Study on Coping Strategies and Factors Associated with Stress, Among Nurses Working in Intensive Care Unit, New Delhi, India

Nursing professionals working in Intensive Care Units are challenged with high level of stress evolving due to critical condition of patients as well as urgency in decision making at life threatening situations. This makes Intensive Care Units more stressful place for working. Stress affects the emotional status which results into negative feelings hindering the care provided to patients. Study aimed to assess Coping strategies and factors associated with stress among staff nurses. Results showed the major coping strategies were used by the nurses including positive reappraisal, accepting responsibility and escape avoidance. Confronting coping was least used by the nurses. Factors like positive support and healthy work environment made level of stress less among nurses working in intensive units.


INTRODUCTION
Health care professionals are exposed to variety of stressors which they deal with patient's co-morbidities, high job demands from patients and their families, complex technology, urgent care, work overload and their workplace settings. Nursing profession due to this complexity is considered as a stressful profession. Nurses are exposed to intense stressors arising from the demand of their job such as poor staffing pattern, high workload, communication breakdown, death of patients and sometimes pressure from medication errors (Sexton et al., 2009). The profession also exposes nurses to unpleasant but unavoidable long working hours, lots of paper work, social vices such as physical abuse from patients and relatives.
The changing need of society, change in medical technology, extended and expanded role of nurses with modernize knowledge and skills makes today's nurses are more exposed to job related stress, which can lead to burnout, low self-esteem, absenteeism, depression, anxiety, frustration and sometimes cognitive malfunction. (Kumar, Pore, Gupta, and Wan, 2016) depicted stress among nurses was higher compared to doctors. Stress may have impact on their health, but also on the quality of care that they provide in ICUs (Farquharson et al., 2013).
According to American Psychological Association, various factors are considered as source of stress such as low salaries, heavy workloads, lack of opportunity for growth and advancement, unrealistic job expectations, job security and lack of participation in a decision-making (Stress Advocate 2009). According Geuens, Braspenninga, Bogaert, Franck (2015) environmental factors that causes stress to health care professionals on regular basis are pain, suffering, and death of patients. To deal with increasing stress in day to day life and manage these stressors many coping strategies are used by nurses. Coping strategies are intended to maintain wellbeing, injury to write off the harmful effects of stressful situations coping is the ability or efforts made by person to overcome the stress (Lazarus 1966).
Coping strategies are cognitive and behavioural efforts to reduce existing demands, determined by the way individuals use the strategies for external and internal resources such as health, beliefs, responsibility, support, social skills , materials and basic resources to decrease the stress level. Individual may engage in some different forms of coping such as attempting to improve the concrete situation and taking actions to relative the emotion of the stressful events and not actually removing the conditions. Other form of coping such as denial may be used as a defence mechanism which may keep a pressure away from feeling overwhelmed.

METHODS AND TOOLS
The research approach adopted in this study was Quantitative Research Approach with cross sectional research design. Study was conducted in various Intensive Care Units of selected hospitals, New Delhi. 96 nurses were selected who were working in ICUs and met the inclusion criteria. Tools used were Socio demographic profile, Ways of Coping a tool, developed by Lazarus and Folkman (University of California, San Francisco) to collect the data. Tool contained 66 items to identify a stressful encounter that occurred recently, where it took place and what happened next Reliability of tool was tested and was found to be 0.96. Ethical approval for the study was obtained from Institutional Ethical Committee. Witten informed consent was obtained from each participant.
International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470 @ IJTSRD | Unique Reference Paper ID -IJTSRD21551 | Volume -3 | Issue -2 | Jan-Feb 2019 Page: 988   Table 2 depicts frequency and percentage of nurses working in ICUs according to their personal and professional qualification. It shows 67.7% of the nurses were working as patient care executive, and 14.6% were having designation as nurse. Nearly half (52.1%) of them were sole bread winner for the family. More than half (55.2%) the nurses were not having dependent family members. Majority (89.6%) of nurses working in ICUs were not having any family members with chronic illness. With regard distance of travelling, 61.5% of nurses use to travel less than 5 kilometres for their work. Time taken to reach workplace was less than 30 minutes for 64.6% of nurses. 6% of nurses were working in liver coma ICU, 18.8% of nurses working in TICU as well as SICU and 19.8% of nurses were also working in HDU. More than half of the nurses (57.3%) were having experience of their working area between 0.3 to 2 years and 16.7% of the nurses were having experience between 5 to 8 years.  Table 3 depicts frequency percentage distribution of nurses according to their working condition. The data indicates 38.5% of the nurses reported that most of the times they were having adequate physical facility to care patients, whereas 9.4% reported that they never had adequate facility to render their care. Nearly three-fourth of nurses (71.9%) reported that they never had conflict with physicians.

Frequency and percentage distribution of nurses working in ICUs according to professional characteristics
Seventy five percent reported that there were no conflicts between nurse and their supervisors. Nurses (65.6%) never had Conflicts with colleagues. More than half (65.6%) nurses reported that sometimes only doctors were present in emergency situations and half (55.2%) of the nurse said doctors were always present in emergency situations in ICUs. Less than half (46.9%) of the nurses got help from their supervisors.  Table 4 elicits coping strategies adopted by nurses working in ICUs. It is evident from data that positive reappraisal (51.57%) was the highest coping strategies used by nurses followed by accepting responsibility (47.33%) whereas escape-avoidance (35.70%) was the lowest coping strategies used by nurses working in ICUs. Association between coping strategies and selected socio demographic profile  Table 5 depicts the association between coping strategies score and demographic profile. It is evident from data that there was no significant association found between coping strategies and demographic profile such as gender p=0.74, marital status p=0.14, professional qualification p=0.05, monthly income p=0.87, accommodation of nurse p=0.37. There was no significant association between coping strategies score and socio-demographic profile. Therefore null hypothesis was accepted and research hypothesis was rejected.  Table 6 depicts association between coping strategies score and sample characteristics. The data indicates that there was no significant association found between coping strategies score and sample characteristics such as designation p=0.78, sole bread International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470 @ IJTSRD | Unique Reference Paper ID -IJTSRD21551 | Volume -3 | Issue -2 | Jan-Feb 2019

Level of coping strategies among nurses working in Intensive Care Units (ICUs)
Page: 992 winner for the family p=0.41, dependent family member in the family p=0. 32, chronic illness among family members p=0.75, distance of travelling for work p=0. 75, travelling time p=0.11.Therefore null hypothesis was accepted and research hypothesis was rejected.  Table 7 depicts association of coping strategies score and professional characteristics. The data indicates that there was significant association found between coping strategies and sample characteristics such as working area of nurse (p=0.001). It is also evident that there was no association found between coping strategies and sample characteristics such as total nursing experience (p=0.63), total ICUs experience (p=0.75) and working area experience in years (p=0.66). Therefore the null hypothesis was not accepted and research hypothesis was not rejected. Further to assess the direction of association between stress score and current working area of nurses, Post-hoc test was applied (table 20)  Table 8 shows association of coping strategies score and nurses working in ICUs working environment. It is evident that there was no significant association found between coping strategies and sample characteristics such as adequate physical facilities in ICUs p=0.09, conflicts with physicians p=0.56, supervisors p=43, colleagues p=0.16, and availability of doctors in emergency situations (p=0.07) and help available from supervisors (p=0.22). Therefore null hypothesis was accepted and a research hypothesis was rejected.

DISCUSSION
In the current study, suggests that coping positive reappraisal (51.57%) was highest coping strategies used by nurses followed by accepting responsibility (47.33%) whereas escape-avoidance (35.70%) was the lowest coping strategies used by nurses working in ICU. The findings are similar to study done by Jose and Bhatt. Ramezanli in his study reported that nurses were using emotional focused coping strategies more than problem-focused strategies. The findings show significant association between coping strategies and current working area of nurses. (TICU) had adopted more coping strategies than other nurses and were less stressed. This may be due to stable workplace environment of Transplant Intensive Care Unit. Correlation was found between stress and coping strategies among nurses working in ICUs. Supported by Liu.

CONCLUSION
Coping is multidimensional concept where individual perception can be affected by an individual's belief and values. People may use different coping strategies at various time points. Positive reappraisal is frequently used coping strategies among nurses. Less experience increases more stress in the professional life of a nurses. Pressure and conflicts between physicians, supervisors, and colleagues contributes to amplify the stress levels. Although environment with helping and supporting colleagues and availability of doctors while handling difficult situation make a difference in coping with stressful situations.

RECOMMENDATIONS
Periodic assessment of nurses working in intensive care units for stress must be implemented in all hospitals. Provision of counselling services for the staff would be the great idea to identify and treat stress and stress related disorders and miss happenings in the health care environments. Development of stress free workplace, for sharing problems without fear of being punished or judged. Deep breathing and other relaxation techniques may be helpful to teach and reduce stress.