It is well documented in literature that nursing is a stressful occupation (Laws & Hawkins, 1995). With the prevalence of the nursing shortage, health care cutbacks, increasing patient demands and complexity of care, nurses may be experiencing increased incidences of stress in the workplace. Nurses are at high risk of experiencing physical and mental illness due to the increased stress and lack of support and control they have in their profession (Baldwin, 1999). Stress affects the health of individuals by placing huge demands resulting in emotional, physical, and behavioural responses (Black, Hawks, & Keene, 2001).

Levi (1990) discusses occupational stress in general and describes �conditions of work most adverse to workers� health are found in . . . nursing� ( 7). Bowman and Stern (1995) conducted a study on occupational stress, and chose a sample of nurses as their participants. Bowman and Stern chose nurses for the study because the nursing profession is commonly characterized by �relatively intense stress, high job turnover, and early burnout� (Present Investigation section, 3). Levi adds that these occupations are deemed stressful because these workers are exposed to high psychosocial stress, physical workload, and a low level of decision making and control. Many researchers are aware of a nurse�s tremendous responsibility for people�s lives �in an arena of constant pressure, conflict, and change� (Bowman & Stern, Present Investigation section, 3). Levi mentions that these workplaces are designed �almost exclusively with an eye toward efficiency and cost� ( 1). Although, according to Omdahl and O�Donnell (1999), stress and burnout are very costly to individuals and organizations.

In order to understand the aspect of nurses experiencing stress, we must first gain a greater understanding of what stress is. There were many definitions of stress discovered in the literature. Omdahl and O�Donnell (1999) define stress as an �imbalance between the perceived external demands on a person and his or her abilities to cope through the employment of cognitive, behavioural and physiological adaptation� ( 6). Lazarus provides a different approach at describing the term stress and defines it as �a very broad class of problems differentiated from other problem areas because it deals with any demands which tax the system, whatever it is, a physiological system, a social system, or a psychological system, and the response of that system� (as cited in Hopkinson et al., 1998, 6). Black et al. (2001) simplifies the definition of stress by describing it as a �result of an imbalance between the demands placed on a person and one�s ability to adapt� (p. 35). Although the concept of stress is defined in this way by many researchers, Smith (as cited in Hopkinson et al.) expresses that �defining the term �stress� itself presents problems . . . [which] is reflected in the lack of agreement amongst researchers about the nature of stress� ( 5). Briner and Reynolds (as cited in Hopkinson et al.) adds on to this by explaining that the concept of stress is flawed and that there needs to be new developments and theory generation regarding the theories on stress.

The definition of stress relating to the context of nursing practice is expressed in many of the literature. Cox (as cited in Hopkinson et al., 1998) defines stress as a process rather than a stimulus or a response, and adds that experiences with high demands and constraints which offer low resources and support for solving the problem are most likely to cause stress. This explanation of stress identifies its involvement with the experience of nurses working in high stress environments. Nurses experience increasing demands in the workplace and have limited support in their occupation to assist them in decreasing their experiences with stress. Stordeur, D�hoore and Vandenberghe (2001) explain that nurses who experience an imbalance between efforts spent at work and rewards obtained are more likely to experience stress and burnout. Nurses experience many demands on the job and nurses are constantly coping with constant time pressures, maintaining their competence in a rapidly changing field, placing themselves at risk of physical assault, experiencing ethical dilemmas, are often experiencing changes in the workplace, and experience a lack of control on how client care (Rainham, 1994). There are many more causes of stress in nursing and the demands listed by Rainham are only a minute part of the bigger picture. With all of the stressors experienced in nursing and the small rewards obtained in return, it�s no surprise that nurses are experiencing stress.

In order to obtain a perspective on the stress experienced in nursing, we must first examine the root causes of stress in the profession. From the various literature gathered, it is apparent that there are many causes of stress in nursing practice. Rainham (1994) describes some specific stressors experienced in the nursing profession; these stressors include demands of the actual occupation, job security and stability, the people at work, safety issues, self esteem, lack of support, and problems which occur outside of work. External factors such as a nurse�s work environment and problems away from work such as family, relationships, and society may be causing stress in the nurse. Internal factors may include the nurse and any factors such as conflict, decisions, and ethical dilemmas that a nurse may have to deal with.

External Factors
Most of the literature gathered regarding the causes of nursing stress in the workplace were consistent with one another and mostly related to work environment factors. Hopkinson et al. (1998) revealed in their study that nurses considered stress causing factors in the workplace was compatible with existing stress literature; factors causing stress in nursing practice included workload, organizational support, patients and their family, role confidence and competence, and home/work conflicts. Not only does the nurse have to experience stress in the workplace, the nurse also has other sources of stress that may be found in problems away from work (Rainham, 1994). The nurse may experience stress from all aspects of his/her life; there are stressors that may be present in their families, society, friends, and the workplace is an additional stressor to those already causing stress in the nurse.

Internal Factors
Internal factors causing stress may include factors such as internal conflict, decision-making, and ethical dilemmas that the nurse may be experiencing. Cole, Slocumb, and Mastey (2001) identify many internal sources of stress such as providing care to dying patients, fear of making mistakes, high workload and task overload, interpersonal conflict, and patient care issues. Many nurses may experience conflict from within regarding their patients and the ethical dilemmas that may arise with patient care. This source of stress increases as nursing staff encounter increasing numbers of acutely ill patients and endure pressures to conform and adapt to rigorous standards of �cost-containment and quality assurance programs� (Stordeur, D�hoore, & Vandenberghe, 2001, 1).