THE RELATIONSHIPS AMONG WORKPLACE

STRESSORS, COPING METHODS,

DEMOGRAPHIC CHARACTERISTICS, AND
HEALTH IN AUSTRALIAN NURSES
ESTHER M. CHANG, PHD,* JOHN DALY, PHD,y KAREN M. HANCOCK, PHD,z
JOHN W. BIDEWELL, PHD,§ AMANDA JOHNSON, MHSCED,t
VICKIE A. LAMBERT, DNSC,b AND CLINTON E. LAMBERT, PHD#

Nursing is known to be stressful. Stress detrimentally can influence job satisfaction, psychological
well-being, and physical health. There is a need for increased understanding of the stress that
nurses experience and how best to manage it. Three hundred twenty Australian acute care public
hospital nurses participated in a study by completing four questionnaires that examined (a) how
various workplace stressors relate to ways of coping, demographic characteristics, and physical
and mental health and (b) which workplace stressors, coping mechanisms, and demographic
characteristics were the best predictors of physical and mental health. Significant correlations
were found between stressors and physical and mental health. Multiple regression showed age to
be the only significant predictor of physical health. The best coping predictors of mental health
were escape–avoidance, distancing, and self-control. Other significant predictors of mental health
were support in the workplace, the number of years worked in the unit, and workload. Mental
health scores were higher for nurses working more years in the unit and for those who used
distancing as a way of coping. Mental health scores were lower for nurses who used escape–
avoidance, lacked workplace support, had high workload, and used self-control coping. The
findings have implications for organizational management, particularly in terms of recommenda-
tions for stress management, social support, and workload reduction. (Index words: Australia;
Coping; Health; Nurses; Stress) J Prof Nurs 22:30 – 38, 2006. A 2006 Published by Elsevier Inc.

W ORK STRESSORS CAN be defined as bantecedent

conditions within one’s job or the organization
which require adaptive responses on the part of the
employeesQ (Jex & Beehr, 1991, p. 312). According to
Lazarus and Folkman (1984), stress is experienced only
when situations are appraised as exceeding one’s re-
*Professor of Nursing and Director of Research, School of Nursing, sources. Thus, a person may interpret additional work
College of Health and Science, University of Western Sydney, Sydney, responsibilities as a threat whereas another may regard
Australia. extra responsibilities as a challenge. Role stress is an
yProfessor and Head, School of Nursing, College of Health and individual’s experience of incongruity between perceived
Science, University of Western Sydney, Sydney, Australia.
zResearch Associate, School of Nursing, College of Health and Science,
characteristics of a specific role and what is actually
University of Western Sydney, Sydney, Australia. occurring within the role (Lambert, Lambert, & Ito,
§Professional Officer, School of Nursing, College of Health and 2004). The negative reaction to role stress is role strain,
Science, University of Western Sydney, Sydney, Australia. experienced as frustration, with burnout a possible
tLecturer, School of Nursing, College of Health and Science, consequence. Burnout is characterized by emotional
University of Western Sydney, Sydney, Australia.
bInternational Nursing Consultant, Lambert & Lambert Nursing
exhaustion, depersonalization, and reduced personal
Consultants, Odenton, MD. accomplishment (Maslach & Jackson, 1986).
#International Nursing Consultant, Lambert & Lambert Nursing There is growing understanding that work-related
Consultants, Odenton, MD. stress negatively affects the health of workers. Particular
Address correspondence and reprint requests to Dr. Chang: School concern has been expressed about the effects of stress
of Nursing, College of Health and Science, University of Western
Sydney, Parramatta Campus, P.O. Box 1797, Penrith South DC 1797,
on health care professionals, especially nurses (Cox,
Sydney, Australia. E-mail: e.chang@uws.edu.au Griffiths, & Cox, 1996; Lambert & Lambert, 2001).
8755-7223/$ - see front matter Many studies have investigated the effects of stress on

30 Journal of Professional Nursing, Vol 22, No 1 (January–February), 2006: pp 30– 38

doi:10.1016/j.profnurs.2005.12.002 A 2006 Published by Elsevier Inc.
ROLE STRESS IN AUSTRALIAN NURSES 31

nurses’ health and well-being (Lambert, Lambert, Itano, ing include problem-solving activities and seeking
et al., 2004). There is agreement that work-related stress information, whereas those of emotion-focused coping
detracts from the quality of nurses’ working lives, may include behaviors such as seeking others’ company,
increases minor psychiatric morbidity, and may con- cognitive responses including denial of the true situa-
tribute to some forms of physical illness. A review of the tion, and looking optimistically at the problem (Payne,
literature from 1990 to 2000 by Lambert and Lambert 1991). How a person views the availability and
(2001) found five major categories of research into role effectiveness of resources influences perceptions of
stress in nurses. These included work environment threat and the coping strategies used (Lazarus &
factors associated with role stress, factors that influence Folkman, 1984). Folkman and Lazarus (1985) sug-
and predict role stress, model testing, physiological and gested that people often use both problem-focused and
attitudinal factors, and evaluation of instruments to emotion-focused strategies when coping with stress.
assess role stress. Some studies suggest that problem-focused coping
Work environment factors found to be commonly strategies may prevent burnout, whereas avoidance or
associated with role stress are lack of control over the emotion-focused strategies contribute to it (Ceslowitz,
job, high job demands, lack of support in work 1989; Chiriboga & Bailey, 1986). However, many of the
relationships, dealing with death and dying, being stressors involved in nursing are not amenable to change
moved among different patient care units within the by an individual nurse, so changing one’s attitude toward
organization, shortage of essential resources including the stressor(s) and using emotion-focused strategies may
nursing staff, and excessive workload. Environmental form an important part of coping (Boyle, Grap, Younger,
factors include uncooperative family members and & Thornby, 1991). This may explain why some studies
clients; inability to reach physicians; unfamiliarity with have not found a relationship between problem-focused
situations; concern for poor quality of nursing staff, coping and burnout (Boyle et al., 1991; Duquette,
medical staff, and patient care; perceived inability to Kerouac, Sandhu, Ducharme, & Saulnier, 1995).
deliver quality nursing care; shift rotation; time Studies on nursing stress by Tyler and Cushway (1992,
demands; state laws restricting the ability to carry out 1995) revealed that use of avoidance coping and
the advanced practice role; poor relationships with perceived workload predicted mental distress. In their
supervisors, co-workers, and physicians; low organiza- study on coping, Boumans and Landeweerd (1992)
tional commitment; and managing family and work found that active problem solving related positively to
responsibilities. Influencing factors reported in studies job satisfaction and negatively to health complaints in
include commitment to career and conflict with others more than 500 nurses. Healy and McKay (2000)
at work; job-induced tension and the intent to quit one’s examined relationships between nursing work-related
job; social support; interdomain conflict between work stressors and coping strategies as well as their effect on
stressors and family stressors; poor communication; nurses’ job satisfaction and mood disturbance. Results
caring for AIDS patients; self-esteem and social intima- showed a significant positive relationship between
cy; psychological hardiness; ways of coping; fun at nursing stress and mood disturbance and a significant
work; being female; being married; distrust; and work– negative relationship between nursing stress and job
family conflict (Lambert & Lambert, 2001; Lambert, satisfaction. The use of avoidance coping and the
Lambert, Itano, et al., 2004). Research reported over the perception of work overload were found to significantly
last few years have found role stress to be related to predict mood disturbance. Planful problem solving was
nursing shortages (Aiken et al., 2001; Janiszewski the most frequently reported coping strategy used by
Goodin, 2003), age (Janiszewski Goodin, 2003), being nurses, but no significant association between partic-
a new graduate (Chang & Hancock, 2003), violence in ipants’ reported use of planful problem solving and
the workplace (Jackson, Clarem, & Mannix, 2002), and mood disturbance or job satisfaction was found. Payne
models of organizing work in terms of functional (2001) also found planful problem solving to be the
nursing, team nursing, and primary nursing (Makinen, most frequently used strategy, followed by emotion-
Kivimakim, Elovainio, & Virtanen, 2003). focused coping. This finding differs from that of Bou-
mans and Landeweerd (1992). The findings of Healy
and McKay provide some support for a transactional
Ways of Coping With Stress model of stress because situational factors were found to
Lazarus and Folkman (1984, p. 141) defined coping as influence the nurses’ coping and perceptions of stress. A
bconstantly changing cognitive and behavioral efforts to transactional model views coping as a process that is
manage specific external and/or internal demands that influenced by cognitive appraisal and is context depen-
are appraised as taxing or exceeding the resources of the dent (Lazarus & Folkman, 1984).
person.Q Coping efforts may be directed externally The abovementioned studies suggest that nurses use
(problem focused) or internally (emotion focused). various ways of coping with work-related stress but that
Problem-focused coping may be viewed as attempting the use of avoidance coping for nurses is generally
to manage or change the problem causing the stress, detrimental to their health. Planful problem solving may
whereas emotion-focused coping attempts to alleviate be linked to better mental health, but some studies have
emotional distress. Examples of problem-focused cop- found no such relationship.
32 CHANG ET AL

Table 1. Demographic Characteristics of the Sample The specific aims of this study were to determine the
following:
Percentage of
Characteristic the Sample (%) c the relationships among role stress, ways of coping,
Female 91 demographic characteristics, and physical and mental
Married 70 health in Australian nurses working in a hospital;
With children 58 c which independent variables (workplace stressors,
Working full time 49 ways of coping, and demographic characteristics) best
Staff nurse 79
predict physical health in Australian nurses working
Supervisory/Managerial position 17
in a hospital; and
Country of birth
Australia 64
c which independent variables (workplace stressors,
UK 17 ways of coping, and demographic characteristics) best
Asia 8 predict mental health in Australian nurses working
Europe 6 in a hospital.
New Zealand 2
Plan to leave job within 12 months 20 Methodology
Some likelihood of leaving 51
nursing within 12 months
Participants
The sample consisted of 320 Australian registered nurses
who were listed on the New South Wales Nurses
Registration Board (NRB) database. The inclusion crite-
Although research in the United States and the United ria were having a license to practice nursing in New South
Kingdom have identified a variety of workplace stressors, Wales and currently working in an acute care public
coping strategies, and physical and emotional outcomes hospital. Participants had a mean age of 42.67 years (SD =
of workplace stress, there is a lack of research addressing 9.58 years, range = 23–68 years). Further details on the
these factors in the Asia Pacific region (Lambert, demographics of the group are shown in Table 1.
Lambert, Itano, et al., 2004). The current study formed
part of an international project that measured role stress Instruments
in nurses from the Asia Pacific and Oceania regions, The four questionnaires used for this study were the
including Japan, Thailand, South Korea, United States following:
(Hawaii), New Zealand, and Australia, using similar
methodology and tools. This article reports on the 1. Demographic Data Questionnaire
Australian findings. This study extends previous nurs- 2. Nursing Stress Scale (NSS) (Gray-Toft & Anderson,
ing stress studies by measuring a wide variety of coping 1981)
strategies that might be used by Australian nurses in 3. Ways of Coping Questionnaire (WAYS; Folkman,
dealing with their work stress. Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986)

Table 2. Details of the Instruments Used for the Study

Instrument Content Scaling

Demographic Data Sex, age, number of those living in household, number of years Six-point scale: 1 = not at all
Questionnaire worked as a nurse and on current clinical unit, plans to leave to 6 = definitely
current nursing position, and estimated dollar income.
Nursing Stress Lists various situations bthat commonly occur Four-point scale: 0 = never to 3 =
Scale (34 items) [for a nurse] in a hospital unitQ very frequently; high score = stress
situation encountered more often
WAYS (68 items) Wide range of cognitive and behavioral responses to stressful Four-point scale: 0 = does
situations; assesses eight ways of coping: (1) confronting, not apply or not used to
(2) distancing, (3) self-controlling, (4) seeking social support, 3 = used a great deal ; high score =
(5) accepting responsibility, (6) escape–avoidance, often used the response for
(7) planful problem solving, and (8) positive reappraisal that scale
SF-36 Health Survey Assesses nine health concepts: (1) limitations in physical activities Various numbered item scales
Version 2 because of health problems, (2) limitations in social activities because within; items summated to give
(36 items) of physical or emotional problems, (3) limitations in usual role activities physical and mental scores,
because of physical health, (4) bodily pain, (5) general mental health, as well as eight subscale scores;
(6) psychological distress and well-being, (7) limitations in usual high scores = better health
role activities because of emotional problems, (8) vitality (energy
and fatigue), and (9) general health perceptions
ROLE STRESS IN AUSTRALIAN NURSES 33

4. Short-Form (SF)-36 Health Survey Version 2 (Ware, Table 4. Correlations Between SF-36 Physical and Mental
Kosinski, & Dewey, 2002). Health and Participant Demographics
These questionnaires were selected because of their Correlations
validity and reliability and the availability of their Physical Mental n
translations into other languages that were required
Age .26* .07 291
for an international study. Further details on these Household .04 .05 303
instruments are shown in Table 2. Years worked as a nurse .23y .08 301
Years on current clinical unit .10 .11 304
Procedure Plans to leave current job .14 .21y 304
After obtaining ethics approval from the university, we Annual income .09 .09 266
approached the NRB for assistance in recruiting partic- *P b .0001.
ipants by accessing its database of nurses. The NRB yP b .001.
randomly selected 900 nurses from its database and
posted the surveys on our behalf, as we had no access to Data Analysis
the names and addresses of the potential participants.
The 900 nurses each received an introductory letter with The analysis examined the strength and direction of the
survey background, purpose, as well as ethical safeguard relationship between each WAYS coping method scale
information and an anonymous reply-paid envelope score and physical and mental health as measured by
along with the four questionnaires. The response rate United States SF-36 norm scores. Zero-order correla-
was 36%, with 320 surveys returned. tions revealed bivariate relationships with other varia-
bles. Forward stepwise regressions controlled for sex,
age, live-in spouse, non-English speaking background,
number of tertiary qualifications, and workplace stress.
Table 3. Descriptive Statistics for Stepwise Multiple Regression A conservative .01 P value of significance was used for
Variables Pearson’s correlation analysis because of the large
number of correlations. The stepwise regressions iden-
Predictor of Health M Mdn SD n
tified the demographic (binary or continuously scaled),
Age (years) 42.59 44.00 9.60 308 stress, and coping variables with the strongest unique
No. of those living in household 3.42 3.00 2.01 321 relationships to physical and mental health. Physical
No. of years worked in 7.72 6.00 6.62 321 and mental health were analyzed as separate dependent
current unit variables. A Type 1 error rate of .05 was used for the
Likelihood of leaving 2.19 1.00 1.54 321
regression analyses.
nursing within next
12 months (1–6 scale)
Annual household 77.38 70.00 39.13 281 Results
income /$1,000
NSS scales Table 3 shows descriptive statistics for sample demo-
DD 8.58 8.00 4.35 325 graphics, NSS scales, and WAYS coping strategies as
CP 6.35 6.00 2.78 324 well as for the SF-36 physical and mental health scores.
IP 3.55 3.00 1.92 323 The most common source of nursing stress was
LS 2.98 3.00 2.09 324 workload, followed by death and dying, uncertainty
CN 6.07 6.00 3.30 297 about treatment, and conflict with physicians and
WL 11.29 12.00 3.95 297 nurses. The least reported stressors were perceived lack
UT 6.35 6.00 3.28 297
of support and inadequate preparation.
WAYS scales*
CC 5.38 (11) 5.00 3.55 307
D 5.14 (10) 5.00 3.45 307 Table 5. Correlations Between NSS Subscales and SF-36
SC 8.95 (16) 9.00 4.05 307 Physical and Mental Health
SS 7.65 (16) 7.00 4.30 307
AR 3.42 (10) 3.00 2.77 307 Correlations
EA 5.91 (9) 5.00 4.59 307 NSS Subscale Physical Mental n
PS 8.61 (18) 9.00 3.72 307 DD .17* .19y 308
PR 6.38 (11) 6.00 4.62 306 CP .18* .31z 307
SF-36 Physical 50.87 52.26 8.47 310 IP .14 .27z 306
SF-36 Mental 44.29 47.96 12.73 310 LS .14 .40z 307
DD indicates death and dying; CP, conflict with physicians; IP, inadequate CN .18* .30z 286
preparation; LS, lack of support; CN, conflict with nurses; WL, workload; WL .20y .32z 286
UT, uncertainty about treatment; CC, confrontational coping; D, UT .21y .28z 286
distancing; SC, self-controlling; SS, seeking social support; AR, accepting
responsibility; EA, escape–avoidance; PS, planful problem solving; PR, *P b .01.
positive reappraisal. yP b .001.
*Values in parentheses are percentages. zP b .0001.
34 CHANG ET AL

Table 6. Correlations Between WAYS Subscales and SF-36 with reduced physical health. All sources of nursing
Physical and Mental Health stress were significantly correlated with diminished
mental health, with some correlations (eg, for lack of
Correlations
support) approaching moderate strength. Physical
WAYS Subscale Physical Mental n health was not significantly related to any of the coping
CC .09 .16* 291 scales, as seen in Table 6. None of the coping strategies
D .09 .00 291 listed in the WAYS was significantly associated with
SC .14 .25y 291 better mental health. Coping strategies that correlated
SS .05 .01 291 significantly with mental health all tended to diminish
AR .07 .17* 291 mental health.
EA .08 .45y 291
PS .11 .08 291
PR .08 .04 290 Physical Health Stepwise Regression Results
*P b .01. Table 7 shows regression results for physical health.
yP b .0001. The multiple correlation was .38, and the adjusted R 2
was .12, F(7, 250) = 6.08, P b .0001, showing that the
variables in the model as listed in Table 3 accounted for
Looking at the relative scores (percentages describing 12% of physical health variance. Age is the only
the proportion of effort for each coping strategy), individually significant predictor in Table 7, with
planful problem solving was the most used coping higher age being associated with poorer physical health.
strategy, accounting for 18% of the coping, followed by The partial and semipartial correlations for age indicate
self-control (16%) and seeking social support (16%). a low–moderate relationship between age and physical
The SF physical score mean of 50.87 was close to health when controlling for other predictors in the
norms for the general United States population of 50 table. All other predictors lacked any substantive,
(Ware et al., 2002), suggesting that physical health was unique relationship with physical health.
within normal levels. The mean mental health score of
44.29 was more than half a standard deviation lower Mental Health Stepwise Regression Results
than the United States norm of 50, suggesting a slightly Table 8 shows the variables to emerge from the mental
poorer level of mental health compared with the general health stepwise regression. The multiple correlation was
United States population. strong at .61, and the overall model was significant,
F(10, 247) = 14.80, P b .001. The adjusted R 2 was .35,
Correlations With Physical and Mental Health indicating that the listed predictors accounted for 35%
Tables 4 – 6 present zero-order correlations between SF- of the variance in mental health scores. Significant
36 physical and mental health scales and the various individual predictors of mental health included the
predictors (demographics, stress, and coping). Table 4 coping factors of escape–avoidance, lack of support,
shows that increased age and more years worked as a workload, distancing, and self-controlling as well as the
nurse (themselves correlated .81) significantly related to demographic factor of years in the unit. No other
reduced physical health. Number of years worked in the individual predictor was significant. Mental health
unit was significantly correlated with number of years scores were higher for more years in the unit and
having worked as a nurse (r = .47, P b .0001). Plans to distancing and lower for escape–avoidance, lack of
leave current job correlated negatively with mental support, workload, and self-controlling. Seeking social
health. The correlations in Table 4 are all fairly low. support came just short of significance.
Table 5 shows that more frequent stress from dealing As seen in Table 8, the partial correlation for escape–
with death and dying, conflict with physicians, conflict avoidance was in the moderate range. Other significant
with other nurses, workload, or uncertainty about partial correlations were in the low–moderate range. All
treatment was significantly albeit weakly correlated other (nonsignificant) partial correlations were small,

Table 7. Stepwise Regression Summary for SF-36 Physical Health

B SE of B B SE of B pr sr t (250) P n
Intercept 69.18 2.96 23.38 .0000
Age .29 .06 .26 .05 .29 .28 4.79 .0000 308
NSS DD .09 .07 .18 .15 .08 .07 1.22 .2239 325
NSS LS .09 .08 .37 .30 .08 .07 1.20 .2312 324
NSS CN .10 .08 .26 .20 .08 .08 1.32 .1868 297
NSS WL .10 .08 .21 .17 .08 .07 1.27 .2048 297
NSS UT .09 .09 .23 .23 .06 .06 1.01 .3134 297
WAYS SC .08 .06 .17 .13 .08 .08 1.30 .1937 307
ROLE STRESS IN AUSTRALIAN NURSES 35

Table 8. Stepwise Regression Summary for SF-36 Mental Health

B SE of B B SE of B pr sr t (247) P n
Intercept 54.75 2.92 18.76 .0000
Years in unit .12 .05 .22 .10 .14 .12 2.29 .0227 321
Income/$1,000 .06 .05 .02 .02 .08 .06 1.26 .2074 281
NSS LS .23 .06 1.39 .36 .24 .20 3.90 .0001 324
NSS WL .13 .06 .42 .19 .14 .11 2.23 .0266 297
WAYS D .18 .06 .68 .22 .19 .16 3.11 .0021 307
WAYS SC .13 .07 .42 .21 .13 .10 2.00 .0464 307
WAYS SS .11 .06 .32 .17 .12 .10 1.92 .0562 307
WAYS EA .40 .06 1.10 .16 .39 .34 6.70 .0000 307
WAYS PS .09 .06 .29 .21 .09 .07 1.43 .1544 307
WAYS PR .10 .06 .29 .18 .10 .08 1.62 .1068 306

indicating no substantive relationship between these Physical health was significantly negatively correlated
predictors and mental health. with years worked as a nurse, dealing with death and
dying, conflict with physicians and other nurses,
workload, and uncertainty about treatment. However,
Discussion these relationships were not significant when entered
The aim of this study was to describe the relationships into the regression analysis. When controlling for other
among demographic characteristics, workplace stres- predictors, increasing age was the only significant
sors, coping mechanisms, physical state of health, and determinant of lower physical health scores. One would
mental state of health among Australian nurses. Mean expect physical health to decline with age. Given the
scores for physical and mental health demonstrated that low-to-moderate correlations and lack of significant
Australian nurses in this sample had normal levels of predictors of physical health, there are limited evidence
physical health and slightly-lower-than-normal levels of for the major impact of role stress and coping on
mental health. It is not possible to conclude from the physical health in this sample of nurses.
findings whether nursing caused lower mental health, Relationships were identified between workplace
given that this was not a prospective study. However, stressors, ways of coping, and mental health. Significant
the results suggest that a substantial proportion of predictors of higher mental health scores were having
Australian nurses may have support needs in terms of worked more years in the unit and using distancing as a
mental health. coping mechanism. There was also a significant and
The most common source of nursing stress was moderate correlation between the number of years
workload, followed by death and dying, conflict with worked as a nurse and the number of years worked in
physicians, uncertainty about treatment, and conflict the unit. It is possible that the experience gained from
with nurses. The findings that workload and death and working more years in the unit reduces the likelihood of
dying were the most common sources of nursing stress experiencing role ambiguity (i.e., the lack of clear
are consistent with the cross-cultural comparisons of consistent information about the behavior expected in
workplace stressors made by Lambert, Lambert, and Ito a role; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964,
(2004). The least reported stressors were perceived lack p. 23) because expectations are understood after many
of support and inadequate preparation. This is consis- years of service. New graduates commonly experience
tent with the findings of Healy and McKay (2000) and role ambiguity, which may explain their greater ten-
Tyler & Cushway (1992, 1995). dency to experience role stress (Chang & Hancock,
Planful problem solving was the most used strat- 2003). Charnley (1999) also found that being a newly
egy, followed closely by self-control and seeking qualified nurse was associated with increased role stress,
social support. Other studies have reported planful supporting the current findings.
problem solving to be the most commonly used way Nurses in this study who used distancing were more
of coping (Healy & McKay 2000; Payne 2001). In the likely to have better mental health. Distancing may
cross-cultural comparative study conducted by Lambert, enhance one’s mental health if it involves looking on the
Lambert, and Ito (2004), only the nurses from the bright side of things and not taking things too seriously.
United States (Hawaii) were found to exercise planful Not dwelling excessively on stressful issues may help
problem solving as the most frequently used coping some nurses cope with work stressors.
mode when compared with nurses from Japan, Thai- The use of self-control as a way of coping, however,
land, and South Korea. This could suggest that planful was associated with poorer mental health. Self-control
problem solving is a coping mode more often used in includes responses such as keeping others from knowing
western cultures, such as Australia and the United how bad things are and trying to keep feelings to oneself.
States, rather than in eastern cultures. Whereas self-control generally has not been found in
36 CHANG ET AL

other research to be related to role stress in nurses, use objective measures, such as work absenteeism, in
Lambert, Lambert, and Ito (2004) found distancing to be addition to self-reports.
a positive predictor of good mental health in hospital Another limitation of the study is the relatively low
nurses from South Korea and the United States response rate (36%). However, low initial response rates
(Hawaii). Thus, further research is needed to examine are typical for mail surveys, with 40% considered a
the influence of both distancing and self-control. reasonable response for a first mail out (Deakin
Lower mental health scores also were predicted by University, 2004). Ideally, it would be desirable to
the use of escape–avoidance, lack of support, and high interview participants, but face-to-face interviews can
workload. These findings suggest that escape–avoidance introduce their own particular biases. Mail surveys are
as a coping strategy may not enhance mental health. an efficient mode of conducting research. This study’s
This is consistent with other research that found sample size of 320 provides high statistical power,
escape–avoidance to be negatively related to mental increasing the generalizability of the results.
health (Lambert, Lambert, Itano, et al., 2004; Lambert, Although there were numerous significant correla-
Lambert, & Ito, 2004). Other research have found tions, many of them demonstrated a low statistical
avoidance coping and perceived workload to predict strength. As well, it is important not to draw causal
mental distress in nurses (Tyler & Cushway, 1992, relationships from the current correlational findings.
1995). In addition, Healy and McKay (2000) found
avoidance coping and the perception of work overload Implications and Recommendations
to significantly predict mood disturbance. The escape– There was no evidence that role stress negatively
avoidance items in the WAYS describe responses that affected the physical health of the nurses in this study
may give a semblance of relief from a stressor, at least independently of other predictors. The findings do
temporarily, but fail to address the fundamental cause of however support the recommendation that stress edu-
the stressor, and, as such, they are likely to fail as a long- cation and management strategies be used to reduce the
term coping strategy. Examples of escape–avoidance negative effects of mental stress in nurses. In particular,
coping in the WAYS include bhoping for a miracleQ; interventions that concentrate on individual coping
fantasy and wishful thinking; sleeping; eating; drinking, strategies may be useful, such as emphasizing other
smoking, and using drugs; denial; and taking stress out styles of coping that seem to be helpful to mental health
on other people. These stress responses amount to a (distancing rather than escape–avoidance and self-
little more than displacement activity. Their failure to control). However, no causal relationship can be
address the problem at the source may be sufficient to concluded from this study, so the utility of such
render them maladaptive. interventions needs to be tested, possibly via an
Lambert, Lambert, Itano, et al. (2004) and Lambert, experimental study to examine their efficacy.
Lambert, and Ito (2004) found that high workload Given that lack of support was found to predict poor
levels and lack of support were associated with poorer mental health, enhancing social support through engag-
mental health. High workload leads to strain and ing in social activities and peer support could be
increases the likelihood of burnout (Janssen, de Longe, important for nurses, particularly given the continual
& Bakker, 1999). The current research suggests that changes in the health system. The finding that high
better provision of support within the workplace and workload was associated with poorer mental health
reducing associated stress could enhance mental health. suggests that excessive workloads require attention from
Garrett and McDaniel (2001) used a cross-sectional management, especially because safe work environments
survey in nurses and found that a negative social climate are legally required. Reducing the effect of environmental
in the workplace predicted greater burnout. They stressors such as workload, staffing, and assisting nurses
suggest that social support is particularly needed to to balance priorities may be effective interventions.
improve the social climate in times of change and work Increased staffing is desirable, but there is a current
environment uncertainty and that such an improvement nursing shortage. If high stress from excessive workload
can prevent burnout. Others also have concluded from and inability to cope are driving nurses away from the
their research that burnout may be avoided by facilitat- profession, remaining nurses will be all the more exposed
ing positive social interactions in the organization to excessive stress, raising the likelihood that they too
(Janssen et al., 1999). will leave, thus worsening the problem. This bpositive
feedback loopQ leads staff shortages to self-aggravate.
Limitations of the Study and Suggestions Allowing greater flexibility in work hours, increasing
for Future Research nursing enrollments, and attracting ex-nurses back to the
The unavoidable use of self-report measures as used in profession may help address workload problems (Chang,
this study does assume that the respondents gave Hancock, Johnson, Daly, & Jackson, 2005) and the stress
honest, valid responses and comprehended the ques- that goes with them, thereby further reducing staff
tions. Another problem is that negative mood can shortages and, in turn, the associated stress.
inflate correlations between subjective measures of The results found a slight tendency for nurses who
stress and well-being (Terry, Nielsen, & Perchard, had worked on the unit for a short time to have poorer
1993). One way of addressing negative affectivity is to mental health, implying that specific or more vigorous
ROLE STRESS IN AUSTRALIAN NURSES 37

interventions are needed for newer staff. Examples factors and strategies for moving forward. Nursing and Health
include orientation and mentoring to reduce role Sciences, 7, 57 – 65.
ambiguity, along with clear communication of role Charnley, E. (1999). Occupational stress in the newly
expectations. Nursing unit managers might assist by qualified staff nurse. Nursing Standard, 13, 33 – 36.
Chiriboga, D., & Bailey, J. (1986). Stress and burnout
specifying the roles of new staff and by showing
among critical care and medical surgical nurses: A compara-
experienced staff how to help new staff adjust to their
tive study. Critical Care Quarterly, 9, 84 – 92.
role and to the work environment. Nursing unit Cox, T., Griffiths, A., & Cox, S. (1996). Work-related stress
managers must also ensure that there are routine in nursing: Controlling the risk to health. Geneva: International
support mechanisms to provide for the mental health Labour Office.
needs of all nurses in the ward. Deakin University. (2004). Survey techniques. Retrieved
Rather than adopting escape–avoidance strategies, a June, 2004, from www.deakin.edu.au/~agoodman/sci101/
better solution would be empowering nurses to reduce chap8.php.
or eliminate sources of stress. Both the actuality and the Duquette, A., Kerouac, S., Sandhu, B., Ducharme, F., &
perception of empowerment would be required in this Saulnier, P. (1995). Psychosocial determinants of burnout in
instance. The process of empowerment would involve geriatric nursing. International Journal of Nursing Studies, 32,
443 – 456.
giving nurses greater control of workplace events.
Folkman, S., & Lazarus, R. (1985). If it changes it must be
In summary, this study suggests that physical health progress: Study of emotion and coping during three stages of a
levels were in the reference range whereas mental health college examination. Journal of Personality and Social Psychol-
levels were slightly low among our sample of Australian ogy, 48, 150 – 170.
nurses, suggesting that Australian nurses need greater Folkman, S., Lazarus, R., Dunkel-Schetter, C., DeLongis, A.,
attention to having their mental health needs met. & Gruen, R. J. (1986). Dynamics of a stressful encounter:
Physical health was not influenced by the experience Cognitive appraisal, coping, and encounter outcomes. Journal
of role stress. Some ways of coping with role stress in of Personality and Social Psychology, 50, 992 – 1003.
nurses predicted better mental health, whereas others Garrett, D., & McDaniel, A. (2001). A new look at nurse
were directly related to poor mental health. This study burnout: The effects of environmental uncertainty and social
reinforces previous recommendations that workload climate. Journal of Nursing Administration, 31, 91 – 96.
Gray-Toft, P., & Anderson, J. G. (1981). The Nursing Stress
needs to be reduced to improve mental health in nurses
Scale: Development of an instrument. Journal of Behavioral
whereas social and peer support are important in helping Assessment, 3, 11 – 23.
nurses cope with the stressors of nursing. In these Healy, C., & McKay, M. (2000). Nursing stress: The effects
respects, some of the factors found to influence mental of coping strategies and job satisfaction in a sample of Aus-
health in Australian nurses are similar to those found in tralian nurses. Journal of Advanced Nursing, 31, 681 – 688.
nurses from the United States, United Kingdom, Japan, Jackson, D., Clarem, J., & Mannix, J. (2002). Who would
Thailand, and South Korea, but other relationships want to be a nurse? Violence in the workplace — A factor in
found significant in these countries were not found in recruitment and retention. Journal of Nursing Management, 10,
this study. The participants from various countries were 13 – 20.
found to use similar coping strategies and to have similar Janiszewski Goodin, H. (2003). The nursing shortage in the
sources of nursing stress. It is possible that differing United States of America. Journal of Advanced Nursing, 43,
335 – 350.
organizational structures in the Australian health system
Janssen, P., de Longe, J., & Bakker, A. (1999). Specific
may explain some of these differences. However, this determinants of intrinsic work motivation, burnout and
hypothesis needs to be tested further. turnover intentions: A study among nurses. Journal of
Advanced Nursing, 29, 1360 – 1369.
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