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Letter to the Editor

Mental Health of Chinese Nurses in Hong Kong: The Roles of Nursing Stresses and Coping Strategies

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Daniel Fu Keung Wong, PhD, MSW, BSW, RSW
Sharon Shui King Leung, MSW, RSW
Christopher Ko On So, MSW, BSW, RSW
Debbie Oi Bing Lam, PhD, Msoc Sci, Bsoc Sci

Abstract

This study examined the sources of stress and mental health of nurses in Hong Kong. It also attempted to explore the functions of coping strategies in determining the stress and mental health of nurses. Results showed that more than one-third of the nurses could be considered as having poor mental health. While supervisory role produced the highest level of stress, organizational environment also created a substantial amount of stress for nurses. The most frequently used coping strategies were positive ones, including direct action coping and positive thinking. This study confirmed the hypotheses that nurses who adopted more positive and fewer negative coping strategies had better mental health, but failed to substantiate the moderating effects of coping on stress and mental health of nurses. Changes in the hospital care delivery system and socio-cultural factors in Hong Kong were put forward to explain the results. Implications of the findings and limitations of the study were discussed.

Citation: Wong, D., Leung, S., So, C., Lam, D. (May 1, 2001) "Mental Health of Chinese Nurses in Hong Kong: The Roles of Nursing Stresses and Coping Strategies" Online Journal of Issues in Nursing. Vol. 6 No. 2. Available www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume62001/No2May01/ArticlePreviousTopic/MentalHealthofChineseNursesinHongKong.aspx

Keywords: nursing stress, mental health, coping strategies, Chinese nurses in Hong Kong

Introduction

The nursing profession is increasingly characterized by occupational stress, frequent job turnover, and job dissatisfaction (Cooper, 1986; Hawley, 1992). Nurses attend to the emotional needs of patients and their families, as well as undertake managerial responsibilities such as supervising junior staff. The demands of these roles make nurses vulnerable to stress and psychological ill health (Glass, McKnight & Valdimarsdottir, 1993).


Developments in medical science and technology, rapid patient turnover, the rising dependency level of patients, and the emergence of professionalism in nursing have increased the complexity and volume of nursing care.

The establishment of the Hospital Authority in Hong Kong led to major reforms aimed at providing more patient-centered and outcome-oriented services (Medical Services Development Committee, 1995). Nurses now have greater management responsibilities at both the ward and hospital levels (Medical Services Development Committee, 1995). Developments in medical science and technology, rapid patient turnover, the rising dependency level of patients, and the emergence of professionalism in nursing have increased the complexity and volume of nursing care.

Nurses have experienced a number of difficulties since the establishment of the Hospital Authority in Hong Kong. First, the introduction of ward manager has created a great deal of role confusion for nurses in the ward (Chan, 1993). Under the new structure, a ward manager is in charge of the management and administration of the ward while a nursing officer is given the tasks to supervise clinical nurses to carry out direct patient care. However, clinical nurses, ward managers, and nursing officers have found that it is difficult to clearly separate clinical activities from administration. As a result, they are not sure who is responsible for making decisions on certain ward activities (Chung, 1994).

Another difficulty faced by nurses in the ward is increased demand for administrative accountability. Under the new structure, nurses have to produce more statistics and written reports on their activities on the ward. While nurses support the idea of quality assurance, and are willing to produce the reports, they often feel torn between spending time in direct patient care and administrative activities. Indeed, nurses have alleged that they have to perform a great amount of administrative duties on the ward (Mok & Chan, 1996).

This is perhaps closely related to the third difficulty experienced by nurses. Hospital Authority is in charge of manpower planning and recruitment of new nurses. The introduction of the new structure has appeared to create more administrative work for nurses while failing to ease the longstanding shortage of hospital nurses in Hong Kong. As a result, nurses experience even more burden at work. The Hospital Authority has cited a shortage of 580 nurses in Hong Kong (about 3.5%) (South China Morning Post, April, 1996). Consequently, nurses are required to work longer hours with fewer resources. This may explain why the turnover rate for nurses increased from 4.1% in 1986 to 12% in 1991 (Medical Services Development Committee, 1996).

Some of the stresses mentioned above are an inherent feature of the profession while others stem from institutional practices. However, there is little research on the sources of nursing stress experienced by nurses and on the ways in which nurses cope with stresses at work in Hong Kong. The purpose of this study was to (a) explore the sources of nursing stress of nurses in Hong Kong, (b) examine the general mental health of nurses in Hong Kong, (c) understand the coping strategies used by nurses when they are under stress, and (d) examine how coping strategies affect the mental health of nurses.

Conceptual Framework

This study employed a transactional model of stress and coping in exploring the stress, coping and mental health of nurses in Hong Kong. According to this model (Lazarus & Folkman, 1984), stress is an outcome of a transaction or relationship between the person and the environment. When the environmental stressors are perceived by an individual to be demanding and to have exceeded his/her personal resources to cope with them, the person will experience stress. Using this model, there are three major sets of variables that can be identified: (a) sources of nursing stress, (b) outcomes of stress, and (c) intervening factors.

Sources of Nursing Stress

Sources of stress are perceived as environmental stressors that directly impact on the mental health of an individual, and also elicit coping responses. Many studies that have explored the sources of stress of nurses (e.g. Bailey & Walker, 1980; Heim, 1991; Numerof & Abrams, 1984). Gray-Toft and Anderson (1985) found that workload was cited as the most frequent cause of stress, particularly among student nurses. They maintained that the problems of "too little time" are likely to be exacerbated by conflicting demands and changing priorities in the work place. Nurses had to choose between conflicting priorities among their patients, with physical tasks tending to take precedence over psychological or emotional work.

Direct patient care was also named as one of major source of stress for some nurses, especially the clinical nurses in the wards (e.g. Heim, 1991). Some nurses mentioned that they lacked assertiveness skills in managing "difficult patients."

Numerof and Abrams (1984) identified the organizational environment as a major source of perceived stress. Excessive paperwork, lack of involvement in decision-making, lack of feedback from supervisors regarding job performance, meeting the perceived demands of immediate supervisors, and conflict with other health care providers were also identified as sources of anxiety (Bailey, & Walker, 1980).

Nurses in supervisory roles have also reported job-related stress. Leatt and Schneck (1980) found that head nurses suffered from the difficulties of handling their dual role as clinicians and managers. They also complained of lacking the specialized training that would enable them to feel more able and confident in their management roles.


Internalization of an exclusively subordinate image of nursing could result in reduced self-esteem and acceptance of the handmaiden role, which could in turn produce stress.

The doctor-nurse relationship is another source of stress for nurses. In one study, nurses saw their main function as assisting and supporting the doctor (Buckenham & McGrath, 1983). Internalization of an exclusively subordinate image of nursing could result in reduced self-esteem and acceptance of the handmaiden role, which could in turn produce stress.

In Hong Kong, there are very few studies that have examined the sources of stress faced by nurses. In a few studies conducted by the Hospital Authority, nurses typically spent between 50% and 60% of their time on direct patient care. Another study on nursing activities in the neonatal intensive care unit in 1993 indicated that nurses spent 60% of time on direct patient care and a further 40% on indirect patient care and personal time. Nurses felt that work schedules were determined by crises rather than by planning. However, none of these studies examined stresses faced by nurses in Hong Kong.

This study attempted to identify the sources of nursing stress experienced by nurses in Hong Kong. Sources of nursing stress were defined as environmental stressors that nurses in Hong Kong faced in their daily work situations. The stressors were the organizational environment, work demands, direct patient care, supervisor's role, and doctor-nurse relationships.

Outcomes of Nursing Stress

Studies on stress and coping have examined a variety of outcome variables. These include physical or somatic outcomes such as coronary heart disease, social outcomes such as a loss of a job, and psychological outcomes such as psychological well-being, life satisfaction, and mental health (Golberger & Breznitz, 1982).

Mental health as a psychological outcome has been widely explored. Singh (1989) found that employees who experienced high role stress manifested more symptoms of free floating anxiety, obsessive neurotic depression, hysterical neurosis, phobic anxiety, and somatic concomitants of anxiety. Revicki and May (1989) also found that marital status was significantly related to depression. Married nurses were less likely than unmarried nurses to report symptoms of depression. This study hypothesized that nurses who had more stress would have poorer mental health outcomes.

Generated from the above cited studies, outcome of nursing stress was conceptualized in terms of the number of psychological distress symptoms experienced by nurses, and these symptoms fell into the categories of anxiety, depression and somatic concerns.

Coping as the Intervening Variable

Folkman, Lazarus, Gruen, and DeLongis define coping as "the person's cognitive and behavioral efforts to manage the internal and external demands in the person-environment transaction"(1986, p. 572). In times of stress, an individual normally engages in certain coping strategies to handle the stressful situations and their associated emotions. The more an individual adopts adaptive coping strategies, the less his/her stress, and the better his/her mental health. For example, Havlovic and Keenan (1995) found that employees in business fields most frequently utilized direct action coping to handle job difficulties. This was followed by the use of help-seeking behaviors and positive thinking. However, employees rarely used avoidance and alcohol use to handle difficulties and stresses at work. In another study, Kavsek and Seiffge-Krenke (1996) found that positive coping was correlated with better mental health of adolescents under study.

Tyler and Cushway (1995) found that problem-solving and active coping strategies (e.g. trying to resolve the problem, talking to other nursing colleagues about the problem, considering different colleagues for handling the problem) were most commonly used among nurses. In another study (Frisch, Dembeck, & Shannon, 1991) nurses handled work stress through using personal support networks, broadening the scope of professional concerns, and identifying problem-solving resources. Nurses rarely used avoidance or resignation strategies such as seeing the situation as the result of fate, acting as if nothing had happened, or avoiding being with people.

Some studies have demonstrated a relationship between coping and mental health. Ebata and Moos (1994), Simoni and Peterson (1997) and Strivastava (1991) found that positive coping (e.g. problem solving action, logical analysis, information seeking) was positively related to well-being. In contrast, avoidance coping (e.g. denial or suppression of feelings) was associated with maladjustment to life stress. We hypothesized that nurses who engaged more often in positive coping and less in negative coping would have better mental health.


We hypothesized that nurses who engaged more often in positive coping and less in negative coping would have better mental health.

While the role of coping in nursing stress and mental health has not been well defined, studies in other populations have found that coping moderated the impact of stresses on mental health of the groups concerned (e.g. Kwok & Wong, 2000). This study also examined the moderating effect of coping on nursing stress and mental health of nurses. In other words, we hypothesized that when confronted with high levels of work stress, nurses who utilized more positive and fewer negative coping strategies would have better mental health outcomes.

In this study, coping was referred to as the cognitive and behavioral efforts used by an individual to handle difficulties and stresses at work. Behavioral strategies included direct problem-solving activities, use of alcohol, avoidance and help-seeking behaviors adopted by nurses. Cognitive strategies were those related to positive thinking.

Method

Sample
This study was a one-time cross sectional survey in which data were collected through mailed structured questionnaires. Subjects were selected from the membership list of more than 11,000 registered nurse members of the Association of Hong Kong Nursing Staff. Those whose membership numbers ended in "6" were selected and questionnaires were sent to them accordingly.

Data Collection Procedures
A questionnaire containing items about nursing stress, coping strategies, mental health, and demographic characteristics was distributed to 10 nurses in a pilot test in July 1998. On the whole, participants in the pilot test found the questionnaire agreeable and only very minor modifications were made on the questions regarding the demographic characteristics of respondents.

Since this questionnaire was self-administered, a letter was attached to the front page explaining the purpose of the study, time required to complete the questionnaire, and how to return the questionnaire. Of the 1,000 questionnaires distributed, 269 were completed and returned. Another 72 questionnaires were returned unopened because the recipients had moved. Thus, the actual response rate was about 29%. This relatively low response rate is common in studies using mailed questionnaire.

Instrument
The questionnaire consisted of the following four sections:

  1. Nursing Stress Inventory. The Nursing Stress Inventory was used to examine the sources of nursing stress experienced by nurses in Hong Kong. This scale covered a wider spectrum of nursing stressors and has been used widely in the West (e.g. Numerof & Abrams, 1984). The instrument was developed by Numerof and Abrams (1984), and was translated into Chinese by the research team. It contained 46 items dealing with 6 different areas of nursing stress: organizational environment, work demands, emotional aspects of care, death-related issues, lack of procedural/administrative support, and supervisor's role. Items are scored on a five-point Likert scale, with the anchors of "no stress" (scored as 1) and "a lot of stress" (scored as 5). The Cronbach's alpha score of the scale in this study was 0.96. For its subscales, the Cronbach's alpha scores for organizational environment, work demands, emotional aspects of care, death-related issues, lack of procedural/administrative support and, supervisor's role were 0.83, 0.76, 0.75, 0.86, 0.58, and 0.57 respectively.
  2. Coping Strategies Scale. The Latack's coping subscale was used to measure coping strategies used by nurses to handle nursing stress because this scale had been used with diverse professional groups with good reliability and validity (e.g. Latack, 1986; Latack & Havlovic, 1992) The scale was translated into Chinese by our research team. The instrument has 26 items designed to measure 5 dimensions of coping strategies: avoidance/resignation, positive thinking, direct action, help seeking and alcohol use. The nurse indicates on a Likert scale how often a specific coping strategy was used in the past three months, from "Never" (scored as 1) to "Almost every time" (scored as 5). In this study, the Cronbach's alpha score for the scale was 0.76. For its subscales, the Cronbach's alpha scores for avoidance/resignation, positive thinking, direct action, help seeking and alcohol use were 0.63, 0.77, 0.65, 0.60, 0.69 respectively. When items were regrouped into positive coping (direct action, helping seeking and positive thinking) and negative coping (avoidance/resignation and alcohol use). The Cronbach alpha score for positive coping was 0.81 and negative coping was 0.63.
  3. General Health Questionnaire-30 (GHQ-30): The Chinese version of GHQ-30 validated by Shek (1987) was used to measure the mental health status of nurses because this scale had proven reliability and validity and has been widely used in Hong Kong (e.g. Shek, 1987; Shek & Tsang, 1993). This scale measured the psychological distress symptoms experienced by an individual. There are five factors in this scale: anxiety, depression, sleeping disturbances, social dysfunction, and feelings of inadequacy. Based on the 0-0-1-1 method, (0 = better than before and same as before; 1 = worse than before and much worse than before), respondents who rate a current mental health condition as worse or much worse than before is considered as having a distress symptom (Shek, 1987). An individual who had more than 6 distress symptoms in GHQ-30 is considered at risk of developing poor mental health. The Cronbach's alpha score achieved in this study was 0.92. For its subscales, the Cronbach's alpha scores for anxiety, depression, sleeping disturbances, social dysfunction and feelings of inadequacy were 0.86, 0.84, 0.65, 0.74 and 0.82 respectively.
  4. Personal characteristics of respondents: The questionnaire also requested personal information including age, sex, marital status, education, religion, occupational grade, number of years of service in nursing and number of years of service in unit.

Results
The majority of nurses were female, in their early- to mid- thirties, and worked in direct patient care in the public hospitals of Hong Kong (Table 1).

Table 1
Demographic Characteristics of Respondents (N = 269)

Characteristic

Frequency

Percentage

Sex

Female
Male

244
25

91
9

Age

Below 20
21-30
31-40
41 or above

8
130
95
33

 

3
48.1
35.2
13.7

Marital Status

Single
Married
Separate/divorce

 

141
20
3

 

54.1
44.4
1.5

Religion

No religion
Christian/catholic
Buddhist
Others

 

133
116
6
14

 

49.3
43
2.2
5.5

Education level

Secondary
Undergraduate
Postgraduate

 

222
44
3

 

82.2
16.3
1.5

Types of hospital

Public
Private
Others

 

235
20
14

 

87
7.4
5.6

Types of nurses

Enrolled
Registered
Mid-wives Students
Others

 

165
56
2122
5

 

61.1
20.7
7.88.1
2.3

Types of wards

Emergency
Geriatric
ICU
Medical
Psychiatric
Obstetric
Surgical
Pediatric
Others

 

11
10
27
102
14
24
45
11
25

 

4.1
3.7
10
37.8
5.2
8.9
16.7
4.1
8.5

Ranks of job

Managers
Ward-in-charges
Direct clinical nurses
Others

 

9
20
210
27

 

3.4
7.4
77.8
11.4

Year of service in ward

1-5 years
6-10 years
10 or above

 

211
27
31

 

78.4
10
11.6

Year of service in nursing

1-5 years
6-10 years
11-15 years
16-20 years
20 or above years

 

98
69
39
33
30

 

36.4
25.7
14.5
12.3
11.1

Table 2 documents the intensity of stress among the six sources of nursing stress experienced by nurses in this study. The assumption of a "Supervisor's Role" created the most stress for nurses in this sample. "Death-related Issues" also led to a great deal of the stress experienced by the nurses. Particularly, nurses found taking care of the young terminally ill patients and informing the family that their relative has just died to be stressful. "Organizational Environment" issues included meeting the demands of their supervisors and communication problems with management.

Table 2
Mean Intensity of Sources of Stress (N = 269)

 

Mean

S.D.

Supervisor's Role

3.17 0.91
Death-related Issues

2.92

0.89

Organizational Environment

2.89

0.65

Work Demands

2.86

0.86

Lack of Procedural/Administrative Support

2.58

0.75

Emotional Aspects of Patient's Care

2.56

0.77

Thirty seven percent of the sample had GHQ-30 scores greater than 6, indicating that they were at risk of developing poor mental health (Shek, 1987) (Table 3). The most frequent complaints were "Feelings of Inadequacy in Handling Daily Activities." Nurses felt that they could not concentrate on what they did, and were unhappy about the way they did things. "Anxiety Issues" included feeling constantly under stress and that life is a constant struggle.

Table 3
Mean Factor Scores for GHQ-30 Scale (N = 269)

 

Mean

S.D.

Feeling of Inadequacy

2.28

0.29

Anxiety Issues

2.16

0.54

Social Dysfunction

2.10

0.40

Sleep Disturbance

1.94

0.78

Depression

1.77

0.59

"Direct Action" coping strategies were the most frequently used among the five types (Table 4). These included strategies such as trying to work harder, being more efficient, and reorganizing the work. The second most frequently used group of coping strategies was "Positive Thinking." These included reminding oneself that one is equally competent to handle situation that others have succeeded in doing, and perceiving the difficult situation as one that gives opportunity for learning. Respondents also used "Avoidance/Resignation" to handle stressful situations. One such strategy was to try to tell oneself not to worry about the problems. Within the group of "Help-seeking Strategies," consulting with others (other than your boss) about ways of solving problems was the most frequently used strategy. However, it was found that "Alcohol Use" was the least frequently used group of coping strategies. Respondents tended to use more positive, behavioral and cognitive coping strategies to handle stressful situations at work. In terms of "Negative Coping Strategies," respondents used more "Avoidance/Resignation" and very little "Alcohol Use" to deal with their stress.

Table 4
Mean Coping Strategy Scores (N = 269)

 

Mean

S.D.

Direct Action

3.44

0.45

Positive Thinking

3.23

0.60

Avoidance/Resignation

3.14

0.50

Help-Seeking

3.11

0.50

Alcohol Use

1.21

0.45

Positive Coping

3.25

0.41

Negative Coping

3.14

0.50

One-way ANOVA showed that nurses with tertiary education had significantly better mental health, fewer depressive symptoms, and used more positive coping strategies than nurses with secondary school education. They also were better able to utilize help-seeking strategies than the ones with secondary school education (excluding the professional nursing training), F= 4.55, p < 0.05; F = 4.69, p < 0.05; F = 4.69, p < 0.05; F = 4.46, p < 0.05 respectively. Nurses holding administrative positions in the hospitals utilized significantly more direct action, help-seeking and positive coping strategies than nurses performing clinical duties, F = 7.24, p < 0.001; F = 9.93, p < 0.001; F = 7.93, p < 0.001 respectively.

The intensity of stress experienced by nurses correlated positively and significantly with their mental health, as indicated by GHQ-30 (Table 5). It should be noted that about half of the questions in the Nursing Stress Inventory might not be applicable to all respondents; hence the number of responses to this inventory varied. Among those potentially "not applicable" questions, the number of respondents choosing "not applicable" ranged from 27 to 193 cases. Further analyses of the subscales revealed that anxiety, depression and overall mental health level correlated significantly with all subscales of stress, which included organizational environment, emotional aspects of care, death issue, supervisor's role and work demands.

Table 5
Correlations between Nursing Stress and Mental Health

 

GHQ
-30

A
n
x
i
e
t
y

D
e
p
r
e
s
s
i
o
n

Feelings of Inadequacy

Social Dysfunction

Sleep Disturbance

Nursing Stress

0.19**

0.31***

0.23***

0.04

0.05

0.11

Organizational Environment

0.32***

0.36***

0.34***

0.09

0.18**

0.2**

Death Issue

0.15*

0.15*

0.18**

0.05

0.06

0.18

Emotional Aspect of Care

0.19**

0.23***

0.23***

0.04

0.05

0.11

Work Demand

0.23***

0.26***

0.28***

0.06

0.06

0.13*

Lack of Procedure / Administrative Support

0.21***

0.24***

0.24***

0.06

0.08

0.11

Supervisor's Role

0.32**

0.37***

0.36***

0.06

0.17

0.27*

*

p < 0.05, **p < 0.01, ***p < 0.001

Table 6 presents the correlations between coping and mental health of the respondents. Generally speaking, the more the respondents used positive coping strategies, the better their mental health outcome (r = -0.21, p < 0.001). Similarly, the more respondents used negative coping strategies, the poorer their mental health (r = 0.238, p < 0.001). The Coping Scale contained several questions that might not be applicable to all respondents; hence the number of responses to this scale varied. Those who chose "not applicable" ranged from 23 to 89 cases. Analyses of subscales revealed that direct action coping strategies were not related to any of the mental health subscales as indicated by GHQ-30. While fewer anxieties were related to more positive thinking and fewer avoidance coping strategies, fewer depressive symptoms were correlated significantly with more positive coping, more help-seeking behaviors and fewer avoidance coping strategies. The symptoms of social dysfunction were related to fewer positive coping strategies and more avoidance coping strategies. Likewise, sleep disturbance was related to the use of fewer positive thinking. It could be concluded that positive coping strategies were consistently related to better mental health. In contrast, avoidance behaviors were consistently related to poorer mental health.

Table 6
Correlations between Coping Strategies Used and Mental Health

 

Direct Action

Help-
seeking

Positive Thinking

Avoidance

Alcohol Drinking

Positive Coping

Negative Coping

Anxiety

0.03

-0.10

-0.23***

0.20***

0.17**

-0.14*

0.27**

Depression

-0.08

-0.17**

-0.28***

0.26***

0.07

-0.23***

0.24**

Feelings of Inadequacy

0.05

-0.03

-0.08

0.19**

0.06

-0.03

0.19**

Social Dysfunction

-0.04

-0.10

-0.22

0.16**

0.02

-0.17**

0.14**

Sleep Disturbance

-0.01

-0.02

-0.23***

0.07

0.03

-0.13*

0.08

GHQ-30

-0.00

-0.14*

-0.29***

0.24***

0.06

-0.21***

0.24***

p < 0.05, **p< 0.01, ***p< 0.00

Hierarchical regression analyses were performed to explore the independent and moderating effects of nursing stress and different coping strategies on the mental health of respondents (Table 7). First, nursing stress was entered in a block, and was followed by the five types of coping strategies which were entered separately into the equation to predict the mental health of respondents. Lastly, the interaction effects of positive coping and nursing stress and negative coping and nursing stress were entered separately as well. Results showed that the total explained variance of all these variables on mental health was 22.2%, R = 0.47 (8, 260), F = 9.30, p < 0.001. Positive thinking alone contributed about 8.8% of the changes in the mental health of respondents, R= 0.27 (1, 267), F = 21.49, p < 0.001. Nursing stress also explained about 7.4% of the variance in mental health of nurses, R = 0.43 (3, 265), F = 19.55, p < 0.001. However, the interaction effects of nursing stress and positive coping and nursing stress and negative coping did not make any significant contribution to the mental health of nurses. Thus, coping did not appear to moderate the effect of nursing stress on mental health of nurses.

Table 7
Hierarchical Regression of Mental Health on Coping Strategies and Nursing Stress of Respondents

 

Beta

R2

R2 Change

F Change

Step 1

Nursing Stress

0.27

0.07

 

21.49***

Step 2

Avoidance and Resignation

0.17

0.10

0.03

7.77**

Step 3

Positive Thinking

-0.28

0.18

0.08

26.04***

Step 4

Direct Action

0.13

0.19

0.01

4.18*

Step 5

Help-seeking

-0.08

0.20

0.00

1.62

Step 6

Alcohol Use

0.15

0.22

0.02

7.78**

Step 7

Nursing Stress X

Positive Coping

0.01

0.22

0.00

0.00

Step 8

Nursing Stress X

Negative Coping

0.15

0.22

0.00

0.10

*p< 0.05, **p< 0.01, ***p< 0.001

Discussion

Although this was a randomized sample of nurses taken from the Association of Hong Kong Nursing Staff, the population was unlikely to be exhaustive because some nurses did not join the Association. Another drawback of this study was that the Coping Strategies Scale had not been validated for use in the Chinese population, and further and more rigorous tests are needed to establish its validity. It also will be important to establish the normative scores for Chinese population for this instrument. This will facilitate meaningful cross-cultural comparisons of similar groups such as nurses. This study explored certain variables that might contribute to the mental health of nurses in Hong Kong. The relatively low explained variances obtained in this study points to the need to examine other variables that may have more influence on mental health of nurses. For example, social support has been found to intervene in the relationship between job stress and psychological outcomes of nurses (e.g. Anderson, 1991; Constable & Russell, 1986).

Health-care System Variables

Decentralization of responsibilities, outcome-oriented service and patient-centered service are three aspects of the "new management initiative" of the Hospital Authority in Hong Kong (Medical Services Development Committee, 1993) that might have been related to the high level of stress found among nurses in this sample. With the decentralization of responsibilities to the ward level, nurses, particularly the ward managers, have taken up more managerial responsibilities, including the supervision of ward nurses, the accomplishment of a wide range of organizational operations and resource management, as well as the delivery of quality patient-centered care. They are also required to work independently and efficiently and with very little support from other medical personnel. It is no wonder why nurses performing supervisory roles experienced the highest level of nursing stress, and poor mental health. Indeed, ward managers had to assume managerial responsibilities that they had never encountered before. Many might not have had the managerial training to perform the supervisory roles. Thus, some of them might experience feelings of incompetence and fear of making mistakes. This finding substantiates that of Gray-Toft and Anderson (1981), who found that work stress was the result of dual lines of authority imposed by medical and administrative staff which created inter-role conflict and ambiguity among nurses.

Under the outcome-oriented service approach initiated by the Hospital Authority, nurses have to produce a greater amount of statistics and written reports on their activities. While the goal of this outcome-oriented approach is to ensure quality of nursing services, nurses often find themselves torn between spending time on direct patient care and increased administrative duties (Mok & Chan, 1996). Nurses in this study experienced stresses commonly associated with organizational environment and work demands, such as meeting the demands of supervisors and doctors, dealing with the conflicting demands of administration and management, and meeting the needs of patients (Simoni & Peterson, 1997; Tyler, Carroll & Cunningham, 1991; Tyler & Cushway, 1995).

In the past, patients were passive recipients in the health care system and most of them were unaware of their own rights. As a result, the stress generated from patients' demands was comparatively less. However, the increased emphasis on "patient-centered service" by the Hospital Authority in Hong Kong (Medical Services Development Committee, 1995), has resulted in a corresponding increase in expectations for the quality of patient care. Patients have become more aware of their rights. As the public calls for a health system of greater accountability, such demands from patients and the public may exert additional challenges as well as create considerable stress among medical professionals, particularly nurses.

Given that nurses in this sample experienced a great deal of stress at work, it is certainly not surprising to find that nursing stress alone explained about 7.4% of the variance in the mental health of nurses. Indeed, 37.5% of nurses in the sample were at risk of developing poor mental health. In general, they felt inadequate in handling daily activities and were anxious about overcoming problems or making mistakes. This percentage is much higher than a number of local studies on other target groups such as parents with disabled children in Hong Kong and parents with younger children. The percentages in the two studies were 23.8 and 31 respectively (Kwok & Wong, 2000; Shek & Tsang, 1993). The high incidence in this sample can be explained at least partially by the above-mentioned changes in the health care delivery system.

Sociocultural Factors

Nurses with tertiary education tended to have better mental health, fewer depressive symptoms, more positive coping strategies and were better able to use help-seeking coping than nurses with secondary education. One possible explanation is that nurses with tertiary education are more equipped with the knowledge and skills to provide direct patient care to patients. Moreover, tertiary education could improve the confidence and sense of commitment to the job among nurses.

The present study also found that married nurses had significantly better mental health, fewer symptoms of depression, social dysfunction and feelings of inadequacy than nurses who were unmarried. Married nurses may receive support and understanding from their spouses, and thus buffer them from building up stresses at work. These findings are consistent with studies done by Boey (1999) and Tyler and Cushway (1995).

The most commonly used coping strategies by the nurses in this study were those involving direct action and problem-solving, such as spending more time and energy on solving the problem, trying to organize work more efficiently, and planning work in a way that is manageable. This is consistent with previous findings (Boey, 1998; Boey, Chan & Ko, 1998), and may be due to a stronger sense of self-efficacy in well-educated professionals, who would be more prone to adopt direct action strategies to deal with work stress (Lu and Chen, 1996). In addition, the frequent use of direct action strategies is said to reflect the pragmatic nature of Chinese people in dealing with difficulties in life. Indeed, Hwang (1977) and Wong and Kwok (1997) found that Chinese subjects actively utilized personal resources to help them deal with difficulties in life.

Positive thinking was another coping strategy frequently used by nurses to handle their work stress. The frequent utilization of strategies such as "remind oneself that if other has succeeded in handling the situation, so can I" and "perceive the situation as one that gives opportunity for learning" appeared to have helped the nurses in this sample persevere in difficult work situations. These strategies may have allowed the nurses to continue to adopt direct action coping strategies to handle their difficulties at work.


Our sample of nurses adopted fewer avoidance/resignation strategies. One way of explaining this is that, although nurses faced a great deal of work stress, they felt they could still manage the situations and did not have to resign and accept the situations as unalterable.

The less frequent use of avoidance/resignation strategies reinforces the observation that nurses in this sample were generally more inclined to take actions to resolve a problem than to avoid it. However, when avoidance/resignation strategies were used, nurses in this sample tended to "try not to worry too much about the problem" or "to accept that nothing can be done as the situation cannot be changed." The utilization of avoidance/resignation strategies is consistent with the Chinese Taoist philosophy of doing nothing, which suggests that individuals in adverse life circumstances have to persevere, and accept whatever comes before them (Hwang, 1977; Shenkar & Ronen, 1987). Our sample of nurses adopted fewer avoidance/resignation strategies. One way of explaining this is that, although nurses faced a great deal of work stress, they felt they could still manage the situations and did not have to resign and accept the situations as unalterable. This argument is supported by the fact that nurses in this sample used positive thinking strategies frequently to handle work stress.

Coping as a Moderator of Nursing Stress and Mental Health

The findings of this study supported the hypothesis that the more positive coping strategies used, particularly positive thinking and help-seeking strategies, the better the mental health of nurses, in terms of less anxiety, depression, and social dysfunction. In contrast, avoidance coping was significantly associated with poorer mental health. These findings are consistent with a number of overseas studies (Boey, Chan & Ko, 1998; Boumans & Landeweerd, 1992; Revicki & May,1989).

The findings did not demonstrate the moderating effects of coping on nursing stress and mental health. Rather, results showed that positive thinking, direct action coping strategies, avoidance/resignation, and alcohol use exerted direct effects on the mental health of respondents. Particularly, positive thinking explained about 8% of the total variance in the mental health of nurses in this sample. This makes one wonder whether coping involves an attitudinal dimension. In other words, individuals who have a positive attitude towards coping will be more prone to use positive coping strategies, thus leading to better mental health. The opposite is true for those with a negative attitude towards coping. Indeed, this idea is related closely to the concept of self-efficacy. Individuals who feel that they are capable of handling a situation will normally exert efforts to solve the issues involved. Future research may need to look into the possibility of self-efficacy as a possible determinant of coping.

Recommendations

Provide training opportunities for nurses in Hong Kong. Changes in an organization are inevitable, particularly in the context of budgetary constraints and greater accountability in the use of resources. However, staff should be trained with knowledge and skills to meet the new challenges. As a result of the recent reform of the Hospital Authority in Hong Kong, nurses are given greater responsibility for the management of wards, department and hospital level. This implies that nurses, particularly those at the managerial level, who experienced a higher level of stress in this study, should be provided with more support in order to work efficiently and competently. Training on nursing leadership, interpersonal skills, financial and resources management skills should be conducted to equip ward managers with adequate knowledge and skills to cope with their demanding managerial role.

To prepare clinical nurses to take up the changing and expanding roles and responsibilities demanded by patient-centered care, training should emphasize providing for the emotional needs of patients and their families, and management as well as care delivery skills. Courses on psychosocial care of specific patient groups (e.g., terminally ill patients and cancer patients) and on communication skills should be included in the nursing curriculum.


The substantial number of nurses with poor mental health scores suggest then need for developing stress management strategies.

Organize stress management programs for nurses. The substantial number of nurses with poor mental health scores suggest then need for developing stress management strategies. A number of intervention models for stress management have been developed in the West (e.g. de-Anda, 1998; Mudore, 1998), but stress management programs for nurses in Hong Kong are lacking. Since it has been documented that a cognitive-behavioral group approach to stress management is effective for other target groups (Wong, 1996; Wong, Sun, Tse & Wong, 2000), this approach may be tried with nurses in Hong Kong. Programs to assist nurses to examine and strengthen their positive cognitive coping skills may improve their mental health. Another way is to help nurses engage in positive experiences in problem-solving. Assisting nurses to learn problem-solving skills can also increase positive coping and improve mental health outcomes (Dupper & Krishef, 1993).

Authors

Daniel Fu Keung Wong, PhD, MSW, BSW, RSW
dfkwong@hkucc.hku.hk

Daniel Fu Keung Wong, PhD, MSW, BSW is an Assistant Professor at the Department of Social Work and Social Administration, The University of Hong Kong. Dr. Wong and his research teammates are interested in conducting research on occupational stress and mental health of professional groups in Hong Kong. Particularly, they are keen to explore the socio-cultural factors that affect the stress and mental health of different occupational groups.

Sharon Shui King Leung, MSW, RSW

Sharon Shui King Leung, MSW, RSW is a lecturer at the City University of Hong Kong. She is interested in examining how stress affects people's mental health and has conducted research on the stress and coping of mature students in Hong Kong.

Christopher Ko On So, MSW, BSW, RSW

Christopher Ko On So, MSW, BSW is the Director of the Hong Kong Down Syndrome Association. He is also a candidate for the Doctor of Education Program of The University of Bristol, United Kingdom. His thesis is related to occupational stress and mental health of secondary school teachers in Hong Kong.

Debbie Oi Bing Lam, PhD, MSoc Sci, BSoc Sci

Debbie Oi Bing Lam, PhD, MSoc Sci, BSoc Sci, is a lecturer at the Department of Social Work and Social Administration, The University of Hong Kong. Dr. Lam has interest in studying stresses and mental health of different population groups, including the nursing profession.

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© 2001 Online Journal of Issues in Nursing
Article published May 1, 2001


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