Coping strategies for occupational stress used by nursing professionals in the hospital environment:  scoping review

Claudia Cristiane Filgueira Martins Rodrigues1, Kinsa Yasmin Andrade Alves1, LannuzyaVeríssimo e Oliveira1, Pétala Tuani Cândido de Oliveira Salvador1

1 Federal University of Rio Grande do Norte

ABSTRACT

Objective: To identify and map the coping strategies related to occupational stress used by nursing professionals in the hospital environment. Method:  This is a  scoping review based on the recommendations of the Joanna Briggs Institute. Data collection occurred in June 2020, in databases indexing scientific articles, dissertations and theses. The data were analyzed by simple descriptive statistics.  Results:  The final sample consisted of 63 studies, of which 49 (77.8%) corresponded to articles. The coping strategies with occupational stress presented in the studies were:  Active coping;  Self-care; Integrative and Complementary Practices; Social support; Training; Organizational support; and Negative strategy. These should include levels of primary prevention, secondary and tertiary prevention.  Conclusion:  The coping strategies that were included in the studies included measures that ensure the reduction of work overload; help the development of skills to deal with stress; and develop special care programs.

Descriptors: Occupational health, Occupational Stress, Adaptation, Psychological, Nursing professionals. Hospitals.

INTRODUCTION

The concept of stress has been widely used today to designate a set of biopsychosocial manifestations. These include increased heart rate and blood pressure, sweating, muscle pain, anxiety, fatigue, irritability, insomnia, eating disorders, decreased concentration capacity and other harmful effects that affect the individual's quality of life, overall performance and interpersonal relationships (1).

It is known that, throughout life, every individual deals with agents that predispose the emergence of stress, both in the personal and professional dimensions. In the professional sphere, the technological advance and the consolidation of the neoliberal system stimulated the demands for productivity and incited competition, which in turn increased stress among workers  (2).

Thus, stress is already a pathology recognized by the International Labour Organization and can cause numerous physical and psychological demands to the individual. It can be manifested by  mild symptoms such as frequent headaches, tachycardia, eating and sleep disorders or even evolve to a chronic disease such as systemic arterial hypertension (2).

Nursing professionals are among the professionals most susceptible to work stress because  they are commonly subjected to work overload, structural deficiencies, precarious work relationships and undervalued professionals. Moreover,  due to its work process, nursing deals with the suffering, anguish and pain of patients and family members on a daily basis (3).

Nursing professionals working in the hospital context  need to make immediate and frequent decision-making; handling hard technologies; the administration and supervision of personnel; and direct and indirect care to critically ill patients or patients at risk of imminent death(4). These factors often result in professional dissatisfaction and increased occupational stress  (5).

Studies show that the high level of occupational stress among nursing professionals is related to temporary incapacitation to work, absenteeism and the higher occurrence of iatrogenic diseases, with a negative impact on the quality of care provided to patients (6,7).

In this context, coping strategies emerge. It is worth making a distinction between the concept of the term coping strategies and the concept of  coping presented in the literature. The word  coping,  comes from the English verb to cope, which means to face, fight,  or compete (8).

Thus, they correspond to all cognitive and behavioral efforts, with two main functions, namely: I- the management or alteration of the stressful event and; II- the control, reduction or elimination of emotional responses to the stressful event (9).

The coping strategies are the actions that are primarily used by professionals to deal with occupational stress. It should be added that such strategies can be constantly changeable, according to the characteristics of the stressor and the requirements of the context. It appears that individuals develop different ways of coping, even in the face of the same conflicting situation (10).

In this sense, different studies seek to understand the forms of coping used in relation to the stress of nursing professionals, especially in the hospital context, in order to understand the work and relational dynamics as well as the forms of expression / positioning of these individuals, favoring improving the quality of professional life(4-11).

Thus, it is pertinent to map the strategies for coping with occupational stress used by nursing professionals in the hospital environment, especially in the current context, in which the Covid-19 pandemic is experienced, which has required these professionals to make many adaptations in order to overcome the daily challenges that the pandemic requires. It is understood that this mapping can support the reflection and implementation of care strategies for nursing professionals.

In view of the above, the following questions were asked: what are the strategies for coping with occupational stress used by nursing professionals in the hospital environment? Thus,  the objective is to identify and map the strategies for coping  with occupational stress used by nursing professionals in the hospital environment.

METHOD

A scoping review conceptualized by the Joanna Briggs Institute as a type of literature review directed at the mapping of concepts related to a certain type of theme (12) and presented according to the recommendations  of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation  (13).

To systematize the construction processes of this scoping review, a research protocol was adopted, registered in the Open Science Framework, and structured with the items: type of study, objective, sample composition, question formulation, inclusion criteria, exclusion, data collection, data extraction and data synthesis.

Thus, the objective was delineated and answered from the analysis of scientific productions - articles, dissertation and theses - on the  coping strategies with occupational stress used by nursing professionals in the hospital environment - corresponding to the sample of this study.

The formulation of the question followed the mneumonic PCC, in which: 1) P (population) - Nursing Professionals; 2) C (concept) - coping with occupational stress; and 3) C (context) - Hospital area. Thus, the following research question was obtained: "How do nursing professionals in the hospital area cope with occupational stress?"

First, in order to identify the existence of studies and protocols similar to the concepts of this scoping review, in June 2020, a search was conducted in the JBIClinical Online Network of Evidence for Care and Therapeutics (COnNECT +), Database of Abstracts of Reviews of Effects (DARE), International Prospective Register of Ongoing Systematic Reviews (PROSPERO) and The Cochrane Library. There was a study that contemplated the "concept" and "context" similar to the aforementioned research question, however the "population" comprised health professionals. Thus, no protocols and reviews with a similar theme were identified.

After this stage, the research strategies were developed. The identification of Medical Subject Headings  (MeSH) and Health Sciences Descriptors (DeCS), consistent with the pre-established PCC mneumonic, occurred from the search in the PubMed Central portal (PMC) and in the Cumulative Index to Nursing and Allied Health Literature  (CINAHL)  and Virtual Health Library (VHL) database.

Thus, the research strategies were outlined: 1) MeSH: (Nurses  OR  nursing)  AND  (adaptation OR coping strategies OR Coping  OR Coping OR work stress  OR  Burnout  OR  coping style) AND hospital; and 2) DeCS: (nursing professionals OR nursing team) AND (psychological adaptation OR Coping OR coping strategies OR coping OR occupational health OR workload) AND (hospitals OR hospital or hospital context).  

The sample selection occurred in June 2020, through the use of the research strategies cited in the databases PubMed, CINAHL,  Web of Science ,Scopus,  Nursing Database (BDENF), VHL and Education Resources Information Center (ERIC), which was performed by accessing the Federated Academic Community in the Journal Portal of the Coordination of Improvement of Higher Education Personnel (CAPES).  

In addition to the studies indexed in the above databases, a search was carried out in portals that make dissertations and theses available, such as: Capes Theses Catalogue and Dissertations, Europe E-Theses Portal (DART), Electronic Theses Online Service (EThOS), Scientific Repository of Open Access of Portugal (RCAAP), National ETD Portal and Theses Canada.

Researches with a qualitative and quantitative approach were included, published in full and in the Portuguese, Spanish or English languages. Editorials, experience reports and theoretical essays were excluded. No time limit was defined.

The pre-selection of the studies was conducted by reading the title and abstract. The final sample was selected through full readings. On that occasion, the variables were collected: type of study, year of publication, country of origin, author's education, theme, type of research, data collection procedures, data analysis procedures, research subjects, environment data collection and detailing of strategies to cope with stress.

These variables were arranged and tabulated in a Microsoft Excel  spreadsheet, and then the data were analyzed using simple descriptive statistics.

Regarding ethical aspects, because the data are public domain, the Ethics and Research Committee was not required according Resolution No. 510/2016 of the National Health Council.

RESULTS

Among the initial number of studies, 63 (0.1%) were included in the final sample (Figure 1): 49 (77.8%) articles, 12 (19.0%) dissertations and 2 (3.2%) theses, which were published between 1990 and 2020, with the highest number of publications in the last six years – 2015 to 2020, a period in which 40 (63.5%) studies on the theme were published.

Figure 1. Flowchart adapted from PRISMA ScR.

 Source: Adapted from PRISMA

The component studies of the final sample were produced by Nursing (56; 88.9%), Medicine (5; 7.9%) and Psychology (2; 3.2%) professionals and were developed within 16 different countries, with emphasis on the research conducted in Brazil (34; 54.0%) and in the United States (10; 15.9%) (Figure 2).

Figure 2. Countries in which the studies were conducted, in absolute numbers.

Regarding the theme mentioned by the authors of the selected studies, 43 (68.3%) mentioned researching strategies to cope with stress, while the others (20; 31.7%) used the classification "coping strategies". Regarding the latter, it is emphasized that 18 (28.6%) studies came from Brazil, which may show a preference for the use of the term "coping strategies" in other countries.

Regarding the methodological approach used by the studies, there is a significant emphasis on quantitative research (48; 76.2%) in the study of coping with stress, so that only 10 (15.9%) studies used a qualitative approach and 1 (1.6%) combined both types of approach. It should be noted that 4 (6.3%) literature review studies were included, which were not classified in this regard. Table 1 highlights the data collection instruments used by the researchers, as well as their analysis procedures.

Table one. Methodological approach, collection instruments and analysis procedures of the selected researches.

Source: Prepared by the authors.

Among the instruments used to identify strategies for coping with stress, the analyzed studies used the following instruments the most: Lazarus and Folkman Coping Strategies Inventory, a self-applicable instrument composed of 66 items, which groups the strategies on the axes of confrontation, remoteness, self-control, social support, acceptance of responsibility, escape and avoidance, positive reassessment and problem solving; and the Simple Coping Style Scale, a scale that subdivides coping strategies into positives, such as support from family or friends, and negatives, such as procrastinating, trying to forget everything, etc.

As for the subjects participating in the analyzed research, the studies that investigated the coping strategies for stress for nurses predominated (36; 57.1%), followed by those who researched the nursing team as a whole (20; 31.7%). Three (4.8%) investigations included only nursing technicians, another 3 (4.8%) studied the nursing team and physicians together, and 1 (1.6%) included medical students as participating subjects.

Except for literature review type studies (4; 6.3%) components of the final sample of this scoping review, all studies evaluated coping with stress in the hospital environment (59; 93.7%), which was investigated in conjunction with the context of home care  and Pre-Hospital Care in only 1 (1.6%) study. Some authors specified the hospital sector that was analyzed, with an emphasis on: the surgical center (5; 7.9%); The Intensive Care Unit (4; 6.3%);the  emergency room (2; 3.2%); and wards (2; 3.2%).

Table 2 lists the strategies for coping with stress mentioned by the analyzed studies.

Table 2. Stress/coping strategies explained  by the analyzed studies.

Source: Prepared by the authors.

In general, it was emphasized that coping strategies need to involve three levels of prevention: 1) primary prevention, which includes job clarification, increased autonomy and control that employees have to reduce work overload; 2) secondary prevention, in order to help workers develop coping skills as a way to deal with stress; and 3) tertiary prevention, offering special assistance programs, i.e., treatment for workers suffering from stress-related disorders.

DISCUSSION

The results indicate that the studies were published in 16 different countries and primarily in three areas of knowledge, all in the health area, an aspect that reflects the great repercussion of the theme coping with stress, especially in the health area (14).

In addition, the scientific articles study category (white literature) stood out, which is associated with a wide dissemination of knowledge on this topic in search platforms that are easily accessible (15).

It was also possible to identify the increase in the number of publications on the subject in the last six years. This fact may be related to the notorious relevance of mental and behavioral illnesses during this period. After all, these types of diseases, manifested by crises of anxieties, stress, fatigue and professional exhaustion, have been a recurrent subject in the work context, especially of health professionals (16).

These diseases are responsible for a significant reduction in the potential for job supply, for the increase in absenteeism and for the social exclusion of thousands of people, generating high economic and social costs (17).

It should be noted that the area of knowledge that most conducts research on the theme is nursing, because, historically, it is a profession that works directly contact with stressful factors and with human suffering (18).

Among the situations that can trigger stress in the work of nurses, studies highlight the physical and psychological burdens present in this context, such as: high responsibility in caring for the other; limitation of professional autonomy; rhythms, times and demands. Thus, it is possible to evidence that stressors are inherent to the nursing profession in any of the work environments of these professionals (19).

Therefore, knowing how to deal with these demands and with the physical and mental responses that stress can trigger in this organism is of paramount importance in order to minimize possible harmful consequences for these professionals.

Thus, the responses to a stress reaction, which triggers physical, psychological and behavioral symptoms, can be equalized through the use of coping strategies, which prevents the professional from getting sick as a result of  occupational stress (19).

In the meantime, coping strategies for stress are widely used resources to minimize the negative consequences of stress. These terms were present in the results of this study.

It is highlighted that the studies that mentioned coping identify the situations that individuals perform to face or adapt to the demands of stress present in the work environment. Studies report that it is possible to identify coping strategies focused on the problem, such as decision making, guidance or support, self-control, etc. And others still focused on emotion such as emotional outpouring (22;23).

In relation to coping strategies, some studies include social support actions, such as being with friends or family, relating well with co-workers; listening to music and being heard with respect to your problem (24).

It was also possible to identify that most studies presented a quantitative methodological design, an aspect that is justified by the fact that both stress and coping have scales are easily applied to participants, which allows the measurement of the stress level experienced by the individual, its phases and its signs and symptoms (25, 26, 27).

Coping scales allow you to capture the possible organizational influences they have on a particular group of individuals. However, it is important to highlight that qualitative research is also relevant because they start from the active listening of what is experienced by these professionals,  specificities that enable a direct reflection of their professional practice, helping them to face and adapt to the stress experienced in their work environment  (27).

Regarding the coping strategies identified in the studies, it was possible to classify them into three categories. The first one refers to primary prevention, referring to a clarification of the real role occupied  by professionals in the search reduce  work overload in services.

A study on the perspective of stress experienced by nursing professionals highlights that it is necessary to encourage these workers to actively participate in improving the work environment and in the recognition of the work process in order to minimize excessive demands and work accumulation (28).

In the meantime, as this recognition occurs, professionals are able to maintain an appropriate work flow, minimizing the stressful demands present in the work environment.

Another aspect addressed as a coping strategy by the studies was classified as secondary prevention, which concerns the ways in which workers can cope and face stress in the daily routine of their activities. A study points out that from the improvement of emotional intelligence, improving the ability to recognize the meanings of emotions and relationships in the work environment, it is possible to guide actions to better adapt to this medium  (29).

In addition, the use of Integrative and Complementary Practices (ICPs) highlights a reduction of occupational stress,  identified in a study with North American nurses, from the use of meditation focused on breathing, yoga and mindfulness (30). At this same level, other practices such as auriculotherapy, music therapy in the workplace favor the reduction of stressful demands and enable well-being in work performance.

Another category highlighted in the studies and classified as tertiary prevention was the offer of special assistance programs for professionals who suffer from stress-related disorders. Research on the theme demonstrates the relevance of psychological support during the work day, in order to improve the quality of life of the professionals involved and who are experiencing difficulties with their work relationship.

Thus, it is extremely important that the institution can recognize stress as a disorder capable of making the professional sick and that emotional and physical support can be offered to them. Therefore, it is essential to implement policies that value workers; the creation of healthy working conditions; the reduction of working hours per shift; adequate staff replacement; integration among workers; and the promotion of organizational and criminal justice, respect and education.

CONCLUSION

63 studies published between 1999 and 2020 from 16 different countries and three different areas of knowledge were analyzed. Among coping strategies highlighted, it was possible to categorize them into three levels of stress prevention: 1) primary prevention, which includes job clarification, increased autonomy and control that employees have to reduce work overload; 2) secondary prevention, in order to help workers to develop coping skills as a way to deal with stress; and 3) tertiary prevention, offering special assistance programs, i.e., treatment for workers who suffer from stress-related disorders.

As a limitation, it can be reported that the word coping and coping strategy are not controlled descriptors, which may have contributed to the non-selection of some studies. It is important to emphasize that the results should be understood according to the time limit of the data collection period.

It is hoped that this study contributes to the promotion of this relevant theme today in which coping strategies should be the guide for the well-being of these professionals in the work context.

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Received: 07/17/2020

Revised: 09/01/2020

Approved: 09/24/2020