when nurses cry: coping with occupational stress in thailand

When nurses cry: coping with occupational stress inThailand

Rana Pongruengphanta, Paul D. Tysonb,*aBurapha University, Bangsaen, Chonburi, ThailandbBrock University, St. Catharines, Ontario, Canada

Received 24 July 1999; received in revised form 29 January 2000; accepted 7 February 2000

Abstract

Anecdotal reports of people feeling better after they cry support theories that link crying to the reduction of stressafter a period of prolonged sympathetic activation. A sample of 200 nurses were asked to rate their occupationalstress, job satisfaction, and crying as a coping strategy. Crying was found to be an important symptom of home/

work con¯icts and pressures related to dealing with patients, but did not substantially reduce these sources of stress.Supporting the stress-bu�ering hypothesis, nurses with lower intrinsic job satisfaction seemed to bene®t fromemotional crying whereas dissatis®ed nurses who cry infrequently reported the highest levels of stress. 7 2000

Elsevier Science Ltd. All rights reserved.

Keywords: Nursing; Occupational stress; Coping; Crying

1. Introduction

Cross-culturally, crying is a signal which usually

communicates emotional distress. There have beenextensive speculations about emotional crying andsince the suppression of crying has been hypothesized

to underlie many disorders (Gross and Levenson,1993), it is not surprising that attention has beenfocused on its potentially positive bene®ts. Theories

have proposed several bene®cial functions of crying torelease negative emotions, stress-related biochemicals,and recover from prolonged sympathetic activation(Frey and Langseth, 1985).

The cathartic release of emotions is largely based onanecdotal evidence from people who report that ``hav-ing a good cry'' releases pent-up emotions (Frijda,

1986). Unfortunately studies found that, compared

with female students who did not cry during sad ®lms,

students who cried reported greater levels of stress,

negative emotional experiences, and higher levels of

sympathetic arousal (Gross et al., 1994). There are sev-

eral problems with these studies which limit their ap-

plicability to the hypothesis that crying has bene®ts. In

addition to problems with the subject sample, crying

has been conceptualized as a trait which re¯ects stable

ways of coping in which individuals are classi®ed as

people who frequently cry or rarely cry. For example,

Kraemer and Hastrup (1988) used a restricted sample

of high and low frequency criers instructed either to

cry or not to cry. Another problem is that experimen-

tal manipulations may not qualitatively and quantitat-

ively generalize to an occupational setting. Crying as a

coping strategy for occupational stress may restore

homeostasis, but only after a prolonged period of

increased physiological arousal stimulated by more

International Journal of Nursing Studies 37 (2000) 535±539

0020-7489/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved.

PII: S0020-7489(00 )00031-6

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* Corresponding author.

potent sources of stress than cry-eliciting ®lms (Tyson,1998).

After decades of studying stress and coping, Lazarus(1993) points out that people manifest a variety of cop-ing responses in¯uenced by the source of stress, indi-

vidual's appraisal, and situation in the workplace(Dewe et al., 1993). Studies of stress in nurses haveidenti®ed several common sources of stress derived

from data collected from a nationwide survey of NewZealand nurses (Dewe, 1987), from nurses within theUK (Hingley and Cooper, 1986), the USA (Humphrey,

1992), Taiwan (Tsai, 1993), and Thailand (Pongrueng-phant and Tyson, 1997). Empirical studies report thatnurses who report high levels of workload used moreproblem solving strategies, nurses who were stressed

by patient demands and home/work con¯icts usedmore emotionally focused strategies, and avoidancewas the most reliable symptom of stress and job dissa-

tisfaction (Tyler and Cushway, 1992; Tyson and Pon-gruengphant, 1996). As a form of emotion-focusedcoping, one sensible hypothesis is that when nurses

cry, it is a reliable symptom of occupational stress andjob dissatisfaction.The primary research hypothesis is that crying, as a

coping strategy, has bene®cial bu�ering e�ects onstress and job satisfaction. Coping is considered anintervening variable that may moderate the e�ects ofstress on an outcome variable such as job satisfaction.

Without a bu�ering e�ect, crying is predicted to bepositively related to stress; however, the strength ofthis relationship would be reduced to the extent coping

might successfully moderate the outcome variable.Statistically, the bu�ering hypothesis is tested by look-ing at interactions between stress, crying, and job satis-

faction whereas signi®cant main e�ects suggest thatcrying is a symptom of stress. The level of complexityis increased when ®ve sources of nursing stress as wellas measures of intrinsic and extrinsic job satisfaction

are added to the list of hypothesized main e�ects andinteractions.

2. Method

2.1. Subjects and research setting

The study was conducted in seven hospitals in Bang-

kok and in seven hospitals in three provinces along theeastern seaboard of Thailand. Of the 240 question-naires distributed to Thai nurses, 120 were sampled

from Bangkok and 120 sampled from three easternprovinces. Bangkok is a major metropolitan centre insoutheast Asia and has a population in excess of six

million. The eastern seaboard of Thailand is a develop-ing industrial and tourist area and has 948 thousand inChonburi, 464 thousand in Chachoengsoa, and 597

thousand in Rayong province. Within each region, 60nurses were randomly sampled from three public hos-

pitals and 60 were randomly sampled from four pri-vate hospitals. Eighty seven percent of thequestionnaires were returned, but six male respondents

and three technical nurses were eliminated. Theremaining 200 female professional nurses, who gradu-ated from a 4 year B.S. University programme, had a

mean age of 32.5 years (SD=7.3).

2.2. Measures

2.2.1. Nurse stress indexThis index consists of 30 items and nurses were

asked to rate the potential stressor on a six point scale(Harris, 1989). The index has been subdivided into sixsubscales assessing ®ve major sources of occupational

stress; Managing Workload, Organizational Supportand Involvement, Dealing with Patients and Relatives,Home and Work Con¯icts, and Con®dence and Com-

petence in Role.

2.2.2. Crying coping strategyThis indicator asked nurses to rate how frequently

they used crying to release tension as a coping optionrated on a six point scale with 0=never, 1=infre-quently, 2=sometimes, 3=frequently, 4=very fre-

quently, and 5=all the time with format andinstructions similar to Amirkhan's (1990) CopingStrategy Indicator.

2.2.3. Job satisfactionThis measure includes 20 items and nurses were

asked to rate how they feel about their present job ona ®ve point scale ranging from ÿ2=very dissatis®ed to0=neutral to +2=very satis®ed. The short form ofthe Minnesota Satisfaction Questionnaire (Weiss et al.,

1967) can be divided into intrinsic and extrinsic satis-faction subscales. The 12 item intrinsic subscaleincludes factors such as ``the chance to make use of

my abilities'' and ``the feeling of accomplishment I getfrom my job.'' The six item extrinsic subscale addressesindividual satisfaction with factors such as pay, com-

pany policies, and management. The ®nal general satis-faction scores were computed by averaging across all20 items in the scale.

2.2.4. TranslationThe questionnaire items were translated from Eng-

lish to Thai by the ®rst author (R.P.) and indepen-

dently translated back into English by nurses. TheEnglish translations were reviewed by the secondauthor (P.T.) and questionable items were retranslated.

This reiterative back translation process was utilizeduntil there was agreement by both authors. The com-plete questionnaire was then submitted to ®ve hospital

R. Pongruengphant, P.D. Tyson / International Journal of Nursing Studies 37 (2000) 535±539536

sta� nurses for item by item comments concerningitem ambiguity and relevance.

3. Results

As a coping strategy, nurses in Thailand did not cryvery frequently, but when they cried it was a symptomof stress. The average nurse reported crying ``infre-

quently'' (M=1.59, SD=1.27) with about 15% cryingmore than ``frequently'' on the six point scale. Cryingwas signi®cantly correlated (r= 0.181, p< 0.025) with

the Nurse Stress Index and, in particular, was sympto-matic of home/work con¯icts (r = 0.247, p < 0.001),dealing with patients (r = 0.171, p < 0.025), and rolecon®dence (r=0.152, p<0.05).

Surprisingly, crying among nurses was not signi®-cantly correlated with the primary sources of occu-pational stress or with job satisfaction. Crying was not

signi®cantly related to workload pressures due to

insu�cient time (r = 0.104, p = 0.151) or resources (r= 0.048, p = 0.503) necessary to complete nursing

tasks. Job satisfaction, as an outcome variable closelylinked to coping with stress, was hypothesized to be

negatively related to crying. Although negatively corre-lated, total job satisfaction (r=ÿ0.132, p = 0.065),

intrinsic (r=ÿ0.098, p = 0.172), and extrinsic(r=ÿ0.091, p = 0.202) measures were not signi®cantly

predicted by how frequently nurses cope with stress bycrying.

In this study, the primary hypothesis focused on thebene®cial interaction between stress, crying, and job

satisfaction. Researchers recognize that low corre-lations between coping and a source of stress may

mean that the coping strategy was a bu�er of stress(Aiken and West, 1992). In the case of crying, the hy-

pothesized direct relationship between the amount ofworkload and crying can be cancelled out by the ben-

Table 1

Stress-bu�ering interactions between crying and job satisfaction

Crying strategy & total job satisfaction Stress=TJS+Cry+Cry w TJS Interaction e�ect

Nurse Stress Indicator F (3,172) R 2=26.85% 10.98%��a

Managing Workload 1 F (3,184) R 2=17.41% 7.92%��


Organizational Support F (3,186) R 2=17.36% 0.98%

Dealing with Patients F (3,188) R 2=5.16% 0.73%

Home & Work Con¯ict F (3,184) R 2=14.77% 2.99%��

Con®dence in Role F (3,190) R 2=19.48% 9.36%��

Crying strategy & intrinsic job satisfaction Stress=IJS+Cry+Cry w IJS Interaction e�ect

Nurse Stress Indicator F (3,172) R 2=24.68% 9.76%��



Organizational Support F (3,186) R 2=11.52% 2.23%�


Home & Work Con¯ict F (3,184) R 2=14.70% 1.82%�


Crying strategy & extrinsic job satisfaction Stress=EJS+Cry+Cry w EJS Interaction e�ect

Nurse Stress Indicator F (3,175) R 2=16.63% 2.28%�

Managing Workload 1 F (3,187) R 2=7.60% 1.48%

Managing Workload 2 F (3,192) R 2=11.80% 0.55%

Organizational Support F (3,189) R 2=20.33% 0.05%


Home & Work Con¯ict F (3,187) R 2=10.48% 0.26%


a �p<0.05 ��p<0.025 ��p<0.01 ��p<0.001.

R. Pongruengphant, P.D. Tyson / International Journal of Nursing Studies 37 (2000) 535±539 537

e®cial e�ects of the coping strategy. According to thestress bu�ering hypothesis, the level of stress will

depend on how e�ectively a coping strategy can suc-cessfully prevent stress from lowering job satisfaction.Therefore, nurses who were very satis®ed with their

job may cry for di�erent reasons than nurses who wereunder stress and dissatis®ed with their job.The interaction between crying and job satisfaction

was found to be a signi®cant predictor of stress evenafter the main e�ects had been removed from the mul-tivariate equation (Aiken and West, 1992). Table 1

shows the interactions for the Nurse Stress Index andsix sources of stress as well as intrinsic and extrinsicsubscales of job satisfaction. The per cent of nurses'stress predicted by a variable or interaction is equal to

the correlation squared, for example, a multiple corre-lation of 0.5182 means that 26.85% of the variancewas accounted for by the two main e�ects plus the in-

teraction. In this case, the interaction of total job satis-faction and crying accounted for 10.98% of thevariance in the Nurse Stress Index. Predicting this

amount of variance is extremely unusual given thatmost studies ®nd that signi®cant interactions with cop-ing strategies, such as social support, account for 2±

3% of the variance (McClelland and Judd, 1993).These interactions indicate that crying may be a

symptom or bu�er of stress depending on the sourceof stress and job satisfaction (Table 1). Workload, the

primary source of occupational stress, was signi®cantlyand directly related to crying when nurses were intrin-sically satis®ed with their job. Time (Managing Work-

load 1) and resource (Managing Workload 2) pressuresincreased the frequency of crying among nurses whowere satis®ed with their job. On the other hand com-

pared to nurses who did not cry, nurses who wereambivalent about their job and expressed theiremotions by crying experienced less stress. Crying, as acoping strategy, was found to bu�er workload press-

ures in nurses who were less satis®ed with their job,but was symptomatic of stress in nurses who wereintrinsically satis®ed with their occupation.

4. Discussion

Studies of occupational stress, particularly in thehealth care professions, emphasize a task-oriented, pro-

blem solving coping strategy as the most adaptive wayof dealing with the pressures of workload, inadequateresources, role ambiguity and other sources of stress.

Emotional coping strategies such as crying, being con-sidered palliative and ine�ective, may temporarilyreduce the emotional distress, but have few adaptive

outcomes (Lazarus, 1995). The two hypotheses thatemotional crying is a symptom of stress or bene®cialbu�er are not mutually exclusive; the bu�ering e�ect

of crying may reduce the pathogenic in¯uence of stress

without eliminating the negative relationship betweenstress and job satisfaction. There is evidence from thisstudy that supports both hypotheses. When attempting

to cope with some kinds of stress, such as dealing withdying patients, crying among nurses was a clear signalof emotional distress. The reported interactions also

suggest that, compared to nurses who cry infrequently,emotional crying may bene®t nurses with lower intrin-

sic job satisfaction.In this study, emotional crying associated with con-

¯icting home/work demands and dealing with patients

and relatives was correlated with higher levels of stressand crying as a coping strategy did not appear to have

stress-bu�ering e�ects. Although crying was ine�ectivefor nurses, other studies have found that strategiessuch as support from husbands in Japan had a stress-

bu�ering e�ect on home/work con¯icts particularlywhen husbands shared childcare and domestic duties(Matsui et al., 1995). Pressures related to their relation-

ship with di�cult patients and nurses' feelings aboutdeath and dying are common sources of stress and

typically elicit emotional coping strategies (Douglas etal., 1996). Stress management has been reported tobu�er this source of stress, for example, structured

debrie®ng sessions conducted by a mental health pro-fessional and sta� within 24±72 hours of the deathhave been an e�ective means of decreasing the associ-

ated stress (Martin, 1993). The results of this study areconsistent with previous research (Martin and Labott,

1991), crying was found not to have a cathartic, stress-reducing function in nurses when exposed to particularsources of stress such as coping with dying patients.

When nurses cry it can be an important symptom ofemotional distress, but colleagues should examine in-teractions with the source of stress and individual's job

satisfaction before interpreting the message. There isevidence from the interactions in this study that nurses

intrinsically satis®ed with their accomplishments on thejob, but not coping well with workload pressures andfeelings of inadequate knowledge of their areas of

responsibility, especially when required to performsome of the Doctor's functions, were found to cry as asymptom of stress. For colleagues or management, cry-

ing should serve to communicate nurses' level of stressand to motivate action to alleviate crying by providing

social and organizational support (Bunce and West,1994).In addition, the interactions lead us to focus on

nurses who are not satis®ed with their job and do notemotionally cope with stress by crying. In the present

study, this group of dissatis®ed nurses reported thehighest levels of occupational stress which suggeststhat they are in desperate need of stress management

interventions. A variety of coping strategies such asdenial, avoidance, and repression of emotions may

R. Pongruengphant, P.D. Tyson / International Journal of Nursing Studies 37 (2000) 535±539538

result in nurses crying infrequently as well as cultural,stylistic, and dispositional determinants (Decker and

Borgen, 1993). The tendency for emotional restraintamong Chinese people has been found to have nega-tive stress-bu�ering e�ects (Liang and Bogat, 1994).

Although emotional control might be e�ective whenconfronting short duration stressful events, individualswho chronically disengage from emotional aspects of

the situation have higher risks of depression and healthproblems (Weidner and Collins, 1993).As seen in Table 1, crying can bu�er a variety of

sources of stress including workload pressures, butonly signi®cantly reduced stress among nurses whowere less satis®ed with their job. One interpretation ofthis study's signi®cant interactions is that crying

among nurses with low intrinsic satisfaction may bu�erstress by focusing attention on controllable sources ofstress and attracting support from colleagues, but vigi-

lance may amplify stress when confronted withuncontrollable events and intractable working con-ditions. The best scenario and realistic goal of stress

management interventions is to move as many nursesas possible into the group who cry infrequentlybecause they thoroughly enjoy their job and feel very

con®dent that they are e�ectively treating patients andcoping with occupational stress.

Acknowledgements

The authors gratefully acknowledge the cooperation

of the nursing sta� in the 14 hospitals which partici-pated in the study.

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