According to the World Health Organization (WHO) (2018) ‘work-related stress is the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and that challenge their ability to cope’.
When work pressures become excessive or otherwise unmanageable, this leads to stress—and this can damage an employee's health and the organisation's performance (Abdul Rahman et al, 2017). Stress has been directly linked to seven of the ten leading causes of death in both sexes worldwide, and one of those causes, cardiovascular disease, is noted to have a distinct connection with occupational and organisational stress (Schnall et al, 2016).
Health is not merely the absence of disease or infirmity but a positive state of complete physical, mental and social wellbeing; a healthy working environment therefore is one in which there is not only an absence of harmful conditions but also an abundance of health-promoting elements (WHO, 2018). The WHO has urged all organisations to provide continuous assessment of risks to health, including appropriate information and training on health issues and the availability of health-promoting organisational support practices and structures, as work-related stress is not an acute or toxic condition that can be cured through treatment (Quick and Henderson, 2016).
The emergency department (ED) is recognised as one of the highly stressful areas of nursing because of its constantly changing, highly systemised and demanding environment (Nespereira-Campuzano and Vázquez-Campo, 2017; Crilly et al, 2017). Research has identified several causes of stress among ED nurses. These include interpersonal conflicts between doctors and other health professionals (Duffy et al, 2015), a heavy workload (Crilly et al, 2017), witnessing death and the suffering of patients, nursing a child who has been sexually abused, experiencing or witnessing violence against staff (Duffy et al, 2015; Crilly et al, 2017), and mass casualty incidents (Crilly et al, 2017).
Another area known for high levels of stress in nursing is the critical care unit (CCU) (Cavalheiro et al, 2008; Elshaer et al, 2017). This is a working environment that requires nurses to be both scientifically knowledgeable and aware of the current technical and technological changes (Cavalheiro et al, 2008). Critical care nurses are exposed to a number of stressors such as a confined working environment, artificial lighting, air conditioning, workplace architecture, constant demands from superiors, highly demanding routines, lack of human resources, noisy and sophisticated equipment, and the possibility of nursing patients in pain or who may die (Cavalheiro et al, 2008).
Method
Aim
The aim of this study was twofold:
Design and setting
This was a descriptive cross-sectional study using a self-administered questionnaire among ED and critical care staff at the largest referral hospital in Brunei.
Data collection
In total, 165 nurses from ED and critical care services were invited to participate in the study. Of these, 85 nurses (a 52% response rate) joined the study. Participants' sociodemographic data are set out in Table 1.
| Frequency | % | |
|---|---|---|
| Age (years) | ||
| 20–29 | 18 | 21 |
| 30–39 | 38 | 45 |
| 40–49 | 22 | 26 |
| ≥50 | 7 | 8 |
| Gender | ||
| Female | 59 | 69 |
| Male | 26 | 31 |
| Marital status | ||
| Married | 63 | 74 |
| Single | 22 | 26 |
| Designation | ||
| Nurse officer/senior staff nurse | 6 | 7 |
| Staff nurse (diploma level) | 68 | 80 |
| Assistant nurse (certificate level) | 11 | 13 |
| Work setting | ||
| Emergency | 40 | 47 |
| Surgical intensive care unit | 28 | 33 |
| Medical intensive care unit | 17 | 20 |
| Work experience (years) | ||
| 1–4 | 11 | 13 |
| 5–9 | 25 | 29 |
| 10–14 | 18 | 21 |
| ≥15 | 31 | 37 |
Research tools
Stress coping strategies were measured using the Ways of Coping questionnaire, developed by Folkman and Lazarus (1988). This tool consists of 66 items divided into eight component scales across two categories: problem-oriented coping strategies and emotion-oriented coping strategies.
Problem-oriented coping strategies (Folkman and Lazarus, 1988) comprise:
Emotion-oriented coping strategies (Folkman and Lazarus, 1988) comprise:
The tool has a four-level Likert-response scale (from 0 = not used to 3 = used a great deal).
Sociodemographic information (such as age, gender and marital status) and employment background details (such as qualification and number of years working) were also obtained. Prior to conducting the study, a pilot was carried out to establish the reliability and validity of the questionnaire.
Data analysis
A validation procedure was conducted to re-establish validity and reliability estimates of the Ways of Coping component scales. Inter-scale correlation, corrected item-total correlation (CITC), and Cronbach's alpha were computed to establish discriminant validity, convergent validity and internal consistency reliability respectively of the numerical scales. Descriptive statistics were then examined. The scores for each scale were then calculated as follows: the sum of raw scores was first calculated, followed by mean score and relative score. A higher raw score indicates that particular coping behaviours were used more often than others. Finally, association between coping behaviours and sociodemographic factors were compared using the independent t test for independence and one-way analysis of variance (ANOVA). All statistical analysis was computed using the statistical software package SPSS v21. A p value of less than 0.05 was considered significant (two-tailed).
Ethical considerations
This study was reviewed and approved by the joint institutional review boards of the University of Brunei Darussalam and the Ministry of Health.
Results
Table 2 provides the validity and reliability estimates for the component scales of Folkman and Lazarus's Ways of Coping questionnaire. In terms of validity, the instrument was modified according to the changes suggested by participants in the pilot study to improve face and content validity. CITC for all numerical scale ranges was above 0.4, indicating good convergent validity, except for item 28 (confrontative coping scale) and item 35 (self-controlling scale). The correlation matrix showed that all the scales had good discriminant validity (r value was between 0.3 and 0.7), except for the correlation between the planful problem-solving scale and the positive reappraisal scale, which had loading above 0.70, indicating a high correlation. In other words, the items might be measuring similar latent variance. In terms of reliability, Cronbach's alpha coefficient was in the range of 0.6 to 0.80, indicating adequate to good internal consistency reliability.
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Alpha | |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | 0.637 | |||||||
| 2 | 0.55** | 1 | 0.736 | ||||||
| 3 | 0.54** | 0.59** | 1 | 0.537 | |||||
| 4 | 0.49** | 0.27* | 0.32** | 1 | 0.721 | ||||
| 5 | 0.47** | 0.43** | 0.62** | 0.55** | 1 | 0.562 | |||
| 6 | 0.61** | 0.58** | 0.68** | 0.38** | 0.57** | 1 | 0.756 | ||
| 7 | 0.48** | 0.36** | 0.62** | 0.56** | 0.69** | 0.47** | 1 | 0.642 | |
| 8 | 0.54** | 0.46** | 0.66** | 0.54** | 0.69** | 0.48** | 0.81** | 1 | 0.745 |
1 = Confrontative coping scale; 2 = Distancing scale; 3 = Self-controlling scale; 4 = Seeking social support scale; 5 = Accepting responsibility scale; 6 = Escape-Avoidance scale; 7 = Planful problem-solving scale; 8 = Positive reappraisal Alpha = Cronbach's alpha
Source: Folkman and Lazarus (1988)
Ways of Coping scores
From the data, the authors observed that nurses in the ED and CCUs were mostly using the planful problem-solving coping strategy, followed by positive reappraisal, distancing, seeking social support and accepting responsibility strategies (Table 3). Confrontative coping and escape-avoidance behaviours were the least exhibited by the participants.
| Mean | Standard deviation | Relative score (%) | 95% CI | |
|---|---|---|---|---|
| Planful problem-solving scale | 2.0 | 0.49 | 15 | (14.4, 15.5) |
| Positive reappraisal scale | 1.9 | 0.50 | 14 | (13.8, 14.8) |
| Distancing scale | 1.7 | 0.56 | 13 | (12.4, 14.1) |
| Seeking social support scale | 1.7 | 0.58 | 13 | (12.2, 13.7) |
| Accepting responsibility scale | 1.7 | 0.56 | 13 | (12.4, 13.5) |
| Self-controlling scale | 1.6 | 0.51 | 12 | (11.7, 12.8) |
| Confrontative coping scale | 1.4 | 0.47 | 11 | (10.3, 11.3) |
| Escape-avoidance scale | 1.2 | 0.57 | 9 | (8.0, 8.6) |
SD = standard deviation; CI = confidence interval; Scoring: lowest = 0, highest = 3
Relationship between coping strategies and sociodemographic factors
Even though ‘confrontative coping’ was least used, those who were married (mean = 1.5, SD = 0.45) had significantly higher scores than those who were single (mean = 1.0, SD = 0.43) (F-statistics = 4.68, p<0.001).
In addition, those who worked in the medical intensive care unit (mean =401.44, SD = 0.39) scored significantly higher on escape-avoidance coping behaviours compared with those working in the ED (mean = 1.0, SD = 0.58) (F-statistics = 3.27, p=0.043).
No statistical significance was detected between other coping strategies and the sociodemographic factors.
Discussion
To the authors' knowledge, this is the first study examining job-stress coping strategies among nurses in Brunei. The study demonstrated that the Folkman and Lazarus Ways of Coping questionnaire is a valid and reliable tool for use in this setting. The authors found that the participants were mostly using problem-oriented coping strategies, particularly planful problem solving; similar findings have been reported in other research (Fiske, 2018). This is a widely used coping strategy, possibly because it gives a sense of control through careful step-by-step planning, and thus works best for individuals whose stress factors are within their control and who can therefore manage stress factors effectively (Nes and Segerstrom, 2006). In fact, those employing problem-oriented coping strategies have demonstrated higher mental health indicators, meaning that they are at lower risk of mental health disorders (Chang et al, 2007).
The second most frequently used coping strategies were positive reappraisal, an emotion-oriented coping strategy, which is also among the top three used by participants in other research (Healy and McKay, 2000; Deklava et al, 2014). Nurses who used emotion-oriented coping strategies demonstrated higher psychological competencies, and significantly better professional behaviours and personality traits (Shirey, 2006). Emotion-oriented coping strategies are favoured by people whose personality allows them to easily enter into and sustain a state of emotional arousal in response to, or in anticipation of, emotionally laden stressful events (Shirey, 2006). However, a meta-analysis revealed that those using emotion-oriented coping strategies have poorer health outcomes because they have been associated with negative styles of emotional coping such as alcohol and drug consumption, and the root cause of the stress was not addressed (Penley et al, 2002). In contrast, positive reappraisal has demonstrated benefits in terms of psychological health (Shiota and Levenson, 2012). In general, females are more likely to use positive reappraisal (Deklava et al, 2014); however, the present study did not find a significant association between gender and positive reappraisal coping strategies.
A notable difference between the present and previous studies was the significantly higher usage of escape-avoidance behaviours among medical intensive care nurses compared with ED staff. Escape-avoidance behaviours do not address the cause of stress, although they may provide stress reduction in the immediate or short term—staff may use escapist fantasies to minimise the severity of the situation (Morita, 2008). Nurses often used this particular coping due to the fast pace and heavy workload in their working environment (Wang et al, 2011).
Another finding was the association between confrontative coping and marital status, where those who were married demonstrated higher confrontative behaviour. The multiple roles of nurses after marriage could be contributing reasons for the use of this strategy (Shiji et al, 2016). This could be due to difficulties in balancing work and family life. In work by Ribeiro et al (2015), male nurses and those who worked night shifts were found to be more likely to exhibit confrontative behaviours.
A major contribution of this study has been to provide a baseline for different stress coping strategies and to highlight concerns about nurses in high-pressure environments using negative coping behaviours; this could be used in future stress management interventions. However, this preliminary study limits generalisation of findings owing to the small sample size, which might also reduce its power to detect significance and increase type 1 errors. More studies of a prospective nature, with larger sample sizes and that also consider additional variables, such as culture, attitude and beliefs, are required to provide in-depth understanding.
Conclusion
This study has demonstrated the different types of coping strategies that nurses working in high-pressure environments employ and looked at the poor health outcomes linked to using negative coping styles. Future stress management interventions should target staff employing negative coping strategies—in this case, nurses working in medical intensive care and staff who are married—to promote positive coping strategies and enhance supportive working environments to enable nurses to provide better quality care to patients.