INTRODUCTION:

Workplace plays a vital role in the life of an employee. Poor workplace, that is deficient in essential work conditions, may fail to facilitate in achieving individual and organizational goals and result in situations causing stress. According to Wagner and Hollenbeck (2005), Occupational stress is an emotional state, which is unpleasant, and it arises from the perceived uncertainty that a person can’t meet demands of the job. Work stress can be viewed as any negative, stressful or difficult situation of hardship that is encountered in the occupational setting (Jackson, Firtko and Edenborough, 2007 ). Unsafe, unpleasant and demoralising work conditions can ruin the entire system in an organisation (Jain, 2015).

Prior research in work stress has made it clear, through the fundamental stress theory, that onset of disorders or distress is linked to stressful life events. Since 1930s stress has been in scientific literature and from late 1950s in the nursing literature.

Every workplace has the potential to cause stress, but work environment of nurses can be more stressful than the other health care professionals. There are manifold factors that have been associated with stress specific to the nursing profession. Staff shortage, patient’s death and suffering, workload, time pressures, demands of patients and relatives, exposure to infection etc. are few stressors to name which makes nurses vulnerable to workplace stress. Today workplace stress has become a long standing concern of health care industry. Workplace stress does not only cause personal damage to individuals but to organisation as well. Working in an environment wherein nurses deal with people alone is taxing enough, managing and providing care to patients with an vast range of illnesses, diseases, injuries with an even more enormous range of interventions needed to save or improve the quality of life of the patients. Considering reality and go on with what they need to do for their patients some stress coping strategies used by nurses help themselves to adapt and cope with the workplace stress. Nursing profession demands high level of responsibility in the care of the patients.

When an individual attempts to minimize the negative feelings arising from a negative event, this is considered as coping process (Lowe and Bennett, 2003). Coping is usually of two types, emotion- focused and problem- focused. The problem- focused coping is external, in which an individual attempts to manage or change the problem causing the stress. Whereas in emotion-focused activities, coping attempts to alleviate emotional distress, which may be internally directed (Lambert and Lambert, 2008). Research on nurses has indicated that workplace stress among nurses, leading nurses to quit job, resulting in mental and physical disorders, spoiling occupational relations, and affecting nursing care quality and job dissatisfaction.

OBJECTIVES OF THIS PAPER:

To identify and review studies related to workplace stress and coping strategies in Indian settings.

LITERATURE REVIEW:

The literature was reviewed to understand concepts of stress and coping and to identify significant findings derived by researchers who worked in the area of workplace stress and coping. With an objective to extend previous studies conducted in India on nursing workplace stress and coping strategies, literature based on conceptual understanding and empirical studies, etc., are referred. Sources of information include books, journals, dissertation, thesis and on line databases.

Best and Kahn (1992), states that review of literature helps the researcher in many ways. It assists to assess what is already known, what is still unknown and untested, justified the need for replication, throw some light in the feasibility of the study and problems that are encountered.

WORKPLACE STRESS AND COPING STUDIES IN INDIAN CONTEXT:

The following studies are reviewed from Indian context on workplace stress and coping among nurses.

Gupta and Adhikari (2008), measured role stress among 89 nurses working in civil hospital in West Bengal, India. Data was collected using Organizational Role Stress (ORS). Inter-role distance, role expectation conflict and role overload were found to be highest factors resulting in stress experience among nurses. The respondents in the study reported either highly stressed or moderately stressed and impact of stress was seen on psychological and physiological functioning of nurses.

Bhatia, Kishore, Anand and Jiloha (2010), conducted a cross- sectional study among 87 nurses working in two of the tertiary care teaching hospitals of Central Delhi. Occupational Stress Questionnaire was used which was modified to suit Indian settings and population and pre-tested. It was found that majority (87.4%) of nurses reported their job as stressful. Severe or extreme job stress was reported by 32.2% of nurses. The most stressful source of stress was time pressure and least was discrimination. Most of nurses resorted to positive coping strategies. Talking to people was reported as the most effective coping strategy at the workplace. No negative coping strategies such as smoking or drinking were reported by nurses in handling stress. No significant difference was found in job stress level among married and unmarried nurses but married nurses showed a tendency towards being more stressed than those who were unmarried. The workplace stress results in inability to efficiently handle stressful events among nurses in their personal lives.

Sudhaker and Gomes (2010) conducted a study among 60 nurses working in multispecialty in Mangalore, using convenient sampling technique. The objective was to determine the occupational stress and coping strategies used by nurses to overcome workplace stress. The tools used were Job Stress Index and Coping Checklist. Different coping strategies were used by nurses such as discussion with spouse, problem solving and engaging themselves in hobbies like reading, music etc. The results showed strong negative correlation between job stress and use of coping strategies by nurses.

Eswari and Saravanan (2011), investigated stress level among women nurses working in various nursing homes in Coimbatore city, Tamil Nadu. The study findings revealed that 52% had moderate stress in the area of conflict with supervisor and torture by higher authorities. It was found that 48.2% had moderate stress related to lack of recognition, insufficient equipment and work overload. Moderate stress was reported by 40.6% of respondents towards fear of making mistakes and unpredictable scheduling. The study also found other areas of stress for women nurses. Sixteen problems were identified among which “conflict with team members” ranked first followed by others such as “insufficient training shift duties”, “problems and lack of security at workplace”. The study concluded that insufficient equipment and frequent change of work pattern do not affect women nurses to a great deal.

Devi, Kanjana, Kavitha and Devi (2012), conducted a study among nurses in various states of India such as Karnataka, Kerala, Tamil Nadu and Maharashtra. Multi-centric purposive technique was used with sample size of 100 nurses. The questionnaire for data collection consisted of self explanatory questions related to workplace aspects and interaction with relatives causing stress.

Vijay and Vazirani (2012) conducted a comparative study to assess stress and stress busters among nurses using a questionnaire developed by the researcher. It was found that low salary, job security, interpersonal skills and improper behaviour of relatives and friends were main stressors for the nurses working in private hospitals. The government hospital nurses encounter stressors such as number of working hours, frequent change in shifts; poor quality of infrastructure, the number of patient handled everyday and dealing with patients with contagious disease. Spending time with the family was found to be main stress buster for nurses.

Roopalekha- Jathanna, Latha and Prabhu (2012), examined stress and coping abilities of 329 nurses working in the super speciality hospital in Kerala, India. Descriptive survey design was used. The data was collected using Expanded Nursing Stress Scale (ENSS) and Brief Cope (Carver 1997). The most frequently stressful areas rated by respondents were ‘patients and their family’ and ‘workload’, whereas ‘inadequate emotional preparation’ and ‘discrimination’ rated as least stressful situations. Further analysis revealed that nurses work in operation theatres and emergency units experience high level of stress in the area of conflicts with other care professionals. Nurses working in ICU’s experience high level of stress in area of feeling inadequately prepared to help with the emotional needs of a patient or patient’s family. The results indicated use of adaptive positive appraisal strategies being frequently used by nurses.

Katyal (2013), investigated burnout among 50 nurses working in government and 50 nurses from private hospitals in Chandigarh and Punjab, India. Four hospitals were randomly selected using lottery method out of which two were government and were two private hospitals. Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to assess burnout among nurses. It was found that in government hospitals majority (52%) of nurses experience high level of emotional exhaustion, 44% of nurses experience moderate level of depersonalization and 62% of them experience low level of personal accomplishment. The study findings revealed that nurses working in government hospitals experienced higher level of burnout than the nurses working in the private hospitals. The researcher had attributed higher level of burnout among nurses in government hospitals to possible factors such as heavy workload, poor work environment, frequent night shifts and poor support from administration and superiors.

Jose and Bhat (2013) carried out a study to determined level of stress and coping among 104 nurses in Udupi and Mangalore district, Karnataka. The setting of the study was selected Medical colleges and government hospitals. Nursing Stress Scale (NSS) and Ways of Coping Questionnaire was used to measure stress and coping respectively. The results revealed majority of samples experienced low stress followed by moderate and high stress. Sub areas of stress were death and dying and workload whereas lack of staff support was least stressful. Positive reappraisal followed by seeking social support was found to be most frequently used coping and accepting responsibility was found to be least used. It was found that nurses with diploma qualification, married and working in intensive care units experienced higher stress.

Joy, Ravindranath and Thomas (2013), explored the relationship between demographics and stress coping skill among 499 nurses using coping strategies inventory. Findings revealed that stress coping skills do not differ on basis of gender, age and marital status. It was found that use of stress coping skills was higher among government nurses and with experience of more than 15 years.

Kakade, Kakade, and Devi (2014), examined the factors responsible workplace stress and coping abilities of nurses caring for the patients in intensive care units. A descriptive exploratory survey design was used with sample size of 100 using non-probability purposive sampling method. The sample consisted of nurses working in two hospitals under private trust in Maharashtra, India. The tools used for data collection were Stress rating scale and coping questionnaire. The study showed that majority (59 %) had good coping abilities and 41 % of nurses had average coping abilities. There was no impact of demographic variables of nurses on their stress or coping abilities. It revealed that there was no significant association between the level of stress and coping abilities.

A study conducted by Divinakumar, Pookala and Das (2014), investigated perceived stress among 298 female nurses working in 30 different government hospitals in central India. Data was collected using Perceived Stress Scale (PSS-10). It was found that 48.32% of sample scored above 17 score PSS-10 which indicated high stress level. No significant difference was found between PSS-10 score and marital status and professional qualification. But significant difference was found between PSS-10 score and day and night duty nurses at the time of study. It can be concluded from this study that nurses were highly stressed and shift duties plays role in experience of stress.

Pawar (2014) examined the level of stress among nurses working in intensive care units of the hospitals in Navi -Mumbai, Maharashtra, India. The descriptive survey design was adopted for the study in order to identify level of stress and its association to selected demographics. The stress level was identified using modified version of Expanded Nursing Stress Scale. The results of the study showed that 42% of nurses were severely stressed, 34% had moderate stress, 14% had mild stress and 10% had very severe stress. The very severe stress level was highest (30%) in the area of patient and families followed by problems related to supervisors (22%). A significant relationship was found between the level of stress and demographic variables such as age, years of experience and educational qualification.

Mohite, Shinde and Gulavani (2014), assessed job stress among nurses working at the tertiary care hospital in Karad city, Maharashtra. The 100 nurses were selected for the study using convenient sampling technique. The Expanded Nurses Stress Scale (ENSS) an expanded version of the Nursing Stress Scale (NSS) widely used measurement scale in nursing research across globe. The study also found that age, sex, years of experience and professional education had no association to stress. The study findings revealed frequent cause of stress among nurses were workload situations and supervisors. The study concluded that measures need to be taken to decrease work load and resolve conflict among nurse supervisors.

Rawal and Pardeshi (2014), examined stress among 850 nurses working in selected public hospitals and private hospitals in Pune, Maharashtra. Findings revealed that interpersonal relationships issues such as conflicts with patients, doctors, and colleagues frequently leads undesirable personal stress in the working environment.

Saini, Kaur and Das (2014), conducted study among 73 nurses working in medical surgical units (ICU) at Nehru Hospital, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. The data was collected using modified Work Stress Symptom Scale (WSSS) and Coping Checklist (CCL). The findings revealed that 51% of nurses experience high stress. The factors responsible for causation of stress were lack of goal clarity, role ambiguity, role conflict, poor interpersonal relations, workload, improper performance appraisal, lack of job autonomy and job challenge. The stress was low among nurses who were having good interpersonal relations and clarity of the goals on the job. The problem solving coping strategy was most frequently used by the nurses.

Shastri (2014) identified causes of professional stress and its impact on mental health of the nurses. The study revealed inadequate information, lack of support from peers and superiors, harassment results in professional stress at the workplace. Stress experience is further increased due to communication gap, lack of resources and work overload. The impact of psychological stress on mental health fitness of the nurses was established.

Doraiswamy and Deshmukh (2015) examined the relationship between meaningful work and role stress among 141 nurses working different states of India. Significant correlation was found between meaningful work and role stress. The result indicated need to design job to enhance autonomy, support and flexibility for the benefit of organization and the nurses.

Fernandes and Nirmala (2015) investigated work stress and coping among 51 nurses working in different hospitals of Goa, India using qualitative approach. The main aim was to identify the situations that contribute to work stress and coping strategies used. Majority of nurses reported their work as stressful. The work stress was related to supplies/equipments, staffing and workload, peer problems and relational problems among medical and support staff. “Staff shortage” was main stressor for majority of nurses. The coping strategies used were problem avoidance, Mental Disengagement, Problem solving/planning, religious coping and social support.

Saini, Kaur and Das (2016), conducted study among 285 nurses working in general and Intensive Care Units (ICU) at Post Graduate Institute of Medical Sciences, Chandigarh, India. The data was collected using modified Work Stress Symptom Scale (WSSS) and Coping Checklist (CCL). It was found that nurses working in ICU experience moderate level of stress while nurses from general wards had high level of stress. Workload, role ambiguity and less social support amounted for stress experience. The findings revealed that younger nurses had higher level of stress and female nurses had more than males. Higher stress was experienced by the married nurses. Coping strategies used were such as problem solving and religious coping are used.

Shiji, Sequera and Mathew (2016), investigated stress and coping among married staff nurses using purposive sampling technique. The tools used for data collected were developed by the researcher. The stress score was highest in the professional area and overall stress score was moderate. The coping strategies used by the nurses included planful problem solving, confrontive coping, self-control, and seeking social support. Other ways included escape/avoidance and accepting responsibility, confrontive coping. The least coping strategy used by the nurses in the area of escape avoidance. Study findings revealed significant negative relationship between stress and coping strategies. No association was found between perceived stress level and coping strategies with the demographics of the nurses.

RESEARCH GAP AND SCOPE FOR FURTHER RESEARCH:

Review of the literature on nurses reveals limited research is done in Indian settings. Also, most of the studies conducted in India seem to be using the scales developed outside the country to measure stress and coping. The researcher could not identify any comprehensive measurement scales developed to measure stress and coping strategies in India.

It has been noticed that none of the scales reported have used any dimensions typically found in health care settings in India and else-where in the recent years. For example, image of the nursing profession held by the nurses themselves may have a significant impact on the stress levels experienced at workplace. Similarly, self health concerns of nurses do not seem to have caught the attention of other researchers but due to the increasing risk perceived from emerging diseases like AIDS, SARS, EBOLA, and others have heightened stress of affecting self, among nurses. While Discrimination dimension had been a part of some of the existing stress measuring scales, the items are based on global scenario and not found in Indian context. Therefore, if used in existing format, nurses may not relate to them and report differently from actual situations faced by them at workplace. So there is a need to modify/ moderate the items under such sub-scales to adapt the scales to local work environment.

More importantly, none of the instruments used to measure coping of individuals is adapted to the nursing profession. As the nurses’ workplace is unique and nurses report high levels of workplace stress, they may be using coping strategies exclusive to the profession, which may not be captured using the existing scales. A need to design an exclusive instrument to measure coping strategies of nurses is strongly felt.

CONCLUSION:

Very few studies have been documented in India regarding the workplace stress and coping strategies used by nurses. Stress and coping has been extensively researched internationally, those findings may not be very relevant to nurses in India. Owing to the facts such as their standards, services offered at the international hospital settings and provision of health services are different to those in India, it might not be appropriate to use the results of previous international studies to explain stress and coping among Indian nurses.

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Received on 20.11.2016 Modified on 18.12.2016

Asian J. Nur. Edu. and Research.2017; 7(3): 449-454.

DOI: 10.5958/2349-2996.2017.00088.X