A search was conducted using electronic databases in the fields of nursing medicine education psychology and sociology. Using ProQuest Direct and EBSCO search engines the following databases were accessed: CINAHL (Cumulative Index to Nursing and Allied Health Literature) MEDLINE in PubMed Ovid and PsycINFO. The search terms were grouped in the following key concepts: (a) occupational stress in nursing (b) stress perception in nursing (c) occupational stressors in nursing (d) nursing generational diversity and (e) coping in nursing. In a commentary on patient safety in nursing practice from the Agency for Healthcare Research and Quality Hughes and Clancy7 reported that complexity and bullying represent 2 clear examples of nurse stressors. Li and Lambert8 concluded that nurses who are more satisfied with their job are more likely to remain in the workforce and to be committed to delivering high-quality patient care. Hall9 found that healthcare professions have some unique characteristics leading to occupational stress including physical responsibility for people potential catastrophic effects on the patient and the employee frequentexposure to pain and suffering and exposure to infectious diseases and potential hazardous substances. Hamaideh et al10 identified that death and dying were the strongest stressors perceived by Jordanian nurses. In this study workload and guidance were found to be the most supportive behaviors provided to nurses facing stress followed by emotional support.10
Carver and Candela11 concluded that considering the global nursing shortage managers should increase their knowledge of the generational diversity. It is suggested that understanding how to relate to multiple generations can lead to improved nursing work environments.11 Repar and Patton12 found that the combined effects of compassion fatigue chronic grief and emotional and physical exhaustion led to significant burnout and prolonged job dissatisfaction in the nursing profession. In this study using guided sessions a massage therapist gave 10-minute chair massages and a visual language or musical artist engaged participants in imaginative and creative activities such as poetry reading free writing guided imagery and listening to live music.12 The results suggest that the activities reduce some of the unpleasant stressful and tension-producing emotions that nurses typically experience at work leaving them more peaceful and energized.12 Based on the findings of this review of the literature it is recognized that stress is a major component of nursing and can be detrimental to nurse retention. In addition most studies identified some differences that exist between the present generational nursing cohorts in terms of values and beliefs. No studies were identified reporting how work-related stress affects different generations of nurses how the generations perceive stress and what coping styles are used.
A descriptive correlational design was used to examine the relationship of occupational stress age years of experience and education level and stress perception among a sample of MS RNs. Measures of perceived stress and coping were compared between the 3 age cohorts to determine if there is a difference between these groups. The researcher used 4 instruments that were administered in the following order: a demographic tool the Nursing Stress Scale (NSS)13 the Perceived Stress Scale (PSS)14 and the Ways of Coping Scale (WAYS).15
A 4-item demographic questionnaire developed by the researcher was used to describe the participants and to measure select study variables such as age gender years of experience and the highest level of education.
The NSS scale was designed to measure the frequency in which hospitalnurseshad work-related sources of stress.
The NSS consists of 34 items that describe situations that have been identified as causing stress for nurses in the performance of their duties. The subscales measure workload uncertainty about treatment conflict with other nurses conflict with physicians inadequate preparation lack of support and death and dying. Responses are assessed on a 4-point Likert scale ranging from (1) never stressful (2) occasionally stressful (3) frequently stressful and (4) extremely stressful.
The PSS scale is used to measure the individuals perception of stress. The scale also includes a number of direct questions about current levels of experienced stress. The PSS consists of 10 questions. Each item is designed to identify how unpredictable uncontrollable or overloaded the respondent has found his/her life to be within the last month prior to completion of the tool. Responses are assessed on a 5-point Likert scale with 0as never 1 as almost never 2 as sometimes 3 as fairly often and 4 as very often. The PSS is scored by reversing responses (eg 0 = 4 1 = 3 2 = 2 3 = 1 and 4 = 0) to the 4 positively scored items (items 4 5 7 and 8) and then summing across the scale. A higher score indicated a higher level of perceived stress.
The WAYS scale measures coping processes. As the definitive coping measure the WAYS can assess and identify thoughts and actions that individuals use to cope with the stressful encounters of everyday living. It measures coping processes. The Ways of Coping Scale is a 66-item questionnaire where the subject responds on a 4-point Likert scale (0 = not used; 1 = used somewhat 2 = used quite a bit and 3 = used a great deal) indicating the frequency with which each strategy is used. Eight coping factors are measured by the WAYS of coping scale: confrontive coping distancing selfcontrolling seeking social support accepting responsibility escape-avoidance planful problem solving and positive reappraisal.
Through the process of convenience sampling participants were accessed from a 680-bed MagnetA hospital in a healthcare system in Miami Florida. This hospital has a total of 262 MS nurses who work on 6 MS units. A total of 5 MS units were included excluding the authors unit to avoid bias. The different units varied in turnover rate generational compositions and length of experience; however all these units reflected high nurse satisfaction scores as measured by the National Data Base of Quality Indicators RN survey.
Based on the research hypotheses stated for this study a power analysis was conducted for multiple regressionusing 4 predictors (yielded a sample size of 84) a bivariate correlation (yielded a sample of 84) and 1-way analysis of variance (ANOVA) using 3 independent groups (yielded a sample size of 159). It was anticipated that some questionnaires may be returned incomplete and therefore unusable. As a result a total of 200 questionnaires were distributed to achieve the desired sample size for this proposed study of 159. Therefore a convenience sample of 200 MS nurses who work at a 680-bed hospital in a Florida healthcare system was used for this study. MS nurses were used as this study sample because of inadequate amount of literature available describing this populations occupational stressors stress perception levels and coping styles. The sample consisted of MS RNs who worked mainly full-time 12 hours shift. The majority was females ranging in age between 21 and 61 years. Their years of experience ranged between 1 and 40 years. Most of them held a BSN. Gen X (31-51 years old) constituted 46.6% of the sample (see Table Supplemental Digital Content 1 http://links.lww.com/JONA/A356).
Prior to data collection approvals were obtained from the university and the hospitals institutional review board and from the chief nursing officer of the facility. A cover letter from the author was used to explain to participants the information related to the aims benefits potential risks data collection procedures and data management strategies data reporting and dissemination of the findings of the study. The researcher attended the MS unitsstaff meeting and posted flyers soliciting nurses participation. The researcher also visited the MS units for about 10 minutes biweekly to reach out to RNs who were not present at the staff meetings. The exclusion criteria were verbally explained to nurses using the cover letter and the flyer. Participants were asked to drop the sealed survey envelope in a locked box at the nursing station. The researcher collected data biweekly for an 8-week period.
Each participant was assured privacy and anonymity. Participants were informed that participation in this study is voluntary and that they could decline to participate at any point in the study without penalty. Potential participants were informed this was an exempted study and that a returned completed survey indicated consent to voluntarily participate. After reading the cover letter and agreeing to participate in the study the participants were given the cover letter and the questionnaire in an envelope along with a pen. The length of time to complete the questionnaire was estimated to be 35 to 45 minutes. Unit nurse managers agreed to grant time on the job for nurses to complete the questionnaire.
The questionnaire used to collect data included a researcher-developed demographic instrument with items to measure participant variables as well as 3 standardized instruments. The NSS scale was used to measure the frequency in which hospital nurses had work-related sources of stress13; the test-retest coefficient for the total scale was 0.81.13 The PSS scale was used to measure the individuals perception of stress14 ; reliability of the PSS was determined and the coefficient Cronbachs ! scores for each test respectively were .84 .85 and .86.16 Finally the WAYS scale was used to assess and identify thoughts and actions that individuals use to cope with the stressful encounters of everyday living15; reliability was determined and the 8 scales Cronbachs ! scores were as follows: confrontive coping (! = .70) distancing (! = .61 selfcontrolling (! = .70) seeking social support (! = .76) accepting responsibility (! = .66) escape-avoidance (! = .72) planful problem solving (! = .68) and positive reappraisal (! = .79).17
Findings of the Study:
Four hypotheses were tested. Statistical analyses included multiple regression bivariate correlation and 1-way ANOVA.
Hypothesis 1 sought to determine if the measure of stress perception among MS nurses was determined by scores on 4 predictors: occupational stressors age years of experience and educational level. The research hypothesis was accepted. Regression analysis found that 28.3% (R2 = 0.283 adjusted R2 = 0.265) of the variance in the dependent variable was explained by the model and that the relationship was significant F4 156 = 15.40 P = .00 (Tables 1 and 2). However examination of the weights revealed that occupational stressors were the only predictor that contributed to the model. Therefore occupational stressors such as workload death and dying and lack of support are predictors of the perceived stress level among this sample of RNs. The stress perception level is thus determined by the type of occupational stressor that the nurse is exposed to. However age years of experience and educational level of MS RNs were not determinant factors of the stress perception level.
Hypothesis 2 considered the correlational relationship between the scores for stress perception and those for ways of coping. The research hypothesis was accepted. As participants perception of stress increased so didtheir use of ways to cope with the stress. Bivariate correlation analysis found that ways of coping was significantly correlated with perception of stress r = 0.357 P G .00 (2-tailed). Therefore there was a positive correlation between the perceived level of stress and the use of the different ways of coping. The higher the stress perception level is among the nurses the higher the likelihood of using the ways of coping behaviors.
Hypothesis 3 considered differences in scores on the measure of perceived stress between the 3 age cohorts baby boomers Gen X and Gen Y. The research hypothesis was accepted. ANOVA determined that there was a significant difference in the scores for perceived stress between the age cohorts F2158 = 4.07 P = .02. Post hoc Tukey identified that the scores for perceived stress from the Gen X cohort differed significantly from those scores provided by the Gen Y cohort P = .02 with the Gen Y cohort reporting the higher level of perceived stress (Table 3). Based on these results Gen Y reported a higher level of perceived stress than did the Gen X and the baby boomers. The literature suggests that Gen Y expects immediate feedback and information.18 Gen Y does not know a time without the Internet and instant text messaging; therefore they crave stimulation and are easily bored leading them to expect instant gratification.18 Unlike Gen Y Gen X and baby boomers are more experienced and have been in the nursing profession for a longer time. Baby boomers are loyal and are willing to dedicate more time to their work than to their own families1 ; they have learned to adjust to difficult situations and new technologies.18 In addition the means of the relative scores for the 7 subscales for types of stressors were calculated and ranked in ascending order for the entire sample. The 2 most frequently reported occupational stressors were workload and death and dying (Table 4).
Hypothesis 4 considered differences on scores for the measure of ways of coping between the 3 age cohorts. The research hypothesis was rejected. ANOVA testing found there was no significant difference for the scores for ways of coping between the age cohorts of baby boomers (n = 22; mean 1.48 [SD 0.66]; SE 0.45) Gen X (n = 75; mean 1.33 [SD 0.38]; SE 0.04) and Gen Y (n = 64; mean 1.41 [SD 0.381]; SE 0.05) F2158 = 1.12 P = .33. The means of the relative scores for the 8 subscales for ways of coping were calculated and ranked in ascending order for the entire sample (Table 5).
The mean scores for the 8 subscales for the 3 age cohorts were then compared using 1-way ANOVA. There was a significance between the groups for escape-avoidance F2158 = 5.83 P = .00 and for self-controlling F2158 = 3.44 P = .03 (Table 6).
Post hoc Tukey was performed to determine which groups were different on the scores for escape-avoidance and self-controlling subscales. Gen Y reported higher use of escape-avoidance behaviors when dealing with stressfuleventscompared with Gen X and baby boomers. Given this result Gen Y tends to avoid the stressor than to try to face it. Baby boomers reported higher use of self-controlling behaviors when dealing with occupational stressors compared with Gen X and Gen Y. The higher age and years of experience of baby boomers may explain why self-controlling is a highly used way of coping among this age cohort.
A total of 161 nurses working in an MS environment in 1 hospital setting participated in this research. Fourhypotheses were tested. Occupational stressors were found to be a significant predictor for perceived stress but the demographic variables of age years of experience and educational level were not predictive of this criterion. The results showed that the higher the stress perception level the higher the nurses use of coping behaviors. The 2 most highly reported stressors among all MS RNs were workload and death and dying regardless of the generational differences. Gen Y reported the highest scores on the stress perception scale compared with the other 2 generations. There was no difference between the 3 age cohortsscores on the ways of coping scale. However when comparing the mean scores of the subscales Gen Y used escape-avoidance behaviors more frequently than did other generations while baby boomers used self-controlling behaviors more.
This study enables nurse leaders to identify the needs of individual employees in order to promote individual growth retention and work satisfaction. An essential element for nurse leaders is to create an environment with open communication because assumptions and criticism are often the cause of stress.18 In order for nurses to perform their jobs safely and proficiently hospitals and nursing administrators should create interventions to decrease nursesstress. Guidance emotional support and tangible assistance as well as various types of social support are needed so that nurses are able to balance their professional and personal lives.19 Nurse leaders can provide opportunities involving stress management programs for nurses in each age group especially Gen Y nurses.
Administrators in schools of nursing will be able to incorporate changes needed to foster learning in a high-stress environment. Identifying stress perception levels of each generation could benefit nursing students to help improve their performance outcomes which may lead to better retention rates at the school of nursing. Based on this study Gen Y reported the highest perception of stress levels. This information can be used to add stress management programs and courses to current academic programs in schools of nursing and hospitals.
It is hoped that this research will lead to further qualitative researches enabling nurse leaders to explore how each nursing generation acts in presence of workrelated stress. Supplying the nurse leaders with this information can help them support and assist nurses in each nursing generation when dealing with stress thus increasing nurse retention.
This study will also assist public health policy makers to identify work-related stress in the nursing workforce as a high priority. Findings may assist public health policy advocates to bring work-related stress and unhealthy work environment back to the front. Advocating for programs and initiatives that assist in creating a healthy and less stressful work environment should be a priority if leaders would like to retain the nursing workforce (Table 7).
Significance of the Study:
The results of this study provide data to inform nurse leaders regarding the recognition and development of coping skills among the generations in the nursing workforce. Using this information should assist in the retention of nurses as leaders deal with complex and challenging care issues. Nurse researchers may build on these findings and conduct future research further exploring the presence of stress and the differentiating issues among the generations of nurses in the workforce.
Nursing educators hospital leaders nursing researchers and public policy makers are expected torecognize the differences in occupational stressors perceived levels of stress and coping styles based on values and beliefs of baby boomer Gen X and Gen Y nurses in order to alleviate or reduce work-related stress among nurses. This in turn may result in improving quality of care and patient safety and outcomes and reducing nursing shortage and turnover.
The sample was one of convenience the participants were selected from 1 hospital and the selection process was dependent on accessibility of the sample to the researcher. Therefore generalizability of the results was limited. Also there is a likelihood that the respondents answered in a socially desirable manner knowing that the researcher is employed at the same organization. In addition the length of the questionnaires was a limitation because of the time constraint placed on the nurses. Nurses may not have completed the questionnaires as directed because of time pressure. Another possible limitation is lack of standardization of the conditions under which the research study is carried out such as the administration of the instruments. Another limitation would be the selection of the subjects. Each subject may differ from the other in age ability gender or racial/ethnic composition. In addition there is the possibility that some characteristics of the participants selected for the study interact with some aspects of the instruments. Examples of such characteristics could include prior experiences learning personality factors or any traits that might interfere with their responses to the questionnaires.
Implications for Nurse Leaders:
Reducing stress in nursing is an important subject that will improve patient safety nursing turnover staff satisfaction patient satisfaction and patient outcomes.20 Nurse leaders should be educated about the aspects of managing multiple generations in the workforce and techniques and programs that support the development of coping behaviors and skills among nurses. Identification of occupational stressors and the implementation of interventions to mitigate these are a key role for nurse leaders20 (see Document Supplemental Digital Content 2 http://links.lww.com/JONA/A357).
Findings from this study should lead to other quantitative and qualitative studies exploring the variables that can lead to a better understanding of the occupational stressors encountered by nurses their perceived levels of stress and the coping styles among the different generations. By exploring these variables it is hoped that nurse leaders will have a better understanding of each generations needs regarding occupational stress and that nurses will be empowered to make positive changes to their work environment and support the delivery of quality and safe patient care.