Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil.

ORIGINAL ARTICLE

WORK-RELATED STRESS AND COPING: A SURVEY ON MEDICAL AND SURGICAL

NURSES IN A MALAYSIAN TEACHING HOSPITAL

ZA Emilia1, I Noor Hassim2

1
Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia
43400 Serdang, Selangor Darul Ehsan, Malaysia & 2Department of Community Health, Medical Faculty,
Hospital Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak 56000 Cheras, Kuala
Lumpur, Malaysia.

ABSTRACT

Background: A cross-sectional study on work-related stressors among nurses in a public teaching

hospital had also attempted to explore functions of coping strategies in determining stress.
Materials and Methods: A structured bilingual questionnaire (English-Malay) on symptoms and
sources of stress, and coping style measure was disseminated to medical and surgical nurses working in a
teaching hospital in Kuala Lumpur. Socio demographic information and stress management methods were
inquired. Frequency in workplace stressors were assessed using Nursing Stress Scale. Stress symptoms
and home-life stressors were evaluated using Personal Stress Inventory. Measurement of coping strategies
was performed using Coping Orientation for Problems Experienced questionnaire.
Results: A total of 181 questionnaires were disseminated and 151 (83.4%) were satisfactorily
completed by nurses. It was found that the prevalence of work-related stress among medical and surgical
nurses was 49.3% (N=74/150). Analysis of dichotomized outcome (between Stress and No stress group)
illustrated high workload (t-value=4.122; p<0.001), concerns about death and dying (t-value=2.784;
p<0.05) and conflict with physicians (t-value=3.821; p<0.05) as the highest stress contributing factors.
Socio demographic factors such as age, marital status, salary per month and tenure of service were not
significantly (p≥0.05) associated with stress. Sources of stress from the home life were found to be
significantly associated with stress experienced (t-value=3.971; p<0.05). Pearson’s correlation analysis
between coping and stress scores demonstrate significant (p<0.05) positive association of avoidance,
acceptance and venting of emotion with higher stress levels. Multiple linear regression analysis on selected
variables demonstrates that high workload (B=1.052; p<0.05), conflicts with physicians (B=1.398;
p<0.05), lack of support (B=0.346; p<0.05) and coping through venting of emotion (B=2.207; p<0.05)
significantly contributes towards determining nurses stress. This model explains 44.8% (adjusted R
square=0.448) in the variation of stress scores.
Discussion: High workload as a stressor has been repeatedly mentioned in literature on work-
related stress among health professionals, as in this study. Findings suggest that sources of work-related
stress do not differ much from other nurses with different specialty. Other significant stressors were
associated with death and dying concerns and conflicts with doctors. Coping by acceptance, venting of
emotion and avoidance contribute significantly to stress and thus could be categorized as maladaptive
instead of working as a buffering factor to reduce work-related stress.
Conclusion: Findings of this study supports the hypothesis that workload is still the major source
of work-related stress among the study population. Besides the usual recommendation for the management
team to put effort to reduce the workload problem faced by nurses, stress management program if any
should emphasize on educating nurses in selecting the most adaptive coping methods could be used at both
personal as well as organizational levels in order to ameliorate the impact of work-related stress on job-
related strain and health.

Key Words: work related stress, nurses, coping strategies, teaching hospital.

Corresponding author: ZA Emilia, Faculty of Medicine

and Health Sciences, Universiti Putra Malaysia, 43400
Serdang, Selangor Darul Ehsan, Malaysia
Tel: 03-89472358
(e-mail: emilia@medic.upm.edu.my)

55
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1
INTRODUCTION
Nursing is, by its nature a stressful
profession1. Nurses work in high-stress
environments since their main responsibility
focuses upon providing help to patients who are
usually encountering life crisis. Many researches
have focused on the causes and effects of work-
related stress among the nursing profession2-6. In
Malaysia, a study done by Rokiah in 1994,
showed that more than 49.5% of nurses in a
public hospital in Kuala Lumpur experienced
stress due to workplace factors whereas a study
among community nurses in Kelantan have
depicted the prevalence of work-related stress to
be at 38.5% 7, 8.
Stress is the result of conflicting
internal and external pressures that causes strain
and alter the effectiveness of individuals9.
According to the Lazarus & Folkman model,
stress is an outcome of a transaction or
relationship between the person and the
environment10. This model demonstrates that a
person will experience stress when the
environmental stressors are perceived to be
demanding and have exceeded the personal
resources present in order to cope with them.
From a systems perspective, the sources
of occupational stress for nurses radiate in
concentric circles from the individual to the
extra-organizational, including those at the
immediate, work environmental and
organizational levels11. A review of studies
across cultures and nursing specialties indicates
that common occupational stressors for nurses
include workload, role ambiguity, interpersonal
relationships, and death and dying concerns12-14.
In addition, Hipwell et al. also points out that
most nurses rated high workload and dealing
with death and dying as their major stressful
event15. Review on work-related stress among
nurses will conclude that workload could be the
principal predictor of health and well-being
among all the potential sources of stressors
related to nursing9.
Sources of stress that have a direct
impact on the mental health of an individual will
also elicit coping responses. The differences in
coping methods use could greatly affect the
response to stressors. In times of stress, an
individual normally engages in certain coping
strategies to handle stressful situations and their
associated emotions15. Coping is a process of
moderating the effects of stress on mental and
56
physical health to prevent distress, burnout and
psychological maladjustment10. Lazarus and
Folkmanhave also identified two distinct coping
strategies; emotion-focused coping which could
alleviate emotional distress and problem-focused
coping which attempts to manage or alter the
problem causing distress10.
There have been a few studies that
suggest the use of problem-focused coping
strategies may prevent stress whereas avoidance
or emotion-focused strategies could contribute to
stress15, 17, 18. Emotion-focused strategies may be
maladaptive because they focus on the source of
distress and thus exacerbate it, or because they
put off dealing with the problem17. However,
many of the stressors involved in nursing are not
amenable to change, thus emotion-focused
strategies may form an important part of
coping19. Hence, the moderating influence of
coping is likely to depend on the amount of
coping, source of stress, individual’s appraisal
and situation in the workplace.
This current study attempted to explore
work-related stress, risk factors involved and the
mediating effect of coping mechanism on stress
of medical and surgical nurses in a teaching
hospital in Malaysia. This study employed a
transactional model of stress and coping in
exploring work related stress, factors involved
and coping of medical and surgical nurses in
which research have been limited. Therefore, it is
hoped that this study will not only be able to
illuminate the present work-related stress
experienced by the nurses, but could also
contribute towards the design of a suitable
intervention program which is tailor made to fit
the nurses population.
MATERIALS AND METHODS
Study design
In December 2005 to February 2006,
we conducted a cross sectional survey in which
data were collected through self-administered
structured questionnaires. Subjects were all
medical and surgical U29 nurses working in a
teaching hospital in Kuala Lumpur.
Sample size determination
Sample size for the prevalence of work-
related stress was estimated using guidelines by
Lwanga and Tye for a 95% confidence interval
(CI) and prevalence of 49.5% and 38.5% for
work-related stress by Rokiah and Majdah
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1
respectively7, 8, 20. With the absolute precision of
11% and assuming a 10% non-response rate, the
sample size was calculated to be 174 subjects
from a minimum of 154 subjects.
Methods
Permission to carry out the study was
obtained from the Medical and Ethics Research
Committee of Universiti Kebangsaan Malaysia.
Questionnaires were sent out by hand to 181 U29
nurses according to their respective medical and
surgical wards in the participating hospital. A
consent form was included in the questionnaire
booklet and it was stressed that participation was
on voluntary basis and confidentiality of
information was assured. To maximize the
response rate, a reminder notice was sent to non-
respondents three weeks after the initial handing
out of questionnaires and if not successful, then
direct personal contacts were made.
Subjects
Subjects were identified from the
nurses’ registry obtained from the Nurses
Management Department. From the registry, a
total of 181 names were selected after excluding
those who were on maternity leave, those who
were unavailable due to attendance at courses,
and those who were on no pay leave or have
transferred during the study period.
Subjects eligible for the study were
further selected using the inclusion and exclusion
criteria. Those who were working as U29 nurses
regardless of being local or otherwise, with a
tenure of 3 months or more were chosen as the
inclusion criteria, whereas nurses with chronic
medical condition which were known to affect
the emotional state of an individual and their
stress level such as cardiovascular disease,
diabetes mellitus, hypertension and
hyperthyroidism were not included in the study.
Research instrument
The self-administered questionnaire have been
contrived to consist questions on socio
demographic backgrounds, measurement of
stress levels, instrument to determine both work-
related (i.e. Nursing Stress Scale) and personal
stressors (i.e. Personal Stress Inventory) and to
assess coping style (i.e. Coping Orientation for
Problems Experienced). In order to reduce
misinterpretations, the questionnaire was made
bilingual, using Malay and English. The original
57
English version was translated into Malay using
the back-to-back translation method7,21.
Socio Demographic Factors
Demographic information obtained
included age, education level, marital status,
salary per month and number of years in nursing
experience.
Personal Stress Inventory
There are two separate parts to Personal
Stress Inventory or PSI where the first part of the
inventory was used to measure psychological
and physiological symptoms of stress, and the
second part inquired about personal and family
factors that could affect stress22.
The first part of PSI consisted of 11
psychological and physiological subscales which
add up to 52 items (musculoskeletal system- four
items, gastrointestinal system- six items, other
physical system- six items, depression- six items,
anxiety- ten items, energy level- three items,
diet- five items, activities- three items,
relationship- three items and sleep- three items).
Measurement for symptoms occurrence during
the previous 1 month was based on a four-point
Likert scale (with ‘3’ and ‘0’ bringing the
highest and lowest weightage respectively) and
raw scores were calculated by summing the item
scores which comprise each subscale. The scores
obtained were later dichotomized to Stress (score
of 36 ≥) and No stress (score of < 36) group7.
Receiver operator characteristic (ROC) curve
analysis was used to determine the cutoff point
that, as Rokiah correctly point out, minimizes the
total number of false-positives and false-
negatives. This study estimated the reliability of
PSI by the alpha Cronbach value of 0.937.
The second part of PSI consisted of 12
items and method of scoring was similar to the
first part of PSI (i.e. 4-point Likert scale). A
study done earlier on a nursing population in a
different state21 demonstrated the mean
reliability denoted by alpha Cronbach was 0.96.
Nursing Stress Scale
The Nursing Stress Scale (NSS) was used to
measure frequency of work-related stressors22.
The scale consisted of 34 items comprising
seven subscales: Death and dying (seven items),
conflict with physicians (five items), inadequate
preparation to deal with the emotional needs of
patients and their families (three items), lack of
support (three items), conflict with other nurses
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

and supervisors (five items), workload (six
items) and uncertainty concerning treatment (five
items). The NSS is scored on a 4-point scale
from never (0) to very frequently (3) and yields
seven subscale scores. Raw scores were
calculated by summing the item scores which
comprise each subscale and relative scores were
calculated by dividing each raw subscale score
by the number of items comprising that
particular subscale. A high score would be
anticipated in an individual who finds a stressor
frequently problematic. Mean reliability across
the subscales, estimated by alpha Cronbach was
0.89.
87 (58.0%) respondents who were married and
63 (42.0%) were single.
The majority of the respondents (n=90;
60.0%) have an income of RM1000 to RM1500
and 83.3 % had been working as a nurse for less
than 5 years (n=125). Occupancy in a unit of less
than 2 years (n=93; 62.0%) scored the highest
mean in all the 13 wards. Socio demographic
characteristic among nurses in medical and
surgical wards were shown on Table 1.

Coping Orientation for Problems Experienced

(COPE)

The subscales in COPE were used to measure

general coping strategies used by in order to
handle stress17. We have translated the scale into
Malay using a back-to-back translation method.
The instrument has 60 items designed to measure
15 dimensions of coping strategies: positive
appraisal, mental disengagements, venting of
emotion, instrumental support, active, denial,
religion, humor, behavioral disengagement, self
restrain, emotional support, substance abuse,
acceptance, suppression of other activities and
planning. The nurse then indicates on a Likert
scale how often a specific coping strategy was
used generally in a stressed situation, from
"Never" (scored as 0) to "Almost every time"
(scored as 4). In this study, reliability was
estimated at 0.91 (Cronbach alpha).

RESULTS
Descriptive statistics, Pearson
correlations and multiple linear regression
analyses were carried out using the Statistical
Package for the Social Sciences (SPSS) version
12.02.
This study was conducted among nurses
in 13 medical and surgical wards in a teaching
hospital in Kuala Lumpur. Out of the181 nurses
who were eligible for the study, 151 were
involved in the study, giving a response rate of
83.4%. Most of the respondents were of Malay
ethnicity (n=140; 93.4%) and 3.3% (n=5) of the
respondents have other nationality besides
Malaysian (i.e. Myanmar).
All of the 13 medical and surgical
wards have a majority of nurses between the age
of 26 to 30 years old (n=81; 55.4%). There were

58
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

Table 1: Socio demographic characteristics of medical and surgical nurses

Frequency (%)
Variables
Medical and
Medical Surgical
Surgical
(N=67) (N=83)
(N=150)
Age (years)
≤ 26 26 (48.1) 28 (51.9) 54 (36.0)
26 – 30 36 (44.4) 45 (55.6) 81 (54.0)
31 ≥ 5 (33.3) 10 (66.7) 15 (10.0)

Ethnic
Malay 64 (45.7) 76 (54.3) 140 (93.4)
Indian 2 (40.0) 3 (60.0) 5 (3.3)
Others 1 (25.0) 4 (75.0) 5 (3.3)

Marital status
Single 31 (49.2) 32 (50.8) 63 (42.0)
Married 36 (41.4) 51 (58.6) 87 (58.0)

Salary (RM)
≤ 1000 3 (75.0) 1 (25.0) 4 (2.7)
1001 – 1500 43 (60.0) 47 (40.0) 90 (60.0)
1501 – 2000 13 (40.1) 19 (59.9) 32 (21.3)
≥ 2001 3 (42.9) 4 (57.1) 7 (4.7)

Tenure (years)
≤5 53 (42.4) 72 (57.6) 125 (83.3)
6 – 10 9 (60.0) 6 (40.0) 15 (10.0)
11 ≥ 4 (44.4) 5 (65.6) 9 (6.0)

Tenure in unit (years)

≤2 44 (47.3) 49 (52.7) 93 (62.0)
3-4 10 (40.0) 15 (60.0) 25 (16.7)
5-6 10 (41.7) 14 (58.3) 24 (16.0)
7≥ 2 (40.0) 3 (60.0) 5 (3.3)

The overall prevalence of stress was 49.3% between both category of nurses was also proven
(n=74), with higher stress prevalence occurring to be significant as shown from the Pearson’s
among medical ward nurses compared to the chi-square analysis (χ2=5.20; p<0.05) (Table 2).
surgical ward nurses. The differing prevalence

59
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

Table 2: Distribution of stress prevalence among nurses

Frequency (%) Statistical Difference

Ward Total test value
Stress No stress p valuea

Medical 40 (59.7) 27 (40.3) 67 5.20* <0.05

Surgical 34 (40.9) 49 (59.1) 83

Total 74 (49.3) 76 (50.7) 150

a
Pearson’s χ2 statistical test
* Significant when p<0.05; NS: Not Significant, p≥0.0

The Pearson’s chi-square analysis between
categorical socio demographic variables (i.e.
marital status) and stress did not show any
significant association (p≥0.05). Independent t-
tests were used to compare the mean numerical
difference for age, salary per month and tenure in
service between dichotomized Stress and No
stress group. The details could be observed in
Table 3a and Table 3b.

Table 3a: Relationship between socio demographic factors and

work-related stress

Mean±SD
Socio demographic Statistical Difference
factors Stress No Stress test value
(N=76) (N=74) p valuea
Age 26.6±4.1 28.0±6.1 1.662 NS

Salary (RM) 1442.0±287.0 1543.0±390.0 1.715 NS

Tenure (years) 3.9±4.0 5.2±6.4 1.484 NS

Tenure in unit (years) 2.6±1.7 2.8±1.8 0.747 NS

a
Student’s statistical t-test
* Significant when p<0.05; NS: Not Significant, p≥0.05
SD: standard deviation

Table 3b: Relationship between marital status and work-related stress

Frequency (%) Difference

Variable Stress No Stress Statistical p valuea
(N=76) (N=74) test value

Marital status 0.404 NS

Single 33 (52.4) 30 (47.6)
Married 41 (47.2) 46 (52.8)

a
Pearson’s χ2 statistical test
* Significant when p<0.05; NS: Not Significant, p≥0.05

60
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

Work-related factors, especially high work load,
were the most frequent stressor experienced by
nurses in the Stress category, as shown by the
average score obtained (mean±standard
deviation). Concerns about death and dying were
the second most frequent stressor faced by the
nurses and this was followed by conflicts with
physicians. The distribution in mean scores for
other factors which was not mentioned is
included in Table 4. Differences in mean scores
between both the Stress and No stress group
warrants a t-test analysis and it was shown that
all of the seven work-related factors were
associated with stress (p<0.05).

Table 4: Work-related stressors and its relationship to stress

Mean±SD
Difference
Variables Statistical test
Stress No Stress value p value

Work load 9.51±3.08 7.64±2.42 4.122* <0.05

(S=74; NS=75)

Death and dying concerns 7.58±3.12 6.00±3.72 2.784* <0.05

(S=73; NS =75)

Inadequate preparation 3.03±1.56 2.42±1.80 2.196* <0.05

(S=74; NS =76)

Lack of support 3.22±1.97 2.04±1.80 3.797* <0.05

(S=74; NS =75)

Unsure of treatment 5.68±2.10 4.81±2.33 2.383* <0.05

(S=73; NS =74)

Conflicts with physicians 5.82±2.82 4.18±2.40 3.821* <0.05

(S=74; NS =74)

Conflicts with friends 4.29±3.01 3.28±2.55 2.199* <0.05

(S=73; NS =75)
.

a
Student’s statistical t-test
* Significant when p<0.05; SD: standard deviation
(S=Number of stress respondents; NS=Number of no stress respondents)

Analysis on the frequency of personal and family
factors contributing to stress, it was found that
the mean score for nurses in the stress group
(9.36±5.85) was significantly (t-value=3.971;
p<0.05) higher when compared to nurses who
were not stressed (5.96±4.54).
Table 5 presents the correlations
between coping and stress scores of the sample
population. Venting of emotion was found to
have the highest correlation with stress score
(r=0.498; p<0.05). This was followed with
mental disengagement (r=0.351; p<0.05) and
denial (r=0.252; p<0.05). The coping strategies
of positive reappraisal and religion showed a
negative correlation (r=-0.029; p≥0.05 and r=-
0.127; p≥0.05 respectively) however, correlation
was not statistically significant.

61
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

Table 5: Coping strategies and its relationship to stress

Pearson’s
Coping strategies p value
Correlation, r a

Problem solving
Active 0.033 NS
Planning 0.039 NS
Suppression of other activities 0.209* NS

Support seeking
Instrumental support 0.173 NS
Emotional support 0.203 NS
Venting of emotion 0.498* NS

Avoidance
Denial 0.252* <0.05
Mental disengagement 0.351* <0.05
Behavioral disengagement 0.196* <0.05

Acceptance
Acceptance 0.251* <0.05
Positive reappraisal -0.029 NS
Self-restrain 0.186 NS

Substance abuse 0.097 NS

Religion -0.127 NS

Humor 0.196 NS

a
Correlation between stress and coping scores
* Significant when p<0.05; NS: Not Significant, p≥0.05

With all the significant (p<0.05) and important
work factors, non-work factors and coping
strategies that were potential predictors to work-
related stress included, the preliminary main
effect model was obtained. All the independent
variables were fitted into multiple linear
regressions and the final main effect model was
obtained using the backward method. This model
explained 44.8% of the variance of work-related
stress among medical and surgical nurses in a
teaching hospital as shown by the adjusted R
square value of 0.448. The model obtained was
significant (F=11.223, p<0.05) with R value of
0.701. Work load (B=1.052; p<0.05), lack of
support from nurses and supervisors (B=0.346,
p<0.05) conflicts with physicians (B=1.398,
p<0.05) and venting of emotion (B=2.207,
p<0.05) as a coping strategy was found to
contribute to stress scores significantly. Table 6
shows the details of the variables tested in the
multiple linear regression.

62
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

Table 6: Predictor of work-related stress among medical and surgical nurses

Standard
Independent variables Ba p value
errors

Venting of emotion 2.207* 0.843 <0.05

Conflicts with physicians 1.398* 0.542 <0.05
Work load 1.052* 0.527 <0.05
Lack of support 0.346* 0.771 <0.05
Mental disengagement 0.900 0.717 NS
Denial 1.285 0.706 NS
Behavioral disengagement 1.338 0.894 NS
Suppression of activities -1.000 0.702 NS
Acceptance 0.896 0.710 NS
Non-work related stressor 1.863 0.258 NS

Constant -8.768

a
Multiple Linear Regression Analysis
* Significant when p<0.05; NS: Not Significant, p≥0.05
Adjusted R2 = 44.8%

DISCUSSION In this study, workload was found to be

Work-related stress is one of the most
common problems among workforce but
unfortunately its presence has always been
disregarded. This study focused on nurses’ stress
and coping strategies as a moderating effect of
stress. Objective of the study was to determine
the prevalence of stress among medical and
surgical ward nurses in a teaching hospital in
Kuala Lumpur and other factors involved.
Results showed that the overall prevalence of
stress among medical and surgical nurses was
49.3% with 59.7% among the medical ward
nurses and 40.9% among the surgical ward
nurses. Previous stress study among nurses
showed a prevalence of 49.5% in Rokiah and
38.5% in Majdah7, 8. Another study that focused
on nurses in Hospital Tengku Ampuan Afzan
found the stress prevalence to be at 42.5%24.
As far as socio demographic
characteristics were concerned, factors such as
age, salary per month, marital status and tenure
in service among the respondents in this study
did not suggest any relationship with stress. This
could be explained by the fact that the population
of nurses has a homogenous socio demographic
characteristic and the effects of socio
demographic characteristics were neutralized.
the principal contributor to work-related stress.
Review of studies across cultures and nursing
specialties regardless whether the study was
done locally or otherwise, indicates that the most
commonly cited work-related stressors for nurses
was workload1, 7-8, 23, 25, 27-29. Workload was also
associated with inadequacy in the number of
staffs, increase of paper work, inadequate time to
complete nursing work, inadequate time to
provide emotional support to a patient and also
unpredictable staffing and scheduling23. Nurses
that have to produce a greater amount of written
reports on their activities for the purpose of
ensuring the quality of services often find
themselves torn between spending time on direct
patient care and increased administrative duties23,
30
. Narayan et al. and Escot et al. stressed that
even though work overload, interpersonal
conflict and lack of support are major stressors,
they might be compounded by inadequate
training, lack of time to deal with psychological
components of care giving in terminal care, and
relationship difficulties with other medical
staff31, 32.
Other nursing stressors such as death
and dying concerns, conflicts with physicians
and uncertainty regarding treatment in this study
was also found to be significantly associated

63
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1
with stress. It was found that among oncology
nurses in the pediatric department, death and
dying concerns were the most common stressor
faced by the nurses33. In the present study,
conflicts with friends, lack of support and
inadequate preparation are among factors that
have a significant relationship with stress even
though the mean scores obtained were
comparatively smaller than other factors.
Reviews from other nursing studies found that
occupational stressors are idiosyncratic to
different nursing specialties and further
investigation is required in order to fully
understand these differences.
Factors external to the work
environment, such as personal and family life
was found to influence stress. For nurses, the
interaction between demands of work and those
of family life often exacerbate work-related
levels of stress. In this study, we found that there
were significant relationship between family
factors and stress. This correlates with a study
across six different occupations including
nursing, where it was found that the most
significant sources of work-related stress that
contribute to overall work stress were conflicting
demands between work and family, and
performance pressures34. Dual responsibilities
are likely to add a significant load on nurses’
physical and mental health, and the load itself
might be an additional source of work-related
stress35, 36. Although stressors in the domain of
work and home life are often studied in isolation,
it is important to acknowledge that the
relationship between the demands of work and
home is an important source of occupational
stress.
Across other studies, coping strategies
commonly used by nurses are problem solving,
avoidance and social support18, 36. It was found
that in this study, avoidance, acceptance,
suppression of other activities, venting of
emotion, denial, mental and behavioral
disengagement as coping methods were
associated with stress. Surprisingly, venting of
emotion which was identified to be in the origin
of social support scale, did not concur the buffer
theory of positive coping. In fact, findings did
not demonstrate the moderating effects of coping
on stress score but shows that coping strategies
could be maladaptive. According to Parikh et al,
the moderating influence of coping is likely to
depend on the type of mechanism that is used.18.
Hence, it seems that in the occupational domain,
individual coping responses may not be highly
useful when compared to group and
64
organisational strategies because work-related
stress experiences cannot always be coped with
in an efficient way if only the individual coping
level is taken into account37. Another explanation
for the correlation between coping mechanism
and stress was that increased use of coping
mechanisms was thought to be brought on when
individuals become aware of its presently
stressed situation.
Limitations encountered in this study
includes the design of the study itself, where it is
a cross-sectional study, hence the ability to
determine the adaptive or maladaptive effect of
coping on stress could not be done. So it is
imperative that a longitudinal study design is
pursued. Nevertheless, this study did give a
picture of work-related stressors faced and the
coping strategies used among nurses medical and
surgical nurses in a teaching hospital in Kuala
Lumpur. This information could be used to assist
in stress interventions and management process.
Improved coping is important for
prevention and cure at multiple levels. At the
personal level, individual therapy that may
include identification of stressors and coping
skills can reduce work stress, as suggested by
Weinberg and Creed6. Facilitating the use of
problem-solving skills and support networks via
nurse support groups could be implemented. At
the organizational level, it is recommended that
attention be paid to a better nurse–patient ratio to
reduce workload and the promotion of team
working38.
CONCLUSION
Findings showed work-related stressors
such as workload, concerns about death and
dying and conflict with physicians appears to
create a substantial amount of stress. Sources of
stress from the home life were found to be
contributed by financial problems, inadequate
time for family, conflict with husband and
conflict with friends. Socio demographic factors
were not associated with stress. Coping
mechanisms which have significant association
with stress includes venting of emotion,
avoidance, acceptance, denial, mental
disengagement, behavioral disengagement and
suppression of other activities. Work load,
conflicts with physicians, lack of support and
coping through venting of emotion explains
44.8% of variation in stress score distribution.
Findings of this study supports the hypothesis
that work factors contributes significantly to
stress. Little evidence for buffering effects of
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1
coping mechanism was found but the use of
negative coping such as avoidance, acceptance
and emotion venting will contribute to stress.
Significant correlation between positive coping
mechanism and stress were thought to be
brought on by increased use of coping
mechanisms when an individual is aware of its
presently stressed situation. Stress management
programs which emphasized on specific stressors
and coping mechanisms are important for nurses
at both personal as well as organizational levels
to ameliorate the impact of occupational stress
on job-related strain and health.
REFERENCES
1. Dewe, P.J. Identifying the causes of
nurses’ stress: a survey of New Zealand
nurses. Work & Stress 1987; 1:15-24.
2. Menzies, I.E.P. A case study in the
functioning of social systems as a
defence against anxiety. Human
Relations 1960; 13: 95–121.
3. Hingley, P. & Cooper, C.L. 1986. Stress
and the nurse manager. Wiley, New
York, NY.
4. Humphrey, J.H., 1992. Stress among
women in modern society. Charles C.
Thomas, Springfield, IL.
5. Tyson, P.D., Pongruengphant, R. &
Agarwal, B. Coping with organisational
stress among hospital nurses in southern
Ontario. Int J Nurs Stud 2002; 39(4):
453–459.
6. Weinberg, A. & Creed, F. Stress and
psychiatric disorder in healthcare
professionals and hospital staff. Lancet
2000; 335: 533-537.
7. Rokiah Mohd. 1994. Prevalens tekanan
dan penyebab tekanan kerja di kalangan
jururawat terlatih Hospital Kuala
Lumpur. Tesis Sarjana. Universiti
Kebangsaan Malaysia.
8. Majdah Mohamed. 1999. Prevalen stres
dan faktor pekerjaan di kalangan
jururawat masyarakat di Negeri
Kelantan. Tesis Sarjana. Universiti
Kebangsaan Malaysia.
9. Munro, L., Rodwell, J. & Harding, L.
Assessing occupational stress in
psychiatric nurses using the full job
strain model: The value of social
support to nurses. Int J Nurs Stud 1998;
35(6): 339–345.
10. Lazarus, R. & Folkman, S. An analysis
of coping in a middle-aged community
65
sample. J Health Soc Behav 1980;
21(3): 219-239.
11. Baguma, P. Stress and coping among
Ugandan nurses. J Psychol Afr 2001;
11(1):16–37.
12. Motowildo, S.J., Packard J.S. &
Manning, M.R. Occupational stress: Its
causes and consequences for job
performance. J Appl Psychol 1986;
71(4): 618-629.
13. Revicki, D.A. & May, H.J.
Organizational characteristics,
occupational stress, and mental health in
nurses. Behav Med 1989; 15(1): 30-36.
14. Levi, L., Lunde-Jensen, P. 1996. A
model for assessing the costs of
stressors at national level: Socio-
economic costs of work stress in two
EU member states. Dublin: European
Foundation for the Improvement of
Living and Working Conditions.
15. Folkman, S. & Lazarus, R. An analysis
of coping in a middle-aged community
sample. J Health Soc Behav 1980;
21(3): 219-239.
16. Folkman, S., Lazarus, R., Dunkel-
Schetter, C., DeLongis, A. & Gruen, R.
The dynamics of a stressful encounter:
cognitive appraisal, coping, and
encounter outcomes. J Pers Soc Psychol
1986; 50: 992-1003.
17.Carver, C.S., Scheier, M.F. & Weintraub,
J.K. Assessing coping strategies: A
theoretically based approach. J Pers Soc
Psychol 1989; 56:267-283.
18. Parikh, P., Taukari, A. & Bhattacharya,
T. Occupational stress and coping
among nurses. J Health Manage 2004;
6(2): 115-122.
19. Boyle A., Grap M.J., Younger J. &
Thornby D. Personality hardiness, ways
of coping, social support and burnout in
critical nurses. J Adv Nurs 1991;
16:850-857.
20. Lwanga, S.K. & Tye, Cho-Yook. 1986.
Teaching health statistics: twenty lesson
and seminar outlines. Switzerland:
World Health Organization.
21. Agus Salim, M.B, Noor Hassim, I &
Jefferelli, SB. Stress intervention study
among health nursing staff in two health
districts in Terengganu, Malaysia. J
Occu Safety Health 2004; 1:77-81.
22. O’Donnell, M.P., Jaffe, D.T. & Zindler-
Wernet, P. 1984. Stress assessment. In.
O’Donnell, M.P. & Ainsworth, T.H.
 Jabatan Kesihatan Masyarakat 2007: Jilid 13 Bil. 1

(eds). Health promotion in the work 35. Greenglas, E.R. Burnout and gender:
place, pp. 185-220. New York: John Theoretical and organizational
Wiley. implications. Can J Psychol 1991; 32:
23. Gray-Toft, A. & Anderson, J.G. Stress 562-572.
among hospital nursing staff: Its causes 36. Majomi, P., Brown, B.B. & Crawford,
and effects. Soc Sci Med 1981; 15:639- P. Sacrificing the personal to the
647. professional: community mental health
24. Mazalan Razali. 2002. Kajian prevalen nurses. J Adv Nurs 2003; 42 (5): 527–
stres jururawat terlatih di Hospital 538.
Kuantan, Pahang. Tesis Diploma 37. Ganster, D.C., Mayes, B.T., Sime. W.E.
Siswazah Kesihatan Pekerjaan. & Tharp, G.D. Managing occupational
Universiti Kebangsaan Malaysia. stress: A field experiment. J Appl
25. Bailey, J.T., Steffen, S.M. & Grout, J.W. Psychol 1982; 67:533-542.
The stress audit: Identifying the 38. Steenkamp, W. C. & van der Merwe, A.
stressors of ICU nursing. J Nurs Educ E. The psychosocial functioning of
2001; 19:15-25. nurses in a burn unit. Burns 1998; 24:
26. Leatt, P. & Schneck, R. Differences in 253-258.
stress perceived by head nurses across
nursing specialties in hospitals. J Adv
Nurs 1980; 5(1): 31-46.
27. Ivancevich, J. M., & Smith, S. V. Goal
setting interview skills training:
Simulated and on-the-job analyses. J
Appl Psychology 1981; 66: 697-705.
28. Hipwell, A.E., Tyler, P.A. & Wilson,
C.M. Occupational health hazards of
hospital staff nurses: Overview and
psychosocial stressors. AAOHN J 1989;
37: 232-237.
29. Callaghan, P, Tak-Ying, S.A. & Wyatt
P.A. Factors related to stress and coping
among Chinese nurses in Hong Kong. J
Adv Nurs 2000;l 31(6):1518-27.
30. Mok, E.S. & Chan S.S.C. Work and
family roles of female nurses: sources
of stresses and coping strategies. Hong
Kong Nurs J 1996; 73:12-19.
31. Narayan, L., Menon, S. & Spector, P.E.
Stress in the workplace: A comparison
of gender and occupations. J Org Behav
1999; 20(1): 63–73.
32. Escot, C., Artero, S., Gandubert, C. &
Boulanger, J.P. Stress levels in nursing
staff working in oncology. J Int Soc
Invest Stress 2001; 17(5): 273–79.
33. Kushnir, T., Rabin, S., & Azulai, S.
1997. A descriptive study of stress
management in a group of paediatric
oncology nurses. Cancer Nurs 1997; 20:
414-421.
34. Chan, B.K., Lai, G., Ko, C.Y. & Boey,
K.W. Work stress among six
professional groups: The Singapore
experience. Soc Sci Med 2000; 50(10):
1415–1432.

66