INTRODUCTION

Nursing staff have been identified to pos­sess high level of work stress (Dickinson & Wright 2008; Healy & McKay 1999; Wang & Patten 2001; Weinberg & Creed 2000) given the nature of their work envi­ronment. Common sources of stress among nursing staff include workload, leadership style, professional relation­ships and emotional demands (McVickar 2003). Perception of stress is very sub­jective and depends on the interaction between such individuals and his or her environment (McVickar 2003). 

In Malaysia, stress among nursing staff is prevalent (Emilia & Noor Hasim 2007; Majdah 1999; Rokiah 1994). Rokiah (1994) reported more than 49.5% of nurses in a public hospital in Kuala Lumpur had stressful experience related to workplace factors. A study among medical and surgical nurses in a teaching hospital in Kuala Lumpur reported work­load as a major source of stress (Emilia & Noor Hasim 2007). 

Nursing staff working in the same dis­cipline as well as different disciplines or different workplaces may face different stress level which depends on the inte­raction of the multiple factors involved. Psychiatry and emergency medicine are among two highly stressed working envi­ronments for nursing staff (Kilfedder et al. 2001; Yang et al. 2001). Psychiatric nursing staffs have to cope with emo­tional burden handling patients who are mentally ill. They face aggression, abuse and emotional trauma such as suicide among the patients that they treated. On the other hand, nursing staff working in emergency medicine faced a different emotional burden of having to deal with emergency cases and death among pa­tients that they see in casualty. 

Stress among nursing staff has to be dealt efficiently since it may lead to vari­ous emotional problems that may be af­fecting work functioning. Work stress among the emergency nursing staff has been associated with Posttraumatic Stress Disorder symptoms but the causal nature of such relationship needs to be further established (Judith et al. 2003).

The subjective experience of stress is the balance between two processes. i.e. the process of primary appraisal to de­termine the meaning of event and a process of secondary appraisal which takes place to assess one’s coping abili­ties (Taylor 1990). The big question asked is, how do nursing staff working in stressful environment adapt and cope with such stressors? 

This study aimed to compare stress level among nursing staff working in dis­ciplines of psychiatry and emergency medicine, identify common coping styles used and to determine the relationship between stress and coping styles among nursing staff in the above disciplines.

MATERIALS AND METHODS

This was a cross-sectional, study ex­amining coping styles and stress level among nursing staff working in two stressful disciplines i.e. psychiatry and emergency medicine in two public hos­pitals in Klang Valley. A total of 106 nursing staffs were universally sampled from the psychiatric ward and the emer­gency department.

Demographic data such as age, sex, race, marital status and duration of working at the current workplace were collected. Self-rated questionnaires were used and subjects were given two weeks to complete the questionnaires. Stress Arousal Checklist (SACL) (Cox & Mackay 1985; Corcoran & Fischer 2000) as­sessed stress level whereas coping in­ventory for Stressful Situations (CISS) (Endler & Parker 1990) assessed coping styles among the subjects. The stress dimension of the SACL refers to the subjective experience in response to the external environment (e.g. tense, relaxed, apprehensive, worried) whereas the arousal dimension refers to the ongoing somatic or autonomic activity (e.g. ener­getic, drowsy, stimulated, activated). The stress scores ranged from 0 to 18 whereas the arousal score ranged from 0 to 12, whereby higher scores reflected more stress and arousal.

The CISS is a 48 item questionnaire measuring coping styles i.e. task, emo­tion, avoidance, distraction and social diversion coping. Nursing staff with good understanding of English and consented to participate were included. The study was approved by the ethical committee of the respective settings.

Statistical analysis

The statistical package of Social Science was used to analyse the data. Indepen­dent t-test, Chi-square test, correlation test, and ANOVA test were used to ana­lyse the data.

RESULTS

A total of 106 respondents participated in this study. The mean age for psychiatric nursing staff was 31.45+ 53 whereas the mean age for casualty nursing staff was 28.62+5.36. There was a statistically significant difference in age between the two groups with the psychiatry nursing staff being significantly older than the casualty nursing staff. Other demo­graphic data showed insignificant differ­ence between the two groups (Table 1).

Stress level among the nursing staff in both disciplines was shown in Table 2. There were no significant differences in stress levels between the two groups.

The most commonly used coping style among the nursing staff in both groups was task coping and the least was social diversion. There were no significant dif­ferences in terms of coping styles be­tween the groups (Table 3).

Relationship between stress and coping styles were demonstrated in Table 4.  Stress showed significant weak correla­tions with task coping and emotion cop­ing. For stress dimension, there was a statistically significant weak negative correlation with task coping. However, a statistically significant weak positive cor­relation was found with emotion coping. In other words, the higher the stress level, signified lesser use of task coping but the more use of emotion coping.

A reverse was seen for the arousal di­mension. There was a statistically signifi­cant weak positive correlation with task coping suggesting more use of task cop­ing in a higher level of arousal. There was a statistically significant weak nega­tive correlation with emotion coping sug­gesting the higher the arousal, the lesser use of emotion coping.

DISCUSSION

In keeping with previous studies, both psychiatry and emergency medicine nursing staff reported similar stress in the two different disciplines of nursing (Kilfedder et al. 2001; Wang & Patten2001; Watson et al. 2009). Many factors such as individual, work and organisa­tional factors have been identified to contribute to nursing stress (McVickar 2003). A complex interaction exists be­tween these multiple factors.

This study examined the relationship between stress and coping styles, a fac­tor that can be intervened to help reduc­ing stress level among nursing staff. The most commonly used coping style among the nursing staff in both groups was task coping whereas social diversion is the least used. It is unclear why the nursing group chooses task coping and not other coping styles. Coping styles are said to be influenced by both the   genetic and environmental factors (Busjahn et al. 1999). It has been suggested that differ­ent stressful situations may override indi­vidual’s preference of choice of coping styles (Endler & Parker 1990). For in­stance, work-related problem commonly lead to task coping whereas health-re­lated problem leads to more emotion-focus coping (Yang et al. 2001). This may explain the choice of task coping among the nursing staff.

In relation to the two dimensions of stress, this study  found significant weak negative correlation between stress di­mension and task coping but positive correlation between emotion coping and stress dimension. In other words, the higher the stress level, the lesser use of task coping but more use of emotion coping. Possibly, in a highly stressful situation, it is easier for an individual to respond emotionally in order to reduce stress as compared to cognitively re­structuring the problems to alter the stressful situation. Thus, in a highly stressful situations, emotion coping is more commonly used compared to task coping. Therefore, it is understandable that nurses working in stressful environ­ment would be using more of emotion coping compared to task coping.

Interestingly, the finding is vice-versa with arousal dimension. There was a weak negative correlation between emo­tion coping and arousal, but a positive correlation with task coping. The higher level of arousal, the more use of task coping but lesser use of emotion coping. This was difficult to explain. Possibly, coping style was not the primary factor in determining stress in this situation but other factors in the individual, environ­ment or organization play more roles.

Why is work stress among the nursing staff important? It has been shown that stress related to work as well as from outside source, contributed to anxiety and depressive disorders among health staff (Weinberg & Creed 2000). A Canadian National Population Health Survey found significant association be­tween work stress and major depression (Wang & Patten 2001).

Being an important constituent the medical team, nursing staff need to be physically and mentally fit. In certain situ­ations, they are exposed more to the daily stress compared to other members of the medical team. For instance, psy­chiatric nursing staffs are usually the first liner to handle aggressive patients before doctors arrive. They need to be physi­cally and mentally stable to cope with daily work stress. Listening to patients’ emotional problem can also be mentally exhausting thus the need to be mentally fit themselves. Nursing staff that are not mentally healthy, may be more vulnera­ble to develop counter-transference when handling patients’ emotional and psycho­dynamic issues.

Mental health of the nursing staff de­pends on the level and source of stress they experienced as well as their ways of coping (Pryjmachuk & Richards 2007). Adaptive coping styles will help the nurses coping better with their daily stress. Various studies in Malaysia have found   avoidance coping to be asso­ciated more with poor mental health (Chong 2000).

While this study does not help in our understanding of choices of coping styles among the nursing staff, the importance of stress and coping styles among the nursing staff cannot be underestimated.

Nevertheless, this study has its own li­mitations. Firstly, the cross-sectional de­sign allows relationship between va­riables to be identified at one point in time only. Secondly, the sample popula­tion may not represent the nursing pop­ulation in Malaysia due to the small sam­ple size and limited to two hospitals in Klang Valley only. Finally, other con­founders such as life-event, social sup­port and personality were not controlled thus may give important impact on the findings. Future studies may need to im­prove on the method to allow a better interpretation of findings to facilitate bet­ter understanding and allow better inter­vention in terms of stress among the nursing staff and their choices of coping styles.

CONCLUSION

In terms of stress level, there was no sig­nificant difference found between the psychiatry and the casualty nursing groups. Task coping was the most com­monly used coping styles among the nursing staff in this study. Significant re­lationship was found between stress and task and emotion coping styles. Stress among nurses needs to be given more serious consideration and proper inter­vention. Regular stress management program which include effective coping styles should be introduced in the workplace to minimize the problem.

ACKNOWLEDGEMENTS

The authors would like to acknowledge Universiti Kebangsaan Malaysia, Ministry of Health and the respective hospitals.