International Journal of Nursing Sciences 4 (2017) 418e429

H O S T E D BY Contents lists available at ScienceDirect

International Journal of Nursing Sciences

journal homepage: http://www.elsevier.com/journals/international-journal-of-
nursing-sciences/2352-0132

Review

An integrative review of the influence of job strain and coping on

nurses' work performance: Understanding the gaps in oncology
nursing research
Dhuha Youssef Wazqar a, *, Mickey Kerr b, Sandra Regan b, Carole Orchard b
a
Faculty of Nursing, King Abdulaziz University, Al-Sharafeyah Street, P. Box: 42828, Jeddah, 21551, Saudi Arabia
b
Arthur Labatt Family School of Nursing, University of Western Ontario, 1151 Richmond Street London, Ontario, N6A3K7, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Nursing is known to be a stressful profession that can lead to physical and psychological health issues
Received 12 May 2017 and behavioural problems. In oncology, workload among nurses is believed to be increasing in
Received in revised form conjunction with rapidly increasing numbers of patients with cancer and staff shortages worldwide,
7 July 2017
therefore it is essential to sustain a quality oncology nurse workforce. Numerous studies have presented
Accepted 14 September 2017
Available online 20 September 2017
evidence on job strain, effects of coping strategies, and nurses' work performance within healthcare
settings, but few have focused on oncology settings and none of these on nurses working in Saudi Arabia.
The purpose of this review was to summarize empirical and theoretical evidence concerning job-related
Keywords:
Coping
stressors in nurses, particularly oncology nurses, and the interrelationships among job strain, coping
Job strain strategies, and work performance in this population. Search strategies identified studies published on
Nurses studies in peer-reviewed journals from 2004 to 2016. Twenty-five nursing studies were found examining
Review the relationships among the concepts of interest. Common job-related stressors among oncology nurses
Work performance were high job demands, dealing with death/dying, lack of job control, and interpersonal conflicts at
work. Job strain was found to be significantly linked to coping strategies, and negatively associated with
work performance among nurses in general. There is no existing empirical evidence to support the
relationship between coping strategies and work performance among oncology nurses. The present
evidence is limited, and a considerable amount of research is required in the future to expand the
oncology nursing literature. Research is needed to investigate job-related stressors and their effects on
oncology nurses.
© 2017 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction designs, including both non-experimental and experimental

research to more fully understand the relationships between job
Whittemore and Knafl's [1] integrative review process was used strain, coping strategies, and work performance. Theoretical and
to search literature for studies focusing on the concepts of job empirical literature on job strain, coping strategies, and work per-
strain, coping strategies, and work performance. This integrative formance in nursing and seminal literature was summarized and
process framework involved identifying the research problem, analyzed based on this framework to synthesize what is known
conducting an organized search of the published studies, evalu- about this phenomenon in professional oncology nursing practice.
ating the quality of data, extracting and analyzing data, and Nurses work independently and in collaboration with other
critiquing and presenting the findings to improve the rigour of the healthcare professionals within teams to help people to achieve
process when conducting an integrative review [1]. This review optimal health and functioning [2]. Certainly, nurses are exposed to
process permits the inclusion of studies utilizing different research a wide range of job-related stressors that may impact their job
satisfaction, leading to poor work performance, absenteeism, and
intension to leave their position or even the nursing profession [3-
* Corresponding author. 5]. One important source of work-related stress is job strain. Job
E-mail addresses: dwazger@kau.edu.sa (D.Y. Wazqar), mkerr@uwo.ca (M. Kerr), strain is identified as a chronic problem among nurses interna-
sregan4@uwo.ca (S. Regan), corachard@uwo.ca (C. Orchard).
tionally. Job strain has been widely investigated and refers to a
Peer review under responsibility of Chinese Nursing Association.

https://doi.org/10.1016/j.ijnss.2017.09.003
2352-0132/© 2017 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429 419

pattern of responses that occur when a disparity exits between job literature needs to be examined to help provide an understanding
demands and the level of control the employees have to satisfy of current oncology nurses' work environment and its impact on
those demands, challenging their ability to cope [6,7]. Researchers job strain in oncology nurses' work outcomes. Given the increasing
found that job strain may lead to some forms of behavioural, complexity of today's healthcare work environment, the significant
physical and mental concerns including cardiovascular diseases, nursing shortage, the increasing number and severity of cancer
hypertension, burnout, emotional exhaustion, sleep disturbance, cases, and the recognition of the oncology nurses' role in relation to
breast cancer, and substance use among nurses working in different patient safety [28], a better understanding of the effects of job
specialities and healthcare settings [8-12]. Previous research has strain and coping strategies on oncology nurses' work performance
suggested that nurses use a variety of coping strategies when facing is vital to sustaining an adequate oncology nurses workforce and
stressful situations in their work settings [12-14]. Coping strategies safe environments for practice. This is particularly relevant to a
are actions or steps employed by an individual to reduce or rectify country such as Saudi Arabia (SA) that depends on the interna-
the harmful effects of stress [15]. How individuals use coping tionally educated nurses to meet its healthcare needs for care of
strategies is, in part, determined by their external and internal re- patients with cancer. This integrative review aims to identify
sources encompassing individuals' beliefs, health, support, social common job-related stressors experienced by oncology nurses and
skills, responsibilities, and available material resources [16]. nurses working in other specialities and to summarize empirical
Lazarus and Folkman [15] have documented two fundamental and theoretical evidence concerning the relationships among job
coping strategies, problem-focused (PFCSs) and emotion-focused strain, coping strategies, and work performance to provide a more
(EFCSs) (Table 1), based on transactions between the individual comprehensive understanding of this phenomena. This knowledge
and their work environment. However, research findings indicate is significant, as it may provide the foundation for the development
that individuals utilize both PFCSs and EFCSs when experiencing of programs and workplace interventions to help oncology nurses
demanding and stressful conditions [5,17]. Research suggested that deal with their job strain more effectively and therefore strengthen
EFCSs can lead to problems for individual's growth, health and their coping strategies and enhance nurse work performance.
well-being, and could impact their quality of service delivery
[17,18]. Undoubtedly, these outcomes are critical for nursing ad- 2. Problem identification
ministrators/managers when dealing with work performance in
light of nurse retention difficulties. The focus of this integrative review was to provide information
Work performance in nurses can be viewed as the effectiveness on job-related stressors in nurses, particularly oncology nurses, and
of the nurse in carrying out his/her roles and responsibilities the interrelationships among job strain, coping strategies, and work
related to direct patient care [19]. Borman and Motowidlo [20] performance in this population. This integrative review synthesizes
hypothesized that work performance can be divided into two existing nursing studies in the area of job strain and work perfor-
distinct categories: contextual performance (CP) and task perfor- mance, and will also identify gaps in oncology nursing scholarship
mance (TP) (Table 1). There are many factors reported by nurses to guide future research. The following research question guided
that may affect their work performance, including high levels of job this review: What is the relationship between job strain, coping
strain that have been discussed above, lack of skills and training, strategies, and work performance among registered nurses,
inadequate feedback, poor communication, and supervisor support particularly oncology nurses?
[22,23].
The relationship between work performance, coping strategies, 3. Data search strategy
job strain, and individual characteristics has also been documented
in non-nursing groups, such as physicians, college teachers, avia- The literature search strategy adopted was designed to capture
tion ground crews, and athletes [24-27]. Theoretically, job strain published empirical and theoretical literature related to job strain,
and EFCSs are perceived to negatively correlate with work perfor- coping strategies, and work performance among nurses, and
mance [26]. However, little is known about the interrelationship particularly with oncology nurses. To retrieve related articles,
among job strain, coping strategies, and work performance in the searches were conducted of the following electronic databases:
nursing profession, especially among oncology nurses. The nursing Cumulative Index to Nursing and Allied Health Literature (CINAHL),

Table 1
Definition of Concepts.

Job strain (JS)

The combination of a high level of psychological workload demands and low work-related decisional latitude [6].
Job Demands (JD)

Psychological stressors present in the work setting such as workload demand, time constrains, conflicts and ambiguities about obligations and needed skills in a job [6].
Job Control (JC)

The ability of an employee to make decisions about his/her own work [6].
Coping strategies (CSs)

Actions or steps employed by an individual to reduce or rectify the harmful effects of stress [15].
Emotion-focused coping strategies (EFCSs)

Actions that an individual takes to change individual attitudes towards emotions caused by external stimuli, such as complaining and escape-avoidance [17].
Problem-focused coping strategies (PFCSs)

Adjusting actions that include altering or managing the problem within the individual or the environment, such as problem-solving and self-control [17].
Work performance (WP)

The effectiveness of the individual in carrying out his/her roles and responsibilities related to direct patient care [19].
Contextual performance (CP)

Activities that are not directly associated with individuals' core tasks but form the institutional, social or/and psychological environment [20].
Task performance (TP)

The individual's capability with which he/she carries out accomplishments which add to the institution's practical core [20].
Oncology nurse (ONs)

A nurse who specializes in treating and caring for people who have cancer [21].
420 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429

MEDLINE, SCOPUS, PUBMED, and PsycINFO and used the following statistical data analysis, (8) a link between theoretical framework
keywords in combination: “job strain”, “job stress”, “coping”, and findings, and (9) generalizability of results. On the other hand,
“coping strategies”, “work performance”, “nurses”, “oncology”, and qualitative research studies were evaluated on: (1) methodological
“oncology nurses”, and were limited to the English-language. Some congruency with the indicated philosophical view, (2) study
electronic databases did not specifically identify oncology nurses as questions, (3) data collection procedures, (4) data analysis methods,
a subject title; thus, oncology as a keyword was used within articles (5) results interpretation, (6) ethical considerations of the study
during searching in these databases in an effort to include all process, and (7) the basis for existing conclusions. Each abstract
related studies. In order to focus on the most current literature, the was reviewed to determine if the publication met the inclusion
review examined studies within the12-year period from 2004 to criteria. The majority of research publications were completed on
2016. Studies addressing both oncology and non-oncology nurses populations other than nurses and did not address the core ques-
were included. Unpublished studies, documents, editorials, and tion of this review resulting in 650 articles being eliminated.
descriptive reports limited to discussing ideas and experiences Twenty-three abstracts primarily met the inclusion criteria and the
about job strain, coping strategies, and work performance, articles studies were retrieved and reviewed. Manual searching of the
about instrument development, and studies published in other reference lists of these 23 articles identified two additional refer-
languages were excluded. Also, studies that focused on job strain, ences not previously identified from electronic searches (Fig. 1).
coping strategies, and work performance among academic nursing Therefore, the organized literature search yielded 25 articles that
staff, nursing managers/administrators, nursing students, other met the inclusion criteria for this review, of which 19 were quan-
healthcare professionals, patients with cancer, and informal care- titative research studies three were mixed methods article, two
givers, such as family members were excluded. Focusing on qualitative research studies, and one systematic review study
studies conducted among nurses allowed the researcher to better (Table 3).
identify gaps in nursing scholarship and highlight opportunities for The 25 articles represent nursing studies from the following
improving both nursing research and practice in the future. The countries: three articles each from Iran and Brazil, two articles each
electronic database searches yielded 828 possible citations utilizing from Jordan, China, Japan, Australia, Indonesia, and one article each
the extensive subject headings (Table 2). Eliminating identical ci- from Hong Kong, Twain, Malaysia, India, Uganda, Ghana, Portugal,
tations resulted in 673 articles that mentioned job strain/job stress South Africa, and the United States.
and coping strategies, job strain and work performance.
All abstracts or article citations found through the computerized 5. Data extraction and analysis
search were reread either in print or online, and full study articles
were saved if they met the following inclusion criteria: (1) pub- Data extracted from each article encompassed the study
lished in an English language journal, (2) studies focused on objective, design, setting, sample, and data collection procedures.
oncology nursing or nurses practice, (3) described or examined the Also, the results and discussion sections were reread, and research
phenomena of job strain, coping strategies, and work performance findings that investigated the relationships among job strain,
among nurses or included one or more tools to collect information coping strategies, and work performance and individual charac-
on job strain, coping strategies, and work performance in nurses, teristics among nurses, were extracted. Data extracted from theo-
and (4) selected studies could be either qualitative or quantitative retical studies encompassed study type, objective, and explanations
or mixed methods. The reference lists of included articles were also or conclusions examining interrelationships among concepts of
reviewed to identify additional related studies. There was no direct interest. Extracted data from the included research studies were
follow-up with the investigators of any study to retrieve supple- then reviewed and consolidated into groups according to the
mentary data. similarities in meaning and/or descriptions. Data were grouped,
and then compared, summarized, and finally findings were inter-
4. Data quality evaluation preted across and within research studies to recognize themes or
concepts that found relationships between concepts of interest
Research studies that met the inclusion criteria were assessed among nurses in general, including oncology nurses. The data
for their quality by comparing their relevance to the primary review quality from the quantitative studies items were rated as (1) yes, (0)
question by individually evaluating each for quality of data through no or unclear, and summary data quality score was tabulated. Ac-
utilization of either the Qualitative Assessment and Review In- cording to their evaluation score, research studies were ordered as
strument or the Checklist for Assessing the Validity of Descriptive/ high (7-10), average (4-6), and low (1-3) quality. The qualitative
Correlational Studies from the Joanna Briggs Institute [29,30]. studies were rated from average quality (4 out of 10) [47] to high
Quantitative research studies were evaluated for the presence of: quality (6 out of 10) [48]. Assessment of the qualitative studies
(1) sample recruitment procedure, (2) representativeness and using the critical appraisal tool [29] found an absence of reflexivity,
sufficient sample size, (3) inclusion criteria, (4) a connection be- limitations in purposive sampling [47,48], and lack of clear dis-
tween the theoretical framework and hypothesis, (5) instruments cussion regarding coping strategies [48].
validity and reliability, (6) ability to compare groups, (7) suitable Three mixed methods research studies [13,45,46] were rated as

Table 2
Electronic Search of Databases.

Database Search Key Terms Used in all Databases No. of Titles & Abstracts

CINAHL, Job strain Or job stress & coping strategies & nurses 8
MEDLINE-OVID, Job strain OR job stress & work performance & nurses 38
SCOPUS, Coping strategies & work performance & nurses 259
PUBMED, and Job strain & coping strategies & work performance & nurses 419
PsycINFO Job strain OR job stress & coping & oncology nurses OR oncology 103
Job strain OR job stress & work performance & oncology nurses OR oncology

Total no. of citations 828

 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429 421

828 potential citation using subject

heading: Job strain & coping & work
performance & nurses OR oncology
nurses
155 excluded: were duplicates or did
not focus on nurses

673 potential citations

650 excluded based on abstract

review: did not meet inclusion
criteria and did not address the core
question
25 articles, 23 potential articles, 2
additional potential citations from
manual search

19 2 qualitative 3 mixed 1 systematic

quantitative studies methods review

Fig. 1. Summary of search strategy and selection of relevant literature.

average quality, Beh and Loo [13], and Fathi et al. [45] were rated as often-cited job-related stressors reported by nurses
5/10, and Ida et al. [46] was rated as 4/10. Three quantitative studies [4,5,12,19,31,33,35,36,39,43-47]. Eight studies reported that job
were rated as high [5,33,39], eight were average demands/work overload were identified as the best predictors of
[3,12,19,31,32,35,37.38], and eight were low quality [14,34,36,40- mental and physical health resulting in emotional exhaustion,
44]. Some of these studies did not use random sampling [33,35], depression, and anxiety among nurses in nursing speciality practice
and did not explicitly study hypotheses or they attributed impor- [4,12,13,33,39,40,46,48]. Work settings may pose varying levels of
tance to findings that were not statistically significant [3,36]. Other job demands. For instance, nurses who worked in critical care,
researchers used non-validated tools (e.g. questions developed by emergency, oncology, and nephrology units reported higher levels
the study authors) [34,35,40,42] to assess the main study variables. of job demands and lower levels of job control than those working
Another chose only one or two items from other psychometrically in other nursing specialities [12,36,41,43]. These results may be
tested scales without re-assessing their psychometric properties attributed to increased workload and emotional exhaustion expe-
[3]. In a further set of studies, data collection procedures rienced by nurses working in acute care units that require nurses to
[31,32,36,40,42,43] and data analytic techniques [36,41] were have comprehensive knowledge and skills to provide the necessary
deemed to be either unclear or inadequate. The sample sizes of the level of care to these patients [12,36,43].
19 quantitative studies ranged from 70 to 491 nurse participants Furthermore, researchers reported that nurses working in
representing different specialities: nephrology, medical, surgical, publicly funded hospital had the highest mean stress score
pediatric, psychiatric, Obs/Gyn, operation room (OR), emergency, (88.27 ± 20.87) while those working in privately funded not-for-
critical care, intensive care unit (ICU), oncology, and out-patient profit hospitals' means scores ranged from 73.35 (SD ¼ 16.4) to
clinics. In the qualitative and mixed methods studies, the sample 76.09 (SD ¼ 23.5), reportedly due to high job demands and exces-
sizes ranged from 10 to 28 nurses in the former and from 126 to 502 sive workload [5]. Further analysis of the previous study indicated a
nurses in the latter. Participants in the studies were primarily significant difference in mean stress scores reported in publicly
clinical nurses offering direct care to patients. Findings proposed versus privately funded hospitals (F ¼ 14.46,P < 0.0001) [5]. On the
three themes: (i) job strain in nursing, (ii) coping strategies and job- other hand, another study conducted by Fathi et al. [45] explored
related stressors among nurses, and (iii) work performance and workplace stressors and coping among 126 publicly funded hos-
job-related stressors among nurses. pital nurses, found that most nurse participants (n ¼ 89, 71%)
experienced low levels of stress in their workplace resulting based
6. Data presentation on their ratings on overall job-related stressor subscales (inclusive
of job demands) (61.69 ± 14.12 [33-132]).
Data presentation is the last phase in this integrative review Six studies found that role conflict, role ambiguity, and lack of
process and focuses on the evidence that supports the review's recognition for professional competence are significant sources of
conclusion [1] (Table 3). stress among nurses, and may be associated with negative conse-
quences at the organizational and individual nurse levels [3-
6.1. Job strain in nursing 5,12,40,43]. Role ambiguity arises when there is a lack of clarity
in the roles an employee is expected to fulfill, while role conflict
Nursing is commonly perceived as a demanding, challenging, occurs when an employee is subject to competing or conflicting
and stressful profession. Based on the reviewed studies, high job sets of expectations and demands in the organization [49]. Inter-
demands, lack of job control, and low social support were the most personal relationship problems were also recognized as another
Table 3

422
Summary of included studies that examined job strain, coping strategies and work performance among nurses.

Authors/Year/ Study Design Participants Sample Size Instruments Data Analysis Findings
Country

AbuAlRub (2004) Descriptive, Convince sample of nurses from 303 Nursing Stress Scale (NSS) [51] Cronbach's areliability A curvilinear (U-shaped) relationship was found
[19] (USA, correlational, Cross- different units of hospitals Six Dimension Scale of Nursing testing(0.65e0.95) between JS and WP.
Canada & UK) sectional Design Performance (6-DSNP) [60] Pearson's correlation Significant negative correlation was found between
Social Integration Scale (SIS) [68] Hierarchical regression job strain and social support from co-workers (r ¼ -
0.14, P < 0.05).
20% of the variation in WP was explained by
background variables, social support from
coworkers, JS and interaction between JS and social
support from coworkers.
Perceived social support from coworkers
moderated the relationship between JS & WP.
AbuAlRub and Al- Correlational, Cross- Convince sample of nurses from 206 Nursing Stress Scale (NSS) [51] Cronbach's a reliability testing Non-significant negative relationship between JS
Zaru (2008) [3] sectional Design medical, surgical, pediatric, McCain's Intent to stay Scale [69] (0.75e0.93) and WP was found (r ¼ -0.11, P ¼ 0.13).

D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429

(Jordan) emergency, renal and Obs/Gyn Recognition Scale (RS) [62] Chi-squared test Significant negative correction was found between
units of 4 public hospital Hierarchical regression JS and intension to stay at work (r ¼ -2.4, P ¼ 0.01).
Significant positive correction was found between
WP and intension to stay at work (r ¼ 2.3, P ¼ 0.02).
Azizollah et al. Descriptive, Stratified random sample of 491 Job Stress Survey Questionnaire (HSE) Cronbach's a reliability testing Significant negative correction was found between
(2013) [31] Correlational Design nurses from hospitals Job Performance [61] (0.84e0.89) JS and WP (r ¼ -0.42, P ¼ 0.001). Significant negative
(Iran) Pearson's correlation correction was found between job demands and WP
Regression analysis (r ¼ -0.44, P ¼ 0.000).
Significant negative correction was found between
job control and WP (r ¼ -0.39, P ¼ 0.000).
Beh and Loo(2012) Mixed Methods A random sample of female 185 Questionnaire developed by the Absolute frequencies (n) and The three major job-related stressors were heavy
[13] (Malaysia) nurses from different units of a researcher based on the literature relative frequencies (%) workload (64.2%), poor working conditions (67.9%),
publicly funded hospital review Analysis method of qualitative and repetitive work (73%).
Structured interview data Was not reported Social support (38%), control (45%), symptom
management (30%) and escape (19%) were the most
used CS.
Bianchi (2004) [32] Nurses from cardiovascular 76 Nursing Stress Evaluation Cronbach's a reliability testing The four major job-related stressors were working
(Brazil) units of a publicly funded Questionnaire (NSEQ) [52] (0.80e0.95) conditions (4.07 ± 1.26), personnel management
hospital Ways of Coping Questionnaire (WOCQ) Mean and standard deviation (3.90 ± 1.39), nursing care (3.58 ± 1.29) and
[59] Spearman's coordination of unit (3.56 ± 1.34). Positive
Correlations reappraisal (1.87 ± 0.47), seeking support
Fisher test (1.81 ± 0.50), and self-controlling (1.79 ± 0.43) were
most used CSs. No demographic characteristics
were related to sources of stress. Statistically
significant relationships between job-related
stressors and CSs (P < 0.05).
Cai et al. (2008) Correlational, Cross- A convenience sample of nurses 188 Nursing Stress Scale (NSS) [51] Cronbach's a reliability testing High job demands (6.16 ± 3.241) and dealing with
[14] (China) sectional Design from psychiatric units of 3 Simple Coping Strategies (0.84e0.90) death/dying (5.627 ± 2.780) were the highest of all
hospitals Questionnaire (SCSQ) [57] Mean and standard deviation the job-related stressors. Nurses tended to use
Correlations PFCSs (22.069 ± 6.185) more frequently than they
use EFCSs (9.255 ± 4.0477). A significant positive
relationship between job strain and PFCSs (r ¼ 0.39,
P < 0.01)
Chang et al.(2006) Predictive, Sample of Nurses from different 320 Nursing Stress Scale (NSS) [51] Pearson's correlation The most common sources of nursing stress were
[33] (Australia) correlational, Cross- units of acute care publicly Ways of Coping Questionnaire (WCQ) Forward stepwise regressions high job demands (11.29 ± 3.95), followed by death
sectional Design funded hospitals [59] Stepwise regressions and dying (8.58 ± 4.35), and conflict with colleagues
Short-Form (SF)-36 Health Survey (6.35 ± 2.78).
Version 2 [70] Planful problem solving was the most used CS,
accounting for 18% of the coping, followed by self-
control (16%) and seeking social support (16%).
Strong significant correlations were found between
 JS, CSs, and mental and physical health (R2 ¼ 0.35, F
(10.24) ¼ 14.8, P < 0.001).
Chen et al. (2009) Correlational, Cross- Sample of nurses from OR of 7 112 Stressor Scale Cronbach's a reliability testing Interpersonal relationship (2.64 ± 0.67), patient
[34] (Twain) sectional Design teaching hospitals Stress Coping (0.61e0.94) safety (3.39 ± 1.01) and work environment
Strategy Scale (3.11 ± 0.80) were the most job-related stressors.

Chen et al. (2009) Job satisfaction scale Independent t-test, Job Stressors were positively related to destructive
[34] (Twain) Developed by researchers for the study Analysis of variance (ANOVA) coping strategies (r ¼ 0.24, P < 0.01).
purpose Pearson's correlation
Donkor (2013) Descriptive, Cross- A systematic random sample of 70 Developed by the researcher for the Absolute frequencies (n) and The most common sources of nursing stress were
[35](Ghana) sectional Design nurses from different units study purpose relative frequencies (%) high job demands (44.2%), followed by conflicts
Semi-structured interview Bar charts with supervisors (17%) and conflict with colleagues
(17%).
56% of nurses strongly agreed that JS affects nurses'
performance.
70 nurses said JS has negative relationship with
performance.
Cronbach's a reliability

D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429

Fathi et al. (2012) Mixed Methods Stratified random sample of 126 Nursing Stress Scale (NSS) [51] Sources of stress included dealing with death/dying
[45] (Indonesia) nurses from 3 units (medical, Brief COPE [58] testing(0.86e0.98) (2.07 ± 0.57), high job demands (1.96 ± 0.51) and
surgical & ICU) of two tertiary Semi-structured focus group interview Pearson & Spearman's lack of social support (1.69 ± 0.57)
public hospitals correlations Most commonly CSs used were EFCs (e.g. religion)
Analysis of qualitative data was (3.51 ± 0.66).
not reported Significant relationship between JS and CSs (P <
0.05).
Positive relationship was found between job
demands and EFCSs.
Gholamzadeh et al. Descriptive, Cross- Sample of nurses from 90 Nursing Stress Scale (NSS) [51] Cronbach's a reliability testing Sources of stress included dealing with patients or
(2011) [36] sectional Design emergency units of 3 teaching Ways of Coping Questionnaire [59] (0.88) their relatives, high job demands and lack of social
(Iran) hospitals Chi-squared test support.
Absolute Frequencies (n) and EFCSs were more used (59.4 ± 16.1) than PFCSs
relative frequencies (%) (18.9 ± 16.1).
Gomes et al. (2013) Descriptive- Nurses from oncology head and 96 General Health Questionnaire (GHQ) Cronbach's a reliability testing Female oncology nurses had a greater degree of JS
[12] (Portugal, exploratory, Cross- neck surgery units of 3 central, [71] (0.70e0.87) (P ¼ 0.49).
Europe) sectional Design public hospitals Occupational Stress Inventory (OSI) Absolute frequencies (n) and The most common sources of JS included High job
[53] relative frequencies (%) demands (52%, n ¼ 50), death/dying (47%, n ¼ 45)
Brief COPE [58] Bivariate analysis and lack of recognition (45%, n ¼ 43).
Independent samples t-test Most commonly CSs used by oncology nurse when
Pearson correlation dealing with JS were planning (48%, n ¼ 46)
(5.55 ± 1.60), active coping (56%, n ¼ 54)
(5.41 ± 1.43), acceptance (49%, n ¼ 47) (5.06 ± 1.38)
and self-distraction (40%, n ¼ 38) (4.94 ± 1.59).
Statistically significant differences are only found
regarding substance use, with the male group
having higher values (P ¼ 0.011).
Significant negative correlation between general
health and avoiding coping strategies (avoidance,
Self-distraction and Denial) (P < 0.05).
Hays et al. (2006) Descriptive,Cross- Convince sample of nurses from 135 The Ways of Coping Questionnaire Cronbach's a reliability testing Dealing with death/dying (53%), inadequate
[37] (USA) sectional Design a variety of ICUs of 7 acute (WCQ) [59] (0.93) preparation (52%) and staff shortages (50%) were
public hospitals ICU Stressors Scale was developed by Pearson's correlation the most common stressors.
researchers Analysis of variance (ANOVA) Escape-avoidance (62%) and confrontive coping
(60%) were common CS used.
Statistical significance was not found among
demographic variables and stressors or coping.
Idaetal.(2009) [46] Mixed Methods Design Convince sample of nurses of a 502 JCQ [55] Cronbach's a (0.73e0.86) A significant relationship was found between JS and
(Japan) major publicly funded hospital Sense of Coherence (SOC) [72] Factor analysis WP(r ¼ -0.61, P < 0.01).
Pearson's correlation Job demands and lack of skills were the most
sources of JS.
(continued on next page)

423
Table 3 (continued )

424
Authors/Year/ Study Design Participants Sample Size Instruments Data Analysis Findings
Country

Jannati et al. (2011) Descriptive, Qualitative A purposive Sample of nurses 28 Semi-structured interview Observation Ground theory approach Job demands, lock of control and interpersonal
[47] (Iran) Design from different units of 5 relationship were common job-related stressors
teaching hospitals among nurses. Symptom management, control, and
emotional were common used CSs.
Lambert et al. Predictive, Nurses from different units of 310 Nursing Stress Scale (NSS) [51] Cronbach's a reliability testing The most common sources of JS included high job
(2004) [39] correlational, Cross- six teaching and private The Ways of Coping Questionnaire (0.84e0.92) demands, lack of social support, conflict with
(Japan) sectional Design hospitals, located in the central, (WCQ) [59] Multiple correlation colleagues and death/dying. Significant positive
western, and southern Short-Form (SF)-36 Health Survey [70] Stepwise multiple regression correlation was found between JS and CSs (P ¼
0.01). Significant positive relationships were found
between age, years of nursing experience, level of
income, and nursing education and job-related
stressors (P < 0.05).
Lambert and Descriptive, Convince sample of nurses from 102 Nursing Stress Scale (NSS) [51] Cronbach's a reliability testing High job demands was the most cited job stressor
Lambert (2008) Correlational Design a variety of ICUs of 4 public Brief COPE [58] (0.82e0.90) (11.0 ± 3.72; range, 4-18), while planning was the

D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429

[38] (China) hospitals Spearman's correlation most frequent CS used (5.14 ± 1.04; range, 3-8).
High job demands were positively correlated with
EFCSs (P < 0.05).
Lim et al. (2010) [4] Systematic Review Sample of nurses from different 27 Articles Databases Search High job demands, lack of social support, role
(Australia) units Manual Search conflict, role ambiguity and interpersonal
relationships were identified as the most common
job-related stressors in reviewed studies. Nurses
used a variety of CSs: planful problem solving,
seeking social support, self-controlling, escape
eavoidance and self-distraction. The uses of PFCSs
are associated with good mental health and well-
being outcomes.
Moola et al. (2008) Exploratory, A purposive sample of nurses 10 Semi-structured Focus group NUD*IST 4 software CCNs experienced stressful situations due to high
[48] (South Descriptive and from CCUs of 5 hospitals interviews job demands and lack of social support. Avoidance-
Africa) Contextual, Qualitative Field notes escape was the most common CS used.
Muazza (2013) Correlational, Cross- sample of female nurses from 60 Developed by the researcher for the Absolute frequencies (n) and The most common sources of JS included role
[40](Indonesia) sectional Design different units of a publicly study purpose relative frequencies (%) conflicts (72%), workload (76.8%), and relationships
funded hospital Correlations with supervisors and colleagues (59%).
Regression analysis Headache (65.5%), hypertension (37.9%) and
respiratory problems (50%) were the most common
symptoms associated with JS among nurses.
Significant negative relationship was found
between JS and WP (r ¼ -0.64, P ¼ 0.000).
Nabirye et al. Correlational, Cross- Convince sample of nurses from 333 Nurse Stress Index (NSI) [54] Cronbach's a reliability testing Nurses experienced high levels of JS with mean
(2011) [5] sectional Design medical, surgical, pediatric and Job Satisfaction Survey (JSS) [64] (0.81e0.93) scores ranging from 75.5 to 90.3.
(Uganda) Obs/Gyn. units of 4 private and Six Dimension Scale of Nursing Mean (M) and standard Significant difference in JS and WP mean scores
public hospital Performance (6-DSNP) [60] deviation (SD) among the different hospitals, (F ¼ 14.46, P < 0.001).
Pearson's correlation Significant negative relationship was found
One-way analysis of variance between JS and WP (r ¼ -0.13, P ¼ 0.02).
(ANOVA)
Post-hoc test
Rodrigues and Descriptive- Nurses from different oncology 77 Demographic data Inventory developed Cronbach's a reliability testing The most common sources of JS included death/
Chaves (2008) exploratory, Cross- units of 5 public hospitals by authors (0.54e0.75) dying (29%), conflict with colleagues (17%) and high
[41] (Brazil) sectional Design Coping Strategies Inventory (CSI) [15] Mean and standard deviation job demand (16%).
Positive reappraisal (0.75) (10.34 ± 4.96, problem
solving (0.73) (9.91 ± 3.94), and Escape-avoidance
(0.73) (6.07 ± 4.62) were the most used CSs.
Most commonly CSs used by oncology nurse were
PFCSs.
Sudhaker and Correlational Design Convince sample of nurses from 60 Performa of nurses Job Stress Index Absolute frequencies (n) and Seeking social support was the most used CS,
Gomes (2010) different units of 2 tertiary Coping checklist relative frequencies (%) accounting for 95% of the coping, followed by
[42] (India) hospitals Developed by study's researchers Correlation matrix problem-solving (93%) and symptom management
 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429 425

important job-related stressor among nurses in the reviewed

P < 0.01) and confrontive CSs (r ¼ -401, P < 0.01.).

the most used CSs. Significant negative correlation
(12.33 ± 2.92). Evasive (19.23 ± 5.66), confrontive

symptoms (3.44 ± 0.59), self-control (2.79 ± 0.59)

Surgical nurses experienced moderate level of job
studies. Different types of interpersonal problems encountered

(17.46 ± 4.79) and optimistic (15.81 ± 3.94) were

strain. Most common job stressors included high

Most CSs commonly used were management of

was found between JS and optimistic (r ¼ -432,
Strong negative correlation between JS and CSs

were conflict with co-workers, physicians, and supervisors

(3.51 ± 0.78), and role conflicts (3.45 ± 0.73).

job demands (15.36 ± 2.95), lack of support
(13.32 ± 2.92) and inadequate preparation [4,33,34,35,39,40-43,47]. These conflicts could be another source of

(3.47 ± 0.67), interpersonal relationships

Sources of JS included high job demands
stressor affecting nurses' mental and physical health [33,39,40] and
quality of nursing care [35,40,43], and leading to job dissatisfaction
[38]. In two cross-sectional studies that examined the most com-
mon job-related stressors experienced by oncology nurses, high job

and avoidance (2.63 ± 0.32).

demands, dealing with death/dying, communication issues, emer-
gency situations, interpersonal staff conflicts, lack of recognition,
(r ¼ -0.92, p < 0.05).

inadequate preparation, and low salaries were identified as high

sources of stress among oncology nurses in both Portugal and in
Brazil [12,41].
The reviewed studies used different instruments to measure
(93%).

nurses' job strain, including: Inventory of Stress in Nurses (ISN)

[50], Nursing Stress Scale (NSS) [51], Job Stress Index [42], Nursing
Stress Evaluation Questionnaire (NSEQ) [52], Occupational Stress
Inventory of Stress in Nurses (ISN) [50] Cronbach's a reliability testing
Mean and standard deviation

Work Limitations Questionnaire (WLQ) Mean and standard deviation

Inventory (OSI) [53], Nurse Stress Index (NSI) [54], Job Stress Survey
Questionnaire (HSE), and the Job Content Questionnaire (JCQ) [55].
The Nursing Stress Scale (NSS) developed by Gray-Toft and
Pearson's correlation

Note: (JS) job strain, (CSs) coping strategies, (PFCSs) problem-focused coping strategies, (EFCSs) emotion-focused coping strategies, work performance (WP).

Anderson [51] was the most common job strain measure used,
which accounted for 50% of articles [3,14,19,33,36,38,39,44,45].
(0.79e0.95)

6.2. Coping strategies and job-related stressors among nurses

Out of the 25 reviewed studies, 18 studies (72%) examined the

influence of and perception of coping strategies and experiences of
job strain in nurses who were working in healthcare settings [4,12-
Occupational Coping Scale (OCS)
Jalowiec Coping Scale (JCS) [56]

14,32-39,41-48]. Twelve studies (48%) (seven cross-sectional, two

Nursing Stress Scale (NSS) [51]

mixed methods, two qualitative studies, and one systematic re-

view) explored the relationship between job-related stressors and
coping strategies among nurses in different hospital units in Iran,
Hong Kong, China, Brazil, South Africa, USA, Malaysia, and
Indonesia. Four cross-sectional studies (16% of total studies)
assessed the relationships between job-related stressors, coping
strategies, individual characteristics, and mental and physical
[73]

health among nurses in Brazil, Australia, Japan, and India

[33,39,42,43], while two cross-sectional studies (8% of the total)
examined relationships between job-related stressors, coping
strategies, individual characteristics, and job satisfaction among
129

ICU nurses in Chinese nurses [34,38]. Only two studies described

98

the diversity of coping strategies utilized by oncology nurses to deal

Nurses from nephrology units

with stressful situations in their work settings and linked them

Sample of nurses from acute
surgical units of 3 hospitals

with nurses' health and well-being [12,41]. Researchers reported

that oncology nurses used more problem-focused than emotion-
of teaching hospital

focused strategies, such as positive reappraisal, problem-solving,

planning, and acceptance (Table 3). However, many researchers
found that increased job strain levels among nurses are signifi-
cantly associated with increased utilization of EFCSs, such as
escape-avoidance, denial, venting, and symptom management
coping strategies in seven studies [34,37,38,42,43,45,48], and
confirmed a significant positive relationship between job demands
[44] (Hong Kong) Correlational, Cross-

and EFCSs among 228 Indonesian and Chinese nurses from

Umann et al.(2014) Descriptive, Cross-

different units [38,45]. In addition, six studies provided evidence

sectional Design

sectional Design

that EFCSs are frequently related to increased stress, mental and

Wang et al. (2011) Descriptive,

physical problems, and job dissatisfaction [4,12,13,33,38,48]. In

contrast, some researchers noted that neither coping strategy
recognized as being any better than another by study's participants
[36,41].
As shown in Table 3, instruments used to assess and to identify
[43] (Brazil)

the common coping strategies included: Jalowiec Coping Scale (JCS)

[56], Occupational Coping Scale (OCS) [43], Simple Coping Strate-
gies Questionnaire (SCSQ) [57], Coping Strategies Inventory (CSI)
[15], Brief COPE [58], Coping Checklist [42], Ways of Coping Ques-
tionnaire (WCQ) [59], and open Semi-Structured Interview (12%)
426 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429

[47]; [48]. Ways of Coping Questionnaire (WCQ) [59] was the most reported work overload/high job demands (15.61 ± 2.95), lack of
commonly used instrument to assess coping strategies among social support (13.32 ± 2.92), and moderate levels of job strain
nurses [32,33,36,37,39]. (76.7 ± 14.9) [44]. Nursing education was found to be positively
correlated with seeking social support, acceptance, and self-blame
6.3. Work performance and job-related stressors among nurses as ways of coping with job strain, while negative correlations be-
tween age and nursing experience and these coping strategies were
Out of the 25 reviewed studies, seven studies (28%) explored the found (P < 0.05) [38,39]. Furthermore, only one study (6%) con-
relationship between work performance and job-related stressors ducted by Gomes et al. [12] indicated that statistically significant
among nursing populations in Uganda, Ghana, Japan, Indonesia, the differences were found regarding substance abuse with the male
USA, Canada, Britain, Iran, and Jordan, using random and non- nurse group having higher levels when working in head and neck
random sampling methods [3,5,19,31,35,40,46]. Two of these surgery oncology units (Mann-Whitney U (P ¼ 0.01)). In addition,
studies included samples of nurses who had more than 9-year's Nabirye et al. [5] found significant differences in job strain and
nursing experience [19,46], and three included nurses who had work performance means by type of hospital with publicly-funded
more than one year's nursing experience [3,5,40]. Only one study hospitals having the highest mean score for job strain (F ¼ 14.46,
enrolled nurses working in different units and countries and held a P < 0.0001), and the lowest mean score for work performance
diploma, an associate, or bachelor degree in nursing [19]. Three (F ¼ 7.95, P < 0.001) among Uganda nurses, indicating that nurses
were cross-sectional studies carried out among nurses from working in publicly funded hospitals had significantly poorer work
different units, where data were collected through self-reported performance than those who worked in privately funded hospitals
questionnaires [3,5,19]. Only one of these studies used a mixed (t ¼ -3.425, P < 0.05).
methods design to examine 502 nurses across different units in a
major hospital in Japan and reported relationships between job 6.5. Limitations of included studies
strain, work performance, and individual characteristics [46]. Data
were collected through self-reported questionnaires and semi- The included studies in this integrative review have some
structured interviews, and analyzed using univariate and bivar- serious theoretical and methodological limitations. First, most
iate statistics, and factor analysis. Findings revealed that nurses' reviewed studies used a cross-sectional research design and,
perceived barriers to better work performance included high job therefore, an inference regarding casual relationships among study
demands (usually exacerbated by staff shortages), lack of control variables cannot be drawn [63]. Future research should consider
over work, lack of social support, lack of skills and knowledge, alternative methods, such as longitudinal studies, that would then
insufficient rewards and lack of recognition for professional temporality to be determined, providing stronger evidence for
competence. Five studies confirmed a significant negative rela- causal relationships between study variables in organizations
tionship between work performance and job strain among nurses [63,64]. Second, this review found that most studies used a non-
from different units [5,31,35,40,46]. Several studies reported con- random sampling method. In addition, nurses who had partici-
flicting findings. In a study of 206 Jordanian nurses working in four pated in the reviewed studies were working in different types of
publicly funded hospitals, researchers found a non-significant units and had varying work experiences. Third, most studies did not
negative relationship between work performance and job strain report how sample sizes were determined (e.g. power analysis).
(r ¼ -0.11, P ¼ 0.13) [3], while in an earlier study of 3030 nurses from Therefore, this may limit the ability of a study to determine sta-
different units found that job strain was negatively correlated with tistical significance if the sample size was inadequate [63]. While a
work performance (r ¼ -0.10, P < 0.05), and that the squared term of theoretical framework was sometimes mentioned, only six studies
job strain was positively correlated with work performance (24%) [5,13,34,37,45,47] described a conceptual model that included
(r ¼ 0.01, P < 0.05) [19]. Researchers in all seven reviewed studies study variables and their relationships. Of the theoretical frame-
suggested that developing programs and workplace interventions works provided, one (4%) research study [5] used the Karasek's
should concentrate on reducing the above-mentioned job-related Demand-Control Model [6] and the Lazarus and Folkman's Trans-
stressors to help enhance nurses' work performance. As shown in action Model of Stress and Coping [15]. Unlike most of the included
Table 3 these reviewed studies used the following instruments to studies, only one study (4%) by Fathi et al. [45] provided theoretical
measure work performance: The Six Dimension Scale of Nursing definitions that were not only well stated, but also were consistent
Performance (6-DSNP) [60], Job Performance [61] and Recognition with the theoretical framework supporting the work. The absence
Scale (RS) [62]. The 6-DSNP [60], was used in two studies [5,19], of theoretical definitions of constructs and the lack of adequate
while one study used two performance indicators (nursing care information about theoretical frameworks, made it difficult to
quality and sickness-absence) to assess work performance among identify the consistency between operational definitions, theoret-
502 Japanese nurses [46]. ical definitions, and their link to theory in most of the studies.
Observation of these issues is consistent with earlier findings in an
6.4. Demographic and work-related variables integrative review of job stress and coping strategies in nurse
mangers research [65]. Hence 48% of the included studies (n ¼ 12)
Individual nurse and work characteristics, such as age, gender, were either atheoretical or failed to report a theoretical framework
educational backgrounds, years of experience, family situation, and to support the study work. It should also be noted that all reviewed
type of hospital were found to have an impact on nurses' percep- studies were published in English. Non-English articles, which may
tion of stressful situations, work performance, and their capacity to contain useful information, were excluded, therefore potentially
exercise coping strategies. In six studies, examining job-related hindering a more comprehensive understanding of the relation-
stressors and individual characteristics among Japanese nurses, ships between the concepts of interest in this review.
Chinese, Twine, and Ugandan nurses, researchers noted that older
nurses with more work experience and higher levels of nursing 7. Discussion
education were more likely to experience higher levels of job strain
[5,14,34,38,39,46]. In contrast, a study carried out with nurses in This review aimed to summarize empirical or theoretical
Hong Kong found moderate levels of job strain among 66% of research regarding job strain in nursing and its relationship among
younger nurses with a mean age of 30 years (n ¼ 65, SD ¼ 6.5) who the job-related stressors, coping strategies, and work performance
 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429 427

among nurses, particularly those working in oncology units. From recognized in a recent non-experimental study among nurses
the review, it is clear that studies examining the relationships be- working in SA publicly funded hospitals (n ¼ 380) [67]. However,
tween these variables are predominantly non-experimental quan- different results have been reported in other studies regarding the
titative studies using self-reported instruments. A potential cause relationship between job strain and work performance. High job
for investigators' preference for conducting non-experimental strain was reported to lead to low work performance
studies rather than experimental and interventional studies may [5,31,35,40,46], and nurses with moderate levels of job strain
be due to problems related to access to subjects or research perform better than do those with high or low levels of job strain
expertise of researchers [2]. However, while most studies utilized [19]. Finally, a significant gap in the nursing literature appears to
valid and reliable instruments, other researchers utilized self- exist regarding job strain, coping strategies, and work performance
developed tools (e.g. Performance of Nurses [42] and Stress among oncology nurses, given that there are only two published
Coping Strategy Scale [34]). The Nursing Stress Scale [51], which studies addressing the relationship between job strain and coping
what used in 50% of the stress measurements, was the most used strategies among oncology nurses from Portugal and Brazil [12,41].
instrument. Furthermore, most studies reported internal consis- This researcher has not found any study examining the relation-
tency reliability coefficients (Cronbach's a) for their instruments, ships between job strain and work performance among oncology
which are in acceptable ranges (a > 0.70) (Table 3). However, there nurses. Only one published study examined the relationship be-
was only limited qualitative research conducted in this area, with tween job strain, work performance, and intention to stay at work
only two qualitative studies conducted by Jannati et al. [47] and among nurses in one of the Middle-East counties (Jordan) [3].
Moola et al. [48] included in this review, possibly because the Consequently, the relationship between coping strategies and work
construct of job strain is relatively easily measured by existing performance among oncology nurses remains unknown, given that
stress and coping strategies survey tools. Evidence from the the researcher was unable to find any published studies in this area.
reviewed studies indicated that nurses experience moderate to In addition, no study has been conducted about the above rela-
high levels of job strain, particularly nurses who worked in tionship in SA. Thus, future research is required to examine the
oncology, ICU, emergency, and nephrology units. The majority of effects of job strain and coping strategies on oncology nurses'
the studies recognized high job demands to be the most prominent health and work performance.
job-related stressor among nurses. This was followed by lack of
social support, dealing with death and dying, lack of job control, 7.1. Nursing implications
role stress, interpersonal relationships, and lack of recognition.
Even though the settings of these studies varied, the findings were This review contributes to the body of knowledge regarding job
similar in terms of job-related stressors and the effects of job strain strain, coping strategies, and work performance, and identifies
on nurses' health, job satisfaction, and work performance. How- knowledge gaps in the nursing literature. Our review indicated that
ever, the review found a need for further understanding of stressors there is a lack of knowledge about job strain and its influence on
related to interpersonal relationships in work settings, mainly coping strategies and work performance in current oncology
associated with supervisors and physicians [33,43]. The included nurses. Although a small body of literature exists to explain the
studies found that individual nurses may perceive stress quite relationship between job strain and coping strategies in oncology
differently and choose to implement associated coping strategies nurses, little current research exists regarding oncology nurses
accordingly (e.g. [38,39]). It was noted that although nurses within the Middle-East context to provide a distinct understanding
recognized the same four highest job-related stressors (job de- of oncology nurses' work environments and interrelations of these
mands/work overload, lack of job control and social support, and variables of interest. Identifying the effects of job strain and making
dealing with death/dying), there were differences in coping stra- use of effective coping strategies (PFCSs) may play a crucial role in
tegies adopted. The most frequently used reported coping strate- decreasing job strain and enhancing oncology nurses' work per-
gies in stressful situations by those hospital nurses, irrespective of formance. Findings from this review may also increase awareness
country, were: escape-avoidance, seeking social support, denial, among nurse managers and administrators about the impact of job-
symptom management, planful problem-solving, and self-control, related stressors experienced by nurses, particularly oncology
although not always in that order. The majority of the studies nurses, and the means that help to alleviate stressors in the
highlighted that nurses utilize EFCSs more than PFCSs which can workplace and promote healthy work environments. It is also
lead to greater risks for mental and physical health issues. This important for nursing administrators/managers to understand why
finding is supported in a systematic review conducted by Lim et al. some nurses are coping effectively when facing stressful situations
[4], examining stress and coping in Australian nurses. However, in the workplace while others are not. Findings may provide sup-
oncology nurses use mainly PFCSs, such as positive reappraisal and port for enhanced organizational coping resources, and develop-
problem-solving, to deal with stressors in their work settings [41]. ment of programs to help nurses use effective coping strategies to
Positive reappraisal coping described as an individual's effort to stay mentally and physical well within today's healthcare envi-
produce positive meaning by concentrating on personal develop- ronment. These strategies may be delivered at both the organiza-
ment and may have a spiritual dimension [15]. This type of coping tional and individual levels. At the organizational level, attention to
may be utilized more frequently when oncology nurses view their retention of existing nurses by reduction of job demands/work
faith as valuable in their nursing practice, therefore they do not lose overload may be achieved by hiring new nurses to reduce nurse/
their faith when encountered with stressful situations [66]. patient loads, enhancing communication among healthcare pro-
Consequently, it may allow them to change something about fessionals to reduce frustration in trying to gain clarity when
themselves in order to better cope when they face a similar situa- transmitting information, providing support from nurse supervi-
tion again. sors to nurses, and increasing rewards and recognition. Knowing
Among seven of the included studies, six potential predictors for job-related stressors that exist in healthcare settings and devel-
work performance were reported among nurses. These predictors oping management strategies to decrease these stressors may be
included high job demands, lack of job control, lack of social sup- beneficial. At the individual level, providing in-service education
port, insufficient rewards, lack of skills and knowledge, and lack of and training for nurses through workshops, and counselling
recognition [3,5,19,31,35,40,46]. Some of these predictors, such as regarding job stress management can assist nursing staff to
job demands, job control, and job resources (social support), were enhance their coping skills when dealing with stressful workplace
428 D.Y. Wazqar et al. / International Journal of Nursing Sciences 4 (2017) 418e429

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