Our primary purpose was to evaluate how CROS might play a role in the experience of nursing stress, based on nurses’ reports of effort-reward-imbalance. There continues to be a need to elucidate the mechanisms by which nurses’ work environments influence outcomes such as health and productivity [40]. In addition to the high turnover rate, nurse stress also leads to medical errors, patient morbidity and mortality [2, 5], low self-esteem, and increased absenteeism [15]. The most devastating of the listed effects of nurse stress is suicide and suicidal ideation by nurses [41]. Despite abundant research on the phenomenon of nurse stress, barriers to resolving the issue of workplace stress for nurses persist. To that end, we feel that this study demonstrates that CROS can help explain how communication can function to both exacerbate and alleviate the negative postliminary effects of work stress for nurses. Our findings also allow us to make targeted recommendations for improving work conditions and ultimately for improving outcomes such as lost productivity and poor general health among nurses.

There are two key findings that are integral to this study. First, among nurses, CROS functions to serve as an effort in the effort-reward-imbalance model. This was especially true for those nurses who had low reported perceived organizational support. In this sense, nurses reported the greatest imbalance between their efforts and their rewards when they had no outlet to discuss their stressors with others and they did not feel particularly supported by their organization. The second important finding comes from our member-checking interviews, which supports and informs the quantitative findings. Nurses from our sample relied heavily on their colleagues for social support, especially when their working conditions were not good (a common experience from nurses). Those nurses who talked about the combined effects of all other stressors with limited (or no) provisions for supportive interactions (i.e., CROS) reported the greatest stress-outcomes. Taken together, our findings point to the importance of recognizing CROS as an organizational variable for nurses and underscore the importance of bolstering interpersonal communication systems in healthcare settings. Below we describe the theoretical implications of our findings, some practical implications for nurses, and some directions that we expect this research to take.

It is unsurprising that the data revealed that nurses experience CROS. Organizational members may have a range of reasons for why they feel restricted in their ability to discuss their work stress. These causes of CROS include individual power dynamics, risks associated with self-disclosure, fear of conflict, fear of burdening others, and social inappropriateness. Furthermore, workers may fear partner unresponsiveness or futility of discussion, especially if the conversational partner has little familiarity with the organization or the nature of the work [26, 42, 43]. The data presented here indicate that these same factors are quite prevalent for nurses and do, as expected, contribute to CROS.

External forces may also serve to restrict communication such as organizational privacy policies (e.g., the Health Insurance Portability and Accountability Act or “HIPAA”) or other systemic prohibitions against talking to others about the workplace [24]. In some cases, workers may feel that they are comfortable speaking to members of a particular relational domain and not others (e.g., friends/family vs. co-workers, or supervisors vs. subordinates). Our data demonstrates that these dynamics, which have been explicated in the literature in a variety of professions, exist among nurses and function in expected ways for this population [24,25,26, 42].

Results indicated that nurses do experience CROS and that its associated distress covaries with overall nursing stress, both of which vary by nursing type. Additionally, these findings extend the previously reported explanations for how CROS functions noted above. Specifically, the subcomponents of the CROS phenomenon have differential effects. For instance, feeling restricted in one’s ability to vent frustrations may function differently to exacerbate stress than feeling as though one cannot effect change within their workplace. This proposition needs to be examined directly in future studies. However, there does appear to be preliminary evidence in our data to indicate that when CROS relates to specific workplace stressors that nurses feel stymied in their ability to change, their experiences in the workplace are worsened.

In the case of this sample, we show effects on lost productivity, insomnia, and poor general health. These findings support the contention that nurses’ outcomes are at least indirectly affected by their ability to productively discuss their stress in a way that leads to actual change. Our thematic analysis of the member-check data further explains these findings -- feeling CROS with respect to feeling empowered to make change (such as with managers and other superiors), resulted in increased distress among nurses.

We also were able to show that CROS distress is inversely related to organizational support which is consistent with prior literature suggesting better outcomes in more supportive environments [44]. These findings support existing theorizing [24], suggesting that CROS exerts its negative effects by preventing the translation of support into action and/or because one’s illusions of perceived support are shattered when they realize that they cannot enact any support they thought that they had.

We are also able to shed additional insight on research indicating that nurses in particular, struggle with work-life-integration [45]. Nurses who feel more CROS may also feel a stronger need to compartmentalize their feelings about work and therefore suffer more ill effects due to a lack of support. The interview findings highlight the anguish nurses feel when they are unable to discuss their work stress with family or friends because they worry that they are not allowed to, that they will not be understood, or because they simply do not want to burden others with their problems. This leads to the feeling that others lack empathy for them and of internalization of their problems.

We should note that these results reflect the nature of nursing work prior to the start of the COVID-19 pandemic. More recent work suggests that these issues not only have not gone away but have increased, as Craw and colleagues [19] discovered. They found that nurses reported greater social pressures at work, compounded by the complexities of managing the stress associated with emergency care during the pandemic. In fact, through their interview study with working nurses, Craw and colleagues [19] explicated a primary theme that emerged among COVID-19 nurses -- that “nobody else understands.” The nurses they interviewed reported challenges with communicating to family members and friends about their stressful experiences all the while struggling to communicate with fellow nurses, as they were all experiencing similar stressors [19]. In these cases, nurses felt a sense of CROS and are prevented from fully utilizing their social support networks. As such, we believe the findings presented herein are especially important to consider given that working conditions have become even more stressful for nurses over time.

In previous work [24, 25] the general existence and prevalence of CROS has been identified. Subsequent work has shown that CROS is found in a variety of organizational settings such as the Catholic Church [46], among university faculty [26] and graduate teaching assistants [42], and can help in the theoretical explanations for both the structure and function of workplace stress. The present study extends those findings by examining prevalence and effects of CROS in a specific occupational subcategory that we expect to be particularly affected by this phenomenon. Given the life-or-death consequences associated with stress among nurses [19, 44, 47,48,49], we felt that examining CROS in this population was important.

Effort reward imbalance is an insidious construct in organizational stress research [50], as when chronic, the feeling of imbalance becomes a toxic feature of a worker’s organizational experience [21]. Perceived imbalance is linked to specific neurological and neuroendocrine responses. “The recurrent experience of failed reciprocity is expected to afflict the health and well-being of working people by compromising their self-esteem and by eliciting negative emotions with special propensity to elicit sustained autonomic and neuroendocrine activation of the organism” [22]. For instance, researchers evaluating physiological data from the famed Whitehall II study found that ERI was associated with waking cortisol profiles [23]. Furthermore, a 52-country epidemiological study with nearly 30,000 participants found that coronary heart disease was elevated among individuals with high efforts and low rewards at work [51]. When examining nurses specifically, Bakker and colleagues [20] found that those nurses who reported a greater imbalance (high efforts to low rewards) also reported greater levels of burnout. Furthermore, their data also revealed a moderating effect of intrinsic effort (or need for control), where burnout was highest among those nurses who reported an imbalance and a need for control. This is important for the present investigation, as reciprocity in the support dynamic is an element in nurses’ reported need for control.

While conventional thinking might view explicit organizational stressors (e.g., long working hours, dangerous working conditions, etc.) as being prevalent efforts, we believe that other more implicit variables also play an important role in understanding the full scope of efforts. Our findings support the notion that CROS is likely an effort in this model. This is important, as CROS is an interactive-communicative variable – as described earlier, CROS prevents a person from potentially enacting support structures or engaging their own support schemas. While other theorists have connected a variety of psychological constructs to ERI [20, 21, 23], we are the first to demonstrate how CROS fits into this model.

When considering the deleterious effects of ERI, we found that CROS serves to amplify the effects – those nurses who reported the highest amount of CROS stress with the lowest amount of organizational support and the highest levels of ERI had the highest amounts of nursing stress. When CROS distress was low, organizational support was high, and ERI was below 1.00 (indicating more rewards compared to efforts), nursing stress was the lowest. These quantitative findings were echoed among the nurses we interviewed. Taken together, we believe that, for these nurses, CROS was a meta-stressor [24] that served to amplify the experience of nursing stress, since it functioned as an organizational effort.

Importantly, our study specifically focuses on nurses’ reports of ERI. Nurses experience a variety of stressors as a function of their work environment and occupations [17, 52] and their relationships with patients and coworkers [44]. For nurses, ERI predicts burnout [20]; therefore, it was no surprise that we found that the nurses in our sample also experienced ERI. Additionally, nurses in our sample reported negative associations between ERI and organizational support and perceived general health, and ERI was positively associated with insomnia and productivity lost. These results paint a troubling picture for nurses who report high efforts, low rewards, high levels of insomnia, lower productivity, lower organizational support, and lower perceived general health.

Ultimately these findings help extend our understanding of how ERI and CROS function in this context and provides a more robust explanation for how downstream negative effects (such as lost productivity and insomnia) are amplified in the nursing profession. Put simply, not having the ability to garner support through communicative channels in a high stress situation with low organizational support can lead to an imbalance in how rewarding work is. This is important, as the nurses we spoke with told us that their reason for getting into the nursing profession was to help people – their reward was intrinsic. An exacerbation of ERI can have a devastating effect on a nurse’s work-life experiences and their vocational identity. The results from this study indicate that for many nurses feeling communicatively restricted lessens their perceptions of rewards and/or increases the burdens or efforts associated with the work. For many nurses, the intrinsic reward associated with nursing was outweighed by the costs. That imbalance has the potential for a wide variety of negative stress-related outcomes. For these reasons, we believe that a focus on the practical implications is warranted.

Taken as a whole, we can explain a mechanism by which communication plays a role in how nurse stress influences nurses’ lived outcomes. Our data allowed us to reflect the experiences of a range of individuals across demographic categories and from a representative range of nursing professionals. As such, we are confident that these findings generalize to nurses in the US, providing valuable insight into this population. Given the importance of addressing nurse stress outlined above, we believe this to be a significant contribution to the body of knowledge on nursing.

Per National Institutes of Occupational Safety and Health recommendations, alleviating work stress often requires change on the part of organizations. However, the wholesale changes and cultural shifts advocated by scholars have not been readily embraced [53]. While many organizations provide access to employee assistance programs, data suggest that they are underutilized [54] and, individuals tend to be hesitant to seek formal mental health care [55]. As a result, workers are often left to rely on informal social support to address their workplace stress [56,57,58,59]. However, sufficient social support is not always readily available.

Recognizing the systemic communication issues that nurses face in the workplace can lead to avenues for significant change. Furthermore, we suggest that interventions aimed at reducing CROS could reduce ERI. The reduction of ERI would lead to improvements in downstream health and psychological outcomes for workers [20, 50, 60, 61]. To the extent that communication is a major stressor that is moderated by CROS, targeted interventions aimed at improving communication can be cost efficient mechanisms for reducing the negative stress-related outcomes we see for nurses and in nursing organizations. For instance, organizations that support appropriate levels of open communication within the organization can (1) reduce CROS, and (2) improve nurses’ perceptions of support therein affecting two of the variables that lead to negative outcomes [48]. Furthermore, in a study of 201 hospital nurses, Apker and colleagues [62] discovered that nurses who co-create synergistic team communication systems are less likely to leave their organizations, thereby demonstrating the importance of high-quality team-based communication in reducing turnover. Thus, we encourage management to actively cultivate an environment where nurses do not feel restricted in their ability to discuss concerns. To the extent that our findings suggest that futility of communication is especially distressing, we feel that it can be particularly useful for organizations to consider open communication policies. Furthermore, managers should act on issues nurses communicate to them, thereby addressing both the underlying stressors and the exacerbating effects of restricted communication pertaining to those stressors. This two-pronged approach can lead to the most marked improvements.

Although communication that leads to change can be transformative, simply being receptive to open discussion of stressors or job efforts can also in and of itself also help alleviate some of the negative effects associated with nursing work. We are not the first to note the importance of communication in improving nurses’ workplace environments [2]. For instance, a recent white paper indicated that when it comes to ways mental health employees suggest reducing job related burnout, the two most common themes in the responses were staff camaraderie and personal connections with co-workers, and the development of a culture of openness to acknowledge and discuss burnout [63]. Other research also shows that workplace support for nurses is associated with decreased burnout and desire to quit [2]. In our own findings, we saw that those who reported less CROS, reported experiencing catharsis and stress reduction by virtue of their sense of open access to supportive communication and lack of restrictedness. In sum then, these findings are supportive of organizational changes that focus specifically on communication processes that reduce CROS and improve organizational support.

This project affords insight into the role of CROS within the ERI framework for nurses and allows us to make specific recommendations for changes that can improve outcomes of interest like nurse stress and productivity. However, some limitations must be noted. First, we acknowledge that data were collected cross-sectionally and at a particular point in time. Although the interview data provided support for the logic of our conclusions, any causal claims would need to be explored further using longitudinal methods. While our dataset did include good diversity with respect to nursing type, we did not see much ethnic or racial diversity. Therefore, replicating this work with a larger and more diverse sample might bolster our claim of generalizability and can elucidate nuances in experiences that exist within subpopulations of nurses. Furthermore, given that the global pandemic has fundamentally altered the nature of healthcare work, additional work on how CROS functions in a post-COVID world may be needed to fully understand nurses’ experiences and we believe this to be an important avenue for future research. Finally, we believe that investigating the ethical obligations of organizations in reducing ERI and CROS would be valuable. Given that ERI has been framed as a form of organizational injustice [64], it stands to reason that addressing CROS can make for a more just organizational climate. Such positioning should be investigated in future work.