Identifying stress-relevant events in everyday nursing practice using psychophysiological outcomes - an observational multimethod study

Abstract

Stressful working conditions contribute substantially to nurses’ sickness absence and workforce shortages. However, prior research has largely focused on general job demands and resources, providing limited insight into which everyday work events are associated with acute stress responses. This study examined event-related observer-rated and physiological stress indicators during nurses’ work using ecological momentary assessment combined with ambulatory heart rate variability (HRV) monitoring. A non-interventional, multimethod field study was conducted with nurses from a German university hospital. During an 8-hour shift, trained observers continuously recorded work events and rated momentary stress, while HRV (root mean square of successive differences; lnRMSSD) was assessed via wearable electrocardiography. Events were categorized into clinical care burden, organizational burden, and positive events. Associations between event categories and observer-rated stress and lnRMSSD, controlling for physical activity, were examined using multilevel models. Additional analyses examined individual characteristics (age, sex, chronic stress) and patient call system events, including call reasons. Data from up to 85 nurses and 1,617 event-level observations were analyzed. Clinical care burden was consistently associated with higher observer-rated stress compared to other event categories, while positive events were associated with the lowest observer-rated stress. For HRV, clinical care burden was associated with lower lnRMSSD than organizational burden, whereas no significant differences were observed between positive events and other categories. An exploratory association between sex and lnRMSSD was observed, with male nurses showing higher values. Chronic stress was associated with higher observer-rated stress. Patient call system events did not differ significantly from non-call work events in observer-rated stress or HRV. However, call reason was associated with observer-rated stress, with calls related to comfort and service issues rated as less stressful than acute medical needs and care and mobilization support calls. No significant HRV associations were found. Psychophysiological indicators in nursing vary across everyday work events, with clinical care burden emerging as the most consistently stress-associated event category. The combination of event-based assessment and ambulatory physiological monitoring is feasible in routine clinical practice and enables identification of stress-relevant situations with high ecological validity. These findings may inform targeted interventions to improve nurses’ working conditions.