Stress, coping and mental well-being in hospital nurses

STRESS MEDICINE, VOL. 8: 9 1-98 (1 992)

STRESS IN THE COMMUNITY

STRESS, COPING AND MENTAL WELL-BEING IN HOSPITAL NURSES

PATRICK TYLER*, PhD AND DELIA CUSHWAY, MSc, C. Clin.Psycho1. School of Psychology, University of Birmingham, Birmingham B15 2TT, UK

SUMMARY

Previous studies on stress in nurses have demonstrated positive but low correlations between stress measures and indicators of mental distress. The present study was designed to investigate further this relationship and the extent to which it is attenuated by coping strategies. Questionnaires on sources of stress, coping strategies and health outcomes were administered to 72 nurses in one large general hospital. The results indicated that staff conflicts and workload stress increased with grade of nurse and that workload stress and organizational support and involvement differed between wards, whereas there were no differences between groups in coping strategies or mental health outcomes. Negative mental health outcomes were mainly predicted by nurses’ perceptions of excessive workload and their adoption of avoidance coping strategies. The main recommendations arising from the study, therefore, were that stress-related disorders in nurses could be alleviated if sufficient resources were allocated so that excessive workloads were reduced, and if stress management programmes could be initiated so that appropriate coping strategies would be adopted.

KEY woms-Stress, coping, well-being, nurses.

Nursing is widely assumed to be a stressful occupa- tion, although a number of authors have suggested that this assumption has not been properly docu- mented.’,2 There is substantial evidence for higher rates of mortality, including deaths from suicide and stress-related d i ~ e a s e , ~ burnout and absentee- ism,4 psychiatric admissions and physical illness in nurses. A number of studies have now attempted to relate outcome measures such as these to spe- cially designed measures of stress in nursing. For example, Harris’ has found that scores on the Nurse Stress Index’ are significantly correlated with the Crown-Crisp Experiential Index (CCEI), a puta- tive measure of common symptoms of psychoneur- otic disorders. The highest correlation reported was 0.41 when the hysteria scale was excluded from the CCEI. Tyler et d6 reported a correlation of 0.29 between the Nursing Stress score and the total score on the General Health Questionnaire (GHQ),9 another measure of mental health outcomes.

*For correspondence. Tel: (021) 414 4924.

Correlations such as those reported above provide some circumstantial evidence, but do not demonstrate conclusively, that occupational stress causes ill-health. There is some suggestion that people who are higher on trait anxiety or neuroti- cism score higher both on stress scales and on mental health outcome scales such as the CCEI and the GHQ. Thus preexisting individual differences in personality could underlie the relationship between perceived stress and mental health. More- over, the apparently simple relationship really raises other questions. What, for example, are the main sources of stress and how are they individually related to outcome measures? What strategies are used for coping with stress and how successful are they?

If environmental stress is the most important factor predisposing to psychiatric disorder and psychosomatic illness, it might be expected that the correlations would be higher than those reported provided that the scales were satisfactorily reliable and valid. When faced with stress, however, every- one has certain coping strategies which they charac-

0748-8386/92/02009 1-08$05.00 0 1992 by John Wiley & Sons, Ltd.

92 P. TYLER AND D. CUSHWAY

teristically use and some of which are more successful than others. In general, active coping strategies such as seeking out help, reorganizing one’s work or engaging in exercise are found to be more successful in alleviating the effects of stress than the passive or avoidance coping strategies such as ignoring the situation. There is very little work on the combined effects of stress and coping on health outcome.

The present study was therefore designed to ana- lyse the relationship between stress, coping and health outcome in a group of nurses.

METHOD

Subjects

All qualified nurses in the Renal Directorate of a large general hospital in the English Midlands were invited to take part in the study. From 120 nurses who were circulated and requested to fill in a questionnaire, we received 72 usable returns. Thus the response rate was 60 per cent. Because the responses were anonymous it was not possible to follow up non-responders.

Questionnaire A questionnaire package was made up, consist-

ing of six component questionnaires, always pre- sented in the same order. The components were:

Nursing Stress Scale (NSS).8 Each of 34 items is answered on a four-point frequency response scale, scored 0-3 (‘never’, ‘occasionally’, ‘frequently’, ‘very frequently’). There are seven subscales of the NSS (see Table 1); these represent the major sources of stress found in previous studies on nurses, mainly in the USA.

Nurse Stress Index (NSI).’ Each of 30 items is answered on a five-point intensity response scale, scored from 1 (‘causes me no pressure’) to 5 (‘causes me extreme pressure’). There are six subscales of the NSI; these represent the main sources of stress found in a recent British study of nurse managers.” We have not previously used this index, but it was included because of its concentration on workload- related stress sources, found to be the main source of stress in previous studies.

Job satisfaction (NSI). Five items are measured on a five-point Likert scale from 1 (strongly dis- agree) to 5 (strongly agree); the higher the score, the higher the level of job satisfaction.

Table I-Means for all respondents of item scores for each subscale in the questionnaire

Mean SD

NSS subscale Workload 1.50 0.53 Inadequate preparation 1.23 0.64 Death and dying 1.20 0.49 Uncertainty over treatment 1.16 0.52 Conflict with doctors 0.97 0.48 Conflict with other nurses 0.90 0.54 Lack of social support 0.85 0.66

NSI subscule DPR Dealing with patients and

relatives 2.48 0.84 MW2 Managing the workload 2 2.42 0.82 OSI Organizational support and

involvement 2.38 0.85 MW 1 Managing the workload 1 2.31 0.76 CCR Confidence and competence in

role 2.10 0.54 HWC Home/work conflict 1.71 0.57 JS Job satisfaction 3.06 0.08

GHQsubscale Social dysfunction Somatic symptoms Anxiety and insomnia Severe depression

1.02 0.35 0.80 0.52 0.72 0.47 0.20 0.36

Coping scales Active cognitive coping 1.32 0.51 Active behavioural coping 1.27 0.49 Avoidance coping 0.66 0.42

General Health Questionnaire (GHQ28).9 Each of 28 items is answered on a four-point response scale of relative ill-health (feeling worse than usual), ranging from 0 to 3 . There are four subscales of the GHQ (see Table l), and in addition a ‘caseness’ score is obtained for each person; a score of 5 or more overall is taken as an indication of poor mental health (there is found to be 87 per cent con- currence with psychiatric assessment, according to the GHQ manual).

Coping questionnaire.” Each of 33 items on the coping questionnaire is answered on a four-point scale, scored from 0 to 3 (‘no’, ‘yes, once or twice’, ‘yes, sometimes’, and ‘yes, fairly often’). There are three subscales representing different response strategies (active cognitive coping, active behavioural coping and avoidance coping).

Stress management. A short questionnaire was devised to discover whether respondents would be

STRESS AND NURSES 93

interested in participating in a stress management programme.

Procedure With the cooperation of the hospital manage-

ment, the questionnaire packages were addressed personally to each qualified nurse working in one directorate of a large general hospital. They were accompanied by a letter explaining the purposes of the study and requesting cooperation, and an envelope addressed to the authors. The questionnaires were completed anonymously and returned to a postbox positioned in each ward area.

RESULTS

The mean scores for each factor or subscale on the questionnaire are shown in Table 1. As has previously been found with nurses, workload and dealing with death and dying patients and their relatives were the largest sources of perceived stress, although on average no source was exper- ienced very frequently or very intensely. On the GHQ the ‘caseness’ mean was 3.49. Of the 72 nurses in the study, 21 (29 per cent) had scores of 5 or more.

Relationship of stress measures to grade of nurse

greater as nurse grade increased. Several measures of stress became significantly

On the NSS these were: Conflict with doctors (F,,59 = 1 2 . 3 8 , ~ < 0.001) Conflict with other nurses (Fi,6,, = 9 . 2 7 , ~ < 0.01) Workload (F,,6,, = 4 . 7 7 , ~ < 0.01)

On the NSI they were: Managing the workload 1 (Fi,6i = 19.46,

Managing the workload 2 (Fi,6i = 6 . 7 4 , ~ < 0.05) Organizational support and involvement

The total NSS and NSI scores were also linearly related to grade of nurse (NSS: Fi,57 = 7.16,

None of the coping measures or the outcome measures (GHQ) showed a similar systematic relationship with grade.

p < 0.001)

(F,,59 = 9.39,p < 0.01)

p < 0.01; NSI: Fi,5, =6.36,p < 0.05).

Relationship of stress measures to ward area

areas in the following stress sources: There were significant differences between ward

NSS: Workload (p < 0.05) Uncertainty over treatment (p < 0.01)

NSI: Managing the workload 1 (p < 0.05) Managing the workload 2 (p < 0.05)

Although total stress measures on the NSS and NSI did not differ between wards, a single item asking how stressed nurses felt did show a difference (p < 0.05). The general finding was that measures of stress were lower on the intensive care unit (ICU) and renal ward, and higher on the renal dia- lysis unit and urology ward.

There were no differences between ward areas on the GHQ or coping measures.

Correlations among stress measures Almost all the stress scores were correlated signi-

ficantly with all others, so there is undoubtedly an underlying general stress factor. Overall the NSS total score was correlated with the NSI total 0.76 (p < 0.001). Looking at NSS scales which most closely resembled NSI scales: death and dying correlated most strongly with dealing with patients and relatives: r = 0.64; conflict with doctors correlated most highly, but only moderately, with both managing the workload, 1 and 2 scales: r = 0.52 and r = 0.55; inadequate preparation correlated with dealing with patients and relatives: r = 0.59; lack of social support was only weakly related to NSI measures - the highest r was with organizational support and involvement: r = 0.50; conflict with other nurses was related to organizational support and involvement: r = 0.65; workload showed the highest correlations with both the managing the workload, 1 and 2 scales r = 0.70 and r = 0.76; uncertainty over treatment also correlated best with the two managing the workload, 1 and 2 scales: r = 0.61.

It is noticeable that there was no strong correlation with either NSI scale home/work conflict or confidence and competence in role among the NSS scales, and that the two managing the workload scales correlated fairly well with all the NSS scales but were not clearly differentiated.

Stress and social support

All nurses were asked if they had a friend, a partner or a member of the family to whom they could talk about problems at work. GHQ scores were generally lower (but not significantly so) if they had somebody to talk to - thus giving a hint that social support is a factor in preventing a nega-


tive outcome for work-related stress. An odd result was that anxiety/insomnia was higher in single/ unpartnered people if they could talk to a partner, but higher in rnarried/partnered people if they could not (p < 0.05). The overall GHQ showed the same trendp = 0,053).

Active behavioural coping strategies were significantly more frequently used if nurses could talk over their feelings with a friend or a partner. Avoi- dance coping strategies were more likely if nurses did not have a partner.

Coping strategies and stress sources

For each of the three coping strategies, a stepwise multiple regression was used to find which of the sources of stress best predicted use of that strategy.

Active cognitive coping was predicted by workload (p = 0 . 3 4 , ~ < 0.01); active behavioural coping was predicted by confidence and competence in role (p = 0.29, p < 0.05); avoidance coping was predicted by conflict with doctors (p = 0 . 4 0 , ~ < 0.001) and conflict with other nurses (p = 0.36, p < 0.01).

Perhaps a way of interpreting these results is to suggest that the coping strategy adopted in each case is ineffective in reducing the corresponding source of stress.

Outcome measures (GHQ), stress sources and coping strategies

For the GHQ caseness measure and each of the GHQ subscales a stepwise multiple regression was calculated to determine which stress scale and coping strategy best predicted that outcome.

GHQ was predicted by home/work conflict (p = 0.33) and managing the workload 1 (p = 0.32); anxietyhsomnia was predicted by avoidance coping (p = 0.32); social dysfunction was predicted by avoidance coping (p = 0.36); severe depression was predicted by managing the workload 2 (S = 0.37) and inversely by active behavioural coping

It appears that high workload combined with use of an avoidance coping strategy (or not using an active behavioural one) are negative indicators for good mental health.

(p = -0.29).

Diferences between nurses above and below the GHQ threshold

It may be more appropriate to treat the GHQ caseness score as a threshold measure rather than

as a continuous variable. Therefore, in order to look in more detail at the factors which best predict an above-threshold GHQ, all nurses were divided into two groups - those falling above and below the threshold of 5. An analysis of variance was carried out between these groups on the stress and coping strategy scores.

None of the NSS scales significantly differentiated the two groups (workload and death and dying were almost significant). On the NSI, managing the workload 1 and 2 and confidence and competence in role showed significant differences at p < 0.01, and differences in organizational support and involvement were significant at p c 0.05. In all cases the above-threshold group also reported experiencing higher stress.

The only coping measure which differentiated the groups was avoidance coping (p < 0.05). The above-threshold nurses used avoidance coping techniques significantly more frequently.

A discriminant analysis was carried out to determine whether the individual items on the two stress questionnaires could be used to distinguish between nurses who were above or below the GHQ threshold. In discriminant analysis a weighted combination of the predictor variables is obtained and this serves as a basis for assigning cases to groups. The weights were estimated using the SPSS/PC + ‘discriminant’ function, so that they resulted in the best separation between the groups. By combining the two stress questionnaires it was found possible to obtain 100 per cent separation between the above- and below-threshold nurses. Table 2 shows the weights, or standardized canonical discriminant function coefficients, associated with the items which contributed to the discriminant function. To interpret the table it is desirable to look at the general pattern of positive and negative contributors, rather than individual items whose weights may depend on the presence of other items in the equation. It can be seen that items which are most strongly positively related to mental strain are those involving decision-making, feelings of lack of infor- mation or involvement and anxieties about competence or expertise. Items that are negatively related to strain tend to reflect much more concrete concerns, for example time pressures, conflicts with senior staff and breakdown of equipment.

A similar discriminant analysis was carried out to determine whether individual items on the coping questionnaire could distinguish between nurses who were above or below the GHQ ‘caseness’ threshold. This time discrimination was not as good,


Table 2-Prediction of GHQ ‘caseness’ by NSS and NSI items

Table 3-Prediction of GHQ ‘caseness’ by coping items

Coping itemspositiveIy related to a high GHQ score Stress items positively related to a high GHQ score (The weighting of each item in the discriminant function equation is shown in the first column)

o.84 Tried to reduce tension by drinking 0.83 Kept my feelings to myself 0.75 Talked with spouse or other relative about the

2.65 NS12

1.73 NSS2l 1.32 NSS34

1.22 NSS13

1.21 NSI6

1.12 NSSlO

0.98 NSS6

0.94 NSI9

0.84 NSI29 0.84 NSS29

0.83 NSI19

0.77 NSI3

0.61 NSI4

My nursing and administrative role conflict Watching a patient suffer Not enough staff to adequately cover the unit Doctor not being present when a patient dies Lack of specialized training for present task Fear of making a mistake in treating a patient Listening or talking to a patient about approach death I only get feedback when my performance is unsatisfactory Job vs home demands Difficulty in working with a particular nurse or nurses on ward The demands of others for my time at work are in conflict Management misunderstands the real needs of my department Dealing with relatives

Stress items negatively related to a high GHQ score -2.13 NSS28 Not enough time to complete all my

- 1.53 NSS5 Conflict with a senior nurse - 1.42 NSS 1 Breakdown of equipment - 1.27 NSS30 Not enough time to provide emotional

- 1.21 NSS2 Criticism by a doctor - 1.14 NSI30 Bringing about change in staff/

organization - 1.08 NS17 I spend time fighting fires rather than

working to a plan - 1.04 NS126 Deciding priorities -0.85 NSI5 I need to absent myself from work to

-0.85 NSS9 Conflict with a doctor -0.83 NSI22 Bereavement counselling -0.72 NSI8 Management expects me to interrupt

-0.30 NSII 8 Tasks outside of my competence

nursing tasks

support for patient

cope with domestic problems

work for new priorities

although considerable separation was achieved. The items which contributed to the discriminant function are shown in Table 3, together with their weights. One is tempted to identify the high, positively weighted items with rather inefficient coping

problem 0.72 Used individuaVgroup counselling 0.59 Tried not to act too hastily or follow my first

hunch 0.59 Refused to believe that it had happened 0.40 Went over the situation in my mind to try to

understand it 0.33 I knew what had to be done and tried harder

to make things work 0.32 Prayed for guidance andlor strength

Coping -0.83

-0.55 -0.50 -0.45 -0.43

-0.38

-0.32 -0.31 -0.27

items negatively related to a high GHQ score Talked to other nursing colleagues about the problem Got away from things for a while Took things a day at a time, one step at a time Used relaxation techniques Bargained or compromised to get something from the situation Considered several alternatives for handling the problem Avoided being with people in general Accepted it; nothing could be done Took it out on other people when I felt angry or depressed

-0.24 Didn’t worry about it. Figured everything would work out

strategies, because they are more often used by nurses who are above the caseness threshold, while the negatively weighted items might be viewed as more effective strategies, which tend to place their users below the threshold. However, it may be seen that there are some recommended strategies in the first, positively weighted group and some non- recommended strategies in the second, negatively weighted group. Caution should be used in interpreting the results of these analyses.

Stress management Most nurses indicated that they would be inter-

ested in participating in stress management ses- sions: 75 per cent would be interested in participating in the development of a stress management programme for nurses working on their ward area; 79 per cent would like to attend a stress management programme which comprises a short training course specifically designed to help nurses


on their ward area; 61 per cent would like to attend support group meetings for nurses on their ward area; 60 per cent would attend peer support infor- mal gatherings; 65 per cent would like one-to-one counselling to be available as and when the need arises in their work; 88 per cent would like to attend workshops in work-related topics, for example dealing with relatives, bereavement, etc.

The last of these options is the one favoured by most people when asked which they found most attractive.

DISCUSSION

The finding that there are differences in stress profiles between wards and grades, but no difference in overall amount of stress or health outcome, sup- ports the previous work of Hipwell et al.” and of Tyler et a1.,6 who showed that differences in stress profiles between the public and private sectors were not reflected in different health outcomes. As in the previous studies, it is clear that the largest source of stress on the NSS is workload closely followed by inadequate preparation and death and dying. On the NSI the latter two sources are combined in the scale ‘dealing with patients and their relatives’, and this proved to be the largest source, followed by the two workload-related scales, and organizational support and involvement.

These findings, taken in conjunction with those from other studies, do suggest that there are two main factors that concern nurses and make nursing a highly stressful profession. One factor is located in the physical environment and structure of the work, and results from the combination of insuf- ficient staffing, conflicting time pressures and the perception of a lack of equipment and resources, which give rise to a feeling of having a heavy workload. A second factor is intrinsic to nursing, that is, the problem of dealing with suffering or dying patients and their relatives. An important clue to the possible origin of this stress source is the relati- vely high mean score of the inadequate preparation scale and the correlation between this scale and the dealing with patients and relatives scale. Nurses who were stressed by dealing with suffering and dying patients apparently felt that they lacked some of the skills required in this area and indicated that they could benefit from further specialized training in the psychological skills required for nursing. The

importance of a psychological component is indicated in two of the items which contribute to the inadequate preparation scale: feeling inadequately prepared to help with the emotional needs of a patient’s family and feeling inadequately prepared to help with the emotional needs of the patient. Other commonly found sources of stress in nursing, especially conflicts among staff and uncertainties over treatment, were not as prominent in this study; nevertheless they cannot be ignored as potential contributors to stress-related ill-health in those nurses who were affected.

There is not yet general agreement in psychology about the appropriate classification of the coping strategies which people use to deal with stressful situations, and several models have been proposed. In view of this lack of consensus, there seemed little point in adopting a complex model; we therefore used the Moos et d.” questionnaire, which produced three scores: those for active cognitive, active behavioural and avoidance coping. These corres- pond fairly well with the models used by others such as Olsson et and Bailey and Clark.14 The multiple regression analysis showed that the active cognitive coping strategy seemed to be used more by those who reported higher workload-related stress; the active behavioural strategy was used more by those who reported higher stress caused by a lack of confidence and competence in their role; and the avoidance coping strategy was most closely associated with stress caused by conflicts with other staff. There are two ways to interpret this result. One is that there is common agreement among nurses about the best way to deal with different sorts of stress. If, for example, you are affected by high workload, you should plan your time better (cognitive); if you suffer from a lack of confidence in your abilities, you should talk to a friend or a professional person (behavioural); if you are having problems with a senior sister or a doctor, there is not much to be done, so ignore the situation (avoidance). An alternative interpretation, by con- trast, is that these are the strategies that do not work for coping with the specific associated stress sources. After all, the nurses who adopt them are the ones reporting higher stress than those who do not. Perhaps spending one’s time thinking about work does not get it done, and complaining to friends does not help improve one’s confidence and competence: thus, an inappropriate coping strategy can contribute to the stress felt.

It has often been emphasized that stress does not necessarily result in-ill health and can even be


beneficial. So the most important questions from this study revolve around the relationship of the stress sources and coping strategies to our main outcome measure, the General Health Question- naire. The results of the multiple regression analysis were a little disappointing in that only one of the outcome measures, namely severe depression, was affected both by a stress source (managing the workload 2) and by a coping strategy (the inverse of active behavioural coping). The latter relationship is unsurprising as depression often manifests itself as a lack of active behavioural coping. For the other measures, anxiety and insomnia and social dysfunction, use of avoidance coping was the most important contributor, regardless of the source of stress; and for the overall GHQ score, workload again appears as a significant predictor of a negative outcome for stress, this time supple- mented by a contribution from home/work conflict. The discriminant analysis on the GHQ caseness measure supported the view that negative health outcomes were mainly produced by a combination of workload-related stress and the use of an avoidance coping strategy. Tyler et a1.,6 who did not include a coping questionnaire in their study, also found that workload was the main predictor of negative mental health outcomes in nurses.

The discriminant analysis of individual stress and coping items also provided a more fine-grained analysis of the factors influencing health and well- being in nurses. Interpretation of this analysis is not easy, because items which received a high positive weight in predicting caseness were often quite similar to those which received a high negative weight. For example, the most positively weighted item, my nursing and administrative roles conflict, was fairly similar to the most negatively weighted, not enough time to complete all my nursing tasks. However, in this example and in others there is a more concrete feel to the negatively weighted items, while the positively weighted ones refer to more general problems. If a nurse is more inclined than average to endorse fairly general stress items, but less likely than average to be specific about the complaints, it seems that he/she is more at risk for poor mental health. The analysis of individual coping items was also interesting. Among the positively weighted (therefore maladaptive response) items were, as expected, several examples of avoidance coping: trying to reduce tension by drinking more, keeping one's feelings to oneself, refusal to believe that it had happened. Among the negatively weighted (more adaptive response) items were

several positive coping techniques: talking to colleagues, using relaxation techniques, taking things as they come, compromising. However, there were also some more unexpected associations: talking with spouse or other relative and using counselling had high positive weights, while getting away from things and avoidance of people were negatively weighted. As previously stated, the weighting of individual items should be viewed with caution; for example, counselling may be highly effective but only used by those who are most in need of it, and therefore most stressed.

In conclusion, this study has found rather high rates of potential mental distress in a group of nurses which was selected to be fairly representative of their profession. This is especially the case given that our sample, like the profession as a whole, largely consisted of young unmarried women (nor- mally a healthy population), and that nursing as a profession is known to attract people who are more emotionally stable and more extraverted than the general p~pula t ion . '~ Even if our sample is biased by the possibility that people are less likely to return a questionnaire if they are satisfied (they are also less likely to return one if they are very depressed), hospital managements must be con- cerned by the substantial numbers who are suc- cumbing to the effects of occupational stress and are unable to cope adequately.

The results of this study would suggest that two major recommendations can be made. First, although there are a number of sources of stress which affect nurses, there is one which clearly pre- dicts negative health outcomes; that is work over- load, caused largely by inadequate staffing and compounded recently by organizational changes. The remedy is clear enough perhaps to local managements, but the necessary decisions can probably only be made at much higher levels. Secondly, inappropriate avoidance coping techniques for dealing with stress have an important negative impact on health outcomes. Organizational support for stress management programmes should be provided on a regular basis in all regional health services. it seems likely that commercially available stress management schemes may not be very successful, however, unless they are properly tailored both to the needs of the individual and to the specific source of stress. We have seen that coping strategies which may be useful in one situation can be inappropriate in another. On-the-job training through workshops in specific psychological skills would also prove beneficial in alleviating certain types of stress.


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Stress, coping and mental well-being in hospital nurses