Association of coping style and psychological well-being in hospital nurses

Abstract

Introduction: Nursing jobs are among the occupations experiencing high levels of stress. Level of psychological well-being and coping style with stressful situations among nurses has large impact on their job performance. Limited information exists about the relationship between coping styles and psychological well-being among nurses, so the present study examined the way of coping and the level of psychological well-being as well as their relationships among nurses. Methods: In this correlational study, 100 nurses from Shahid Sadoughi University of Medical Sciences were selected by multi-stage random sampling in 2012. Lazarus and Folkman's coping styles and Ryff's psychological well-being Questionnaires were completed by self-report method. Collected data were entered software SPSS ver. 13 and then analyzed using Pearson correlation test. Results: The results showed EFCSwere more used  but PFCSstyle was less used with a little difference by mean (SD) of  87.91 (10.76) vs. 73.12 (12.15). Between EFCSand some psychological well-being dimensions such as purpose in life (P=0.01, r= -0.28) and personal development (P=0.03, r=-0.024), a significant negative association and between PFCSstyle and purpose in life, a significant positive relationship was found (P=0.006, r=0.31). Conclusion: Considering that PFCSstyle is more effective in solving problems and job stress, as well as, the increased use of EFCSis associated with adverse health consequences, improvement of nurses' coping strategies to cope better with stressful events by skill training and promotion of nurses' psychological well-being level is recommended.

Introduction

Job stress has a great impact on various aspects of life of working people. Coping strategies and stress response is more important than stress itself. Whatever better ways to deal with stress is applied, stress will be less damaging.¹ Different styles of coping with stress are defined such as problem- focused style (PFCS) and emotional-focused style (EFCS).² PFCS includes problem solving to get rid of stress like managing the problem that causing stress and EFCS, including the use of emotional responses during stressful situations such as mental rumination or blaming others.³ PFCS is more effective in solving the problem than EFCS. In addition, excessive use of EFCS is related to negative consequences such as poor compatibility with trauma, depression and anxiety.⁴ Coping with the stress of life can influence on mental health and well-being. Psychological well-being focuses on the positive and negative emotions and increase pleasure and decreases negative moods.⁵ It depends on several factors such as individual (self-esteem, optimism), demographic character- istics (gender, age, education, and marital status), economic status (physical health, social interaction).⁶

Psychological well-being consists of six dimensions, including autonomy (independence and self-determination), environmental mastery (the ability to manage one's life), personal growth (being open to new experiences), purpose in life (believing that one's life is meaningful), self-acceptance (a positive attitude towards oneself and one's past life) and positive relations with others (high quality relationships).⁵

How individuals cope with stressful situations such as job stress, determines health and well-being of people in that situation. Efficient coping leads to good results such as happiness, personal development, life satisfaction and impacts on their job performance. Nursing jobs are among the occupations that nurses experienced high levels of stress.⁷ In a study it was found that 27% of hospital nurses experienced symptoms of stress and 38% reported having consultation with physician in the past 6 months.⁸

Nurses are a main group of health service providers, but they have to face physical and psychological problems such as permanent confrontation with the patient, having responsibility for human health, being exposed to health hazards, performing clinical processes, dealing with critically ill patients, the lack of adequate equipment, dealing with emergencies and unexpected situations, a lot of noise in the workplace and shift work. They all are stressful factors in nursing job that can reduce the quality of patient care, reduce sound and timely decisions, skills, ability of the staff and cause job dissatisfaction, feelings of inadequacy, depression, antipathy, exhaustion from work, absenteeism, delays at work and thus threaten the lives of patients and the quality of provided services.⁹

In a study of job stress ad coping strategies among nurses, it was found that mean score of stress was high and EFCS was more used among nurses than PFCS¹⁰; but, in another study nurses used mainly PFCS.¹

The issues of psychological well-being and coping among nurses are of major concern to all managers in the field of health care and have large impact on the nurses' performance. The information in these fields would be useful for promotion of nurses' mental health and thereby improve the quality of patient care. According to our research, very few studies have been conducted on the relationship between coping style and psychological well-being of nurses, so this study investigated coping styles of nurses' to stress and their relationship to nurses' psychological well-being in hospitals related to Shahid Sadoughi university of medical sciences.

Materials and Methods

This correlational study was included nurses from three hospitals of Yazd Shahid Sadoughi university of medical sciences. Subjects who had at least three years' work experience and at least bachelor's degree in nursing were included in the study. Multi-stage random sampling was used for selection of these subjects. Firstly, three hospitals from Shahid Sadoughi University hospitals were selected randomly. Then, in proportion to the total number of nurses in each hospital and based on the previous study¹¹ Krejcie and Morgan's formula,¹² 100 subjects who had inclusion criteria were selected randomly from a list of nurses in the nursing office.

Iranian version of Lazarus and Folkman's coping styles and Ryff's psychological well-being Questionnaires were used. Demographic information such as gender and age were also evaluated.

Coping Styles Questionnaire (CSQ): This questionnaire contained 66 questions and was produced by Lazarus and Folkman in 1985 and measures two broadly coping styles, i.e. PFCS and EFCS.¹³

Each of these coping styles is measured through 4 subscales. So that emotion-focused coping strategy includes four subscales: 1 - confrontation coping (questions number: 6, 7, 17, 28, 34, 46), 2 - distancing (questions number: 12, 13, 15, 21, 41, 44), 3 - self-controlling (questions number: 10, 14, 35, 43, 54, 62, 63), 4 - escape avoidance (questions number: 47, 50, 58, 59, 11, 16, 33, 40) and Problem-based strategies include 1 - seeking social support (questions number: 8, 18, 22, 31, 42, 45), 2 - accepting responsibility (questions number: 9, 25, 29, 51), 3 - plan full problem solving (questions number: 1, 26, 39, 48 , 49, 52), 4 - positive reappraisal (questions number: 20, 23, 30, 36, 38, 56, 60). The 16 remaining questions are for checking the correctness of response (Polygraph).¹⁴ Responses rate statements on a likert scale of 0 to 3, with 0 indicating “I have not used “and 3 indicating “I have used a lot“. Sixteen questions in the questionnaire are not scored; Global score range from 0 to 150. In this questionnaire, the coefficient of internal consistency for each of coping strategies has been reported 0.66 to 0.79.¹³ In Padyab's study, face and content validity of Iranian version of Lazarus and Folkman's questionnaire were acceptable. Testing reliability of questionnaire for the internal consistency method using cronbach's coefficient alpha yielded cronbach's alpha of 0.88.¹⁴

Ryff's Psychological Well-Being Scale (RSPWB): This questionnaire consisted of 84 questions and 6 dimensions of psychological well-being: autonomy, environmental mastery, and personal growth, purpose in life, self-acceptance and positive relations with others. Each dimension contains 14 questions. Responses were on a 6 degree Likert scale (1= strong disagreement, 6= strong agreement). Responses are totaled for each of the six dimensions. For each dimension, a high score indicates that the respondent has a mastery of that area in his or her life. Conversely, a low score shows that the respondent struggles to feel comfortable with that particular concept. Global score range from 84 to 504. Cronbach's alpha of psychological Well-Being Scale has been 0.94. Higher scores indicate better psychological well-being.¹⁵ In a study was by Zanjani Tabasi et al., reliability coefficient for this questionnaire using internal consistency method was 0.94.¹⁶

After presenting the necessary explanations about the study objectives and how to complete the questionnaire to study population, questionnaires were given to each of them. Entry into the study was voluntary and informed written consent was obtained from each participant. We assured subjects that their information will remain confidential. Collected data were entered into the SPSS ver. 13. The correlation between coping styles and psychological well-being was examined by Pearson correlation test. Paired-t-test was used to compare mean of the two coping styles. P≤ 0.05 was considered significant level.

Results

Eighty-eight nurses responded to our questionnaire (response rate= 88%). In this study, 72% of the subjects were female and 28% were male. Mean (SD) of nurses' age was 38.5 (8.53) years.

EFCS was more used by nurses than PFCS. The lowest and highest scores among psychological well-being dimensions were belonged to autonomy and positive relationships respectively (Table 1).

Table 1. Mean scores and Confidence Interval of 95% for mean of coping styles and psychological well-being of nurses (n=88).

Variable	Mean (SD)	95% CI
Psychological well-being subscales
purpose in life	53.29 (4.95)	49.36, 56.24
autonomy	47.07 (4.49)	43.98, 49.76
positive relationships	56.61 (6.14)	51.87, 60.23
environmental mastery	53.77 (6.21)	48.96, 57.58
personal growth	54.66 (8.19)	49.74, 60.35
self-acceptance	52.16 (4.96)	49.26, 55.21
Psychological well-being
total score	52.93 (6.03)	48.59, 54.96
Coping style
problem-focused	73.12 (12.15)	64.57, 83.93
emotion-focused	87.91 (10.76)	72.65, 96.12

The result of this study shows a negative relationship between purpose in life and EFCS (r = -0.28, P = 0.01). This means that as much the purpose in life is reduced, the use of EFCS is higher, and vice versa. There was a significant negative correlation between EFCS and personal growth (r = -0.24, P = 0.03). The results show that there was a significant positive relationship between PFCS and purpose in life (r = 0.31, P =0.006) ( Table 2).

Table 2. Correlation of coping styles with psychological well-being of nurses. (n=88).

Psychological well-being	Emotion-focused coping style		Problem-focused coping style
	r	p	r	p
purpose in life	- 0.28	0.01	0.31	0.006
autonomy	- 0.11	0.3	- 0.04	0.67
positive relationships	0.07	0.49	- 0.05	0.63
environmental mastery	- 0.20	0.06	- 0.01	0.91
personal growth	- 0.24	0.03	- 0.15	0.17
self-acceptance	0.16	0.15	0.20	0.07
Psychological well-being	- 0.21	0.06	- 0.10	0.36

Discussion

The results of this study showed EFCS was more commonly used than PFCS. This study indicates a significant negative relationship between EFCS and purpose in life. EFCS and personal growth are negatively related. More over there is a significant positive relationship between PFCS and purpose in life.

There are limited studies in the field of coping strategies in nursing; like our study, in a study of job stress ad coping strategies among nurses who work in admission and emergency department, EFCS was more used among nurses than PFCS by mean and standard deviation of 59.4 ( 16.1) vs. 18.9 (16.1)¹⁰ ; but in Akouchekian's study that was conducted on 47 psychiatric nurses, psychiatric nurses use problem-oriented technique was used more than emotion-oriented technique.¹ In Moszcynski's study in 2003, nurses of trauma department used problem-focused and EFCS.¹⁷ In another study, most nurses used coping styles such as planning, problem solving, avoidance and wishful thinking to reduce stress at work¹⁸, however, in a study was observed that about 40% of the nursing students were occasionally used problem-oriented coping styles.¹⁹ Although there is no superiority to the use of emotion-focused or PFCS for solving life problems, the use of PFCS is accompanied with a greater sense of self-control and self-efficacy.²⁰ PFCS is the most useful and effective coping responses, but some researchers believe that men are generally used PFCS as an effective coping style and women generally tend to focus on emotions and emotional discharge and try to use strategies that control and reduce their emotional responses.^21,22 One of the major causes that EFCS was more used in this study may be that female nurses consisted the main proportion the participants (72% vs. 28%).

The result of the present study was similar to other studies that indicate there is a significant negative relationship between EFCS and purpose in life.⁴ EFCS is cognitive and behavioral efforts to master the subject, endurance, and reduce and minimize environmental needs or demands. In fact an individual uses EFCS to reduce negative and harmful emotion quickly. This strategy applies for stressful emotional situations, but in long term cannot be considered as an effective strategy.⁴People who are not purposefully in life, believe that their lives have no value and meaning, that's why they do not make great efforts to solve their problem. If goes wrong for them, they only use the excitement. Because of this, negative relationship between purpose in life and EFCS, seems reasonable.⁴

The results indicate that the EFCS and personal growth are negatively related; it means whatever personal growth increase, use of EFCS will reduce. Personal growth is continuing capabilities and abilities of individuals. When personal growth is high in individuals, they tend to increase their forces and talents to solve the problems.⁵ Therefore, it is expected that a person who has high personal growth, to use strategies such as problem solving and positive appraisal, and to attempt solving the problem, rather than reducing the difficulty. The results of this study are similar to other studies assessed health problems and coping strategies of individuals; and also shown that passive coping should be decreased for improving health.^11,23

In line with Feldman's study²⁴ the current study showed that there is a significant positive relationship between PFCS and purpose in life. This means that whatever use of PFCS increased, purpose in life increases. PFCS strategy is considered as adaptive strategy. In PFCS strategy, in order to reduce the effects of stress, a person directs the activities, and believes that the factors causing stress can be controlled; that is why people who are purposefully in life, looking for solving the problem. The results of Feldman's research showed that people, who use PFCS, can be better coped with the disease and show more improvement²⁴; Therefore, by development of personal growth and purpose in life among nurses, their coping strategies will promote.

Different styles of coping are skills that will affected by teaching and experience and can also be changed; Therefore, for modifying coping styles of nurses and consequently increase in mental health, the following suggestions are recommended; Formulate training programs and skills to deal with stressful events and the use of modern teaching aids, and providing the necessary fields for nurses to experience coping styles in a variety of situations, including analyzing stressful situations, play a role in experimental and clinical settings, training skills to effectively deal with daily work problems, practice skills that improve confidence and create conditions for the development of mental health of nurses as well as the training those skills to nursing students. Also identification of the workplace stressful factors is essential to take any appropriate action; therefore, stress management programs should be based on information about conditions and background factors and organizational stress. Results of several studies suggest that whatever social support be greater in nurses, using effective methods and techniques of coping with stress increase. Thus, taking into account that increase nurses' social support, associate with increasing ability to cope with stress, in a very sensitive and stressful occupations such as nursing, attention to the increasing social support by improving nursing management, administrative communication, and better social security may be useful for nurses.^1,25

Descriptive and correlational nature of this study is one of the limitations and therefore causal relationship cannot be deducted from these findings. Also, we did not assess the effect of socioeconomic status, number of children and religious backgrounds. More over, this study was limited to a group of nurses of Shahid Sadoughi university of medical sciences. By including demographic factors in future studies, the potential interactive effects of these factors may be determined.

Conclusion

In this study EFCS were more used but PFCS was less used. The findings of the present study indicate there is a significant negative relationship between EFCS and purpose in life. EFCS and personal growth are negatively related as well as there was a significant positive relationship between PFCS and purpose in life. Considering that PFCS is more effective in solving problems and job stress, and because increased use of EFCS is associated with adverse health consequences, we can improve nurses' coping strategies for stressful events, as well as, promotion of personal development and purpose in life.

Acknowledgement

We would like to thank nurses who made this study possible. The authors are also grateful to the research deputy of Shahid Sadoughi University of Medical Sciences for their financial support. Thanks to Dr. Ahmad Shojaaddiny-Ardekani for his cooperation.

Ethical issues

Entry into the study was voluntary and we assured study population that their information will remain confidential. The study was approved by the ethics committee of research of Shahid Sadoughi University of Medical Sciences.

Conflict of Interest

The authors declare that they have no competing interests.