Download - Stress and coping in hospice nursing staff. The impact of attachment styles

Stress and coping in hospice nursing staff. The impact ofattachment styles

Andrew C. Hawkins1, Ruth A. Howard2* and Jan R. Oyebode2

1 Birmingham & Solihull Mental Health NHS Trust, UK2 The University of Birmingham, UK

* Correspondence to: ClinPsyDCourse, School of Psychology,The University of Birmingham,Edgbaston, Birmingham, B152TT, England, UK. E-mail:[email protected]

Abstract

Previous research suggests that the attachment style developed during childhood informs adult

attachment styles, which in turn affects adult relationships and responses to stress. This study

considers the sources of stress in hospice nurses and addresses the potential impact of their

attachment styles on stress and coping experiences. Adult attachment style, stress and coping

were measured in 84 nurses recruited from five hospices.

The results supported previous research regarding the most common sources of stress in this

nursing group. The study found partial support for the hypothesis that nurses with insecure

attachment styles experience more stress than securely attached nurses. Hospice nurses with a

fearful or dismissing attachment style were found to be less likely to seek emotional social

support as a means of coping with stress than hospice nurses with a secure or preoccupied

attachment style.

Supervision, support and career-long training for nurses in hospices are recommended.

Further research is needed to clarify the involvement of attachment style in hospice nurse stress

and coping experiences.

Copyright # 2006 John Wiley & Sons, Ltd.

Keywords: cancer; nurse; stress; coping; attachment

Background

Nurse stress in the National Health Service

Research has highlighted stress as a significantproblem for nurses and the National HealthService [1–3]. Stress has been found to contributeto burnout, mental health problems, absence fromwork, recruitment difficulties and poor health caredelivery [4–7].

Staff stress in hospice/palliative care settings

Relatively few studies have investigated hospicenurse stress and coping, and findings to date havebeen equivocal [8–11]. Research suggests thesenurses experience at least moderate levels ofwork-related distress [12,13], but not necessarilyhigher levels than other nursing specialties [14].Exposure to the death and dying of patients, nursesfeeling inadequately prepared to deal with theemotional needs of patients and their families, andorganisational factors such as high workload, lackof resources and lack of support have been foundto be significant sources of stress for hospice nurses[15–18].In line with changes in the nursing profession,

the recent organisational climate of hospice nursinghas placed a greater influence on providing

emotional support to patients and their families,and an increased emphasis on developing a close,intimate and holistic relationship with patients[11,19–24]. A number of studies have highlightedthe significance nurses place on their relationshipswith patients [25–28].

It has been suggested that without the provisionof adequate support, this ‘New Nursing’ [29]approach could pose new, personal challenges fornurses, with potential implications for their well-being [30–32].

Attachment theory

A potential source of stress for hospicenurses involves the exposure to a rapid succes-sion of deaths and, hence, the multiple makingand severing of attachments with patients[21,33].

Cancer patients are extremely vulnerable and,because of this vulnerability, often enter into aclose relationship with their caregivers. In movingtoward emotional closeness with a patient, thenurse perceives the patient’s problem from thepatient’s perspectives and develops empathy, whichcan assist the nurse with interactions with thepatient. The disadvantage of this kind of relation-ship for the nurse, however, is that if the patient

Received: 28 September 2005

Revised: 2 March 2006

Accepted: 15 March 2006

Copyright # 2006 John Wiley & Sons, Ltd.

Psycho-OncologyPsycho-Oncology 16: 563–572 (2007)Published online 27 September 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1064

dies, the nurse must deal with the painful effects ofloss, separation and termination [34].

Attachment theory was originally developed by

Bowlby [35–37] to understand the child’s tie to the

main caregiver and the effects of its disruption

through separation, deprivation and bereavement.

Bowlby [38] defined attachment as ‘the propensity of

human beings to make strong affectional bonds to

particular others’ (p. 201).

Three types of attachment style were observed in12-month-old children: secure (66% of sample),insecure–avoidant (20%), and insecure-ambivalent(12%). These were characterised by differingresponses to separation and reunion with theirmothers [39]. These attachment styles and distribu-tions have since been consistently confirmed.

Adult attachment

A fundamental tenet of attachment theory is thatthe attachment style developed in the infant-carerrelationship influences future relationships,through the internalisation of these relationshipexperiences [36,40–43].Bartholomew [44] proposed a four-category

model of adult attachment (see Figure 1), whichhas since received considerable empirical support[45–47]. According to Bartholomew [43] adultswho develop a positive model of other people asbeing potentially available and supportive andthemselves as worthy of acceptance and supportcan be categorised as securely attached. Secureindividuals are comfortable using others as asource of support when needed. Individuals whodevelop a positive model of others but a negativemodel of self are categorised as preoccupied.Preoccupied adults become preoccupied with theirattachment needs and actively attempt to get theneeds for acceptance and approval met in closerelationships. This often leads to an overlydependent style. Bartholomew includes two sub-types of anxious-avoidant attachment styles: fear-ful and dismissing. Individuals who hold a negativemodel of self and a negative model of others are

termed fearful. Adults who have developed apositive model of self but a negative model ofothers are categorised as dismissing. Fearful anddismissing adults have been found to avoid closecontact and seeking social support from othersespecially under conditions of stress as they havelearnt that other people are not a source of security[37,43,48,49].

The impact of attachment styles on mental health

Attachment styles may contribute to later inter-personal functioning and emotional self-regulation[50–54]. Adults with a secure attachment style aregenerally more resilient in stressful situations,experience greater emotional health, greater levelsof perceived social support, better work adjust-ment, and adopt more adaptive strategies forcoping with negative affect than insecurely at-tached adults [53,55,56]. Individuals who hadinsecure attachments to their parents as childrenmay be at risk for complicated bereavementexperiences later in life [21] or long-term physiolo-gical and neuro-biological stress responses [57].According to Holmes [58], mental health might

be influenced by attachment relationships through3 distinct pathways:

1. The disruption or breaking of bonds, beingtraumatic, may lead to disturbance

2. Future relationships may be detrimentallyaffected by internalised disturbed early attach-ment patterns, making the individual moreexposed and vulnerable to stress

3. A person’s current perception of theirrelationships and consequent use of them maymake the person more vulnerable to stress in theface of adversity.

Health care professionals’ attachment styles

Little research has been carried out into the effectsof health care professionals’ attachment style ontheir occupational wellbeing. Leiper and Casares[59] found that the attachment style of clinicalpsychologists impacted on their approach to, andexperience of, clinical practice.Although attachment styles were not specifically

investigated in her longitudinal study of juniordoctors, Firth-Cozens [60] found that negativeperceptions of early family relationships andadverse early family events related to later occupa-tional stress. She suggested that investigations intoearly family life were warranted in occupationalstress research.

Aims

Firstly, this study aims to build upon previousstudies investigating sources of stress and coping

Positive Model of Other

SECURE PREOCCUPIED

Positive Model of Self

Negative Model ofSelf

DISMISSING FEARFUL

Negative Model of Other

Figure 1. Diagrammatic summary of Bartholomew’s [44]model of adult attachment

Copyright # 2006 John Wiley & Sons, Ltd. Psycho-Oncology 16: 563–572 (2007)

DOI: 10.1002/pon

564 A.C. Hawkins et al.

strategies adopted by hospice nursing staff. Sec-ondly, this study investigates the potential impactof hospice nurses’ attachment styles on theirexperience of stress and coping. It is consideredplausible that the factors below could result ininsecurely attached hospice nurses experiencingmore (frequent) stress than securely attachednurses:

* Having an insecure attachment style may serveto predispose hospice nurses to stress in general(not specific to working in a hospice).

* Having a fearful or dismissing insecureattachment style may make hospice nursesmore vulnerable to stress as they may be lesslikely to access the helpful resource of emotionalsocial support.

* Having an insecure attachment style may leavehospice nurses particularly vulnerable to stressin the context of losses experienced followingpatient deaths.

Hypotheses

H1: Working with ‘death and dying’ will be themost frequent source of stress for hospice nurses.H2: Seeking emotional social support will be the

most commonly adopted coping strategy forhospice nurses in stressful situations.H3: There will be a sub-population of hospice

nurses who have insecure attachment styles.H4i: Insecurely attached hospice nurses will

experience stress significantly more frequently thansecurely attached hospice nurses.H4ii: Insecurely attached hospice nurses will

experience significantly more psychological com-ponents of ill health than securely attached hospicenurses.H4iii: Insecurely attached hospice nurses will be

absent from work significantly more than securelyattached hospice nurses.H5: Insecurely attached hospice nurses will

experience stress related to death and dyingsignificantly more frequently than securely at-tached hospice nurses.H6: During stressful situations hospice nurses

with fearful and dismissing attachment styles willseek emotional social support significantly lessfrequently than hospice nurses with secure orpreoccupied attachment styles.

Design

The study comprised a cross-sectional surveydesign. Well-validated and established question-naires measuring adult attachment style, stress, andcoping strategies were sent to hospice nurses at fivehospices in the West Midlands, U.K.

Method

Participants

Questionnaire packs were distributed to all nursingstaff (215) in the 5 hospices, and 84 questionnaireswere returned (39%). Ninety-nine percent of theparticipants were female, and the mean age was 46(range 27–62). Fifty-seven percent were working ininpatient hospice settings, 24% in community/home liaison teams, 12% in day hospices and 8%worked across various hospice settings (4% did notspecify). The mean amount of experience of work-ing in palliative care settings was 9 years (range 1–35). Of the participants that specified, 19% wereun-qualified nursing assistants (A–C grades), 43%were staff nurses (D–E grades), 18% were seniornurses (F–G grades), and 20% were managerialgrade nurses (H–I grades).

Measures

Experiences in Close Relationships Scale}ECR [61]

The ECR is a 36-item self-report measure of adultattachment style, which requires participants toreflect on their typical ways of relating in close/romantic relationships. Reviews of self-reportmeasures of adult attachment suggest that theECR has the best psychometric properties of theavailable measures [62,63].

Nursing Stress Scale}NSS [64]

The NSS is a 34-item self-report measure. Itproduces scores on seven subscales relating todifferent sources of stress. Scores relate to thefrequency with which certain situations are experi-enced as stressful and the subscale scores can besummed to give an overall stress score [64]. TheNSS has good test-retest reliability and goodinternal consistency. The measure has also beenfound to highly correlate with state & trait anxiety[64].

General Health Questionnaire}(GHQ-12[65])

The GHQ-12 is a brief self-administered health-screening questionnaire, which measures psycholo-gical components of ill health. From the GHQ-12 itis possible to assess for GHQ-caseness, whichindicates clear psychological distress [2] or poten-tial psychiatric morbidity [66]. It is a well-validatedand established measure, recommended for re-search in the caring professions [67].

Days and episodes absent from work during the last 6

months

Participants were asked to estimate the number ofdays and episodes that they had been absent fromwork during the last 6 months, excluding annual orstudy leave. In their review of stress management

565Stress and coping in hospice nursing staff


DOI: 10.1002/pon

approaches for the health and social care profes-sions, Carson and Kuipers [67] recommend re-search to monitor absence from work as an indexof stress.

The COPE [68]

The COPE is a 60-item self report questionnaire,with satisfactory internal consistency and validity,measuring coping styles adopted under stressfulconditions. The measure incorporates 13 concep-tually distinct scales and can be used to measuresituation specific or dispositional coping. For thepurposes of this study the COPE was used tomeasure dispositional coping.

Biographical information

Data was collected on nurse age, sex, ethnicity, jobtitle and grade, type of hospice work, years ofexperience in palliative care nursing, and recentmajor life events.

Procedure

Formal ethical approval was gained. Brief pre-sentations were then carried out with the nurses ateach hospice and written information offered topotential participants. Questionnaire packs, includ-ing the questionnaire, an information sheet, con-sent form and stamped-addressed envelopes werethen sent to hospice managers, who distributed thepacks to all nurses. The Ethics Committee did notpermit follow-up notices to be sent to potentialparticipants.

Results

The data was analysed using the Statistical Packagefor the Social Sciences version eleven. Tests forparametric assumptions were conducted prior tothe selection of the statistical analyses.

H1: Working with ‘death and dying’ will be themost frequent source of stress for hospice nurses

Table 1 displays the median scores and inter-quartile range for the seven subscales of the NSS indescending order.A Friedman non-parametric within-subjects

analysis of variance (ANOVA) revealed a signifi-cant chi-squared value (w2 ¼ 133:91; df¼ 6;p50.01) for the scores on the NSS subscales.Pair-wise differences were then examined using a

series of Wilcoxen Z tests. As multiple pairedcomparisons were undertaken, the inherent pro-blem of a large family wise error rate was adjustedfor by only considering a more conservative alphalevel of 0.01.

‘Death and dying’ was not found to be sig-nificantly more frequently experienced as a stressorthan ‘workload’ (Z¼�0.l2, p¼ 0.88). Therefore,hypothesis H1 was not supported. However, ‘deathand dying’, ‘workload’ and ‘inadequate pre-paration’ were found to be significantly morefrequent sources of stress than the other foursources investigated in the study (Z¼�4.04,p50.01).

H2: Seeking emotional social support will be themost commonly adopted coping strategy forhospice nurses in stressful situations

Table 2 displays the median scores and the inter-quartile range on the COPE.Seeking emotional social support was not the

most common coping strategy in this study, thushypothesis H2 was not supported. However,seeking instrumental and emotional social supportboth feature in the top four coping strategiesadopted.A Friedman non-parametric within subjects

ANOVA revealed a significant chi-squared value(w2 ¼ 536:1; df¼ 14; p50.01) for the COPE sub-scales. Pair-wise differences in these subscales were

Table 1. Median scores for the Nursing Stress Scale subscales(n¼ 84)

NSS subscale Median

(range 1–4)

Inter-quartile

range (25–75

percentile)

Death and dying 2.0 2.00–2.43

Workload 2.0 1.83–2.50

Inadequate preparation 2.0 2.00–2.33

Uncertainty 1.80 1.60–2.00

Conflict physician 1.80 1.40–2.00

Lack of support 1.67 1.33–2.00

Conflict nurse 1.60 1.2–1.80

Table 2. Median scores for the COPE subscales (n¼ 84)

COPE Subscale Median

(range 4�16)

Inter-quartile

range (25�75

percentile)

Positive reinterpretation and growth 12 10–13

Planning 12 9.5–14

Seeking instrumental social support 11 10–14

Seeking emotional social support 11 8–14

Active coping 11 9–13

Acceptance 10 9–13

Restraint coping 9 8–11

Focus on and venting of emotions 9 7–11

Suppression of competing activities 8 7–10

Mental disengagement 7 6–9

Turning to religion 6 4–11

Behavioural disengagement 6 4–7

Denial 4 4–6



DOI: 10.1002/pon

examined using Wilcoxen Z tests. The top sixcoping strategies were significantly higher thannext seven coping strategies measured by theCOPE (Z ¼�4.14; p 5 0.01).

H3: There will be a sub-population of nurses whohave insecure attachment styles

Table 3 displays the proportion of hospice nursesin this study with each of the four attachment stylesas well as the distribution of participants in theattachment categories with those found in otherstudies.Approximately half of the sample has insecure

attachment styles, supporting hypothesis H3. Thisproportion of participants is higher than otherstudies with health care professionals [59,69], andgeneral population samples [39,70,71].

H4i: Insecurely attached hospice nurses willexperience stress significantly more frequentlythan securely attached hospice nurses

Participants were classified as either securely orinsecurely attached based on their scores on theECR. The two groups of participants were thencompared on their mean total scores on the NSS(see Table 4).An independent samples t-test indicated that the

difference between the two groups was notstatistically significant (t80 ¼ 0:61; p ¼ 0:55).

H4ii: Insecurely attached hospice nurses willexperience significantly more psychologicalcomponents of ill health than securely attachedhospice nurses

Securely or insecurely groups of participants werethen compared on their mean total scores on theGHQ (see Table 5).A parametric independent samples t-test re-

vealed that the difference between the groups onGHQ Total scores was not statistically significant(t80 ¼ �1.7; p¼ 0.09).

GHQ caseness results

The GHQ prevalence rate for the securely attachednurses was 22%, compared to a 40% prevalencerate for the insecurely attached nurses (pre-

occupied¼ 40%; fearful¼ 43%; dis-missing¼ 36%). A chi-squared test indicated thata significantly higher proportion of the insecurelyattached group scored at a caseness level (at risk ofpsychiatric morbidity) than the securely attachedgroup (w2 ¼ 11:58; df¼ 1; p50.01, n¼ 84). Nosignificant differences were found between theGHQ prevalence rates of the three insecureattachment groups.Taken together these results suggest that overall,

insecurely attached nurses do not experience more(psychological components of) ill health thansecurely attached hospice nurses (in support ofthe null hypothesis), but that a sub-population ofinsecurely attached staff are more likely to be atrisk of developing psychiatric morbidity due tovery high levels of stress. Therefore, hypothesisH4ii gains partial support.

H4iii: Insecurely attached hospice nurses will beabsent from work for significantly more days thansecurely attached hospice nurses

According to the Mann Whitney U tests theinsecurely attached group were absent for signifi-cantly more days than the securely attached group(U ¼ 649.5; df ¼ 81; p¼ 0.04), but the differencebetween the groups for episodes absent wasnot statistically significant (U ¼ 700; df ¼ 81;p ¼ 0.10). Thus, providing partial support forhypothesis H4iii.

Table 3. A table displaying the distribution of participants with each attachment style

Current

study %

Harding

[71] %

Leiper and

Casares [59] %

Tyrell and

Dozier [69] %

Ainsworth

et al. [39] %

Hazan and

Shaver [70] %

Secure 52 69 69.9 90 66 56

Preoccupied 18 4 9.2 12 ambivalent 20 ambivalent

Fearful 17 20 Avoidant 18.4 Insecure 10 20 avoidant 24 avoidant

Dismissing 13 7

Table 4. A table comparing securely with insecurely attachednurses on the NSS scores

Nurse group Number

of nurses

Mean total

NSS

Standard

deviation

Securely attached 42 65.64 9.92

Insecurely attached 40 64.30 10.11

Table 5. A table comparing securely and insecurely attachednurses on GHQ scores

Nurse group Number

of nurses

Mean total

GHQ score

Standard

deviation

Securely attached 42 10.83 3.79

Insecurely attached 40 12.55 5.27



DOI: 10.1002/pon

H5: Insecurely attached hospice nurses willexperience stress related to ‘death and dying’significantly more frequently than securelyattached hospice nurses

The mean scores of secure and insecurely attachednurses on the ‘death and dying’ subscale of the NSSwere equal (secure: 2.16, SD 0.31; insecure 2.16, SD0.40).An unrelated t-test confirmed that there was no

significant difference between the two groups (t80¼ 0.001; p¼ 0.99). Therefore, Hypothesis 5 wasnot supported.

H6: During stressful situations hospice nurseswith fearful and dismissing attachment styles willseek emotional social support significantly lessfrequently than hospice nurses with secure andpreoccupied attachment styles

The fearful and dismissing participants werecompared as a group with the secure/preoccupiedgroup on scores for the emotional social supportsubscale of the COPE (see Table 6).Table 6 indicates that the secure/preoccupied

group were more likely than the fearful/dismissinggroup to draw on emotional social support as acoping strategy when experiencing stress. A t-testindicated that the difference between the twogroups on the emotional social support subscalewas statistically significant (t78 ¼ �2.57, p ¼0.01). Therefore, hypothesis H6 was supported.

Discussion

Issues relating to the ‘death and dying’ of patients,a high ‘workload’ and ‘nurses feeling inadequatelyprepared to deal with the emotional needs ofpatients and their families’ were highlighted as themain sources of stress for hospice nurses in thisstudy. This is consistent with another recent studywhich also identified these as the three mostcommon sources of stress in a group of 89 femalehospice nurses recruited from nine hospices [17]. Anumber of other quantitative and qualitativestudies also support these factors as major sources

of stress for hospice/palliative care nurses[13,15,18,72–74].It is interesting to note that the six most

commonly adopted coping strategies include arange of ‘problem-focussed’ (‘planning’, ‘seekinginstrumental social support’, ‘active coping’) and‘emotion-focussed’ (‘acceptance’, ‘positive reinter-pretation and growth’, ‘seeking emotional socialsupport’) approaches [75]. Papadatou [76] foundevidence that fluctuating between focusing on andprocessing emotional reactions, and then focussingon practical tasks whilst suppressing emotionsmight be an adaptive and healthy approach toworking with dying patients, reducing the like-lihood of burnout. Folkman and Lazarus [77] alsosuggest that both emotion-focussed coping andproblem-focussed coping might be more or lessadaptive depending on the nature of the stressor.Payne [17] found that ‘Planful Problem-solving’

and ‘Positive Reappraisal’ related to reduced levelsof hospice nurse burnout. These strategies may besimilar to ‘planning’ and ‘positive reinterpretationand growth’ respectively and, therefore, may behelpful coping strategies for nurses to develop.Perhaps supervision and support groups could beused to encourage these approaches to coping withstress. ‘Positive reinterpretation and growth’ mayrelate to an important moderator of the stressresponse for palliative care and oncology nursingstaff}that of developing meaning from the workcontext [78].Social support was found to be an important

coping strategy for hospice nurses, which isconsistent with previous research into hospicenurses [9,13,16] and the wider nursing litera-ture [79].Uniquely, this study investigated the potential

relationships between hospice nurses’ attachmentstyles and their experience of stress and coping.However, the results appear equivocal as towhether having an insecure attachment style mightpredispose nurses to higher levels of work-relatedstress. Based on total scores on the NSS and theGHQ, and episodes absent from work, the studyfound that there was not a significant differencebetween the levels/frequencies of stress experiencedby securely attached and insecurely attachednurses. However, when considering the prevalencerate of GHQ caseness and days absent from workover the previous six months, there is some supportfor the proposition. The latter position would beconsistent with other studies that suggest having aninsecure attachment style may predispose people tomental ill health [53,58].It was also hypothesised that nurses with

insecure attachment styles might experienceissues relating to the death and dying of patientsas more stressful than securely attached nursingstaff. However, there was no support for thishypothesis.

Table 6. A table comparing nurses with a fearful or dismissingattachment style with nurses with a secure or preoccupied styleon the Emotional Social Support subscale of the COPE

Number

of nurses

Mean emotional

social support

score (COPE)

Standard

deviation

Fearful/dismissing

attached

23 9.7 3.07

Secure/preoccupied

attached

57 11.8 3.31



DOI: 10.1002/pon

Consistent with previous research (e.g.[37,43,48], the results from the study support thehypothesis that nurses with a secure or preoccupiedattachment style would be more likely to seekemotional social support when experiencing stressthan nurses with a fearful or dismissing attachmentstyle.Overall, the results relating to the influence of

attachment style on hospice nurse stress appearinconclusive, and further research is warranted.

Implications of results and recommendationsfor practise

Consistent with the finding from this study thatdeath and dying is a significant source of stress forhospice nurses, it is recommended that hospicescontinue to develop processes to help nurses copewith stress associated with this issue [80]. Smith [81]suggests that nurses should recognise their need togrieve and encourages nurses to say goodbye to thedead patient, attend funerals or services held at thehospice, light candles, keep remembrance booksand share their experiences with colleagues.Blanche [82] and Lewis [83] describe componentsof staff bereavement support packages, whichreceive some empirical support.Opportunities for clinical supervision and reflec-

tive practice have recently been highlighted asimportant resources for staff working in cancersettings, and could facilitate nurses to reflect onand anticipate both patient and staff responses tolosses [84–89]. Hopkinson, Hallett and Luker [90]propose a useful model for nurses caring for dyingpeople, which aims to help shape their expectationsand prepare nurses for encounters with death anddying, and which may be a useful educational andsupportive resource.Overwork was also found to be a frequent source

of stress for hospice nurses in this study, whichperhaps warrants further recognition and examina-tion by managers [74,91]. It has been suggested thatwork overload may become an increasing source ofstress for palliative care nurses as their role extendsto involvement with patients earlier in the illnesstrajectory in order to ease pressure on acuteservices [92].Consistent with the finding that hospice nurses

often feel inadequately prepared to deal with theemotional needs of patients and their families,practical nursing skills training could be compli-mented by basic communication and counsellingskills training [17,89,93]. Training to help nurses tounderstand their and their patients’ responses toloss has also been recommended [94]. Spall andCullis [85] and Payne [17] discuss how it isimportant that nurses learn to emotionally invest‘appropriately’ and to not become enmeshed orover-involved in the nurse patient relationship,

perhaps alternatively adopting a ‘present butseparate’ position [85], or developing ‘detachedconcern’ [17]. Clinical Psychologists may be wellqualified to contribute to clinical supervision andthe development and maintenance of communica-tion and counselling skills through teaching andtraining (see [95]).Social support appears to be an important

coping strategy for many hospice nurses.Although some authors have questioned the

efficacy of staff support groups (e.g. [96]), othercommentators recommend their use even in theabsence of good quality studies [16,82,94].The extent to which hospices and individuals

pursue, take up or provide the previously discussedapproaches for stress management may be limitedby a culture of ‘professionalism,’ commonlyreported within nursing teams which suggests thatit is not professional to express emotions withpatients or colleagues [34,80,97,98]. Nurses mayfeel they need permission from themselves and theorganisation before engaging in the vital process ofacknowledging and expressing the emotional nat-ure of the work [21].A proportion (nearly half in this study) of the

nurses with particular attachment styles may bemore vulnerable to the effects of stress and lessinclined to seek emotional social support or sharetheir feelings with colleagues. Therefore, it isimportant that opportunities are provided for arange of coping strategies to be developed [21, 99].Prompt recognition and support for those underparticular stress, and access to confidential supportthrough professional counselling or therapy is alsorecommended [74,94,100].

Limitations of study

Although, this study recruited a satisfactorynumber of participants, the response rate of 39%was surprisingly low. Other similar studies gainedresponse rates in the region of 50% [13,15,17]. Thisbrings into question the extent to which the resultsfrom this study can be considered representative ofthe nurses in the five target hospices. The length ofthe questionnaire and the particularly low responserate (10%) from one of the research centres maypartially account for the low overall response rate.Stigma often associated with stress might also haveinfluenced the response rate.The study relied heavily on self-report measures

and although the confidential and independentnature of the research was emphasised it is stillpossible that answers were given in a sociallydesirable way.Self-report attachment style measures such as the

ECR have been criticised for presuming thatparticipants will be able to articulate how they feelin close/romantic relationships [70]. An alternative



DOI: 10.1002/pon

research tool for this study could have been theAdult Attachment Interview [41]. However, this isvery lengthy to administer and requires priortraining [42].

Future research

This study has considered ‘death and dying’ as ageneral source of stress. However, it has beensuggested that certain aspects of patient death maybe particularly difficult for nurses, such as when a‘favourite patient’ or a young patient dies[101,102]. There has also been recent discussionabout concepts of ‘good and bad deaths’ forpatients and their families (e.g. [103,104]. Theimpact of these different aspects or types of patientdeath on hospice nursing staff may be a worthwhilearea of future research.Research investigating the involvement of at-

tachment styles in health professionals’ work andfunctioning is in its infancy, and the author is notaware of any other studies to date that haveinvestigated the impact of attachment styles onhospice nurses. This study revealed mixed findingsaround whether having an insecure attachmentstyle might predispose hospice nurses to workrelated stress. Therefore, it is recommended thatfurther studies be carried out to clarify theseequivocal results.Another interesting area of research might

consider different approaches to hospice care bynurses with Fearful or Dismissing attachmentstyles compared to nurses with a Secure orPreoccupied style. It is tentatively hypothesisedthat nurses with the former attachment styles maynot become as emotionally involved with patients,focusing more on practical nursing tasks instead.

Acknowledgements

We appreciate the contributions of Helen Brittain andRosalind Talbot. We also send our sincere gratitude to allthe participants in this study

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