1. Introduction
Nurses play a very important role in healthcare, unfortunately, the difficulties related to their work expose them to various health hazards. Work-related stress, combined with everyday stress, has a negative impact on many aspects of nurses’ lives. Excessive physical and mental strain on nurses contributes to many health complications. Work-related stress is one of the most serious health and safety challenges. It is ubiquitous and often cannot be prevented, but it can also act as a motivating factor. Research shows that every fourth employee in the general labor environment experiences stress. It is associated with many costs, not only economic, but also in the form of health disorders. Stress in the workplace can affect anyone, regardless of the position held, the sector of work or the size of the institution in which they work [
1,
2].
Nurses are the most numerous group of healthcare professionals in almost all countries in the world. The working conditions of the nursing staff impose high mental and physical demands on this professional group. Nurses, while performing their duties, must show many professional and personal qualities, and above all, the ability to deal with stress. Assessment of the impact of stress on the work and health of nurses can be an important element in preventing many threats, including burnout, which refers to the emotional depletion and loss of motivation that result from prolonged exposure to chronic emotional and interpersonal stressors on the job. Nurse burnout is the state of mental, physical, and emotional exhaustion caused by sustained work-related stressors such as long hours, the pressure of quick decision-making, and the strain of caring for patients who may have poor outcomes [
3].
Stress is a potential determinant of health because it determines the mental state of a person, which is a reflection of the reaction to environmental conditions. A special place full of stressors is the work environment [
4]. Interactions between stress and employees’ health problems are becoming important. Each person experiences stress differently, which is an indispensable element of work and personal life. The threshold of resistance to the impact of various stressors varies from individual to individual. The pace of the modern world is a factor contributing to the occurrence of situations that cause psychological discomfort [
5].
The group particularly exposed to stressors in the workplace are nurses who engage in social, psychological or physical problems of their patients, often working in strenuous conditions and under the influence of strong emotions. The literature review of the subject shows that the most effective style of dealing with professional problems among nurses is the style focused on the task and seeking social contacts. Due to their profession, the ability to control emotions is undoubtedly required among nurses because the health, life, and safety of others depend on how effectively they cope with stressful situations [
6]. Nurses who tend to deal with stress through an emotion-focused style are more likely to report higher levels of occupational stress. Maslach states that nurses and midwives belong to the professions exposed to the burnout syndrome, which occurs in a situation of chronic stress typical of social professions [
7]. The consequence of long-term stress exposure is the risk of psychosomatic disorders. The intensification of this phenomenon was noted along with the COVID-19 pandemic, when a significant impact of stress on the mental health of nursing staff was observed [
8,
9,
10,
11,
12,
13].
The World Health Organization (WHO) defines work-related stress as the response that people may have due to emerging work-related needs and pressures that do not match their knowledge or skills, and that pose a significant challenge to their ability to cope with them [
14]. Managing stress is defined as cognitive behavior and problem solving that are used to tolerate, minimize or eliminate stress. The use of appropriate stress coping strategies allows to reduce the risk of certain stress-related diseases [
15].
Many studies confirm that personality traits are an important factor influencing the identification or response to stressful events [
16]. One of the most widespread theories of personality is the five-factor personality model known as the Big Five. This model covers the five main dimensions of personality: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Neuroticism is characterized by a susceptibility to experiencing negative emotions, such as anxiety, anger, insecurity, impulsiveness, and sensitivity, especially to psychological stress. Extroverted people are self-confident, friendly, talkative, playful, stimulate-seeking and are characterized by enthusiasm, energy, and a cheerful mood. Openness to experience is a positive evaluation of life experiences, tolerance towards novelty, cognitive curiosity, impulsiveness, originality and creativity. Agreeableness is characterized by cooperation, morality, sympathy, low self-confidence, a high level of trust in others, a tendency to be happy. It is worth noting that personality traits allow you to react to different situations in a specific way; therefore, maladaptive personality traits, e.g., neuroticism, are associated with increased exposure to stressful life events and thus may make people more susceptible to experiencing negative emotions or frustration [
17].
Whereas adaptive personality traits (e.g., conscientiousness) facilitate coping with stresses of everyday life [
18].
Managing stress is a regulatory process that can reduce the negative feelings re-sulting from stressful events. Moreover, it is a dynamic process that changes over time in response to changing requirements or the assessment of the situation [
19]. There are three main styles of coping with stress in the literature: task-focused, emotion-focused, and avoidance-focused. Task-focused stress management is the basic adaptive control style that allows to control emotions and focus on the implementation of a specific task. The style focused on emotions is associated with experiencing and trying to release emotions related to a stressful situation. Avoidance-focused coping is a cognitive and behavioral effort aimed at minimizing, denying or ignoring stressful situations [
16,
20].
Personality traits have important implications for the intrapsychic and interpersonal resources of an individual, and therefore, they fall within the options of coping with stressful situations. The literature review of the subject shows that adaptive personality traits are significantly positively associated with active coping styles. While maladaptive personality traits are positively associated with avoidance-focused coping with stress. Based on this information, it can be observed that people with a maladaptive personality are more likely to experience psychological distress because they probably use a maladaptive coping style, such as coping with avoidance [
21]. Therefore, the most effective style of dealing with professional problems among nurses is a style focused on the task and seeking social contacts. Due to their profession, the ability to control emotions is undoubtedly required among nurses because health, life, and safety of others depend on how effectively they deal with stressful situations [
22]. Nurses who tend to deal with stress through an emotion-focused style are more likely to report higher levels of occupational stress.
The aim of the study was to evaluate the impact of coping strategies in predicting the overall health of nurses. The study also assessed the impact of personality traits and emotional control (anger, depression, anxiety) on the choice of style of coping with stress among nurses.
2. Materials and Methods
2.1. Setting and Design
The study was conducted among 811 nurses who agreed and met the inclusion criteria, which included:
Employment in one of the hospitals in the West Pomeranian Voivodeship;
Bachelor’s or master’s degree in nursing;
At least one year of work experience.
The selection of the group was random and resulted from the particular exposure to stress of the respondents resulting from the specificity of the profession, i.e., contact with sick, suffering and dying people, heavy workload, and deficiencies in therapeutic teams.
The research was carried out using the traditional method, by disseminating paper versions of questionnaires among nurses working in the West Pomeranian Voivodeship.
The study was conducted in accordance with the guidelines of the Helsinki Declaration and approved by the Ethics Committee of the Pomeranian Medical University in Szczecin (KB-0012/102/12/2013). Our study was conducted with ethical considerations in mind. Informed consent was required and participation in the study was voluntary. In addition, participants were guaranteed anonymity and confidentiality, and the possibility of withdrawing from the study at any stage.
2.2. Research Instrument
The study used a diagnostic survey method with the use of the survey technique. The following questionnaires were employed to collect the research material:
2.3. Statistical Analysis
The statistical analysis was performed with the use of the Excel 2007 (Microsoft Corporation, Albuquerque, NM, USA) spreadsheet and Statistica version 7 (TIBCO Software, Palo Alto, CA, USA). The collected data were analyzed using the r-Pearson correlation coefficient. The p value < 0.05 was adopted as statistically significant.
Descriptive statistics (count, mean, medians, modes, fashion count, maximum, minimum, lower and upper quartile, range, quartile range, standard deviations, proportions) and statistical inference were used to calculate and interpret data, and relationships between variables [
27]:
χ2 statistic (chi-square)—used to investigate the relationship between two qualitative or quasi-quantitative features. The null hypothesis assumed the independence of the analyzed features, while the alternative hypothesis stated the existence of a statistically significant relationship between them. The results of the analysis were a multi-way table with the chi-square statistic and the p-value calculated for it. The null hypothesis was rejected in favor of the alternative if the statistical significance p was greater than the assumed significance level α (α = 0.05). When the test probability exceeded α, it was found that there were no grounds for rejecting the null hypothesis;
p-value—used to obtain the values of the selected statistics, which were observed assuming that the null hypothesis is satisfied;
Sample randomness test—Stevens series test—aimed at checking whether the recorded results in this respect can be generalized to a larger number of cases. Before applying the procedures of statistical inference, it allows to make sure that the collected observations meet the postulate of randomness of the sample.
The collected data on personality traits according to the NEO-FFI Questionnaire and the styles of coping with stress according to the CISS Questionnaire were subjected to a multivariate analysis based on linear ordering according to A. Balicki’s pattern, which allows to organize the set of features of multidimensional objects. The pattern method makes it possible to create a hypothetical pattern with respect to which the distances from the real points are determined. The model becomes a certain ideal, but unreal model object with the best values of the variables: for positive variables—the highest, and for negative variables—the lowest. The smaller the distance between the object and the pattern is found, the more similar the object and the higher the level of complex phenomena of a given object. The taxonomic measure is the synthetic quantity calculated on the basis of the distance from the standard, which is the resultant of all variables characterizing the tested objects.
4. Discussion
4.1. Assessment of the Styles of Coping with Stress of the Respondents
The results of our own research indicate that the dominant style of coping with stress among the surveyed nurses is the one focused on emotions, followed by the style focused on avoidance. Research by Nyklewicz W. et al. [
28] and Perek et al. [
29] showed that the dominant style of coping with stress among nurses is the task response to stress. Nurses used constructive ways of coping with stress, which consisted of making efforts to solve the problem through cognitive transformations or attempts to change the situation and the implementation of tasks entrusted to them. These reports are consistent with the research results by Wilczek-Rużyczka and Król [
30], which emphasize that nurses who tend to cope with stress through the style focused on emotions more often declare a higher level of occupational stress. Research by Isa et al. [
31] showed that problem-oriented coping strategies were the most common ones used by nurses. Similar results were also obtained by Fiske et al. [
32]. Probably the choice of this stress coping strategy results from a sense of control through careful step-by-step planning, which allows for effective management of stress factors. Moreover, in the study by Chang et al. [
33], it was observed that people using problem-oriented coping strategies showed a higher index of mental health, which means lower risk of mental health disorder.
The studies by Healy et al. [
34] showed a significant positive relationship between stress in nurses and mood disorders, and a significant negative relationship between stress and job satisfaction. It was observed that the use of avoidance and the perception of work overload is a significant predictor of mood disorders. In addition, studies by Deklava et al. [
35] showed that one of the dominant coping strategies among nurses is the emotional coping strategy. It is worth noting that nurses who used emotion-oriented coping strategies showed higher psychological competences and significantly better professional behavior and personality traits. Emotion-oriented coping strategies are preferred by people whose personality allows them to easily enter and maintain a state of emotional arousal in response to or anticipation of emotionally charged stressful events [
28]. In addition, the meta-analysis by Penley et al. [
36] showed that people using emotional coping strategies have worse health outcomes because they choose negative styles of coping with emotions, such as alcohol and drug use, and the root cause of stress is not removed.
In the case of studies by Wang et al. [
37], it was shown that workload, lack of support, and inadequate preparation are the most common stressors for surgical nurses, who most often chose coping strategies that can be characterized as avoidant, confrontational, and optimistic. All of these strategies are considered to be the most effective stress reduction strategies.
Research by Betke et al. [
38] conducted among Polish nurses during the COVID-19 pandemic showed that the respondents most often declared using strategies which included the active ways of coping with stress, focused on the problem.
In the case of the studies by Kupcewicz et al. [
39], it was observed that nurses with increased positive orientation more often used both problem-focused strategies (such as planning and active coping) and strategies reducing stress and negative emotions (such as positive revalidation, seeking support, and emotional acceptance).
On the other hand, studies by Portero de la Cruz [
40] showed that the most frequently used coping strategy was problem-focused coping, and the least frequent coping by avoidance, which is consistent with the results of other studies [
41,
42,
43,
44].
4.2. Assessment of the Mental Health of the Respondents
The analysis of authors’ own material shows that 53.9% of the respondents do not have a risk of mental health disorders. In the case of the analysis of the results of measuring health condition (GHQ-12), research by Nyklewicz et al. [
20] showed a positive dimension of mental health in over half of the surveyed nurses (61%). In turn, Makowska and Merecz noted that mental health disorders occurred in 26.6% of the respondents [
25]. Studies by Bazazan et al. [
45] showed that respondents achieved a GHQ-12 score above the cut-off point for about one-third of the inpatient nurses surveyed. This means that mental distress is fairly common among this group of health professionals and broadly agrees with findings in other countries. Both studies by Su et al. [
46] and Suzuki et al. [
47] showed that there is a high prevalence of psychiatric disorders among nurses working in a hospital. Research by Chatziioannidis et al. [
48] carried out on health care workers who had been harassed or witnessed intimidation of others found that these people had higher GHQ-12 scores, indicating psychological stress. Similar results were obtained by Ramirez et al. [
49]. The problem of mental health impairment among health care workers is large, as demonstrated by numerous studies. A study by Portero et al. [
50] conducted among 235 doctors and nurses showed that 32.3% of professionals had mental disorders. Even clearer differences were observed in the studies by Sanchez-Lopez et al. [
51] who showed that nursing staff achieved significantly worse results in terms of mental health than the entire population.
Research by Javadi-Pashaki [
52] showed that half of the respondents had health disorders. In addition, studies by Noorian et al. [
53], Sahraiana et al. [
54], and Maghsoudi et al. [
55] confirm the occurrence of mental health problems among nurses. During the COVID-19 pandemic, an increase in mental health problems was particularly noted among nursing staff [
7,
8,
9,
10,
11,
12].
On the other hand, research by Betke et al. [
56] showed that among practicing nurses, there are three specific types of health conditions of nurses, i.e., “healthy individuals”, nurses “with disorders”, and “malcontents with health problems”. Healthy people are nurses with the best somatic health and the lowest burden of chronic diseases. The “disturbed” nurses represented poor somatic health but the best mental health. Moreover, these nurses enjoyed physical well-being. “Malcontents with health problems” are the group of nurses where the most risk factors for physical and mental well-being have been identified. These nurses reported the highest burden of chronic diseases and a stronger tendency to report somatic complaints. Moreover, nurses from this group opted for the least adaptive strategies of coping with stress.
4.3. Assessment of the Suppression of Emotions among the Respondents
The results of our own research indicate that the surveyed nurses are characterized by an average level of suppression of emotions. Research of Nyklewicz et al. [
28] showed that 74% of respondents experienced above-average severe anxiety. Most nurses used anger, depression, and anxiety suppression. Most of the respondents suppress their emotions to an average extent. Anger is suppressed moderately and heavily by 69% of people, depression by 72%, and anxiety by 76%.
In recent years, more and more attention has been paid to the psychological adaptation of health care workers. Their work is associated with emotions that significantly affect the daily functioning and life of the medical staff. In addition, it has been reported that nurses often find it difficult to regulate their emotions because of emotional dissonance, which is the difference between the emotions they experience and those they need to express. Research by Han et al. [
57] showed that among nurses who reported significant stress, 44.4% chose anger as the most frequently experienced emotion and suppressed anger more than expressed it. Additionally, Cox et al. [
58] showed that women who cannot properly express their anger and use indirect methods of coping with anger or suppress their anger are more prone to depression and anxiety than women who express this anger. The suppression of negative emotions is associated with ruminations, which may eventually cause, maintain or worsen depressive and anxiety symptoms [
59]. Research by Kim et al. [
60] confirms that the work of a nurse influences the intensification of depressive and anxiety symptoms in the mechanism related to the suppression of anger.
4.4. The Relationship between the Styles of Coping with Stress According to the CISS Questionnaire and Selected Variables (General Health, Personality, Suppression of Emotions)
Our own research has shown statistically significant relationships between the styles of coping with stress according to CISS and selected variables such as general health, personality or suppression of emotions (anger, anxiety, depression).
It was observed that people with mental health disorders according to the GHQ-30 questionnaire were characterized by a high intensity of the style focused on emotions—30.2% (p = 0.000), the style focused on avoidance—18.7% (p = 0.002), and on engaging in alternative activities—32.3% (p = 0.000).
Pouranghash Tehrani et al. [
61] showed that task-oriented and emotional coping strategies have the largest share in predicting mental health. In turn, Livarjani et al. [
62] noted that, among coping strategies, the emotional strategy was a significant predictor of health, and it was found that with the increase in the emotional strategy, the general health condition deteriorated. In the case of the studies by Iannello and Balzarotti [
63], it was observed that task-focused or avoidance-focused styles were predictors of lower work-related stress, while the emotional-focused style was associated with higher levels of stress.
The authors’ own research showed that 44.84% of people with a low level of the task-focused style were characterized by a low level of conscientiousness, while 28.83% were characterized by a low level of openness to experiences. The respondents who achieved high intensity in the emotional style, in this case, 26.15% of the respondents, were characterized by a high level of neuroticism, while 24.32% had a low level of extraversion, and 22.81% had a low level of openness to experience. Persons reaching high-intensity style focused on avoidance tended to be high in the case of 16.04% in neuroticism and high in the case of 17.24% in extraversion. People with a high level of avoidance style were characterized by low intensity—22.52% in the case of agreeableness and 27.59% in the case of conscientiousness. Moreover, in the case of high achievers in engaging in alternative activities, 33.16% were characterized by a high score in neuroticism, and 25.73% were characterized by a low level of extraversion. Among the respondents with a high score in engaging in alternative activities, 34.23% were low in agreeableness, 50% had little conscientiousness, and 24.69% had a high level of openness to experience. In addition, 23.91% of respondents with high levels of socializing scored high on agreeableness and 21.40% scored high on conscientiousness.
Studies by Portero de la Cruz et al. [
41] showed that problem-focused coping was negatively correlated with depression and social dysfunction. It should also be noted that a significant positive correlation was found between emotional-focused counseling and depression. The use of adaptive coping styles has a positive impact on physical and mental well-being, coping with stress, and overall performance among health care workers, which is associated with improved quality of care, greater patient safety, and a decrease in health care costs [
43,
64].
Nurses, due to the specific working conditions, struggle with many physical and mental problems. Prolonged and continuous stress is detrimental to the health of nurses and contributes to organizational inefficiencies, so it is important to introduce some intervention measures that enable nurses to cope with stress. It is important to create a friendly, supportive, and collaborative working environment.