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Occupational stress is a recognized problem in health care workers.1 Nursing has been identified as an occupation that has high levels of stress.2 In an investigation conducted by the National Institute for Occupational Safety and Health in the USA, nurses were found to be one of the occupations that had a higher than expected incidence of stress-related health disorders.3 It was found that job stress brought about hazardous impacts not only on nurses' health but also their abilities to cope with job demands. This will seriously impair the provision of quality care and the efficacy of health services delivery.3,4. In a study of job stress among hospital nurses, it was found that 27% of the subjects experienced psycho physiological symptoms of stress, and 38% reported consulting a doctor in the past 6 months. It has also been found that different nurses experience job stress different.3 4(Josef, 2003). In recent years there has been broad discussion on the nature of stressors experienced by members of "high risk" occupations and professions, for instance nursing and emergency workers, whose role is to support others through trau-matic scenarios.5 Recognition is growing that health care professionals, especially emergency department staff, are at risk for experiencing critical incidents.7 Emergency Department nurses are in a position that is expected to deal with additional stressors. These include unexpected numbers of pa-tients at any time, unexpected rapid changes in patients' situations, and response to distressing or traumatic incidents such as sudden death, patient violence, inappropriate attendees, and physical or verbal abuse on a daily basis. Emergency nursing is a highly stressful profession.7
Most people can cope with stress for short periods but Chronic stress produces prolonged changes in the physiological state.8 Effectiveness of coping behaviors depends on the situation in which they are used. Some coping behaviors may work well for some situations but not for others.9 In general terms, coping are a strategy that helps people reduce stress and solve problems8. Folkman et al. (1986) define coping as "the person's cognitive and behavioral efforts to manage the internal and external demands in the person-environment transaction.9 People differ in the coping strategies that they adopt for dealing with stressful incidents.10 Individual's coping strategies should be viewed and assessed within their particular social, cultural, and situational context.11. In a study by Li and Lambert (2008) on 102 intensive care nurses in china by a self-report questionnaires indicated that most workplace stressors was overload and most commonly used coping strategy was planning.(12). In another study by Burgess and Wallymahed (2010) they found that certain personality trait such as openness and extraversion were associated with less perceived stress from the patient and relative in Intensive care unit nurses.13
Knowing what emergency workers do to cope and survive extreme incidents may help us understand and assist those who are more at risk of traumatic reactions .14.
The issues of job stress, coping, and burnout among nurses are of universal concern to all managers and administrators in the area of health care.2 Therefore, the specific aim of the study was to investigate the sources of occupational stress and coping strategies among nurses who are working in emergency department in Shiraz-Iran. Thus the knowledge obtained would be useful in the formulation of recommendations to promote the health of these nurses and thereby improve the quality of care provision in emergency department.
All these stresses can be modified in a posi-tive way by the use of appropriate stress management skills.
Materials and Methods
In this descriptive study the sample consisted of 90 emergency department nurses from three large teaching hospitals in Shiraz who volunteered to study. All of respondents in this study held a baccalaureate degree.
Shiraz is located in the South West of Iran. It is one of the biggest city of Iran and Capital city of Fars Province with a rich culture and many sightseeing places.
A questionnaire, which consisted of three sections, was used to collect information regarding job stress and the adopted coping strategies of nurses working in emergency department. The first section attempted to delineate nurses' 'personal profile, such as rank, and year of service in nursing, marital status, descriptive demographic statistics. The second section of the questionnaire contained 60 items to identify the sources of job stress. This questionnaire had been developed following a literature review. A 4-point Likert-type scale was used ranging from "no stress" (scored as 1) to "a lot of stress" (scored as4). A total score representing the overall frequency of stress experienced by a nurse was obtained by adding the nurse's responses to all 60 items. The range of the scores was from 0 to 240, with a higher score indicating higher job stress.
The third section used Lazarous standard questionnaires to determine the types of coping strategies, used by nurses to cope with job stress. According to Folkman and Lazarus' cognitive appraisal model of coping15. Coping involves a conscious effort to reduce stress. Within this model, coping strategies can be broadly categorized as either problem-focused ' attempts to manage or alter the problem causing the stress ' or emotion-focused 'attempts to regulate emotional responses to the stressful situation. 16, 8
The main body of the Lazarous question-naires contained 66 coping statements reflecting a wide range of thoughts and actions that people use to deal with taxing events. Fifty of the items on the questionnaire are divided into eight empirically constructed scales. The scales are described as follows: Confrontive Coping, Distancing, Self-Controlling, Seeking Social Support Accepting Responsibility, Escape-Avoidance, Planful Problem Solving, Positive Reappraisal.16 Validity and Reliability of Ira-nian Version of Folkman and Lazarous Ways of Coping has been tested by Padyab and Ghazinour. It showed a good face and content validity. The Reliability of Ways of Coping questionnaire has been tested using the internal consistency method. The cronbach-alpha was 0.88.17.
Descriptive statistics were used to illustrate the demographic profile of the respondents, the frequency of the adopted coping strategies and the mean scores of job stress, sources of stress. In addition, the response mean of each of the 66 coping statements and eight coping scales is determined for the sample for both the Use and Effectiveness sections. Data were cross tabulated and Chi square tests of significance calculated. The SPSS software version11.5 was used to analyze the data.
A total of 90 emergency department nurses from three large teaching hospitals were stu-died. The aim of the study was to investigate the sources of occupational stress and coping strategies among nurses.
The greatest proportion of respondents was women (86.7%), range 23-50 years, had less than 5 years of clinical experience (56.7%). (Table 1)
The overall mean score of the Nursing Stress Scale was high (mean ' SD = 162.28 ' 35.28) they experience high frequency of stress.
The study identified the following stressors as the major sources of stress between 60 stressors: problems related to physical environment, Work load, dealing with patients or their relatives and handling their anger or aggressive behaviour, being exposed to health and safety hazards, lack of support by nursing administrators, a physician not being present in a medical emergency, lack of equipment
The most common strategy used by nurses was Self ' Controlling (The mean score was 12.92 with a standard deviation of 3.8) and Positive Reappraisal (Mean=12.92, SD=3.5) and the strategy least used was an Accepting Responsibility (Mean=5.65, SD=2.62). (Table 3).
In present study Problem-focused approaches were generally less used (Mean=18.9, SD=16.1) but an emotion-focused strategy were more used (Mean = 59.4, SD = 16.1). There was a significant relationship between the use of the Con-frontive coping scale and sex, the women used of this coping strategies more. There was no significant relationship in the use of any coping scale and other demographic variables considered in this study. The majority (74.4%) of nurses reported that they were satisfied with their jobs.
With regard to the sources of stress, this study reveals that the' problem related to physical environment' created the most stress for nurses who are working in Admission and &Emergency department in Nemazee hospital in Shiraz. 'Also, lack of equipment, work load, lack of support by nursing administrators, being exposed to health and safety hazards, dealing with patients or their relatives and handling their anger, criticism or aggressive behavioral, a physician not being present in a medical emergency are the most common stressors among nurses in Admission and &Emergency department in Shiraz. These stressors are similar to those identified in previous studies. Numerof and Abrams (1984) identified the organizational environment as a major source of perceived stress.18 In a study performed by McFarlane D, et al (2004) the major sources of stress was the external environment and the amount and quality of the workload.19
Callaghan et al (2000) in a study at-tempted to identify the factors related to stress and coping among Chinese nurses in Hong Kong. The major sources of stress were related to nursing issues like too much work, interpersonal relationships, and dealing with hospital administration.20
This study explores the coping strategies used by the nurses who working in Admission and &Emergency department in Shiraz. In present study, it was found that the most common strategy used by nurses was Self ' Controlling and Positive Reappraisal and the strategy least used was an Accepting Responsibility. Exercising self-control is a cultural character trait common in nurses within Asia. Prior research has shown self-control to be the major coping method of nurses from Japan and Thailand, Chinese.2,21
The second most common strategy used by the nurses who working in Admission and &Emergency department in Shiraz was positive reappraisal. One of the reasons why positive reappraisal may be used more is because this coping strategy has a religious dimension, and nurses who are working in Iran utilize more religious coping than to do others. May be spirituality play a major role. In addition, both painful problem solving and positive reappraisal are coping methods that can be enhanced through increased educational preparation and work experience.22
All of respondents in this study held a baccalaureate degree. It is possible that the reason that they used positive reappraisal coping mode was because of the educational background.
The results of the study were similar to previous research. In a study that performed by Xianyu, Vickie &Lambert (2006) to Investigate of the relationships among workplace stressors, ways of coping, and the mental health of Chinese head nurses. Positive reappraisal, planful problem solving, and self-control were found to be the three most frequently identified ways of coping.2.
Also In a study preformed by Bianchi (2004) he attempted to identify the stress and coping among cardiovascular nurses in Brazil. The results identified work conditions as the major source of stress for nurses and use of positive reappraisal, self-controlling skills, and social support to cope with job stress.23
In this study accepting responsibility was the least frequently used coping strategy among nurses in Admission and Emergency department in Shiraz. This suggests that they tend not to blame themselves nor think that it is their sole responsibility to address the problem. Similarly ,In a study conducted by Ryan, Quayle (1999) in Ireland to identify the stress in psychiatric nursing, they found The most frequently reported method of coping was the use of self-controlling strategies (mean=9.44,SD=4.59) while the least fre-quently reported method of coping was accepting responsibility, (mean = 3.55, SD = 2.99).24
Bianchi (2004) states that nurses are using coping strategies based on personal resources.23. According to Folkman and Lazarus' cognitive appraisal model of coping (Folkman, 1984), coping involves a conscious effort to reduce stress.22. Within this model, coping strategies can be broadly categorized as either problem-focused ' attempts to manage or alter the problem causing the stress ' or emotion-focused 'attempts to regulate emotional responses to the stressful situation.15.
In present study emotion-focussed ap-proaches were generally more used (Mean = 59.4, SD; 16.2) and problem-focused strategy less used (Mean = 18.9, SD = 5.3). Collins and Jones, 2002 has been found that the decision to employ a particular coping strategy is influenced by one's perceptions of personal control over the stressful situation. Where an individual perceives a stressful situation to be beyond their control, they are more likely to utilize emotion-focused coping strategies; where the individual perceives an opportunity to alter the situation, problem-focused coping strategies will be preferred.15. In the present study, Accepting Responsibility were generally less used, may be for this reason problem-focussed strategy less used, because Problem-focused ways of coping was reported by those with problems concerned with Responsibility. Also it may be they felt that solutions to the problem were outside their control. It is important to note that problem related to physical environment remain as the major reported sources of stress in this group of nurses. It was concluded that the scale of Self ' Controlling and Positive Reappraisal was reported to be the most used by emergency department nurses. In present study emotion-focused approaches were generally more used.