Stress dimensions, patterns of coping, and psychopathological risk among nurses: a person-centred approach

Coping is defined as the thoughts and behaviours mobilized by individuals to manage internal and external stressful situations [34, 35]. Coping responses have been widely studied in the literature, they have been labelled in different ways, and assessed by using diverse measurement tools [36‐42]. However, despite the specificities, there is a rather great consensus on adopting broad categories—derived from theory and research – to label coping strategies. The first – and more adopted – coping taxonomy concerns the classification into emotion-focused coping strategies (i.e., efforts made to manage the negative emotions linked to the stressful situation) and problem-focused coping strategies (i.e., efforts made to actively face the situation by taking actions/making plans to change it) [36‐42]. However, coping has often been categorized also in terms of active coping (i.e., including both emotion-focused and problem-focused strategies) and passive coping (e.g., denying/avoiding the stressor) [43, 44]. This latter sub-division has been proposed to deepen and further distinguish those emotion-focused strategies that can be more adaptive, such as seeking social support and positive distraction, from those that can be less effective, such as avoiding, denying, or minimizing the stressors [45, 46].

Nevertheless, despite these slight differences in taxonomy, research has reached a clear consensus on the idea that there are no “good” and “bad” strategies in itself, yet the effectiveness of coping strategies needs to be evaluated by using a more complex dynamic approach [34, 35]. In this perspective, whereas the earlier works on coping adopted a trait-based approach, so conceptualizing coping as a rather static and stable set of individuals’ responses, afterward, coping research has evolved, and greater emphasis has been given to situation-based models, which considered stress, health, and coping as dynamic processes [47, 48].

Within the latter perspective, the transactional model of stress and coping represents the most renowned and influential theory [49]. According to this perspective, “the person and the environment are viewed as being in a dynamic, mutually reciprocal, bidirectional relationship” [34]. Stress is determined by the interplay between individual and situational factors, and it derives from two processes, namely the primary appraisal (i.e. individuals’ evaluation of the situation/stressor) and the secondary appraisal (i.e. perceived coping resources available to deal with the situation/stressors) [34, 35, 39, 49].

The authors also suggested that individuals have habitual coping preferences, so that stress and coping processes can be moderately stable across diverse stressful situations [34]. It is therefore clear that the transactional model of stress and coping has promoted research advancements on the possibility of shedding light on the role of individual differences in stress and health/occupational health processes [22, 47].

In the same research direction, in the last decades, the person-centred approach has been proposed [15‐24]. From a methodological point of view, this conceptual framework focuses on individuals instead of study variables [50]. Specifically, whereas, on the one hand, the variable-centred approach aims to examine the effects of one/more independent variables on one/more outcomes by applying statistical methodologies such as Regression Analyses and Structural Equation Models, on the other hand, the person-centred approach aims to identify subgroups of people based on the selected variables—and then it aims to compare their characteristics—by applying statistical methodologies such as cluster analysis and latent profile analysis [15‐24, 50].

The application of this approach to coping research has several advantages [22]. It allows researchers to account for the idea that people may use more than one strategy to deal with stress according to the situation, yet people tend to predominantly use the same pool of strategies across several situations. Moreover, this approach allows for capturing unique nuances in coping responses (i.e., people can be classified into distinguished groups even in cases where some coping strategies are adopted to a roughly similar extent by them). Furthermore, by identifying patterns of coping and then exploring differences in perceived stress and health according to the belonging to the emerged patterns, researchers can call into practice the value of the application of a transactional approach for developing more adequate and efficient programs and interventions addressing the specificities/differences among groups of individuals.

This study proposed a research application of the DRIVE-Nurses Model [12‐14] and adopted the person-centred approach [15‐24] with the aim to target two main objectives: 1. To identify distinguished patterns of coping strategies (Problem-Focused; Seek-Advice; Self-Blame; Wishful-Thinking; Escape/Avoidance) adopted by nurses to deal with stress; 2. To test potential differences between nurses belonging to the different patterns of coping in terms of perceived levels of Demands (i.e., Efforts), Resources (i.e., Rewards, Job Control, Social Support), and Psychopathological Symptoms (i.e., Anxiety, Phobic-Anxiety, Obsessive–Compulsive, Somatization, Depression, Interpersonal-Sensitivity, Hostility, Psychoticism, Paranoid-Ideation). In line with the abovementioned objectives, and considering the research reported above, the following hypotheses have been tested.

Nurses can be differentiated based on unique combinations of coping strategies (patterns of coping).

Perceived levels of Demands, Resources, and Psychopathological Symptoms reported by nurses will statistically significantly vary according to the emerged patterns of coping.

In line with the growing calls for putting individuals at the centre of research/interventions, and responding to the need to develop targeted interventions fostering nurses’ ways to deal with stress and promoting their psychological and occupational health effectively [66, 75], the present study was designed with a twofold objective, namely to identify patterns of coping strategies adopted by nurses to deal with perceived stress, and, therefore, to investigate potential differences in perceived levels of Demands, Resources, and Psychopathological Symptoms reported by nurses belonging to the different patterns that emerged.

Concerning the first research objective, preliminary data from correlation analyses aligned with the research that adopted the coping taxonomy distinguishing active and passive coping strategies [43, 44] and provided initial evidence supporting our first hypothesis (H1), namely that nurses can be differentiated based on unique combinations of coping strategies. From this perspective, findings from cluster analysis fully supported H1 and, specifically, nurses were grouped into three distinguished categories according to the ways they deal with work-related stress, which were labelled as Active/Solution-Oriented, Passive/Disengaged, and Dysregulated/Emotion-focused. Somewhat in line with previous research on coping profiles [23, 24], the first two out of three clusters roughly reflected the polarization activity-passivity, while a middle ground cluster (i.e., Dysregulated/Emotion-focused) was featured by the prominent recourse by nurses to emotion-focused strategies.

However, findings should be discussed by also considering the second research objective/hypothesis (H2) (i.e., differences in perceived Demands, Resources, and Psychopathological Symptoms according to the emerged patterns of coping), so achieving a greater understanding of the conceptual and statistically significant differences featuring these three groups. Specifically, the Active/Solution-Oriented group included nurses who share a higher degree of activity and engagement (i.e., pronounced recourse to problem-solving/ lower tendency to rely on passive strategies) and, at the same time, they seem to display also a tendency to deal with emotional aspects of stressful situations by personally taking charge of the events they may encounter in everyday working life (i.e., moderate – but not high – recourse to self-blame strategies). It is possible to hypothesize that this latter tendency to feel guilt/blame themselves can be linked to their pronounced recourse to active strategies. Indeed, self-blame is indirectly related to perceived control [76], so that people who frequently self-blame are more likely to believe they have greater control over situations. From this perspective, when considering the data on differences in Demands/Resources (H2), findings showed that nurses belonging to this group perceived not only lower levels of effort but also higher levels of all resources—including job control—so further endorsing the hypothesized link between self-blame and control. This should be carefully considered in light of our findings on their psychological health conditions. Indeed, although nurses belonging to Active/Solution Oriented group reported a better and more adjusted psychological profile, they still reported a noteworthy psychopathological risk, mainly in terms of symptoms of paranoid ideation (i.e., distrustful thoughts/behaviours and fear of loss of autonomy), depression, and somatization.

From this perspective, the nursing work—in its nature (e.g., being daily at the forefront of relationships with ill and/or dying patients and with the suffering of the patient’s relatives) may collide with the relevant sense of agency and control featuring nurses belonging to this group, since it implicitly requires nurses to deal with the idea that despite every "action" and "task" has been conducted adequately yet still something can go wrong. This can potentially elicit feelings of helplessness, frustration, and guilt. Therefore, despite the high sense of control/agency may represent the key resource driving nurses’ continuous search for solutions, yet it should be carefully addressed in order to prevent it from becoming a double-edged sword harming their wellbeing.

However, overall, data aligned with previous research [23, 24] by suggesting that nurses belonging to the Active/Solution Oriented group are at a lower risk of occupational stress and psychological suffering. Also, not only do they resort to advice-seeking strategies fairly frequently, but they also seem to perceive an adequate payback (i.e. in their work experience, support is not only sought but it is also found), so potentially feeding reciprocal positive individual-environment transactions.

On the opposite pole, the Passive/Disengaged group (that is the largest group) included nurses characterized by a certain degree of disengagement and low activation. It is possible to hypothesize that nurses belonging to this group are the least motivated and engaged in their work, yet it is also possible to trace back and link this profile to high emotional burden, compassion fatigue, and defensive responses [57‐59]. In other words, nurses belonging to this group may feel exhausted and feel such a lack of control over events that they may have responded by defending themselves, thus becoming cynical, fatalistic, detached, and avoidant [77].

The latter hypothesis could be supported if one examines findings from testing H2. Indeed, nurses belonging to this group perceived lower levels of resources (control/support) and they also exhibited a significantly higher risk (in most cases doubled compared to the Active/Solution oriented group) of reporting clinically relevant levels of psychopathological symptoms – mainly in terms of paranoid-ideation (whose symptomatology goes from mild suspiciousness/distrust to full persecutory delusions [78, 79]), but also anxiety, somatization, interpersonal sensitivity, and depression.

From this perspective, interventions targeting nurses belonging to the Passive/Disengaged group should carefully consider their significant risk of being detached, self-deloused, and depersonalized as a consequence of extremely high levels of stress/perceived low control and support. Indeed, we need to also take into account the growing body of research which have linked paranoid thinking/behaviours to work-related stress, burnout, and depression [80‐83], which seems to align with our findings.

Given that nursing/caring is an extremely emotionally demanding profession [84, 85], nurses belonging to this latter group require particular attention when defining tailored support interventions. Indeed, their predominant tendency to minimize or deny the stressors also having positive unrealistic expectations which are often far from reality (i.e., extremely high use of wishful thinking coping), to detach when instead hyper-engaged and hyper-involved (i.e., higher imbalance between perceived efforts and rewards, extremely high use of avoidance coping), to recur to self-criticism along with perceiving lack of control over situations (i.e., lower control and higher use of self-blame coping), and to try to seek-advice along with perceiving – at the same time – lack of support at work (i.e., low perceived support with high recourse to seek-advice coping), but also their moderate recourse to problem-solving in such complex vicious circle of unfulfilling individual-environment transactions, expose them to extremely high risk.

From this perspective, about one-half of nurses belonging to Dysregulated/Emotion-focused group displayed clinical symptoms referable to psychoticism (i.e., this latter needs to be considered along a continuum from mild interpersonal alienation and withdrawal to severe psychosis with symptoms such as hallucinations and thought control), about 40% reported clinically relevant symptoms of somatization, interpersonal sensitivity, and paranoid ideation, about 30% anxious and depressive symptomatology, and over 20% hostility. These findings – which fairly aligned with research linking stress/work-related stress, emotional dysregulation, interpersonal sensitivity, and psychotic symptoms [86, 87], and with recent evidence warning about a vicious circle of stress, conflict, individual and interpersonal suffering among nursing professionals [60]—highlighted the urgent need to develop interventions promoting awareness, adjustment processes and emotion regulation strategies among nursing professionals.

Furthermore, researchers, practitioners, and healthcare managers could benefit from this study not only for developing future research but also for implementing more adequate, efficient, and tailored evidence-based programs/interventions. From this perspective, three distinct groups of nurses were identified, for whom specific interventions need to be designed and implemented. This will also ultimately provide benefits for the whole healthcare staff and the healthcare organization and could foster the welfare of the society (i.e., promoting better work engagement, high standards of quality of care, better relations within/outside the wards, and higher performance).

Specifically, for nurses belonging to the Active/Solution Oriented group, who appear to handle stress more adequately and were at lower risk of stress and psychological discomfort, interventions can be focused on supporting the active strategies they already adopt and on continuously preserving and enhancing those key work resources they actually need, namely rewards, control, and support (i.e., so keeping fostering positive exchanges with the environment). This is in line with research highlighting the utmost need to implement evidence-based interventions for stress management within the healthcare environments [9, 10, 75] along with studies on nurses’ patterns of coping suggesting the effectiveness of promoting the use of active/problem-solving strategies among nurses to prevent psychological disease and enhance their wellbeing [23, 24]. Yet, findings from the present study also suggested that training/support programs should also consider the need to critically reflect and foster awareness of nurses’ need for control (and their tendency to blame) to further reduce their risk and promote their psychological and occupational health.

For nurses belonging to the Passive/Disengaged group, who may be either demotivated or disillusioned and highly defended and who were at moderate/intermediate – but still considerable – risk for psychological suffering and occupational stress, key resources within the working environment (i.e., control/autonomy and support) should be strengthened and, at the same time, interventions should be implemented to foster emotional regulation strategies that enable them to be/be again engaged in their care work and to find/re-discover the reasons for their professional choice. This is in line with recent research underlining the need to develop interventions aiming at reducing avoidance and promoting engagement among nurses [88].

For nurses belonging to the Dysregulated/Emotion-focused group, who are at extreme psychopathological risk and in great suffering at work, timely interventions and paths of psychological support must be proposed and offered in the work contexts. Considering research demonstrating that training/programs focused on emotion regulation can be effective in reducing stress and promoting wellbeing among nurses [89, 90], a particular focus must be given to the management of emotions, i.e. on the possibility of handling the different situations that feature the everyday life of nurses, who have chosen a very delicate and emotionally charged profession. This is by promoting the ability to recognize their ways to appraise situations, tolerate and manage stress and frustration, and adjust to the (difficult) daily reality.

Despite the abovementioned results and implications, some limitations need to be underlined. Firstly, the sample size is relatively small and restricted to the Italian public healthcare context, thus limiting the generalizability of research results. Indeed, despite the sample being rather representative by sex, age, and wards, future research could be conducted with a larger sample, and it would be interesting to also investigate these profiles across genders, various generations, specific wards, along with different cultures and nations to explore possible differences and commonalities. Secondly, the cross-sectional design limits the possibility of determining the stability of the identified patterns over time, and future studies could be developed with a longitudinal design to verify whether the identified patterns of coping can be confirmed across the different life and career stages. Also, a pre-to-post interventional study could be developed to test the effectiveness of tailored support programs/interventions aiming at promoting awareness of own coping responses, emotional regulation, and adjustment processes among nurses. Thirdly, despite the application of the DRIVE Model-Nurses Version allowing the investigation of a wide range of dimensions, our findings have raised the interest to examine further individual (e.g., personality functioning) and situational characteristics (e.g., type of stressful situations) according to these profiles. This – indeed – would allow researchers/practitioners to achieve an even deeper understanding of stress and health processes among nursing professionals.

Notwithstanding the abovementioned limitations, in conclusion, the study findings captured three unique nuances in coping responses by nurses and provided evidence supporting differences in stress and health processes based on them. Fostering nurses’ awareness of their latent coping patterns and supporting active approaches and adequate emotional regulation strategies for stress management should represent a key goal when defining interventions promoting nurses’ health within and beyond the healthcare settings.