Accepted: 8 November 2017

DOI: 10.1111/jocn.14165

REVIEW

Stress and ways of coping among nurse managers: An

integrative review

Leodoro J Labrague RN, DM, Lecturer1 | Denise M McEnroe-Petitte PhD, RN, Associate
2
Professor | Michael C Leocadio RN, DNM, Professor3 | Peter Van Bogaert PhD, RN,
Professor4 | Greta G Cummings PhD, RN, FAAN, Professor5

1
Sultan Qaboos University, Muscat,
Sultanate of Oman
Aims and objectives: To appraise and synthesise empirical studies examining
2
Kent State University, Tuscarawas, Ohio, sources of occupational stress and ways of coping utilised by nurse managers when
USA dealing with stress.
3
Emilio Aguinaldo College, Manila,
Background: The Nurse Manager’s role is challenging yet draining and stressful and
Philippines
4
University of Antwerp, Antwerp, Belgium has adverse consequences on an individual’s overall health and well-being, patients’
5
University of Alberta, Edmonton, AB, outcomes and organisational productivity. Considerable research has been carried
Canada
out; however, an updated and broader perspective on this critical organisational
Correspondence issue has not been performed.
Leodoro J Labrague, Sultan Qaboos
Design: An integrative review.
University, Al Khoudh, Muscat, Oman.
Email: leo7_ci@yahoo.com Methods: Five databases (Cumulative Index to Nursing and Allied Health Literature,
SCOPUS, PubMed, PsychINFO and MEDLINE) were searched to identify relevant
articles. Search terms and MeSH terms included: “charge nurse,” “coping,” “coping
strategy,” “coping style,” “psychological adaptation,” “psychological stress,” “stres-
sors,” “nurse manager” and “unit manager.” Twenty-two articles were included in
this review. Reporting followed the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses statement guidelines.
Results: Four themes were identified: moderate stress levels, common sources of
stress, ways of coping and the impact of nurses’ characteristics on stress.
Conclusions: Nurse managers experienced moderate levels of stress mainly from
heavy workloads, lack of resources and financial responsibilities. Enhancing social sup-
port and promoting job control were seen as important in reducing work stress and its
related consequences. Additional studies using a more rigorous method and a larger
sample size preferably in multicultural settings would shed more light on this topic.
Relevance to clinical practice: Hospital and nurse administrators play an important
role in promoting supportive structures for daily professional practice for nurse
managers through staffing, organisational resources, support services, leadership and
stress management training.

KEYWORDS
charge nurse, coping, coping strategy, coping style, nurse manager, psychological adaptation,
psychological stress, stressors, unit manager

1346 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:1346–1359.
LABRAGUE ET AL. | 1347

1 | INTRODUCTION
What does this paper contribute to the wider
Occupational stress remains as an important organisational issue global clinical community?
confronting nursing professionals due to its adverse consequences
• Findings of this review have added new knowledge on
on staff outcomes and patient safety. Nurse managers (NMs) just
the current psychological states in NMs, which could
like other staff nurses are not immune and are susceptible to work-
potentially guide hospital administrators in the formula-
related stress (Kath, Stichler, Ehrhart, & Sievers, 2013; Udod & Care,
tion and implementation of interventions to address
2011; Warshawsky & Havens, 2014). Today’s nurses’ work environ-
stress as an important nursing management issue.
ment is characterised by increasing healthcare complexity, poor
• Enhancing social support and promoting job control were
staffing, ever changing patients’ care needs and the expanding role
seen as important in the light of the various stressors
of NMs have contributed significantly to the stress experiences in
that confronts NMs.
NMs. Moreover, NMs have to deal with several personalities both in
• Highlights the need for interventions aimed at developing
the upper and lower levels of management in the organisation or
job resources in NMs particularly in terms of job control
unit with different perspectives and competing values (McSherry,
and social support.
Pearce, Grimwood, & McSherry, 2012; Pegram, Grainger, Sigsworth,
& While, 2014).

O’Brien-Pallas, Murphy, Shamian, Li, & Hayes, 2010) and eventually

1.1 | Review of literature
their productivity (Hayes et al., 2012). Chronic stress in NMs may
Nurse managers are key players in the healthcare setting and play also have implications on how they effectively manage work envi-
a tremendous role in creating a healthy work environment where ronments for their subordinates in their units and sustain leadership
nurses are able to provide quality and safe patient care while within healthcare settings (Steege, Pinekenstein, Arsenault Knudsen,
achieving organisation goals and outcomes (McSherry et al., 2012). & Rainbow, 2017).
However, the current healthcare situation is alarming as many hos- While there is evidence of growing literature on stress and cop-
pitals are besieged to recruit and retain NMs as a result of the glo- ing among NMs around the globe, a wider perspective on this
bal shortage of nurses, which continuously poses a major threat to topic is scarce. To date, only one study was located synthesising
the hospitals’ ability to sustain quality nursing care to patients and studies on stress and coping among NMs from 1980–2003 (Shirey,
sustain staff outcomes. This situation is further aggravated by the 2006). Although the review of the findings by Shirey (2006) is
increasing number of NMs who are leaving or intending to leave enthralling, since then, several studies have been published. With
their current job due to occupational stress and burnout. In a the rapid advancement in the healthcare system and the expanding
study, involving 291 NMs working in the United States (USA) acute of the role NMs, an updated study synthesising and appraising
care hospitals, about 62% reported planning to leave their jobs recent research studies on this topic is critical. Such perspective is
within the next 2–5 years with stress and burnout as the primary vital to fully understand these experiences among NMs and to for-
reason (Warshawsky & Havens, 2014). Therefore, organisational mulation scientifically tested interventions to reduce stress and
efforts must be made to keep and maintain this vital nursing work- enhance coping. Nursing administration must take into considera-
force. tion that NMs are not created when they graduate from any level
Available evidence suggested that one in every six NMs experi- of nursing education programmes. Nurse managers need to grow
ence occupational stress and burnout (Van Bogaert, Adriaenssens, in the organisation and additionally be mentored in their specific
et al., 2014) from various stressors such as role conflict, work/time roles to be effective for the unit and overall healthcare facility.
pressure, job overload, role ambiguity, inadequate social support, Therefore, this review is a vital step in the development and imple-
inadequate leadership and organisational constraints (Brown, Fraser, mentation of interventions and strategies to reduce or prevent
Wong, Muise, & Cummings, 2013; Kath, Stichler, Ehrhart, & Schultze, stress among NMs and to enhance their positive coping mecha-
2013; Kath, Stichler, Ehrhart, & Sievers, 2013; Udod & Care, 2011). nisms.
Persistent exposure and failure to manage stress are associated with
negative consequences on an individual such as fatigue, emotional
exhaustion, work dissatisfaction, turnover intention and poor mental 2 | AIMS
health (McVicar, 2016). Persistent exposure to stress not only affects
negatively the health of NMs, but also with their decision-making This is an integrative review which critically appraised and synthe-
process that may potentially affect staff, patients and organisational sised empirical studies examining sources of occupational stress and
outcomes (Shirey, Ebright, & Mc Daniel, 2013). Other studies linked ways of coping utilised by NMs when dealing with stress. Further,
work stress with higher incidence of medical errors, adverse patient this review identified gaps in the existing literature to inform and
events and errors, low quality of patient care (North et al., 2013; determine future research.
1348 | LABRAGUE ET AL.

3 | METHODS 3.3 | Search criteria

Articles were selected based on the following inclusion criteria: (i)
3.1 | Design
peer-reviewed publications of original research examining stress and
An integrative review of the literature was undertaken. This review coping among NMs, (ii) had been published from 2000 onwards (iii)
method is considered as the broadest research review method as it and written in the English language. In this review, Nurse Manager is
allows for inclusion and synthesis of research with varying method- defined as licensed nurses holding the title of a unit manager, ward
ologies to facilitate understanding of research topics relevant to manager, first-line nurse managers, charge nurse or ward sister, and
nursing and healthcare and to identify gaps in the research (Whitte- is in charge of at least one patient care unit. Nurse executives and
more & Knafl, 2005). The review analysis method included a rigorous nurse directors were excluded in this study as they have limited con-
and a systematic approach of the process such as (i) identification of tact with staff nurses within the ward or unit.
the problem, (ii) systematic search of literature, (iii) comprehensive
examination or evaluation of data, (iv) data analysis and (v) data pre-
3.4 | Search outcome
sentation. Reporting followed the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analyses) statement guideli- The initial search yielded 301 papers. Article titles and abstracts
nes (Moher, Liberati, Tetzloff, & Altman, 2009). were screened and matched against the inclusion criteria resulting in
102 studies. After examining the methodological quality of the arti-
cles, 22 were identified to be relevant to the review.
3.2 | Search strategy
Six bibliographic electronic databases were searched to obtain rele-
3.5 | Methodological quality appraisal and level of
vant studies such as CINAHL, Medline, Psych Info, ERIC, EMBASE
evidence
and SCOPUS. A database search was performed in December 2016
to locate studies published from 2000 onwards. Search terms and To appraise the methodological quality of the quantitative and quali-
MeSH terms included: “charge nurse,” “coping,” “coping strategy,” tative articles included in the review, the authors utilised the Qual-
“coping style,” “psychological adaptation,” “psychological stress,” Systs, a systematic review tool developed by Kmet, Lee, and Cook
“stressors,” “nurse manager” and “unit manager.” Further, manual (2004). The tool incorporates two scoring systems (for quantitative
searching of publications through reference lists was carried out to and qualitative studies) to systematically assess the quality of
identify additional sources. Figure 1 shows the PRISMA flow dia- research encompassing a broad range of study designs and consisted
gram utilised in searching and selection of the relevant literature. of 10 indicators in which a score of zero to two were assigned. The

CINAHL, SCOPUS, PubMed, Hand search of literature

PsychINFO
Identification

(n = 12)
MEDLINE
(n = 289)

All records
(n = 301)
Screening

Titles and abstracts screening

(n = 257)
Papers excluded because titles and
abstracts not meet the selection criteria
(n = 155)
Eligibility

Full text screening

(n = 102)
Papers did not meet the selection
criteria
(n = 80)
Included

Studies included in the F I G U R E 1 PRISMA flow diagram

review utilised in identifying references for the
(n = 22) review [Colour figure can be viewed at
wileyonlinelibrary.com]
LABRAGUE ET AL. | 1349

quality of quantitative primary articles was appraised by evaluating The sample sizes ranged from 5–2616 with a response rate that
its research questions or objectives, research design, connection to a ranged from 26%–97.4%.
theoretical framework, methods, subjects and subject selection, In the quantitative studies, a variety of scales were used to mea-
appropriateness of sample size, analytical method or data analysis, sure stress. In the qualitative inquiries, data were collected through
presence of estimate variances in the outcomes and appropriateness in-depth questioning, semistructured interviews, telephone inter-
of conclusions. The quality of qualitative studies was determined by views and focus group interviews. In this review, more than 50% of
its research questions or objectives, appropriateness of research the studies had no reliability details and did not report validity infor-
design, description of the study context, connection to a theoretical mation. In studies reporting reliability, Cronbach’s alpha ranged from
framework, sampling strategy, data collection method, description of 0.46–0.98 (see Tables 1 and 2 for the characteristics of studies
the analytical method, use of verification procedure, conclusions and included).
reflexivity of the account.
Finally, the hierarchy of evidence developed by Melnyk, Fineout-
4.2 | Participants characteristics
Overholt, Stetler, and Allan (2005) was used to determine the level
of evidence for each study. The hierarchy of evidence is categorised In the studies reporting participant age range, the average age was
into seven levels: Level I (evidence from systematic reviews or meta- between 31–62 years old. The average work experience as a nurse
analysis of relevant clinical trials), Level II (evidence derived from at manager ranged from 1–11.8 years. Sampled nurses worked from var-
least one well-delineated randomised controlled trial), Level III ious healthcare settings such as acute secondary hospitals, university
(well-delineated clinical trials without randomisation), Level IV hospitals, general hospitals, older people and long-term care facilities.
(well-delineated cohort and case–control studies), Level V (systematic
reviews of descriptive and qualitative studies), Level VI (evidence
4.3 | Methodological quality score and level of
derived from a single descriptive or qualitative study) and Level VII
evidence
(the opinions of authorities or report of expert committees).
Using the QualSysts, the quality score of quantitative studies in this
review ranged from 85%–100% and 85%–95% for qualitative studies
3.6 | Data extraction and synthesis
of a possible score of 100% (see Table 1). Most quantitative studies
Following quality appraisal, data extraction was performed by the showed limitations with regards to sampling size, inadequacy of vari-
first and second author (LJL and DMP) who are specialised in the ance estimates in the outcomes and incomplete description of sub-
field of nursing administration and management. The following vari- ject selection. For the qualitative studies, common issues were lack
ables were extracted from each article: (i) authors, (ii) research of philosophical underpinning and reflexivity in the study report. In
design, (iii) samples/response rate, (iv) instruments, (v) key findings, this review, quality scores were not used to exclude studies. Regard-
(vi) country and (vii) quality score/level of evidence (Table 1). ing the level of evidence, all studies were of low quality (level of evi-
A thematic analysis approach to data synthesis was adopted fol- dence VI).
lowing the technique used by Braun and Clarke (2006). A systematic
approach consisting of six steps was undertaken: familiarisation of
4.4 | Themes
data, generating initial codes, searching for themes, reviewing
themes, defining and naming themes, and producing the report of Four themes were identified in the review: moderate stress levels,
the analysis. The overarching themes were discussed, reviewed and common sources of stress, ways of coping and the impact of nurses’
agreed by all members of the research team. Discussions were con- characteristics on stress. Further, based on the thematic analysis, we
ducted between the authors to come to a consensus on the most identified the taxonomy of stressors and coping styles among NMs
suitable structure and names for the themes. including examples of concepts under each domain (see Table 3).

4 | RESULTS 4.5 | Levels stress in NMs

Four studies reported levels of stress in NMs (Admi & Eilon-Moshe,
4.1 | Study characteristics
2016; Judkins, Massey, & Huff, 2006; Kath, Stichler, Ehrhart, &
Twenty-two studies published from 2000 and beyond were Schultze, 2013; Kath, Stichler, Ehrhart, & Sievers, 2013). Using the
included in this review. Twelve (54%) studies used a quantitative Charge Nurse Stress Questionnaire (CNSQ), stress levels in NMs
design and the remaining studies (45%) with a qualitative design. from three countries (Thailand, Israel and USA) were compared. The
About 50% of the studies were conducted in the USA (n = 5, 24%) mean stress level of all samples was 2.84 indicating moderate levels
and Canada (n = 6, 29%), and the remaining studies were from of stress; however, when countries were compared individually, sig-
various countries including Belgium, Sweden, China, United Arab nificantly higher stress levels were found in Thai charge nurses
Emirates, Japan and the UK. One study was conducted in three (M = 2.96, SD = 0.67) and low in Israeli nurses (M = 3.32, SD = 0.70;
countries: Israel, USA and Thailand (Admi & Eilon-Moshe, 2016). Admi & Eilon-Moshe, 2016). Work experience and higher academic
 1350

T A B L E 1 Summary of quantitative studies on NMs stress and coping

|

Quality
Score/Level
Authors Research design Samples/Response rate Instruments Key findings Country of Evidence
1. Adriaenssens Cross-sectional N = 318 nurse managers Brief Symptom Inventory • Job demands explained 8% of variance with better-perceived Belgium 100%/
et al. (2017) Design Response Rate = 66.1% (de Beurs & Zitman, 2005) work/time pressure related to lower levels of psychosomatic Level VI
Cronbach’s alpha = 0.85 distress
• A more positive perception of decision authority was related
to less psychosomatic distress
• A positive perception of social support from the staff members
was found to be predictive of lower levels of psychosomatic
distress
2. Admi and Cross-sectional N = 2,616 charge nurses Charge Nurse Stress Questionnaire • Mean stress level of the total sample was 2.84 implying Israel, USA, 95%/
Eilon-Moshe Design Response Rate = (Admi & Eilon-Moshe, 2016) moderate level of stress. Thai charge nurses had higher Thailand Level VI
(2016) 26% to 83% Cronbach’s alpha = 0.46–0.84 stress levels, and the Israelis had lower stress
• Responsibility burden contributed to higher stress in
Thai nurses, while lack of resources was the leading
stressor in US and Israeli samples
• Stress levels decrease with age and
experience in Israel and Thailand
• Higher stress was found among nurses with
6 to 10 years of experience in US samples
• Higher stress was found among younger
nurses with 6 to 10 years of experience in Thailand
3. Jamal and Cross-sectional N = 67 nurse Job Stress Scale • Job stress correlated with overall burnout and its Canada 90%/
Baba (2000) Design manager,/173 nurses (Parker & De Cotiis, 1983) three dimensions among managers and nurses Level VI
Response rate = 89% Cronbach’s alpha = 0.85 • Female nurses with high job stress experienced
more health problems than male nurses in similar situations
• Job stress significantly negatively correlated with
job satisfaction organisational
commitment in the nursing samples
• Job stress was significantly positively correlated
with psychosomatic health problems in the nursing sample
4. Johansson Cross-sectional N = 64 first-line Webb-Questionnaire for • Approximately 10–15% of first-line managers and Sweden 95%/
et al. (2013) Design managers/908 Psychological and nurses reported signs of being at risk Level VI
nurses Social Factors at Work (Hasson, for stress-related ill health
Arnetz, Theorell, & Anderberg, 2006) • 6% of the first-line manager reported that they
Cronbach’s alpha = 0.73 to 0.84 felt sad or distressed about their job most or all of the time
• First-line managers reported being able to cope with
these demands without a greater risk of stress-related symptoms
• Both samples reported that they could
handle job stress effectively
LABRAGUE

(Continues)
ET AL.
TABLE 1 (Continued)
Quality
Score/Level
LABRAGUE

Authors Research design Samples/Response rate Instruments Key findings Country of Evidence
ET AL.

5. Judkins Cross-sectional N = 16 nurse Perceived Stress Scale (PSS) (Cohen, • NMs reported moderate to high stress levels USA 85%/
et al. (2006) Design managers Kamarck, & Mermelstein, 1983) • NMs reporting low stress used 35% fewer sick hours Level VI
Cronbach’s alpha = 0.53 than their low hardiness, low stress counterparts
• NMs reporting high hardiness and high stress used
57% fewer sick hours than those reporting low
hardiness and low stress
• NMs reporting high hardiness and high stress used
33% fewer sick hours than the high hardiness
and low stress group
6. Hewko Cross-sectional N = 95 nurse managers Researcher-designed tool • Common stressors were: work overload or work–life balance Canada 90%/
et al. (2015) Design Response rate = 33% inability to ensure quality patient care, insufficient resources Level VI
and lack of empowerment and recognition
7. Kath, Stichler, Cross-sectional N = 392 nurse Stress in General Scale (Stanton, • Mean score was 3.66 indicating moderate USA 95%/
Ehrhart and Design/Online managers Balzer, Smith, Parra, & Ironson, 2001) levels of subjective stress Level VI
Sievers (2013) survey Subjective Stress Scale (Motowidlo, • Role overload, organisational constraints and role
Packard, & Manning, 1986) ambiguity were the best predictors of stress
Cronbach’s alpha not reported • Personal variables did not predict stress
• Nurse leaders who were stressed but reported
higher autonomy experienced higher job satisfaction,
higher organisational commitment and fewer mental
health symptoms
8. Kath, Stichler, Cross-sectional N = 480 nurse managers Subjective Stress • Job stress mean was 3.66 suggesting USA 95%/
Ehrhart and Design Response rate = 75.5% Scale (Motowidlo et al., 1986). moderate stress levels Level VI
Schultze (2013) Cronbach’s alpha = 0.75 • Role overload, organisational constraints and
role conflict predicted job stress in NMs
• Organisational constraint and role conflict
accounted 7% and 6% of the variance in stress scale
9. Kath Cross-sectional N = 393 nurse managers Stress in General (SIG) Scale • NMs reported high levels of stress, USA 95%
et al. (2012) Design Response rate = 9.8% (Stanton et al., 2001) although stress decreased with age Level VI
Cronbach’s alpha = not reported • Autonomy was the most effective buffer,
followed by social support and predictability
10. Luan Comparative N = 79 head nurses and Nurse Job Stressors Inventory • Job stress rate for senior nurses was China 85%/
et al. (2017) design 145 senior nurses Scale (Li & Liu, 2000) higher than for head nurses Level VI
Cross-sectional Response Rate = 97.4% Cronbach’s alpha = 0.98 • Time allocation and workload problems
Design rated highest for both groups among the subscales
• Job stress correlated positively with burnout
(Continues)
|
1351
 1352 | LABRAGUE ET AL.

education in the Israeli samples than Thai were seen as important in

Score/Level
of Evidence
explaining these variations. In the USA, Judkins et al. (2006) exam-

Level VI

Level VI
Quality

100%/

90%/
ined stress levels in 16 NMs working in large tertiary hospitals using
the Perceived Stress Scale (PSS). The mean PSS score was 33.1
(SD = 3.9) out of a possible mean score of 56 indicating moderate
Country
Belgium

stress levels. Similar findings were seen in two separate studies by

China
Kath, Stichler, Ehrhart, & Schultze (2013), Kath, Stichler, Ehrhart, &
Sievers (2013). Kath, Stichler, Ehrhart and Sievers (2013) examined
job stress levels in NMs who were members of the Association of
Women’s Health, Obstetrics and Neonatal Nursing (AWHONN) using
the Subjective Stress Scale (SSS) through an online survey. The mean
SSS score was 3.66 (SD = 0.85) in a scale of 1–5 suggesting moder-
• Coping strategies were from positive reappraisal,

• Age correlated negatively with workplace stress ate levels of subjective stress. Similarly, a moderate stress levels
• Sources of stress were from workload, death/

were obtained in one study involving 480 NMs from 36 acute care
• Work/time pressure, decision authority and
social support were found to nursing unit
• Job characteristics were related to work

hospitals in the USA (Kath, Stichler, Ehrhart, & Schultze, 2013).

planful problem-solving and self-control
managers’ work-related stress and

dying and conflict with physician

stress in nursing unit managers

4.6 | Sources of stress

well-being as hypothesised

4.6.1 | Job demand

Several studies (59%) identified higher job demands and heavy work-
loads as being important in explaining stress experience in NMs
Key findings

(Admi & Eilon-Moshe, 2016; Adriaenssens, Hamelink, & Van Bogaert,

€m, H€aggstro
2017; Akkela & Leca, 2015; Hagerman, Engstro € m,
Wadensten, & Skytt, 2015; Hewko, Brown, Fraser, Wong, & Cum-
mings, 2015; Kath, Stichler, Ehrhart, & Schultze, 2013, Kath, Stichler,
Ehrhart, & Sievers, 2013; Kelly, Lankshear, & Jones, 2016; Luan,
Wang, Hou, Chen, & Lou, 2017; Miyata, Arai, & Suga, 2015; Shirey,
(Gray-Toft & Anderson, 1981)

McDaniel, Ebright, Fisher, & Doebbeling, 2010; Van Bogaert, Tim-

(de Beurs & Zitman, 2005).

Cronbach’s alpha = 0.843

Cronbach’s alpha = 0.89
Brief Symptom Inventory

mermans, et al. 2014; Xianyu & Lambert, 2006). Out these studies,
five utilised a cross-sectional design using validated scales. For
Nursing Stress Scale

instance, in two separate studies conducted in China, NMs identified

several factors that caused significant stress; workload problems
Instruments

were rated highest among the different stressors followed by time

allocation, and dealing with physicians (Luan et al., 2017; Xianyu &
Lambert, 2006). Kath, Stichler, Ehrhart and Schultze (2013), Kath,
Stichler, Ehrhart and Sievers (2013) examined individual and work
N = 540 nurse managers
Samples/Response rate

Response Rate = 68%

environment factors that contributed to stress experience in NMs in

the USA using the Job Stress Scale (JSS). Work overload explained
• N = 92 nurse

for 13% of the variance in the JSS. Other factors that predicted
managers

stress in NMs were organisational constraints, role conflict and role

ambiguity. Using a researcher-designed scale, Hewko et al. (2015)
surveyed 95 NMs from different healthcare facilities in Canada to
assess factors that contributed to their turnover intentions and psy-
Research design
Cross-sectional

Cross-sectional

chological distress, finding work overload, imbalance in work–life,

lack of resources and lack of recognition as main contributors.
Design

Design
(Continued)

Similarly, “heavy workloads” as the main source of stress in NMs

were also observed in three studies utilising a qualitative approach.
11. Van Bogaert,

Lambert (2006)

For example, Akkela and Leca (2015) explored work-related stress in

12. Xianyu and
Adriaenssens,

Timmermans,
Van Bogaert,
et al. (2014),

et al. (2014)

Romanian NMs working in selected hospitals in United Arab

TABLE 1

Emirates using a hermeneutic phenomenological approach. Nurse

Authors

managers reported being stressed mainly from heavy workloads fol-

lowed by the organisational environment, dealing with staff and the
T A B L E 2 Summary of qualitative studies on NMs stress and coping
LABRAGUE

Samples/ Quality Score/Level

ET AL.

Authors Research design Response rate Instruments Key findings Country of evidence
13. Akkela and Hermeneutic N = 10 nurse In-depth, • Sources of stress originate from: organisational environment, heavy UAE 85%/Level VI
Leca (2015) Phenomenological managers semistructured, workload, interpersonal relationships and the place itself
Approach face-to-face
interview
14. Hagerman Qualitative N = 14 nurse Content Analysis • Sources of stress were: not having a balance between their perceived Sweden 90%/Level VI
et al. (2015) Design managers responsibilities, structural conditions and the organisational demands,
budget responsibility and conflicts of interest and organisational politics
15. Miyata Qualitative N = 15 nurse Semistructured • Three descriptive themes related to nurse managers’ stressors were identified: Japan 85%/Level VI
et al. (2015) Exploratory managers interviews (i) role overload, (ii) loneliness and (iii) role conflict
Descriptive • Ways of coping with stress included: sufficient support and advice, taking
Design mental breaks when off duty (awareness of the importance of taking time
off recognising physical symptoms, such as fatigue, and use of
individual coping strategies
16. Kelly Grounded N = 40 nurse Semistructured • Chronic stressors included workload, financial pressures, unclear role boundaries, UK 95%/Level VI
et al. (2016) Constructivist managers telephone lack of corporateness and feelings of vulnerability. Acute stressors listed by
Study interviews respondents included patient complaints or unexpected evidence of suboptimal
care, crisis situations and service relocation
• Strategies to maintain resilience included: personal factors, intra-organisational
support systems and external relationships
17. Keys Qualitative N = 16 generation 9 Semistructured • Stress was from inflexible organisational cultures, a lack of opportunities for USA 90%/Level VI
(2014) Design nurse managers interviews upward mobility, the need to be available at all times and feeling
stereotyped or undervalued
18. Shirey Qualitative N = 21 nurse Content • Sources of stress fell into two categories: issues related to actual nurse USA 95%/Level VI
et al. (2010) Descriptive managers Analysis manager work (specific responsibilities related to the role) and issues
Design surrounding nurse manager work (peripheral issues that arise in the role)
• NMs used a combination of both emotion-focused (those strategies
dealing with negative emotions) and problem-focused (those strategies
for solving specific stress-related problems) strategies
• Health related outcomes of stress were feeling overwhelmed,
heightened sense of awareness
19. Udod and Qualitative N = 5 nurse In-depth • Common stressors were financial responsibilities, inadequate Canada 90%/Level VI
Care (2011) Design managers Questioning human resources, managing others, interpersonal distress, middle
management roles and competing priorities
• Main coping ways were peer and supervisor support, cognitive
coping strategies, and social and personal strategies
(Continues)
|
1353
 1354 | LABRAGUE ET AL.

country itself. In Japan, Miyata et al. (2015) conducted a semistruc-

Quality Score/Level
tured interview in 15 NMs to determine their sources of stress and

90%/Level VI

95%/Level VI

85%/Level VI
coping strategies. Three common sources of stress were identified:
of evidence

work overload that accompanied their position, the responsibility of

managing of unit-related issues and problems, and dealing with
organisational and staff expectations and demands. Similar finding
was noted in one study in the UK (Kelly et al., 2016). Stress origi-
Country
Canada

Canada

Canada
nated mainly from workloads along with dealing with patient com-
plaints, managing crisis situations and service relocation.
In a study, including 21 NMs from US acute care hospitals, NMs
• Six descriptive themes emerged from identified stressors: fiscal responsibilities,
inadequate human resources, managing others, intrapersonal distress, middle

• Three descriptive themes emerged from coping strategies: peer and superior

reported a significant amount of stress as a consequence of higher

• Coping strategies utilised were planful problem-solving, reframing situations
senior management’s disconnection, adhering to regulations and standards,

• Sources of stress were from working with limited resources, responding to

• Common stressors reported were categorised into themes: working with

responsibilities relative to their role and other issues and concerns

limited resources, responding to organisational change, putting out fires,

continuous change within organisational work complexities, and senior

support, cognitive coping strategies and social and personal strategies

that arise in the performance of this role (Shirey et al., 2010). In two
separate studies in Belgium, an increase in job demands inherent
from their role as NMs along with significant workloads, time pres-
• Ways of coping included: planful problem-solving, reframing sures and lower decision authorities explained significant variances
in the psychological stress levels in NMs (Adriaenssens et al., 2017;
Van Bogaert, Timmermans, et al. 2014). In addition, not being able
to handle organisational responsibilities and heavy administrative
and having social support from all directions

management’s disconnection from practice

management role and competing priorities

workloads caused significant stress in NMs as it significantly affected

and being pulled in different directions

their core work responsibilities in the nursing unit (Hagerman et al.,

situations and having social support

2015). A similar finding was found in Thai nurses where job demands
contributed to their high stress perceptions (Admi & Eilon-Moshe,
2016).

4.6.2 | Resources management

Key findings

Five studies reported a lack of or inadequate resources as the main

source of stress in NMs (Admi & Eilon-Moshe, 2016; Hewko et al.,
2015; Udod & Care, 2012; Udod, Cummings, Care, & Jenkins, 2017;
Udod, Udod, et al., 2017). For instance, Udod and Care (2012) iden-
Interviews, FGD
Interview, FGD

tified a lack of qualified staff to meet quality patient care as one of

Semistructured

the top stressors among NMs. In a cross-country, comparative study,

Instruments

Individual
Analysis

US and Israeli NMs rated a “lack of resources” as the top leading

Content

stressor with means of 2.92 and 2.77, respectively (Admi & Eilon-
Moshe, 2016). Three qualitative studies yielded similar findings. A
Web survey in Canada reported higher turnover intention, lower job
satisfaction and higher stress levels in NMs as a consequence of fre-
Response rate

N = 17 nurse

N = 23 nurse

quent exposure to stress-inducing situations such as inadequate

N = 5 nurse
managers

managers

managers
Samples/

human/fiscal resources, heavy workloads and an insufficient ability

to ensure providing of quality care (Hewko et al., 2015). In two
recent studies in Canada, the majority of sampled NMs identified
working with inadequate financial and human resources in their daily
Research design

unit operation to manage patient care as their top source of stress

Exploratory

Exploratory

(Udod, Cummings, Care, & Jenkins, 2017; Udod, Udod, et al., 2017).
Qualitative

Qualitative

Qualitative
Inquiry

Inquiry
Design
(Continued)

4.6.3 | Financial management

Care and Jenkins
20. Udod & Dean

21. Udod, Udod,

Few studies reported issues related to organisational budget or

et al. (2017)
Care (2012)

finances as the main source of their stress (Hagerman et al., 2015;

Cummings,
TABLE 2

22. Udod,

Kelly et al., 2016; Udod & Care, 2012). For example, in Sweden,
Authors

(2017)

NMs reported having full responsibility of their unit’s budget yet

they were excluded in the budgeting process. In addition, NMs were
LABRAGUE ET AL. | 1355

T A B L E 3 Taxonomy of stressors and coping styles among NMs

Constructs Dimension Concepts
Determinants Job Demand High professional requirements due to leadership position and administrative workload;
of Stress management of unit demands and challenges; and pressure from balancing organisational and
staff demands and expectations
Resource challenges Lack of qualified or competent healthcare providers; fiscal or financial limitations and
structural inadequacies
Financial competence Poor financial decisions due to nonexposure; nontraining and/or limitations in understanding
and management financial management; and pressure to function within financial limitations despite further
healthcare requirements
Coping Decision latitude or control Positive perceptions of authority; ability to control situations; and independent decision-making
Strategies Organisational support Professional (formal, mostly from administrators and direct supervisors) and personal support
(informal, colleagues, staff nurses and mentors) within organisations which increases the coping
mechanism of NM

often pressured to remain within the allocated budget despite the demonstrated positive outcomes. These findings suggest that it is
increase in the number of patient care needs (Hagerman et al., important to encouraged hospital administrators to develop empiri-
2015). A major stressor identified in a qualitative study by Udod and cally tested strategies to increase decision authority in NMs (Kath,
Care (2012) were concerned mainly with the financial management. Stichler, Ehrhart, & Sievers, 2013).
All NMs reported having trouble understanding the budgeting pro-
cess and financial management which often lead to difficulty in for-
4.7.2 | Organisational support
mulating financial decisions for the unit. In one study in the UK,
NMs had to deal with staffing problems and limited resources which A number of returned papers examined coping strategies employed
undermined the quality of patient care due to fiscal austerity as a by NM to mitigate and manage stress effectively. Of the 22 studies
consequence of long-standing financial crisis in the country (Kelly reviewed, seven reported the use of “intra-organisational support” as
et al., 2016). the most frequently utilised coping method in NMs (Adriaenssens
et al., 2017; Kelly et al., 2016; Miyata et al., 2015; Udod & Care,
2012; Udod, Cummings, Care, & Jenkins, 2017; Udod, Udod, et al.,
4.7 | Ways of coping
2017; Van Bogaert, Timmermans, et al., 2014). In a study involving
318 first-line nurse managers, a perception of social support from
4.7.1 | Decision latitude or control
other staff contributed to their lower levels of occupational stress
In four studies, higher job control or decision authorities were and the intent to leave the organisation (Adriaenssens et al., 2017).
associated with lesser occupational stress and higher occupational In one study, increased social support from supervisors and staff
well-being in NMs (Adriaenssens et al., 2017; Johansson, Sandahl, & were strongly linked with increased job engagement, job satisfaction,
Hasson, 2013; Kath, Stichler, & Ehrhart, 2012; Van Bogaert, Timmermans, lower turnover intentions and work stress (Van Bogaert, Timmer-
et al. 2014). Adriaenssens et al. (2017) examined predictors of work- mans, et al., 2014).
related stress and occupational well-being in four hundred and Similar findings were observed in the qualitative studies that
eighty-one (481) Belgian NMs. Decision authority explained 9% of were reviewed. In a semistructured interview in 15 NMs from five
the variance in psychosomatic distress indicating lesser occupational hospitals in Japan, three coping strategies were identified by the
stress in NMs who had adequate decision-making authority. A study respondents. Sufficient support from other staff, from their adminis-
by Van Bogaert, Timmermans, et al. (2014) yielded similar findings. trators, and nursing directors was cited as critical to mitigate and
Work-related characteristics such as lower work/time pressure and manage stress at work followed by taking mental breaks and imple-
higher perceptions of decision authority were associated with lesser menting individual coping strategies (Miyata et al., 2015). In a
work stress and turnover intention, higher work engagement and grounded constructivist study by Kelly et al. (2016), involving 40
higher job satisfactions in NMs. In a study, including 64 first-line NMs from different healthcare settings, intra-organisational support,
NMs at a university hospital in Sweden, 81% reported having control that is support from the chief executive and medical director, and
over the tasks they were performing. Such higher levels of job con- access or support from a trusted colleague were cited as important
trol led to significant reduction in the effects of the stressful work sources of support to cope and maintain resilience against stress.
environment in NMs (Johansson et al., 2013). In the USA, decision Qualitative inquiries in Canada yielded similar findings where support
authority moderated the negative effects of subjective stress on job from top and lower management was cited as one of the top coping
satisfaction, turnover intention and mental health in NMs. Nurse strategies employed to deal with stressors (Udod, Cummings, Care,
managers who had high stress and high levels of decision authority & Jenkins, 2017; Udod & Care, 2012; Udod, Udod, et al., 2017).
1356 | LABRAGUE ET AL.

validated, were not specific assessing stress and coping in NMs. Psy-
4.7.3 | Impact of nurses’ characteristics on stress
chometric properties of the instruments used were seldom reported
Few studies examined the relations of NM’s stress experience with in many studies appraised. As reliability and validity of the scales are
their demographics and other constructs such as work satisfaction, critical issues in the use of measurements as it reflect the extent to
organisational commitment, health status and job burnout. In a multi- which an instrument measures the construct of interest (Benett,
country study by Admi and Eilon-Moshe (2016), younger Israeli 1993), this may have had an effect on the reliability and generalisa-
nurses with fewer years of work experience as charge nurses had tion of the review findings. Further, among quantitative studies, only
significantly higher stress than those with experienced nurses one study (Luan et al., 2017) conducted power analysis to determine
(p < .01) with longer experience as charge nurses (p < .01). In Thai the sample size, and in the remaining studies, convenience samplings
and the US samples, higher stress levels were found in nurses with were employed. These factors when considered may give a different
6–10 years of charge nurse experience. In addition, Thai charge perspective about the subjects (stress and coping) being studied and
nurses having diploma degrees experienced significantly higher stress may affect the review outcomes.
levels than those with Bachelor of Science (BS) or master’s degree Of great concern was that all of the studies reviewed utilised a
(p < .0001). Both Admi and Eilon-Moshe (2016) and Xianyu and cross-sectional research design. Folkman and Lazarus (1988) argued
Lambert (2006) found that an increase in nurses’ ages decreased that stress and coping evolved overtime as a consequence of individ-
stress levels, while Jamal and Baba (2000) found higher stress levels ual adaptation. The fact that 50% of the studies in the review were
in female nurses when compared to male nurses. Conversely, in cross-sectional warrants further research using a longitudinal design
some studies, personal variables such as monthly income, number in to track changes in the stress and coping across time.
the household, years or experience as NMs (Kath, Stichler, Ehrhart, Stress and coping are profoundly affected by the number of fac-
& Sievers 2013; Xianyu & Lambert, 2006) and gender (Admi & Eilon- tors such as individual characteristics, individual resources, value sys-
Moshe, 2016) did not yield significant contributions to their stress tem, personality, support system and environmental or organisational
experiences. context (Edwards, 1988; Persike & Seiffge-Krenke, 2016). These
factors may guide in the selection of appropriate strategies to help
reduce stress and enhance coping among NMs; however, in the cur-
5 | DISCUSSION
rent review, only very few studies considered these factors. More-
over, findings of this review showed that only one study (Luan et al.,
5.1 | Future research directions
2017) was conducted examining how coping skills reduced stress in
This systematic review appraised and synthesised available evidence NMs.
examining sources of occupational stress and ways of coping utilised
in NMs. A total of 22 studies consisting of 12 quantitative studies
5.2 | Review findings
and 10 qualitative studies informed our findings. While we found
some evidence demonstrating considerable stress levels in NMs, cau- Despite the varying scales used to identify stress and coping in
tion should be observed when interpreting the review findings due NMs, a common finding among articles reviewed is the perceptions
to absence of high-quality evidence for review. Methodological of moderate levels of stress among NMs. Specifically, NMs experi-
limitations such as lack of statistical power, inadequacy of variance enced higher job demands mainly from heavy workloads, low deci-
estimates in the outcomes, presence of confounding factors, lack of sion authority, inadequate resources and financial responsibilities.
philosophical underpinning and lack of reflexivity in the study report Further, a higher job control in terms of decision authority was
some studies reviewed may threaten the credibility, reliability and associated with lower psychological distress. Nurse managers play a
trustworthiness of the review findings. pivotal role in the healthcare organisation in the provision of high-
Although most studies were conducted from different countries, quality care and in the achievement of organisation outcomes
the majority of the studies were conducted in Western countries (McSherry et al., 2012). In addition, NMs are directly involved in a
and all but one (Admi & Eilon-Moshe, 2016) considered the cultural wide range of activities in the units from directing nursing activities
background of each study when interpreting the findings. Few stud- of staff nurses to complex administrative functions (McSherry et al.,
ies suggested that the meaning of job control and social support var- 2012; Shirey, 2006). Nurse managers are also actively engaged in
ied according to countries and cultures (Ibrahim & Ohtsuka, 2014; dealing with higher and lower management managers (McSherry
Verhoeven, Maes, Kraaij, & Joekes, 2003); therefore, more research et al., 2012; Pegram et al., 2014). These tasks are daunting and
is needed to further validate how culture influences stress experi- could be potential sources of stress. The findings corroborated with
ences and coping mechanisms in NMs. those in the previous studies and have theoretical implications. First,
Several gaps in the research methodology were identified in this the findings of this review are in agreement with previous studies
review that may affect the generalisation, comparison, validity and associating the lack of manpower and material resources, heavy
reliability of findings. An important aspect that warrants attention in workloads, performance expectations, higher work/time pressure,
this review was the utilisation of diverse scales used for data collec- low job control, low perceptions of social support, role conflict and
tion across the studies. In addition, some instruments used, although role meaningfulness to NMs perceptions of stress (Kath et al., 2012;
LABRAGUE ET AL. | 1357

Shirey et al., 2010; Van Bogaert, Adriaenssens, et al., 2014). Second, 7 | RELEVANCE TO CLINICAL PRACTICE
evidence linking to decision authority and occupational stress was
thus confirmed and supports the Demand–Control–Support (DCS) Measures to manage stress and enhance coping in NMs are of para-
Model. mount importance in light with the tremendous role NMs play in
Based on the DCS Model, persistent exposure to high job fostering the work environment that enables nurses to work effi-
demands such heavy workloads, inadequate resources and financial ciently in order to achieve positive outcomes in patients and the
responsibilities could potentially harm the health and well-being of organisation. The suggested taxonomy of stressors and coping styles
an individual and the organisation; however, adequate job resources in this review may guide hospital and nursing administrators in for-
such as job control (decision authority) can serve as a buffer to mulating empirically tested strategies to reduce and prevents stress
counter the negative effects of high demand (Aronsson et al., and enhance coping in NMs.
2017; Hessels, Rietveld, & van der Zwan, 2017; Schaufeli, Bakker, As heavy workloads were cited as the leading cause of stress,
& Van Rhenen, 2009). Hospital administrators may consider this workloads of NMs need to be revisited and possibly reduced. For
model in formulating interventions aimed at preventing occupa- instance, core functions of the NMs such as direct clinical supervision
tional stress by strengthening and enhancing job control among of their staff and provision of staff support may be enhanced by reduc-
NMs. ing administrative functions. The addition of “charge nurses” on each
It can be gleaned from this review that NMs utilised positive shift with managerial responsibilities for the day to day running of the
coping strategy mainly from social support (from staff and superi- unit for the shift assigned may be helpful. This could also include such
ors). According to Folkman and Lazarus (1988), the use of social areas as personnel evaluations, mentoring of staff members and assist-
support as a way of coping with stress is an effective means of ing with financial measures. In addition, assigning of staff nurses to
dealing with stress as it targets the cause of stress thus offering such areas as quality improvement data collection, follow-up phone
long-term stress relief. It is strongly linked with positive health out- calls postdischarge, placing of staff nurses and other ancillary staff on
comes in an individual. Additionally, in the DCS Model, adequate various committees such as new products, performance improvement,
social support is considered to be an important job resource along and a safety committee, may not only assist with lessening the work-
with job control as it moderates the negative impact of high job loads of both the NMs and charge nurses, but also allow those who
demands on stress reactions by interacting with job stressors (Kara- participate in these committees or tasks, become “valued for their con-
sek & Theorell, 1990). Mounting evidence showed that social sup- tributions” to the unit and overall the healthcare facility.
port from supervisors and co-workers are good predictors of Provision of relevant trainings for NMs to enhance career planning
occupational stress in the nursing population (Blanco-Donoso, Gar- skills, leadership skills, financial and budgeting skills, and decisions mak-
nez, 2017; Schaufeli et al., 2009).
rosa, Demerouti, & Moreno-Jime ing skills may better prepared them for their role and deal effectively
Adequate social support is also linked to lower depressive symp- with various organisational stressors in the workplace. Involving NMs in
toms and lower turnover intentions and has the potential to budgeting and strategic planning processes in the unit may promote cul-
enhance employee competence and professional growth (Saijo ture of shared accountability and decision-making. The NMs should be
et al., 2016). Interventions aimed at reducing work-related stress in specifically involved in the day to day staffing of the unit, purchases and
NMs should be directed towards strengthening social support, thus future budgetary needs of the unit must be considered.
reducing stress and enhancing their overall health (Schaufeli et al., The reviewed findings also highlight the need for interventions
2009). aimed at developing job resources in NMs particularly in terms of
job control and social support. This can be achieved through positive
working relationships, staffing adequacy, higher job autonomy and
6 | CONCLUSION adequate organisational support services (Aiken et al., 2011; Laschin-
ger, Nosko, Wilk, & Finegan, 2014; Purdy, Spence, Finegan, Kerr, &
Findings of this integrative review added new knowledge on the cur- Olivera, 2010). Critical in creating a work environment for NMs is a
rent psychological states in NMs which could potentially guide hos- strong nursing and hospital leadership that supports daily profes-
pital administrators in the formulation and implementation of sional practice and well-being in NMs (Van Bogaert, Adriaenssens,
interventions to address this important nursing management issue. It et al., 2014; Van Bogaert, Timmermans, et al., 2014). In addition,
can be inferred from this review that NMs experience moderate hospital and nurse leaders play an important role in promoting sup-
levels of stress mainly from heavy workloads, lack of resources and portive structures for daily professional practice in NMs. Stress man-
financial responsibilities. Enhancing social support and promoting job agement programmes are critical to prevent the physiological and
control were seen as important in the light of the various stressors psychological consequences of stress in an individual and will ulti-
that confronts NMs. However, further studies, preferably in multicul- mately improve the quality of patient outcomes.
tural settings, using a more rigorous method and larger sample size
would shed more lights on this topic. The need for the development
CONFLICT OF INTEREST
of a unified survey tool that can adequately evaluate stress and cop-
ing in NMs may be necessary. The authors report no actual or potential conflicts of interest.
1358 | LABRAGUE ET AL.

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