Psychometric properties of brief-COPE inventory among nurses

Coping with persistent demands and challenges in the modern healthcare system is increasingly necessary among healthcare professionals [1]. Nurses, in particular, faces high stress and burnout levels from increased workload and work engagement, emotional exhaustion, staff shortages and poor health [2]. Studies have utilized different measurement tools to assess nurses’ coping strategies, in various settings [3, 4].

One of the most widely used measures of nurses’ coping strategies is the Brief-COPE (Coping Orientation to Problems Experienced) inventory, a shortened version of the full 60-items (16 scales) COPE inventory developed by Carver, Scheier, & Weintraub [5]. Based on the Folkman & Lazarus’ Ways of Coping model and the Behavioural self-regulation model, the inventory aimed to assess various positive and negative coping strategies effectively [5]. The inventory was further refined to reduce participant fatigue and item redundancies and eventually the creation of the Brief-COPE inventory, which consists of 28-items with 14 scales [5].

Following sound theoretical guidance, a number of health-relevant studies have provided empirical evidences by using statistical tools to extract underlying domains and test psychometric properties in various settings and populations such as caregivers of people with dementia in the United Kingdom [6], among breast cancer chemotherapy patients in Malaysia [7], people with traumatic brain injury in New Zealand [8], people living with HIV in China [9], person living with HIV/AIDS in India [10], pregnant minority women in the United States [11], adults in Italy [12], and community population in Chile [13]. Brief-COPE is also translated in a number of languages such as French version [14], Malay version [7], Brazilian-Portuguese version [15], and Chilean version [13].

Although several coping strategies instruments exists such as the Folkman and Lazarus’s Ways of Coping questionnaire [16], the Multidimensional Coping Inventory [17] and the Coping Inventory for stressful situation [18], the relatively lengthy items were not particularly useful in long research protocols and clinical research. The 28-items Brief-COPE do not have this shortcoming, and have been used in many studies extensively. However, the validation results have not always been consistent due to the complex nature of coping dimensions on different types of stressors and study populations. In addition, we have not found studies examining validity and reliability estimates of Brief-COPE on nurses in the United Arab Emirates (UAE). In the UAE, majority of nurses are expatriates and coming from diverse cultural backgrounds, predominately Pilipino, Indian, Pakistani, and people from Western and other Arab countries [19]. As nurses move from their own home countries to a different culture of the UAE, they face different types of stressors related to reallocation which require them to develop new coping mechanisms in response to new emerging stressors. The newly stress coping strategies; however, must consider Islamic values and modesty standards of the UAE culture to enhance their acceptance by colleagues and healthcare organization [20]. Therefore, understanding stress coping strategies of nurses, who comprise the largest segment of healthcare system, will guide healthcare policy formation geared toward enhancing positive stress coping mechanisms of nurses to facilitate their smooth transition, minimize their turn over and enhance their job satisfaction. Therefore, this paper aimed to bridge this gap by validating the psychometric properties of Brief-COPE inventory to ensure culturally appropriate usage.

Table 1 summarize the results of CFA model fit indices with respect to Model 1 to Model 4. Chi-square test of absolute model fit (p < 0.001) and other indices including NFT, CFI and GFI indicated all models had poor absolute fit. RMSEA index indicated only Model 1 had cut-off ≤0.08, a good fit. AIC considered Model 4 was comparatively a better model than the others.

Based on the original 14 subscales of brief-COPE inventory, CFA resulted on highly cross-loaded estimates on all factors except for behavioural disengagement, self-blame, substance use, humor, religion, and acceptance. Emotional support and use of informational support loaded on the same factor. Likewise, positive reframing and planning also formed a single factor.

Due to poor model fit with of CFA models and high cross-loadings, EFA was conducted to establish factor structure for our study population. The KMO value (0.85) and Bartlett’s sphericity test (χ2 = 4632.7, df = 378, p < 0.001) indicated good factorability. The scree plot and eigenvalue more than 1 suggested seven factors with five-point optimal extraction (Fig. 1). Varimax rotation with factor loadings more than 0.4 yielded two factor extraction (11 scales excluded humor, self-distraction, and substance use), derives EFA model accounting for 37% of the total variance with the following fit indices: χ2/df = 4.74, RMSEA = 0.099, NFI = 0.75, GFI = 0.84, AIC = 21,790.8. Item-total correlation coefficients ranged from 0.37 to 0.69 and 0.52 to 0.63 for Factor 1 and Factor 2, respectively. Table 2 details the loadings and reliability estimate for this EFA model as well as mean and standard deviation of the scores and floor and ceiling effects.

Initial analysis showed skewed distributions of the responses on several items. Floor effects were present for denial, substance use, and behavioural disengagement. Ceiling effects were significant for acceptance subscale. Although Cronbach’s alpha coefficient for first-order subscales were mostly below 0.70 except for self-blame and religion, there was good alpha estimate for the second-order two-factor EFA model at 0.81 and 0.86, respectively, where the structure is illustrated in Fig. 2.

This study has established the psychometric properties of the Brief-COPE inventory among nurses working in the UAE. Similar to previous studies, our validation estimates have demonstrated inconsistencies with previous models due to the complex nature of coping especially in different parts of the world that could be influenced by culture, different generations, types of stressors, and study populations. This study is timely considering that COVID-19 pandemic has affected health professionals worldwide. In UAE, a total of 250,000 cases have been recorded with 740 deaths, as of 20 December 2020 [31]. Nurses, as front liners, is even more pressing to ensure instruments measuring their coping strategies are both valid and reliable [32‐34].

A number of studies has used Brief-COPE to examine nurses coping strategies [35‐37], however, in the absence of validation study, the results reported may be problematic and disputed. In particular, the CFA models using structure from previous studies did not achieve good fit, observed high cross-loadings, and Cronbach’s alpha of individual subscales were inadequate (although most were above 0.5), which was similarly reported in previous validation studies including the original Brief-COPE study [9, 12, 13, 38]. Nevertheless, the developer of Brief-COPE reported that the flexibility of the inventory encourage researchers to apply and test on different settings and population to extensively either using all the subscales or selectively use relevant scales in their research [38].

Even though Brief-COPE was developed with sound theoretical model, existing validation studies of different version of brief-COPE have produced large variation in empirical evidences, particularly on the dimensionality of the scales, which may limit comparability of results in studies using this inventory. Mohanraj et al. [10] exploration of the Tamil version of Brief-COPE underlying structure among person living with HIV/AIDS in India, yielded a five factor (17-items) model accounting 41.5% of the total variance. Yusoff et al. [7] investigation on Malay version of Brief-COPE among adolescent in Malaysia, produced a nine factor model explaining 71.2% of the total variance. Su et al. [9] generated a six factor model on the Chinese version of Brief-COPE, which explained 55.5% of total variance. Reich, Costa-Ball, & Remor [39] constructed a four factor (24-items) model of the Uruguayan version, and more recently, Gloria & Peña [40] produced an eight-factor (24-items) model on the Chilean version. In our study examining nurses in the UAE, we suggested a two-factor (22-items) model that explained 37.0% of the total variance. Substance use subscale was excluded because UAE is an Islamic country, and items on alcohol is not relevant. Self-distraction and Humor subscales were slightly difficult to justify, however, considering highest score was Religion subscale, we could postulate that religiosity would most likely have preceded them.

Overall, a two-factor second-order model provides a good model to interpret coping strategies among nurses in the UAE, which is timely considering nurses around the world is currently battling different types of stressors in addition to the COVID-19 pandemic situation. Our study also highlighted the need to account for cultural diversity in coping research as studies on translated version of Brief-COPE had yielded inconsistent underlying constructs. Re-assessment of this exploratory structure is critically warranted on nurses from different study settings and population to ensure accurate measurement of coping strategies.