Assignment: Organization Cultural, Morale, and Productivity

O R I G I N A L R E S E A R C H

A qualitative analysis of stress, uplifts and coping in the personal

and professional lives of Singaporean nurses

Joanne Lim, Julie Hepworth & Fiona Bogossian

Accepted for publication 4 December 2010

Correspondence to J. Lim:

e-mail: [email protected]

Joanne Lim BA (Psychology) MSocSci

(Health Practice)

Research Fellow

School of Nursing and Midwifery, The

University of Queensland, Brisbane, Australia

Julie Hepworth BA (Hons) PhD CPsychol

(BPS)

Postgraduate Research Coordinator

School of Nursing and Midwifery, The

University of Queensland, Brisbane, Australia

Fiona Bogossian BAppSci MPH PhD

Director of Research

School of Nursing and Midwifery, The

University of Queensland, Brisbane, Australia

L I M J . , H E P W O R T H J . & B O G O S S I A N F . ( 2 0 1 1 )L I M J . , H E P W O R T H J . & B O G O S S I A N F . ( 2 0 1 1 ) A qualitative analysis of stress,

uplifts and coping in the personal and professional lives of Singaporean nurses.

Journal of Advanced Nursing 67(5), 1022–1033. doi: 10.1111/j.1365-2648.2010.

05572.x

Abstract Aim. This paper is a report of a descriptive study of nurses’ experiences of daily

stress and coping.

Background. Much of the research on stress in nursing is quantitative and has

focused on only work stressors. Moreover, few studies have examined the uplifting

side of living and the role it may play in moderating stress. A theoretical framework

on stress and coping, ‘hassles’ and ‘uplifts’ was used to examine nurses’ experiences

across their personal and professional lives from a qualitative perspective.

Methods. A purposive sample of Singaporean hospital nurses (n = 23) identified

using a snowball sampling technique, participated in two sets of email interviews in

2009. The qualitative data were analysed using thematic analysis.

Results. Three themes were identified as constituting daily hassles: (i) time pres-

sures, (ii) nature of nursing work and (iii) multiple roles. Uplifts were expressed in

relation to one main theme of feeling good extending across nurses’ personal and

professional lives. Three themes were identified as ways of coping: (i) taking time

out, (ii) seeking emotional support and (iii) belief systems.

Conclusion. The interaction between personal and professional life plays a major

role in Singaporean nurses’ experiences of stress and coping. However, stress may be

ameliorated through effective management and strong familial support. Nurses and

employers are recommended to use uplifts and identify ways of coping to minimize

attrition and contribute to the development of a healthy workforce.

Keywords: coping, interviews, nurses, nursing, qualitative, Singapore, stress

Introduction

Stress is widespread in the nursing profession with common

stressors such as work overload and dealing with death and

dying (Lambert et al. 2004, Sveinsdottir et al. 2006, Verhae-

ghe et al. 2008). For Singaporean nurses, major stressors are

related to work including shortage of staff, high work

demands and conflict at work (Lim et al. 2010). However,

research to date has focused on work-related stressors

without considering the contribution of family and social

stressors in everyday living. These daily experiences of

stressors are measured as ‘hassles’ within Lazarus and

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J A N JOURNAL OF ADVANCED NURSING

Folkman’s (1984, 1987) theoretical framework on stress and

coping. On the other hand, daily experiences that bring joy

and happiness are measured as ‘uplifts’ and are believed to

predict positive affect (Kanner et al. 1981). Research has also

overlooked the existence of uplifting situations that may ease

stressful experiences (Lavee & Ben-Ari 2008).

In terms of coping, Singaporean nurses frequently use

problem orientation skills, seeking social support and relax-

ation techniques (Lim et al. 2010). As Folkman and Lazarus

(1988) state, seeking social support can be both an emotion-

focused and a problem-focused strategy. This research seeks

to explore daily hassles and uplifts faced by nurses and to

understand nursing stress and coping strategies using Lazarus

and Folkman’s (1984, 1987) transactional model of stress

and coping.

Background

There are two main approaches to the measurement of

stress: the life events (Rahe et al. 1964, Holmes & Rahe

1967, Rahe 1978) and the daily hassles (Kanner et al. 1981,

Lazarus 1984, Lazarus & Folkman 1989). The life events

approach concentrates on traumatic events such as the

death of significant others and job loss, while the daily

hassles approach emphasizes the influence of everyday living

from daily hassles and life events. This study employed

Lazarus’s concept of daily hassles that are appraised as

salient and harmful or threatening to the endorser’s well

being (Lazarus 1984). On the other hand, daily uplifts are

experiences and conditions of daily living that have been

appraised as salient and are positive or favourable. Kanner

et al. (1981) stated that uplifts are likely to play an

important role in coping and may buffer the presumed

adverse effects of hassles.

Lazarus (1966, 1999) was a pioneer in stress and coping

research and the transactional model developed by Lazarus

and Folkman (1984) is a benchmark for the measurement of

stress and coping that is widely employed in research (see

Machleit et al. 2005, Lavee & Ben-Ari 2008). The model

integrates stress, appraisal and coping theories with a central

focus on individual responses to psychologically stressful

situations and/or environments. According to Lazarus (1984,

p. 19), stress is; ‘any situation in which internal and/or

external demands are appraised as taxing or exceeding the

adaptive or coping resources of an individual’. Coping refers

to the person’s cognitive and behavioural efforts to manage

those taxing demands of the person–environment interaction

(Folkman et al. 1986a).

Accordingly, stress in nursing would be represented in

terms of the presence of disruptive environmental factors,

such as excessive workload or demands from patients, the

appraisal of these factors as potentially threatening by the

nurse and the secondary appraisal of the nurse’s availability

of coping resources. If the demands exceed the nurse’s coping

resources, which may include personality factors and the

availability of social support, there may be negative conse-

quences.

Stress and coping instruments typically have a quantitative

focus and some have been revised in response to criticism of

their weak psychometric properties, unstable factor struc-

tures and lack of cross-validation (De Ridder 1997, Maybery

& Graham 2001, Maybery et al. 2002). Additionally, these

instruments suffer from low internal inconsistency, a lack of

test–retest reliability and inadequate research on construct

and predictive validity (Steed 1998, Hahn & Smith 1999,

Folkman & Moskowitz 2004). Therefore, a qualitative

methodological approach was considered important to

explore nurses’ experiences of stress and coping beyond

traditional stress and coping measurements. Additionally, by

drawing on Lazarus and Folkman’s (1984) theoretical

framework, it was possible to conduct a study that described

nurses’ stress together with uplifts and coping strategies

across their personal and professional lives whereby a much

fuller picture of stress could be described.

The Study

Aim/s

The aim of the study was to describe nurses’ experiences of

daily stress and coping.

Design

This research builds on a previous quantitative study (Lim

et al. forthcoming) that employed Lazarus and Folkman’s

(1989) Hassles and Uplifts Scale and Folkman and Lazarus’s

(1988) Ways of Coping Questionnaires to examine stress and

coping strategies in Queensland and Singaporean nurses.

However, the response rate for Singaporean nurses (19Æ5%)

was lower than Queensland nurses (30%; Lim et al. forth-

coming) and may be attributed to disinterest in surveys in

Asian cultures (Harzing 1997, King 2006). Consequently, a

qualitative approach was adopted to explore further the

Singaporean nurses’ experiences of daily hassles and uplifts

and their coping strategies. A postpositivist paradigm

informed the qualitative methodology because the purpose

of the research was to obtain a snapshot of the day-to-day

reality of these nurses in order to gain an understanding

of their subjective experiences (Guba & Lincoln 1994).

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Therefore, the interview data were treated as examples of

participants’ everyday experiences.

Sample/participants

A purposive sample of Singaporean nurses was identified using

a snowball sampling approach (Atkinson & Flint 2001)

whereby the initial participants identify potential additional

participants through their networks who will provide ‘infor-

mation-rich’ cases. The snowball sampling approach began

with the lead author obtaining permission from two nurses in

Singapore to assist with recruitment. To encourage participa-

tion, we included the incentive of entering all participants’

email addresses into a lucky draw to win a S$100 shopping

voucher. To prevent study emails being treated as spam, the

subject field included study details. Recruitment commenced

in May 2009 and was completed by November 2009. As the

snowballing progressed, twenty-three nurses were recruited

and participated in the first interview. With the exception of

two, all the nurses participated in the second interview, and no

reason was given for non-participation. The sample size was

determined by the ‘saturation’ of interview content (Pope et al.

2000), and by this, we mean that when no new information

was being given in the interviews, the sampling ceased.

Data collection

As one of the key aims of qualitative research is to understand

phenomena from the participants’ viewpoint (Wilkinson

et al. 2004), the semi-structured interview was selected to

collect data about nurses’ experiences of stress and coping.

Data were collected in 2009 via open-ended questions sent to

participants by email; a method justified by evidence (Choi

2008) that Singaporeans prefer email communication. Email

interviews have several advantages including their time and

cost efficiency, and enable researchers to access a diverse

population (Meho 2006). Additionally, asynchronous com-

munication maintains participants’ anonymity, while they

have the freedom of self-disclosure (Opdenakker 2006). In

this study, participants were required to answer the questions

asynchronously by replying to initial prompts. The interview

schedule for the first set of interviews was informed by

previous quantitative research (Lim et al. forthcoming) that

identified nurses’ experiences of stress, and required a

qualitative approach to clarify nurses’ daily experiences of

stress and coping. The lead researcher (JL) sent follow-up

emails in order to clarify the participants’ meaning of any

specific use of language/concepts (see Table 1).

The second interview was developed using questions

formulated from the responses from the first interview in

order to explore further the stress, uplifts and coping (see

Table 2).

Each participant’s interview data were saved as an

individual word document, stored on the first author’s secure

computer and all interviews were later printed and analysed

individually as well as across the set of interviews.

Ethical considerations

A university ethics committee approved the study stating that

the project complied with the provision contained in the

National Statement on Ethical Conduct in Human Research

and complied with the regulations governing experimentation

Table 1 Interview schedule for first interview

1a. Can you tell me about your everyday hassles?

1b. Research has indicated that Asian nurses experience ‘too many

responsibilities’, ‘problems getting along with fellow workers’,

and ‘job dissatisfactions’, ‘troubling thoughts about the future’,

‘not getting enough sleep’ and ‘not having enough time’ as major

hassles. Can you talk about your own experiences in these areas?

2a. Can you tell me what makes you feel uplifted?

2b. Research has indicated that Asian nurses experience laughing,

relating well with friends and meeting your responsibilities. Can

you talk about your own experiences in these areas?

3a. If you are stressed, what do you do to cope?

3b. Research has indicated that Asian nurses seek support from their

friends and families. Can you talk about this in terms of your

own experience?

4. Could you please give me your approximate age (under 30; 31 or

older)?

Table 2 Interview schedule for second interview

1. Could you tell me what ‘being lucky’ means to you? Do you think

that the hassles or uplifts you experienced are influenced by luck?

If so, please describe an example.

2. Some people have told me that ‘no disturbances from superiors/

relatives’ means a lot to them. Can you please describe an example

or time when you were disturbed by relatives or superiors?

3. People have talked about having ‘too many responsibilities’ as

being stressful. Can you please describe what it means to you to be

for example, a good worker, good mother, good wife, good

daughter and good daughter-in-law.

4. What is ‘money’ to you? Does having or not having money have

any impact on you (good and bad ways)?

5. Do you go shopping as a means of stress relief? When you make

the purchase, how do you feel and how long does this feeling last

for?

6. When you are stressed with a particular issue, what do you do to

help you manage the situation?

7. If you could change anything in the world to make it less stressful

for you, what three things would you do?

J. Lim et al.

1024 � 2011 Blackwell Publishing Ltd

on humans. The participant information sheet was emailed to

each nurse individually and included clear statements about

the voluntary nature of study participation and that they

were free to leave the study at any time, and that confiden-

tiality would be maintained. It was also made clear to

participants that study participation was not in any way

linked to their employment. Participants were also sent

written consent forms by email and they returned signed

forms to the lead researcher (JL) by email.

Data analysis

The interview transcripts were initially analysed by the lead

researcher (JL) as data were being collected whereby she

noted prominent features in each transcript. Subsequently,

individual interviews were systematically analysed using

thematic analysis based on Pope et al.’s (2000) five stages

of analysis: (1) familiarization – transcripts were read and re-

read several times in order to list key ideas and recurrent

themes, (2) Identifying a thematic framework – identify key

issues and preliminary topics and constant comparison of

data to establish analytical categories, (3) Indexing – refine

and reduce categories into broader themes, (4) Charting –

rearrange data according to the thematic framework where

they relate and (5) Mapping and interpretation – define

concepts and find associations between themes to provide

explanations for the findings.

The purpose of thematic analysis is to represent directly an

individual’s point of view through descriptions of experi-

ences, beliefs and perceptions (Luborsky 1994). By drawing

on Pope et al.’s approach, it was possible to identify key

themes and sub-themes in the first instance and refine these

after multiple readings of the transcripts and through

consultation with co-researchers.

Validity and reliability/rigour

In order to maximize the validity of the analytic interpreta-

tions, two of the researchers independently analysed the

individual interview transcripts and the identification of

themes and sub-themes across the interviews. This approach

was taken to both sets of interviews. When inconsistent

interpretations arose between the researchers, they were

referred to the third researcher for discussion until a

consensus was reached. The systematic approach to the

analysis provides additional rigour to the study. The trans-

parency of the research design and analysis contributes to the

establishment of an ‘audit trail’, which documents the steps

and decisions undertaken from the transcripts of raw data

through to the final interpretation (Wolf 2003).

Results

Sample

The purposive sample comprised of 23 Singaporean female

nurses aged between 22 and 55 years (see Table 3 for

demographic characteristics). The majority of participants

worked full-time, had been employed for a minimum of at

least 2–5 years and worked in the similar nursing setting of

restructured hospitals in Singapore, which are government

owned, privately managed and may or may not have attached

private clinics. The majority of nurses in this study were

single and did not have children.

Summary of the theoretical framework and major themes

The study findings were interpreted in relation to Lazarus and

Folkman’s (1984, 1987) transactional model of stress and

coping. Seven main themes about stress, uplifts and coping

were identified together with 23 subthemes (see Table 4).

Illustrative quotes are reported verbatim.

Sources of stress

Three themes were identified from the data: (i) time pressures,

(ii) nature of nursing work and (iii) multiple roles.

Theme 1: Time pressures

Nurses experienced considerable time pressures, which they

expressed in relation to five sub-themes: (1) the work

Table 3 Demographic characteristics of Singaporean nurses (n = 23)

n %

Hospital setting

Public 3 13Æ1 Private 5 21Æ7 Restructured 15 65Æ2

Employment status

Full-time 23 100

Part-time 0 0

Years of experience

Less than 1 1 4Æ3 2–5 16 69Æ6 More than 6 6 26Æ1

Marital status

Single 12 52Æ2 Married 11 47Æ8

No. of children

0 16 69Æ6 1–2 6 26Æ1 >3 1 4Æ3

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commute, (2) too many patients, (3) workflow, (4) col-

leagues’ disrupting work and (5) work/home responsibilities.

Nurses’ commute to work was perceived to be an

unpleasant but unavoidable part of everyday life as Susan

states: I hate the morning darkness, crowded buses and

among other things...I hate the hassles of having to wake up

early...[sigh]...’.For Susan, and for some of the other nurses,

this commute added a significant length of time to their

working day, which had an impact on both their personal

and professional lives.

A heavy patient load also contributed to time pressures

resulting in nurses not having enough time to carry out all the

tasks required by patients. Yasmin states: ‘Too many patients

to handle in a day and the time scheduled for each patient is

limited.’ The pressure on nurses was amplified when col-

leagues such as doctors, nurse researchers or interpreters

interrupted their patient schedule:

[a hassle is when]When work does not flow well due to the overlook

of other departments or mistake in workflow because it’ll cause

interruption in work and cause delays. (Hebe)

Doctors coming in late for consultation which will then hold back the

clinic session and angry patients demanding a reason for seeing

Doctors later than their appointment time. (Betty)

As well as managing a changing appointment schedule,

nurses dealt with an emotional backlash from patients.

For those nurses who had family commitments as mothers

and daughters, the significance of time pressures was height-

ened because they had to fulfil work and home responsibil-

ities and meet family expectations. Xania and Ally describe

their breadth of duties:

I have so many things to do in a day. Work is already hard and got to

take care of family too. Going to work every morning, getting my

children ready for school and dropping them off, getting to work on

time, picking my children from school. (Xania)

We have so many things to do everyday, going to work, fulfilling

work duties, rush home to fulfil home duties, cook, clean, prepare for

the next day. Time is always not enough. (Ally)

Theme 2: Nature of nursing work

The nature of nursing work included five sub-themes (1) too

many responsibilities, (2) workload, (3) working relation-

ships, (4) lack of recognition and (5) demanding patients and

relatives.

Jessie describes multiple nursing responsibilities and how

they become burdensome:

I am facing too many responsibilities at work. I have to manage a

pool of patients on hand, monthly and quarterly reports to submit to

three different departments, supervise my juniors at work, and teach

2 new staffs at work.

With the shortage of staff, nurses were also expected to fulfil

non-nursing responsibilities:

We bear too much responsibilities because not only are we nursing

the patients, we have PR to do, service recovery etc. Plus we have

individual assignments in the ward and I’m in charge of the

pharmaceutical section. (Julia)

The workload was very heavy due to the shortage of staff. The staff

nurses had to be in charged of everything, from the patients’ food to

the different procedures the patients are suppose to go for that day…. be responsible for any mistakes done by the junior nurses who were

in the same team. (Hebe)

They also identified the importance that their work relation-

ships had for efficiency and their morale:

Table 4 Main and sub-themes for stress, uplifts and way of coping

Main themes Sub-themes

Sources of

stress

Time Travelling to work

Too many patients

Workflow

Doctors late for appointments

Work/home responsibilities

Nature of

nursing work

Too many responsibilities

Demanding patients and relatives

Workload

Working relationships

Lack of recognition

Multiple roles Work

Personal

Sources of

uplifts

Feeling good Professionally

Appreciation of the nurse:

patients’ gratitude and

pay increments

Good, reliable

relationships at work

Patient’s health improving

Personally

Personal activities

Money

Laughing

Good social relationships

Ways of

coping

Taking time out Breaks at work

Rest and relax

Shopping

Seek emotional

support

Family – Husband

Colleagues

Belief systems Role of luck

Fatalistic thinking

Spiritual interventions

J. Lim et al.

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Getting along with workers is a big issue at my workplace. People

just seem to be backstabbing and playing politics all the time. (Ally)

Poor teamwork with superior. I have a unapproachable superior,

whom will look for us to help her to do her work and yet when we

need help, she is no where to be found. And when she see that we are

busy, she’ll ask us to do documentation audit which can be done on

some other day when there is lesser patients. Not promoted even

though promotion long due. (Casy)

Nurses complained of a lack of recognition and advancement

at work in spite of performing well:

We had to do OT everyday and were not appreciated by our

managers. Little recognition was given to the staff. (Hebe)

Job dissatisfactions – they include no recognition from the organi-

zation and career advancement. (Tanya)

I have been working for 2 year and not able to upgrade yet. (Lisa)

Amid nurses’ anxieties and worries, patients and/or relatives

could be particularly demanding:

Finicky relatives make for a nurse’s nightmare especially those

wealthy relatives. Some come in large numbers and they monitor

your every movement. They expect us to take care of the patient as

though she is the only patient in the ward. (Jemma)

Theme 3: Multiple roles

Multiple roles were also a source of hassle across nurses’

personal and professional lives. In the extract below, Rachel

describes the multiple roles that nurses in the hospital setting

have to fulfil:

Nurses have too much patient load and extended roles to play

especially in the ward. A senior staff are required to be in numerous

projects work, infection control officer of the area, prepares schedule

for students, roster for staff, giving talks and seminars, preceptoring,

acting nurse manager, ordering requisites and handling PR [public

relations] case or students which can be very hectic. (Rachel)

Additionally, in their personal lives, nurses had to meet the

Singaporean cultural expectations of them as daughters,

parents and/or spouses. Ally illustrates how these expecta-

tions can be overbearing and stressful for women:

This is like the worst kind of stress that we are all facing now

especially for Chinese. People always see in women, wife-material,

mother-material….. I have to be a good wife, a good daughter, and an extremely good daughter-in-law. I have to also excel in my work

in order to impress my in-laws and make my parents proud. I have

to do my best in everything, from taking care of my family and my

in-laws, to earning good money to prove that I’m good and smart. I

really hate it why we must impress others and put all sort of stress

on ourselves. … we still need to take care of ourselves, be pretty and look good so that our husbands will not strayed. Somehow I

have to do everything perfectly …. I don’t like it that I have to please people that I don’t like just because I have to do it. It’s

ridiculous. (Ally)

Sources of uplifts

One main theme was identified as being the source of uplifts,

‘feeling good’ across nurses’ personal and professional lives.

Theme 1: Feeling good

For these nurses, feeling good in the professional arena meant

that they experienced uplifts through being appreciated,

having reliable working relationships and patients’ health

improvements:

It can be just a ‘thank you’ from a patient that you had attended to

which means that they appreciate your service. (Yasmin)

When receive compliments from patients and manager. When we

hear that there will be bonus or increment, it will definitely enlighten

our day! (Jolene)

With heavy workloads, nurses commented how important

collegial work was to resolve everyday situations and that

positive working relationships lightened nurses’ mood:

I feel great when work problems are solved and when we have good

teamwork at the office. (Whitney)

So far I’ve been lucky in that we’ve got good team mates and nurses

in outpatient here are supportive and fun to talk to so however bad

days we had, we managed to get by quite happily... (Betty)

Improvements in patients’ health were a major uplift at work

as Jemma describes:

There is no better uplift than to see your patients cured (as in

successful surgery/treatment) and discharged from hospital. This

piece of news brings a bright and broad smile on them. They will be

so grateful for all the care and attention rendered by nurses during

their stay. (Jemma)

In terms of feeling good personally, nurses experienced uplifts

through leisure activities, having disposable income, laughing

with their friends and social relationships that relieved stress.

Watching drama series that I like. Playing games on internet.

Cooking for my friends. Shopping. (Ally)

If I am really stressed out with my work, I will call my friends to go

out for a drink, go clubbing, to de-stress..If time allow, will go spa,….

Now I enrolled into yoga class and guess it also help to de-stress and

uplift my feelings and I think it work well. (Jolene)

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Money is everything to me... Of course having money have impact on

me in goods way. For me I see money as an uplift... I can buy what I

want which also help the economy. haha.. I can buy what I need and

no need to keep bothering other people to lend me... (Yoko)

Another way in which nurses’ relieved stress at work was

through humour and laughing together:

Laughter helps to lift up the ever building tension at work and a stress

reliever whether or not you manage to clear your work to meet

datelines. (Rachel)

Sharing a joke and laughing is evidence of enjoying one’s work.

Friendship is very important because nurses rely on one another to

uplift their day and their work for obvious reasons. Stating it clearly

and crudely, we are dealing with the sick and the terminal. So at

times sharing a light moment with fellow colleagues makes a great

difference to the kind of job we are doing. Otherwise the day will be

night and the night will be nightmare. (Jemma)

Nurses in this study also enjoyed spending time and relating

well with friends and family for companionship and

support:

Having good time with friends and family, like eating out, nice

food and entertainment. Just hanging out with my partner. Relating

well with friends help me feel better in the day as there are

common grounds between us and you know that you are not alone.

(Ally)

Ways of coping

When nurses talked about coping, their responses included

three themes: (i) taking time out, (ii) seeking emotional

support and (iii) belief systems.

Theme 1: Taking time out

Taking time out through short breaks at work, snack breaks,

rest and relaxing activities helped nurses to cope.

We have this locker that are stashed with lots of snacks and goodies

that most of us will snack on in between cases in the OT. This help us

to relief hunger as well as stress. (Yvette)

Out of the working environment, nurses relaxed by

listening to music, meditation and going to the spa.

Sleeping was also a common way for nurses to get away

from stress. An additional common coping strategy among

nurses was taking time out to go shopping as Ally describes

below:

Shopping and not thinking about it, just switch off and relax.

Shopping to relieve stress for me is to shop simply anything I like. It’s

a very bad habit to use shopping to de-stress but I love shopping. …

Somehow all your troubles are gone. But when the bills arrived, that’s

when the pain sets in…. every time I feel stressed up, I still revert to

shopping. (Ally)

Theme 2: Seek emotional support

For these nurses, family members, husbands and other nurses

were all sources of emotional support:

If I find I’m being too stress, I will talk things out with my parents and

siblings when I asked them out for dinner or over my lunch time.

Usually to ask them for their opinions or feedback cause sometimes

when I’m too stress I can’t think so by asking them they may give me

a better solutions to act upon or I just want their moral support.

(Rachel)

Husband plays an important role in my life..whenever I have trouble

and problem, I will talk to him and seek for his support and

encouragement. (Jolene)

As nurses we need to shoulder pain and sadness together. I once get

scolded by a patient though it has really nothing to do with me at all!

I seek comfort by sharing my ordeal with my team. Some showed

their anger, some showed their sympathy, some even vengeful. So it’s

touching to know that you are really not alone and that as nurses,

every one of us is the same. And we know will support each other

through thick and thin of life. (Susan)

Theme 3: Belief systems

Nurses also drew on individual belief systems in terms of the

role of luck, fatalistic thinking and spiritual interventions to

cope with stress. By drawing on luck, nurses were able to

make sense of the changing patterns of their work, both good

and bad, and saw themselves as part of a larger context over

which they had less control.

Yes, anything that happens from day to day is all depends on luck.

For instance, if you are lucky everything will go well and smoothly

throughout the day and anything crop up there will always be a

miracle or guiding angel to help you. (Jolene)

I believe some things happened for a reason. For e.g. when something

bad happens, I always say it is bad luck. Maybe not doing well at

work, I blamed it on bad luck. Bad relationships with work

colleagues can be considered bad luck as well. (Ally)

Nurses attributed hassles and uplifts to being an inevitable

part of life, and as the main reason for why they had to accept

the societal norms.

Obviously too many responsibilities will consequently result in being

stressful. The responsibilities that we assume in life as a person in

different roles inadvertently translate into stress marks. This is life

and life is about being responsible. (Jemma)

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It is normal that we are expected to be a good wife and mum. This is

the role of woman. I have to always meet the expectation of the

society. (Xania)

Religion also played an important role in nurses’ coping

especially when they believed that either they did not have

another source of support or that the only real power was

through spiritual intervention:

Think it through, ask people around me who can help. If not, I’ll ask

for divine intervention. (Esther)

There’s no one I can talk to openly except God. (Xania)

Discussion

Study limitations

This study has two main limitations: sampling and the use of

email interviews. First, because snowball sampling relies on

the initial contacts to identify additional research partici-

pants, it may have attracted a homogenous group. While

collecting data from similar information-rich cases is valu-

able, subsequent research may explore stress and coping in a

more diverse sample. Second, internet filters may have

screened recruitment emails and the potential exists for the

lucky draw to have been treated as junk mail. There were two

losses in the second interview, so data from the initial

interview could not be confirmed further with these individ-

uals. A possible threat to authenticity in email interviews may

occur if the participant was unable or unwilling to elaborate

on an answer that was not clear in the original submission

(Hamilton & Bowers 2006). Possible explanations for the

lack of completion of the second interview could include time

pressures, not checking emails frequently, or feeling that they

had nothing more to add to initial response. As Bampton and

Cowton (2002) have noted, participants may also choose not

to commit to an interview process with the possibility of

unpredictability and insecurity.

The three themes of stress showed that Singaporean nurses

experienced stress in areas across their personal and profes-

sional lives and contrasts with previous work-focused studies

(e.g. Boey et al. 1997 and Chan et al. 2000). Despite the

widespread availability of domestic help in Singapore (Barr

2000), nurses found juggling home and work duties

burdensome. To some extent, this paradox is explained by

the expectation on Singaporean women to be actively

involved in domestic responsibilities (Lim et al. 2003). This

is in contrast with Winwood et al. (2006)’s findings that

domestic responsibilities were not related to fatigue and

recovery but shift work was the main casual factor for long-

term stress and fatigue in a sample of Australian nurses.

Boey et al. (1997) also found that family demands were least

stressful for the nurses; however, they were the most

significant when related to anxiety, depression and a sense

of inadequacy.

Time pressures were a prominent hassle among nurses

especially the work commute. Most Singapore hospitals are

not located by public transport particularly with the Mass

Rapid Transit (MRT) rail system, which is the major form of

transport (Statistics Singapore 2006). Even when located near

MRT stations, it often requires a walk of at least 15 minutes

and can be inconvenient or dangerous for nurses working

early morning or late shifts. This would require nurses to take

buses and interchange with either another bus or train before

they arrive at their workplace with an average journey time of

51 minutes (Statistics Singapore 2006). In order to minimize

travelling hassles, hospitals may consider providing shuttle

bus services at specific train stations to eliminate this stressor.

Employers may also consider providing transport subsidies

for nurses working shifts.

Singaporean nurses described good working relationships,

particularly with their nursing colleagues, but doctors and

administrative staff complicated their work. This finding is

similar to Boey et al.’s (1997) research that also reported

interpersonal conflicts to be one of the work stressors

reported by Singaporean nurses. A possible explanation for

this could be the lack of communication across positions in

the Asian community where the working culture is hierar-

chical and power-centred (King 2006). In-service pro-

grammes targeting interpersonal relationships may help by

promoting better communication, formation of work groups

and frequent discussions between healthcare personnel.

Interpersonal relationships could also become stressful

when patients and/or relatives were demanding. Similar to

Lateef et al. (2001) and Yang et al. (2001, 2002), they

frequently experienced patient-related difficulties and aggres-

sive patient behaviour. Consumers often have high expecta-

tions of hospitals, however, service quality in Singapore is

found to be generally below expectations (Lim & Tang

2000). Finding fault and complaining about everything are

part of the Kiasu values many Singaporeans possess (King

2006, Barr & Skrbis 2008). Therefore, nurses were in the

forefront of complaints and/or unpleasant behaviour from

health consumers who were dissatisfied with their care.

Nurses also experienced stress about job security, which is

consistent with previous research (Chan & Morrison 2000,

Tan & Tan 2004). These studies showed that Singaporean

nurses experienced a high level of work stress, job dissatis-

faction and insecurity. Concern about future job prospects

and security is common in Singapore as employees often

JAN: ORIGINAL RESEARCH Stress and coping of Singaporean nurses

� 2011 Blackwell Publishing Ltd 1029

complain of low pay and high workload (Sullivan &

Gunasekaran 1994).

The cultural expectation that Singaporean women will

fulfil multiple roles at home and work was a major source of

stress. Singaporeans are socialized to be multi-faceted indi-

viduals, and expected to perform at optimum in all aspects in

order to succeed (Singapore21 2003). Apart from the many

roles at home and work, nurses are expected to excel in these

roles (see Quah 1998).

The findings on psychological and social stress experienced

by Singaporean nurses need to be addressed accordingly as

Winwood and Lushington (2006) reported psychological

work demands to have an adverse impact on nurses’ sleep

quality and to impair recovery from work strain, which may

result in serious maladaptive stress outcomes.

In terms of uplifts, nurses enjoyed feeling good personally

and professionally. At work, nurses appreciated patients’

gratitude for their health care and recognition by hospital

management through promotion and pay increments. Nurses

also valued good working relationships, in line with Lateef

et al.’s (2001) findings where 92Æ4% of nurses felt that having

good relationship was the most important factor at work.

Personally, nurses enjoyed participating in individual and

social leisure activities in their spare time. Activities such as

surfing Internet, watching films, visiting spas and undergoing

facials were all uplifting for these nurses. According to Kau

et al. (2004), Singaporeans rely on leisure and play to feel

socially connected with people and to achieve a balance in

their lives. Laughter was also a source of an uplift, which is

often seen as a stress-coping method (Iwasaki et al. 2005).

In nurses’ personal and professional lives, money was an

important uplift confirming the findings by Lim et al.

(forthcoming) where Singaporean nurses reported uplifts

such as ‘having enough money’ and ‘getting money the

unexpected ways’. This is not surprising as Singapore has

long been characterized as a ‘money-faced’ society where

money matters most to many Singaporeans (Perera 1996).

The three themes about coping strategies showed that

nurses relied heavily on taking time out, emotional support

and personal beliefs. They valued resting and relaxing by

taking short breaks at work, practising meditation, listening

to music and going for short walks, which is similar to those

strategies reported in previous research (Boey et al. 1997).

Nurses in this study also engaged in shopping for stress relief.

Iwasaki et al. (2005) noted feeling recharged or rejuvenated

through leisure was significant for women juggling family/

home demands and work responsibilities.

Seeking social support was a common strategy among

nurses, although in this study, they sought emotional rather

than instrumental support from their families and colleagues.

Singaporeans are very family oriented, which helps them feel

appreciated and treasured and they often turn to family for

help or advice (Kau et al. 2004). Studies by Boey (1998,

1999) ascertained that family support plays an important,

positive role in managing Singaporean nurses’ stress. It is

interesting to note that Singaporean nurses did not receive

sufficient instrumental or emotional support from the work-

place.

Singaporean nurses also coped by drawing on their own

personal beliefs whether these were formal religious or

cultural beliefs, and commonly attributed events to luck.

Similarly, a study conducted with Singaporean medical staff

showed that superstitious beliefs were widespread in daily life

especially with the aim of attracting good luck and avoiding

bad luck in the working environment (Lim et al. 2007).

What is already known about this topic

• Nurses experience work-related stressors such as work overload, shortage of staff and dealing with death and

dying.

• Past research has overlooked the contribution of family and social stressors on nurses’ overall experiences of

stress and coping.

• Nurses use problem orientation and social support, particularly family support, as coping strategies.

What this paper adds

• An expanded understanding of how stress and coping are experienced by Singaporean nurses in their personal

and professional lives.

• Uplifts may have a moderating effect on nurses’ experiences of stressors.

• Emotional support is crucial in nurses’ coping of stressors in their personal and professional lives.

Implications for practice and/or policy

• Individuals and employers should focus on the resolution of work and family conflicts to strengthen

nurses’ morale and minimize specific stressful

experiences.

• Nurses’ daily stress may be reduced through the identification and recognition of possible uplifts in

everyday living that ameliorate unpleasant experiences.

• Workplace and individual interventions that promote effective coping strategies may contribute to the

prevention of workforce attrition.

J. Lim et al.

1030 � 2011 Blackwell Publishing Ltd

Singaporean nurses in this study also sought spiritual

interventions to help them get through difficult situations,

although at times they chose to do nothing because of a belief

in fatalism. Instead of actively confronting the problem,

Singaporean nurses may well feel better by drawing on

spirituality to help regulate their emotions.

This study is unique in that it employed a qualitative

research design using email interviews to describe Singapo-

rean nurses’ experiences of stress and coping, how these

manifest across both nurses’ personal and professional lives.

Furthermore, the study included an exploration of the

uplifting aspects of daily living that may counteract the

detrimental effects of everyday stress. In terms of methods,

several measures were undertaken to maximize participation

such as incentivizing and clearly communicating the intent of

emails in the subject heading. Having the first researcher from

the same cultural background also helps in the understanding

of cultural differences and the development and conduct of

meaningful research (Suh et al. 2009).

The Internet and other social networking tools are emerg-

ing mechanisms for participant recruitment and data collec-

tion worldwide (Dillman et al. 2009, Suarez-Balcazar et al.

2009). Given the cultural behaviours of Singaporeans with

respect to research participation (Fang 2001, Teo 2001), this

method may be more suited to studies of Asian cultural

groups. Research on Asian populations should use culturally

appropriate research methods recognizing that cultural

behaviours play an important role in the decision to partic-

ipate in research. Further research should also explore

Singaporeans’ preference for research methods including

postal surveys, and face-to-face, telephone and e-interviews.

Conclusion

In contrast with existing research on nurses and work-related

stress, this study concludes that experiences of stress across

both personal and professional lives are a major concern for

these Singaporean nurses. By drawing on Lazarus and

Folkman’s (1984, 1987) transactional model of stress and

coping, we were able to explore a broader range of what

constitutes stress and its alleviation including uplifts and

coping strategies.

It is recommended that hospital management considers the

exposure to a broader range of stressors than just work-

related stress. Hospital management should address these in

work practices such as identifying uplifts in performance

planning. They should also focus on building stronger

rapport by providing social networking opportunities where

nurses can find emotional support from peers and supervi-

sors. It is anticipated that implementing these recommenda-

tions allows retention of quality nurses and promotes a

healthier workplace.

Funding

This research received no specific grant from any funding

agency in the public, commercial or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

JL, JH & FB were responsible for the study conception and

design. JL performed the data collection. JL & JH per-

formed the data analysis. JL was responsible for the drafting

of the manuscript. JH & FB made critical revisions to the

paper for important intellectual content. JH & FB supervised

the study.

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