Coping Strategies Used by Registered Nurses in Acute and Critical Care Settings: A scoping review protocol

Abstract

Background & Purpose: Acute and Critical Care (ACC) settings are a highly demanding and specific environment for registered nurses (RNs) to provide care in, and the use of coping strategies is key to supporting their work-related well-being. However, currently, there is a lack of comprehensive evidence on how RNs in ACC settings, specifically, cope with work-related stressors. Therefore, this review will summarize the international literature on coping strategies RNs use in ACC settings to deal with work-related stressors.

Methods & Procedures: Scoping review using the JBI methodology. Databases to be searched include Medline, Embase, CINAHL, Web of Science, and Cochrane Library. The report will consider references if focused on the coping strategies RNs use to manage work-related issues in ACC settings worldwide. Quantitative, qualitative, experimental, and gray literature will be considered if relevant to our topic. Two independent reviewers will screen, extract, appraise, and analyze the reports. Tables, charts, and diagrams will be used as applicable for data presentation.

Expected results/discussion/conclusion: This review will provide comprehensive evidence on coping strategies RNs use in ACC settings to manage work stressors; such evidence will guide quality improvement strategies and tailored interventions aimed at improving working-related well-being among this population.

Keywords: critical care, nurses, coping strategies, organ donation.

Implications for Nurses

Registered nurses in acute and critical care settings often report challenges in developing healthy coping mechanisms despite those being essential in keeping their work-related well-being.

This review will provide comprehensive evidence on how coping strategies used by registered nurses in acute and critical care settings to manage work stressors.

Evidence will guide quality improvement strategies and tailored interventions to improve working-related well-being among this population.

Background

Registered nurses (RNs) in acute and critical care (ACC) settings provide care to critically ill patients in specialized fields of healthcare (Morton & Thurman, 2023). The working environment of RNs in ACC may include direct (e.g., bedside care in intensive care units, cardiac care units, surgical units, burn units, and emergency departments) (Hewett, 2019; Green & McIntyre, 2011) or indirect care (e.g., RNs working in deceased organ donation settings as organ donation coordinators) (Silva e Silva et al., 2020). ACC settings are high-pressure and demanding environments that can introduce many stressors to the practice of healthcare professionals, resulting in workplace stress (Morton & Thurman, 2023). The Canadian Centre for Occupational Health and Safety (2018) defined workplace stress as “the harmful physical and emotional responses that can happen when there is a conflict between job demands on the employee and the amount of control an employee had over meeting these demands” (para. 2).

Substantial metanalytical findings report a high prevalence of work-related stress among RNs in ACC settings (Epp, 2012; Hiler et al., 2018; Milutinović et al., 2012; Vahedian-Azimi et al., 2019). Stressors faced by RNs in ACC have diverse origins, including but not limited to moral distress, fast-paced environment, high complexity of critically ill patients, lack of knowledge and continuous contact with grieving and human suffering (Epp, 2012; Hiler et al., 2018; Milutinović et al., 2012; Vahedian-Azimi et al., 2019). In addition, unique stressors were introduced and/or exacerbated for ACC RNs during the COVID-19 pandemic, such as high workloads and nursing shortages, which have impacted both their professional and personal lives (Gamble et al., 2022; Kissel et al., 2023; Martin et al., 2023). Constant exposure to work-related stress and emotional demands from work in ACC often leave RNs susceptible to work-related issues such as burnout and compassion fatigue and may result in reduced work-related well-being, increased turnover and decreased quality of life (Alharbi et al., 2020; Silva e Silva et al., 2022; Friganović et al., 2019).

Coping strategies play a key role in helping nurses to manage work-related stress, build resilience and reduce the incidence of work-related issues (Burgess et al., 2010; Gomes et al., 2013; Zhang et al., 2020). According to the American Psychological Association (2018):

Coping strategies can be defined as “an action, a series of actions, or a thought process used in meeting a stressful or unpleasant situation or in modifying one’s reaction to such a situation. Coping strategies typically involve a conscious and direct approach to problems, in contrast to defense mechanisms” (para. 1).

 Coping strategies may be considered healthy (e.g. relaxing or distracting activities, social support), unhealthy (e.g. negative self-talk, substance use), or a combination of both, depending on the consequences of their use and whether they lead to positive or negative effects in the long-term (Lu et al., 2015; Stallman et al., 2021). Despite the importance of adopting healthy coping strategies, nurses often report difficulty developing healthy mechanisms to support them (Hersch et al., 2016; Zheng et al., 2018). Therefore, we need to understand what forms of coping mechanisms are used by RNs and some of the barriers and facilitators for these techniques.

Although there is a substantial amount of research conducted on coping strategies among nurses (Chong & Abdullah, 2016; Iwanowicz-Palus et al., 2022; Kim et al., 2021; Temeng et al., 2023; Zhang et al., 2020; Zheng et al., 2018), to our knowledge, there is a lack of evidence specifically on how RNs in ACC settings utilize coping strategies to support their role and help manage work-related stress. Since ACC RNs provide care in such unique environments, it is important to consider their individualized use of coping mechanisms to understand how to support them best. Such evidence can help guide clinicians and researchers on improving RNs in ACC coping mechanism use, resilience and work-related well-being and minimizing job turnover and negative consequences resulting from work-related stress. Therefore, this scoping review aims to summarize the international literature on the coping strategies RNs use in ACC to deal with work-related stressors.

A preliminary search was conducted at MEDLINE, Prospero, Epistemonikos, Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, and Open Science Framework to locate similar works, including published reviews or undergoing protocols. The searches revealed review evidence available among RNs and coping (Lim et al., 2010a; Lim et al., 2010b); however, none specific to RNs in ACC settings were identified. In addition, a limited review was undertaken to associate burnout, coping strategies and job satisfaction among RNs in ACC (Friganović et al., 2019). Thus, despite somewhat existing work, there is a need for comprehensive reviews to summarize the international literature on the topic, including the different coping strategies and their impact on RNs in ACC.

Review questions

Overarching research question:

What reported coping strategies have been used by RNs working in ACC settings worldwide to deal with work-related stressors?

Specific research questions:

What resources are available for RNs working in ACC settings to support the implementation of healthy coping strategies?

How have RNs in ACC settings been supported by their employers to develop healthy coping strategies?

Was there any education provided to RNs in ACC on how to implement healthy coping strategies, and how was it delivered?

How has the use of unhealthy coping strategies impacted job performance and/or the development of work-related issues?

Inclusion criteria

Participants

This scoping review will consider documents with a target population of RNs in various roles providing direct care to patients and their families in ACC settings. The job title and education of RNs will be reviewed from the applicable sources (if available) to ensure that only those who are employed and working as RNs are selected. Some examples of job titles that may be considered include RN, senior nurse, nurse manager, staff nurse, charge nurse, or those with a diploma, bachelor’s, master’s or higher degrees that are required to become an RN.

Concept

The main concept of interest in this review is coping strategies used to deal with work-related stressors. The terms used to describe our concept of interest can vary and may include coping mechanisms, adaptation techniques, stress management strategies, emotional regulation methods, resilience-building approaches, psychological defence mechanisms, mindfulness, cognitive behaviour therapy, arts-based therapy, self-regulation, self-compassion, progressive muscle relaxation training, arts-based debriefing, grounding, coping skills, etc. These terms were identified during our brief review of the literature when describing coping mechanisms used by RNs.

Context

References will be considered if they are focused on ACC settings, such as Acute Care Units, Emergency Rooms, Organ Donation, Intensive Care Units, Critical Care, Cardiac Care, Operating Rooms, Paediatric Intensive Care Units, Burn Units, Emergency Medical Services and others. These were some of the more commonly identified critical care settings identified within the literature on ACC settings (Green & McIntyre, 2011; Hewett, 2019).

Types of sources

This scoping review will consider experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies, will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports and descriptive cross-sectional studies for inclusion. Qualitative studies will also be considered that focus on qualitative data, including but not limited to designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research. Text and opinion papers will also be considered for inclusion in this scoping review.

Exclusion Criteria

The search will be restricted to literature published from 2000 onwards to provide information regarding recent developments; those published before this time will be excluded. Documents exploring coping strategies among various healthcare providers (along with RNs) but not differentiating the results for nurses from those providers will be excluded as the aim was to analyze mechanisms specifically used by RNs. Lastly, sources focused on nursing students will not be considered.

Methods

Scoping review guided by the Joanna Briggs Institute (JBI) methodology for scoping reviews (Peters et al., 2021). The title of the review was registered at the JBI collection (JBI, 2022) and Open Science Framework (Silva & Silva e Silva, 2024). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) will be used to guide the reporting of this review (Page et al., 2020).

Search strategy

The search strategy is being developed to locate both published and unpublished studies. An initial limited search of MEDLINE was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each database and/or information source, including Embase, CINAHL, Web of Science, and Cochrane Library. Studies published in any language will be included.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote20, and duplicates will be removed. Then, all unique reports will be imported into Covidence for data management, screening, and extraction. Titles and abstracts of located sources will be screened by two independent reviewers for assessment against the inclusion criteria for the review. A pilot review will first be performed between these two independent reviewers to ensure consistency of at least 90% between the screening. Two independent reviewers will then assess the full text of potentially relevant citations in detail against the inclusion criteria. Reasons for excluding sources that do not meet the inclusion criteria at the full-text level will be recorded and reported in the scoping review. Any disagreements between the reviewers at each stage of the selection process will be resolved through discussion or with an additional reviewer.

Data extraction

Data will be extracted using the data extraction tool developed for this review, which includes aspects relevant to our research questions, such as the coping strategies used, potential effectiveness, and others. The data extraction tool (Appendix II) will be pilot-tested for this review, and all extractions will be performed by an independent reviewer and peer-reviewed by a second reviewer. Any disagreement during the extraction process will be resolved through discussion or with the input of the first author as the third reviewer.

Data analysis and presentation

The data extracted will be analyzed quantitatively and qualitatively. Quantitative analysis will include a simple numerical count to describe the characteristics of studies and reports. Qualitative analysis will include an inductive content analysis approach of the extracted data to find the consensus and organize the report into major categories. Lastly, tables, charts, and diagrams will also be used as applicable for data presentation to help clarify key aspects and describe the significant findings from the review.

Expected results

This review will provide comprehensive evidence on coping strategies RNs use in ACC settings to manage work stressors; such evidence will guide quality improvement strategies and tailored interventions aimed at improving working-related well-being among this population.

Quality Appraisal

Two independent reviewers will thoroughly assess the methodological quality and relevance of the selected literature using the Mixed-Method Appraisal Tool (MMAT) (Hong et al., 2018). An additional reviewer will resolve any disagreements between reviewers.

Potential Limitations

Despite the potential of this review, some limitations may impact our findings. The publication bias may skew results towards studies with positive outcomes, potentially overlooking unsuccessful coping strategies. The heterogeneity of included studies regarding methodologies and populations may hinder direct comparisons. Moreover, the generalizability of results may be limited due to variations in healthcare systems and cultural contexts across different regions. Furthermore, the dynamic nature of coping strategies and the possibility of incomplete assessment may not fully capture the evolving landscape of RNs’ coping mechanisms in ACC settings. Despite these limitations, efforts have been made to mitigate bias and provide a comprehensive synthesis of available evidence.

Acknowledgments

The authors would like to thank information specialists Dagmara Chojecki and Ian Gordon, who supported the development and implementation of the search strategies, and Brock University, who supported the resources needed to develop this protocol.

Funding

This study is funded by Canadian Blood Services; Canadian Blood Services receives funding from the provincial and territorial Ministries of Health and the federal government through Health Canada.

Conflicts of Interest

Amina Silva, Vanessa Silva e Silva, and Kendra-Lee Dupuis have no conflict of interest to declare; Lee James and Ken Lotherington receive a salary from Canadian Blood Services, and Sonny Dhanani is a hospital donation physician paid by Ontario Health.

References

Alharbi, J., Jackson, D., & Usher, K. (2020). Personal characteristics, coping strategies, and resilience impact on compassion fatigue in critical care nurses: A cross‐sectional study. Nursing & Health Sciences, 22(1), 20-27.

American Psychological Association. (2018). APA Dictionary of Psychology: Coping strategy. https://dictionary.apa.org/coping-strategy.

Burgess, L., Irvine, F., & Wallymahmed, A. (2010). Personality, stress and coping in intensive care nurses: a descriptive exploratory study. Nursing in Critical Care, 15(3), 129-140. https://doi.org/10.1111/j.1478-5153.2009.00384.x

Canadian Centre for Occupational Health and Safety. (2018). Health Promotion/Wellness/Psychosocial. Retrieved from https://www.ccohs.ca/oshanswers/psychosocial/stress.html

Chong, L. & Abdullah, A. (2016). Community palliative care nurses’ challenges and coping strategies on delivering home-based pediatric palliative care: A qualitative study. American Journal of Hospice and Palliative Medicine, 34(2), 125-131. doi: http://doi-org.proxy.library.brocku.ca/10.1177/1049909115607296

Epp, K. (2012). Burnout in critical care nurses: A literature review. Dynamics, 23(4), 25-31.

Friganović, A., Selič, P., & Ilić, B. (2019). Stress and burnout syndrome and their associations with coping and job satisfaction in critical care nurses: A literature review. Psychiatria Danubina, 31(suppl. 1), 21-31.

Gamble, K., Murthy, S., Silverberg, S.L., Gobat, N. & Puchalski Ritchie, L.M. (2022). Canadian critical care nurses experiences on the front lines of the COVID-19 pandemic: A qualitative descriptive study. BMC Nursing, 21, 330. doi: 10.1186/s12912-022-01105-8

Gomes, S. d. F. S., Santos, M. M. M. C. C. d., & Carolino, E. T. d. M. A. (2013). Psycho-social risks at work: Stress and coping strategies in oncology nurses. Revista Latino-Americana de Enfermagem, 21, 1282-1289. doi: 10.1590/0104-1169.2742.2365

Green, R.S. & McIntyre, J. (2011). The provision of critical care in emergency departments in Canada. Journal of Emergencies, Trauma, and Shock, 4(4), 488-493. doi: 10.4103/0974-2700.86638

Hersch, R. K., Cook, R. F., Deitz, D. K., Kaplan, S., Hughes, D., Friesen, M. A., & Vezina, M. (2016). Reducing nurses’ stress: A randomized controlled trial of a web-based stress management program for nurses. Applied Nursing Research, 32, 18-25. doi:10.1016/j.apnr.2016.04.003

Hewett, D. (2019). Fast facts for the critical care nurse. (2^nd Ed.). Springer Publishing Company. doi: 10.1891/9780826177216

Hiler, C. A., Hickman Jr, R. L., Reimer, A. P., & Wilson, K. (2018). Predictors of moral distress in a US sample of critical care nurses. American Journal of Critical Care, 27(1), 59-66. https://doi.org/10.4037/ajcc2018968

Hong, Q.N., Pluye, P., Fabregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, MP., Griffiths, F., Nicolau, B., O’Cathain, A., Rousseau, MC. & Vedel, I. (2018). Mixed Methods Appraisal Tool (MMAT) Version 2018. doi: 10.3233/EFI-180221

Iwanowicz-Palus, G., Mroz, M., Kowalczuk, K., Szlendak, B., Bien, A. & Cybulski, M. (2022). Nurses coping with stressful situations: A cross-sectional study. International Journal of Environmental Research and Public Health, 19(17), 1-11. doi: doi.org/10.3390/ijerph191710924

Joanna Briggs Institute. (2022). Systematic Review Register. doi:https://jbi.global/systematic-review-register

Kim, Y.H, Kang, Ya., Ok, J. H. & Choe, K. (2021). Expert nurses’ coping strategies in ethically challenging situations: A qualitative study. BMC Nursing, 20(1). https://doi-org.proxy.library.brocku.ca/10.1186/s12912-021-00709-w

Kissel, K.A., Filipek, C. & Jenkins, J. (2023). Impact of the COVID-19 pandemic on nurses working in intensive care units: A scoping review. Critical Care Nurse, 43(2), 55-63. doi: 10.4037/ccn2023196

Lim, J., Bogossian, F., & Ahern, K. (2010a). Stress and coping in Australian nurses: A systematic review. International Nursing Review, 57(1), 22-31. https://doi.org/10.1111/j.1466-7657.2009.00765.x

Lim, J., Bogossian, F., & Ahern, K. (2010b). Stress and coping in Singaporean nurses: A literature review. Nursing & Health sciences, 12(2), 251-258.

Lu, D.-M., Sun, N., Hong, S., Fan, Y.-y., Kong, F.-y., & Li, Q.-j. (2015). Occupational stress and coping strategies among emergency department nurses of China. Archives of Psychiatric Nursing, 29(4), 208-212. https://doi.org/10.1016/j.apnu.2014.11.006

Martins, B., Kaminski-Ozturk, N., O’Hara, C. & Smiley, R. (2023). Examining the impact of the COVID-19 pandemic on burnout and stress among U.S. nurses. Journal of Nursing Regulation, 14(1), 4-12. doi: 10.1016/S2155-8256(23)00063-7

Milutinović, D., Golubović, B., Brkić, N., & Prokeš, B. (2012). Professional stress and health among critical care nurses in Serbia. Arhiv za higijenu rada i toksikologiju, 63(2), 171-179.

Morton, P. G., & Thurman, P. (2023). Critical care nursing: A holistic approach: Lippincott Williams & Wilkins.

Page, M., McKenzie, J., Bossuyt, P., Boutron, I., Hoffmann, T., & Mulrow, C. (2020). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. MetaArXiv. 2020. In.

Peters, M. D. J., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2021). Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Implementation, 19(1), 3-10.

Silva, A. & Silva e Silva, V. (2024). Coping Strategies used by registered nurses in acute and critical care settings: A scoping review. doi: 10.17605/OSF.IO/QMK2V

Silva e Silva, V. Hornby, L., Almost, J., Lotherington, K., Appleby, A., Silva, A.R., Rochon, A. & Dhanani, S. (2020). Burnout and compassion fatigue among organ and tissue donation coordinators: A scoping review. BMJ Open, 10(1-8). doi: 10.1136/bmjopen-2020-040783

Silva e Silva, V., Hornby, L., Lotherington, K., Silva, A., Rochon, A., Sarti, A., & Dhanani, S. (2022). Uncovering work-related problems among organ donation coordinators: The BRiC Research Program. Transplantation, 106(9S), S315.

Stallman, H.M., Beaudequin, D., Hermens, D.F. & Eisenberg, D. (2021). Modelling the relationship between healthy and unhealthy coping strategies to understand overwhelming distress: A Bayesian network approach. Journal of Affective Disorders Reports, 3, 1-7. doi: https://doi.org/10.1016/j.adr.2020.100054

Temeng, E., Hewitt, R., Pattinson, R., Sydor, A., Whybrow, D., Watts, T. & Bundy, C. (2022). Nurses’ coping strategies caring for patients during severe viral pandemics: A mixed-methods systematic review. Journal of Clinical Nursing, 33, 242-254. doi: 10.1111/jocn.16711

Vahedian-Azimi, A., Hajiesmaeili, M., Kangasniemi, M., Fornes-Vives, J., Hunsucker, R. L., Rahimibashar, F., Pourhoseingholi, M.A., Farrokhvar, L. & Miller, A. C. (2019). Effects of stress on critical care nurses: A national cross-sectional study. Journal of Intensive Care Medicine, 34(4), 311-322. doi: 10.1177/0885066617696853

Zhang, Y., Wang, C., Pan, W., Zheng, J., Gao, J., Huang, X., Cai, S., Zhai, Y., Latour, J.M. & Zhu, C. (2020). Stress, burnout, and coping strategies of frontline nurses during the COVID-19 epidemic in Wuhan and Shanghai, China. Frontiers in Psychiatry, 1154. doi: 10.3389/fpsyct.2020.565520

Zheng, R., Lee, S. F., & Bloomer, M. J. (2018). How nurses cope with patient death: A systematic review and qualitative meta‐synthesis. Journal of Clinical Nursing, 27(1-2), e39-e49. doi: 10.1111/jocn.13975

Appendix I – Search Strategy Medline

Database(s): Ovid MEDLINE(R) ALL 1946 to July 05, 2023
Search Strategy:

Appendix II – Data Extraction Tool

Return to Spring/Summer 2024 Journal