Abstract

Background: Collaboration between nurses and physicians is linked to positive outcomes for patients, especially in psychiatric units. However, effective collaboration poses challenges as work stressors. So, effective work stressors coping strategies have the highly concern from organization management as a method for maintaining high level of collaboration. Aim: This study aimed to explore the effect of working stressors coping strategies program on nurse physician collaboration. Design: Quasi experimental design was used. Setting: This study was carried out at Benha psychiatric hospital. Sample: All convenient nurses and physicians worked at in-patient care units. Tools: Two tools were used, questionnaire to assess work stressors and collaborative practice scale (CPS) questionnaire. Result: There is a negative correlation between work stressors and nurse-physician collaboration (P<0.001) with a positive effect of coping strategies program on them. Conclusion: Work stressors coping strategies are essential for promoting nurse-physician collaboration which in turn promote organizational success. Recommendation: Maximizing nurse-physician collaboration holds promise for improving quality patient care and creating satisfying work environment for nurses and physicians.

1. Introduction

Nurses play a vital role in any health care setting and cover the largest workforce; they act as direct care providers who serve patients twenty-four hours a day, seven days a week. This gives nurses a unique view on both patient care and hospital services ¹. They act as the mediators between the physician and the patient and in the front line of health services ². Conflicts between nurses and physicians have been set as one stressor in the work environment ³. Nurses may face both verbal and physical abuse when conflict increases with physicians which in turn affect their collaboration and productivity ⁴.

The workplace stress is normal. While, excessive stress can interfere with productivity, performance and affects the physical and the emotional health. Often, the ability to cope with stress can mean the difference between success and failure at work. Not everything in the work environment can be controlled, but that doesn’t mean the person is powerless-even when he\she is in a trouble. Whatever the work demands or ambitions are, there are steps taken to be protected from the damaging consequences of stress and increase job satisfaction ⁵.

Stress can be defined as the result of any emotional, physical, social, economic, or other factors that need a response or change. It is believed that some types of stress are normal (sometimes called "challenge” or "positive stress") but when stress becomes overwhelming, it cannot be handled, both mental and physical changes happened ⁶. Workplace stress can be described as the physical and emotional outcomes that occur when there is variance between the demands of the job and the amount of control the individual has in meeting those demands ⁷.

Certain factors go parallel with work-related stress. Some common workplace stressors are: Low payment, excessive workloads, lack of growth or advancement opportunities, absence of engaging or challenging work, lack of social support or control over job-related decisions and conflicting demands or ambiguous performance expectations, fear of being laid off, more overtime due to staff cutbacks, enforced to perform to meet rising expectations but with no increase in job satisfaction and pressure to work at ideal levels-all the time ⁸.

Symptoms of stress vary from one to another; but according to ⁹ these symptoms can be categorized as cognitive, physical, emotional, and behavioral. While Segal, et al. ⁵ stated that overwhelming feeling at work, decrease confidence and increase feeling of anger, irritability, or withdrawal. While excessive stress at work leads to feeling anxious or depressed, apathy, lack of interest in work, sleeping problems, fatigue, distractibility, muscle tension or headache, stomach problems, social withdrawal, lack of sex drive, and using alcohol or drugs .

Excessive exposure to psychosocial stressors produces considerable job stress, resulting in various problematic short and long term consequences as depression and sleep problems. It also has been associated with low job satisfaction, increased psychological distress, physical complaints and absenteeism. Several studies have found that high levels of job stress promote feeling of inadequacy, self-doubt, and decrease self-esteem among nurses. As a group, nurses tend to have higher rates of mortality and high rates of stress-related disease, psychiatric outpatient consultation, and psychiatric admissions ¹⁰.

Coping is a constant changing in cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as overtaking the resources of the person ¹¹. Effective utilization of coping mechanism overlaps with the experienced level of stress. This means that a stress level can be decreased extremely if a person knows how to cope with stressors ¹². In addition to that a person who has experienced a cluster of stressful life events would be able to cope successfully with life if he/she is able to adjust coping strategy to match the demands of the situation ¹³.

There are eight coping strategies nurses can use to cope with stress. These strategies tend to be either problem-focused or emotion-focused in nature. The eight strategies include: confrontive coping, distancing, self-control, seeking social support, accepting responsibility, escape-avoidance, planful problem-solving and positive reappraisal ¹⁴.While, Melnick, ¹⁵ offers strategies to decrease the work stress, before it becomes a manner of the life: act rather than react, take a deep breath, eliminate interruptions, schedule the day for energy and focus, eat right and sleep well.

Collaboration is defined as “the interactions between nurse and physician that enable the knowledge and skills of both professions to synergistically influence the patient care provided ¹⁶. Interdisciplinary collaboration helps in decreasing costs, improving patient care, and economy of decision making ¹⁷. Moreover, a strong link was found between collaboration among team members and risk-adjusted patient length of stay ¹⁸. Improving Collaboration between nurses and physicians is a high priority for nurse administrators. Studies show that nurses who practice collaboratively with physicians experienced less “burnout,” and recruitment and retention rates are higher than nurses who practice in non-collaborative environment ¹⁹.

Efforts to increase collaboration between nurses and physicians are notable because of their impact on patient outcomes such as decreased morbidity and mortality ^{20, 21}. The goal should focus on conflict resolution because most nurse-physician conflicts occur in the areas of general plan of care, specific orders, and patient disposition. Conflict is natural and part of interactions with others ^{22, 23}.

Nursing as a profession has levels of stress. Furthermore, psychiatric and mental health nursing has been reported as ahighly stressful specialty. So, job stress causes hazardous impacts not only on nurses’ health but also on their abilities to cope with job demands.Nurses, when experiencing great stress, draw upon various coping strategies, and obviously, their manner of coping with stress influences interdisciplinary collaboration and the quality of their professional performance. Thus, it is essential to identify the various coping strategies to reduce stress, improve collaboration between nurses and physicians and enhance health patient outcomes.

This study aimed to explore the effect of working stressors coping strategies program on nurse physician collaboration.

The study supposed the following hypothesis:

• There is relationship between levels of work stressors and nurse - physician collaboration pre and post program

• Personal characteristics may affect on levels of work stressors and nurse - physician collaboration

• The coping strategies program has a positive effect on level of nurse- physician collaboration when dealing with work stressors.

2. Subject and Methods

Research design: Quasi experimental design was used.

Research setting: The study was carried out at in-patient units at the psychiatric mental health hospital in Benha City. The hospital capacity is 277 beds. It serves psychotic patients and includes 6 departments (5 for males and 1 for females). The total numbers of the patients were 232 patients (38 females and 194 males) and the total number of the staff was 163 nurses.

A Convenient sample of all nurses and physicians were working in the previously mentioned hospital and accepted to participate in this study. A total number was 176 (140 nurses and 36 physicians).

Two tools were used for data collection

Tool 1: Self-administrated Questionnaire: It consists of two parts.

Part one: Personal characteristics of studied sample as age, sex, job and years of experience.

Part two: Work stressors questionnaire by American Institute for Preventive Medicine (2012) ²⁴. It consists of 11 items namely: disagreement & indecision, pressure on the job, job description conflict, communication & comfort with supervisor, job related health concerns, work overload stress, work under load stress, boredom induced stress, problem of job security, time pressure, and job barrier stress. Each topic contains 5 sub-items.

Scoring system: The questionnaire consists of five- point Likert scale, Never, Rarely, Occasionally, Usually, and Constantly. The scoring system for the answer was “1” never, “2” rarely, “3” Occasionally, “4” Usually, and “5” Constantly. Within each area, Scores will range from 5 to 25. Overall scores will fall within the 55 to 275 range. The total score was categorized as follows:

• < 50% Weak level of work stressors

• 50->75% average level of work stressors

• < 75% high level of work stressors

Tool (2): Collaborative Practice Scale (CPS) ²⁵. It used to measure perceptions of collaboration between nurses and physicians. The CPS has two forms, one for nurses and the other for physicians.

A-The Collaborative Practice Scale for nurses: it has 9 items divided to two factors; first factor (five items) measures the degree to which a nurse directly asserts professional expertise and opinions when interacting with physicians about patient care. The second factor (four items) measures the degree to which a nurse clarifies with the physician mutual expectations regarding the nature of shared responsibilities in patient care. Each item is scored on 6-point scale, ranging from never (1) to always (6). The first factor has a maximum score of 30 and the other 24.

B-The Collaborative Practice Scale for physicians:

The CPS for physicians has 10 items that are divided into two factors of five items each. The first factor: (five items) measures the degree to which a physician acknowledges the importance of nurses 'unique contribution to different responsibilities in patient care. The second factor (five items) measures the degree to which a physician seeks consensus with nurses regarding mutual responsibilities and patient care goals. Each item is scored on the same 6-point scale. Each of the two factors has a maximum score of 30 (total maximum score 60).

• < 50% Weak level of nurse - physician collaboration

• 50->75% average level of nurse - physician collaboration

• < 75% high level of nurse - physician collaboration

Implementation of the program: An in-service training program was developed by the researchers based on the knowledge and practices needs. It was also supplemented with information based on review of relevant literature about coping strategies of work stressors on nurse and physician collaboration. The implementation of the program consisted of three phases:

Preparatory phase: Based on the result obtained from assessment tools and review of literature, the program content was developed by researcher in the form of Arabic booklet.

General objective: This program was improving of nurses and physicians knowledge, practices about work stressors’ coping strategies to enhance their collaboration.

The program's specific objectives were that the nurse and physician who attended the program should be able to:

• Define and list causes, types, symptoms and manifestation of work stressors

• Efficiently provide coping strategies with continuous work pressures

• Theoretical part: it included one session included define work stressor, types, symptoms and manifestation of work stressors

• Practical part: this part covered coping strategies with continuous work pressures (relaxation technique, change attitude about work stressors, etc.). The time required for the program implementation was 3 months with approximately 4 sessions (1 for theoretical part &3 for practical part).

• Evaluation of the programs’ success was based on the improvement of the nurses' knowledge and practices. This evaluation was done before the program, then immediately after the end of the program and after three months using the same tools in each time.

An official permission to conduct the study was obtained from the Dean of Faculty of Nursing–Benha University, Manager of Benha psychiatric and mental health hospital to carry out the study after explaining the purpose of the study.

*Validity: The tools were translated into Arabic language and reviewed to ascertain their content validity by five experts in nursing and medicine. The validity was 97.6%.

*Reliability of tools: Chronbach alpha coefficient was calculated and was 0.86, indicating good reliability.

It was carried out before starting data collection. It consisted of 10% of the study sample selected randomly their number was (20) to test the applicability and clarity of the tools. Also, it helped to determine time needed for filling up the questionnaire. The pilot subjects were not included in the main study sample.

The researchers explained the aim of the study to each nurse and physician and informed about the confidentiality of obtained data and only used for the purpose of the research. Nurses and physicians have ethical rights to participate or withdrawal from the research at any time. Oral consent was taken from them to participate in the study.

The field work included all available nurses and physician working in psychiatric hospital. They consisted of 140 nurses and 36 physicians. First, the researcher collected all available nurses, then collected available physician to be acquainted with them, explained to them the objectives of the research and its expected outcomes, and they filled in the questionnaire (pre-test) through two days/week (Sunday& Monday). This process took two months (November 2016 & December 2016). A program was given to all nurses and physician, then a post test was given to them. They took about 15-20 minutes to fill in the questionnaires in the unit and the researcher took about 10 minutes to explain any vigorous items. Nurses divided into 7 groups, each group 20 nurse one group weekly. Physicians divided also into 5 groups, each group 7 physicians due to lack of chance to be present at one time. This process took 3 months from January 2017 to March 2017.

The program was implemented in the form of brain storming and group discussion. Suitable teaching aids prepared specially for the program were: booklet, flipchart, video, demonstration & re-demonstration and real situations. At the end of each session, nurses and physicians' questions were discussed to correct any misunderstanding, which has been happened. A different teaching strategy was used in implementation of the program, e.g. discussion, video and role play. To ensure that the nurses and physicians understand the program content, each session was started by a summary about what was given through the previous one and objectives of the new one were mentioned. To ensure exposure of all subjects to the same learning experience all nurses and physician received the same protocol content using the same teaching methods, discussion and booklet. At the end of the sessions, the researcher distributed the questionnaire to make a post test.

Statistical presentation and analysis of the present study was conducted, using the mean, standard deviation and t-test [Unpaired], Paired t-test, Linear Correlation Coefficient [r] Chi-square ANOVA a by SPSSV21. Unpaired T-test was used to compare between two groups in quantitative data. Unpaired T-test was used to compare between related samples

3. Results

Table 1: Shows personnel characteristics distribution of the studied sample. The total number of studied sample was (176), the majority of them were nurses (79.55%) compared to (20.45%) were physicians. It was noticed that the majority of the studied sample were female (84.66%) and a high percentage of them (58.5%) with age less than 30 years (27.27% from 20-25 years and 31.25% from 25 <30 years old). Regarding years of experience it was found that more than two-fifth of them (44.32%) had from 5<10 years.

Table 2: Shows that, there are a highly statistical significant differences between nurse-physician work stressors levels at psychiatric hospital pre and post program. The total work stressors level in pre program was average (61.4%) but post program become weak level (19.3%).

Table 3: Reveals that, there are a highly statistical significant differences between nurse–physician collaboration levels pre and post program at studied psychiatric hospital. During pre program the level of physicians’ collaboration was higher than nurses’ collaboration but post program the level of nurses’ collaboration became high. Also, the level of nurse physician collaboration post program was higher than pre.

Figure 1: Illustrates that, there is a negative correlation between work stressors and nurse physician collaboration with a highly statistical significant difference P value (<0.001*).

Table 4: Documents that, there are a highly statistically significant differences between personal characteristics of studied sample and work stressors in relation to all items except job and sex.

Table 5: Documents that, there are a highly statistically significant differences between personal characteristics of studied sample and collaboration in relation to all items except job and sex.

4. Discussion

A worldwide shortage of nurses has been acknowledged by the Global Advisory Group of the World Health Organization (WHO) ²⁶. As a result, nurses cannot avoid encountering an increase in workplace stressors. Nurses working in psychiatric care are no exception. Working in psychiatric care brings an additional set of workplace issues, such as constantly dealing with special and sensitivity psychiatric patient, death and dying, controlling patients' pain, and helping patients and family members contend with patients' illness. So, effective stress management and coping strategies are very important ⁷.

In order to examine the correlation between work stressors and nurse-physician collaboration, the present study revealed that there is a negative correlation between work stressors and nurse physician collaboration with a highly statistical significant difference P value (<0.001*) which means that when the level of work stressors increase, the level of nurse physician collaboration decrease and vice versa. This depends on if an individual knows how to cope with stressors to decrease the stress.

In line with this finding Eliadi, (1990) in Konstantinos & Christina ²⁷ found a negative association between inter-professional nurse physician collaboration and stress. Also, Bratt, et al., ²⁸ & Olatunji, Mokuolu and Dare ²⁹ found that significant associations between job stress and nurse-physician collaboration. Moreover, Olatunji, Mokuolu and Dare ²⁹ found that nurses report higher Level of stress, lower level of nurse-physician collaboration and consequently lower level of job satisfaction compared with the doctors. In addition to White ³⁰ found that psychiatric nurses who utilizing effective coping methods frequently experienced less stress.

As well, the present study revealed that there are a highly statistically significant differences between personal characteristics of studied sample and both work stressors and nurse physician collaboration in relation to all items except job and sex. This may be related to the effect of coping strategies program that taught the nurses how to cope effectively with work stressors by using effective coping strategies which in turn affect level of nurse- physician collaboration.

Findings are not consistent with published reports by Timmins and McCabe ^{31, 32} reported that gender and education level, may play an important role in nurses’ lack of assertive behaviors when communicating with physicians which affect nurse-physician collaboration. Also, this result was incongruence with Jose & Bhat ³³ reported that no significant association between stress and nurses’ age.

In order to assess work stressors and nurse physician collaboration, the present study revealed that the average level of physician collaboration pre program was higher than nurses. This may be related to the nature of their job that enables more collaboration and respect between them rather than collaboration with nurses. On the other hand, after coping strategies program the level of nurses’ collaboration and nurse physician collaboration become highly. This result confirms the effect of coping strategies program on increasing mutual understanding between them which will improve provided patient care. Additionally, a highly statistically significant difference between nurse-physician collaboration pre and post program.

Findings were consistent with Schmalenberg, et al., ¹⁷ evaluated the concept of collaboration and showed that increased collaborative coaching between nurses and physicians. In this respect, Nelson, King & Brodine, ¹⁶ showed that significant differences in perceptions of collaborative behaviors between nurses and physicians.

The result of the present study revealed that the level of work stressors pre program was average, this may be related to decreased nurses ability to cope with work stressors effectively which increase the level of work stressors. While, post program level of work stressors was weak this confirms the effect of program and importance of coping strategies because the stress outcomes can be either positive or negative depending on the effectiveness of coping strategies. This result agreed with Mozhdeh, et al., ³⁴ & Dagget, Molla and Belachew ³⁵ found that mean overall job-related stress level was moderate.

Moreover, there are a highly statistically significant differences between studied sample work stressors pre and post program. The highly mean and standard deviation during pre program was time pressure, job barrier stress, and pressure on the job while post program these items become decrease. Also, the total work stressors mean and standard deviation pre program was higher than post.

Moreover, Konstantinos & Christina ³⁶ identified the number of stressors for mental health nurses working in hospitals included the poor professional relationships as the lack of collaboration between doctors and mental health nurses, conflicts between nurses and doctors, and lack of doctors’ respect for nurses’ opinions and their participation in decision making about patients’ care. Also, Konstantinos & Christina ³⁶ mentioned that mental health nurses are become stressed by difficulties in relationships and conflicts with other staff nurses they work.

This result supported by Edwards & Burnard ³⁷ mentioned that the primary source of stress among psychiatric nurses is job pressures.

Additionally, Boey, et al., (1997) in Abdalrahim (2013) ³⁸ examined work stress in 1043 nurses from three public hospitals and found that one-third of this population reported extreme work stress due to staff shortage and high demands from work resulting in work overload as the most stressful situation for nurses. Also, Lateef, and Anantharaman, (2001) in Abdalrahim, (2013) ³⁹ found in a sample of 80 emergency nurses that more than half of their sample rated stress levels as “moderate to extreme”.

5. Conclusion

The findings of the present study concluded that effective stress management and coping strategies is one of the very important steps towards goal achievement. More importantly, negative correlation work stressors between nurse physician collaboration with a highly statistical significant differences were found. The level of nurse physician collaboration is high after coping strategies program also there are a highly statistically significant differences between pre and post program. As well the level of work stressors post program lower than pre. These conclusions lead to ensuring the study hypothesis that there is a relationship between work stressors and nurse-physician collaboration, and personal characteristics may affect on levels of work stressors and nurse - physician collaboration, also, the coping strategies program will have a positive effect on levels of work stressors and nurse physician collaboration.

6. Recommendations

Based on the study results and conclusions, in relation to effect of work stressors coping strategies program on nurse physician collaboration, the following recommendations are suggested.

- Adding coping strategies for work stressors as a basic topic for nursing student's curriculum.

- Assertiveness training for nurses to improve assertiveness skills and self-esteem.

- Maximizing nurse-physician collaboration holds promise for improving quality patient care and creating satisfying work environment for nurses and physicians

- It is important for nurses and physicians to develop a new culture of collaboration which merges the unique strengths of each discipline with the mutual goal of quality patient care

References