Literature Review-Nursing Research

Running head: LIVING WITH THE DYING 1

Living with the Dying

Difficulties Coping and Adapting to Stress in Oncology Nursing

Kaylee Blankenship, Alyssa Cardinal, LeAnna Ceglia, Maggie Fabry, Cassandra Landrum, and

Noel Silviera

California State University, Stanislaus

LIVING WITH THE DYING 2

Difficulties Coping and Adapting to Stress in Oncology Nursing

Background and Significance

The field of nursing is not just a career path, but an enterprise. Taking on multiple sick or

dying patients and being responsible for keeping them comfortable, healthy and living is quite

the undertaking for any nurse. Accepting the likelihood of complications that may result in death

requires an individual with incredible courage and adaptability. Even the greatest nurses

eventually meet their match when overcome with the stress and burnout that go hand-in-hand

with oncology nursing. According to Rodrigues and Chaves (2008), there are at least six stressful

situations that nurses encounter: death of a patient, emergency situations, relationships with the

nursing team, work processes, relationships with the patient or family, and relationships with the

physician. These are only a few of the issues that contribute to the phenomena of stress and

burnout in the field of nursing.

Stress is one of the most prevalent clinical problems experienced by nurses, specifically

on the oncology unit (Rodrigues and Chaves, 2008). Oncology, the field of medicine devoted to

cancer treatment, is a unique unit for nursing professionals because the patients and families

have especially depleted morales. When one considers the effect that working in the presence of

sick and dying patients can have on a nurse, it is easy to understand the increased levels of stress

among this units nursing staff. An inability to cope compounds the effects of increased stress

levels. Although some hospitals offer counseling services, the majority of nurses either do not

know of their existence or feel they are not beneficial (Gallagher and Gormley, 2009). The

following research studies include nurses with experience levels ranging from less than one year

to over thirty years. The articles highlight the factors causing stress in nursing and reveal

innovative methods for coping.


Literature Review

According to Hayashi et al. (2006), the purpose of their study was to create scales in

order to assess difficulties, coping, and adaptation factors that oncology nurses experience in

both short-stay and outpatient wards, extract constructing factors from the scales, and discover

any correlations between the scales and certain sociodemographic factors. The design used was a

cross-sectional survey with convenience sampling. A sample of 360 nurses was originally

gathered, however, the part-time nurses and managers were later eliminated from the data

analysis reducing the sample size to 155 and leaving only full-time nurses. A questionnaire

consisting of 97 questions was used, with answered based on a four-point Likert scale that

ranged from 1 (strongly disagree) to 4 (strongly agree). As a result of the study, researchers were

able to develop scales that measured difficulties, coping, and adaptation among oncology nurses.

They were able to identify four factors of difficulties, three factors of coping, and five factors of

adaptation of oncology nurses. A multiple regression analysis was done using the Adaptation

scale score as a variable, and the Difficulties and Coping scale scores and demographic factors as

independent variables. The study suggests that coping does indeed play a significant role as a

predictor of adaptation. Despite large workloads and inadequate care environments nurses were

still able to provide high quality care to oncology patients in out-patient and short stay settings.

Researchers followed a conceptual framework for adaptation that was based on Lazarus

and Folkmans stress, appraisal, and coping theory. This study was based on a previous study the

same researchers had performed in 2001. All information appears accurate according to the

theoretical framework. The study took place in 14 Japanese hospitals so it is not generalizable to

the global population, however, the study did gather a significant amount of participants (n=155).

Participants were allowed one month to take and mail the survey back to the researchers. They


could have allowed more time for the nurses to take the survey and find an easier way to collect

them, that way more people might have participated. The study has very clear and concise

measurement standards and sampling. However, they ended up cutting some of their participants

from the data analysis for less skewed results. They also used convenience sampling instead of

randomized. A variety of demographic variables were used and these along with the Difficulties

and Coping scale scores were the independent variables. External validity is somewhat limited

based on lack of generalizability since the study was only performed in 14 hospitals in

Japan. Instrumentation is a possible threat to internal validity because the researchers are

creating a new tool to measure coping, difficulties, and adaptation.

Gallagher and Gormley (2009) created a study on the topic of stress, burnout and support

systems in pediatric bone marrow transplantation (BMT) nursing. The study consisted of 30

BMT staff nurses at a pediatric BMT center in a large, academic, pediatric medical center in the

midwestern United States and used a descriptive nonexperimental design, (p. 682). Gallagher

and Gormley evaluated previous research studies on the topic, but found little feedback on the

areas of job satisfaction and specific stressors causing burnout. The pair did, however, use the

Maslach Burnout Inventory (MBI) and a demographic questionnaire to collect data from the

staff; reliable tools used in previous studies. As part of the study, nurses were asked to rank

their top three work-related stressors [...] Critical illness or acuity of patients was the most

stressful factor, and long work hours was the least stressful factor (p. 683-684). The study

correlated increased years of nursing experience with decreased levels of emotional exhaustion

and depersonalization (p. 684). Therefore, the longer an individual is exposed to death and dying,

the easier it becomes. Despite the high levels of stress and exhaustion, the researchers observed

that nurses still felt a relatively high level of personal accomplishment. Lastly, the study found


that most nurses were aware of the support systems available to them, however they were unsure

of the systems helpfulness. Nurses felt that increasing the effectivity of the support systems

would improve the feelings of personal accomplishment and decrease levels of stress and

burnout.

The sample size (n=30) was somewhat small for this particular study. Unfortunately, the

participants were all from one location and cultural diversity was not mentioned. This prohibited

the findings from being generalizable to all populations. Therefore, there was a threat to external

validity. The use of reliable instrumentation provided accurate measurement of the levels of

stress in the nursing oncology unit, as well as the nurses perception of support systems. There

was no sign of selection bias, major historical occurrences, sample maturation, or mortality.

Therefore, there were no threats to internal validity. The concept of this study was fascinating,

but could have been improved with a larger, more diverse sample, which would expand the

findings and allow for a broader generalization of the results.

According to Jones, Wells, Gao, Cassidy, and Davie (2011), the purpose of their study

was to examine the work stress among the oncology staff on the phenomenon of burnout. This

phenomenon is known to affect a high percentage of oncology staff. More specifically, it was

aimed to study all groups of staff that work in a regional oncology unit to determine the

correlations of work stress and the associations between staff perceptions of the work

environment (demand, control, support, effort and reward), work-based social support, emotional

distress and job satisfaction (p. 47). The design of this study involved a questionnaire. An

information letter and consent letter to participate were sent to all of the staff in the oncology

department cancer center in North East Scotland. Out of the one hundred and sixty-eight

oncology staff who received the information and consent form, only eighty-five chose to


participate. As a result, about one-third of the staff either agreed or strongly agreed that they

have often thought about leaving their current employer, 17% intended to look for a new job in

the next year, and about 40% indicated a desire to leave . As far as correlations and associations,

age was related to satisfaction at work, distress was not related to demand, reward was not

related to distress, and low control meant less satisfaction. The study unveiled than an

astounding 28% of staff reported work-related stress as a reason for sick leave over the last year.

One strength of the study was that it delivered informative letters and consent forms to

the participants, thereby protecting them. However, there were also limitations when it came to

this study. One of the limitations was the fact that the response rate was only 50.6% of the entire

staff. Another limitation was that there was evidence of responder bias. It turned out that the

participants who were more likely to respond were older females who were either nurses or part

of the support staff. Because the study was a questionnaire it was not random, meaning the study

was not a good candidate for obtaining a good overall sense of the oncology staff.

According to Ekedahl and Wengstrm (2010), the purpose of their study was to

investigate nurses' coping strategies when working with oncology patients, with particular

attention paid to the religious sections of coping resources. The study was qualitative and the

design was a research approach using stories to describe human actions. Both authors of the

study used semi-structured interviews lasting from sixty to one-hundred and twenty minutes. The

interview guides did not change, but discussions led to further exploration of areas in order to

receive more information. The material collected was then analyzed in two steps. The first step

was inductive and the second was abductive. The sample used in the study was fifteen Swedish

nurses. Thirteen of the nurses were female and two were male and all worked in hospices,

oncology wards or outpatient services for patients with advanced cancer. The participants were


chosen using the snowballing technique, meaning that the first few participants to be chosen

were asked to help the researchers suggest other nurses to be included in the study. Of the

fifteen nurses, twelve worked day shifts while the other three worked night shifts. They ranged

in ages from thirty to sixty. Three nurses were from age thirty to forty, eight nurses were from

age forty-one to fifty, and four nurses were from age fifty-one to sixty. The researchers found

that of the fifteen nurses, six were church-going Christians, one was a private Christian, four

were private existential or spiritual, two were Caritas Christians, one was an atheist and one was

classified under the other category. The results contained participant quotes used to describe

their religious orientation as well as quotes used to describe the impact that their orientation has

on their ability to cope at work. The results demonstrated the fact that there are many different

parts in the nurses orienting system. Nurses seem to use both previous experiences and

knowledge gained through working with cancer patients to help them cope. The authors

highlight the importance of, "handling stress by means of religious coping strategies" (p.

536). They advocate for these religious coping strategies to be implemented in basic nursing

education. The authors go on to note that nurses must have access to several coping strategies

in order for them to cope effectively (p. 536). Having only one strategy may leave nurses

vulnerable and unable to cope as well.

This article has both strength and weaknesses that contribute to its overall

significance. One of the strengths of the article is the protection of human participants. The

study was first approved by the Regional Research Committee before it was conducted. Another

strength is that is has a theoretical framework which is caring philosophy research and the

psychology of religion and coping. Also, the strategy the authors used to interview and analyze

the information was appropriate and compatible with the purpose of the study. The study also


demonstrates good credibility. Firstly, the study is credible because the interviews were audio

taped and transcribed and then given to each of the participants for review and editing. This

gave each participant the opportunity to make sure that their experiences were still recognizable

as their own after the transcription. Secondly, the study is credible because the interviews were

long enough for the authors to gather sufficient data to explore the phenomenon fully. One

additional strength is the audibility. The research process was documented in detail, and I was

able to follow the researcher's reasoning throughout the article. A weakness of the study was

fittingness. Because this study only involved Swedish nurses, it would not be suitable to apply

the findings to all oncology nurses. Had the study incorporated nurses from a variety of cultures,

the study would be more fitting. One additional weakness was the use of the snowball technique

for the selection of participants. This decreased the studys randomization and fittingness.

The study performed by Villani et al. (2011), aimed to test the effectiveness of self-help

stress management made available via cell phones for oncology using the stress inoculation

training (SIT) methodology (p. 1). Oncology nurses encounter moral distress because they lack

autonomy in patient care decisions, but must ensure that the care given to their patients meets

their professional ethical standards. Oncology nurses, like other nursing specializations, also

experience large workloads and sometimes are faced with being required to perform tasks they

may not have the skills for. Oncology nurses typically must deal with psychologically taxing

components of their specialization in relation to decline in patient positivity and death. The

study used questionnaires as part of a collective case study to understand how oncology nurses

viewed their jobs, how they perceived their stress, what coping skills they used, and how

effectively they were able to use these coping skills for self-help stress management. Thirty

female nurses were selected to participate in the study. In order [t]o test the efficacy of Mobile


Stress Inoculation Training (M-SIT), a between-subjects design was used to compare the

experimental condition with a control group (p. 4). Fifteen of the participants were randomly

selected to serve as the control group and watched videos on their mobile phones which did not

offer self-help stress management strategies. The other fifteen women, the experimental group,

were given access to self-help stress management technique videos via their mobile phones. The

results indicated that after watching seven of the eight videos, the experimental group

experienced a statistically significant decrease in stress and anxiety, decrease in denial about

their stress, and felt equipped with effective coping skills and relaxation techniques.

The research studys strengths included the avoidance of morbidity in their short-term

study and use of questionnaires, which are considered to be reputable internationally to evaluate

the nurses. They used these surveys to select the nurses with the highest susceptibility to stress

for their study over a ninety day period. An experimental study was then performed with the use

of a control group to compare results. The study did, however, have its limitations. It relied

entirely upon convenience sampling and self-reporting, and the sample size was small. It lacked

generalizability because it involved only female oncology nurses with at least five years of

experience in the specialization of oncology. The participants were also not given the same

questionnaires.

The study by Rodrigues & Chaves (2008) took place in oncology wards of five large-

scale hospitals in the city of Sao Paulo, Brazil. The purpose of the study was to identify the

stressful factors for nurses working in oncology and to find what coping strategies are used. The

six most prevalent stressors addressed in the study included death of a patient, emergency

situations, relationships with the nursing team, work processes, relationships with the patient or

family, and relationships with the physician. There were eight strategies used by nurses to cope


with these stressors including confrontation, withdrawal, self-control, social support,

responsibility acceptance, escape-avoidance, problem solving, and positive reappraisal. In this

descriptive-exploratory study that used quantitative approach resources, 77 nurses were

administered two questionnaires that were taken after being asked to think about a workplace

situation that occurred the week prior to the study. The first questionnaire was demographic and

the second was called the Folkman and Lazarus Coping Strategies Inventory, which consisted of

66 items related to strategies used to deal with stressful situations. Questions were scored using a

likert scale from 0-3, 0 meaning strategy not used and three meaning it was used very much. MS

Excel 2002 was used to store data and the Cronbach Alpha Coefficient was used to test the

reliability of the questionnaires. Situations that nurses reported causing the most stress at work

were patient death (28.6%), emergency situations (16.9%), and relationship issues with the

nursing team (15.5%). The coping strategy used by most nurses was positive reappraisal (10.34)

and problem solving (9.91) although escape-avoidance was also statistically significant.

The study contained a few limitations posing threats to internal and external validity, but

had strengths as well. The first limitation relates to the demographic questionnaire that failed to

ask about ethnicity, which is important information needed in order to generalize findings.

Another threat is the fact that 70.1% of the nurses in the study do not have oncology training

because most Brazilian universities do not teach the subject. However, it was noted that the

nurses average time working in oncology was 72.7 months and all participants had worked for

at least one year. The article did not have a theoretical framework, didnt mention completing a

power analysis and failed to state how participants were gathered. The participants were also all

from the same city of Sao Paulo. The strengths included having both male and female


participants, participant age ranges varied from twenty to fifty years of age and a consideration

for the protection of human participants.

Implications for Practice

Interventions within oncology settings concentrate on strategies to improve communication,

stress management and emotional support, however interventions have been found to be of

most importance (Jones, 2013).

Short staffing, rotating shifts or schedules, and critical illness or acuity are the three most

stressful factors for oncology nurses (Regan & Gallagher, 2009)

The lack of an effective support system available to oncology nurses further contributes to

the presence of stress and burnout among the profession (Regan & Gallagher, 2009).

Use of mobile devices as a means of self-help stress management that is accessible to the

nursing professional as an individual as needed, even on the job (Villani et al., 2011).

Handling stress by means of religious coping strategies needs to be acknowledged and

implemented (Ekedahl & Wengstrom, 2010).

It is important to improve work environments so that nurses do not become fatigued and can

collaborate with other departments and health-care workers for the benefit of patient care

(Hayashi et al., 2006).

From the literature provided, it is clear that stress is a significant problem that nurses

working in the oncology setting face. Not only do nurses in this setting have to deal with

extremely unique and often psychologically taxing situations, they also experience long hours

with large workloads and ineffective management. These factors often leads to decreased job

satisfaction and increase overall stress levels. The literature differs in how stress was measured

and the ways in which nurses cope and adapt in oncology departments. In order to help with this


stress, hospitals and other institutions have begun creating new ways of coping and adapting

specifically for oncology nurses. Other researchers have developed tools to measure these

difficulties as well as coping and adapting factors in oncology nursing to better understand what

these nurses are experiencing. Future research should focus on oncology nursing and correlations

between coping strategies and variables such as personality, previous experiences, and social

support. Additional studies will need to be performed in order to verify the validity of the tool

created by Hayashi et al (2006) that includes a larger survey of nurses. The current studies focus

on specific countries so further studies will need to be performed in which multiple cultures are

incorporated in order to make results more generalizable to the global population. The mobile

phone study also implicated a need for a larger quantity of participants and a study that evaluates

the long-term effects of self-help stress management. The use of mobile phones should also be

compared to similar studies using mobile devices and different media as a means of self-help

training. As new tools arise, current models and research on coping and adapting in oncology

nursing need to be considered and evaluated.


References

Ekedahl, M., & Wengstrm, Y. (2010). Caritas, spirituality and religiosity in nurses' coping.

European Journal of Cancer Care, 19(4), 530-537.

doi:http://dx.doi.org.ezproxy.lib.csustan.edu:2048/10.1111/j.1365-2354.2009.01089.x

Gallagher, R., & Gormley, D. (2009). Perceptions of stress, burnout, and support systems in

pediatric bone marrow transplantation nursing. Clinical Journal of Oncology Nursing,

13(6), 681-685. doi:http://dx.doi.org/10.1188/09.CJON.681-685

Hayashi, N., Komatsu, H., Sakai, Y., Iba, N., Tonosaki, A., & Katagiri, K. (2006). Perceived

difficulties and coping as predictors of adaptation among cancer nurses. Japan Journal of

Nursing Science, 3(2), 131-141. doi:10.1111/j.1742-7924.2006.00066.x

Jones, M. C., Wells, M., Gao, C., Cassidy, B., & Davie, J. (2013). Work stress and well-being in oncology settings: A multidisciplinary study of health care professionals. Psycho-

Oncology, 22(1), 46-53. doi:10.1002/pon.2055

Rodrigues, A., & Chaves, E. (2008). Stressing factors and coping strategies used by oncology

nurses. Revista Latino-Americana De Enfermagem (RLAE), 16(1), 24-28.

doi:http://dx.doi.org.ezproxy.lib.csustan.edu:2048/10.1590/S0104-11692008000100004

Villani, D., Grassi, A., Cognetta, C., Toniolo, D., Cipresso, P., & Riva, G. (2011). Self-help

stress management training through mobile phones: An experience with oncology nurses.

Psychological Services. Advance online publication. No Pagination Specified.

doi:10.1037/a0026459

Literature Review-Nursing Research

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