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Hospital downsizing, individualresources, and occupational stressors innursesEsther R. Greenglass a & Ronald J. Burke aa Department of Psychology , York University , Toronto, Ont.,Canada , M3J IP3Published online: 29 May 2007.

To cite this article: Esther R. Greenglass & Ronald J. Burke (2000) Hospital downsizing, individualresources, and occupational stressors in nurses, Anxiety, Stress, & Coping: An International Journal,13:4, 371-390, DOI: 10.1080/10615800008248342

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HOSPITAL DOWNSIZING, INDIVIDUAL RESOURCES, AND OCCUPATIONAL

STRESSORS IN NURSES

ESTHER R. GREENGLASS* and RONALD J. BURKE

Department of Psychology, York University, Toronto, Ont., Canada, M3J IP3

(Received in final form 12 December 1999)

Restructuring and downsizing are occurring increasingly throughout the workplace. As a result, many individuals are losing their jobs. Many others experience job insecurity as a result of the threat of downsizing. As with most other work spheres, several hospitals are closing, resulting in thousands of layoffs. Since nurses constitute one of the main groups employed in hospitals, they are faced with increasing job shortages. This study examines psychological reactions of nurses in response to stressors resulting from hospital down- sizing. Individual resources, particularly coping strategies and self-efficacy, can affect the extent to which individuals experience distress as a result of downsizing. A self-report, anonymous questionnaire was filled out and returned by 1363 nurses employed in hospi- tals in Canada. Results of this study show that amount of work was a consistent and significant stressor in nurses. The greater the nurse’s workload, the greater her emotional exhaustion, cynicism, depression and anxiety. Further results reported here indicated that control coping and self-efficacy lessened distress on the job and increased job satis- faction, while escape coping was associated with greater psychological distress and less job security.

Keywords: Stress; Nurses; Downsizing; Self-efficacy; Coping

Restructuring and downsizing are occurring increasingly throughout the private and public spheres. As with most tax-funded government services, downsizing is being imposed on the health-care system in Canada. Hospitals are restructuring, merging or closing resulting in the loss of thousands of jobs. In the last few years, more than 3700 full-time equivalent nurses have lost their jobs in Ontario (Davidson, 1994).

* Corresponding author.

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372 E.R. GREENGLASS AND R.J. BURKE

Since the majority of nurses affected are employed in hospitals and since hospital closures are occumng everywhere, nurses are faced with increasing job shortages.

Many nurses believe that deterioration in working conditions has jeopardized patients' well-being. A recent survey reports that 85% of 20,000 nurses believe that understaffing due to budget cuts and down- sizing has reached the point that unsafe conditions exist for patients (Dialogue on Health Reform, 1996). The impact on nurses has been considerable. With fewer qualified staff to care for patients, nurses' workload has dramatically increased. Nurses are reporting higher stress levels, high job insecurity levels and poor morale. The impact on nurses of the sweeping changes associated with restructuring has been considerable and far-reaching. Stress levels in nurses increase when more patients have to be cared for in the same number of hours with a constantly shrinking pool of available qualified nursing staff. And research indicates that work overload in nurses is a significant pre- dictor of negative mental health outcomes (Tyler and Cushway, 1995), stress (Gray-Toft and Anderson, 1983; Kaufman and Beehr, 1986; Moore et al., 1996), less job satisfaction (Schaefer and Moos,1993) and burnout Armstrong-Stassen et al., 1994). Moreover, workload has emerged as one of the most consistent stressors occurring in nurses, including acute care nurses, surgical nurses and general hospital nurses (Gray-Toft and Anderson, 1983; Tyler and Cushway, 1995).

Additional stresses resulting from hospital restructuring include deterioration in hospital facilities and services, staff layoffs, beds closed, bumping (where one nurse replaces another due to greater seniority), and use of generic workers to replace trained nurses. R N s are increas- ingly being replaced by less well-trained practical nurses and nursing assistants. The increasing use of unregulated generics are an additional stressor for nurses. Not only are they taking over traditional nursing duties, they often have to be trained on the job and supervised, most often by RNs. Workforce reductions that accompany organizational changes represent major stress for nurses. Not only are nurses seeing others lose their jobs, they live on a daily basis with job insecurity since they do not know if or when their own hospital will close. And, job insecurity itself has been associated with psychological distress and poor health (Catalan0 et al., 1986; Roskies and Louis-Guerin, 1990).

An individual's coping strategies has been the subject of extensive research in the area of job stress and burnout. Research on coping has

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HOSPITAL DOWNSIZING, RESOURCES AND STRESSORS 3 73

distinguished between problem-focused, or instrumental approaches, to coping and emotional-focused coping. While problem-focused cop- ing is directed toward managing the source of stress, emotion-focused coping is aimed at regulating emotional responses elicited by the situa- tion (Folkman and Lazarus, 1980). Many agree that problem-focused coping is an effective individual coping strategy given research find- ings that it is negatively related to distress symptoms (Billings and Moos, 1984; O’Neill and Zeidner, 1985). Greenglass (1988) reports negative relationships in managers between job anxiety and problem- focused coping, and in particular, internal control, a coping strategy which depends on one’s own efforts to change the situation. The same research also found significantly negative correlations between job anxiety and preventive coping. Additional findings indicate that emo- tional or palliative coping, including wishful thinking and self-blame are positively correlated with psychological distress such as job anxi- ety, depression and somatization, and negatively associated with job satisfaction (Greenglass, 1993), thus suggesting that palliative coping itself may be a distress symptom.

Latack (1986) has developed a measure of coping which differenti- ates between control and escape oriented coping. As such, the scales encompass the dichotomy between emotion-oriented and problem- oriented coping discussed by Lazarus and Folkman (1984). Control coping involves discussions with supervisors, making a plan of action, and generally consists of actions and cognitive reappraisals that are proactive and take-charge in tone. Escape coping by definition tends not to be problem-focused, since it is designed to get the person away from the situation causing the stress. Escape coping involves denial and avoidance processes.

Previous research indicates that control coping may be more effec- tive in reducing distress than escape or more passive forms. In a study of mental hospital workers, those who used control coping strategies were less emotionally exhausted and had more positive assessment of their personal accomplishments, and those who used escapist coping experienced more emotional exhaustion (Leiter, 1991). Armstrong- Stassen (1994) reports that job layoff survivors who used escape cop- ing reported lower job performance and higher intent to leave the organization. Those who engaged in control coping reported greater commitment to the organization, higher job performance, and lower intent to leave the organization.

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374 E.R. GREENGLASS AND R.J. BURKE

Thus, when workers are under stress, coping strategies and behaviors involving mastery or problem-solving are associated with more positive outcomes than escape or more passive forms of coping. It is expected then, that nurses experiencing hospital downsizing who employ control coping would report less anxiety, depression and greater professional commitment than nurses who use less control coping. Escape coping in nurses should be associated with greater distress symptoms including anxiety and depression, and less professional commitment.

It has been further shown that some personality variables are asso- ciated with less chronic disease and stress (Carver and Scheier, 1993; Slangen et a1.,1993). Perceived self-efficacy, as a personal resource, reflects the person’s optimistic self-beliefs about being able to deal with critical demands by means of adaptive actions. It can also be regarded as an optimistic view of one’s capacity to deal with stress. Low self-effi- cacy is a central factor in the etiology of burnout (Fishman and Cherniss, 1990). For Leiter (1991), burnout is inconsistent with a sense of self- determination or self-efficacy; burnout diminishes the potential for sub- sequent effectiveness. Nurses experiencing downsizing in their hospitals who are high in self-efficacy should experience less distress and more professional commitment than those who are lower in self-efficacy.

In the present study, extent of downsizing is quantified by asking respondents to indicate specific restructuring initiatives that had occurred in their hospital from a list of 16. Examples of restructuring initiatives are, “staff layoffs,” “beds closed,” “budget cuts”. It is expec- ted that nurses who are employed in hospitals with more restructuring initiatives will show higher levels of distress and burnout than those employed in hospitals with less initiatives.

Given that downsizing and restructuring lead to stressful con- sequences, the effects of downsizing can be understood within a stress- and-coping framework. Research indicates that downsizing and restructuring present situational dimensions that can elicit job insecur- ity, cynicism, emotional exhaustion, burnout, anxiety and depression. The main model employed in the present study is consistent with those generally applied to the study of stress and coping (see Fig. 1). Burn- out and stress are outcome measures which vary as a function of individual or person variables, job-related variables, the number of restructuring initiatives undertaken in a hospital, and organizational demands such as amount of work, bumping and use of generic workers.

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HOSPITAL DOWNSIZING. RESOURCES AND STRESSORS 375

Outcome Measures I , Amountof

FIGURE 1 Hierarchical Regressions -Variables Predicting Outcome Measures: Model.

Outcome measures also vary as a function of individual resources including coping and self-efficacy . Since individuals differ in the extent of their personal resources, i.e., their self-efficacy and coping strate- gies, there should be differences in the extent of stressful outcomes observed. Those individuals who use more control coping should experience less distress than those who employ less control coping. And, high use of escape coping should be associated with more dis- tress. Individuals who are high in self-efficacy should experience less stressful psychological reactions when experiencing hospital down- sizing than those who are lower in self-efficacy .

Outcomes that are studied here include burnout, job ihecurity, job satisfaction, depression and anxiety. Individual resources examined include control and escape coping and self-efficacy. It is expected that the greater the use of control coping by nurses, the greater their job satisfaction, job security and professional efficacy. On the other hand, greater escape coping should be related to more anxiety and greater depression. It is also predicted that greater self-efficacy should be asso- ciated with more positive outcomes including more professional effi- cacy and job satisfaction and less burnout, depression and anxiety. In addition to testing the main effects of resources such as control coping and self-efficacy on reactions to restructuring and downsizing, the pre- sent study also examines the buffering effects of these resources on outcome measures. This is in line with Aneshensel and Stone (1983) who discuss the buffering or moderating effects of social support. In the present context, the interactions between restructuring initiatives, control coping, and self-efficacy are examined on stress and burnout reactions.

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316 E.R. GREENGLASS AND R.J. BURKE

METHOD

Procedure

Respondents

Respondents were primarily women (94.8%). They were employed in at least 11 different nursing units, with approximately two-thirds of respondents working in medical/surgical, intensive care/coronary, emergency, and obstretrics units. One-half of respondents worked part- time and forty-five percent were supervisors. The nurses came from all over Ontario, from communities varying in size from 5000 to over one million people. About one-half of the sample worked in a large hospi- tal (over 250 beds). On average, nurses were employed 13 years in their current hospital.

About 80% of the sample were RNs, either college- or hospital- based. (Thus, the majority of the sample were professional nurses who had completed an approved college or hospital nursing program thus being required to provide continued competency evidence, and to re-register every year.) Eighty percent were married or living with someone; three-quarters had children (approximately 2). The average age of the respondents was 42 (see Table I).

Data were collected using a confidential and anonymous mail-out questionnaire which was sent to 3892 Ontario hospital nurses who were members of the nurses' union. Respondents were randomly chosen from all hospital nurses who were on a membership list consisting of 45,000 nurses in total. Of those sent out, 1363 questionnaires were returned in a self-addressed, stamped envelope thus yielding a response rate of 35%.

Measures

Individuallperson variables are educational level, sex, children (presence versus absence), age, and community size.

Job-related variables are number of hospital beds, number of years worked in present hospital, supervisory duties (presence versus absence), and full- versus part-time work.

Resources

Latack's (1986) 28-item Coping Scale was used to measure control (a = 0.86) and escape coping (a = 0.71). Instructions were modified

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HOSPITAL DOWNSIZING, RESOURCES AND STRESSORS 377

TABLE I Demographic variables and nurses (N= 1363)

Variable n %

Medical/Surgical Intensive care/Coronary Emergency Obstetrics Continuing care/Gxiatrics Operating room Pediatrics Psychiatry Oncology Recovery room Medical/Surgical short stay Other (includes bums, neonatal

Full-time or part-time statm Full-time Part-time D.A. Supervisory job Supervisor Non-supervisor D.A.

intensive care, administration, education)

348 237 159 143 90 87 83 81 65 56 43

276

645 700

18

616 733

14 Hospital size (number of beds) m+ 325 251-400 394 151-250 262 125-150 94 < 125 256 D.A. 32 Community size 1,000,000+ 187 5oO,001-1,000,000 126 250,001-500,OOO 280 100,001-250,000 242 50,OO 1 - 100,000 236

D.A. 48 Number of years employed in current hospital ~=13.31,SD=7.68,Range= < 1 year-38year,n=1355 Education level (highest degree) RNA diploma 14 RN - College diploma 679 RN - Hospital-based diploma 441 Baccalaureate 208 Master’s 10 D.A. 11 Marital status Mamed, living together 1097 Single, widowed, divorced, separated 251 D.A. 15

0-50,OOO 244

25.5 17.4 11.7 10.5 6.6 6.4 6.1 5.9 4.8 4.1 3.2

20.2

47.3 51.4

1.3

45.2 53.8

1.0

23.8 28.9 19.2 6.9

18.8 2.4

13.7 9.2

20.5 17.8 17.3 17.9 3.6

1 .o 49.8 32.4 15.3 0.7 0.8

80.5 18.4 1.1

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378 E.R. GREENGLASS AND R.J. BURKE

Table I (Continued)

Variable n YO

Sex Women Men D.A.

1292 94.8 39 2.9 32 2.3

Note: D.A. =Did not Answer.

to make coping domain-specific. An example of control coping is, “Put extra attention on planning and scheduling.” An example of escape coping is, “Avoid being in this situation if I can.” Self-efficacy (a= 0.87) was assessed using a ten-item perceived generalized self-efficacy scale (Schwarzer, 1993). A sample item is, “No matter what comes my way, I’m usually able to handle it.” Respondents indicated on a four- point scale how true each statement was from not at all true (1) to exactly true (4).

Outcome Measures

The General Burnout Questionnaire (Schaufeli et al., 1996) was used to measure three outcomes relating to the respondent’s job - Emo- tional exhaustion, Cynicism, and Professional efficacy. Emotional exhaustion (a = 0.90) refers to the concept of job stress. An example is, “I feel emotionally drained from work,” while Cynicism (a = 0.82) reflects indifference or a distant attitude towards work. An example is, “I just want to do my job and not be bothered.” Professional efficacy (a = 0.73) refers to satisfaction with past and present accomplish- ments, an individual’s expectations of continued effectiveness at work. An example is, “In my opinion, I am good at my job.” Job security was assessed in a ten-item measure (a = 0.76) appraising job deterioration in seven areas (four from Roskies and Louis-Guerin, 1990) including job lay offs, termination, demotion, deterioration in working condi- tions, voluntary severance, voluntary early retirement, and change in working status from full-time to part-time, and extent of concerns about job security. Job satisfaction (a = 0.82) was assessed with a five- item measure developed by Quinn and Shepard (1974). A sample item is, “All in all, how satisfied would you say you are with your job?” (1 = not at all satisfwd, 4 = very satisfied). Depression (1 1 items) (a = 0.88) and Anxiety (7 items) (a = 0.80) were assessed using the Hopkins

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HOSPITAL DOWNSIZING. RESOURCES AND STRESSORS 379

Symptom Checklist (HSCL) (Derogatis et al., 1979). A sample item of depression is, “Indicate how often you have ‘felt blue’ during the last 3 months.” A sample item of anxiety is, “Indicate how often you have felt nervousness or shakiness inside” (1 = never, 4 = extremely often).

Stressors

Stressors include Amount of Work (a = 0.70), consisting of four items assessing the nurse’s workload (as a result of changes in the hospital). An example is, “I feel my workload is” (1) never too heavy to ( 5 ) almost too heavy. Respondents checked the number that best described their workload. Bumping (2 items) (a = 0.60) assessed the extent to which changes in staff occurred as a result of one nurse replacing another due to greater seniority and Use of Generic Workers (2 items) (a = 0.70) assessed the extent to which generic workers replaced trained nurses on the job.

The Restructuring Initiatives Index (HI) was assessed in a series of questions in which respondents were asked to check specific restruc- turing initiatives from a list of 16 that had occurred in their hospitals. Results indicated that “budget cuts” had occurred in almost the entire sample (94.9%), followed by “staff layoffs” (94.0%) and “beds closed” (91.3%). The practice of “bumping” was reportedly occurring in 88.3% of hospitals; in 83.6% of hospitals, early retirement incentives were being offered to staff. Close to 80% of hospitals were not filling job vacancies, three-quarters of respondents reported closed units and close to 70% said that they experienced a wage and a hiring freeze. Approxi- mately one-half of the respondents reported overtime restrictions on employment or having to switch to a part-time position. Forty-four percent reported job sharing, forty-two percent said that some speci- alty services had been discontinued, and about ten percent said that their work week or work year had been shortened. Only five percent of respondents indicated a rollback in their wages. On the average, respondents indicated 9.57 (SD = 2.64, n = 1362) restructuring initia- tives had taken place at their hospital.

RESULTS

Cronbach alphas on combined variables indicated that reliabilities of the variables were acceptably high. Most were 0.70 or higher. Correlations

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380 E.R. GREENGLASS AND R.J. BURKE

were computed among composite variables in the study. Data showed that, as restructuring initiatives increased, there was a significant and positive increase in emotional exhaustion, cynicism, depression, and anxiety. Results showed that control coping was positively related to professional efficacy, self-efficacy, and job satisfaction. Escape coping was positively related to cynicism, depression, and anxiety. Self-effi- cacy was negatively related to emotional exhaustion and cynicism as well as depression and anxiety. Greater job insecurity was related to greater cynicism and exhaustion, and more escape coping. Amount of work was related to bumping and use of generics (see Table 11).

In order to determine the relative contributions of variables to out- come measures, hierarchical multiple regressions were conducted with variables being entered in blocks. Outcomes included those associated with the job and psychosomatic reactions. Blocks were entered to be consistent with the framework generally used in the literature examin- ing psychological reactions (often strain) in response to stressors or demands in the environment. In a series of regressions, the first block of variables ( 5 ) were those associated with the individual person. These were considered as control variables and include educational level, sex, children, age, and size of community. The second block of variables (4) were job-related and include number of hospital beds, number of years worked in present hospital, supervisory duties, and full-time versus part-time work. The third block of variables that were entered were stressors and include amount of work, bumping and use of generic workers. The fourth block of variables (3) include resource variables such as control coping, escape coping and self-efficacy.

Table I11 presents the total R Square and increase in variance in outcome variables accounted for by each block of variables. Results show that the four blocks of variables accounted for between 13% and 27% of the total variance in outcome measures. Increase in explained variance due to individual and job-related variables tended to be small. The increase in variance due solely to the stressor block ranged from 1% to 20%, with the greatest increase in variance due to stres- sors seen when the outcome variables were job-rated. Individual resources accounted for between 2% and 14% of the variance in out- come variables (see Table 111).

Table IV presents betas and t values for stressors in Block I11 including amount of work, bumping and use of generics. Results

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382 E.R. GREENGLASS AND R.J. BURKE

TABLE 111 Hierarchical multiple regression results: increase in variance accounted for by blocks

Outcome variable Total, @ Blocks

I 11 111' IV Individual/ Job-related Individual Resources

person stressors

Emotional exhaustion 0.27 0.01' 0.03"' 0.20'"' 0.03"' Job satisfaction 0.22 0.02** 0.00 0.15"' 0.05"' Cynicism 0.24 0.01 0.01 0.09"' 0.13***

Professional efficacy 0.18 0.01' 0.02" 0.01' 0.14"'

Anxiety 0.13 0.00 0.01 0.04*** 0.08"'

Job security' 0.19 0.03*** 0.05*** 0.09*"* 0.02***

Depression 0.16 0.00 0.01 0.06"' 0.09"'

Notes: 'Amount of work, bumping and generic workers are the stressors. 'The greater the score, the less job security. 'p<O.O5, **p<O.OI, ***p<O.OOl.

TABLE IV Block 111 - Significant stressor predictors of outcome variables

Outcome variable Predictor variable

Amount of work Bumping Use of generics

beta' t beta t beta t

Emotional exhaustion 0.43 14.36"' . Job satisfaction -0.39 -12.27"' Cynicism 0.30 9.02*** .

Professional efficacy -0.09 -2.58* 0.08 2.37' Job security' 0.23 6.97"' 0.07 2.20' 0.10 2.92"

Depression 0.18 5.18*** 0.09 2.66" Anxiety 0.15 4.26;" 0.11 3.08"

Note: = non-significant variable. 'Betas from multiple regressions where all blocks of variables have been entered. 2The greater the score, the less job security. *p < 0.05, ' p < 0.01, "'p < 0.001.

showed that amount of work was a significant and positive contrib- utor to emotional exhaustion, cynicism, greater job insecurity, greater depression, and more anxiety. Amount of work contributed negatively to job satisfaction and professional efficacy - more work was asso- ciated with less job satisfaction as well as less professional efficacy. Bumping contributed to fewer outcomes - the more bumping the greater the job insecurity, the more depression and anxiety, and the more professional efficacy. Use of generics contributed to greater job insecurity (see Table IV).

The contribution of resources to outcome measures is presented in Table V. Escape coping was a positive predictor of emotional

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HOSPITAL DOWNSIZING, RESOURCES AND STRESSORS 383

TABLE V Block IV - Significant resource predictors of outcome variables

Outcome variable Predictor variable

Escape coping Control coping Self-efficacy

beta' t beta t beta t

Emotional exhaustion Job satisfaction Cynicism Job security' Professional efficacy Depression Anxiety

0.10 3.53"' -0.12 -3.91"' -0.1 1 -3.62"' 0.15 4.82*" 0.08 2.57"

0.26 9.01"' -0.19 -5.83"' -0.08 -2.70** 0.12 3.85"' 0.07 2.05'

0.14 4.62"; 0.25 7.36"' 0.21 6.54'"

-0.27 -1.93"' 0.11 3.66"' -0.26 -7.77""

Nore: . =non-significant variable. 'Betas from multiple regressions where all blocks of variables have been entered. 'The greater the score, the less job security. ' p < 0.05, " p < 0.01, "'p < 0.001.

exhaustion, cynicism, job insecurity, depression, and anxiety. Escape coping was a negative predictor of job satisfaction - higher escape coping was associated with lower job satisfaction. Control coping pre- dicted positively to job satisfaction, professional efficacy, and greater job insecurity. Control coping contributed negatively to cynicism. Self- efficacy predicted negatively to emotional exhaustion, cynicism, depres- sion, and anxiety, and positively to job satisfaction and professional efficacy (see Table V).

In order to test the buffering (interaction) effects of control coping on outcome measures, a series of multiple regressions were conducted where the criteria were job satisfaction, burnout components, depres- sion, and anxiety, and predictors were restructuring initiatives and the interactions between Restructuring Initiatives x Self-Efficacy and between Restructuring Initiatives x Control Coping. None of the interactions were statistically significant.

DISCUSSION

Findings in this study indicate that hospital downsizing and restruc- turing are associated with deleterious and stressful psychological out- comes in nurses as seen in positive correlations between number of restructuring initiatives, emotional exhaustion, cynicism, depression, and anxiety. Additional results of this study indicated that individual resources were significantly associated with both positive and negative outcomes studied. At the same time, the data showed that, on average,

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when comparing contributions of stressors and individual resources to the various outcomes studied, resources accounted for a smaller por- tion of the variance in outcomes above and beyond that accounted for by the stressors. This was particularly true when emotional exhaus- tion, job satisfaction, and job insecurity were examined. When other outcomes were analyzed, however, individual resources tended to be more important contributors to the total variance. For example, indi- vidual resources contributed more than work stressors to the variance in cynicism, professional efficacy, depression, and anxiety. Thus, the data suggest that skills, particularly coping ability, that the nurse brings to her job are more important in predicting not only her feel- ings about her professional accomplishments but also her depression and anxiety. At the same time, a nurse with high professional efficacy may be more likely to engage in control-oriented coping than a nurse who is lower on professional efficacy. Individual resources were less important than work stressors in predicting psychological reactions tied more directly to the job such as, job insecurity, job satisfaction and emotional exhaustion, often referred to as the prototype of stress (Greenglass et al., 1997; Schaufeli and Van Dierendonck, 1993). Find- ings in this study that emotional exhaustion is related to job demands, that professional efficacy is related to resources, and that cynicism is related to both, are consistent with the integrated model put forth by Leiter (1993). The meta-analysis conducted by Lee and Ashforth (1 996) also provides considerable empirical support for the associa- tions found in the present study.

The data suggest that use of control coping was associated with greater job satisfaction and greater professional efficacy. Thus, to the extent that nurses employed coping which depended on their own efforts to change the situation, they were more likely to have greater job satisfaction and more positive feelings about their professional accomplishments. Control coping was also a negative predictor of cynicism in nurses. That is, more control coping predicted significantly to lower nurses’ cynicism about their jobs. It could be that nurses who believe that outcomes are within their control, are less likely to become cynical about their patients when experiencing stress associated with hospital downsizing. It is also possible that cynical nurses are less likely to use control coping and more likely to resort to escape coping. Despite hospital downsizing initiatives, the nurse who uses control

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HOSPITAL DOWNSIZING, RESOURCES AND STRESSORS 385

coping retains her professional integrity, as seen in her higher profes- sional efficacy. The finding that control coping predicted significantly to professional efficacy, coincides with Leiter (1991) who found that control coping strategies used by workers in a mental hospital were related to less emotional exhaustion and to more positive assessment of personal accomplishments. To summarize, nurses who use a pro- blem-focused and proactive approach to stress, also expressed more satisfaction with their occupational role, greater enthusiasm for work, and they continued to hold expectations of effectiveness at work, despite restructuring initiatives. The positive relationship between con- trol coping and job insecurity, a finding that is inconsistent with the others in this study, may reflect a type of suppressor effect since the zero-order correlation between control coping and job insecurity was almost zero (r = 0.04).

In contrast, escape coping was associated with higher levels of psy- chological distress including depression, anxiety, emotional exhaustion and cynicism. As with other palliative coping forms, escape coping appears to be another symptom of distress rather than a coping form since it is consistently associated with psychological symptomatology (Greenglass, 1995; Latack, 1986). Escape coping was also associated with greater job insecurity and less job satisfaction. Workforce reduc- tions, as seen in hospital restructuring, represent a major transition for those who are laid off as well as for those who remain employed in the hospital. Nurses, like other employees, need personal coping strategies for dealing with the chaos associated with these changes. While control- oriented coping represents a high level of energy and optimism about changing conditions, escape coping implies passivity and pessimism, particularly about the possibility of making any changes. This is reflected in the consistent findings of an association between psycho- logical symptomatology and escape coping.

Results of this study showed further that, when undergoing hospital downsizing, the most significant and consistent stressor in nurses was the amount of work they had to do - the greater the nurse’s workload, the greater the nurse’s emotional exhaustion, cynicism, depression and anxiety. More work was also associated with lower job satisfaction, lower professional efficacy and less job security. These findings are expected given that one of the consistent effects of restructuring is a continual reduction in hospital staff, particularly nurses. According to

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research, workload is a consistent stressor in nurses as demonstrated by Moore et al. (1996) in their study of acute care nurses and by Armstrong-Stassen et al. (1994) in their study of burnout in nurses. The hospital’s employment practices including bumping and use of generic workers also contributed to stress in nurses, but to a lesser degree. These practices resulted in less job security, and bumping was associated with greater depression and anxiety.

Present findings showed that high self-efficacy contributed to lower distress in nurses who were experiencing hospital restructuring. High self-efficacy was associated with lower emotional exhaustion, less cyni- cism, less depression and anxiety, and greater job satisfaction and professional efficacy. Additional findings show that, despite failure, appraisals of individuals high in self-efficacy remained positive (Jerusalem and Schwarzer, 1992). Thus, present findings support the conclusion that high self-efficacy contributes directly to lower symp- toms of distress.

Previous research has linked stressors, personality characteristics, coping modes, and stressful outcomes in various conceptual models. And, these are relevant to future study of stress in nurses. For example, Ivancevich and Matteson (1 980) have defined environmental stressors acting through personal stressors (personality attributes and needs) that lead to consequences of stress. In their revised psychological model, Chiriboga et al. (1983) talk about stress appraisals and coping modes intervening between environmental and internal demands and the individual’s adaptive status. For Carroll and White (1981), stress results from an inadequate fit between a person and his/her environ- ment. And, according to the model put forth by Cohen-Mansfield (1995), sources of individual stress lie in work-related demands and individual needs. These interact with resources and the individual’s personality to produce the person-job fit. Lack of fit between the two results in psychological and physiological stress reactions. Individuals’ response to stressors include depression, cynicism, exhaustion, and burnout.

In the present study, there was no evidence to support buffering effects of restructuring of either control coping or self-efficacy on burn- out, job satisfaction, or psychosomatic reactions to stress. The evi- dence for the buffering effect of resources, in particular social support, is controversial (Himle et al., 1989). The present results with control

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HOSPITAL DOWNSIZING, RESOURCES AND STRESSORS 387

coping and self-efficacy parallel previous findings which failed to find buffemng effects of social support on stress (Himle et al., 1989; Linn et al., 1979; Shinn et al., 1984).

One of the limitations of the present study is that the response rate was relatively low, probably due in part to the long questionnaire (13 pages) that respondents were asked to fill out. At the same time, it is worth noting that the current nursing sample was representative of the larger population of nurses on a number of key variables, thus making the response rate less of a problem. For example, the average age of the nurses in the current sample was 42. In Ontario, the average age of nurses is 44 (Report of the Nursing Task Force, 1999). While 47% and 5 1 % of the current sample was employed full- and part-time, respectively, in 1997 in Ontario, 49% of all nurses worked full-time and 47% worked part-time (College of Nurses of Ontario, 1997). In the current sample of nurses, most were women. The nursing profes- sion in Ontario is also mainly women. In the present sample, nurses come from hospitals and communities which vary in size. These are representative of the hospitals in Ontario which also vary in size as do the Ontario communities in which they are located. Taken together, these data strongly suggest that the current sample is representative of the population of nurses in the province of Ontario.

A second limitation of the study is that causal relationships between variables cannot be assumed given the cross-sectional design of this study. Thus, “outcomes” such as anxiety and depression may well influence the degree of coping employed by nurses in addition to or instead of coping determining extent of anxiety or depression. And, third, with the exception of self-efficacy, wbch is a more general mea- sure (Schwarzer, 1993), the variables in this study are domain-specific which tend to be more closely interrelated than are more general vari- ables. Thus, comparisons of the relative strength of relationships involving self-efficacy with relationships involving other variables should be done cautiously.

To summarize, the restructuring process leads to changes in the hos- pital that result in greater job insecurity and lower job satisfaction in nurses. Their reactions to these changes and particularly to the losses experienced as a result of hospital restructuring, would appear to depend a great deal on a nurse’s individual resources. A nurse who uses con- trol coping and/or has high self-efficacy is more likely to maintain an

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optimistic approach to her work and to her accomplishments, despite her (and her hospital’s) losses. Escape coping in nurses is associated with disengagement from the nursing role, lack of enthusiasm, and an indifference towards one’s nursing role. Models of stress and coping need to take account of stressors, job-related and demographic varia- bles, as well as individual resources such as coping and self-efficacy.

Acknowledgments

This paper is part of a paper presented at the International Congress of Applied Psychology, San Francisco, August, 1998. Grateful acknowl- edgement is due to Lisa Fiksenbaum for her assistance and to York University and the Faculty of Arts for supporting this research.

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