Journal of Neonatal Nursing 28 (2022) 37–41

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Journal of Neonatal Nursing

journal homepage: www.elsevier.com/locate/jnn

Stress and social support among registered nurses in a level II NICU

Anna Bry a, b, *, Helena Wigert a, b
a
Division of Neonatology, Sahlgrenska University Hospital, Gothenburg, Sweden
b
Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: To describe sources of stress and workplace social support reported by registered nurses at a level II
Occupational stress neonatal intensive care unit.
Social support Methods: Thirteen semi-structured interviews with nurses were analyzed using qualitative content analysis.
Nurses
Results: Inexperienced nurses found their work highly demanding and were dependent on help from experienced
Neonatal intensive care units
Workplace
colleagues. More generally, a high workload and emotionally taxing situations were described as sources of
stress. Peers provided valuable support, but the single-family room layout of the unit tended to impede contact
among nurses. Support including further education was offered by the organization.
Conclusions: Efforts to counteract the disadvantages of the single-family room layout for nurses are needed. While
continuing to support new nurses, organizations should also pay attention to the needs of the most experienced.

1. Introduction et al., 2017). In today’s family-centered neonatal care, patients’ parents

Excessive occupational stress and the resulting burnout are a serious
and widespread problem affecting nurses and other health care pro­
fessionals (Buckley et al., 2020; Maslach and Leiter, 2017; West et al.,
2016). Burnout is prevalent among staff in neonatal intensive care units
(NICUs), particularly nurses (Rochefort and Clarke, 2010; Tawfik et al.,
2017a). High levels of stress and burnout are not only detrimental to
nurses’ own health and job satisfaction, but are also important factors
contributing to high staff turnover, a chronic and costly problem in
hospitals (Hayes et al., 2012). Deficiencies in the psychosocial work
environment leading to overburdened staff and high turnover can also
compromise patient safety and quality of care in the NICU (Lake et al.,
2016; Profit et al., 2014; Rochefort and Clarke, 2010).
Workplace social support, i.e. various forms of assistance, resources
or encouragement received from coworkers and supervisors, is a crucial
element of a healthy psychosocial work environment (Kossek et al.,
2011; Maslach and Leiter, 2017). Previous studies of nurses and other
health care professionals show the importance of social support in
enabling them to cope with the demands of their work, including
emotional distress (Adriaenssens et al., 2015; Hamama et al., 2019;
Winning et al., 2018).
Nurses in pediatric and neonatal care are exposed to particular
stressors related to the emotional effects of caring for child patients and
the complexity of working with families (Buckley et al., 2020; Larson
are encouraged to be present at the unit as much as they can, and their
involvement in all aspects of their child’s care is emphasized (Davidson
et al., 2017). This model has benefits for families but can add to the
complexity of nurses’ work (Coats et al., 2018; Jackson and Wigert,
2013).
Understanding the sources of stress to which neonatal nurses are
exposed and the strengths and weaknesses of the social support available
to them is a necessary foundation for targeted improvements to their
work environment. However, research analyzing neonatal nurses’ work
environment is scarce. In particular, to our knowledge, no study has
explored the specific work environment of nurses in a level II NICU
(special care nursery), where sick newborns who do not require venti­
lator therapy, including graduates from a level III NICU, are cared for.
These units play an important role both medically and in preparing
parents for the transition to caring for their infant independently at
home, a process to which nurses contribute in crucial ways. In the pre­
sent qualitative study we therefore aimed at describing the aspects of
their work that nurses at a level II NICU perceived as important sources
of stress, as well as the types of workplace social support available to
them.

* Corresponding author. Division of Neonatology, Sahlgrenska University Hospital, Postal address: Rondvägen 10, 41685, Gothenburg, Sweden.
E-mail addresses: anna-kristiina.bry@gu.se (A. Bry), helena.wigert@fhs.gu.se (H. Wigert).

https://doi.org/10.1016/j.jnn.2021.03.010
Received 9 December 2020; Received in revised form 9 March 2021; Accepted 10 March 2021
Available online 21 March 2021
1355-1841/© 2021 The Authors. Published by Elsevier Ltd on behalf of Neonatal Nurses Association. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Bry and H. Wigert
2. Methods
2.1. Setting
This study took place at a level II NICU in a Swedish university
hospital, one of Northern Europe’s largest delivery hospitals. The unit
has fourteen beds in single-family rooms as well as a room with four beds
for continuous monitoring. The staff includes forty registered nurses.
Some infants come to the unit directly after delivery, while others are
graduates of the level III NICU at the same hospital.
2.2. Participants
All registered nurses who had worked at the unit for at least three
months were eligible for participation in the study. A sample comprising
nurses with various levels of experience and work schedules was sought.
Thirteen nurses participated in the study, having given their
informed consent. The participants had been registered nurses for be­
tween 3 months and 38 years (median 6 years) and had worked in
neonatal nursing for between 3 months and 38 years (median 2 years 9
months). Three worked exclusively night shifts, whereas others had a
mixed schedule.
2.3. Procedure
Data collection took place in 2019. The level of staffing and other
conditions at the unit at the time were as usual. Semi-structured in­
terviews were conducted at the unit at a time convenient to the partic­
ipant. The interviewer (first author) was external to the unit and
previously unknown to the participants. Each interview began by asking
for an account of how the participant perceived positive and negative
aspects of working at the unit. After this, specific aspects of nurses’ work
environment were covered based on the interview guide. Follow-up
questions were asked as appropriate, for example to elicit specific ex­
amples. Care was taken to give participants time to elaborate on topics of
special concern to them.
The duration of the interviews was 26–54 min (mean 42 min). The
interviews were audio-recorded and transcribed verbatim. Data collec­
tion continued until data saturation was achieved.
2.4. Analysis
Qualitative content analysis with an inductive approach as described
by Graneheim and Lundman (2004) was performed. Meaning units
aligned with the aim of the study were identified in the text and
condensed to shorter textual units. Each condensed meaning unit was
labeled with a code name. The initial coding covered all data relating to
nurses’ psychosocial work environment. Further analysis focused on
aspects of the data related to topics of stress and social support. Codes
were grouped into categories, after which themes relating to nurses’
perceptions of stressors and forms of social support were identified.
3. Results
Analysis resulted in three themes describing sources of stress and
Table 1
Themes.
Theme
Sources of stress Inexperienced nurses’ limited knowledge of neonatal care
High and complex workload
Emotional intensity of work
Sources of social Support from colleagues: A valuable resource to build
support upon
Support from management: Mixed perceptions
Formal support: Initiatives by the organization
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Journal of Neonatal Nursing 28 (2022) 37–41
three themes describing sources of support, as shown in Table 1.
3.1. Inexperienced nurses’ limited knowledge of neonatal care
The participants described work at the unit as highly demanding for
inexperienced nurses, who mostly had no previous training or experi­
ence in neonatal or pediatric nursing. This gap between their initial level
of competence and the demands of the work was seen as a major source
of stress. After a six-week orientation and trainee period, new nurses
were expected to work independently. This transition was pointed out as
a particularly vulnerable period for inexperienced nurses, who still felt
uncertain of their skills and lacked self-confidence.
“Even as a new graduate you’re expected to know everything both by
parents and by colleagues, and maybe doctors and so on. […] So it’s
incredibly stressful and hard on you psychologically to be new at this
unit”. (Interview 5)
Working in single-family rooms was described as contributing
considerably to the demands on new nurses, since it meant that they had
to attend to patients and answer parents’ questions without the presence
of a colleague. Single-family rooms were also seen as slowing new
nurses’ learning process, since they impeded learning by observation.
Moreover, inexperienced nurses complained of considerable stress
and apprehension due to a lack of previous notice as to when they would
be assigned more advanced duties.
3.2. High and complex workload
Workload, both the sheer amount of work and the variety of tasks the
nurses had to manage, was another important source of stress. Staffing at
the unit was described as often barely adequate, meaning that nurses’
ability to manage their workload was highly vulnerable to unexpected
events such as an influx of seriously ill patients or absences due to
sickness among staff.
Several participants said they often found it impossible to leave work
on time. Also, the ever-present possibility of being contacted on a day off
and asked to fill in for an absent colleague was mentioned as making it
more difficult to relax and recover. While some participants said they
mostly coped well with their workload, others said their work drained
them of energy.
“My private life feels more like recharging to be able to cope with my job:
pack lunches, sleep, stare at a wall, go to work”. (Interview 12)
Work at the unit was described as making high demands on nurses’
ability to prioritize and organize disparate tasks. Circumstances such as
constantly having to check on alarms or lacking peace and quiet to focus
on administrative tasks made it hard to concentrate on one thing at a
time. Experienced nurses mentioned that they were expected to be more
or less constantly available for advising less experienced coworkers; this
was a significant addition to their workload.
3.3. Emotional intensity of work
Emotionally taxing situations that the participants had to deal with
at work, in combination with their acute sense of responsibility for the
patients and their families, could form significant emotional burdens
although the patients at the unit were not critically ill. The extent to
which participants felt emotionally affected by their work varied and
was not seen as necessarily diminishing with experience.
While working with families was described as one of the most
rewarding and meaningful aspects of nurses’ work, it also presented
emotional challenges. The fact that parents were present most of the
time accentuated the impact of their emotional state on nurses. In some
cases, dealing with families’ transition from the level III NICU to the
level II NICU and the expectations of staff that parents had formed at the
A. Bry and H. Wigert
level III NICU was an additional stress factor.
Certain families had a particularly marked emotional impact because
of their exceptional distress or complicated psychosocial situation. At
the same time, participants described the strain of having to control
their own emotions in order to behave in a calm and professional
manner in front of families. Some participants thought that nurses,
especially less experienced ones, would have needed more support and
guidance in how to deal with their own emotions in the face of families’
suffering.
A few participants expressed concern that patients’ safety might be at
risk when nurses’ workload was at its most intense. More commonly,
nurses were troubled by the feeling that patients’ families received less
attention and support than they should have. Lacking time or ability to
do as much for the families as they felt they ought to led, for some, to
feelings of guilt and personal inadequacy. For some nurses this became a
chronic source of frustration and ethical stress.
“It’s a word that unfortunately gets used quite a lot here when there’s
been a lot to do, that you feel insufficient and that it’s … you haven’t been
able to do all you wanted to. And that’s a dangerous feeling to go home
with […] from what I’ve understood from the people who have quit since I
started, it’s a pretty important part of [why they quit]”. (Interview 5)
Participants expressed a strong sense of the importance of their work
and their responsibility for patients and patients’ families. For some,
notably among less experienced nurses, this translated into stress and
fear of what any negligence or error on their part could mean for the
vulnerable infants and families. As a result, some nurses said they felt
obliged, in practice, to exert themselves to the point of neglecting their
own need of recovery.
3.4. Support from colleagues: a valuable resource to build upon
Generally, the participants perceived the climate among staff at the
unit as caring and supportive. The nurses at the unit were described as
interested in each other’s well-being and active in helping their col­
leagues. In general, participants said they felt valued by their colleagues
and received positive feedback from them.
Several factors were seen as hampering access to support from col­
leagues. At busy times all nurses might be too occupied with their own
work to support colleagues. The physical layout of the unit, with single-
family rooms behind closed doors, made it difficult to locate colleagues.
For this reason, even when the unit was adequately staffed with nurses,
nurses could be impeded from asking colleagues for help when they
needed it. Further, some participants regretted that there was little op­
portunity for non-work-related exchanges that might have developed
cohesion among coworkers or provided respite in the work day. Another
hindrance mentioned by a number of participants was the lack of a
private office for nurses. Finally, the high proportion of inexperienced
nurses in the group meant that the need for support could be greater
than the supply of colleagues able to provide it.
Support, including emotional support, from colleagues was viewed
as an invaluable resource but one that was dependent on staff members’
individual initiative and good will, rather than an integral part of how
work on the unit was organized.
“I think it saved me emotionally [as a new nurse] that I have colleagues
who listen and show consideration […] It would have been much harder if
there hadn’t been colleagues I could share things with, just briefly. I don’t
think it’s really thought of as ‘support’ […] it’s more by good luck that the
support is there”. (Interview 4)
3.5. Support from management: mixed perceptions
About half of the participants described their first-line nurse man­
agers as supportive, accessible and willing to listen to their concerns.
39
Journal of Neonatal Nursing 28 (2022) 37–41
Night shift nurses, however, commented that they seldom saw or
communicated with their nurse manager.
Some participants felt that management tended to be too quick to
impose changes in the way things were done on the unit, for example if
families complained about something, rather than listen to what nurses
had to say about the matter.
Some participants said they received sufficient feedback from their
managers, whereas others said they received very little and would have
liked more. One participant felt that managers too easily tended to brush
off new nurses’ anxiety about making mistakes by referring to the or­
ganization’s responsibility for adverse events.
“[they tell you] ‘well, if anything were to happen it’s not your fault, it’s
the organization’s since it’s understaffed’. And I thought, yeah but that
doesn’t help me, I’m still the one who’s responsible […] I would feel just as
awful anyway”. (Interview 13)
Nurse managers were described as caring about nurses’ well-being
and fairly willing to provide support, e.g. by referring staff members
experiencing excessive stress to occupational health services for coun­
seling. Some participants felt that managers should have done more to
address individual nurses’ stress levels before their situation became
dire. But participants also saw managers as having a limited ability to
make adaptations that might help nurses at risk of burnout.
Recent rapid turnover among management was seen by some as
negatively impacting nurses’ confidence in their supervisors and their
ability to count on supervisors’ support.
3.6. Formal support: initiatives by the organization
Recently the introduction program for new nurses had been
expanded in order to provide increased support for new nurses. After
their initial orientation and trainee period was over they continued to
have access to a nurse mentor who was there was to offer guidance and
act as a professional role model. The mentor was seen as an important
resource but was not present at the unit full-time. Over the first year,
new nurses also had access to small-group professional supervision in
nursing care. Some participants wished that nurses with more experi­
ence had also had access to similar forms of support.
The organization was seen as fairly generous with opportunities for
further training and development, which the participants appreciated
and saw as a strength of their workplace.
“[On this point] I have to say I’m extremely positive, almost surprised
[…] I came here and almost immediately I got to take this course in
neonatology, and it’s a lot of fun. And that also makes you feel appre­
ciated, that they want to invest in you”. (Interview 10)
However, fewer forms of support and opportunities for development
were available for the most experienced nurses.
“They’ve invested in new nurses above all, with a lot of training and
opportunities to discuss and reflect [on their work] and so on. But we
older nurses get forgotten […] Some of us have been working for a really
long time and we also need a bit of attention and support”. (Interview 1)
A group reflection session for nursing staff, taking place at the end of
each day shift, had recently been introduced. The sessions allowed staff
to compare notes on how the day had gone and discuss issues of concern,
for example challenging situations they had been involved in. This was
described as a valuable means of coping with emotional stressors at
work.
4. Discussion
One of the most salient strengths of the work environment appreci­
ated by the participants in our study was nurses’ positive attitude to­
wards each other and their readiness to help and support colleagues.
A. Bry and H. Wigert
Nevertheless, such collegial support was limited by a number of cir­
cumstances, including the single-family room layout of the unit. This
layout offers parents in the NICU greater privacy and enables them to
spend time with their infant, but it can also complicate nurses’ work. A
novel finding in our study is the special impact of this layout on nurses
just beginning independent work, who had few opportunities for
learning by observation and felt it was daunting to work alone with
families. Although some studies (Stevens et al., 2010) have shown
enhanced workplace quality in a single-family room NICU layout, in our
study the disadvantages of this environment were more evident,
particularly for inexperienced nurses. More experienced nurses also
regretted the obstacles to contact with colleagues. Similarly, in a pre­
vious study by Hogan et al. (2016), nurses in a single-family room level
II NICU reported a sense of isolation. In view of our results, it would be
important to organize nurses’ work in a way that facilitates communi­
cation and mutual support among nurses. The physical aspects of the
workplace need to be taken into account, for example by providing ways
to ensure nurses can find each other when needed and private office
space for nurses. At the same time, informal collegial support cannot be
a substitute for healthy organizational conditions such as an acceptable
workload and adequate staffing.
We found that patients’ and families’ situation had a significant
emotional impact on nurses although the infants cared for in a level II
NICU are not normally critically ill. Participants mentioned the special
impact of dramatic situations that were outside the normal routine at the
unit and the need to be able to discuss these with colleagues. But they
also spoke of the cumulative emotional impact of day-to-day work with
patients and their families and a constant sense of responsibility that, for
some nurses, shaded into a chronic feeling of inadequacy. Reflection
sessions at the end of the day were an innovation that the nurses had
found helpful as a way of coping with emotional stress. Opportunities for
such sharing should be fostered, especially since a climate where staff
can express their authentic feelings can protect health care staff from
burnout caused by emotionally stressful encounters (Grandey et al.,
2012). Our results also point to a need for training of nurses in dealing
with emotionally taxing aspects of their work, something especially
relevant within family-centered care where close communication with
families is integral to nurses’ work.
The results of our study speak to the importance of adapting support
to the needs of nurses at various stages of their career. Like previous
studies (Labrague and McEnroe-Petitte, 2018), our results show new
nurses’ particular vulnerability to stress. Apart from a general lack of
experience, participants in our study provided information on specific
difficulties for new nurses. For example, inexperienced nurses need to
receive clear information on how their responsibilities will progress as
they gain in competence. Not yet being well-versed in neonatal care is
also liable to make prioritizing and organizing one’s own work harder,
thus making work more stressful. This should be paid attention to in the
training of new nurses. New nurses at the unit we studied appreciated
having access to a nurse mentor whose job was specifically to support
them. This type of mentorship seems worth investing in to provide
assistance and security to new nurses.
At the same time, our results highlight the fact that nurses with
extensive experience in neonatal care also have needs of support that
should not be neglected, a little-studied area. Despite their competence,
experienced neonatal nurses are also at risk for burnout, according to
some studies even more so than less experienced colleagues (Tawfik
et al., 2017b). In addition, they need professional stimulation and
appreciation in order to feel that their work continues to be satisfying
(Loft and Jensen, 2020). Because of their seniority and accumulated
competence, their possible decision to leave can be especially disruptive
for coworkers, including new nurses who rely on their teaching and
support, as participants in our study noted. The value as well as the
amount of the work that experienced nurses perform in teaching less
experienced colleagues should receive recognition, and care should be
taken that this task does not unduly increase their workload.
40
Journal of Neonatal Nursing 28 (2022) 37–41
4.1. Limitations
Since this was a study of one unit, care needs to be taken in applying
the results to other contexts that may differ in various ways. For
example, the hierarchy among Swedish hospital staff (e.g. between
nurses and doctors or between nurses with different levels of expertise)
is less pronounced than in many other countries, which could potentially
have both positive and negative effects on nurses’ stress, e.g. by
increasing their sense of influence in the workplace or by increasing
their burden of individual responsibility. Sweden’s generous parental
leave policy means that parents are free to spend large amounts of time
at the unit, a factor likely to affect nurses’ work environment. Further,
the unit we studied is part of a large university hospital, and nurses’
circumstances may differ from those at a smaller hospital providing less
advanced care.
5. Conclusions
Working in single-family rooms presents particular stressors for
neonatal nurses, especially those who are new to the job, and work
should be organized in ways that counteract its isolating effect. While
continuing their efforts to support new nurses, organizations should also
pay attention to the needs of the most experienced nurses. The question
of what factors help nurses feel that their work continues to be
rewarding after many years merits further research. Neonatal nursing,
involving close collaboration with families in distress, has a significant
emotional impact on nurses, and there is a need to develop interventions
to support and educate nurses in this aspect of their work.
Funding
No external funding.
Declaration of competing interest
None.
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