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Copyright © 2025 By: Ahmed Hassan Shujaa All Rights Reserved

DECLARATION

I, Ahmed Hassan Shujaa, hereby declare that this dissertation entitled:

“Occupational Stress and Coping Mechanisms among Psychiatric Nurses at the Iradah Complex for Mental Health, Riyadh, Saudi Arabia: A Mixed Method Approach”

is the result of my own independent research and investigation. This work has not been previously submitted, in part or in whole, for the award of any degree or qualification at this or any other institution of higher learning.

All sources of information, literature, and data that have been used in the preparation of this dissertation have been duly acknowledged and referenced in accordance with academic and ethical standards.

I further affirm that I have abided by the ethical principles governing research at King Saud University, and I take full responsibility for the content of this work.

Signed: _________________________

Name: Ahmed Hassan Shujaa

Date: _________________________

Endorsed by Supervisor: _________________________ Prof. Adel Saeed Bashatah

APPROVAL PAGE

This dissertation entitled:

“Occupational Stress and Coping Mechanisms among Psychiatric Nurses at the Iradah Complex for Mental Health, Riyadh, Saudi Arabia: A Mixed Method Approach”

has been examined and approved by the supervisory committee and the department as meeting the requirements for the award of the degree of Doctor of Philosophy in Nursing .

DEDICATION

I dedicate this dissertation to my beloved Family, whose unwavering support, love, and guidance have been my cornerstone throughout my academic journey.

To my supervisors, whose wisdom, encouragement, and constructive feedback guided me toward the successful completion of this study.

To my colleagues and friends, whose motivation and companionship inspired me to persevere through challenges and stay committed to excellence.

Finally, I dedicate this work to the memory of my late Father, who sacrifices continue to inspire my pursuit of knowledge and service to others.

ACKNOWLEDGEMENTS

First and foremost, throughout my academic years, I would like to thank Almighty Allah for facilitating challenges throughout my study at KSU. I would like to thank myself for this achievement and everyone supporting me, inspiring me, and creating this challenge to fight difficulties to reach this degree.

As well as, I would like to express my deepest gratitude to my supervisors, Prof. Adel Saeed Bashatah & Saeed Ali Asiri, whose expert guidance, continuous support, and invaluable feedback have been instrumental throughout every stage of this dissertation.

I would like to extend my thanks to the administrative and research staff at the Iradah Complex for Mental Health, Riyadh, for their assistance and cooperation in facilitating data collection. My appreciation also goes to all psychiatric nurses and participants who generously shared their experiences and insights.

I am profoundly grateful to my family and friends, especially my parents, for their unwavering support, patience, and encouragement throughout this journey. Their love and belief in me provided the motivation to persevere through challenges.

Finally, I acknowledge the support of King Saud University for providing the academic environment and resources necessary for the successful completion of this research.

To all who contributed to this work, whether mentioned or not, I extend my sincere thanks and appreciation.

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Occupational or workplace stress is quite common in nursing. Psychiatric nursing is a very high-risk specialty given patient violence, emotional labor, and stressful clinical situations. Aim, this study set out to  explore the level of occupational stress and the coping mechanisms used by psychiatric nurses at the Iradah Complex for Mental Health, Riyadh. Method, grounded in the explanatory sequential mixed-methods design and using the Transactional Model of Stress and Coping as its theoretical foundation, this study used the Nursing Stress Scale (NSS) to measure stress levels on a stratified random sample of 225 nurses. Data Analysis, Quantitative data were analyzed using The Shapiro-Wilk test was conducted to assess the normality of the scores. The independent sample T-test and ANOVA were done to evaluate the differences in the stress scores in psychiatric nurses according to their characteristics, where the T-test was used to investigate the significance between two groups, while ANOVA was deployed for more than two groups. Pearson correlation was conducted to evaluate the relationship between the overall stress scores and two quantitative normally distributed variables (age and years of experience). Linear regression was performed to determine the predictors of perceived stress, multicollinearity test was conducted as a prerequisite for the regression. Then, qualitative data were collected from 15 purposively sampled nurses via in-depth, semi-structured interviews to reach thematic saturation, and thematic analysis was used to analyze coping experiences. Participants reported moderate to high occupational stress levels from stressors, such as lack of support, uncertainty concerning treatment, and workload. Then, various coping methods were identified through thematic analysis and detailed according to adaptive and maladaptive coping mechanisms, including Individual strategies, Collaborative strategies, and Professional strategies. Discussion, the study revealed that psychiatric nurses in Saudi Arabia experience moderate stress, primarily due to workload, patient behavior, and insufficient staffing. Stress levels varied by nationality, experience, and clinical setting. Nurses employed individual, collaborative, and professional coping strategies to manage stress. Enhancing resilience, support, training, and recognition can improve nurse well-being and retention. Conclusion, the study offers a comprehensive understanding of occupational stress among psychiatric nurses in Saudi Arabia, shaped by individual, cultural, and organizational factors. Despite moderate stress levels, workload, inadequate preparation, and patient behavior were key stressors. Nurses adopt diverse coping strategies, highlighting the need for systemic interventions. Recommendations include staffing improvements, flexible scheduling, professional development, and violence prevention.

Keywords: Occupational stress, Coping mechanisms, Psychiatric Nurses

الخلاصة:

الإجهاد المهني أو ضغوط مكان العمل أمر شائع جدًا في التمريض. التمريض النفسي هو تخصص عالي الخطورة للغاية نظرًا لعنف المرضى والعمل العاطفي والمواقف السريرية المرهقة. تهدف هذه الدراسة إلى استكشاف مستوى الإجهاد المهني وآليات التكيف التي يستخدمها ممرضو الطب النفسي في مجمع إرادة للصحة النفسية بالرياض. تعتمد الطريقة، التي تستند إلى تصميم الطرق المختلطة المتسلسلة التوضيحية واستخدام النموذج التفاعلي للإجهاد والتكيف كأساس نظري لها، على مقياس إجهاد التمريض (NSS) لقياس مستويات الإجهاد على عينة عشوائية طبقية من 225 ممرضة. تحليل البيانات، تم تحليل البيانات الكمية باستخدام اختبار شابيرو ويلك الذي تم إجراؤه لتقييم طبيعية الدرجات. تم إجراء اختبار T للعينة المستقلة وتحليل التباين ANOVA لتقييم الاختلافات في درجات الإجهاد لدى ممرضات الطب النفسي وفقًا لخصائصهن، حيث تم استخدام اختبار T للتحقيق في الأهمية بين مجموعتين، بينما تم نشر تحليل التباين ANOVA لأكثر من مجموعتين. تم إجراء ارتباط بيرسون لتقييم العلاقة بين درجات الإجهاد الكلية ومتغيرين كميين موزعين بشكل طبيعي (العمر وسنوات الخبرة). تم إجراء الانحدار الخطي لتحديد متنبئي الإجهاد المتصور، وأجري اختبار التعدد الخطي كشرط أساسي للانحدار. بعد ذلك، تم جمع البيانات النوعية من 15 ممرضة تم أخذ عينات منهم عن قصد من خلال مقابلات متعمقة وشبه منظمة للوصول إلى التشبع الموضوعي، وتم استخدام التحليل الموضوعي لتحليل تجارب التكيف. أفاد المشاركون بمستويات إجهاد مهني متوسطة إلى عالية من الضغوطات، مثل نقص الدعم وعدم اليقين بشأن العلاج وعبء العمل. بعد ذلك، تم تحديد طرق التكيف المختلفة من خلال التحليل الموضوعي وتفصيلها وفقًا لآليات التكيف التكيفية وغير التكيفية، بما في ذلك الاستراتيجيات الفردية والاستراتيجيات التعاونية والاستراتيجيات المهنية. المناقشة، كشفت الدراسة أن الممرضات النفسيات في المملكة العربية السعودية يعانين من إجهاد معتدل، ويرجع ذلك في المقام الأول إلى عبء العمل وسلوك المريض ونقص الموظفين. تختلف مستويات الإجهاد حسب الجنسية والخبرة والبيئة السريرية. استخدم الممرضون استراتيجيات تكيف فردية وتعاونية ومهنية لإدارة التوتر. ويمكن أن يُحسّن تعزيز المرونة والدعم والتدريب والتقدير من صحة الممرضين واستبقائهم. وفي الختام، تُقدّم الدراسة فهمًا شاملًا للتوتر المهني لدى ممرضات الطب النفسي في المملكة العربية السعودية، والذي يُشكّله عوامل فردية وثقافية وتنظيمية. وعلى الرغم من اعتدال مستويات التوتر، إلا أن عبء العمل، وعدم كفاية التحضير، وسلوك المريض كانت عوامل ضغط رئيسية. ويتبنى الممرضون استراتيجيات تكيف متنوعة، مما يُبرز الحاجة إلى تدخلات منهجية. وتشمل التوصيات تحسينات في الكادر، ومرونة في الجداول الزمنية، والتطوير المهني، والوقاية من العنف.

الكلمات المفتاحية: التوتر المهني، آليات التأقلم، ممرضات الطب النفسي

Title Page..................................................................................................................i Declaration..............................................................................................................ii Approval Page........................................................................................................iii Dedication...............................................................................................................iv Acknowledgements.................................................................................................v

List of Figures ........................................................................................................ix

List of Abbreviations .............................................................................................x

Chapter Four: RESULTS....................................................................................

4.1 Quantitative Findings.................................................................................

4.1.1 Demographic Characteristics............................................................

4.1.2 Levels of Occupational Stress...........................................................

4.1.3 Coping Mechanisms Used.......................................................................

4.1.4 Relationship between Demographics, Stress, and Coping...............................

4.2 Qualitative Findings..............................................................................................

4.2.1 Themes and Subthemes from Interviews..............................................................

4.2.2 Nurses’ Perspectives on Coping and Stress...........................................................

4.3 Integration of Quantitative and Qualitative Findings................................................

Chapter Five: DISCUSSION..............................................................................................

5.1 Interpretation of Quantitative Findings............................................................. 5.2 Interpretation of Qualitative Findings................................................................... 5.3 Comparison with Existing Literature......................................................................... 5.4 Theoretical Implications Using the Transactional Model.............................................. 5.5 Practical Implications for Nursing Management...................................................... 5.6 Cultural and Contextual Insights from the Saudi Setting.............................................

Chapter Six: Conclusion and Recommendations.........................................................

6.1 Summary of Key Findings.............................................................................. 6.2 Conclusions.................................................................................................. 6.3 Recommendations for Practice, Policy, and Future Research..................................... 6.4 Contributions to Knowledge.....................................................................................

Appendices.................................................................................................................

Appendix A: Nursing Stress Scale (NSS)................................................................

Appendix B: Interview Guide..............................................................................

Appendix C: Participant Information Sheet and Consent Form............................

Appendix D: Ethical Approval Documents............................................................

Appendix E: SPSS Output / Coding Framework................................................

Appendix F: Research Timeline / Gantt Chart ...................................................

Table 1: G*Power for Sample Size Determination.......................................................................47

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Nursing is considered one of healthcare's most stressful and painful professions, which has consequences for the caregivers' well-being and the patients' safety. The stress is like being stuck in a quagmire of many interrelated factors- acute care, emotional labor, bureaucratic hassles, and often said to be against the organization, such as staff shortages and reduced resources (Almutairi et al., 2022). In such an enabling environment, psychiatric nursing is an extra strain and thus separate from other nursing areas by virtue of its demands. Psychiatric nurses work in settings where human tragedies, traumas, and meddling patient behaviors like verbal and physical aggression test their patience (Hasan & Tumah, 2019). Building therapeutic relationships with people in severe mental health crisis is at the heart of their interventions, requiring enormous emotional investment and resilience, often with no immediate or visible reward for their supportive care.

In Riyadh, the Iradah Complex for Mental Health Facility is one of the class one complexes for such needs in Saudi Arabia. This big psychiatric hospital is like a microcosm where global challenges meet regional and local demands. The health system in Saudi Arabia is undergoing a significant transformation with Vision 2030, which prioritizes modernization of health services, community-based care, and preventive health. However, this concept of modernization has to deal with the present hurdles of cultural stigma, which could help enhance help-seeking among the patients and sometimes from the practitioners too (Al-Dowsari & Khatabeh, 2023). Another secret source of tension for psychiatric nurses could be that their work is undermined or misunderstood. Notwithstanding, the Saudi nursing population is multicultural, comprising Saudi nationals and expatriate nurses from various backgrounds, each with different notions of stress, coping, and professional support. Therefore, practical needs far outweigh academic theorization. Their well-being has been insufficiently researched, but it definitely lies at the core of the level of care they can give to some of the most vulnerable members of society. By investigating this problem in the Iradah Complex, this research will focus on the lived experiences of these workers. It thus will be an important evidence base upon which targeted support programs may be developed (Almutairi et al., 2022). Institutional policy may be informed, and thus broadly support a resilient and sustainable mental health workforce in Riyadh and beyond.

Occupational stress among nurses is a well-documented global phenomenon, and research shows its link to burnout, compassion fatigue, low job satisfaction, high staff turnover, and ultimately poor patient care. Despite this, the knowledge gap regarding the contextual application of the issue in specialist psychiatric nursing in Saudi Arabia is a significant consideration (Alabdullah, 2020; ALRUWAILI, 2024). Global studies provide a framework for understanding nursing stress in a universal context. However, they cannot be applied directly to the Saudi environment as the culture, religion, organizational, and socio-economic determinants that shape how stress is perceived, felt, and addressed are unique (Hasan & Tumah, 2019). The Kingdom’s cultural values centered on family and community solidarity can be both a stressor and a buffer, and religious faith is an influential but under-explored coping mechanism.

As great as it is, the Iradah Complex for Mental Health is not immune to the system-wide ills of healthcare systems worldwide, including high nurse-to-patient ratios, administrative waste, and potential inadequacies in managerial support to frontline staff. There is anecdotal and preliminary evidence of a stressed workforce in the form of absenteeism patterns, turnover, and qualitative, informal accounts of emotional burnout (Alharbi, 2024). Despite these indicators, there is a glaring absence of strong empirical research that systematically explores the quantitative variables of stress and the qualitative factors of coping mechanisms used by the nursing staff. Local studies on nursing stress in general hospitals are present, but no focused mixed-methods study exists on the psychiatric nursing population within a specialist mental health hospital (Alabdullah, 2020).

This lack of localized information is a significant barrier to developing and implementing evidence-based interventions. Without a complete picture of the specific stressors that nurses face and the coping mechanisms they use to deal with them, hospital executives and policymakers are forced to go on assumptions and possibly institute well-intentioned but mis-targeted support programs that are off the mark (Al-Ruwaili et al., 2024). Therefore, this study addresses this gap by comprehensively analyzing occupational stress intensity and coping style among psychiatric nurses in Iradah Complex and collecting valuable information that can guide organizational development, staff well-being, and patient outcomes.

This research aimed to explore the level of occupational stress and coping strategies used by psychiatric nurses at the Iradah Complex for Mental Health in Riyadh, Saudi Arabia. This was achieved by the deliberate and strategic use of a mixed-methods approach, chosen for its ability to give breadth and depth. This research was not just about quantifying the prevalence and intensity of stress responses through a validated statistical measure, but also to qualify and richly contextualize individual lived experiences of coping through narrative research. By combining these two types of evidence, the research gave detailed and multifaceted picture of the staff’s psychological well-being. This went beyond the statistics to capture the voices and stories of the nurses, how they think and act in the everyday struggles of psychiatric care. Additionally, the aim was to identify any differences and trends linked to demographic variables, thus enabling further segmented and targeted analysis of the findings. Ultimately, the knowledge generated by this research was actionable in real time as an initial evidence base to inform the development of targeted systems of support, resilience-promoting programs, and institutional policies that were mitigate occupational stress and build a healthier work culture for psychiatric nurses in this setting.

To translate the general aim of this research into operational and numerical scientific investigation, two specific research objectives have been formulated to guide each phase of the study, from planning to data collection, analysis, and interpretation.

1. To investigate level and frequency of perceived stress by psychiatric nurses.

2. To explore the coping mechanisms used by psychiatric nurses.

The first objective is quantitative: to investigate the level and frequency of perceived stress by psychiatric nurses. to formally measure the prevalence and incidence of subjective occupational stress among psychiatric nursing personnel at Iradah Complex. This was done using the Nursing Stress Scale (NSS). This validated instrument was yield quantifiable scores on the stress level and corresponding sub-domains such as Death and dying, Conflict with physicians, Inadequate preparation, Lack of support, Conflict with other nurses, Workload.

The second objective is qualitative and exploratory: to gain an in-depth understanding of nurses’ lived experience, to explore the coping mechanisms used by psychiatric nurses. This objective went beyond quantifying to examine the what and why of coping strategies, to look into the nuanced, often deceptively complex, and sometimes unconscious ways nurses manage their stressful work. To uncover a rich array of techniques from adaptive strategies like receiving social support and spiritual practices to potentially maladaptive strategies like avoidance, this aim uncovered the micro-level process of individual resilience and adversity through semi-structured interviews. Together, these additional objectives were capture both the statistical reality of stress and the human story of coping, to paint a complete picture needed to develop interventions.

This study was designed to provide clear, empirical answers to three general and related research questions, each exploring a specific aspect of the research problem.

RQ-1: What is the level of occupational stress experienced by psychiatric nurses in Iradah Complex for Mental Health?

RQ-2: How do psychiatric nurses cope with occupational stress?

RQ-3: What are the demographic variables (age, gender, nationality, department, level of education, and years of experience) that affect perceived stress and coping mechanisms among psychiatric nurses?

This study went beyond academic exercise with potential for real-world impact at the theoretical, practical, and policy levels. This study was theoretically test and extend the Transactional Model of Stress and Coping by applying it in the unique Saudi professional psychiatric nursing context. It examined the model's basic assumptions - primary and secondary appraisal and coping attempts - in a context of collectivist social structures, and thus added to the model's cross-cultural validity and gave a new understanding of how cognitive appraisal processes are culturally constructed (Shujaa, A. H., & Bashatah, A. S. 2025). At the practical level, findings had immediate relevance to nursing practice and hospital administration at Iradah Complex. For nurse managers and clinical leaders, the research provided an evidence-based diagnostic tool to determine the exact cause of stress and catalog the coping mechanisms currently available and being used by their employees.

This was valuable in developing targeted and effective interventions such as tailored resilience training programs, facilitated peer support groups, supervised clinical debriefing sessions, and stress management workshops that are contextually and culturally appropriate rather than generically imported. Participating in this research empowered the nurses, gave them a validated voice and reduced feelings of isolation. At the policy level, the results provided a robust evidence base for the Saudi Ministry of Health and other healthcare policymakers. The healthcare workforce is a key pillar as the Kingdom moves forward with its Vision 2030 health sector reform (Hasan & Tumah, 2019). This study informed national policy on nurse retention, occupational safety in mental health settings, and integration of mental health care for caregivers as part of standard operating protocols. By putting a premium on the mental well-being of psychiatric nurses, the health system placed a premium on better quality, safer, and more compassionate patient care, thus creating a virtuous cycle that benefits the community (Hasan et al., 2018).

To achieve clarity, avoid ambiguity, and have a common understanding throughout this dissertation, the following definitions are provided regarding their operational application in this study. Occupational stress has been theoretically defined as an intricate physical, emotional, and psychological harm that results when the demands and pressures exerted from work are beyond the individual (nurse) 's personal, social, or professional capacity to cope with them. Quantitatively and operationally, this study will consider the NSS total score and subscale scores for the frequency of exposure to situations described as stress-provoking (Almutairi et al., 2022). Coping mechanisms refer to all types of conscious or unconscious cognitive, emotional, or behavioral attempts used consciously or unconsciously to manage, endure, alleviate, or regulate any given internal or external demands that are felt as stress or beyond one's capacity (Hasan et al., 2018).

The mechanisms were operationally defined and classified via a thematic analysis of qualitative interview texts, whereby emphasis will be explicitly given to the strategies mentioned by the participants themselves. Operationally speaking, psychiatric nurses are all registered nurses who are officially working with the Iradah Complex for Mental Health and are involved in providing clinical care to the patients in any inpatient or outpatient unit of the complex (Al-Ruwaili et al., 2024). This definition was restricted to exclude nursing assistants, technicians, and nurses who solely perform administrative or supervisory duties without direct contact with patients to ensure a homogeneous study sample relevant to the research questions.

This study has a narrow scope to ensure focus, depth, and manageability. The study is confined to currently practicing registered nurses only in the various clinical departments of Iradah Complex for Mental Health in Riyadh. It does not include other valuable healthcare professionals like psychiatrists, psychologists, social workers, or nursing assistants because these different professional groups' stress and coping resource profiles will likely differ and need separate study. Geographically, the study is limited to this one institution, so the findings are generalizable to this specific setting. The study is cross-sectional; data were collected at one point in time, giving a complete picture of the stress and coping, but cannot track changes over time, show causality between variables, or observe the coping process throughout a person’s career. Moreover, the study relied on nursing stress scale (NSS) and coping (interview), which, while valuable, are prone to intrinsic errors like recall bias and social desirability bias, where people may underreport issues or over report effective coping. These are not limitations but boundaries that define the study scope and ensure clarity of the boundaries within which the conclusions apply.

The dissertation has a linear structure with a six-chapter format, from setting up the research to reporting and interpreting the findings. Chapter One: The introduction provided the background, problem statement, purpose, objectives, questions, and significance of the study. Chapter Two: Literature Review were further critically analyzed the existing research on occupational stress among nurses, especially in psychiatric settings, and justify the selected Theoretical Framework, i.e., the Transactional Model of Stress and Coping. Chapter Three: Methodology presented an organized presentation of the mixed methods design, study context, population, and sampling for the quantitative (n=225) and qualitative (n=15) phases, data collection tools (NSS and semi-structured interview guide), and a plan for analyzing both the statistical and thematic data. Results synthesized the first quantitative results from the survey, and then qualitative themes that explain and build upon the findings to the research questions. Finally, the Discussion and Conclusion interpreted the findings in the light of the literature, conclude, overview the study limitations, and provided practical recommendations for practice, institutional policy, and future research directions, completing the research cycle.

This chapter provided a critical and comprehensive overview of the existing literature on occupational stress and coping mechanisms among psychiatric nurses, focusing on the Saudi healthcare environment and Iradah Complex for Mental Health in Riyadh. This is the foundation of the whole research, systematically reviewing, synthesizing, and critiquing the current literature to establish a clear framework, highlight the gaps, and define the purpose and originality of this mixed-methods study. Through a review of the global, regional, and local literature, this review situated the problem, showing how global knowledge of nurse stress is imported, denied, or specifically articulated within Saudi Arabia’s unique cultural, religious, and administrative mental health care context. The chapter is structured by themes to provide a logical and holistic exploration of the key concepts. It started by critiquing the phenomenon of occupational stress among nurses and its many meanings and theories. Then it reviewed the specific causes and manifestations of this stress among psychiatric nurses, based on empirical studies from around the world. Then the review devoted much space to the coping mechanisms and strategies nurses use to cope with stress and compare their effectiveness and usability.

Moreover, a critical section was also included to address the unique context of Saudi Arabia by outlining the growing but original literature on stress in the healthcare sector in the Kingdom and the acute shortage of studies on its psychiatric nursing community. Finally, the chapter ended with a summary that weaves together the main findings, states explicitly the gap in the research that this dissertation is trying to fill, and stated the research questions that have emerged from this literature review. The scope of this review is broad but focused; it encompasses landmark and recent worldwide studies to establish a firm worldwide grasp of the phenomenon, yet at the same time narrows down to focus on studies in the Middle East and, wherever possible, in the Gulf Cooperation Council (GCC) countries and Saudi Arabia itself. This two-pronged approach ensures that the research is grounded in established global theory. At the same time, it is acute and sensitive to and mindful of the socio-cultural, religious, and organizational factors that define nurses’ practice at Iradah Complex. The review included empirical studies, systematic reviews, meta-analyses, and theoretical articles from the literature on occupational health, psychology, nursing, and health services management, focusing on the last two decades and landmark works.

In a study by Alruwaili et al. (2022), the JD-R model says high-demand jobs drain our physical and mental energy, leading to exhaustion and poor health. Occupational stress in challenging nursing situations is complex beyond feeling under pressure or overwhelmed. Theoretically, it is a negative physical and emotional response when the job demands do not match the nurse’s ability, resources, or needs. The mismatch between the task and the person’s coping ability is a psychological and physiological imbalance. In nursing, it is not one event but an interaction of several environmental, organizational, and personal factors that lead to burnout, compassion fatigue, and decreased individual well-being and patient care quality. The American Nurses Association has identified this as a significant occupational health hazard and its far-reaching impact on the workforce. According to Koroglu & Ozmen. (2022), one theoretical framework central to understanding this concept is the Job Demands-Resources (JD-R) model, which provides a robust way of studying antecedents and consequences of occupational stress. This model says every profession has specific risk factors for job stress, and these can be classified under two broad categories: job demands and job resources (Elsayed et al., 2018). Job demands are those physical, psychological, social, or organizational aspects of the job that require continuous physical or mental effort and thus have some physiological and psychological costs, i.e., high workload, emotional demands of families and patients, and shift work.

On the other hand, Ali et al. (2021) indicate that job resources help achieve work goals, reduce job demands and the accompanying physiological and psychological costs, or enhance personal growth and development, such as supervisor support, autonomy, and participation in decision making. Known as the health impairment process. Conversely, abundant job resources induce a motivational process leading to high work engagement, low cynicism, and improved performance. To nurses, this model is particularly relevant because their profession is not only high acuity and high workload but also has a specialist emotional and psychological cost of managing abusive behavior, severe distress, and complex therapeutic relationships. According to Obbarius et al. (2021), the other key theoretical framework is Lazarus and Folkman’s Transactional Model of Stress and Coping. Stress is defined as a person-environment relationship that the individual judges as taxing or exceeding their resources and threatening their well-being. This model highlights the appraisal cognitive process, where the individual assesses a perceived stressor as threatening or challenging and then assesses their coping resources available. This subjective process is at the heart of nursing, as the same objective patient interaction or workload will be perceived and responded to dramatically differently by different individual nurses based on resilience, experience, and support systems. Furthermore, burnout, typically a symptom of unresolved chronic occupational pressure, is at the core of this issue (Muathen, 2022; Elsayed et al., 2018). Burnout is a complete mental and physical depletion described in the three dimensions of emotional exhaustion, depersonalization or cynicism, and reduced personal accomplishment.

The study by Sacgaca et al. (2023) notes that compassion fatigue, a related concept more prevalent in therapeutic professions, is the erosion of compassion and is generally considered the cost of caring for people in emotional pain. To understand occupational stress in nursing, therefore, this needs to go beyond a cause-and-effect process to appreciate an ongoing transactional dynamic process where organizational arrangements, social interactions, and inner psychological resources within an individual interact daily, shaping a nurse’s susceptibility or resilience to the built-in tension of the job (Almutairi et al., 2024). This richness of theory highlights the need for an integrative approach to investigate and intervene, not just to ward off overwork but to build constructively and sustain robust job and personal resources within nursing professionals.

According to Rayani. (2024), psychiatric nurses' stress comes from an interaction of organizational, client, and professional role factors, each with a specific stress profile that manifests in psychological, physical, and behavioral symptoms. Organizational sources are a common type of stressor, historically based on the structural and functional characteristics of the health system. These include chronic understaffing and sustained patient-to-nurse ratios, so nurses work under time pressure and feel they cannot provide the care they would as professional standards, known as moral distress. This is often compounded by pointless paperwork, bureaucratic activities that take time and energy away from patient care, and a lack of resources or equipment that causes daily frustrations and obstacles (Al‐Gamal et al., 2018). Shift work, especially night shifts, disrupts the body’s circadian rhythms and causes sleep disturbances, fatigue, long-term health effects, and conflict with family and social life. According to Bakhsh et al. (2023), a lack of support from the organization and management, no feedback, appreciation, and career growth opportunities, adds to feeling devalued and powerless. Client-related sources of stress are specific and substantial in psychiatric nursing. Nurses are at risk of patient aggression and violence all the time, and even if no direct incidents are observed, it creates a culture of fear and hypervigilance (Alharbi & Alshehry, 2019; Ahmad et al., 2022).

In the study by Aladah et al. (2020), the affective labor of dealing with therapeutic relationships with patients with severe psychosis, severe depression, or personality disorders is tremendous and intensely stressful. Enduring patient suffering with often slow or nonlinear recovery can empower workers to feel helpless and furious. Managing complex ethical issues such as the trade-off between patient autonomy and mandatory treatment requirements or confidentiality issues has a high affective and cognitive load (Ram & Alharbi, 2025). The third category of role stressors is professional role stressors, which include role ambiguity, where work expectations are unclear, and role conflict, where nurses have incompatible demands from patients, families, doctors, and administrators. The perceived low status of mental health nursing in the overall medical profession and society at large is also stressful and impacts professional pride and identity.

This stress manifests in many ways and can be severe, affecting the nurse, patient, and organization. Psychological symptoms are most apparent, for instance, anxiety, depression, irritability, and emotional exhaustion, which is the core of burnout. This can progress to depersonalization, where nurses unknowingly use callous and impersonal attitudes towards patients as a coping mechanism, referring to them by diagnosis or room number rather than their name (Ahmad et al., 2022; Al‐Gamal et al., 2018). Cognitive symptoms present as difficulty with concentration, memory, and decision making, which is dangerous to patient safety. Physiologically, the body’s stress response can present as chronic fatigue, headache, gastrointestinal illness, musculoskeletal disease, and impaired immune response, making nurses more prone to infection. Behaviorally stressed nurses may have increased absenteeism as withdrawal from the stressful situation at work or presentism – arriving at work when ill, again lowering productivity and standards of care (Alosaimi et al., 2028). Organizationally, high turnover rates are an immediate and costly consequence of unresolved stress, with loss of skilled staff and again workload on those that remain, forming a vicious cycle. Perhaps most importantly, an accumulation of these events can decrease patient care's overall quality and safety, for instance, more medication errors, less therapeutic communication, and worse patient outcomes (Dawood et al., 2017). Understanding this complex interplay of sources and their expressions is not an intellectual exercise but a necessary process to develop intense and effective interventions to break the cycle of stress and its impact on the caregivers themselves and the vulnerable population they are caring for.

According to Alyousef & Alhamidi. (2022), the long-term and massive occupational stress that is part of nursing and specifically of psychiatric care requires many coping strategies. These strategies, or the cognitive and behavioral ways of coping with external and internal demands that are more than the individual’s resources, are the determinants of a nurse’s well-being, career length, and quality of care. The literature categorizes these mechanisms as adaptive (or functional) and maladaptive (or dysfunctional), but this is often a simplistic distinction, as the effectiveness of a strategy depends on the situation. Adaptive coping mechanisms are associated with good long-term outcomes, reducing the negative impact of stress and building resilience. Maladaptive methods may give some relief in the short term but ultimately exacerbate stress and lead to compromised health and functioning. In the study by Alsufyani et al. (2022), knowing this complex landscape of coping is key to moving towards support frameworks for psychiatric nurses in institutions like Iradah Complex. The conceptual underpinnings of the coping model are rooted in Lazarus and Folkman’s Transactional Model of Stress and Coping, where cognitive appraisal plays a central role. According to the theory, an individual first does primary appraisal (assessing whether an event is stressful, positive, or irrelevant) and then secondary appraisal (assessing what coping resources and options one has) (Obbarius et al., 2021). The second attempt at coping is bifurcated into problem-focused coping, which is aimed at addressing the stressor itself and changing the situation, and emotion-focused coping, which is aimed at addressing the emotional hurt of the problem. Both are important in nursing, where some of the stressors are irreversible and need to be controlled emotionally, while others can be addressed directly and changed (Alharbi & Alshehry, 2019; Ahmad et al., 2022).

The study by Sacgaca et al. (2023), a thorough examination of adaptive, problem-focused coping strategies, reveals various active techniques highly valued in the nursing literature. Seeking social support, the most significant buffer, is calling on colleagues, supervisors, friends, or family for emotional support, informational guidance, or tangible help. Within the nursing unit, peer support is a substantial stress buffer; having someone to debrief with who understands the stressors of a complex patient interaction or trauma incident is gold. Formal and informal mentorship programs are also included, providing the less experienced nurse with advice and reducing role uncertainty. Another key problem-focused approach is professional growth and knowledge expansion (Muathen, 2022; Elsayed et al., 2018). For the psych nurse, feeling competent in caring for complex patient presentations is powerful. Ongoing education, workshops on de-escalation techniques or new therapy models, and staying up to date with evidence-based practice immediately increase your self-efficacy and locus of control in the clinical area. This aligns with the job resource development in the Job Demands-Resources (JD-R) model. The study by Sacgaca et al. (2023) states that organizational ability and time management are fundamental problem-focused interventions. Nurses who can prioritize well, delegate when necessary, and prioritize their workload experience less of the horrible-ness that leads to burnout. Organizing for systems change, although often hard, is an advanced-level problem-focused intervention. This is participating in unit councils, providing input to management about stress-causing policies, or participating in quality improvement initiatives to fix stress-causing problems such as understaffing or wasteful processes (Al‐Gamal et al., 2018). While it takes a lot of effort and courage, this addresses the organizational causes of stress, not just the symptoms.

At the same time, adaptive emotion-focused coping strategies are needed to deal with the emotional impact of unchangeable experiences. Research has supported the importance of mindfulness and relaxation training in recent decades. According to Bakhsh et al. (2023), meditation, relaxation training, and progressive muscle relaxation can downregulate the body’s stress response system by reducing cortisol production and the experience of anxiety and emotional exhaustion. These can be done quickly during a shift or as part of a daily routine. Cognitive reframing is another emotion-focused strategy. This is consciously changing the way this view a stressful event – for example, viewing a violent patient assault not as a personal failure but as a manifestation of their illness or viewing a stressful shift as a test of our competence and ability. This targets the evaluation process at the core of the Transactional Model (Al‐Gamal et al., 2018). A strict work-life boundary is a good but sometimes tricky boundary management strategy. This is actively engaging in activities outside of work to recover and detach – hobbies, exercise, quality time with family, etc. Exercise is an excellent technique with a two-fold benefit – it is a proven mood elevator by releasing endorphins and a healthy way to release physical and emotional tension (Muathen, 2022; Elsayed et al., 2018). Finally, self-compassion – treating ourselves kindly in the same way as a struggling colleague- is an emotion regulation technique that protects us from blame and perfectionism, which can lead to burnout.

On the other hand, Alsufyani et al. (2022) study shows maladaptive coping strategies that give temporary emotional relief but have long-term consequences for the nurse, the patient, and the organization. Avoidance coping is common but maladaptive. This can be behavioral avoidance, i.e., taking sick leave to avoid a highly stressful task or a difficult patient, or cognitive avoidance, i.e., mentally switching off at work by daydreaming or distracting oneself on critical tasks. Although it reduces tension in the short term, it does not allow the nurse to learn more adaptive ways of coping and can lead to the accumulation of unresolved issues, which in turn increases anxiety. Suppressing affect is another maladaptive coping pattern often used in the workplace where one has to maintain a poker face. However, the process of constantly suppressing emotions is cognitively exhausting and is associated with more psychological distress and burnout. Venting or complaining without problem-solving can also be maladaptive. Although initially cleansing chronic dwelling on negative job aspects with a group of colleagues can create a vicious cycle of bad affect, perpetuating helplessness and victimhood without leading to problem solving. Far more maladaptive coping responses are drug use, i.e., using alcohol, sedatives, or stimulants to regulate stress or promote sleep. This dangerous path not only endangers the nurse’s physical and psychological health but also erodes professional competence and patient safety (Alharbi & Alshehry, 2019; Ahmad et al., 2022). Moreover, the most extreme form of maladaptive coping in nursing is presentism – coming to work ill in body and mind. A sense of responsibility often drives it in patients and colleagues, fear of letting the team down, or worry about financial penalties. However, presentism is a paradox – the nurse is there but mentally and emotionally absent, leading to reduced productivity, increased risk of error, and long-term damage to their health, spreading the cycle of stress.

According to Alyousef & Alhamidi. (2022), these coping mechanisms are not by chance; multiple individual, social, and organizational factors influence them. At the personal level, hardiness, resilience, and optimism are personality strengths that determine a person's coping style. A more resilient nurse will likely use healthy coping mechanisms like positive reframing and active problem-solving. Age and experience also play a role; experienced nurses have more coping strategies accumulated over years of work, but these too can be prone to chronic compassion fatigue. Cultural and social factors are at work, especially in a collectivist society like Saudi Arabia (Muathen, 2022; Elsayed et al., 2018). The extended family network can be a big reservoir of affective and utilitarian support, a strong shield of protection more likely to be available than in Western individualistic societies. Cultural values can also inhibit open declaration of mental distress or professional psychological treatment due to conjoined stigma, reducing the number of adaptive solutions used. The most significant moderating factor is organizational culture. An organization whose culture celebrates psychological safety, where nurses feel backed up by their management, have access to confidential Employee Assistance Programs (EAPs) and can take breaks and de-brief after critical incidents, will encourage adaptive coping.

Conversely, a blame culture, understaffing, and managerial absence of support will force nurses to use maladaptive strategies of avoidance and emotional suppression. For Iradah Complex psychiatric nurses, the idiosyncrasies of their work—continued exposure to trauma, risk of violence, and emotional intensity of therapeutic relationships—require a super robust and intelligent set of coping strategies. Hence, evidence suggests that interventions must be multi-level to tackle the nurse individual via resilience training and mindfulness interventions, the social level via team cohesion and peer support building, and the organizational level via leadership commitment to creating a sustainable and supportive work environment (Alharbi & Alshehry, 2019; Ahmad et al., 2022). Lastly, adaptive coping is not an individual imperative but an organizational imperative for healthcare organizations that want to preserve their most valuable asset: their nursing staff.

In the study by Alsufyani et al. (2022), the theoretical framework is the backbone of any research investigation; it gives phenomena a systematic way of looking at things, understanding, and interpreting. For occupational stress and coping mechanisms among psychiatric nurses in Iradah Complex for Mental Health, the Transactional Model of Stress and Coping developed by Richard S. Lazarus and Susan Folkman in 1984 has been chosen as the leading guiding theory (Ben-Zur, 2020). Its selection is based on its dynamic, process theory, cognitively mediated view of stress rather than a more static, stimulus-response view of stress as an automatic reaction to some external event. The basic assumption of the transactional model is that stress is not defined by the outside world or the individual themselves, but by the ongoing transaction between the individual and their environment, which the individual perceives as taxing or exceeding their resources and threatening their well-being (Alsolais et al., 2021; Alsufyani et al., 2022).

According to Nisa et al. (2024), this person-environment congruence or its absence is at the heart of the stress experience in a psychiatric hospital's dynamic and sometimes unpredictable context. The model’s applicability in this study is because it can utilize the richness of the detailed, subjective, and dynamic nature of the nurse-patient interaction; two nurses can have the same patient aggression event but perceive and respond to it in totally different ways based on their own individual cognitive appraisals and coping resources (Alharbi & Alshehry, 2019; Ahmad et al., 2022). It is more than just a listing of stressors; it presents an advanced mechanism of understanding the psychological processes determining why specific demands are stressful and how individuals cope.

Figure 1. shows a complex process that starts with the primary appraising process, a cognitive one, where the individual decides if an event with the environment is irrelevant, benign, positive, or stressful. For the psychiatric nurse in Iradah Complex, an event like a patient verbally abusing them is appraised immediately. If irrelevant, no further attention is given (for instance, when a familiar patient is muttering to themselves). The benign-positive view is when the patient is in therapy, and it is a success, so it induces positive affect (Alanazi et al., 2023). A stressful event has three subcategories of appraisal: harm/loss, implying damage already experienced (for instance being depressed after being attacked by a patient); threat, implying future possible damage (for example anticipating violence from an angry patient); and challenge, which conveys possible growth or good out of adversity (for instance seeing hard de-escalation as an opportunity to master a critical skill) (Alsufyani et al., 2022). This is a refined primary appraisal relevant to this study as it considers the threat and harm dimensions of stress and explores the ability of nurses to see demands as challenges, a concept closely related to resilience and commitment.

This second appraisal is a weighing of what can be done. It is connected to the nurse's self-efficacy—their belief in being able to do the lines of action required to manage future situations. The time between the primary appraisal of demand (‘this is a threat’) and the secondary appraisal of resources (‘but I can cope’) determines whether a stress response will occur. A threat appraisal lacking resources will likely produce a high stress response; a challenge appraisal or threat with resources will suppress it. Only after these appraisals are complete, coping processes follow (Amin Mohamedet al., 2023). Lazarus and Folkman define coping as the changing sequence of cognitive and behavioral methods to manage specific external and/or internal demands rated as taxing or above the individual’s resources (Ben-Zur, 2020). The focus of this research on coping processes is already situated within this phase of the transactional model. The model provides a taxonomy of coping efforts into two broad functions: problem-focused coping and emotion-focused coping.

According to Alyousef & Alhamidi. (2022), problem-focused coping is used to manage or modify the problem causing distress. For a psychiatric nurse, this would be direct behavior like asking a colleague to help restrain a patient, using a structured communication method to defuse a situation, changing a patient’s medication, or organizing their workload to manage time pressures. It is most used when the individual sees the situation as changeable. Emotion-focused coping, on the other hand, is about controlling the emotional response to the problem. This is not an avoidance or weakness but often a highly adaptive way when one sees the situation as unchangeable (Alharbi & Alshehry, 2019; Ahmad et al., 2022). Examples would be using cognitive reframing to see an insult from a patient as a symptom of illness rather than a personal insult, doing mindfulness or breathing exercises in the break room to manage acute anxiety after a nasty incident, talking to a supervisor for emotional support to blow off steam, or taking a physical exercise after work to blow off steam.

The transactional model suggests that most stressful interactions are a mix of coping, problem-focused, and emotion-focused, and effectiveness depends on whether the coping mechanism fits with appraised situation controllability. A mismatch, such as trying to problem solve an unmanageable event (for instance, the trajectory of a patient’s chronic mental illness) or using emotion-focused strategies to solve a solvable problem (for example, avoiding an unavoidable difficult conversation), can lead to increased distress (Amin Mohamedet al., 2023). This model was beneficial in analyzing the mixed-methods data and categorizing and evaluating the coping strategies used by the nurses at Iradah, not just as a list but also as adaptive responses to some appraised situations. Applying this model to the specific context of Saudi psychiatric nursing adds a vital layer of cultural and organizational refinement. The primary and secondary appraisal processes are deeply embedded in the institutional, and cultural background of the Iradah Complex. Cultural views towards conflict and authority may influence a nurse’s initial appraisal of a stressor and expression of affect. For example, a strong cultural emphasis on obedience and respect may make the appraisal of conflict with a doctor or senior nurse seen as a catastrophic threat (Sacgaca et al., 2023). Conversely, long-established religious doctrines (for instance, patience, and trust in God) may powerfully influence both primary and secondary appraisal so that a stressful situation may be reappraised as a test of faith or an ordained trial to be endured patiently, and is therefore a very effective emotion-focused coping strategy in itself.

Secondly, secondary appraisal—the estimation of resources—is highly context dependent on the organization's function. Social support, a key resource, is made easy by the collectivist nature of Saudi society, so the work group can be a better source of support than in individualist cultures. However, assessing other resources such as managerial guidance, staff levels, security coverage, and training availability depends on the organizational structure and policies of the Iradah Complex (Amin Mohamedet al., 2023). Therefore, the model is not alone; it operates within the broader Saudi culture and the specific Iradah culture, providing a window into this population's specifics. Using the Transactional Model, this research looked at stress and coping as more than a linear cause-and-effect but a dynamic, psychologically complex process (Alsufyani et al., 2022). It provided the language and framework to systematically deconstruct how psychiatric nurses perceive their needs, what they use as resources, and the knowledge and action pathways they take to navigate their professional landscape. It will yield rich data to inform culture-specific interventions for their well-being.

In the study by Alsufyani et al. (2022), this dynamic and iterative process of appraisal and coping is not a one-off. However, it sets the stage for repeated reappraisals as a function of the outcome of the coping effort, creating a loop that goes on forever and is the basis for understanding long-term adaptation—or maladaptation—of psychiatric nurses. After attempting a coping strategy, the individual reappraises the situation and their emotional state. This reappraisal determines whether the transaction has been resolved; if so, no further action is needed; if not, the stress continues, and a new cycle of appraisal and coping begins (Amin Mohamedet al., 2023). for a nurse at Iradah Complex, practical problem-focused action, say de-escalating an aggressive patient with a new skill, leads to positive reappraisal: the threat is neutralized, self-efficacy increases, and the action is reinforced for future use. Suppose an emotion-focused strategy like suppression does not regulate their distress after a traumatic event. In that case, the negative reappraisal—increased anxiety and intrusive thoughts—means the coping attempt was unsuccessful, and they may try another strategy, or if no other is perceived, they may escalate into chronic stress and feelings of helplessness (Alharbi & Alshehry, 2019; Ahmad et al., 2022). This feedback is the key to understanding how resilience or burnout develops over time.

Figure (1) Lazarus & Folkman’s (1984) Transactional Model of Stress and Coping

Internal demands

External demands

Stressors (demands)

(internal or external

Primary appraisal

(internal or external)

Situation is stressful

Situation is not stressful strststressful

Secondary appraisal

Problem-Focused

Emotion-Focused

Coping

Reappraisal

If coping fails

If coping is successful

stress reduces

Outcomes

The research on occupational stress and coping mechanisms in nursing is vast and global, but finds a typical pattern of themes with local context-specific variations. A summary of previous studies provides the foundation for understanding the extent of the problem, the universality of causes and manifestations, the diversity of coping mechanisms, and the gaps that still exist, mainly in specialized fields and specific cultural environments like Saudi Arabia (Alharbi & Alshehry, 2019; Ahmad et al., 2022). Globally, systematic reviews and meta-analyses have established that nursing is one of the most stressful professions, with burnout syndrome prevalence rates for emotional exhaustion and depersonalization being high for medical and surgical areas. However, a robust body of research has shown that psychiatric and mental health nursing has unique stressors that are clearly worthy of closer examination. Studies done in Western settings by Ram & Alharbi. (2025), and more recently by Ahmad et al. (2022), have all found that while general nurses report high workload and staffing as their main concerns, psychiatric nurses report a combination of these organizational stressors with client-related stressors such as multiple personal exposure to patient aggression, verbal abuse, and emotional depletion from managing complex therapeutic relationships. In the study by Alsufyani et al. (2022), this dual pressure from the patient and the system creates a unique stress profile. An early UK longitudinal study found that the threat of violence perceived, even if no actual episodes occur, is a state of chronic hypervigilance that is extremely draining and leads to higher rates of anxiety and sleep disorders among mental health nurses compared to their overall nursing counterparts (Amin Mohamedet al., 2023).

As per various studies worldwide, the manifestations of this stress are clear but serious. Research under the Job Demands-Resources model has always shown a high correlation between high quantitative and emotional demands and the health impairment route, as it leads to emotional exhaustion, which is the primary component of burnout. A study on a large sample in Australia by Dawood et al. (2017) found that psychiatric nurses reported higher levels of psychological distress and somatic complaints like chronic headaches and gastrointestinal distress, which were attributed to the work environment. Further studies have found a strong association between uncontrolled occupational stress and adverse organizational outcomes, a pattern seen from Canada to Japan. High turnover intentions, increased absenteeism, and most critically, a demonstrated decrease in patient care quality, like increased rates of medication errors and decreased patient empathy ratings, are common outcomes (Amin Mohamedet al., 2023). This global trend shows that nurse stress costs the individual clinician, the organization, and finally the patient. Hence, the case for intervention is strong on ethical and economic grounds.

When examining coping mechanisms, the evidence shows a rich array of strategies nurses use worldwide, influenced by organizational culture, personality, and country. Problem-solving and adaptive strategies are associated with better outcomes. One systematic review by Alosaimi et al. (2018), found that nurses who actively used social support networks professionally and personally outside of work had reduced burnout and higher job satisfaction. Scandinavian country literature, whose countries are known for good work cultures, reports debriefing training and clinical supervision as effective in mitigating the impact of traumatic events. MBSR (mindfulness-based stress reduction) programs in America are effective in reducing anxiety and improving emotional regulation in emergency and psychiatric nurses. However, the literature has more than enough evidence of maladaptive coping. Avoidance coping, such as mental disengagement and withdrawal, is the norm in high-stress, low-support groups (Alharbi & Alshehry, 2019). The trend in many studies is the phenomenon of "presentism" - coming to work while sick, which arises out of a sense of obligation to patients and colleagues, but paradoxically results in decreased performance and longer recovery time. Studies in high-stress environments like the ICU and psychiatry have found a pattern of emotion suppression or compartmentalization as an acute survival mechanism, which, although applicable in the moment, is accompanied by long-term emotional flatness and compassion fatigue if habitualized.

In the study by Alsufyani et al. (2022), despite all this global research, there is a glaring contradiction and a considerable gap when examining the research done in Saudi Arabia and the Arab Gulf. Short-staffing, workload, and patient aggression are consistently mentioned in the limited studies available in the Kingdom, for instance, Ahmad et al. (2022). However, the coping mechanisms and their effectiveness are highly mediated by the unique socio-cultural and religious fabric that Western developed models and measures cannot capture. For instance, while social support is a universal buffer, its manifestation in Saudi collectivist society differs. The role of the hamula (extended family) as a source of ultimate emotional and instrumental support is a vast reservoir that might be even bigger than in Western individualist cultures (Amin Mohamedet al., 2023). On the other hand, the religious and cultural rules may affect coping in a way that others might misinterpret. The embedded Islamic values of faith in God and patience and endurance are not passive resignation but active religious coping strategies that can create enormous resilience and create a meaning-making system in the face of adversity. A study by Almutairi et al. (2024) on Saudi nurses found that spiritual beliefs were a significant factor in managing work-based stress, a finding that is not always clear-cut in secular Western studies. This is a paradox: the sources of stress are universal, but the local cultural toolkit to manage them is parochial.

The most significant gap in the literature and what this study addresses is the lack of research on psychiatric nurses in Saudi Arabia. There are general nursing studies in the Kingdom, but these aggregate all specialties together, thus losing the specific experiences of mental health nurses. As a specialty-oriented hospital, Iradah Complex for Mental Health is a microcosm that integrates the global challenges of psychiatric nursing with the Saudi-specific religious, cultural, and organizational context (Rayani, 2024). There are almost no mixed-methods studies that qualitatively explore these nurses' appraisal processes and coping reactions in their specific context and quantitatively measure the frequency and severity of these events. Previous studies have given a brush stroke description but lacked depth to answer the how and why questions. Saudi psychiatric nurses, how do they judge a patient’s aggression in their culture? Why do they use specific coping strategies and not others? How does the organizational policy at Iradah help or hinder adaptive coping overall? The conclusions of previous international studies are clear: the problem is acute, multi-problematic, and needs a contextually relevant solution (Sacgaca et al., 2023). For this reason, this study aims to merge the methodological complexity of international studies with a deep culture-sensitive investigation to bridge this enormous gap and provide evidence not only theoretically sound but also practically pressing and relevant to policymakers and administrators in Iradah and similar institutions across the GCC region (Muathen, 2022). Doing so will contribute to a more complete global picture of stress in nursing that acknowledges both cross-cultural commonalities and culturally distinctive coping.

In addition, a synthesis of earlier research reveals methodological and conceptual learnings that can inform the design of this study. One dominant trend across the literature is the historical reliance on quantitative, cross-sectional survey designs. Although these studies, with the use of measures such as the Maslach Burnout Inventory (MBI), the Nursing Stress Scale, and the Ways of Coping Questionnaire, have been instrumental in determining prevalence rates and establishing broad correlations, they tend to give a static and superficial view of a very dynamic process (Koroglu & Ozmen, 2022). They can tell us that workload is related to emotional exhaustion, but cannot tell us the rich, contextualized, and process-based how and why of those relationships. The subjective, cognitive process of appraisal that is part of the Transactional Model is too often a statistical variable and is not studied as a lived experience (Ali et al., 2021). This has been acknowledged in subsequent literature with calls for qualitative and mixed-methods designs to develop the nuance of the stress-coping trajectory longitudinally. This study answers that call using a sequential explanatory mixed-methods design, where quantitative results provide the overall relationships and prevalence, followed by deeper examination and explanation in qualitative interviews, and hence the breadth and depth of the phenomenon in Iradah Complex.

According to Alyousef & Alhamidi. (2022), the second important lesson from past research is the often-overlooked element of positive outcomes and resilience. Most nursing stress research, understandably, focuses on adverse endpoints: one’s burnout, turnover, and ill health. However, an increasing number of studies in positive psychology and occupational health are on post-traumatic growth, resilience, and work engagement. A few nurses exist who, one would think, share the same difficult working conditions but survive and thrive. Their strength and appreciation for life are enhanced, and their clinical competencies are improved (Alharbi & Alshehry, 2019). Studies have started to find the sources of this resilience, such as a high degree of coherence, hope, and meaning in one’s work. This research is necessary because it shifts the focus from pathology prevention to well-being and professional satisfaction. To psychiatric nurses who work at Iradah, it is just as important to learn what facilitates resilience as to understand what provokes stress. Therefore, this study was not being a deficit model examination; it was look for and determine the factors—whether individual traits like patience, group resources like family support, or organizational actions like supportive leadership—by which nurses can adaptively manage the stresses of their demanding but essential profession. This focus is crucial to developing interventions that are not only about reducing harm but also about building strength and maintaining a sustainable and healthy mind workforce (Alharbi, 2019).

The synthesis also shows a contradiction in the analysis of some coping strategies, particularly what might be called “avoidance”. While literature classifies avoidance as maladaptive, some context-specific qualitative studies suggest short-term strategic withdrawal can be adaptive and successful in extremely high-stress situations (Alharbi & Alshehry, 2019). To a psychiatric nurse, 5-minute pause in an empty room after a critical incident might be an avoidance strategy that prevents an emotional outburst and allows for re-adjustment. This is to highlight the limitations of rigid categorizations and to put more emphasis on the timing, duration, and intention of a strategy (Alsufyani et al., 2022). This qualitative study aims to capture the nuance in this way by allowing nurses to describe their coping behaviors in their own voices and in the context in which they experienced it, moving beyond predetermined categorizations to expose the utility of a strategy in the transactional relationship of the nurse to their environment at Iradah.

Finally, applying the previous results to the Saudi context is cultural calibration, not a matter of translation. Instruments developed and validated in Western cultures may not measure stressors related to family obligations or religious expectations in Saudi culture. Likewise, some other constructs cannot be adequately studied without reference to the culture in which their expression is deeply rooted, just as Islamic practice-based coping mechanisms such as prayer ( Salah) and reading the Quran are not merely some Western abstract of spirituality but rather an autonomous and deeply embedded system of meaning and emotion regulation (Sacgaca et al., 2023). An experiment could give incomplete and biased findings without the cultural embeddedness in context. Therefore, the quantitative instruments were selected and calibrated in the Saudi setting. The qualitative interview guides were open-ended questions to elicit culturally-specific responses about causes of stress and coping so that the research findings truly reflect the experiences of the Saudi nurses at Iradah. By integrating these lessons from previous research—the need for mixed methods, resilience as the focus, coping subtlety, and cultural calibration—this study aims to provide a comprehensive, rigorous, and contextually relevant knowledge on occupational stress and coping for this critical but understudied population.

A comprehensive and critical review of the literature on occupational stress and coping mechanisms among nurses reveals complete evidence of the problem’s global prevalence and severity, but also with massive conceptual, contextual, and methodological flaws that this study aims to address. According to Bakhsh et al. (2023), the biggest and most significant gap that has been identified is the lack of research targeted to the psychiatric nurses in the Kingdom of Saudi Arabia. Although the global literature is vast, it is mostly from Western, educated, industrialized, prosperous, and democratic (WEIRD) settings whose cultural, religious, and organizational contexts differ from those in the Gulf Cooperation Council (GCC) region specially, in Saudi Arabia. Among the scarce body of nursing stress research in Saudi Arabia, there has been a tendency to view the nursing profession as homogeneous, pooling data from different specialties—medical, surgical, critical care, and psychiatric—into one group (Koroglu & Ozmen, 2022). Although this approach gives a general picture of stress in Saudi nursing, it tends to mask the unique and higher stress profile of psychiatric nurses. Their dual stressors, due to both systemic organizational pressures and the inherent nature of mental health care, require specialized investigation. The specific environment of an independent mental health center like the Iradah Complex for Mental Health in Riyadh, a leading hospital in the region, is a significant environment that has not been researched (Ali et al., 2021). Therefore, the first and most important gap in the study is this huge vacuum in the literature through a focused and in-depth analysis of occupational stress and coping mechanisms among psychiatric nurses in the ward of a large Saudi mental health complex, so that findings are not diluted by the experiences of nurses working in radically different clinical settings.

Besides the broader context, a closer look reveals several specific and related gaps this study can fill. First, there is a huge methodological gap in the existing research on this population. Most of the research globally or in Saudi Arabia has used overwhelmingly quantitative, cross-sectional survey-based methodology as its primary methodology. While these approaches are better than others for establishing prevalence rates and picking up large-scale statistical correlations between variables (like correlating burnout scores with workload), they are not suited for the dynamic, process-bound, and highly subjective nature of stress and coping experience as described by the Transactional Model of Stress and Coping (Sacgaca et al., 2023). They capture a superficial snapshot but cannot answer the key "how" and "why" questions. Can you describe your overall experience with stress in your work environment, including common sources and the frequency at which it occurs? What specific challenges do you face as a psychiatric nurse that contribute to your stress, and how do workplace conditions (e.g., staffing, shift length) affect your stress levels? How do you typically cope with work-related stress, and which coping strategies do you find most effective? Please explain why they work for you. What support systems are available in your workplace to help manage stress? What suggestions would you make to nursing administration to improve support for psychiatric nurses? To address this, this study used a sequential explanatory mixed-methods design. The approach first used quantitative questionnaires to investigate level and frequency of perceived among Iradah Complex nurses, hence establishing a solid empirical base. A very in-depth qualitative phase follows the quantitative phase in the form of semi-structured interviews to explore the coping mechanisms used by psychiatric nurses. This mixed-methods approach is needed because it bridges the knowledge gap between knowing that there is a problem and knowing why it is and how it is lived by the individuals who live through it, hence providing a richer and usable evidence base.

Second, there is an apparent gap between theory and practice. Most studies, especially Saudi-based, are a theoretical and descriptive, listing stressors and coping mechanisms without placing them in a robust theoretical framework to explain the psychological outcomes. This study addresses this by explicitly using the Transactional Model of Stress and Coping as the underlying theory. This framework goes beyond listing stressors and coping responses; it provides an advanced framework to understand the cognitive mediation where environmental demands become stressful (or not) and the consequent deployment of coping efforts. It allows for working through the initial appraisal (for instance, is the aggression of a patient seen as a threat or a challenge?), secondary appraisal (for example, which individual, social, or organizational resources are seen to be available?), and a continuous process of reappraisal based on coping consequences (Amin Mohamedet al., 2023). Through its application to the Saudi psychiatric nursing context, this study contributes not only empirical knowledge but theoretical depth, testing the validity of a Western-developed model in a new cultural setting and perhaps enriching it with concepts which are relevant to the culture, such as patience and trust in God as part of the appraisal and coping processes.

Third, there is a gap in the cultural and religious mediation of stress and coping. While earlier research worldwide has been cited to show that culture impacts the process, there is a noticeable lack of in-depth, insight-generating investigation of how the collectivist, tribal, and Islamic socio-cultural composition of Saudi Arabia affects every stage of the stress-coping process. The extended family as a buffer against stress, the embarrassment of seeking professional psychological treatment, and the use of Islamic rituals like prayer, fasting, and recitation from the Qur'an as the center of emotion-focused coping mechanisms are issues that are mentioned in passing but never become the subject of central analysis (Koroglu & Ozmen, 2022). This study is specifically designed to investigate these culturally-specific factors with its qualitative aspect using open-ended questions where participants are free to redefine their experiences in their own language. This gathered priceless information on the culturally-specific resources that support resilience and the particular obstacles that may hinder adaptive coping for Saudi psychiatric nurses, information that is essential in designing effective and competent intervention programs.

Therefore, these gaps needed context-specific, theoretically and methodologically advanced studies to produce transformative knowledge. This study is one of them. It is justified because psychiatric nurses' well-being is an ethical issue and a key ingredient for high-quality, safe, and humane mental health care services in the Kingdom. In the global literature, uncontrolled stress at work has been linked to high turnover, absenteeism, and compromised care, and thus, the biggest threat to the operational stability and therapeutic effectiveness of critical institutions like Iradah Complex. In line with Saudi Vision 2030 to develop a profitable healthcare industry and improve government services, this study looks at cognition by removing stressors and building adaptive coping resources. A supported and resilient nursing workforce is parallel to this vision.

In addition, the Iradah Complex, as the research site, is a significant finding of the study rationale. As one of the top and specialized psychiatric care centers in the country, the findings of the study will be highly transferable to other psychiatric facilities in Saudi Arabia, where the organizational and cultural settings are similar. The study provided a comprehensive model of coping and stress that includes universal nurse stressors and single Saudi mediators of religion and culture, with a model for future research and intervention that is culturally applicable, not borrowed from another context. Therefore, this research is not an end but a necessary first step. It will produce the first mixed-methods dataset on this topic from this specific context, giving a baseline against which change and the impact of deployed support interventions can be measured in the future. It will make Saudi psychiatric nurses' voices heard and ensure solutions devised for their well-being are based on their lived experience, cultural strengths, and workplaces. In doing so, it will fill a blind spot of great importance in international nursing literature and provide the evidence needed to have a sustainable and mentally healthy psychiatric nursing workforce in Riyadh and beyond, and the long-term effect will be better patient care and advancement of mental health services in Saudi Arabia.

CHAPTER 3: METHODOLOGY

This study was mixed-methods research design, specifically explanatory sequential design, to explore the level of occupational stress and the coping mechanisms used by psychiatric nurses working at Iradah Complex for Mental Health, Riyadh, Saudi Arabia. The reason for using this approach is because of the nature of the research topic, i.e., experiential stress and highly contextual, personal, and subtle strategies used to manage it. A single method approach, quantitative or qualitative, would not be enough. A quantitative survey only would measure the level and frequency of perceived stress, but not the rich qualitative insights, the hidden "why" behind the numbers, the setting-related factors in the Saudi setting and healthcare culture, and the nuanced thinking behind nurses' decision making (Aloufi, 2023). A purely qualitative approach would give rich depth and richness of personal experiences, but not generalizability or quantifiable scope of the issue to make inferences about the problem among the entire population of nurses in the complex (Alomani, 2016). Therefore, integrating both paradigms is beneficial and necessary to build a robust, holistic, and practical understanding of the problem, answering the overall goal of this study.

The quantitative phase was the first and foremost component of this sequential design, using a structured cross-sectional survey to collect numerical data from 225 psychiatric nurses. This phase objectively measured the variables of interest among psychiatric nurses. The questionnaire consist of two parts: a demographic form to collect data on age, gender, nationality, years of experience, level of education and department; a standardized occupational stress measure, best exemplified by the Nursing Stress Scale (NSS) which is validated across various healthcare settings and was developed to measure the causes of nursing stress that are common such as Death and dying, Conflict with physicians, Inadequate preparation, Lack of support, Conflict with other nurses, and Workload. This quantitative component answered nurses' perceptions of sources of stress through items represent some of stressful experiences that psychiatric nurses face at psychiatric hospital. Using the 4-point scale ranging from "Never" to "Very frequently". the data was analyzed using statistical software (SPSS) using descriptive statistics (means, standard deviations, frequencies) to summarize the data and inferential statistics (t-tests, ANOVAs, correlation analyses, regression) to test the relationships among demographic variables, levels of stress, and patterns of coping. This stage gave a general, broad coping and stress landscape map.

The next stage was qualitative, to describe, explain, and elaborate on the quantitative results in the first stage. It involved in-depth, semi-structured interviews of a purposive sub-sample of the first stage participants. The sampling based on the quantitative results to maximize the information from the interviews, for instance, those who reported very high stress, those who mainly used adaptive coping styles. The interview guide was built through semi-structured tool based on the participants' responses. Rather than being pre-developed, the interview guide was developed after the initial analysis of the quantitative data from the NSS surveys. This is essential for the explanatory sequential design, as interviews are structured to investigate further and explain the pilot study results. The guide consists of broad, open-ended questions and follow-up prompts, created and organized around core themes identified through the survey as most critical. For example, the quantitative results pulse high stress levels from the "Conflict with Physicians" subscale (Alharbi & Alshehry, 2019; Ahmad et al., 2022). In that case, the guide had a section on interprofessional relations with questions like, what specific challenges do you face as a psychiatric nurse that contribute to your stress, and how do workplace conditions (e.g., staffing, shift length) affect your stress levels? How do you typically cope with work-related stress, and which coping strategies do you find most effective? Please explain why they work for you. The guide started with open, grand tour questions to put the participant at ease ("Can you describe your overall experience with stress in your work environment, including common sources and the frequency at which it occurs?") before more specific questions based on the quantitative findings, and finish with reflective questions around ideas for change ("What suggestions would you make to nursing administration to improve support for psychiatric nurses?"). This design allows for a conversational flow, enabled participants to tell their stories in their own words, and ensures the rich data collected is directly relevant to understanding the "what" and "how" behind the numbers, thus meeting the central integrative goal of the study.

The interviews were trying to explore the nurses' lived experience, analyzing the contextual pressures in Iradah, the cultural and religious dimensions of their coping (for instance, the role of prayer, family, and community), the cognitive process of choosing a coping method, and the perceived facilitators and barriers to effective coping (Alamri et al., 2023). This stage will answer "how" and "why" questions: Why are nurses in specific units more stressed? How does the coping option have a cultural background in Saudi Arabia? Why might an apparently maladaptive strategy be used repeatedly? The qualitative data will be coded and analyzed using thematic analysis, an identifying, coding, analyzing, and reporting procedure of patterns (themes) within the data to provide rich, detailed, and complex descriptions of the experiences (Koroglu & Ozmen, 2022).

Integration is the most essential part of a mixed-methods design. In this explanatory sequential design, it happens at two points: the bridging point between the two phases and the interpretative stage. This integration is done through follow-up bridging explanations where quantitative outcomes impact sampling strategy and qualitative data collection protocol design. Qualitative phase results will determine some areas to be further investigated and, therefore, guarantee a qualitative phase that is focused and purposeful (Ahmed & Mohammed, 2019; Natividad et al., 2021). For example, a statistical outcome without correlation between years of experience and stress scores would lead to qualitative questions to identify how long experienced nurses have developed resilience over time. The final and most rigorous integration is during the interpretative stage, where the researcher combines the two sets of findings to make a meta-inference (Alharbi & Alshehry, 2019; Ahmad et al., 2022). This will not be a simple recitation of quantitative and then qualitative results; rather, it will describe how the qualitative information sheds light on the quantitative trends, how the narratives frame the statistics, and how the evidence together shows a more complex understanding than either would alone.

Likely contradictions between the datasets will also be analyzed as valuable insights; for example, where quantitative analysis shows high use of a strategy like "positive reframing" but qualitative interviews find that it is used begrudgingly and perceived as unsuccessful, this contradiction alone is a finding, suggesting that there is a complex reality that would be missed by using one methodology (Aloufi, 2023). Therefore, this design is philosophically pragmatic, keeping the research problem at the center and using the methodological tools best suited to its solution and therefore generating empirically sound and contextually sensitive knowledge that leads to more valid, reliable, and actionable findings and recommendations for improving the mental health and well-being of psychiatric nurses in this specific and critical Saudi healthcare facility.

Strategies used in each phase of the study to ensure the robustness and credibility of the mixed-methods design. Reliability and validity were most important in the quantitative phase. The standardized instruments chosen, the Nursing Stress Scale (NSS), was thoroughly checked for appropriateness and suitability in Saudi nursing (Alharbi & Alshehry, 2019; Ahmad et al., 2022). It included a pilot study in a small population of psychiatric nurses from the same environment to test for internal consistency reliability using Cronbach's alpha and face validity. This rigorous process ensures that the instruments measure what they were supposed to measure in the specific population of interest. Hence, it increases the validity of the quantitative findings.

For the qualitative aspect, trustworthiness will be established by techniques such as member checking, where interview transcripts or summaries of interpretations are given back to respondents for verification of accuracy and consistency with their experiences. Moreover, rich, descriptive reporting in the findings chapter, full of verbatim quotes, will allow readers to make transferability judgments about results to similar settings. Combining the two phases optimizes validity through triangulation; combining and interpreting results from different methods maximizes a more convincing evidence base (Koroglu & Ozmen, 2022). By looking for consistencies and inconsistencies across the numeric trends and the narrative reports, the research moves beyond surface-level conclusions to a richly contextualized, strong, and nuanced understanding of occupational stress and coping, and finally ensures that the findings are grounded and the recommendations are data-driven and actionable for the Iradah Complex administration (Alenezi, 2017).

Iradah Complex for Mental Health in Riyadh, Saudi Arabia, is one of the best examples of psychiatric and mental health facilities in the country. The government has invested heavily in this project to cope with the increasing demand for specialized mental health services. As the leading site of this study, a detailed description of its location, infrastructure, organizational layout, and socio-cultural environment is necessary as these components create the context in which the research participants work and therefore are part of what they experience occupational stress and coping strategies. The complex is located in a way that it serves a vast and diverse population from Riyadh and all over the Kingdom, as it is one of the most significant and most specialized referral centers for complex mental illnesses. Its location in the capital allows access to a pool of health professionals and to be part of the city’s healthcare network, but also centralization of advanced psychiatric services, which would be potentially a source of high patient volume and acuity and directly affect nursing workload and stress. The layout and operational characteristics of the complex create a specific work ecology that affects the daily realities of the psychiatric nurses who work there, making the environment a dynamic variable in the research question rather than a static setting.

The complex is a new sprawling site that provides a range of inpatient and outpatient mental health services. It has several special wards, each with its own challenges for nurses. These wards include acute admission wards where nurses care for patients in crisis with unstable behavior and risk of aggression or self-harm; long term rehabilitation wards where nurses care for chronic illness that may involve dealing with therapeutic nihilism and steady progress; forensic psychiatric wards where nurses care for patients in the criminal justice system with additional security and legal concerns; and specialist clinics for conditions such as mood disorders, anxiety, child and adolescent psychiatry and geriatric psychiatry each requiring specific knowledge and interpersonal skills. The physical environment of these wards is therapeutic and safety-focused, with features like locked doors, anti-ligature fixings, and observation rooms.

However, with the need for containment comes a pressurized and sometimes isolating work environment for staff. The complex also has ancillary services like pharmaceuticals, psychological therapy suites, occupational therapy facilities, and in-house medical services for physical health comorbidities. Access and availability of these support systems for the nurses, such as immediate psychological debriefing after a critical incident or easy access to a medical doctor for a patient, are significant contextual factors that can reduce or increase occupational stress (Ahmed & Mohammed, 2019; Natividad et al., 2021). The sheer size and diversity of the complex mean that the experience a nurse gains is highly dependent on the ward they are posted to, and this is something the study will control for through its demographic data collection and analysis.

Beyond the physical environment, the organizational and cultural climate at the Iradah Complex is most important. As a major public healthcare institution, it falls under the Saudi Ministry of Health, so its policies, staffing models, budget constraints, and administrative frameworks are governed by government decrees and the overall vision of the Saudi health sector as per Vision 2030 (Aloufi, 2023). The national goal is to improve the quality and effectiveness of healthcare services, which would translate into accreditation, audit, and performance measurement programs that add to the workload of nurses in an administrative capacity (Koroglu & Ozmen, 2022). The hierarchical nature of the Saudi healthcare system can also impact interprofessional relationships and create sources of stress related to authority, communication, and autonomy for nurses. The nursing staff are a mix of Saudi nationals and expatriates with different cultural backgrounds (for instance, the Philippines, India, and other Arab countries), so a diverse but perhaps challenging intercultural work community where communication styles, professional standards, and coping mechanisms may not all be the same (Labrague et al., 2018). The nurse manager’s leadership style and the overall organizational culture of support – i.e., presence of mentorship programs, equity of rosters, recognition of work, and open communication – are key organizational determinants that are major predictors of global nursing stress and burnout and will be a core area of investigation in the qualitative interviews.

Above all, the setting is embedded in Saudi Arabia’s socio-cultural and religious fabric. The Iradah Complex operates in a setting where Islamic principles govern personal and professional life. This has significant implications for the expression and treatment of mental illness, patient and family expectations of the patient, and nurses’ coping resources (Koroglu & Ozmen, 2022). For example, mental health principles will get mixed up with spiritual health, and actions such as prayer, recitation of the Quran, and seeking guidance from religious clerics are everyday coping strategies for both patients and probably staff. The cultural value given to family and community brings in many visitors for many patients, both a source of strength and an administrative burden for nurses (Alharbi & Alshehry, 2019; Ahmad et al., 2022). Moreover, cultural norms regarding gender segregation affect staffing patterns and patient assignments, and may create stress profiles that are different for male and female nurses. The social stigma surrounding mental illness in most cultures, including Saudi culture, can also be directed towards nurses; nurses face a form of “courtesy stigma” or feeling that their profession is not as respected as other fields of nursing. This cultural context is not an external variable that needs to be controlled, but an internal context through which stress and coping processes must be seen and understood. Coping processes identified in this study will necessarily be colored by this context, with coping behavior such as patience, and social support sought from within the family, which will be the core of these processes (Ahmed & Mohammed, 2019; Natividad et al., 2021). Therefore, the Iradah Complex is more than a physical location; it is a dynamic convergence of physical, organizational, professional, and cultural forces that together form the lived experience of its psychiatric nursing staff, and its accurate description is crucial to the validity and relevance of this study.

In addition, the temporal framework of the study is part of the setting. Iradah Complex and all other healthcare facilities worldwide are in the post-COVID-19 pandemic era. This has left a permanent mark on the healthcare environment with additional new stressors such as continued fear of contagion, trauma of managing patient isolation and visitor limitations, and extra workload due to additional infection prevention protocols. Moreover, the complex occurs during a rapid change in Saudi society, led by Vision 2030 (Koroglu & Ozmen, 2022). Policies to increase female numbers in the workforce and rebalance the economy are changing the social fabric that directly impacts the profession of nursing and potentially upending traditional gender relationships within the team, as well as building expectations of professionalization and career progression. This dynamic environment with old and new forces is the immediate context in which nurses navigate their professional journey (Labrague et al., 2018). The stress experiences and coping strategies reported by the participants cannot be separated from this specific moment in the history of the organization and the country. To see Iradah as a dynamic system changing under internal and external pressures is crucial in interpreting the results extensively and sensitively, so the results would address the reality of the time in psychiatric nursing in this strategic institution.

The foundation of any good research study starts with defining the population in question and selecting a representative sample from within that population. This mixed-methods explanatory sequential study defines two populations simultaneously: one for the initial quantitative phase and another, more specific population for the qualitative follow-up phase. The total population of the quantitative phase includes all registered nurses who directly participate in patient care in the various clinical units of the Iradah Complex for Mental Health in Riyadh (Ahmed & Mohammed, 2019; Natividad et al., 2021). This definition does not include administrative nursing staff, instructors, and others with only supervisory roles who have no direct bedside care because their work-related stress and coping mechanisms are likely to be qualitatively different from those in direct clinical practice (Aloufi, 2023). This covers a broad spectrum of experiences between cultures, seniority grades, and specialties, so that the quantitative data would represent the complex's core nursing workforce.

This sample is heterogeneous, includes individuals of different nationalities (Saudi and non-Saudi), sex (male and female, likely in separate units as per cultural custom), years of experience, and level of education (diploma, bachelor’s degree, advanced degrees). This heterogeneity is the strength of the study as it allows us to investigate whether demographic and occupational factors (for instance, age, sex, years of experience, nationality, level of education, department) correlate with perceived level of stress and with preferred coping behaviors (Koroglu & Ozmen, 2022). The sampling frame, i.e. the actual roster upon which the quantitative sample was drawn, was constructed in collaboration with the hospital’s nursing administration to get a comprehensive and accurate roster of all the nursing personnel who are eligible to be selected, so that each individual has an equal, non-zero chance of being selected, thus upholding the principles of probabilistic sampling and ensuring the maximum representativeness of the results.

After the quantitative data was collected and interpreted, the qualitative stage drilled down into the stories behind the statistics. Therefore, for this second stage, the population is not independent but a purposively selected sub-population of the original quantitative study participants. The emerging patterns from the survey data defined this qualitative population. It was participants whose responses are most profound, unique, or representative of trends that need to be explored. For example, suppose the quantitative findings show a subgroup of inpatient department nurses with very high stress scores and high emotional support coping. In that case, this group is a key population of interest for the qualitative phase. Therefore, nurses with over 20 years of experience and low levels of reported stress are another relevant sub-population from which interview participants can be selected. This way of synchronizing the two populations ensures that the qualitative phase is in tandem with and informed by the quantitative results, the basic function of the explanatory sequential design. The sampling scheme for selecting individuals from this defined qualitative population will be purposive and discussed later (Labrague et al., 2018). The ultimate goal of this two-staged approach of population identification is to cover the breadth of the phenomenon among the whole nursing staff and the depth of lived experience in specific, strategically chosen parts of the staff, hence an exhaustive and multi-faceted understanding of occupational stress and coping at Iradah Complex.

Exclusion criteria, on the other hand, are in place to protect potential participants and the data. They excluded if, at the time of data collection, they are on long-term absence (i.e., long-term sick leave, maternity leave, sabbatical), as their estimation of occupational stress at the time would be invalid. Also excluded will be nursing staff Nurses with less than a year of experience in psychiatric nursing. Nurses who is not currently employed in a psychiatric setting. Nurses is unwilling or unable to commit to the entire process. Hence, the sample is of staff who are fully embedded in the systems and culture of the organization (Koroglu & Ozmen, 2022). These quantitative phase inclusion criteria will give us an active, experienced, and clinically involved sample of nurses. According to the quantitative results, a further layer of inclusion criteria will be applied for the qualitative interview phase. As discussed, participants will be purposively sampled from the quantitative sample according to their survey responses (Koroglu & Ozmen, 2022). However, all the initial inclusion criteria (working now, at least a year experience, direct patient contact) must still be met at the interview stage to ensure continuity and purpose.

3.3.2 Sample Size Determination

Sample size determination is also an important step that aims to balance statistical power, practical constraints, and methodological appropriateness, and differs for this study's quantitative and qualitative parts. For the quantitative part, the goal is to get a significant enough sample to get reasonable estimates of population parameters (i.e., mean stress ratings) and to identify statistically significant associations between variables (for instance, the correlation between years of experience and problem-focused coping) with sufficient power (Alharbi & Alshehry, 2019; Ahmad et al., 2022). Additionally, Statistical analysis included descriptive statistics to summarize the sources and frequency of stress and inferential tests such as chi-square, correlation and multiple regression analyses to examine relationships between variables. to calculate the required sample size, we conducted a power analysis using G*Power, taking into account the study design, research questions, and the number of groups and factors. Initially, we performed an F-test as the test family to assess whether there were significant differences in variance across multiple groups. This approach is commonly used in ANOVA, as it allows for comparisons between several groups. Furthermore, we implemented a two-way ANOVA to examine coping mechanisms across groups while considering the influence of additional factors. We also conducted an a priori power analysis to determine the necessary sample size based on three key parameters: effect size, significance level (α), and statistical power (1 - β). For the analysis, we assumed a medium effect size (f = 0.25), a significance level of 0.05 (the standard threshold for Type I error), and a desired power of 0.80, which is typically considered adequate to detect a true effect if one exists. Eventually, based on these assumptions, the required sample size, as calculated by G*Power, was determined to be 225 participants as required to achieve reliable results.

3.3.3 Sampling Technique

For the qualitative stage, the sampling aim changes dramatically from general to deep, context, and explanation. Therefore, a non-probability, purposive sampling is not only appropriate but necessary. The exact method was initially criterion-based purposive sampling, followed by maximum variation sampling based on the quantitative findings. The initial criterion for selection is to have completed the quantitative questionnaire (Alomani, 2016). After analyzing the questionnaire findings, participants were purposively sampled according to predetermined criteria. For example, the researcher selected extreme or deviant cases (for instance, the highest and lowest stress scores), typical cases (individuals whose responses are around the mean), critical cases (individuals working in a unit identified as high-stress), or homogeneous cases (for instance, only experienced nurses to learn more about their resilience). This method ensured that the interview participants are rich with information well-suited to explain the quantitative results. Recruitment was iterative until thematic saturation. This systematic and theory-driven sampling in the qualitative phase is the process that allowed for the integration of the two stages of the study, as the qualitative sample is constructed from the quantitative data to provide the depth of understanding needed.

All investigations, studies, and inquiries require verified data collection methods. In this case, there was a scale for organizing the data for the first phase and an interview guide for the second. Both are necessary as they complement each other and provided information from different contexts concerning the probing research questions. The questionnaire for numerical details was a tested and accepted tool for transforming constructs such as occupational stress and coping methods into measurable data that can be understood through statistics (Alharbi & Alshehry, 2019; Ahmad et al., 2022). In addition to being appropriate for the nursing field, especially in a hospital environment, it should have been employed in earlier studies for benchmarking purposes. For this research, it is essential to consider the local culture and use simple language. The qualitative tool must be adaptable and encompassing to enable the collection of rich and detailed stories that delve deeper into the fine details, setting, and personal significance of the quantitative trends discovered in the first phase. It needs to be framed, considering the findings from the first phase, so that the qualitative phase can fully explain the story. Each of these tools makes up the data collection plan, helping to build the overall understanding of the phenomenon. The remainder of this document will discuss the selected quantitative instrument, the Nursing Stress Scale (NSS), and the design and development of the in-house semi-structured interview guide.

3.4.1 Nursing Stress Scale (NSS)

The NSS was the primary tool for measuring workplace stress in the first stage of this study. The NSS is an internationally validated instrument designed for nurses. Gray-Toft and Anderson developed this scale, which is widely used for research in hospital settings. Still, it is also very effective in identifying the pressing sources of stress in nursing. This tool is valuable because it doesn’t give a general score but highlights specific areas of concern. The instrument has 34 items that depict potentially stressful situations. Nurses are asked to report how often they encounter these situations. They respond to a Likert scale, usually 0-3, and select a value that best represents how often they experience that situation. The responses are never, occasionally, frequently, or very frequently. The NSS is comprehensive as it breaks down stressors into seven categories: Death and Dying (e.g. performing procedures that patients experience as painful), Conflict with Physician (e.g. criticism by a physician.), Inadequate Preparation (e.g. feeling inadequately prepared to help with the emotional needs of a patient's family.), Lack of Support (e.g. Lack of an opportunity to talk openly with other unit personnel about problems on the unit), Conflict with Other Nurses (e.g. Conflict with a supervisor), Workload (e.g. Unpredictable staffing and scheduling), Uncertainty concerning Treatment (e.g. Inadequate information from a physician regarding the medical condition of a patient). The Nursing Stress Scale (NSS), shown in the table below, as constructed by Gray-Toft and Anderson (1981), measured the frequency of exposure to stressful situations. The scale includes 34 items spread over seven subscales.

3.4.2 Semi-Structured Interview Guide

The qualitative data was gathered through semi-structured interviews. The semi-structured tool helped to cover the critical issues methodically, along with unplanned and spontaneous follow-ups, allowing probes to be based on the participants’ responses. Rather than being pre-developed, the interview guide was developed after the initial analysis of the quantitative data from the NSS. This is essential for the explanatory sequential design, as interviews are structured to investigate further and explain the pilot study results. The guide consists of broad, open-ended questions and follow-up prompts, created and organized around core themes identified through the survey as most critical. For example, the quantitative results pulse high stress levels from the "Conflict with Physicians" subscale. In that case, the guide had a section on interprofessional relations with questions like, what specific challenges do you face as a psychiatric nurse that contribute to your stress, and how do workplace conditions (e.g., staffing, shift length) affect your stress levels? How do you typically cope with work-related stress, and which coping strategies do you find most effective? Please explain why they work for you. The guide started with open, grand tour questions to put the participant at ease ("Can you describe your overall experience with stress in your work environment, including common sources and the frequency at which it occurs?") before more specific questions based on the quantitative findings, and finish with reflective questions around ideas for change ("What suggestions would you make to nursing administration to improve support for psychiatric nurses?") (Alenezi, 2017). This design allows for a conversational flow, enabled participants to tell their stories in their own words, and ensures the rich data collected is directly relevant to understanding the "what" and "how" behind the numbers, thus meeting the central integrative goal of the study.

The tools used in this mixed-methods study was validated. For the quantitative phase, the psychometric properties of the Nursing Stress Scale (NSS) was tested in the Saudi nursing population. Reliability refers to the consistency and stability of the measuring instrument. A pilot study was done to establish the internal consistency of both scales, and the data was analyzed using Cronbach's alpha. An alpha of 0.7 0 or above was considered acceptable, meaning the items within each subscale measure the same underlying construct. Test-retest reliability was also done on a small sample to see if the scores are stable over a short period, as long as the measured construct is stable. Validity, or how well the instrument measures what it should be measuring, was addressed in several ways. Content validity was established by having a panel of psychiatric nurses, with Saudi experience review the translated instruments for completeness, clarity, and relevance. Construct validity was examined using factor analysis (exploratory and confirmatory) on the data to ensure that the items load onto the theoretical subscales as in the original instruments (Gray-Toft, P., & Anderson, J. G. (1981). Convergent validity was established by looking at the NSS's correlation with other variables it was related to, i.e., self-reported overall stress levels. A pilot study was done to test the instrument's dependability for the population concerned (n=20). The internal consistency of the NSS was calculated using Cronbach's alpha and compared with the original study and other validation studies.

Table 3: Reliability Coefficients (Cronbach's Alpha) for the NSS.

During the qualitative phase, set validity and reliability are re-cast as trustworthiness and are secured through various strategies. Prolonged engagement with the setting (rapport established during the quantitative phase) and repeated observation during the interviews, member checking (participants review transcripts or summaries for accuracy), and triangulation of data sources (nurses from different units and experience levels) was used to establish credibility (internal validity). Transferability (external validity) was achieved through thick, rich descriptions of the context and participants in the findings chapter, where the readers can establish the transferability of the findings to other settings. Dependability (reliability) was assured by maintaining an audit trail for all decisions made, data collected, and analytic procedures undertaken, such that an external auditor can trace the research process. Confirmability (objectivity) was assured by reflexivity, in which the researcher recognizes, reflects on, and attempts to bracket as much as possible the biases, assumptions, and influence on the research process and allows the participants' voices to emerge. Mixing quantitative and qualitative data also assists in ensuring the validity of the study by complementarity and triangulation. The study provides more substantial evidence through multiple methods because of the triangulated findings. Therefore, the meta-inferences regarding occupational stress and coping mechanisms at Iradah Complex are stronger.

For the qualitative phase, the semi-structured interview guide was also piloted. A draft guide was developed after the pilot quantitative data analysis. The guide was then piloted with 3 psychiatric nurses, and the pilot interviews was tape-recorded and transcribed. The pilot finalized the flow and phrasing of the questions, how well they elicit rich and detailed responses, and the average duration of the interviews. The researcher also used this session to practice probing skills and refine interviewing skills. These pilot participants asked to give feedback on the interview process. This feedback used to revise the guide, for instance, reordering questions for a better flow or rephrasing prompts that did not yield productive responses. Moreover, the entire data management process for the qualitative data-from audio recording and transcription software to the initial coding process-was piloted within this study to ensure efficiency and accuracy before the main study. The lessons from the pilot study are invaluable; they allowed us to perfect all the instruments and procedures, hence minimize errors, enhance the validity and reliability of the instruments, and ensure a smooth and efficient conduct of the main study, and in the process protect the resources and integrity of the full-scale research project.

3.7 Data Collection Procedure

Stage two, qualitative recruitment, started when the quantitative data is cleaned and analyzed. Participants was purposively selected from the emerging themes of the quantitative sample. Since the surveys were anonymous, a new recruitment process is needed. A general invitation was sent via email describing the inclusion criteria and asking those who fit the description and are willing to be interviewed to contact the researcher directly. This protects the anonymity of the initial survey while allowing information-rich cases to be recruited. Participants who volunteer was screened against the inclusion criteria and given a separate interview information sheet. Written consent to participate and audio-recording was obtained before the interview. The interviews were 15-20 minutes long, conducted in a private, quiet room in the complex, at a time convenient to the participant, and audio-taped with permission. Field notes was taken to note non-verbal cues and contextual comments. This step-by-step process ensured ethical, systematic, orderly quantitative and qualitative data collection, providing a solid foundation for a robust and insightful analysis.

3.8 Data Analysis

Data analysis of this explanatory sequential mixed-methods study is a thorough and systematic process that follows the two-step design, dealing with the quantitative and qualitative data sets properly and strictly before finally combining them to get the overall picture of the research problem. Analysis is not linear but iterative, where findings from the qualitative phase inform reinterpreting the quantitative results and vice versa in a dialectical process. The goal is to make meta-inferences-conclusions that are more than the sum of the parts from either dataset. The process started with individual analysis of the quantitative data. This initial analysis serves two purposes: first, to answer the primary quantitative research question on level and frequency of perceived stress; and second, and more importantly for mixed-methods design, to identify the exact patterns, outliers, or anomalous results to be used to inform directly the sampling strategy and the line of questioning to explore the coping mechanisms for the follow-up qualitative phase. Then, the qualitative data collected through interviews are used to build contextual, rich accounts of the quantitative trends.

3.8.1 Quantitative Data Analysis (Descriptive and Inferential Statistics)

3.8.2 Qualitative Data Analysis (Thematic Analysis)

3.9 Ethical Considerations

This research was done in accordance with all ethical protocols and checks, and participants' rights and dignity are maintained throughout the research. Ethically and logically, once clearance is given to collect data, the research started. The research documentation was submitted to the research institution's IRB, including all research protocols, participant description sheets, consent forms, and data collection tools. At the same time, formal approval for the study was requested from the Research Ethics Committee and the administrative management of Iradah Complex for Mental Health in Riyadh. It was crucial to get this dual approval because it ensures that the research complies with international research ethics, local laws, and Saudi traditions within the health care system. The study can only start once all the necessary written permissions were obtained, so ethical compliance is embedded in the project from the very beginning.

The foundation of ethical research is informed consent. The quantitative phase sent a full information sheet to everyone who was asked to participate, outlining the aim, procedures, length of time required, risks, benefits of participation, and measures to keep information confidential. It made clear that participation is voluntary; not participating will incur no penalty or loss of benefits, and you can withdraw at any time with no consequences. For paper questionnaires, signed consent was obtained separately from completing the survey to maintain anonymity. A more formal consent process for the qualitative phase was face-to-face and audio recording. Potential interviewees received a separate information sheet for the interview phase. They were asked to sign and consent to be audio recorded and for anonymized verbatim quotes to be shared in the research.

There is a risk of inducing occupational distress in this study. Talking about work stress may cause distress or discomfort. As a precaution, the questionnaires and interview guides were professional and neutral. Participants were reminded multiple times of their right to skip a question or terminate or withdraw from the interview at any time without consequence. Finally, the principle of justice was upheld by having fair participant recruitment and by reported back the results to the hospital administration and nursing staff in a readable format so that the burden of participation is weighed against the benefit of helping to develop better workplace policies and support systems.

3.10 Limitations of the Study

While the study was meticulously designed with mixed-methods in mind to offer a comprehensive understanding of stress at work, the limitations that the study brings in are key to understanding the study in a better light and to suggesting the areas in which additional research could be conducted in the future-the research design shifts are one of the prominent limitations. An explanatory consecutive design can be beneficial, but it implies that the qualitative phase is, in some ways, tailed and limited to the deliverables of the initial quantitative questionnaire. It brings a risk of not looking into other interesting and unexplored concepts that the Nursing Stress Scale (NSS) earlier failed to capture. For example, a culturally different and newer stress factor or a new coping mechanism not documented in the scales might be common among nurses but stays undetected because the quantitative tool did not mark it as a critical area to investigate further in the qualitative phase. As a second point, the cross-sectional design of the quantitative phase captures only one fixed moment in time for stress. Work-related stress is a dynamic phenomenon and changes with organizational changes, seasonal variation in patient acuteness, and individual variation. The stress levels captured may therefore not represent what nurses experience throughout the year, reducing the longitudinal validity of the findings.

Even an excellent sampling plan like the one in this case were have some limitations. The final population of the quantitative stage is still affected by non-response bias. For instance, with stratified random sampling and attempts at representativeness, nurses facing the highest levels of stress and burnout are less likely to take part in a survey on stress, leading to an underestimation of its true prevalence and severity. At the same time, individuals with a strong interest in the issue might participate in higher numbers, distorting the outcomes. In the qualitative stage, although necessary for the in-depth explanation, purposive sampling disqualifies the possibility of statistically generalizing the interview outcomes to all Iradah nurses or all psychiatric hospitals in Saudi Arabia. The reader must decide because the results are valid only for particular situations. The second limitation is self-reported data in both stages. Social desirability bias is a risk, as participants may underreport harmful coping mechanisms, such as avoidance or drug use, or over report stress as a way to make their work seem more challenging. The nature of stress means that the quantitative measures of stress are perceived, not objective stress markers. In addition, in the interviews, participants’ memories and descriptions are subjective and may be influenced by more recent memories or their mood at the interview.

The study was also limited by its focus on one, even large, mental health complex in Riyadh. Although this allows rich contextual analysis, it limits the geographical and cultural generalizability of the findings to other regions of Saudi Arabia, whose healthcare facilities, and workforce populations may vary. The findings apply only to the institutional, management practice, and resources available in Iradah. Finally, the researcher's presence, despite how difficult it is to bracket biases and establish rapport, necessarily affects the data collection process, particularly in the interviews-the Hawthorne effect. As the researcher attempts to gather information, the respondents will tend to change their answers to match what they believe is appropriate or expected of them. Although acknowledged, this limitation does not undermine the study. Instead, it assists in framing the results with due caution and in the subsequent research design that can utilize longitudinal frameworks, objective methods of measuring stress, multi-site collaborations, and additional methods to minimize response bias to further build upon the groundwork established in this study.

Chapter 4: Results

4.1 Results of the preliminary qualitative Delphi approach.

This component of the study aimed to obtain expert’ consensus on the use of coping mechanisms among psychiatric nurses toward occupational stress in Saudi Arabia. The Delphi approach was adopted over three rounds, where 35 experts shared in the first round, 28 in the second round, and 26 in the third round. The following section describes the characteristics of the panel group and the final list of items suggesting the coping mechanisms toward occupational stress among psychiatric nurses.

Table 1 outlines the demographic characteristics of the panel group over the three rounds, The panel was mostly comprising males, featuring more than 75% representation in every round. Most participants were in the 31–35 years age group, consistently comprising more than 60% of the panel in every round. A comparable pattern is seen in work experience, with most individuals (more than 62%) possessing 6–10 years of experience.

Table 1: Characteristics of the panel group.

Based on the qualitative discussions, 110 statements were suggested as coping mechanisms towards occupational stress among psychiatric nurses. These statements were reviewed by the panelists, resulting in 49 statements that were underwent a second review. Finally, there were 42 statements included in the third round, which received a significant level of agreement as shown in Figure 1 and Table 1.

Figure 1: Number of agreed statements suggesting the coping mechanisms toward occupational stress among psychiatric nurses along the three rounds.

The results shown in Table 2 highlight a strong consensus among the panel group regarding various coping mechanisms for occupational stress among psychiatric nurses. The findings emphasize a multifaceted approach that incorporating organizational skills, self-regulation, social support, professional development, and work-life balance as key strategies for managing stress in psychiatric nursing. Self-regulation and time management received the highest agreement rates (100%–96.2%), suggesting that nurses recognize the importance of structure and proactive stress management. Items such as "To cope with the pressure of work, there is a need to be organized" (100%) and "Self-regulation and self-attitude" (100%) reflect a strong preference for self-discipline and structured work habits in coping with workplace stress. Strategies such as "Seeking professional development opportunities" (96.2%) and "Seek mentorship opportunities to learn from experienced nurses" (92.3%) indicate that continuous learning and guidance from experienced colleagues are valued as stress reduction strategies.

The agreement on "Taking help from other nursing staff" (92.3%) and "Seeking support from other hospital staff when dealing with a difficult patient" (88.5%) further highlights the importance of collegial support and teamwork in managing occupational stress. Strategies related to emotional well-being and self-care were highly valued, with "Recreational activities and relaxation" (92.3%) and "Emotional comfort" (92.3%) being widely recognized as effective stress relief methods. Moreover, "Believing in and feeling good about myself" (92.3%) and "Take deep breathing" (92.3%) further emphasize the role of mindfulness and self-compassion in coping with workplace challenges.

However, there was relatively lower agreement on work-life balance strategies such as "Having a stable home life that is kept separate from my work life" (80.8%) and "Family support is necessary to cope with a job like this" (80.8%) suggesting individual differences in how nurses balance their personal and professional lives. The agreement on "More liaison with other health professionals would make my job less stressful" (80.8%) indicates a perceived need for greater interdisciplinary collaboration to ease workload burdens.

Some coping strategies received lower level of agreement, such as "Take security's support to deal with aggressive patients" (76.9%). This suggests that nurses may not fully trust security personnel to handle aggressive incidents or that alternative de-escalation techniques are preferred.

Table 2: Agreement of the panel group on the final list (third round) of the items suggesting the coping mechanisms toward occupational stress among psychiatric nurses.

4.2 Results of the quantitative component of the study.

This part aimed to evaluate stress scores and determine factors predicting stress it in psychiatric nurses, through a cross-sectional design. 255 psychiatric nurses participated in the study. SPSS (Statistical Package for the Social Sciences, version 26) Software was utilized for the data analysis. The nurses' answers were determined by converting them as Never = 0, Occasionally = 1, Frequently = 2, and Very frequently = 3, yielding a maximum score of 3 for the items, factors, and total score. The Shapiro-Wilk test was conducted to assess the normality of the scores. The independent sample T-test and ANOVA were done to evaluate the differences in the stress scores in psychiatric nurses according to their characteristics, where the T-test was used to investigate the significance between two groups, while ANOVA was deployed for more than two groups. Pearson correlation was conducted to evaluate the relationship between the overall stress scores and two quantitative normally distributed variables (age and years of experience). Linear regression was performed to determine the predictors of perceived stress, multicollinearity test was conducted as a prerequisite for the regression. Accordingly, as VIF exceeded “5” for age with years of experience, therefore, only the “years of experience” was included in the model. A P value of less than 0.05 was considered as an indication of statistical significance.

4.2.1 Characteristics of the study group:

Table 3 presents the characteristics of the participating nurses (n=225), most of them are Saudis (76.0%), with a fairly even gender distribution (53.8% male, 46.2% female). The majority of nurses fell within the 31–40 age range (55.1%), possessed bachelor's degrees (64.4%), and had 6–15 years of experience (60%). The participants mostly work in the inpatient wards (76.0%) and outpatient clinics.

Table 3: Characteristics of the participant psychiatric nurses (n=225).

4.2.2 Response of the nurses on the factors and items describing the possible sources of stress.

Table 4 provides an overview of nurses' perceptions of sources of stress. The average score for “death and dying” was 1.44 (SD = 0.845), suggesting a low degree of stress associated with patient death. Among the specific items, "watching a patient suffer" recorded the highest mean (1.56, SD = 1.076), whereas "The death of a patient" recorded the lowest (1.29, SD = 1.082). Other factors, like "Feeling helpless when a patient fails to improve" and " Listening or talking to a patient about his/her approaching death," yielded comparable mean scores (1.49 each). The “conflict with physicians” mean score was 1.43 (SD = 0.830), indicating minimal stress associated with engagements with doctors. The least stress was noted for "Criticism by a physician" (1.35, SD = 1.003), whereas "Disagreement regarding the treatment of a patient" had the highest average (1.50, SD = 1.053). The stress arising from "Deciding for a patient when the doctor is not available" was also remarkable (1.48, SD = 1.001).

Inadequate preparation exhibited a relatively high mean score (1.65, SD = 0.880) in relation to other factors. The greatest stress was linked to "Being asked a question by a patient for which I lack a satisfactory answer" (1.69, SD = 0.925), with a close mean score for "Feeling unprepared to address the emotional needs of a patient" (1.66, SD = 1.036). Meanwhile, the mean score for “lack mean score was 1.53 (SD = 0.960). Nurses reported comparable stress levels regarding the items, with "Lack of an opportunity to talk openly with other unit personnel about problems on the unit" and "Lack of an opportunity to share experiences and feelings with other personnel on the unit" each recorded a score of 1.56.

The average score for “Conflict with other nurses” was 1.58 (SD = 0.865). The highest stress was noted for "Floating to other units that are understaffed" (1.65, SD = 0.984), whereas "Conflict with a supervisor" and "Challenges in collaborating with a specific nurse outside the unit" had comparable average scores (1.58 and 1.59, respectively).

Workload was the most significant source of stress, having the highest average score (1.69, SD = 0.837). "Unpredictable staffing and scheduling" was identified as the primary source of stress among all factors (1.81, SD = 0.965), with "Breakdown of computer" (1.72, SD = 0.925) and "Not enough time to provide emotional support to a patient" (1.71, SD = 1.057) following closely behind. Finally, “Uncertainty concerning treatment” recorded an average score of 1.60 (SD = 0.948). The greatest stress was reported for "The absence of a physician during a medical emergency" (1.71, SD = 1.075) and "Uncertainty about what information should be communicated to a patient or their family regarding the patient's condition and treatment" (1.63, SD = 1.040). The least stress was linked to " Uncertainty regarding the operation and functioning of specialized equipment " (1.53, SD = 1.061).

Table 4: The psychiatric nurses' responses on the factors and items reflecting possible sources of job stress.

Figure 2 summarizes the mean scores of the factors potentially influencing job stress among psychiatric nurses. The workload is the main source of stress, registering the highest mean score of 1.69, followed by inadequate preparation and uncertainty about treatment, which have mean scores of 1.65 and 1.60, respectively. Aspects such as conflicts with other nurses (1.58), inadequate support (1.53), and facing death and dying (1.44) were moderate stressors. Conflicts with physicians have the lowest average score (1.43), suggesting that it is regarded as the least significant stressor among the evaluated factors. The average overall mean score (1.56) is somewhat moderate; the following section describes the differences in the perceived potential stressors among psychiatric nurses according to their characteristics.

Figure 2: Summary for the mean stress scores for different factors arranged in descending order, and overall mean score.

4.2.3 Differences in the perceived stress factors among psychiatric nurses according to their characteristics.

Table 5 illustrates the differences in the perceived stress factors according to the psychiatric nurses’ characteristics. Male nurses indicated marginally higher stress levels in most areas, with the exceptions being "lack of support" and "uncertainty concerning treatment," where female nurses showed elevated scores. Nevertheless, no statistically significant results were found (P-values > 0.05). Saudi nurses indicated notably elevated stress levels when compared to non-Saudi nurses in all stress factors, especially for "workload" (Saudi: 1.81 ± 0.797; non-Saudi: 1.32 ± 0.859) and "uncertainty regarding treatment" (Saudi: 1.75 ± 0.868; non-Saudi: 1.30 ± 1.039). Statistical significance was noted for the majority of factors (P < 0.001), except for "inadequate preparation" (P = 0.107).

Younger nurses (ages 20–25) indicated the greatest stress for "insufficient preparation" (2.07 ± 0.672) and "uncertainty about treatment" (1.82 ± 0.856). while nurses in the age group of 41–46 years indicated the highest scores for "death and dying" (1.79 ± 0.803) and "workload" (1.90 ± 0.872). Individuals older than 46 years indicated the lowest stress levels among the majority of factors. Notable differences were noted for "conflict with other nurses" (P = 0.024), while other factors did not show statistical significance p>0.05.

Nurses possessing a 3-year diploma indicated the greatest levels of stress on various factors, especially for "workload" (1.91 ± 0.792) and "uncertainty regarding treatment" (1.93 ± 0.991). Individuals holding 2-year diplomas indicated the least stress levels for various factors. Differences were significant statistically for "death and dying" (P = 0.029).

Nurses in the emergency room indicated the highest stress levels for all factors, showing especially elevated scores for "workload" (2.48 ± 0.504) and "uncertainty regarding treatment" (2.46 ± 0.151). Outpatient nurses indicated the lowest stress levels across the majority of factors. Statistically significant differences were identified for "death and dying" (P = 0.047), "conflict with physicians" (P = 0.023), "lack of support" (P = 0.002), "conflict with other nurses" (P = 0.017), "workload" (P = 0.012), and "uncertainty about treatment" (P = 0.003). Nurses who have 1–5 years of experience indicated the highest stress levels for "insufficient preparation" (1.88 ± 0.943) and "uncertainty about treatment" (1.70 ± 0.981), while those with over 15 years of experience presented the lowest stress levels for the majority of factors. The differences were statistically significant for "insufficient preparation" (P = 0.018).

Table 5: The nurses’ perceived stress factors according to their characteristics.

* Statistically significant

4.2.4 Differences in the perceived overall stress scores among psychiatric nurses according to their characteristics.

Table 6 shows that the average perceived overall stress scores for male nurses (1.56 ± 0.721) and female nurses (1.55 ± 0.825) were almost the same, showing no statistically significant difference (P = 0.886). Saudi nurses indicated markedly greater overall stress (1.67 ± 0.711) in comparison to non-Saudi nurses (1.20 ± 0.843) P < 0.001. Nurses in the age group of 41–46 years exhibited the highest average stress score (1.80 ± 0.790), with nurses aged 20–25 years coming next (1.68 ± 0.676). Nurses older than 46 years indicated the lowest stress levels (1.17 ± 0.749). These variations were statistically significant (P < 0.001). Nurses holding a 3-year diploma (1.79 ± 0.796) and those with postgraduate credentials (1.74 ± 0.825) experienced greater stress levels than nurses with a 2-year diploma (1.45 ± 0.791) and bachelor's degrees (1.49 ± 0.743). Nonetheless, these variations are not statistically significant (P = 0.127). Nurses in the ER indicated the highest levels of stress (2.17 ± 0.162), while those in-home healthcare reported lower levels (1.72 ± 0.877). Nurses in outpatient settings reported the least stress (1.22 ± 0.755), these differences are statistically significant p=0.011. Nurses having 1–5 years of experience indicated the highest overall stress levels (1.64 ± 0.855), while those with over 20 years of experience demonstrated the lowest stress levels (1.36 ± 0.682). However, these differences are not statistically significant (P = 0.407).

Table 6: The nurses’ perceived overall stress according to their characteristics.

*Based on Independent sample t test **Based on ANOVA test ***statistically significant

Figure 3, and Figure 4 display that there was a negative correlation the overall stress score and both age and years of experience. However, the Pearson correlation coefficient revealed that while the negative correlation with the years of was statistically significant ( r= -.179, p=0.007), it was not significant for the age ( r= -.093, p=0.163).

Figure 3: Correlation between overall stress score and age of nurses.

Figure 4: Correlation between overall stress score and years of experience.

Table 7 shows the results of a linear regression analysis of the predictor variables of stress in psychiatric nurses. The intercept was statistically significant (p =.040), indicating a baseline effect on stress levels when all predictor variables were included. The findings suggest that both nationality and mid-career experience (6-10 years) are important predictors of stress in psychiatric nurses. Saudi nationality was significantly associated with higher levels of stress (p<.001, Exp(B) = 1.598, 95% CI: 1.254-2.036) compared to non-Saudi nationality. Nurses aged 6 to 10 years had significantly higher levels of stress (p =.038, exp(b) = 1.390, 95% CI: 1.019-1.895) than those aged over 15 years (reference group). On the other hand, gender, educational qualifications, and departmental assignments are less likely to be significant predictors of stress in psychiatric nurses.

Table 7: Regression for the predictors of the level of stress in psychiatric nurses.

4.3 Results of the qualitative component of the study.

The study participants' perceptions and experiences of common stressors and coping strategies are the subject of the qualitative findings presented in this section. The first step was to revise the transcripts to become acquainted with the information gathered. The themes and sub-themes were then created by combining the initial codes that had been identified. Reviewing and naming the created themes and sub-themes was the final stage. A summary of the four primary themes and their expanded sub-themes created from thematic analysis will thus follow the description of the participants' demographics in the next section.

4.3.1 Characteristics of the interviewed participants:

Table 8: presents the demographic and professional characteristics of the 15 participants interviewed in the qualitative study. There is almost equal distribution of males (53.3%) and females (46.7%), with predominance of Saudi nationality (73.4%). Participants were nearly evenly split, with 53.3% under 40 years and 46.7% aged 40 or older. Most participants held a diploma (46.7%) followed by a master’s degree (26.6%). Participants were drawn from multiple clinical departments, with the highest percentage from the inpatient department (40.1%), followed by emergency (33.3%). Almost one-half of them (46.7%) had 15 or more years of experience,

Table 8: Characteristics of the interviewed participants in the qualitative settings (n=15).

4.2.2 Thematic analysis results:

The participants’ reflections were systematically analyzed and categorized into main themes and sub-themes by employing Braun and Clarke’s (2006) approach for thematic analysis. A comprehensive overview of the recognized themes is provided in the table

Table 9: Results of the thematic analysis.

The thematic analysis reveals four major themes related to stressors and coping mechanisms among psychiatric nurses: common sources of stress, the impact of workplace conditions, coping strategies, and support/recommendations. Within each theme, various sub-themes emerge, shedding light on the complexity of occupational stress in psychiatric settings.

Theme 1: Common Sources of Stress

· Description: Stress is primarily driven by patient-related challenges, staffing shortages, and workplace demands.

· Sub-Themes:

· Patient-Related Challenges: The nature of psychiatric care naturally places nurses in challenging situations with patients, which may involve aggression, addiction, and refusal to follow treatment plans. Participant 1 noted, “Dealing with addiction and psychiatric patients tends to be more stressful”, and Participant 3 noted, “Managing agitated, potentially aggressive patients generates daily stress.” While Participant 9 indicated, “Managing uncooperative patient behavior, and frequent patient non-adherence to scheduled appointments.”, and Participant 10 pointed out the stress evolved from patients’ resistance and non-adherence to medical orders, “Patient resistance to following nursing instruction and medical orders.”

· Staff-related challenges: Nurses emphasized concerns regarding staffing shortages and the lack of experience among healthcare staff, resulting in increased workload and stress. Insufficient nursing personnel resulting in extended shifts, a lack of nurses, compels current staff to take on extra hours, leading to exhaustion and stress. Participant 1 stated, “Nursing staff shortages during shifts… might have to oversee five [patients] instead of three.” Also, inexperienced physicians, especially those in residency, might not possess the skills to handle complex psychiatric cases, which increases the burden on nurses. Participant 7 expressed that a significant source of stress is when “ Limited clinical experience among medical team members, particularly resident physicians.”

· Workplace conditions: Participants highlighted multiple factors in the organizational environment that lead to stress. Too many simultaneous obligations and the delegation of administrative tasks beyond their main clinical functions. Participant 13 highlighted, “Performing non-clinical administrative tasks outside typical nursing responsibilities.” The large number of patients in emergency departments, along with competing demands from various hospital departments, resulted in an excessive workload. Participant 4 described it as “Work pressure in the ER with high patient volume.” Moreover, insufficient weekly days off and low financial rewards led to sensations of being unappreciated. Participant 12 stated, “Limited weekly days off, and inadequate monthly compensation.”

Theme 2: Impact of Workplace Conditions

· Description: This theme explores the impact of staffing constraints and departmental settings on the daily stress levels and overall job experiences of psychiatric nurses.

· Sub-Themes:

· Staffing and Shifts: Staffing shortages emerged as a critical issue, particularly when insufficient staff led to longer working hours and delayed patient care, increasing the risk of agitation and safety incidents. Participant 1 stated, “ When a patient goes without a doctor’s evaluation for a week or longer, the likelihood of agitation increases, creating potential risks at any moment.”. In addition, delays in shift transitions and extended shifts due to understaffing further intensified stress and fatigue, as noted by Participant 11, “Delays in nursing staff shift transitions are stressful.”

· Departmental Differences: Departmental differences also played a significant role, with participants working in emergency departments describing inherently high-pressure environments due to unpredictable patient loads and acute clinical demands, as described by Participant 5, who pointed out that “Work in the emergency department is inherently stressful.” On the other hand, despite Participant 15 denoted that stress in home health care is “manageable”, Participant 13 claimed that “Interacting with patients’ families during home visits” is stressful.

Theme 3: Coping Strategies

· Description: Nurses stated that they deployed various coping methods to cope with the complex and emotionally demanding roles of their job. These strategies were generally grouped into individual, collaborative, and professional approaches, each representing stress management’s personal, social, and institutional aspects.

· Sub-Themes:

· Individual Strategies: Personal coping methods were the most commonly mentioned and included deliberate self-regulation techniques like taking brief breaks during shifts (usually 30 minutes for meals, prayer, or relaxation), engaging in mindfulness, and actively controlling emotional responses. Participant 7 noted, “Taking regular 30-minute break for meals and prayers… significantly lower stress.”, Nurses highlighted the significance of disconnecting from emotionally charged circumstances, whether by briefly removing themselves or participating in soothing practices. Participant 6 expressed, “My primary stress management is by temporarily remove myself from the stressful situations by taking 30-minute breaks”. Some upheld work-life boundaries by engaging in after-hours pursuits like physical exercise (e.g., walking, yoga, gym sessions) or hobbies, aiding them in regaining balance and avoiding burnout. Participant 11 denoted, “Maintaining clear boundaries between work and personal life, pursuing outdoor hobbies (e.g., gym workouts, walking, yoga)”

· Collaborative Strategies: were crucial in helping nurses to feel supported in their work setting. Participants often searched for guidance or emotional assistance from colleagues, shift supervisors, or department leaders. Participant 2 said, “Discuss any challenges with either my shift leader or a trusted coworker, and when necessary, escalate issues to the department head for resolution.”

Communication with peers acted as both an emotional release and a means of practical problem-solving, especially when dealing with difficult patients or organizational obstacles. Participant 6 suggested “Discuss specific colleagues to develop prompt solutions,” and Participant 7 added, “Discussing difficulties with seasoned professionals who can provide valuable guidance.”. Collaboration also included team-oriented approaches such as rotating duties, modifying shift schedules, or distributing challenging tasks whenever feasible. Participant 14 advocated “Utilizing workplace flexibility options through taking scheduled time off, and adjusting shift schedules.”

· Professional Strategies: comprised formal methods assisted by the hospital, including engaging in professional development training, obtaining recognition (e.g., verbal commendation, certificates, or monetary rewards), and accessing flexible scheduling options. Participant 14 valued, “Participating in professional development courses to enhance home care skills.” Additionally, Participant 5 declared that, “Honestly, recognition by appropriate rewards is what I find most meaningful in reducing stress”. Moreover, Participant 11 addressed, “Receiving monthly financial compensation, developing strong environmental familiarity through psychiatric hospital experience.”

Nurses emphasized that sufficient nurse-to-patient ratios, fair workload distribution, and chances for skill enhancement significantly helped in lowering stress. Participant 1 argued, “Adequate nurse-to-patient ratios during all shifts, and providing comprehensive support, including recognition programs, moral support, and competitive compensation packages.”

Some also pointed out the importance of functioning in a psychologically safe atmosphere where open dialogue with supervisors was promoted. Participant 5 said, “Discussing concerns with our supervisor creates a positive impact, and provides a supportive environment.”

Theme 4: Support Systems and Recommendations

· Description: This theme highlights the current support systems accessible to psychiatric nurses, as well as the gaps they face in the support while they are performing their job, accompanied by practical suggestions to resolve these issues. The theme presents a critical viewpoint on institutional assistance, emphasizing valuable suggested recommendations for systemic reforms to reduce workplace stress.

· Sub-Themes:

· Current Support: There are several initiatives provided by the hospital to improve the well-being of the psychiatric nurses and reduce work stress. Among these initiatives, the participants emphasized the weekly educational sessions centered on stress management. Participant 2 appreciated “Nursing department provides weekly educational courses, focused on managing stress”. Also, quick response procedures for managing restless patients was acknowledged by Participant 3, “Rapid response protocols for agitated patients in the department”. Moreover, the provision of leisure activities, including celebrations and team outings, Participant 5 indicated the activity of the hospital in “Organizing recreational events and activities, including participation in holiday celebrations and departmental outings”. Lastly, one of the efforts that translated the current support was the adjustable scheduling to meet employee requests, as shown by Participant 9, “Flexible scheduling to accommodate nursing staff requests.”

· Staffing Recommendations: All participants advocated for adequate nurse-to-patient ratios, and hiring additional staff are critical for reducing workload and stress. Participant 1 suggested, “Maintaining adequate nurse-to-patient ratios during all shifts, and hiring highly qualified and experienced nurses.”

· Facility and Policy Suggestions: Psychiatric nurses suggested the establishment of recreational areas in the hospital, such as a gym, restaurant, and café, that could offer areas for exercise, leisure, and social connections. These spaces could assist nurses in recharging during their shifts, particularly in high-pressure psychiatric environments, with no necessity to exit the workplace. Participant 8 suggested, “Provide recreational facilities for nurses - including a gym, restaurant, and café within the hospital premises.”

A further recommendation for hospital decision-makers was to establish nurse rotations between different departments, which could reduce extended exposure to high-stress environments like the emergency department (ER) and encourage a variety of skills. Participant 6 noted , “Monthly rotation of nursing staff across departments”. Moreover, the suggestion to raise monthly rest days from 8 to 10 directly responds to Participant 2 “Increase monthly rest days from 8-10 days”. Increasing the number of rest days could assist in reducing fatigue and enhancing work-life balance, which is acknowledged as an essential personal coping strategy.

The allocation of security staff to tackle safety issues during home visits was argued by psychiatric nurses providing home visit services. Participant 15 emphasized, “For home visits, assigning security personnel for staff protection.”

Leadership Support: Nurses emphasize the vital importance of leadership in creating a nurturing workplace atmosphere. Participant 10 recommended , “Actively listening to nursing staff concerns and promptly addressing issues.”

Summary

The thematic analysis reveals that psychiatric nurses experience considerable stress due to patient behavior, insufficient staffing, and difficult working conditions, particularly in high-pressure settings like the emergency department. Their coping strategies differ significantly, encompassing personal self-care practices, collaborative approaches to problem-solving, and obtaining assistance from professional support services. However, the findings also highlight fundamental issues, such as lack of staffing, limited rest days, and insufficient wages, that require organizational intervention.

The nurses' recommendations are practical and achievable, emphasizing improved staffing, enhanced workplace facilities, and greater engagement from leadership. These suggestions align with the broader literature on healthcare worker well-being, which emphasizes the importance of personal resilience and institutional support to reduce burnout. The focus of the study on psychiatric nursing offers a valuable perspective, as this domain poses unique challenges like managing patient aggression and mood fluctuations.

Chapter 5: Discussion

Stress is considered a typical feature of the healthcare profession, particularly in psychiatric nurses, who are frequently facing a heavy workload with patients of extraordinary demands (Jaber et al., 2025a; Osman & Abdlrheem, 2019). There are a wide coping strategies that are frequently subjective in nature (Bakker & De Vries, 2021; Jaber et al., 2025a). This study is best served by a mixed methods approach, which combines qualitative interviews to examine individual experiences with quantitative surveys to deal with stress and pinpoint coping mechanisms, based on real experiences of psychiatric nurses.

The results showed a moderate degree of stress among the psychiatric nurses, which comes in contrast to the typical understanding of this group, which usually experiences a high level of stress; this difference could be attributed to many factors. The high resilience of psychiatric nurses in Saudi Arabia, observed in a recent study, effectively enables nurses to adjust to stressful situations (Alzahrani et al., 2022). Also, another study revealed that nurses operate in an encouraging, supportive environment, which reduces stress among them (H. Alharbi et al., 2024), which is supported by the findings of the current study, where the nurses reported inadequate support and conflicts with colleagues and physicians as the least stressors among evaluated factors. Lastly, as demonstrated in the qualitative part of the study, psychiatric nurses claimed several stresses coping strategies, including sharing in leisure activities and seeking support from supervisors and colleagues.

Workload came as the highest contributor for stress among psychiatric nurses, which supports the findings of the qualitative analysis and a previous study in Saudi Arabia (Alqahtani et al., 2020). The relationship between workload and stress is a critical and well-documented concern across all nursing specialties, but it is particularly pronounced within psychiatric nursing (T. S. M. Alharbi et al., 2024). Psychiatric nurses caring for patients with complex mental and behavioral health conditions, and sometimes facing aggressive behavior, as evidenced by the qualitative analysis, often create stressful situations that can significantly impact nurses’ well-being (S. Alharbi & Hasan, 2019).

Conflict with physicians and other psychiatric nurses were among the contributors of stress among nurses, which comes in agreement in with previous study in Saudi Arabia focused on comparing this conflict between general nurses and psychiatric nurses. The conflict with physicians stem from the differences in the professional perspectives, and the hierarchy of decision, particularly in lack of clear roles, resulting on perceived lower autonomy among nurses, with increased likelihood of stress (S. Alharbi & Hasan, 2019). Meanwhile, the conflict with other nurses usually arise from the unfair distribution of tasks and shift time between nurses (Çabuk & Acuner, 2025).

Saudi nurses showed significantly higher stress scores in all domains than non-Saudis. This difference that can be attributed to the cultural and societal factors. The general perception of mental illness as a "stigma" (Alattar et al., 2021), might generate a "courtesy stigma" among psychiatric nurses, where there is a negative public attitude towards mental/psychiatric nurses (Alyousef, 2025), could complicate a Saudi nurse's professional identity and lead to psychological distress. This unique sociocultural burden highlights a key difference in stress levels between Saudi nurses and non-Saudi nurses, who came from different cultures, who might have of lower stringent views towards mental illness.

The results revealed a significantly higher level of stress in nurses with 1-5 years of experience, especially concerning resources and uncertainty of treatment. Comparable results were reported in earlier qualitative research conducted in Saudi Arabia, which emphasized the barriers and challenges facing newly graduated psychiatric nurses regarding their "insufficient professional skills and knowledge,". These findings elaborated the discrepancy between academic education and actual clinical experiences, which is reflected on early-career nurses, where they feel unprepared to the specific challenges of a mental health ward. Additionally (Alyousef, 2025). The ambiguity surrounding treatment protocols is a major cause of stress, as mental health care tends to be more flexible compared to medical-surgical treatment, presenting challenges for novice nurses in need of direct instructions (Jabbie et al., 2024). The difficult situation is made even worse by organizational elements. The shortage of nurses in Saudi Arabia frequently results in elevated workloads and insufficient resources, as disclosed by the qualitative component of the current study.

The findings revealed that nurses who work in the Emergency Room (ER) showed higher stress levels, compared to those in-home care who experienced moderate levels, and outpatient clinic who recorded the lowest levels. Recent research affirms that the workplace is a main factor influencing occupational stress for psychiatric nurses. ER is often mentioned as a highly stressful setting, as workers face unpredictable patients experiencing various and often severe psychiatric emergencies, such as aggression and violence, which greatly contribute to stress (Cranage & Foster, 2022). On the other side, although nurses in home care exhibit other sorts of challenges, like professional isolation and insufficient immediate institutional backing, as they are required to care for patients alone, concerning the complicated family relationships and constraints (Jarrín et al., 2017). In contrast, the outpatient roles allow for more structured and scheduled care, allowing nurses to feel more in control of their work environment and patient care, resulting in significantly lower stress (Rudberg et al., 2023).

The thematic analyses of the qualitative compartment revealed that the patients’ behavior is the major source of stress in psychiatric nurses. A previous study in Saudi Artablai who’d that patient behavior is not limited to physical violence but also encompasses verbal abuse, meanwhile, as a nurse profession, requiring a high degree of empathy and emotional resilience, accordingly, psychiatric nursing is particularly vulnerable to the negative impacts of these patient-related stressors, which can lead to burnout, and job dissatisfaction (Sae’d M et al., 2025). A systematic literature review by Lim (2025) underscored the prevalence of patient aggression and violence, noting that nurses are more likely to be physically assaulted, threatened, and verbally abused than any other health professional in mental healthcare settings, revealed that most of workplace varbal violence, followed by physical violence, the study found a statistically significant correlation between the experience of this violence and a lower quality of life for the nurses. The stress derived from patient behavior is not solely about overt acts of aggression. The emotional demands of the job also play a critical role. A qualitative study in Turkey found that the constant exposure of psychiatric nurses to patient violence and the "normalization of violence" as part of the job in acute psychiatric units led to significant psychological stress (Ayhan et al., 2025).

In the same line, insufficient nursing staffing with subsequent increase of workload was a significant source of stress in surveyed nurses. The adverse effect of the inadequacy of nurse professionals has been documented in several studies, for example, Alanazi et al (2023) found that the shortage of staff with high workload is significantly associated with dissatisfaction and nurses’ intention to leave (Alanazi et al., 2023). This finding aligns with broader research indicating that when staffing levels are inadequate, nurses are forced to take on more patients and responsibilities, leading to emotional exhaustion, a core component of burnout, the continuous exposure to stressors without sufficient recovery time creates a stressful work environment (Jaber et al., 2025b).

Nurses identified various coping methods to cope with the emotionally demanding job roles; the strategies were generally grouped into individual, collaborative, and professional approaches. The principal approach of the individual coping strategy was taking a break during the shift time. The effort-recovery model, developed by Meijman and Mulder (2013), outlines the cyclical phenomenon in people who are making effort and keeping focus while working, who are in need of recovery time to restore these resources and improve their performance (Meijman & Mulder, 2013). A study exploring the importance of break time in the nursing profession found that, while many nurses do not have a chance to take breaks, those who can do it report less fatigue and stress (Jaber et al., 2025b). The ability to "temporarily remove myself from the stressful situations," as stated by a participant, is a crucial element of this recovery process, as it helps to prevent the mental and physical exhaustion associated with long exhaustive shifts.

Similarly, the study demonstrated that among the coping strategies adopted by the psychiatric nurse to overcome stress are engaging in various hobbies and physical activity. A study in Argentine by Garcia et. al (2025), found that the engagement of healthcare professional in physical activity can safeguard against potential musculoskeletal injuries, decreasing cardiovascular and control mental health issues, which are exacerbated by prolonged high-stress levels, however, the regular involvement in physical activities id compromised by the lack of time, multiple jobs, and financial constraints, that limit their access to self-care strategies (Garcia et al., 2025). Additionally, hobbies like yoga and hiking demonstrated a positive effect on well-being, with increased endorphin secretion, which ultimately decreases stress significantly (Kaushik, 2025).

Among the collaborative coping strategies followed by the nurses to mitigate stress was seeking guidance from colleagues, supervisors, and leaders. These findings align with previous research on the impact of support on nursing practice. For example, Watson et al (2025) highlighted how peer support can help nurses develop a strong sense of identity, reduce stress, and strengthen their sense of belonging. It was suggested that nurses should actively improve their work environment by relying on peer support. This helps create a strong, flexible team that can handle the challenges of modern healthcare together (Watson et al., 2025).

The nurses affirmed the importance of rotating duties, modifying shift schedules, and distributing challenging tasks, whenever feasible, as coping strategies to alleviate stress. Previous research showed that modifying shift schedules, including offering flexible hours or shorter shifts, enables nurses to attain improved work-life balance with a reduction of fatigue and decreasing emotional stress in nurses, with an overall lower likelihood of burnout than the long-fixed shifts (Dall’Ora et al., 2023). This strategy had been addressed by Jaber et al. (2025), who stated that “HCWs in organizations where workloads are adjusted, more flexible scheduling experience reduced stress and increased satisfaction”(Jaber et al., 2025a). Moreover, re-assigning tough tasks, like managing challenging patients, would alleviate stress by ensuring that no individual nurse is entirely responsible for the pressure of such difficult circumstances (Albohayri et al., 2023). Additionally, the results showed that professional strategies also included engaging in professional training to help in facing stress. The impact of training health professional has been documented as an effective strategy in empowerment, with increasing their competence, which is positively reflected in their confidence and ability to handle challenging situations and decreasing stress (Suleiman-Martos et al., 2020). This notion showed itself in the claim of the nurses that “skill enhancement significantly helped in lowering stress”.

Moreover, the nurses asserted that recognition is crucial for alleviating a sense of stress, aligning with the findings of a recent research, which indicated that all sorts of recognition, from as simple as verbal thankfulness, up to formal awarding and financial incentives, are closely linked with improving morale of nurses, encouraging further improvement, and increasing job satisfaction, which is reflected in their productivity, which ultimately creating a positive vicious circle between these variables (Ahmari et al., 2023).

CHAPTER 6: CONCLUSION& RECOMMENDATION

Conclusion:

This study provides, through a mixed study design (quantitative and qualitative), a comprehensive view for the occupational stress faced by psychiatric nurses in Saudi Arabia, highlighting the influence of individual, cultural, and organizational factors. While psychiatric nurses experience a moderate level of stress, this is a result of their high resilience and a supportive work environment. The strongest stressors were workload, inadequate preparation, and uncertainty about treatment, while aspects like conflicts with other nurses, inadequate support were moderate stressors. Conflicts with physicians and colleagues were the least identified stressors. Significant differences in stress levels were found in nationality, years of experience, and clinical setting. The qualitative analysis stressed the notion of that patients' behavior and situation initiated from low nurse-patient ratios were major sources of stress. In response, nurses actively employ a variety of coping strategies, including taking breaks, engaging in hobbies, seeking support from colleagues, and pursuing professional development.

Recommendations:

1. It is crucial to recruit enough number of psychiatric nurses to achieve an appropriate patient-to-nurse ratio, and decrease workload as a major stressor.

2. Address regulations that decrease long shifts, allowing for flexible scheduling, and provide enough rest periods to mitigate mental and physical exhaustion.

3. Provide professional development opportunities to increase nurses' autonomy and control over clinical decisions, such as leadership training and clinical skills workshops.

4. Establish tolerance policies with clear reporting procedures and support networks to protect nurses from bullying and violence.

5. To address decision-making conflicts between nurses and other colleagues, use evidence-based guidelines and professional ethics training.

6. Develop clear career progression pathways, including promotion opportunities and training, to demonstrate the organization's care about nurses.

7. Establish recreation spaces within the vicinity of the hospital, and organize group outreach leisure time to enhance relationships and reduce stress.

8. Conduct longitudinal studies to monitor the long-term changes in the level of stress after implementing these interventions.

References