Running head: LIVING WITH THE DYING

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

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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.

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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

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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

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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

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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 out- patient services for patients with advanced cancer. The participants were

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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

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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

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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 largescale 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

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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

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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

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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.

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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. PsychoOncology, 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

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