Mental illness and coping strategies of nurses at a university hospitalAbstract
Objective: to identify the presence of mental illness and the coping strategies nurses use at a university hospital in Maceió, Alagoas, Brazil.
Method: a quantitative, cross-sectional, descriptive study between June 2022 and January 2023. The following were used: Sociodemographic and health aspects questionnaire, Symptom Assessment Scale-40-R, and Folkman and Lazarus Coping Strategies Inventory. Univariate descriptive statistics and Pearson’s correlation coefficient were analyzed.
Results: 97 people were interviewed who reported that they had already felt depressed for two weeks or more (34%), had been diagnosed with a mental disorder (35.1%), and were undergoing psychological (8.2%) and psychiatric (7.2%) counseling. They showed more significant impairment in the obsessiveness-compulsiveness dimension and made greater use of the coping strategy Positive Reappraisal.
Conclusion: the study helps to guide nursing managers in implementing programs that encourage coping strategies aimed at improving the mental health of these professionals.
Keywords:
Nursing; Employee Health; Mental Health; Occupational Health Nursing; Psychiatric Nursing..
HIGHLIGHTS
1. 35.1% of nurses had been diagnosed with a mental disorder.
2. Greater involvement of psychopathological symptoms in the obsessiveness-compulsiveness dimension.
3. The most used coping strategy was a positive reappraisal.
4. The least used coping strategy was escaping avoidance.
Resumo
Objetivo: identificar a presença de adoecimento mental e as estratégias de enfrentamento utilizadas pelos enfermeiros de um hospital universitário localizado na cidade de Maceió, Alagoas, Brasil.
Método: estudo quantitativo, transversal, do tipo descritivo, realizado entre junho de 2022 e janeiro de 2023. Foram utilizados: Questionário sociodemográfico e aspectos da saúde, Escala de Avaliação de Sintomas-40-R e Inventário de Estratégias de Enfrentamento de Folkman e Lazarus. Realizada análise estatística descritiva univariada e coeficiente de correlação de Pearson.
Resultados: foram entrevistadas 97 pessoas que relataram que já se sentiram deprimidas por duas semanas ou mais (34%); tinham diagnóstico de transtorno mental (35,1%); estão fazendo acompanhamento psicológico (8,2%) e psiquiátrico (7,2%). Apresentaram maior comprometimento na dimensão obsessividade-compulsividade e utilizaram mais a estratégia de enfrentamento Reavaliação Positiva.
Conclusão: o estudo contribui para orientar gestores de enfermagem na implementação de programas que incentivem estratégias de enfrentamento visando melhorar a saúde mental desses profissionais.
Descritores:
: Enfermagem; Saúde do Trabalhador; Saúde Mental; Enfermagem do Trabalho; Enfermagem Psiquiátrica.
HIGHLIGHTS
1. 35,1% dos enfermeiros tinham diagnóstico de transtorno mental.
2. Maior comprometimento de sintomas psicopatológicos na dimensão obsessividade-compulsividade.
3. A estratégia de enfrentamento mais utilizada foi reavaliação positiva.
4. A estratégia de enfrentamento menos utilizada foi fuga-esquiva.
Resumen
Objetivo: identificar la presencia de enfermedad mental y las estrategias de afrontamiento utilizadas por enfermeros de un hospital universitario localizado en la ciudad de Maceió, Alagoas, Brasil.
Método: estudio cuantitativo, transversal, descriptivo, realizado entre junio de 2022 y enero de 2023. Se utilizaron: Cuestionario sociodemográfico y de aspectos de salud, Escala de Evaluación de Síntomas-40-R e Inventario de Estrategias de Afrontamiento de Folkman y Lazarus. Se analizó estadística descriptiva univariante y coeficiente de correlación de Pearson.
Resultados: se entrevistó a 97 personas que declararon haberse sentido deprimidas durante quince días o más (34%); haber sido diagnosticadas de un trastorno mental (35,1%); estar recibiendo asesoramiento psicológico (8,2%) y psiquiátrico (7,2%). Mostraron un mayor deterioro en la dimensión obsesividad-compulsividad e hicieron un mayor uso de la estrategia de afrontamiento Reevaluación positiva.
Conclusión: el estudio ayuda a orientar a los gestores de enfermería en la implantación de programas que fomenten estrategias de afrontamiento dirigidas a mejorar la salud mental de estos profesionales.
Descriptores:
Enfermería; Salud Laboral; Salud Mental; Enfermería del Trabajo; Enfermería Psiquiátrica.
HIGHLIGHTS
1. Al 35,1% de las enfermeras se les diagnosticó un trastorno mental.
2. Mayor implicación de síntomas psicopatológicos en la dimensión obsesividad-compulsividad.
3. La estrategia de afrontamiento más utilizada fue la revalorización positiva.
4. La estrategia de afrontamiento menos utilizada fue el escape-evitación.
INTRODUCTION
Nursing professionals are essential in the care provided to individuals and are responsible for welcoming everyone who needs some form of care. Nurses are at the heart of care and play a fundamental role in promoting health1. According to the World Health Organization (WHO), mental health is related to an individual’s well-being and ability to thrive in society, even when experiencing stressful situations. According to the WHO’s World Mental Health Report, one billion people live with mental disorders2. In Brazil, mental disorders are the third leading cause of absence from work3.
In addition to the daily psychological pressure among nursing professionals, on March 11, 2020, the WHO declared the COVID-19 pandemic. This pandemic has contributed to the psychological suffering of nurses due to increased work-related stress, fear related to exposure to the viral agent, burnout syndrome, anxiety, and depression4.
Studies have shown that, with the advent of the COVID-19 pandemic, nurses’ mental health has suffered due to work overload and the distress generated by the transmission of the virus5-6. A study in Italy showed that 66% of nurses reported being more stressed5. A study realized in the state of Rio Grande do Norte, Brazil, found that 30.4% of the nursing team had been diagnosed with a mental disorder, the main ones being anxiety (39.6%), depression (38%) and burnout syndrome (62.4%)6.
Thus, this research had the following guiding question: how does mental illness present itself, and what coping strategies are used by nurses at a university hospital? The aim was to identify the presence of mental illness and the coping strategies used by nurses at a university hospital located in the city of Maceió, Alagoas, Brazil.
A review of the literature on the subject revealed a need for more studies on the mental illness of nurses and their coping strategies when faced with stressful situations. Considering that nursing professionals play a central role in the continuous and close care of patients, it is essential to understand the aspects related to the mental illness of these professionals, as well as the relationship between their psychological conditions and the stressful demands of everyday work. This study will provide information that will enable the development of care interventions to improve and promote these professionals’ mental and occupational health.
METHOD
This quantitative, cross-sectional observational study, guided by the STROBE tool (Observational Studies in Epidemiology)7-8.
The research was carried out in 20 sectors where nurses work in a hospital in northeast Brazil. The sectors are Maternity, Obstetric Center, Surgical Center, Pediatric Clinic, Surgical Clinic, Medical Clinic, Oncology Clinic, Neonatal Intensive Care Unit, Adult Intensive Care Unit, Joint Lodging, Kangaroo Neonatal Intermediate Care Unit, High Complexity Oncology Center, Nephrology Sector, Day Hospital, Wound Outpatient Clinic, Phototherapy Outpatient Clinic, Sterilization and Material Center, Hospital Infection Control Committee, Occupational Health and Safety Department, Nursing Division Department.
Considering the total population of 204 nurses working at the hospital, 97 (47.5%) voluntarily agreed to participate in the study. The sample was selected for convenience. The sample included nurses from the hospital in the sectors who were part of the permanent staff on day and night shifts, either in management or direct patient care. Nurses on sick leave or maternity leave during the data collection period were excluded, as were nurses working as resident nurses.
Data collection took place between June 2022 and January 2023. The sectors were chosen with the participants’ voluntary agreement. The approach was carried out during shifts through an invitation and explanation of the objectives, contributions, risks, and benefits. Nurses who agreed to participate were guaranteed free participation in the study and asked to sign an informed consent form beforehand.
Three instruments were used to collect data: a questionnaire on sociodemographic data and aspects of nurses’ mental health and work, the Symptom Assessment Scale-40-R, and the Folkman and Lazarus Coping Strategies Inventory.
The Questionnaire on sociodemographic data and aspects related to professional nurses’ mental and occupational health had objective questions divided into three axes: Socio-economic data, Aspects of mental health and quality of life, and Work aspects. The questions covered age group, color/ethnicity, marital status, maternity/paternity, religion, place of residence, socio-economic status, work activity (management or care), hours dedicated to work, work shift, how long they have worked in the profession and the hospital, weekly hours devoted to leisure, qualification of their mental health, presence of mental disorders, follow-up with psychologists and/or psychiatrists, use of psychotropic drugs, alcohol or tobacco, and physical exercise. This instrument was developed by the researchers in this study and has not been validated.
The Symptom Assessment Scale-40-R (SAS-40-R) is a multidimensional self-assessment scale in which it is possible to investigate the existence of psychopathological symptoms in the individual, not personality traits9. This scale has been validated for Brazil9 and has 40 items, divided into four dimensions (“‘psychoticism,’ ‘obsessiveness-compulsiveness,’ ‘somatization’ and ‘anxiety’), each containing 10 items.
The Folkman and Lazarus Coping Strategies Inventory (IEE, in Portuguese) is a 66-item questionnaire that assesses the thoughts and actions individuals use to deal with the internal or external demands of a stressful event and is divided into the following factors: Confrontation, Withdrawal, Self-control, Social Support, Acceptance of Responsibility, Escape-Excuse, Problem-Solving, and Positive Reappraisal. It aims to understand coping from the cognitive and behavioral responses that people use to manage distress and solve the problems of daily life that cause discomfort10. It was validated in Brazil by Savoia et al.11.
The Statistical Package for the Social Sciences (SPSS) version 23 was used for the statistical analysis. Univariate descriptive statistical analysis was used through distribution measures (absolute and relative frequency), central measures (mean and standard deviation) and bivariate analysis through Pearson’s correlation coefficient.
The research was approved by the Research Ethics Committee, under opinion no. 5.418.217, on May 19, 2022.
RESULTS
The tables illustrating the main results obtained in this study are presented below. Each has been constructed to provide a clear overview of the data collected regarding the nurses’ profiles, mental health, assessment of psychopathological dimensions, and coping strategies used.
The study involved 97 professional nurses. Most of the interviewees were female (n=87-89.7%), with an average age of 39 for both sexes, 58 (59.8%) of whom considered themselves brown or black, 63 (64.9%) were married, 63 (65.0%) were Catholic, and 68 (70.1%) had children. Most reported living in a neighborhood close to the hospital (n=15-15.5%). Nurses spent an average of 36 minutes (39.74%) and nurses 19 minutes (11.47%) getting from home to work, with the car (n=88-90.7%) being the most used means of transport (Table 1).
Of those interviewed, 52 (53.6%) reported working morning and afternoon shifts, 37 (57.8%) reported working 36 hours a week, and 81 (83.5%) carried out care activities. Nurses have an average of 18 hours of leisure time and 10 hours of work time (Table 1).
Of those interviewed, 59 (60.8%) reported having good mental health; 33 (34%) had felt depressed for two weeks or more; 34 (35.1%) had been diagnosed with one or more mental disorders; 46 (47.4%) reported that they had been and eight (8.2%) that a psychologist was monitoring them; 25 (25.8%) reported that they had and seven (7.2%) that a psychiatrist was monitoring them; 24 (24.7%) reported that they had used and 10 (10.3%) that they were using psychotropic medication; 63 (64.9%) reported having a good social relationship; 67 (69.1%) reported practicing physical activity; and 41 (42.3%) consumed cigarettes, alcohol and other substances (Table 2).
The dimension in which nurses are most symptomatic is the one characterized by an average closer to two. Thus, the data shows that nurses (0.60±0.41) and male nurses (0.46±0.27) had a more significant commitment in the obsessiveness-compulsiveness dimension. Nurses were less committed in the anxiety dimension (0.22±0.30) and nurses in the psychoticism dimension (0.19±0.31). It can be seen that nurses are less committed in all dimensions when compared to nurses, with the exception of the anxiety dimension, which was the same for both (Table 3).
Mean and standard deviation of the dimensions of the Symptom Assessment Scale and the factors of the Coping Strategies Inventory for nurses at a hospital. Maceió, AL, Brazil, 2023
The most adopted coping strategy is the one with an average score closest to two. Thus, nurses (1.69±0.58) and male nurses (1.57±0.37) used Positive Reappraisal more as a coping strategy. The least used was Escape-Excuse (0.86±0.53 for nurses and 0.79±0.49 for nurse practitioners). Generally, nurses use the coping strategies analyzed in this study less than nurses (Table 3).
There was a significant correlation between how much a family earns per person and the number of hours worked per week by the nursing professional (p < 0, 05). Thus, a different family’s economic situation may affect nursing professionals who work more hours per week than those who work fewer hours (Table 4).
Pearson’s correlation analysis between work and mental health variables and the Folkman and Lazarus Strategy Inventory dimensions and factors from the Symptom Assessment Scale answered by nurses at a hospital. Maceió, AL, Brazil, 2023.
There was a significant correlation between the use of psychotropic medication and the length of time spent with psychologists (p=0.025) or psychiatrists (p=0.001); and between the length of time spent using psychotropic medication and the length of time spent with psychologists (p=0.000) and psychiatrists (p=0.000). This suggests that there is a relationship between the length of time a person has been followed up by these professionals and the use of psychotropic medication (Table 4).
The study found a correlation between coping (p=0.044), social support (p=0.020), and problem-solving (p=0.012) with weekly working hours. In other words, the way nurses deal with challenges (coping), the support network they have (social support), and their ability to solve problems are related to the number of hours they work per week (Table 4).
The correlation between Psychoticism (p=0.015) and Obsessiveness-Compulsiveness (p=0.016) and the length of follow-up with a psychiatrist suggests that the greater the impairment in the Psychoticism or Obsessiveness-Compulsiveness dimension, the longer the length of psychiatric follow-up (Table 4).
Somatization showed a correlation with the length of time working as a nurse (p=0.033), with the length of time working with a psychologist (p=0.019), and with the avoidance and escape strategy (p=0.003). This suggests that somatization may relate to nurses’ professional experience and the methods they use to deal with stress (Table 4).
Psychoticism shows a significant correlation with various coping strategies. It is related to the distancing strategy (p = 0.035), which involves distancing oneself from the problem or stressful situation and avoiding facing it directly. It is related to problem-solving (p = 0.015), indicating that people with more significant impairment in the psychoticism dimension tend to adopt a more active approach to solving challenges. Furthermore, it is related to positive reappraisal (p = 0.018), a strategy in which the person tries to reinterpret negative situations more positively. Finally, it is related to the avoidance and escape strategy (p = 0.001), suggesting that individuals with more significant impairment in the psychoticism dimension may resort more frequently to avoidance strategies, such as running away or ignoring the problem (Table 5).
Pearson’s correlation analysis between the Folkman and Lazarus Strategy Inventory dimensions and the factors of the Symptom Assessment Scale answered by nurses at a hospital. Maceió, AL, Brazil, 2023
The obsessiveness-compulsiveness dimension is correlated with the avoidance and escape strategy (p=0.000), suggesting that people with high levels of these traits tend to use more avoidance strategies to deal with stressful or uncomfortable situations (Table 5).
The anxiety dimension has a significant correlation with the accepting responsibility strategy (p=0.032), which may indicate that anxious people can take responsibility for the problems or difficulties they face rather than trying to blame other people or circumstances. This dimension also relates to the avoidance and escape strategy (p=0.013). In other words, anxious people tend to avoid or run away from anxiety-provoking situations rather than facing them directly (Table 5).
DISCUSSION
Based on the study’s results, it can be said that most nursing professionals at the hospital are female, with an average age of 39, brown, married, and mothers. Even with the evolution of gender issues in society, female protagonism in nursing is still evident. Data collected by the Federal Nursing Council revealed that 85% of the category is still made up of women and that 60% of Brazilian nurses are up to 40 years old12. Although the driving force behind nursing is still made up of young professionals, one study13 pointed to an exponential growth in nurses aged 65 or over working in their profession in all Brazilian regions between 2003 and 2017. This was not identified in the present study.
The majority have some form of religion, the main one being Catholicism. A study points to the positive impact of religiosity and spirituality on coping with illness, helping to promote quality of life14. One study15 pointed out that the benefits related to individuals with religiosity/spirituality go beyond their psyche, and it was shown that nurses with religion or spirituality had better immunity and greater self-knowledge about their health.
In the current study, most of the professionals interviewed were married. Having a partner can be beneficial in terms of emotional and financial support. However, this marital situation can increase responsibilities, especially in the female population16.
Most nurses use cars exclusively to commute to work. A study17 carried out in Porto Alegre highlights the relationship between transportation by car and apps as a promoter of a better quality of lifestyle since although other transportation options, such as public transport, bicycles, and even walking, provide moments of appreciation of the place, they have limitations in terms of accommodation and the singularities of individuals.
Most professionals work 36 hours a week during the day and carry out care activities. Despite this, it is necessary to examine the quality of life of nurses who work at night. The circadian clock, governed by the suprachiasmatic nuclei, is mainly influenced by light and food. Thus, it plays a fundamental role in hormonal, metabolic, and immunological regulation and mental health18-19.
Mental health and job satisfaction are interrelated. A study of perioperative nurses highlighted the influence of job satisfaction on the relationship between coworkers and the mental health of the worker20.
The nurses (35.1%) reported having been diagnosed with a mental disorder. A study carried out in a hospital emergency unit in the state of São Paulo showed that 91.3% of working nurses had symptoms of depression, and most of them pointed out the link between mental suffering and the lack of infrastructure and management of activities21.
The number of people who were or had been to therapy sessions was higher than those who indicated that they were looking for psychiatric professionals. The search for psychotherapy rather than psychiatry demonstrates these nurses’ interest in self-knowledge and relevance in solving the core of their problems22.
Studies carried out in the states of São Paulo, Rio de Janeiro, and Minas Gerais with nurses revealed that most of these professionals had used some form of psychotropic drug during their lives, including tranquilizers, sedatives, and central analgesics such as tramadol and codeine. The emphasis is on the younger population, and the leading cause for the outcome of medicalization is the high exposure to these drugs and the stressful situations experienced by these professionals23. This reinforces the need to take a careful look at the mental illness of these professionals to promote mental health.
The work environment can contribute to less mental suffering and exhaustion during the working day24. A study indicates that high levels of social support among healthcare workers are associated with lower anxiety levels and greater job satisfaction25.
In this study, 42.3% of nurses used alcohol, tobacco, and other substances. A study 26 carried out in a General Hospital in the state of Minas Gerais found that 32.7% of nurses had consumed alcohol in 12 months (n=72), and tobacco use was 31.4% (n=97).
There was more significant impairment in the Obsessiveness-Compulsiveness dimension in both gender groups and less impairment in the Psychoticism dimension in male nurses and Anxiety in female nurses. A study carried out with nurses at a university hospital in Pernambuco found that they also showed more significant impairment in the Obsessiveness-Compulsiveness dimension, with Anxiety being the lowest dimension27. On the other hand, another study28 found more substantial impairment in the Somatization dimension in both sexes. The Obsessiveness-Compulsiveness dimension, on the other hand, showed a similar impairment to Somatization. The dimension with the least impairment was Anxiety.
The strategy most used in stressful situations by both sexes was Positive Reappraisal, which involves the individual’s ability to reinterpret the situation, seeking to improve it and focusing on the positive aspects29. On the other hand, the least used strategy was Escape and Avoidance, which consists of avoiding or escaping from stressful situations without promoting an effective resolution of the problem10. In an emergency unit at a University Hospital in São Paulo, the coping strategy most used by nurses was Problem-Solving for both sexes. One study30 found that nurses in the Neonatal ICU unit mainly used Self-control coping, with Confrontation being the least used.
The study’s limitation is related to the fact that the sample was intentional and non-probabilistic, limiting the generalization of the results to nurses from other hospitals.
CONCLUSION
This study found that most nurses are brown/black women, married, Catholic, and mothers; they work mainly in direct patient care on the day shift and dedicate 36 hours of their working week. As for their mental health conditions, some of them have been diagnosed with a mental disorder; they are more affected by psychopathological symptoms related to obsessiveness and compulsiveness and mainly use functional coping strategies to solve everyday problems.
The study suggests that there are several correlations between psychosocial factors, such as the use of psychotropic drugs, length of treatment and working conditions, and aspects of the mental health of the participants. It’s worth remembering that correlation does not necessarily imply causation. In other words, one thing does not necessarily cause another, but they have an observed relationship. Despite this, these findings contribute to understanding how people with different psychological profiles deal with stress and how their approaches can be both adaptive and potentially harmful, depending on the situation. This can direct future research or care interventions in the workplace.
These interventions can benefit not only the well-being of nurses but also improve the quality of patient care, as emotionally healthy professionals are better able to face daily challenges effectively and provide higher-quality care.
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HOW TO REFERENCE THIS ARTICLEOliveira MSS, Alvez VM, Lúcio IML, dos Santos PS. Mental illness and coping strategies of nurses at a university hospital. Cogitare Enferm [Internet]. 2025 [cited “insert year, month and day”];30. Available from: https://doi.org/10.1590/ce.v30i0.97844
ACKNOWLEDGMENTS
We thank the hospital for the opportunity to conduct this research, which arose from the Institutional Scientific Initiation Program Code 001.
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Associate editor: Dra. Susanne Elero Betiolli
