Nursing Sample Paper on Salivary Cortisol


The nursing career has been known for shortage and work burden, which are associated with work-related stress among nurses. That stress has physical, psychological, and cognitive negative outcomes for nurses and their patients.
(Farquharson et al., 2013). In this study, salivary cortisol will be measured as a biomarker of stress from novel nurses during the beginning, middle, and the end of their work shift at the medical surgical ward to explore if there is any relationship between stress, and poor job performance looking at the incident reports for one month.

Conceptual definition with physiological link

According to the elasticity theory in physics, stress is defined as how much pressure is applied to a given area(Kranner, Minibayeva, Beckett, & Seal, 2010). There is a linear relationship between stress and the affected object; the more force is given, the more changes in length will occur until the object is bent when it is unable to handle more pressure. (Kranner, Minibayeva, Beckett, & Seal, 2010). Similarly, there is a specific type of stress when it is in an acceptable amount called “Eustress” as claimed by Hans Selye. Eustress affects a human being and leads to productivity. However, Selye defined too much stress as “distress”, which could be beyond someone’ coping and lead to destructivity or even mental illnesses such as anxiety or depression (Kranner, Minibayeva, Beckett, & Seal, 2010). Hans Selye, the father of general adaptation syndrome (GAS) theory operationally defined stress as a nonspecific biological response to changes in normal body equilibrium. Selye generated the word “stressors” as stimulants to be distinguished from the stress as a response. However, Selye could not be satisfied with any final definition of stress as it differs from each person’s perspective.

According to the anxiety and depression association of America, stress is a temporary chemical reaction that resulted from a provoking situation. However, anxiety is the long-term result of perceived stress. There are three modes of stress from three different theoretical perspectives; Stress as a stimulant, reaction, or the effect of two which are stress as an interaction between the environmental stimulus, and human response (Papathanasiou, 2015).

From a biological perspective, stressor alters the normal psychobiological state of the human body system. That alteration stimulates the hypothalamus to secrete corticotrophin-releasing hormone (CRH). CRH triggers the anterior pituitary gland to secrete adrenocorticotropic hormone (ACTH) that initiates the adrenal cortex to release glucocorticoids. The glucocorticoid hormone is cortisol in the human body. Cortisol is an essential hormone in releasing energy by metabolizing fat and protein to glucose and elevating it in the bloodstream. (Clements, 2012). Throughout the day, the normal highest cortisol level would be upon waking up, and it gradually decreases to be at its lowest before bedtime. Cortisol is also considered an important biomarker of physiological stress (Inder, Dimeski, & Russell, 2012).

Lit review on my issue, and biomarker

Nurses view their work shift as a kind of stressor because of many reasons such as the working environment, and the difficulty maintaining social balance. (Rocha, Martino, Grassi-Kassisse, & Souza, 2013). Several studies revealed that high occupational stress among nurses leads to low patient care quality, and it probably could be a threat to patients’ safety. A qualitative study showed that among critical care nurses time pressure especially causes work stress that results in incomplete tasks (Berland, Natvig, &Gundersen, 2008b). In addition, another study has shown that work stress among hemodialysis nurses arising from multiple factors such as poor communication and heavy workload leads to poor patient outcomes. (Hayes & Bonner, 2010). Moreover, Excessive levels of stress might lead to distraction, and the inability to complete a motor task effectively as it impairs concentration and memory (Arora et al., 2010). Reductions in stress would probably increase job satisfaction, improve retention of staff and nurse performance, and thus improve patient care.

(Farquharson et al., 2013). Not all stressors can cause cortisol elevation, however, a stressor that is linked to the evaluative task is strongly associated with elevated cortisol levels (Dickerson &Kemeny, 2004). Moreover, salivary cortisol level has been proven to be higher among nurses during work shift compared to their day off(Rocha, Martino, Grassi-Kassisse, & Souza, 2013).In addition, several investigators have found that more stress occurs during the initial period of clinical practice than in any other period (Sheu, Lin, & Hwang, 2002). Stress and performance have been studied previously, however, without using a biomarker (Arora et al., 2010). Therefore, a relationship between stress and performance using a scientific biomarker is needed among the nurse population. Quantifying this effect is important in raising awareness of the problem so as to institute training to minimize potential errors and safeguard patient care.

Biomarker of stress: what is it, how it is done, how much does it cost, how long does it take for results, what result means?

Salivary cortisol reflects biologically either active free, or/and corticotrophin binding globulin [CBG] cortisol (Clements, 2012). However, it has a 10-fold lower concentration than total serum cortisol.(Inder, Dimeski, & Russell, 2012).Salivary cortisol will be collected by the nurses themselves with an instructions pamphlet, the subjects will be instructed to collect the sample three times in their day shift. Those three times will be around the 12 hours shift. In the beginning, middle around 12 or 1, and in the evening, is the end of the shift. The subjects will be given along with number identification three cotton rolls with high-absorption properties to chewing for about 3 mins, not less than 3 sec included in the Salivettesytem tube (Inder, Dimeski, & Russell, 2012). The subject will be informed to refrain from eating, smoking, and brushing teeth for 1 h before sample collection.

The sample should be stored at 4 °C until received at Pathology, centrifuged at 3000 g for 10 min then stored at “80 °C until assayed. Salivary cortisol has been mostly measured by immunoassay methods (Inder, Dimeski, & Russell, 2012). The measurement shows that the levels are high during the morning and evening. Thus, it is possible that the test results show high levels in the morning and evening. The degrees in temperature used in storage are the probable temperatures of the mouth of human beings that directly influence the level of salivary cortisol.

A healthy human being should have a moderate level of salivary cortisol. But if someone is unhealthy they have high or low levels of salivary cortisol. Just like the levels suggest high levels of salivary cortisol cause diseases such as hypertension, obesity, muscle weaknesses, and high blood sugar. Thereby, it is advisable for people with a high level of salivary cortisol to avoid unhealthy eating habits. Also, a person with a low level of salivary cortisol suffers life-threatening conditions such as weight loss, muscle pain, and abdominal pain. These symptoms are very shaming if not controlled because an individual vomits and diarrheas. Hence people are advised to have healthy eating habits to avoid having under levels of salivary cortisol or over levels.  The results take 24 hours for accurate results but if there is room for mistakes the medical personnel in charge can redo the test for the purpose of clarity. This shows that nurses with high or low salivary cortisol have symptoms of stress in the vent of duty. Consequently, hospitals that observe the needs of their staff should introduce better working condition in relation to the results of salivary cortisol shown by the nurses.


The American Institute of Stress. (2011, October 6). What is stress? Retrieved February 6, 2017, from The American Institute of Stress,

ADAA. Stress. Retrieved January 26, 2017, from

Arora, S., Sevdalis, N., Aggarwal, R., Sirimanna, P., Darzi, A., & Kneebone, R. (2010). Stress impairs psychomotor performance in novice laparoscopic surgeons. Surgical Endoscopy24(10), 2588–2593. doi:10.1007/s00464-010-1013-2

Berland, A., Natvig, G. K., &Gundersen, D. (2008a). Patient safety and job-related stress: A focus group study. Intensive and Critical Care Nursing24(2), 90–97. doi:10.1016/j.iccn.2007.11.001

Berland, A., Natvig, G. K., &Gundersen, D. (2008b). Patient safety and job-related stress: A focus group study. Intensive and Critical Care Nursing24(2), 90–97. doi:10.1016/j.iccn.2007.11.001

Clements, A. D. (2012). Salivary cortisol measurement in developmental research: Where do we go from here? Developmental Psychobiology55(3), 205–220. doi:10.1002/dev.21025

Dickerson, S. S., &Kemeny, M. E. (2004). Acute stressors and Cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin130(3), 355–391. doi:10.1037/0033-2909.130.3.355

Elbuken, G., Karaca, Z., Tanriverdi, F., Unluhizarci, K., Simsek, Y., &Kelestimur, F. (2015). Does cigarette smoking affect serum total cortisol and salivary cortisol levels? Endocrine Abstracts. doi:10.1530/endoabs.37.ep729

Farquharson, B., Bell, C., Johnston, D., Jones, M., Schofield, P., Allan, J., … Johnston, M. (2013). Nursing stress and patient care: Real-time investigation of the effect of nursing tasks and demands on psychological stress, physiological stress, and job performance: Study protocol. Journal of Advanced Nursing69(10), 2327–2335. doi:10.1111/jan.12090

Hayes, B., & Bonner, A. (2010). JOB SATISFACTION, STRESS AND BURNOUT ASSOCIATED WITH HAEMODIALYSIS NURSING: A REVIEW OF LITERATURE. Journal of Renal Care36(4), 174–179. doi:10.1111/j.1755-6686.2010.00194.x

Inder, W. J., Dimeski, G., & Russell, A. (2012). Measurement of salivary cortisol in 2012 – laboratory techniques and clinical indications. Clinical Endocrinology77(5), 645–651. doi:10.1111/j.1365-2265.2012.04508.x

Kranner, I., Minibayeva, F. V., Beckett, R. P., & Seal, C. E. (2010). What is stress? Concepts, definitions and applications in seed science. New Phytologist188(3), 655–673. doi:10.1111/j.1469-8137.2010.03461.x

Rice, V. H. (2000). Handbook of stress, coping, and health: Implications for nursing research, theory, and practice (2nd ed.). Thousand Oaks, CA: Sage Publications.


PAPATHANASIOU, I., Konstantinos, T. S. A. R. A. S., Neroliatsiou, A., &Aikaterini, R. O. U. P. A. (2015). Stress: Concepts, theoretical models and nursing interventions. IN: American Journal of Nursing Science, published online4(2-1), 45-50.

Rocha, M. C. P. da, Martino, M. M. F. D., Grassi-Kassisse, D. M., & Souza, A. L. de (2013). Stress among nurses: An examination of salivary cortisol levels on work and day off. Revista da Escola de Enfermagem da USP47(5), 1187–1194. doi:10.1590/s0080-623420130000500025

Sheu, S., Lin, H.-S., & Hwang, S.-L. (2002). Perceived stress and physio-psycho-social status of nursing students during their initial period of clinical practice: The effect of coping behaviors. International Journal of Nursing Studies39(2), 165–175. doi:10.1016/s0020-7489(01)00016-5