectiveness ……………… …….. ……………..

28

Table 6: Demog raphic Characteristics of the Pretest Group of Emergency Department Nurses ………………………………………………… …….. ……… …

31

Table 7: Significant Kurtosis and Skewness Scores for the Pretest Group

and the 2 nd

Session MPSS - NPA Scale …………………………………… ………… …… ….

34

Tab le 8: Comparisons Pretests on MPSS - R Scores by Groups Using Mann - Whitney U

tests ………………………………………………… ……. … . …… …….

35

Table 9: Comparisons Posttest on MPSS - R Scores by Groups Using Mann - Whitney U

tests …………………………………………………… …….. …… .…. …

36

Table 10: Pretest - post test on MPSS - R in intervention and control groups by using Wilcoxon Signed Ranks Tests …………………………………… ………….. . …….

37

Table 11: Friedman‟s Rank Test for Correlated Samples

Comparisons of Outcome Measures Across Times: Pre - test, T1, T2, T3 and T4 ……… ………………. … . …..

38

Table 12: The Results of t - test Comparisons on PWH (2010) and Taiwan (2001) Groups on the Taiwan MPSS - R S cale s …………………… ……………. ……… . ….

39

Table 13: Reliability Analysis of the MPSS - R Scales Using Hong Kong Participants ………………………………………………… …….. ……………… . …

40

EVALUATION OF THE MEDI PROGRAM

x

Table 14: Job Satisfaction and Self Worth Measure by Groups and Times … ……...

Page

43

Table 15: F

Values For 2 by 2 Mixed ANOVA (Times by Groups) ………… ……..

EVALUATION OF THE MEDI PROGRAM

xi

L ists of Figures

Page

Figure 1: CONSORT 2010 flow diagram …………………………………… ……... .

24

Figur e 2: Consort diagram for assigning participants to treatment conditions ………

32

Figure 3: Groups and Times Main Effect on Job Satisfaction ………… ……… …….

45

Figure 4: Differentiate Change Over Time by Groups for Self Acceptance … ……... .

46

E VALUATION OF THE MEDI PROGRAM

1

Chapter I : In troduction

Statement of the Problem

In the 21 st

century, collaborative efforts among health care professionals and consumers have been

recommended by the World Health Organization

(WHO, 2006 ) . It was also noted that there is an emerging shortage of well tr ained health care professionals (HCPs) , and this is resulting in a good deal of individual and institutional stress. T his is particularly problematic as HCPs are often “ pillars ”

of health care systems. According to the estimation of the WHO , a global defic it of HCPs including physician s, nurses ,

and midwives was 2.4 million in 57 countries (World Health Report 2006, p. xviii).

This is also the case in Hong Kong where there are 17 hospitals with Accident and Emergency Department (AEDs) operating on a 24 hou rs ,

seven days per week

basis . According to the Hospital Authority Statistical Report (2008/09), 830 emergency department (ED) nurses were employed in AEDs treating 2.1 million attendances.

The Prince of Wales H ospital

(PWH) is illustrative of the press fo r services in that it is a university teaching hospital which in 2006 provided emergency service for 607, 544 people in Shatin

district

and trauma care for 1.18 million people ( Census and Statistics Department , 2006). According to PWH online statistics fro m April 2009 to March 2010, the AED of PWH treated 150,530 attendances (Prince of Wales Hospital, 2010). This statistic demonstrate s

the arduous

workload of medical professionals such as ED nur ses.

It should not be forgotten

that in order to maintain emer gency department s

as initial gatekeepers of public heath

services, a stable and efficient workforce is essential. For this to occur, occupational stress and related job burnout must be assessed and, if present, remedied in a timely manner

as it is well

kno wn that excessive occupational stress can

E VALUATION OF THE MEDI PROGRAM

2

lead to multiple biopsychosocial

impairment s such as making clinical errors of judgment, insensitivities to patient needs, personal accidents, and being argumentative ( Cox, Kuk, & Leiter, 1993; Ergun & Karadokovan,

2005). Thus, untreated stress will result in poor patient services.

In this regard, Welbourne, Williams, Eggerth ,

and Sanchez (2004) noted

that HCPs

suffer higher rates of depression than the general population . This is not surprising for those who work

in settings where t rauma, discord, and bereavement are common. Such a situation will likely result in a cute and posttraumatic stress disorder s. The physiology unde rlying such reaction s

has been well documented ( e.g., Sapolsky, 2004).

Including the physio logical, psychological ,

and social

impacts, the costs of occupational stress is quite substantial

including loss es

in productivity, absenteeism, workers compensation

claims , high turnover rates, early retirement , and a reduction in the quality of patient c are ( Muscroft & Hicks, 1998; Hemingway &

Smith, 1999; Bakkerm, Killmer, Siegrist ,

& Schaufeli, 2000; Yang et al. , 2002; Gail et al., 2007).

Encouragingly, stress

can be modified or transformed, which is depended on how one perceives and interprets the mea ning of events . Stress can serve as a stimulus to promote the life growth and learning through continuous adjustment ,

and adaptation of upcoming life events (Clemen - Stone, Eigsti, & McGuire, 1991)

or result in various form of psychopathology.

As the latte r is more common in the former, a number of psychotherapeutic prophylactic program s

had been developed. For example, the Crisis Incident Stress Management (CISM , Everly, Flannery ,

& Victoria, 2002), humo u r

(Morgan, 1997), aromatherapy massage with music ( C ooke, Holzhauser, Jones, Davis ,

& Finucane, 2007) ,

and the program of Attitude and Communication Techniques for

E VALUATION OF THE MEDI PROGRAM

3

Scripps Mercy Aggression Reduction Training ( ACT - SMART , Cahill, 2008). However, empi ri cal validation studies for chronic stress reduction are l acking for these intervention s.

Other interventions including mindfulness - based stress reduction program (Cohen - Katz,

Wiley, Capuano, Baker, & Shapiro, 200 4 ), cognitive relaxation (Yung, Fung, Chan, & Lau, 2004), schema - focused approach (Bamber, 2006; Bamb er & McMahon, 2008) and imagery and meditation (Tsai & Crockett, 1993) were developed for HCPs in general , but not specifically for ED staff .

As a result, an

innovative stress reduction skill training program for ED nurses which included m indfulness, e mot ion al

regulation, d istress tolera nce,

and improved i nterpersonal relationship s

(MEDI) was developed .While this intervention model is original, it was based on Dialectical Behaviour Therapy principles and hav e impacts on both individual and interpersonal l evels. In addition, empirical validation of this program using Hong Kong AED nurses is lacking. Therefore, the present study was implemented to test the efficacy of the stress reduction procedures in a large metro hospital setting.

Literature Review

Stres s is widely defined as “a universal physiological set of reactions and processes created by such a demand” (Lazarus & Folkman, 1984 , p. 2). The key word of “process”

implies

continuous changes, adaptation, growth and learning in order to maintain equilibri um. The interplay between the individual and the environment is highlighted. The definition of occupational stress is “the mind body arousal resulting from the physical and/ or psychological demands associated with the job‟ (Quick, Quick, Nelson ,

& Hurrell , 1997, p.10).

S apolsky (2004) described clearly the cycle of the stress

E VALUATION OF THE MEDI PROGRAM

4

pathways as follows. When the stressors (stimuli) are perceived, the cortex sends the message to amygdale through a preconscious signals. Corticotropin - releasing hormone (CRH) is rel eased which triggers the brain stems to activate the sympathetic nervous system via the spinal cord. Epinephrine and glucocorticoids are released and the muscle, heart and lung response accordingly. When the stress is chronic, glucocorticoids induce the lo cus coeruleus to discharge norepinephrine that link up to the amygdala which initiates the production of more CRH to sustain the stress pathways. The stress pathways are quite similar to everyone, but the occupational stressors can be very unique in differ ent clinical settings. T he occupational stressors can be very unique in different clinical settings.

In the study of Callaghan, Tak - Ying, and Wyatt (2000), one hundred and sixty - eight Hong Kong nurses reported the major sources of occupational stress rela ting to heavy workload, interpersonal relationships, and hospital administration. Concerning occupational stressors of ED nurses, ED nurses not only take care of clinical routines, for example, clinical assessment , immediate treatment, and

trauma resuscita tion, but also develop effective strategic plans during pandemics like SARS, Swine influenza, and Avian influenza.

Specific occupational stressors of emergency setting . D ifferent clinical settings have unique occupational stressors, which are cultivated by

the environmental factors and local cultures . Burns, Cheung, Leung ,

and Leung (2010 , p. 5 )

identified difficulties of AE Ds in Hong Kong, for example, how to support a “see and treat” culture , how to “further

strengthen AEDs role as a gatekeeper”, how to reduce the “ demand from non - urgent patients”, how to “ establish effective manpower planning for AEDs”,

how to

E VALUATION OF THE MEDI PROGRAM

5

further “ improve the patients‟ experience of AEDs, including physical environment, privacy and communication”, and how to “ improve staff morale” .

The study of Graham, Kwok, Tsang, and Rainer (2009, p. 148) indicated that “61 % semi - urgent and non - urgent patients indicated acceptable waiting time was less than or equal to two hours”, but in reality that was almost impossible to achieve. The discrepa ncy between patients‟ expectation of waiting time and the reality of overcrowding in AEDs has been causing different kinds of conflicts among patients, relatives, physicians and nursing staff. In addition, these occupational stressors can cause significant

physical, cognitive,

and emotional problems

if coping mechanisms are insufficient or ineffective.

“ Heavy workload and skill mix ”

were one of the occupational stressors (Gail et al., 2007) that can be the result of access block, insufficient systems, la ck of staff, uncontrollable environment and inadequate resources (Chapman, 1997; Walsh, Dolan ,

&

Lewis, 1998). The meaning of skill mix is that the percentage of registered nurses to other clinical staff members in order to provide good patient

care .

As G ail et al., (2007) have said “ m ass casualty incidents ”

were one of the occupational stressor. One of the famous and significant occupational stress theories was developed by Karasek (1979) who remarked the interplay between job demand and job control. Job demands are defined as psychological stressors which include a requirement for working fast, quick and hard without sufficient time and the conflict of job demands. The conflicting job demands alert our “flight -

fight” response so that the heart rate or ad renaline excretion will be elevated. When the individual perceives his/ her job control is low, healthy and effective coping responses cannot be activated. As a result, the larger physiological responses of psychological stressors will be intensified unles s appropriate

E VALUATION OF THE MEDI PROGRAM

6

strategies for reducing job demands or increasing job control are available. The job demands in the A ED are high and the tremendous uncertainty of patient care can increase the occupational stress among ED nurses. Karasek (1979) termed this s ituation as “high - strain job”. Under this circumstance, a sense of helplessness and victimization can be learned naturally and commonly.

Gail et al.

(2007) went on to note that “v iolence against staff ” that al so intensified the level of occupational str ess. In recent years, many studies ( Crilly, Chaboyer ,

& Creedy, 2004;

Henderson, 2003 ;

Landy, 2005) indicated that the problem of violence and aggression against staff has escalated significantly in emergency departments globally. According to the study re garding prevalence of workplace violence against nurses in Hong Kong (Kwok

et al. , 2006), 76% of Hong Kong nurses in their study reported that they experienced various kinds of violence including verbal abuse, bullying, physical abuse and sexual harassment . This study reflected the problem of violence against nurses is emerging in Hong Kong and it also indicates that one of the high risk workplaces in the hospital of violence is the A ED. The contributing factors of violence against ED nurses are caused by s udden illness or injury of an individual and long waiting times which may be caused by access block or overcrowding. Those stressful situations can lead to intense emotions of patients, relatives and friends in the form of frustration, fear and anxiety.

W ilman and

Wikblad‟s study (2003) reflected ED nurses‟ verbal and nonverbal communications with the patients and relatives were ineffective and a “wait - and - see” policy was being adopted that was labelled as uncaring encounter. As a result, the intense anxie ty and fear can escalate easily to an outbreak of violence or aggression if the needs of the patients are perceived as being ignored. Consequently, the cumulative occupational

E VALUATION OF THE MEDI PROGRAM

7

stress, fear and anxiety can affect ED nurses‟ self confidence, job satisfaction , morale, the quality of patient care and team relationships tremendously (Crilly et al., 2004; He nderson, 2003 ;

Landy, 2005). The symptoms of burnout for ED nurses may develop gradually and unconsciously if the cumulative and intense occupational stress c annot be defused appropriately. According to Cox, Kuk ,

and Leiter (1993, p.179), the definition of burnout is “a concept that variously encompasses three clusters of symptoms: ( a ) exhaustion (intellectual, emotional, or physical), ( b ) depersonalization and

emotional detachment, ( c ) reduced personal accomplishment, helplessness and low self esteem.”

Relationships with colleagues were very important in Chinese culture. Hetherington (1993) reported that major sources of stress for ED nurses were inadequate c ommunication, interpersonal conflicts and divisions between staff. It seemed that this occupational stressor is very universal. It was also significantly relevant to Chinese people. Ho (1993) remarked the concept of the “relational identity” which is defin ed by a person‟s significant social relationships rather than as a person. Also, in Chinese culture, Chinese people emphasize on “face saving” (Ho, 1994) which means that the individual‟s behaviours not only affect himself or herself, but also the family, the social network, the organization and the country. Also, forbearance is important in the Chinese culture. The meaning of forbearance is that to remain in control of one‟s emotion for the sake of maintaining harmonious relationships in stressful situatio ns, interdependence and cooperation. In the long run, hopelessness, helplessness and depression can be caused by maintaining too much forbearance (Eysenck, 1994). Liu, Spector ,

and Shi (2007 , p.209 )

discovered that

that Chinese

employees

(university facult y of all ranks)

tended to suffer “more incidents of job evaluations, work mistakes, indirect conflict, employment

E VALUATION OF THE MEDI PROGRAM

8

conditions, lack of training, anxiety, helplessness , sleep problems, and feeling hot than the Americans.”

Consequently, it would be safe to as sume o ccupational stress can be prominent if the value of forbearance is emphasized in ED department.

“ Death of a child or sexual abuse of a child ”

was viewed as one of the occupational stressors (Gail et al., 2007). O‟ Conner and Jeavons‟ study (2003) sh owed that the most stressful incidents for ED nurses was the death of a child and sexual abuse of a child. The death of a child violates our expectations towards the developmental stages of life. The sudden death of a child or young patient is really a hug e challenge to our concept of constancy. The intense emotions or a sense of our own grief can be triggered by caring for a vulnerable child or over - identifying with a child. Rassin

et al. (2007)

reported that the preparedness including mental preparation f or “ mass casualty events ”

involving children w as

low for ED staff and they can induce heavy occupational stress and helplessness. In Chinese culture, not many people are comfortable talking

about death openly because the topic of death is a taboo which rep resents bad luck. Death triggers our sense of anxiety. Payne, Dean, and Kalus (1998) w ere

to compare the level of death anxiety between ED nurses and hospice nurses. It was shown that ED nurses did not feel comfortable with death and they tended to avoid d eath related thoughts at all cost. The preparedness of death for ED nurses was not enough so that the death of patients often arouse their own death anxiety. In order to avoid thinking about death, it was hard for ED nurses to view the positive sides of de ath including a sense of peace and relief. ED nurses see death as a failure of care; hospice nurses see it as a good and natural stage of life. 90% of ED nurses in this study group tended to take worries home. Emotional exhaustion can result if the cumulat ive emotional stress cannot be defused regularly and

E VALUATION OF THE MEDI PROGRAM

9

appropriately.

“ Exposure to infectious diseases ”

was also being ranked as one of the vital occupational stressors (Gail et al., 2007). Many

dangerous respiratory pathogens may not be identified immediat ely in the emergency setting such as swine flu and severe acute respiratory syndrome (SARS). Those unidentifiable agents cannot be screened simply by using normal equipment within a short period of time. Therefore, psychological and emotional distress can be aroused intensely when the potentially lethal respiratory pathogens cannot be identified or when medical treatment is not effective. The psychological conflict of ED nurses is between their “duty - to - care” responsibility and the health of themselves and their family members ( Lee, Juang, Lee ,

&

Chao, 2005) . Wong

et al. (2005) reported the overall distress of ED nurses was high when compared to doctors during the SARS outbreak in Hong Kong. ED nurses tended to use behavioural disengagement which includes a lack of sensitivity, responsiveness or involvement to the patients‟ situations or needs when their intrinsic factors of insecurity and powerlessness were being elicited. Due to SARS‟ painful experience, the threat of the possibility of being infected by po tentially lethal respiratory pathogens has been high for ED nurses and can lead to tremendous occupational stress.

Speed medicine, however, often results in mistakes that jeopardize quality patient care. Different

health care system may cause various leve ls of occupational stress of the emergency setting. According to the Department of Health R. O. C. Taiwan (2010. p. 88), in 1995, National Health Insurance (NHI) is a mandatory social indemnity. Those who are holding the Republic of China Nationality or re siding in Taiwan for more than four months must enroll

in the NHI. Different types of health coverage are possible according

E VALUATION OF THE MEDI PROGRAM

10

to the specific health needs of patients. Additionally, Taiwanese can flexibly choose thei r desired health care providers. However,

in Hong Kong, health care services at public hospitals are much less expensive than it‟s the case for private health care facilities. People with Hong Kong identity card (HKID) pay 100 dollar per emergency attendance which covers clinical assessment, trea tments, relevant laboratory tests, radiology investigations and medications (Hospital Authority, 2003). Contrary to public h ospitals, private institutions ( e.g., Matilda International hospital ) provide 24 hours emergency room service

that costs an average of 500 Hong Kong dollars from 8 a.m. to 8 p.m. and 800 Hong Kong dollars from 8 p.m. to 8 a.m. These fees do not include any necessary laboratory investigations (e.g., blood tests, radiology examinations) or medications. When Graham, Kwok, Tsang, and Raine r (2009)

interviewed

249 semi - urgent or

nonurgent patients

receiving AED treatment at a public hospital (i.e., PWH) regarding the reasons they sought treatment at public health care facility, it was found that

these patients

expect ed

to obtain more in - dept h laboratory

investigations (56%), additional

professional medical advice (35%), and continuing care (19%) . Because of these reasons, attending emergency service in the public hospital as versus a private facility is a cost - effective choice .

Thus, there is

not difficult to understand why AEDs in public hospitals can be besieged

by patients seeking medical assistance on a continuous basis. It is possible that there may be higher levels of stress in the Hong Kong and Taiwan samples due to differential workloa d demands.

Other treatment approaches to reduce stress in emergency medical personnel. In order to reduce the occupational stressors for ED nurses, it is worthwhile to review what kinds of interventions or stress management programs have been available to offer

E VALUATION OF THE MEDI PROGRAM

11

psychological or emotional support for ED nurses including Crisis Incident Stress Management (CISM , Everly, Flannery ,

& Victoria, 2002), humour (Morgan, 1997), aromatherapy massage with music (Cook e, Holzhauser, Jones, Davis ,

&

Finucane, 2007) and th e program of Attitude and Communication Techniques for Scripps Mercy Aggression Reduction Training ( ACT - SMART , Cahill, 2008).

The original C ISM program was developed by Mitchell in

1983 (Everly et al. ,

2002) and has been used throughout the world, especi ally in ED setting s . CISM

is intended to reduce

the stress occurring after

mass casualty incidents and disasters. By using precrisis factors , individual crisis counselling, group debriefing ,

Full document contains 96 pages
Abstract: Given the taut and demanding working milieu of emergency nurses, the efficacy of a new stress reduction program (Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Relationship, MEDI) was evaluated. The sample from Prince of Wales Hospital consisted of 47 (70% response rate) emergency department (ED) nurses of whom 89.4% worked full time and 10.6% part-time. All completed the Taiwan version of the Medical Personnel Stress Scale-Revised (MPSS-R) which assessed their occupational difficulties, job dissatisfaction, negative patient attitude, and somatic problems. When compared to the Taiwan sample, Hong Kong ED nurses exhibited significantly higher levels of occupational stress with the major strains being heavy workload, insufficient personnel, and conflicts with patients and relatives. A total of 19 emergency department nurses participated the MEDI program (ns = 6 in intervention group and 13 controls). The results of nonparametric statistical analyses of MPSS-R scales showed that the two groups did not change differentially over time. However, with respect to the job satisfaction scale, while those in the intervention and control conditions showed significant improvements ( p <.01), intervention participants ended the study at a marginally higher satisfaction level than controls (p <.06). Similar results were found on self-acceptance scale with those receiving treatments having higher posttest scores than the nontreated participants (p <.06). While the efficacy of the MEDI program was not established, it is important for medical personnel at all levels to systemically and regularly evaluate stress among professionals and support staff. If this is found, then appropriate remedies must be initiated. In this regard, prevention is always the best strategy. Therefore, consideration of ways to avert occupational encumbrance and create more efficacious treatment programs for emergency department practitioners is recommended. Once stress reduction interventions are operationalized, then empirical validation studies must be undertaken. Keywords : Occupational stress, stress management program, emergency department nurses