- Email: [email protected]
Sources of Occupational Stress and Coping Strategies Among Nurses Working in AIDS Care
JANAC Vol.et11, Kalichman al. No. / Stress 3, May/June and AIDS2000 Care
Sources of Occupational Stress and Coping Strategies Among Nurses Working in AIDS Care Seth C. Kalichman, PhD, Violaine Gueritault-Chalvin, MS, and Alice Demi, PhD
Nurses working in AIDS care experience high rates of occupational stress and therefore are vulnerable to emotional exhaustion and occupational burnout. This study surveyed 499 members of the Association of Nurses in AIDS Care regarding their work-related stress experiences and coping strategies for managing stress. Qualitative analyses identified a hierarchical structure of occupational stress, with two supraclusters representing workplace and patient care-related stress and eight specific subclusters of stressors: institutions, personnel, biohazards, death, informing patients, challenging patients, families, and treatment dilemmas. Analyses showed that nurses experiencing stress from their workplace were significantly more likely to use wishful thinking, planful problem solving, and avoidance as coping strategies, whereas stress originating from patient care was more likely to be dealt with using positive appraisal and acceptance. Interventions designed to assist nurses in managing occupational stress and to prevent occupational burnout must include the sources of work-related stress among nurses in AIDS care. Key words: AIDS care, occupational stress, HIV/AIDS caregivers
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urses working in AIDS care experience an array of stressors from multiple sources and therefore are vulnerable to emotional exhaustion and, eventually, to occupational burnout. Research has shown that nurses who provide care to people with HIV/AIDS experience stress with an intensity similarly found among nurses in other areas of chronic care, including
oncology and geriatrics (Kleiber, Enzman, & Guzy, 1993). Health professionals who treat people with AIDS may therefore experience a number of adverse effects of stress, including occupational burnout (Barbour, 1994). Bennett and colleagues (Bennett & Kelaher, 1994; Bennett, Kelaher, & Ross, 1994; Bennett, Miller, & Ross, 1995) have documented high rates of occupational burnout among nurses in AIDS care, implying that AIDS care encompasses significant levels of work-related stress. However, research has not yet described the sources of stress associated with AIDS nursing care. In addition to occupational burnout, stress in nursing is associated with long-term job dissatisfaction (Cooper & Mitchell, 1990) and can lead to immunosuppression and increased susceptibility to illness (De Gucht, Fischler, & Demanet, 1999). Studies suggest that nurses may experience multiple stressors from multiple sources. For example, Fimian, Fastenau, and Thomas (1989) identified eight Seth C. Kalichman, PhD, is associate professor of psychiatry at the Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee. Violaine Gueritault-Chalvin, MS, is a doctoral candidate in psychology at Georgia State University and Alice Demi, PhD, is professor of nursing at Georgia State University. This research was supported by National Institute of Mental Health Grants R01 MH57624 and P30 MH52776. All correspondence should be addressed to Seth C. Kalichman, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226; e-mail: [email protected].
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 11, No. 3, May/June 2000, 31-37 Copyright © 2000 Association of Nurses in AIDS Care
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occupational stressors using a factor analysis of the Nurse Stress Inventory: professional distress, patient care and motivation, time and workload management, personal time disruptions, emotional reactions, behavioral manifestations, fatigue, and physiological manifestations. Fimian et al.’s (1989) conceptualization of stress therefore included both sources and internal manifestations of stress. Use of the Nurse Stress Inventory factor analysis also limited the results to that scale’s pool of items. Nevertheless, findings from previous studies indicate that sources of stress experienced by nurses are heterogeneous and may require multiple coping strategies. Specific Aims The study investigated the sources of stress experienced by nurses who provide or supervise care to people with HIV/AIDS and the strategies nurses use in coping with stress. We used qualitative research methods in identifying sources of occupational stress to avoid imposing a priori assumptions on nurses’ perspectives of stress (Patton, 1990). Self-identified sources of stress were organized using a hierarchical framework, with nurses grouped on the basis of identified stressors. Following the categorical analysis of stressors, we compared the nurses’ identification of various sources of stress on coping strategies.
Method
(Gueritault-Chalvin, Kalichman, Demi, & Peterson, in press). The survey included questions about demographic characteristics and work history experiences. To capture a broad range of work-related stress situations, participants were asked to identify “one of the most stressful situations” they have encountered in their jobs rather than the most stressful circumstance. The survey was created in an open-ended format that required participants to write a response in a blank space. Participants were then instructed to think back on the stressful experience they identified and to indicate the degree to which they used 33 coping strategies. The strategies contained in the survey represented 50% of the items in the Ways of Coping Inventory (Lazarus & Folkman, 1984). The Ways of Coping Inventory is a 66-item self-report instrument that measures coping behaviors used in a particular encounter between the person and situation (Lazarus & Folkman, 1984). Items were selected based on previous coping research with health care professionals in AIDS care (Bennett, Kelaher, & Ross, 1993). The items represented a balance of emotion-focused and problem-focused coping behaviors from the original scale. The degree to which participants responded to coping strategies was indicated on a 4-point Likert-type scale, from 0 (not used) to 3 (used a great deal). For the purposes of data reduction, we conducted a principal components factor analysis, using a varimax rotation. Results indicated eight coping factors with eigenvalues greater than 1. They included the following:
Survey Participants and Procedures Participants were members of the Association of Nurses in AIDS Care (ANAC), who returned postal surveys in 1998; 1,500 nurses were randomly selected from a membership list of 3,000. The nurses, who remained anonymous, were mailed the survey, a cover letter explaining the purpose of the study, and a postage-paid return envelope. A total of 523 nurses (35%) returned the surveys, of which 499 were completed. Survey Design The survey was part of a larger study that investigated occupational burnout in AIDS care providers
1. Wishful thinking—defined as thoughts directed at the way one hopes or wishes a problem could be resolved (seven items, such as, “I had fantasies or wishes about how things might turn out”); 2. Positive appraisal—thoughts focused on placing the problem in a positive light (four items, such as, “I changed or grew as a person in a good way”); 3. Seeking social support—attempts to draw assistance from others (six items, such as, “I talked to someone about how I was feeling”); 4. Planful problem solving—attempts to resolve the problem by taking action (four items, such as, “I made a plan of action and followed it”);
Kalichman et al. / Stress and AIDS Care
5. Avoidance—actively evading the situation (three items, such as, “I slept more than usual”); 6. Acceptance—resigning oneself to the realities of the situation (four items, such as, “I accepted it, since nothing could be done”); 7. Rational problem solving—attempts to use logic and reasoning in resolving the situation (three items, such as, “I tried to analyze the problem in order to understand it better”); and 8. Spirituality—drawing on faith and prayer to manage the situation (two items, such as, “I found new faith”). Factor scores were calculated for each factor and were used as dependent measures in subsequent analyses. Factor scores by definition are internally consistent, weighted linear composites of all items included in the factor analysis. Factor scores provide standardized scores with a mean of 0 and a standard deviation of 1 (Tabachnick & Fiddell, 1989). Data Analyses The first step in the data analyses involved qualitative analysis of responses to the open-ended question on stress. Responses were individually sorted into categories using a systematic hierarchical structuring scheme. They first were sorted into two supraclusters that represented common themes of stress resulting from aspects of the workplace: (a) work environment and (b) stressors resulting from patient care. In the second sorting iteration, sources of stress were divided into subclusters according to content themes that represented common features of the stressful situations. This process was taken to a third iteration, which yielded a finer description of stressors within each subcluster. The criteria for classification development were shared situational properties, mutual exclusivity, and conceptual clarity (Patton, 1990). Nurses therefore were grouped on the basis of the situations they identified as being among their most stressful. Quantitative analyses, or analyses of variance, were conducted to examine differences in nurses’ coping strategies. These analyses also were conducted hierarchically, first testing for differences between the two supra-c lusters (workplace vs. patient care stress groups), with
33
significant differences followed by analyses testing for differences between the eight-stressor subclusters. Significance tests involving coping strategies were first conducted with MANOVAs on the eight factor scores that were derived from the principal components analysis. Significant differences indicated from the MANOVAs were subsequently examined using ANOVAs. Results The mean age of participants was 44.0 (SD = 9.3, range = 23-74). The majority of respondents were women (84%); 16% were men. Participants had been employed a median of 17 years in nursing, with a median of 7 years working in AIDS care. A total of 88% of participants currently provided direct patient care to persons living with HIV/AIDS, 53% had administrative duties, 70% were involved in teaching, and 46% held supervisory positions. In terms of nursing degrees, 50% were RNs, 37% were BSNs, 31% held an MSN, and 4% had their PhD (totals exceed 100% because some nurses held more than one degree). Of the 499 nurses who returned completed surveys, 474 provided responses to the open-ended question regarding work-related stressors. Analyses showed that 60 stressors could not be categorized into the resulting framework (examples include coping with one’s own HIV infection, dealing with child abuse, and providing emergency care to plane crash victims); therefore, remaining analyses were conducted on the 414 nurses who provided stress responses within the empirically derived structure. Results of qualitative response sorting showed that occupational stressors identified by nurses in AIDS care were hierarchically structured into three substantive levels: two supraclusters that represented stressors associated with the workplace and patient care, further delineated into eight major clusters of institution- and personnel-related stressors in the workplace and the patient care stressors associated with biohazards, deaths, informing patients, challenging patients, families, and treatment dilemmas. Figure 1 presents the hierarchical framework of occupational stressors identified by nurses. Sixty-four percent of participants providing stress responses identified patient care as their most
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Figure 1. Differences on Factor Scores of Eight Coping Strategies Between Nurses Identifying Workplace Stressors and Nurses Identifying Patient Care Stressors
significant source of stress, versus 36% of nurses identifying sources of workplace-related stress. Inspection of stress subclusters shows that 20% of nurses identified personnel issues and 20% identified challenging patients as their leading sources of stress. The most frequently identified specific sources of stress within subclusters were staff conflicts (11%) and dealing with resistant patients (7%). To assess the reliability of the classification of responses, an independent rater sorted the stressful situations into the classification system with 90% agreement. Discrepancies were resolved through discussion and consensus between raters; thus, the classification system appeared reliable. Nurses experiencing different sources of stress were subsequently compared on demographic and work history characteristics as well as the eight coping factors.
Demographic and Career Characteristics Analyses testing for differences between nurses who identified workplace stressors versus those who identified patient care stressors failed to indicate significant differences in demographic and nursing career characteristics, such as age, years of nursing, years of working in AIDS, patient loads, or highest nursing degree. Thus, workplace versus patient care situations identified as the most stressful experiences could not be accounted for by individual, employment, or career characteristics of nurses. Coping Strategies Results of a MANOVA showed that nurses who identified workplace-related stressors differed
Kalichman et al. / Stress and AIDS Care
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Figure 2. Hierarchical Structure of Occupational Stressors Identified by Nurses Working in AIDS Care
significantly from nurses who identified patient care stressors on the eight coping strategies, F(8, 403) = 6.31, p < .01. Subsequent ANOVAs showed that nurses who identified workplace stressors as their most stressful experience reported using significantly more wishful thinking, F(1, 403) = 7.01, p < .01, planful problem solving, F(1, 403) = 15.22, p < .01, rational problem solving, F(1, 403) = 3.60, p < .05, and avoidance coping, F(1, 403) = 11.71, p < .01, compared with nurses who identified patient care stressors. However, nurses reporting patient care stressors used significantly more acceptance for coping, F(1, 403) = 5.05, p < .05, with a trend toward using more positive appraisal, F(1, 403) = 3.03, p < .08 (see Figure 2). Because differences were detected between nurses within the two supraclusters of occupational stressors, we conducted further analyses between the eight subcluster groups. Results of a MANOVA showed significant differences between groups on all eight types of coping strategies used for managing occupational stress, F(8, 397) = 4.27, p < .01. As shown in Table 1, institutional sources of stress were most likely confronted using planful problem solving; personnel stressors were most likely faced through avoidance, wishful thinking, and rational problem solving; stressors from biohazards, such as needle-stick injuries,
were met through wishful thinking and avoidance coping; the death stressor was confronted through positive appraisal and acceptance; and the stress of informing patients was countered through spirituality. Nurses indicated few resources for coping with challenging patients, whereas coping with patients’ families drew on positive appraisal and acceptance. Finally, treatment dilemmas, including ethical issues and concerns about quality of care, were most commonly confronted through planful and rational problem-solving strategies.
Discussion Study Limitations About 1 in 3 of the nurses sampled returned completed surveys, a rate consistent with other published surveys of professionals. This survey response rate therefore limits the generalizability of our study findings. In addition, we sampled members of an association of nurses working in the AIDS field and heavily involved in teaching and supervision. This group probably does not represent the larger number working directly with AIDS patients. Finally, we relied on a
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Table 1. Differences Between Nursing Occupational Stress Groups on Eight Coping Strategy Factors
Sources of Stress Institution Personnel Biohazards Death Informing patients Challenging patients Families Treatment dilemmas F(7, 397) p
Wishful Thinking
Positive Appraisal
.01 .25 .72 –.24 –.27 –.03 –.65 .15 4.9 .01
–.15 –.11 .35 .29 –.12 –.25 .31 –.10 2.9 .05
Seeking Social Support –.19 .22 –.34 .20 .15 –.12 –.02 –.03 1.9 .08
Planful Problem Solving
Avoidance
.40 .08 .16 –.55 –.19 –.09 –.07 .51 7.0 .01
.09 .26 .64 –.28 –.93 .11 –.25 –.53 7.3 .01
Rational Problem Acceptance Solving .02 –.22 .35 .27 .03 –.04 .25 –.26 2.3 .03
–.07 .24 –.37 –.21 –.26 .03 –.28 .42 2.9 .01
Spirituality .18 –.16 .33 .20 .48 .28 –.14 –.68 5.0 .01
NOTE: Range = –1 to 1, with higher positive scores indicating stronger endorsement of coping strategies.
standardized measure of coping responses to investigate attempts at occupational stressor adjustment. Nurses therefore may draw on additional coping resources and strategies not captured by our measure. Finally, nurses were asked to recall a stressful event and reflect on how they coped in that situation. The retrospective data were therefore susceptible to distortion and to other sources of memory bias. The current findings therefore must be considered with regard to these methodological limitations. Interpretation of Findings Among nurses working in AIDS care, this study identified 32 different categories of occupational stress experiences. More than one third of stressful events involved institutional settings and personnel aspects of work environments. Stress resulting from sources directly associated with the workplace were confronted through a range of both emotion-focused and problem-focused strategies, including wishful thinking, avoidance, planful problem solving, and rational problem-solving strategies. On closer inspection, it was indicated that institutional stressors, such as administration, managed care, and workload, were most often managed using planful problem solving. However, stress associated with personnel, such as staff conflicts and dealing with supervisors and management, drew on several coping strategies, including wishful thinking, a search for social support, avoidance, and rational problem solving. These patterns of coping suggest that nurses must take a pragmatic
approach to dealing with institutional stressors, perhaps because these problems appear amenable to change. In contrast, personnel-related stressors draw on multiple coping resources, perhaps depending on the nature, extent, and context of the problem. Nurses coped with stress associated with patient care primarily through acceptance. This finding was clarified when the coping responses for individual stressors were inspected. Nurses relied on wishful thinking and avoidance to deal with exposure to HIV, spiritual coping when informing patients of an HIV diagnosis or disease progression, positive appraisal when coping with families, and problem solving when dealing with treatment dilemmas. In contrast, there was no clear pattern of coping with death, and none of the coping strategies seemed relevant to coping with resistant patients. Caring for chronically ill patients and dealing with life and death issues such as suicide, end of life issues, and patient deaths are among the major sources of emotional exhaustion for nurses in AIDS care (Leiser, Mitchell, Hahn, Slome, & Abrams, 1998; Young & Ogden, 1998). Failure to cope with these issues therefore poses a serious threat to job satisfaction and to retention of nurses who care for patients with HIV/AIDS. Directions for Future Research and Practice One of the major findings in this study was an empirically derived schema of work-related stressors associated with HIV/AIDS nursing care. It is therefore essential that the classification of stressful experiences
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established in the sample be replicated and cross-validated, through means including generalization to other areas of AIDS care. Future research is also needed to assess nurses’ access to coping resources and interventions as well as evaluations of relative effectiveness of strategies for managing various work-related stressors. Identification of the strategies that nurses use to address specific stressful events was a necessary first step in the study. However, an analysis of coping effectiveness in relation to the work-related stressful events should be undertaken. Finally, research is needed to evaluate the effects of training, supervision styles, and organizational supports on the reduction of work- related stress in AIDS nursing care. Interventions are needed to assist nurses working in AIDS care to cope with work-related stressors. It is common for institutions to address occupational stress and staff burnout through the establishment of support groups. Although the nurses reported seeking social support for management of personnel problems and dealing with death, there was only modest endorsement for this coping strategy. Support groups for providers therefore may offer limited benefits for nurses experiencing occupation-related stress; accordingly, staff development for coping resources must extend beyond support groups in assisting nurses. Interventions that assess nurses’ individual stress experiences can help in the development of coping skills that match the nature of the stressors (Lazarus & Folkman, 1984). For example, using problem solving as a coping strategy for dealing with patient deaths will not enhance adjustment, because deaths are not a factor within the control of the nurses. The effects of dealing with death, however, can be mitigated by positive appraisal and acceptance coping. On the other hand, problem solving can be effective in coping with treatment dilemmas, which are managed by the treatment team. Therefore, interventions to help nurses identify the appropriate fit between coping strategies and specific sources of stress will likely yield the most favorable results in assisting nurses in the management of occupational stress.
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References Barbour, R. S. (1994). The impact of working with people with HIV/AIDS: A review of the literature. Social Science Medicine, 39, 221-232. Bennett, L., & Kelaher, M. (1994). Longitudinal predictors of burnout in HIV/AIDS health professional. Australian Journal of Public Health, 18, 334-336. Bennett, L., Kelaher, M., & Ross, M. (1993, June). Longitudinal determinants of patient care-related stress in HIV-AIDS health professionals. Paper presented at the IXth International Conference on AIDS, Berlin. Bennett, L., Kelaher, M., & Ross, M. (1994). Quality of life in health care professionals: Burnout and its associated factors in HIV/AIDS related care. Psychology and Health, 9, 273-283. Bennett, L., Miller, D., & Ross, M. (1995). Review of the research to date on impact of HIV/AIDS on health care workers. In L. Bennett, D. Miller, & M. Ross (Eds.), Health workers and AIDS: Research, intervention and cultural issues in burnout and response (pp. 15-34). London: Harwood. Cooper, C. L., & Mitchell, S. J. (1990). Nursing the critically ill and dying. Human Relations, 43, 297-311. De Gucht, V., Fischler, B., & Demanet, C. (1999). Immune dysfunction associated with chronic professional stress in nurses. Psychiatry Research, 85, 105-111. Fimian, M. J., Fastenau, P. S., & Thomas, J. (1989). Stress in nursing and intentions to leave the profession. Psychological Reports, 62, 499-506. Gueritault-Chalvin, V., Kalichman, S. C., Demi, A., & Peterson, J. (in press). Work-related stress and occupational burnout in AIDS caregivers: Test of a Coping Model. AIDS Care. Kleiber, D., Enzman, D., & Guzy, B. (1993). Stress and burnout among health care personnel in the field of AIDS: Causes and prevalence. In H. Van Dis & E. Van Dongen (Eds.), Burnout in HIV/AIDS health care and support: Impact for professionals and volunteers (pp. 23-40). Amsterdam: University of Amsterdam Press. Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Leiser, R. J., Mitchell, T., Hahn, J., Slome, L., & Abrama, D. J. (1998). Nurses’ attitudes and beliefs toward assisted suicide in AIDS. Journal of the Association of Nurses in AIDS Care, 9, 26-33. Patton, M. Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park, CA: Sage. Tabachnick, B. G., & Fidell, L. S. (1989). Using multivariate statistics (2nd ed.). New York: Harper & Row. Young, M. G., & Ogden, R. (1998). End-of-life issues: A survey of English speaking Canadian nurses in AIDS care. Journal of the Association of Nurses in AIDS Care, 9, 18-25.
Sources of Occupational Stress and Coping Strategies Among Nurses Working in AIDS Care Seth C. Kalichman, PhD, Violaine Gueritault-Chalvin, MS, and Alice Demi, PhD
Nurses working in AIDS care experience high rates of occupational stress and therefore are vulnerable to emotional exhaustion and occupational burnout. This study surveyed 499 members of the Association of Nurses in AIDS Care regarding their work-related stress experiences and coping strategies for managing stress. Qualitative analyses identified a hierarchical structure of occupational stress, with two supraclusters representing workplace and patient care-related stress and eight specific subclusters of stressors: institutions, personnel, biohazards, death, informing patients, challenging patients, families, and treatment dilemmas. Analyses showed that nurses experiencing stress from their workplace were significantly more likely to use wishful thinking, planful problem solving, and avoidance as coping strategies, whereas stress originating from patient care was more likely to be dealt with using positive appraisal and acceptance. Interventions designed to assist nurses in managing occupational stress and to prevent occupational burnout must include the sources of work-related stress among nurses in AIDS care. Key words: AIDS care, occupational stress, HIV/AIDS caregivers
N
urses working in AIDS care experience an array of stressors from multiple sources and therefore are vulnerable to emotional exhaustion and, eventually, to occupational burnout. Research has shown that nurses who provide care to people with HIV/AIDS experience stress with an intensity similarly found among nurses in other areas of chronic care, including
oncology and geriatrics (Kleiber, Enzman, & Guzy, 1993). Health professionals who treat people with AIDS may therefore experience a number of adverse effects of stress, including occupational burnout (Barbour, 1994). Bennett and colleagues (Bennett & Kelaher, 1994; Bennett, Kelaher, & Ross, 1994; Bennett, Miller, & Ross, 1995) have documented high rates of occupational burnout among nurses in AIDS care, implying that AIDS care encompasses significant levels of work-related stress. However, research has not yet described the sources of stress associated with AIDS nursing care. In addition to occupational burnout, stress in nursing is associated with long-term job dissatisfaction (Cooper & Mitchell, 1990) and can lead to immunosuppression and increased susceptibility to illness (De Gucht, Fischler, & Demanet, 1999). Studies suggest that nurses may experience multiple stressors from multiple sources. For example, Fimian, Fastenau, and Thomas (1989) identified eight Seth C. Kalichman, PhD, is associate professor of psychiatry at the Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee. Violaine Gueritault-Chalvin, MS, is a doctoral candidate in psychology at Georgia State University and Alice Demi, PhD, is professor of nursing at Georgia State University. This research was supported by National Institute of Mental Health Grants R01 MH57624 and P30 MH52776. All correspondence should be addressed to Seth C. Kalichman, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226; e-mail: [email protected].
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 11, No. 3, May/June 2000, 31-37 Copyright © 2000 Association of Nurses in AIDS Care
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JANAC Vol. 11, No. 3, May/June 2000
occupational stressors using a factor analysis of the Nurse Stress Inventory: professional distress, patient care and motivation, time and workload management, personal time disruptions, emotional reactions, behavioral manifestations, fatigue, and physiological manifestations. Fimian et al.’s (1989) conceptualization of stress therefore included both sources and internal manifestations of stress. Use of the Nurse Stress Inventory factor analysis also limited the results to that scale’s pool of items. Nevertheless, findings from previous studies indicate that sources of stress experienced by nurses are heterogeneous and may require multiple coping strategies. Specific Aims The study investigated the sources of stress experienced by nurses who provide or supervise care to people with HIV/AIDS and the strategies nurses use in coping with stress. We used qualitative research methods in identifying sources of occupational stress to avoid imposing a priori assumptions on nurses’ perspectives of stress (Patton, 1990). Self-identified sources of stress were organized using a hierarchical framework, with nurses grouped on the basis of identified stressors. Following the categorical analysis of stressors, we compared the nurses’ identification of various sources of stress on coping strategies.
Method
(Gueritault-Chalvin, Kalichman, Demi, & Peterson, in press). The survey included questions about demographic characteristics and work history experiences. To capture a broad range of work-related stress situations, participants were asked to identify “one of the most stressful situations” they have encountered in their jobs rather than the most stressful circumstance. The survey was created in an open-ended format that required participants to write a response in a blank space. Participants were then instructed to think back on the stressful experience they identified and to indicate the degree to which they used 33 coping strategies. The strategies contained in the survey represented 50% of the items in the Ways of Coping Inventory (Lazarus & Folkman, 1984). The Ways of Coping Inventory is a 66-item self-report instrument that measures coping behaviors used in a particular encounter between the person and situation (Lazarus & Folkman, 1984). Items were selected based on previous coping research with health care professionals in AIDS care (Bennett, Kelaher, & Ross, 1993). The items represented a balance of emotion-focused and problem-focused coping behaviors from the original scale. The degree to which participants responded to coping strategies was indicated on a 4-point Likert-type scale, from 0 (not used) to 3 (used a great deal). For the purposes of data reduction, we conducted a principal components factor analysis, using a varimax rotation. Results indicated eight coping factors with eigenvalues greater than 1. They included the following:
Survey Participants and Procedures Participants were members of the Association of Nurses in AIDS Care (ANAC), who returned postal surveys in 1998; 1,500 nurses were randomly selected from a membership list of 3,000. The nurses, who remained anonymous, were mailed the survey, a cover letter explaining the purpose of the study, and a postage-paid return envelope. A total of 523 nurses (35%) returned the surveys, of which 499 were completed. Survey Design The survey was part of a larger study that investigated occupational burnout in AIDS care providers
1. Wishful thinking—defined as thoughts directed at the way one hopes or wishes a problem could be resolved (seven items, such as, “I had fantasies or wishes about how things might turn out”); 2. Positive appraisal—thoughts focused on placing the problem in a positive light (four items, such as, “I changed or grew as a person in a good way”); 3. Seeking social support—attempts to draw assistance from others (six items, such as, “I talked to someone about how I was feeling”); 4. Planful problem solving—attempts to resolve the problem by taking action (four items, such as, “I made a plan of action and followed it”);
Kalichman et al. / Stress and AIDS Care
5. Avoidance—actively evading the situation (three items, such as, “I slept more than usual”); 6. Acceptance—resigning oneself to the realities of the situation (four items, such as, “I accepted it, since nothing could be done”); 7. Rational problem solving—attempts to use logic and reasoning in resolving the situation (three items, such as, “I tried to analyze the problem in order to understand it better”); and 8. Spirituality—drawing on faith and prayer to manage the situation (two items, such as, “I found new faith”). Factor scores were calculated for each factor and were used as dependent measures in subsequent analyses. Factor scores by definition are internally consistent, weighted linear composites of all items included in the factor analysis. Factor scores provide standardized scores with a mean of 0 and a standard deviation of 1 (Tabachnick & Fiddell, 1989). Data Analyses The first step in the data analyses involved qualitative analysis of responses to the open-ended question on stress. Responses were individually sorted into categories using a systematic hierarchical structuring scheme. They first were sorted into two supraclusters that represented common themes of stress resulting from aspects of the workplace: (a) work environment and (b) stressors resulting from patient care. In the second sorting iteration, sources of stress were divided into subclusters according to content themes that represented common features of the stressful situations. This process was taken to a third iteration, which yielded a finer description of stressors within each subcluster. The criteria for classification development were shared situational properties, mutual exclusivity, and conceptual clarity (Patton, 1990). Nurses therefore were grouped on the basis of the situations they identified as being among their most stressful. Quantitative analyses, or analyses of variance, were conducted to examine differences in nurses’ coping strategies. These analyses also were conducted hierarchically, first testing for differences between the two supra-c lusters (workplace vs. patient care stress groups), with
33
significant differences followed by analyses testing for differences between the eight-stressor subclusters. Significance tests involving coping strategies were first conducted with MANOVAs on the eight factor scores that were derived from the principal components analysis. Significant differences indicated from the MANOVAs were subsequently examined using ANOVAs. Results The mean age of participants was 44.0 (SD = 9.3, range = 23-74). The majority of respondents were women (84%); 16% were men. Participants had been employed a median of 17 years in nursing, with a median of 7 years working in AIDS care. A total of 88% of participants currently provided direct patient care to persons living with HIV/AIDS, 53% had administrative duties, 70% were involved in teaching, and 46% held supervisory positions. In terms of nursing degrees, 50% were RNs, 37% were BSNs, 31% held an MSN, and 4% had their PhD (totals exceed 100% because some nurses held more than one degree). Of the 499 nurses who returned completed surveys, 474 provided responses to the open-ended question regarding work-related stressors. Analyses showed that 60 stressors could not be categorized into the resulting framework (examples include coping with one’s own HIV infection, dealing with child abuse, and providing emergency care to plane crash victims); therefore, remaining analyses were conducted on the 414 nurses who provided stress responses within the empirically derived structure. Results of qualitative response sorting showed that occupational stressors identified by nurses in AIDS care were hierarchically structured into three substantive levels: two supraclusters that represented stressors associated with the workplace and patient care, further delineated into eight major clusters of institution- and personnel-related stressors in the workplace and the patient care stressors associated with biohazards, deaths, informing patients, challenging patients, families, and treatment dilemmas. Figure 1 presents the hierarchical framework of occupational stressors identified by nurses. Sixty-four percent of participants providing stress responses identified patient care as their most
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Figure 1. Differences on Factor Scores of Eight Coping Strategies Between Nurses Identifying Workplace Stressors and Nurses Identifying Patient Care Stressors
significant source of stress, versus 36% of nurses identifying sources of workplace-related stress. Inspection of stress subclusters shows that 20% of nurses identified personnel issues and 20% identified challenging patients as their leading sources of stress. The most frequently identified specific sources of stress within subclusters were staff conflicts (11%) and dealing with resistant patients (7%). To assess the reliability of the classification of responses, an independent rater sorted the stressful situations into the classification system with 90% agreement. Discrepancies were resolved through discussion and consensus between raters; thus, the classification system appeared reliable. Nurses experiencing different sources of stress were subsequently compared on demographic and work history characteristics as well as the eight coping factors.
Demographic and Career Characteristics Analyses testing for differences between nurses who identified workplace stressors versus those who identified patient care stressors failed to indicate significant differences in demographic and nursing career characteristics, such as age, years of nursing, years of working in AIDS, patient loads, or highest nursing degree. Thus, workplace versus patient care situations identified as the most stressful experiences could not be accounted for by individual, employment, or career characteristics of nurses. Coping Strategies Results of a MANOVA showed that nurses who identified workplace-related stressors differed
Kalichman et al. / Stress and AIDS Care
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Figure 2. Hierarchical Structure of Occupational Stressors Identified by Nurses Working in AIDS Care
significantly from nurses who identified patient care stressors on the eight coping strategies, F(8, 403) = 6.31, p < .01. Subsequent ANOVAs showed that nurses who identified workplace stressors as their most stressful experience reported using significantly more wishful thinking, F(1, 403) = 7.01, p < .01, planful problem solving, F(1, 403) = 15.22, p < .01, rational problem solving, F(1, 403) = 3.60, p < .05, and avoidance coping, F(1, 403) = 11.71, p < .01, compared with nurses who identified patient care stressors. However, nurses reporting patient care stressors used significantly more acceptance for coping, F(1, 403) = 5.05, p < .05, with a trend toward using more positive appraisal, F(1, 403) = 3.03, p < .08 (see Figure 2). Because differences were detected between nurses within the two supraclusters of occupational stressors, we conducted further analyses between the eight subcluster groups. Results of a MANOVA showed significant differences between groups on all eight types of coping strategies used for managing occupational stress, F(8, 397) = 4.27, p < .01. As shown in Table 1, institutional sources of stress were most likely confronted using planful problem solving; personnel stressors were most likely faced through avoidance, wishful thinking, and rational problem solving; stressors from biohazards, such as needle-stick injuries,
were met through wishful thinking and avoidance coping; the death stressor was confronted through positive appraisal and acceptance; and the stress of informing patients was countered through spirituality. Nurses indicated few resources for coping with challenging patients, whereas coping with patients’ families drew on positive appraisal and acceptance. Finally, treatment dilemmas, including ethical issues and concerns about quality of care, were most commonly confronted through planful and rational problem-solving strategies.
Discussion Study Limitations About 1 in 3 of the nurses sampled returned completed surveys, a rate consistent with other published surveys of professionals. This survey response rate therefore limits the generalizability of our study findings. In addition, we sampled members of an association of nurses working in the AIDS field and heavily involved in teaching and supervision. This group probably does not represent the larger number working directly with AIDS patients. Finally, we relied on a
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JANAC Vol. 11, No. 3, May/June 2000
Table 1. Differences Between Nursing Occupational Stress Groups on Eight Coping Strategy Factors
Sources of Stress Institution Personnel Biohazards Death Informing patients Challenging patients Families Treatment dilemmas F(7, 397) p
Wishful Thinking
Positive Appraisal
.01 .25 .72 –.24 –.27 –.03 –.65 .15 4.9 .01
–.15 –.11 .35 .29 –.12 –.25 .31 –.10 2.9 .05
Seeking Social Support –.19 .22 –.34 .20 .15 –.12 –.02 –.03 1.9 .08
Planful Problem Solving
Avoidance
.40 .08 .16 –.55 –.19 –.09 –.07 .51 7.0 .01
.09 .26 .64 –.28 –.93 .11 –.25 –.53 7.3 .01
Rational Problem Acceptance Solving .02 –.22 .35 .27 .03 –.04 .25 –.26 2.3 .03
–.07 .24 –.37 –.21 –.26 .03 –.28 .42 2.9 .01
Spirituality .18 –.16 .33 .20 .48 .28 –.14 –.68 5.0 .01
NOTE: Range = –1 to 1, with higher positive scores indicating stronger endorsement of coping strategies.
standardized measure of coping responses to investigate attempts at occupational stressor adjustment. Nurses therefore may draw on additional coping resources and strategies not captured by our measure. Finally, nurses were asked to recall a stressful event and reflect on how they coped in that situation. The retrospective data were therefore susceptible to distortion and to other sources of memory bias. The current findings therefore must be considered with regard to these methodological limitations. Interpretation of Findings Among nurses working in AIDS care, this study identified 32 different categories of occupational stress experiences. More than one third of stressful events involved institutional settings and personnel aspects of work environments. Stress resulting from sources directly associated with the workplace were confronted through a range of both emotion-focused and problem-focused strategies, including wishful thinking, avoidance, planful problem solving, and rational problem-solving strategies. On closer inspection, it was indicated that institutional stressors, such as administration, managed care, and workload, were most often managed using planful problem solving. However, stress associated with personnel, such as staff conflicts and dealing with supervisors and management, drew on several coping strategies, including wishful thinking, a search for social support, avoidance, and rational problem solving. These patterns of coping suggest that nurses must take a pragmatic
approach to dealing with institutional stressors, perhaps because these problems appear amenable to change. In contrast, personnel-related stressors draw on multiple coping resources, perhaps depending on the nature, extent, and context of the problem. Nurses coped with stress associated with patient care primarily through acceptance. This finding was clarified when the coping responses for individual stressors were inspected. Nurses relied on wishful thinking and avoidance to deal with exposure to HIV, spiritual coping when informing patients of an HIV diagnosis or disease progression, positive appraisal when coping with families, and problem solving when dealing with treatment dilemmas. In contrast, there was no clear pattern of coping with death, and none of the coping strategies seemed relevant to coping with resistant patients. Caring for chronically ill patients and dealing with life and death issues such as suicide, end of life issues, and patient deaths are among the major sources of emotional exhaustion for nurses in AIDS care (Leiser, Mitchell, Hahn, Slome, & Abrams, 1998; Young & Ogden, 1998). Failure to cope with these issues therefore poses a serious threat to job satisfaction and to retention of nurses who care for patients with HIV/AIDS. Directions for Future Research and Practice One of the major findings in this study was an empirically derived schema of work-related stressors associated with HIV/AIDS nursing care. It is therefore essential that the classification of stressful experiences
Kalichman et al. / Stress and AIDS Care
established in the sample be replicated and cross-validated, through means including generalization to other areas of AIDS care. Future research is also needed to assess nurses’ access to coping resources and interventions as well as evaluations of relative effectiveness of strategies for managing various work-related stressors. Identification of the strategies that nurses use to address specific stressful events was a necessary first step in the study. However, an analysis of coping effectiveness in relation to the work-related stressful events should be undertaken. Finally, research is needed to evaluate the effects of training, supervision styles, and organizational supports on the reduction of work- related stress in AIDS nursing care. Interventions are needed to assist nurses working in AIDS care to cope with work-related stressors. It is common for institutions to address occupational stress and staff burnout through the establishment of support groups. Although the nurses reported seeking social support for management of personnel problems and dealing with death, there was only modest endorsement for this coping strategy. Support groups for providers therefore may offer limited benefits for nurses experiencing occupation-related stress; accordingly, staff development for coping resources must extend beyond support groups in assisting nurses. Interventions that assess nurses’ individual stress experiences can help in the development of coping skills that match the nature of the stressors (Lazarus & Folkman, 1984). For example, using problem solving as a coping strategy for dealing with patient deaths will not enhance adjustment, because deaths are not a factor within the control of the nurses. The effects of dealing with death, however, can be mitigated by positive appraisal and acceptance coping. On the other hand, problem solving can be effective in coping with treatment dilemmas, which are managed by the treatment team. Therefore, interventions to help nurses identify the appropriate fit between coping strategies and specific sources of stress will likely yield the most favorable results in assisting nurses in the management of occupational stress.
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