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

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<ul><li><p>Stress and coping in hospice nursing staff. The impact ofattachment styles</p><p>Andrew C. Hawkins1, Ruth A. Howard2* and Jan R. Oyebode21 Birmingham &amp; Solihull Mental Health NHS Trust, UK2 The University of Birmingham, UK</p><p>* Correspondence to: ClinPsyDCourse, School of Psychology,The University of Birmingham,Edgbaston, Birmingham, B152TT, England, UK.</p><p>Abstract</p><p>Previous research suggests that the attachment style developed during childhood informs adultattachment styles, which in turn aects adult relationships and responses to stress. This studyconsiders the sources of stress in hospice nurses and addresses the potential impact of theirattachment styles on stress and coping experiences. Adult attachment style, stress and copingwere measured in 84 nurses recruited from ve hospices.The results supported previous research regarding the most common sources of stress in this</p><p>nursing group. The study found partial support for the hypothesis that nurses with insecureattachment styles experience more stress than securely attached nurses. Hospice nurses with afearful or dismissing attachment style were found to be less likely to seek emotional socialsupport as a means of coping with stress than hospice nurses with a secure or preoccupiedattachment style.Supervision, support and career-long training for nurses in hospices are recommended.</p><p>Further research is needed to clarify the involvement of attachment style in hospice nurse stressand coping experiences.Copyright # 2006 John Wiley &amp; Sons, Ltd.</p><p>Keywords: cancer; nurse; stress; coping; attachment</p><p>Background</p><p>Nurse stress in the National Health Service</p><p>Research has highlighted stress as a signicantproblem for nurses and the National HealthService [13]. Stress has been found to contributeto burnout, mental health problems, absence fromwork, recruitment diculties and poor health caredelivery [47].</p><p>Staff stress in hospice/palliative care settings</p><p>Relatively few studies have investigated hospicenurse stress and coping, and ndings to date havebeen equivocal [811]. 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 signicant sources of stress for hospice nurses[1518].In line with changes in the nursing profession,</p><p>the recent organisational climate of hospice nursinghas placed a greater inuence on providing</p><p>emotional support to patients and their families,and an increased emphasis on developing a close,intimate and holistic relationship with patients[11,1924]. A number of studies have highlightedthe signicance nurses place on their relationshipswith patients [2528].It has been suggested that without the provision</p><p>of adequate support, this New Nursing [29]approach could pose new, personal challenges fornurses, with potential implications for their well-being [3032].</p><p>Attachment theory</p><p>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].</p><p>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 patients problem from thepatients 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</p><p>Received: 28 September 2005</p><p>Revised: 2 March 2006</p><p>Accepted: 15 March 2006</p><p>Copyright # 2006 John Wiley &amp; Sons, Ltd.</p><p>Psycho-OncologyPsycho-Oncology 16: 563572 (2007)Published online 27 September 2006 in Wiley InterScience ( DOI: 10.1002/pon.1064</p></li><li><p>dies, the nurse must deal with the painful eects ofloss, separation and termination [34].</p><p>Attachment theory was originally developed by</p><p>Bowlby [3537] to understand the childs tie to the</p><p>main caregiver and the eects of its disruption</p><p>through separation, deprivation and bereavement.</p><p>Bowlby [38] dened attachment as the propensity of</p><p>human beings to make strong aectional bonds to</p><p>particular others (p. 201).</p><p>Three types of attachment style were observed in12-month-old children: secure (66% of sample),insecureavoidant (20%), and insecure-ambivalent(12%). These were characterised by dieringresponses to separation and reunion with theirmothers [39]. These attachment styles and distribu-tions have since been consistently conrmed.</p><p>Adult attachment</p><p>A fundamental tenet of attachment theory is thatthe attachment style developed in the infant-carerrelationship inuences future relationships,through the internalisation of these relationshipexperiences [36,4043].Bartholomew [44] proposed a four-category</p><p>model of adult attachment (see Figure 1), whichhas since received considerable empirical support[4547]. 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</p><p>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].</p><p>The impact of attachment styles on mental health</p><p>Attachment styles may contribute to later inter-personal functioning and emotional self-regulation[5054]. 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 aect 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</p><p>be inuenced by attachment relationships through3 distinct pathways:</p><p>1. The disruption or breaking of bonds, beingtraumatic, may lead to disturbance</p><p>2. Future relationships may be detrimentallyaected by internalised disturbed early attach-ment patterns, making the individual moreexposed and vulnerable to stress</p><p>3. A persons current perception of theirrelationships and consequent use of them maymake the person more vulnerable to stress in theface of adversity.</p><p>Health care professionals attachment styles</p><p>Little research has been carried out into the eectsof 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 specically</p><p>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.</p><p>Aims</p><p>Firstly, this study aims to build upon previousstudies investigating sources of stress and coping</p><p>Positive Model of Other </p><p>SECURE PREOCCUPIED Positive Model of Self</p><p>Negative Model ofSelf</p><p>DISMISSING FEARFUL</p><p>Negative Model of Other</p><p>Figure 1. Diagrammatic summary of Bartholomews [44]model of adult attachment</p><p>Copyright # 2006 John Wiley &amp; Sons, Ltd. Psycho-Oncology 16: 563572 (2007)DOI: 10.1002/pon</p><p>564 A.C. Hawkins et al.</p></li><li><p>strategies adopted by hospice nursing sta. 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:</p><p>* Having an insecure attachment style may serveto predispose hospice nurses to stress in general(not specic to working in a hospice).</p><p>* 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.</p><p>* Having an insecure attachment style may leavehospice nurses particularly vulnerable to stressin the context of losses experienced followingpatient deaths.</p><p>Hypotheses</p><p>H1: Working with death and dying will be themost frequent source of stress for hospice nurses.H2: Seeking emotional social support will be the</p><p>most commonly adopted coping strategy forhospice nurses in stressful situations.H3: There will be a sub-population of hospice</p><p>nurses who have insecure attachment styles.H4i: Insecurely attached hospice nurses will</p><p>experience stress signicantly more frequently thansecurely attached hospice nurses.H4ii: Insecurely attached hospice nurses will</p><p>experience signicantly more psychological com-ponents of ill health than securely attached hospicenurses.H4iii: Insecurely attached hospice nurses will be</p><p>absent from work signicantly more than securelyattached hospice nurses.H5: Insecurely attached hospice nurses will</p><p>experience stress related to death and dyingsignicantly more frequently than securely at-tached hospice nurses.H6: During stressful situations hospice nurses</p><p>with fearful and dismissing attachment styles willseek emotional social support signicantly lessfrequently than hospice nurses with secure orpreoccupied attachment styles.</p><p>Design</p><p>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 vehospices in the West Midlands, U.K.</p><p>Method</p><p>Participants</p><p>Questionnaire packs were distributed to all nursingsta (215) in the 5 hospices, and 84 questionnaireswere returned (39%). Ninety-nine percent of theparticipants were female, and the mean age was 46(range 2762). 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 135). Of the participants that specied, 19% wereun-qualied nursing assistants (AC grades), 43%were sta nurses (DE grades), 18% were seniornurses (FG grades), and 20% were managerialgrade nurses (HI grades).</p><p>Measures</p><p>Experiences in Close Relationships Scale}ECR [61]</p><p>The ECR is a 36-item self-report measure of adultattachment style, which requires participants toreect 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].</p><p>Nursing Stress Scale}NSS [64]</p><p>The NSS is a 34-item self-report measure. Itproduces scores on seven subscales relating todierent 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 &amp; trait anxiety[64].</p><p>General Health Questionnaire}(GHQ-12[65])</p><p>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].</p><p>Days and episodes absent from work during the last 6</p><p>months</p><p>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</p><p>565Stress and coping in hospice nursing staff</p><p>Copyright # 2006 John Wiley &amp; Sons, Ltd. Psycho-Oncology 16: 563572 (2007)DOI: 10.1002/pon</p></li><li><p>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.</p><p>The COPE [68]</p><p>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 specic or dispositional coping. For thepurposes of this study the COPE was used tomeasure dispositional coping.</p><p>Biographical information</p><p>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.</p><p>Procedure</p><p>Formal ethical approval was gained. Brief pre-sentations were then carried out with the nurses ateach hospice and written information oered 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.</p><p>Results</p><p>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.</p><p>H1: Working with death and dying will be themost frequent source of stress for hospice nurses</p><p>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</p><p>analysis of variance (ANOVA) revealed a signi-cant chi-squared value (w2 133:91; df 6;p50.01) for the scores on the NSS subscales.Pair-wise dierences were then examined using a</p><p>series of Wilcoxen Z tests. As multiple pairedcomparisons were undertaken, the inherent pro-b...</p></li></ul>