Authors: Heyam F. Dalky, Rana S. Obeidat, Rabia H. Haddad, Ashraf Jehad Abuejheisheh
Categories: Research, Occupational stressors, Coping mechanisms, Oncology nurses, Jordan, Cancer care
Source: BMC Nursing
Authors: Heyam F. Dalky, Rana S. Obeidat, Rabia H. Haddad, Ashraf Jehad Abuejheisheh
Oncology nurses are at particular risk for closely related types of distress, such as compassion fatigue, burnout, occupational stress, and moral distress, because they are often the ones who must carry out what they consider to be medically futile treatments that may cause pain in a dying older patient. This study aimed to examine the influence of selected coping mechanisms on occupational stressors among oncology nurses in Jordan.
A descriptive, correlational, cross-sectional design was employed. Data were collected between February and March 2024 from oncology nurses working in three major teaching hospitals in Jordan. Occupational stressors were assessed using the Nurse Stress Scale (NSS), and coping mechanisms were measured using the Brief COPE. Descriptive statistics, Pearson correlation analysis, and hierarchical multiple regression analysis were used to examine relationships between occupational stressors and coping mechanisms.
Pearson correlation analysis revealed a statistically significant moderate positive correlation between the NSS Death and Dying subscale and the Brief-COPE Problem-Focused Coping subscale (r = 0.254, p < 0.01). A significant positive correlation was also found between overall coping mechanisms and occupational stressors (r = 0.33, p < 0.01). Regression analysis further demonstrated that coping mechanisms were significant predictors of occupational stressors (β = 0.441, p < 0.001). The findings indicate that higher coping scores were associated with higher stress levels, suggesting that coping strategies were more frequently employed in response to elevated occupational stress rather than serving as a protective factor.
Jordanian oncology nurses who experience higher stress levels related to death and dying are more likely to employ problem-focused coping strategies, such as actively addressing challenges, seeking solutions, and obtaining support. Although these coping strategies are adaptive, the overall high stress levels observed suggest that occupational stress remains a serious concern for nurses’ well-being and professional performance.
Cancer remains a major global health concern, with a significant prevalence and high mortality rate. It is one of the leading causes of death worldwide, accounting for nearly 10 million deaths in 2020 [1]. Patients diagnosed with cancer, along with their caregivers, face considerable physical, emotional, and psychological challenges across the disease trajectory [2]. As the illness progresses, patients report additional difficulties, including anxiety, emotional distress, and existential concerns [3]. Within this context, oncology nurses are central to providing holistic care, offering both clinical and psychosocial support to patients and families throughout the cancer care continuum [4].
Oncology nurses play a pivotal role in alleviating suffering through empathy, compassion, and the provision of psychological support [5]. Their close, sustained interaction with patients and caregivers positions them to develop strong therapeutic relationships, fostering trust and emotional relief [6, 7]. However, the emotional intensity of oncology care also places nurses at heightened risk of occupational stress, compassion fatigue, burnout, and moral distress. These challenges are particularly pronounced when nurses administer treatments perceived as futile or potentially prolonging patient suffering at the end of life [5].
Globally, oncology nursing has been consistently identified as one of the most stressful nursing specialties due to sustained exposure to patient suffering, end-of-life care, complex treatment regimens, and ethical dilemmas. Studies from North America, Europe, and Asia have reported high levels of occupational stress, burnout, and compassion fatigue among oncology nurses, often exceeding those reported in other clinical specialties [8–10]. International evidence further indicates that stressors such as workload, interprofessional conflict, uncertainty in treatment, and frequent encounters with death and dying are common across healthcare systems, regardless of geographic or economic context. These findings underscore the global relevance of occupational stress in oncology nursing and highlight the importance of understanding how nurses cope with these demands across different cultural and organizational environments. However, the manifestation of occupational stress and the coping strategies employed by oncology nurses are strongly influenced by cultural norms, healthcare system structure, and available organizational support, which vary considerably across regions.
In Jordan, these risks are compounded by systemic limitations, including high patient-to-nurse ratios, limited resources, and insufficient organizational support [5]. Cultural expectations further intensify these stressors, as family involvement in patient care is deeply embedded within Arab culture. Nurses must therefore navigate complex dynamics between patients, families, and healthcare teams, which can amplify their emotional burden [11, 12]. Collectively, these occupational and cultural factors jeopardize nurses’ mental well-being, job satisfaction, and ultimately, the quality of patient care.
Oncology nurses face multiple occupational stressors that influence their physical, emotional, and psychological well-being. These stressors generally fall into several domains as such, (A) Emotional Strain: Nurses frequently provide care for terminally ill patients, exposing them to recurrent grief, helplessness, and emotional exhaustion. This is a major contributor to compassion fatigue and burnout [5, 13]. (B) Workload and Staffing Challenges: High patient-to-nurse ratios, understaffing, and long working hours increase physical and psychological fatigue. In Jordan, these issues are particularly acute in oncology units, contributing to dissatisfaction and burnout [5, 14]. (C) Organizational Stressors: Resource limitations, inadequate professional support, and insufficient training opportunities undermine morale and increase stress. These conditions foster frustration and turnover among oncology nurses [5]. And finally (D) Cultural and Societal Pressures: In Jordanian society, family involvement in treatment decisions often places additional demands on nurses, who must balance professional responsibilities with family expectations. This dual burden heightens stress and emotional fatigue [11, 12]. Furthermore, recent studies in Arab countries, including Jordan, confirm that oncology nurses experience high levels of distress due to emotional demands, organizational challenges, and resource constraints [15, 16]. These stressors highlight the importance of effective coping strategies to maintain nurse well-being and care quality.
In terms of coping mechanisms are typically categorized as emotion-focused or problem-focused strategies [17]. Emotion-focused strategies, such as religious practices, positive reframing, or mindfulness, enable nurses to regulate the emotional consequences of stress. Problem-focused strategies, such as time management, goal setting, and seeking social support, address practical aspects of stress and enhance control over work demands [17]. Evidence suggests that oncology nurses who actively adopt coping mechanisms, particularly social support and effective time management, report lower stress levels and higher job satisfaction [5, 14]. In addition, institutional support further enhances coping by providing resilience training, stress management workshops, and access to psychological services [18]. In Jordan, structured organizational programs are limited, but studies highlight the urgent need to equip oncology nurses with coping resources to reduce stress and prevent burnout [12].
Oncology nursing is among the most emotionally and physically demanding specialties, exposing nurses to continuous patient suffering and terminal care [19]. While occupational stress among nurses has been widely studied in international literature, limited evidence exists in Jordan and the Arab region on the effectiveness of coping strategies in this population. Addressing this gap is crucial to enhancing nurse well-being and improving patient outcomes.
Although occupational stress among oncology nurses has been widely reported in international literature, several important gaps remain, particularly within the Jordanian and broader Arab healthcare context. Existing studies in Jordan have largely focused on describing the prevalence of occupational stress, burnout, or compassion fatigue among oncology nurses, with limited attention to how nurses actively cope with specific stressors such as death and dying, workload, interpersonal conflict, and uncertainty in treatment. Furthermore, most prior research has treated coping mechanisms as general behavioral responses rather than examining their role in explaining variations in occupational stress across different sociodemographic groups. Consequently, it remains unclear which coping strategies are most commonly employed by Jordanian oncology nurses and how these strategies relate to specific occupational stressors inherent to cancer care.
The present study addresses these gaps by systematically examining the relationship between multiple domains of occupational stressors and coping mechanisms among oncology nurses in Jordan. By evaluating coping strategies as predictors of occupational stressors, this study provides context-specific evidence that extends beyond descriptive prevalence estimates and contributes new insights to inform targeted interventions, organizational policies, and nurse support programs within resource-limited oncology settings. In this study, occupational stressors operationalized by the total and subscale scores of the Nurse Stress Scale (NSS) were treated as the dependent variable. Coping mechanisms, measured by the total and domain scores of the Brief-COPE, were treated as the independent variable. Sociodemographic characteristics, including age, sex, and years of nursing experience, were entered as control variables in the regression models.
Therefore, the present study was designed to (1) identify the key occupational stressors experienced by oncology nurses in Jordan, (2) explore the coping strategies they employ, (3) evaluate the effectiveness of selected coping strategies in mitigating occupational stressors, and (4) examine the moderating role of coping mechanisms in predicting occupational stressors across sociodemographic variables.
A descriptive, correlational, cross-sectional study was conducted between February and March 2024. The design was chosen to explore the relationships between occupational stressors and coping mechanisms among oncology nurses in Jordan.
This study was conducted in three major hospitals providing specialized oncology care in Jordan. The hospitals were selected purposively based on their status as large referral and teaching centers that serve diverse patient populations and employ a substantial number of oncology nurses. This approach ensured access to nurses with direct and sustained exposure to oncology practice across different clinical settings.
Within each hospital, a convenience sampling technique was used to recruit participants. All Jordanian registered nurses working in oncology units who met the inclusion criteria were approached during the data collection period and invited to participate. Nurses were informed about the study objectives and procedures, and those who consented were enrolled. This approach allowed for the inclusion of nurses across various shifts and units, maximizing participation while accounting for clinical workload constraints. Although the target sample was 276 (92 per hospital, including a 10% allowance for non-response), 236 nurses returned complete questionnaires. The shortfall from the per-hospital target reflects non-response and incomplete or unreturned questionnaires during the data collection window, primarily related to clinical workload and shift schedules. The final sample still yielded a high response rate (85.5%) and was considered sufficient for the planned correlational and regression analyses.
All instruments were administered in English, which is widely understood by Jordanian nurses. Because nursing education and clinical documentation in Jordan are commonly conducted in English, the English versions were used to ensure consistency with established scoring. Participants were offered clarification for any item wording by trained research assistants without guiding responses.
Sociodemographic Questionnaire
A researcher-developed instrument consisting of five items capturing participants’ age, gender, marital status, years of nursing experience, and workplace.
Nurse Stress Scale (NSS)
The Nurse Stress Scale (NSS), developed by Gray-Toft and Anderson [20], was used to assess the frequency and intensity of occupational stress among nurses. The instrument evaluates stress across seven death and dying (7 items), conflict with physicians (5 items), inadequate preparation (3 items), lack of support (3 items), conflict with colleagues (5 items), workload (6 items), and uncertainty concerning treatment (5 items). Items are scored on a 4-point Likert scale ranging from 1 (never) to 4 (very frequently), with total scores ranging from 34 to 136. The scale has demonstrated strong internal consistency, with Cronbach’s alpha reported at 0.89 for the total scale. Items are summed to produce subscale scores and a total NSS score, with higher scores indicating more frequent exposure to occupational stressors. Subscale scores are computed by summing items within each domain.
Brief-COPE Scale
The Brief-COPE, developed by Carver [21], was employed to measure coping strategies among nurses. The instrument consists of 14 subscales, each containing two active coping, planning, positive reframing, acceptance, humor, religion, use of emotional support, use of instrumental support, distraction, denial, venting, substance use, disengagement, and self-blame. Total score ranges from 28 to 112. Responses are rated on a 4-point Likert scale ranging from 1 (not at all) to 4 (a lot). Reported reliability values indicate acceptable internal consistency, with Cronbach’s alpha ranging from 0.50 to 0.90 across subscales [22, 23]. Two items per subscale are summed (possible range 2–8 per subscale), with higher scores indicating greater use of that coping strategy. For domain-level analyses (if you report them), subscales can be grouped into broader coping domains (e.g., problem-focused, emotion-focused, avoidant) and summed accordingly; higher scores reflect greater endorsement of the domain. Cronbach’s alpha for Brief-COPE in this study was 0.85.
Data collection was conducted between February and March 2024 across all three participating hospitals. To minimize potential shift-related bias, questionnaires were distributed during morning, evening, and night shifts, ensuring that nurses working across different schedules had an equal opportunity to participate. Research assistants coordinated their visits with unit managers to cover multiple shifts and avoid over-representation of any single shift.
Prior to data collection, nine research assistants (three per hospital) received standardized training conducted by the principal investigator. The training session lasted approximately four hours and covered study objectives, eligibility criteria, ethical considerations, informed consent procedures, standardized questionnaire administration, and strategies for maintaining neutrality and confidentiality. We used flyers and recruitment materials ot facilitate data collection. All research assistants were provided with a written protocol to ensure procedural consistency across hospitals and to minimize inter-assistant variability.
Before full deployment, the data collection procedures and instruments were pilot tested with a small group of oncology nurses (n = 15) who met the inclusion criteria but were not included in the final analysis. The pilot testing aimed to assess the clarity of questionnaire items, the feasibility of administration during work shifts, and the estimated completion time. Minor wording clarifications were made based on participant feedback, and the average completion time was confirmed to be approximately 15 min. During the main study, eligible nurses were approached in person, informed about the study, and invited to participate voluntarily. Questionnaires were completed anonymously and returned in sealed envelopes to designated collection boxes supervised by the research assistants. No incentives were provided for participation.
This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval (IRB) was obtained from the Research and Ethics Committee of the Faculty of Nursing at Jordan University of Science and Technology (Reference No. 2024/156/13). and from the Institutional Review Boards (IRBs) of the three participating hospitals. In addition, administrative permissions were secured from the respective hospital directors prior to participant recruitment.
Participation in the study was strictly voluntary. Eligible oncology nurses received detailed written and verbal information about the study’s purpose, procedures, potential risks, and anticipated benefits. Written informed consent was obtained from all participants before data collection. Participants were assured of their right to withdraw from the study at any stage without penalty. Furthermore, confidentiality and anonymity were maintained throughout the research process by coding the data and restricting access exclusively to the research team.
Data were analyzed using SPSS version 25.0. Descriptive statistics (means, standard deviations, frequencies, percentages) summarized demographic characteristics and study variables. Independent t-tests and one-way ANOVA were used to compare stress and coping levels across demographic groups.
Pearson correlation analysis assessed associations between occupational stressors and coping strategies. A two-step hierarchical regression was conducted to test the moderating effect of coping mechanisms on occupational stressors, controlling for sociodemographic variables. All assumptions of parametric tests were verified, including normality, linearity, and homoscedasticity. Statistical significance was set at p < 0.05.
A total of 236 nurses completed the survey. The analysis showed that (see Table 1) the mean age was 31.88 years (SD = 5.15), ranging from 22 to 46 years. Female nurses represented 54.7% (n = 129) of the sample, with male nurses accounting for 45.3% (n = 107). Most nurses had an experience of 10 years or less (60.6%, n = 51). Most nurses (69.1%, n = 163) were married.
Table 1Demographic characteristics of nurses (N = 236)Variable N % Hospital name KAUH5121.6KHCCJUH939239.439.0 Sex Male10745.3Female12954.7 Mean Age M = 31.88SD = 5.15Level of experience in years1–10 years14360.611–20 years9239.0More than 20 years10.4 Marital status Married16369.1SingleDivorced69429.21.7M = Mean Age, SD = Standard deviation
The Pearson correlation coefficient showed a significant positive correlation (r = 0.25, p < 0.05) between occupational stressors and coping methods; however, the correlation magnitude is low. The NSS Death and Dying and Brief-Cope’s Emotion-Focused Coping factors have a significant positive correlation (r = 0.18, p < 0.05). The NSS Death and Dying and Brief-Cope Avoidant Coping showed a significant positive correlation (r = 0.13, p < 0.05). The Total Brief-Cope score also exhibited a significant positive connection with the NSS Death and Dying subscale (r = 0.24, p < 0.05). However, the correlation magnitude for the above relationship was low.
The NSS Conflict with Physicians subscale and the Problem-Focused Coping subscale of the Brief-Cope have a moderate positive connection (r = 0.253, p < 0.05). The NSS Conflict with Physician’s subscale showed a moderate positive connection with the Brief-Cope Emotion-Focused Coping subscale (r = 0.241, p < 0.05). The NSS Conflict with Physicians subscale has a moderate positive connection with the Brief-Cope Avoidant Coping subscale (r = 0.199, p < 0.05), which is statistically significant. Additionally, there is a statistically significant positive connection (r = 0.302, p < 0.05) between the Total Brief-Cope score and the NSS Conflict with Physician subscale. Regarding the third subscale, the NSS Inadequate Preparation subscale and the Brief-Cope’s Problem-Focused Coping subscale have a statistically significant, strong positive link, according to the Pearson correlation coefficient (r = 0.309, p < 0.01). Conversely, there is a small but statistically significant association (r = 0.111, p = 0.088) between the Brief-Cope’s Emotion-Focused Coping subscale and the NSS Inadequate Preparation subscale.
The NSS Inadequate Preparation subscale and the Total Brief-Cope score have a moderately favorable, statistically significant link (r = 0.179, p = 0.006).
The Pearson correlation coefficients show significant relationships between the NSS Lack of Support subscale and the other Brief-Cope subscales. The NSS Lack of Support subscale and Brief-Cope’s Problem-Focused Coping subscale have a positive, statistically significant relationship (r = 0.230, p < 0.05). However, no statistically significant relationship exists between the NSS Lack of Support subscale and Brief-Cope’s Emotion-Focused Coping subscale (r = 0.095, p = 0.144). Similarly, no statistically significant association exists between the NSS Lack of Support subscale and the Brief-Cope’s Avoidant Coping subscale (r = 0.117, p = 0.072). However, a statistically significant moderate positive association exists between the NSS Lack of Support subscale and the Total Brief-Cope score (r = 0.190, p = 0.003). There is a moderate positive correlation between the NSS Conflict with Other Nurses’ subscale and the Brief-Cope Problem-Focused Coping subscale (r = 0.308, p < 0.05). However, no statistically significant link exists between the NSS Conflict with Other Nurses’ subscale and the Brief-Cope’s Emotion-Focused Coping subscale (r = 0.072, p = 0.269). Similarly, no statistically significant link exists between the NSS Conflict with Other Nurses’ subscale and the Brief-Cope Avoidant Coping subscale (r = 0.058, p = 0.375). However, a statistically significant moderate positive association exists between the NSS Conflict with Another Nurse subscale and the Total Brief-Cope score (r = 0.180, p = 0.006). This shows that as nurses’ general use of coping mechanisms, as measured by the Total Brief-Cope score, grows, so do their disputes with other nurses.
The Pearson correlation coefficients provided insight into the relationship between the NSS workload subscale and the several Brief Cope subscales. The NSS workload subscale and the Problem-Focused Coping subscale of the short cope show a statistically significant minor positive connection (r = 0.227, p < 0.05). A small positive association exists between the NSS workload subscale and the Brief-Cope’s Emotion-Focused Coping subscale (r = 0.134, p < 0.05). In contrast, no statistically significant link exists between the NSS Workload subscale and the Brief-Cope’s Avoidant Coping subscale (r = -0.030, p = 0.650). Furthermore, a statistically significant minor positive connection between the NSS workload subscale and the Total Brief-Cope is found.
To investigate the link between NSS Uncertainty over the treatment subscale and Brief-Cope subscales, taking into account the correlation coefficients and significance levels supplied. The Pearson correlation coefficients shed light on the relationship between the NSS Uncertainty regarding the treatment subscale and the various subscales of the brief coping. The NSS Uncertainty Concerning Treatment subscale and the Problem-Focused Coping subscale of the Brief-Cope have a moderate positive connection (r = 0.312, p < 0.05).
The NSS Uncertainty concerning the treatment subscale and the Emotion Focused Coping subscale of the Brief-Cope have a moderate positive connection (r = 0.339, p < 0.05). There is a substantial positive connection (r = 0.447, p < 0.05) between the NSS Uncertainty over the treatment subscale and the Avoidant Coping subscale of Brief-Cope. The NSS Uncertainty concerning the treatment subscale has a significant positive connection with the Total Brief-Cope score (r = 0.494, p < 0.05). We are examining the association between the Total NSS score and the Brief-Cope subscales, considering the stated correlation coefficients and significance levels.
Pearson correlation coefficients provide information on the relationship between the Total NSS score and the Brief-Cope’s various subscales. The Total NSS score positively correlates with the Brief-Cope’s Problem-Focused Coping subscale (r = 0.358, p < 0.05). The Total NSS score has a moderately favorable connection with the Brief-Cope’s Emotion-Focused Coping subscale (r = 0.228, p < 0.05).
The Total NSS score has a statistically significant positive link with the Brief-Cope’s Avoidant Coping subscale (r = 0.182, p < 0.05). The Total NSS and Total Brief-Cope scores have a moderate positive connection (r = 0.329, p < 0.05). See Table 2.
Table 2The relationships between overall and subscales scores of the NSS and the Brief-Cope scalesVariableProblem Focused CopingEmotion Focused CopingAvoidant CopingTotal Brief-CopeNSS Death and dying0.254^^0.176^^0.132^^0.241^^NSS Conflict with Physicians0.253^^0.241^^0.199^^0.302^^NSS Inadequate preparation0.309^^0.1110.0210.179^^NSS Lack of support0.230^^0.0950.1170.190^^NSS Conflict with other nurses’0.308^^0.0720.0580.180^^NSS Workload0.227^^0.134^^-0.0300.130^*^NSS Uncertainty concerning treatment0.312^^0.339^^0.447^^0.494^^Total NSS score0.358^^0.228^^0.182^^0.329^^*Correlation is significant at *p < 0.05; 0.05 level 2-tailed^**^ Correlation is significant at **p < 0.01, 2-tailed
We used the Pearson correlation analysis to examine the relationship between occupational stressors and coping mechanisms. The results show in Table 2 that there was a moderate positive correlation between occupational stressors and coping mechanisms (r = 0.329, p < 0.01).
Pearson’s r was used to examine the association among the variables of the study. The analysis showed a statistically significant positive correlation between coping mechanisms and occupational stressors (r = 0.33, p < 0.01).
To examine the moderation effect of coping mechanisms on the relationship between sociodemographics (age, sex, and experience) and occupational stressors, a two-step multiple hierarchical regression analysis was performed. In Block 1, sociodemographic characteristics were entered, and in Block 2, coping mechanisms were entered. The decision for order of entry was based on the assumption that adding coping mechanisms would significantly improve occupational stressors.
The analysis (see Table 3) showed that model 1, which included sociodemographic factors, explained 5.7% (R^2^ = 0.0.057) of the variance in stress. In this model, age and sex were significant predictors for depression, and the model was significant (F3, 232 = 4.689, p = 0.003). The analysis showed that age and sex were significant predictors of occupational stressors (β = 0.420, p = 0.022), (β = 4.959, p = 0.001), respectively. After the entry of coping in model 2, the total variance explained by the model was increased to 15.5% (R^2^ = 0.155) and the model was also significant (F4,231 = 10.617, p < 0.001). The variables in Step 2 explained an additional 9.8% variance in occupational stressors. The R^2^ value of 0.155 indicates that 15.5% of the variation in the relationship between sociodemographics and occupational stressors is related to the moderating effect of coping mechanisms, with an increase of 9.8%. In model 2, coping mechanisms were also a significant predictor of occupational stressors (β = 0.441, p < 0.001), while age and sex remained significant predictors of occupational stressors (β = 0.646, p = 0.005). In Fig. 1, the analysis revealed that coping mechanisms positively moderate the relationship between sociodemographics and occupational stressors.
Fig. 1The moderating effect of coping mechanisms on the relationship between sociodemographic factors and occupational stressors. The figure illustrates that oncology nurses with higher coping mechanisms (solid line) show a stronger positive association between sociodemographic variables (e.g., age, sex, experience) and occupational stress compared with those with lower coping mechanisms (dashed line). This suggests that coping mechanisms significantly moderate the relationship, amplifying the impact of sociodemographics on stress levels
Table 3Two-step multiple hierarchical examining coping mechanisms moderating effect on the relationship between sociodemographic and personal characteristics and work-related stressors (N = 236)VariablesModel 1Model 2ΒP- valueΒP- valueAge0.2400.0220.6460.005Sex4.9590.0014.1850.005Experience− 1.6580.493-2.9660.199Coping0.441< 0.001R^2^ = 0.057Adj R^2^ = 0.045F = 4. 689, p = 0.003R^2^ = 0.155Adj R^2^ = 0.141***∆ R***^2^ = 0.041F = 10. 617 p < 0.001B: Unstandardized regression coefficient, R² (R-squared): Coefficient of determination, R: Correlation coefficient
This study investigated the relationship between occupational stressors and coping mechanisms among Jordanian oncology nurses. The findings contribute to a deeper understanding of the stressors faced by oncology nurses and the strategies they adopt to manage them, within a healthcare system often challenged by resource limitations. The positive association observed between coping scores and occupational stressors requires careful interpretation. Although coping strategies are often conceptualized as protective, higher coping scores in this study do not necessarily indicate more effective stress management. Rather, they likely reflect increased coping effort in response to heightened stress exposure [10].
The Brief-COPE assesses the frequency with which coping strategies are used, rather than their effectiveness or outcomes [24]. Consequently, nurses experiencing greater occupational stress, particularly in emotionally demanding oncology settings, may report higher use of multiple coping strategies as an attempt to manage persistent stressors, even when these strategies are insufficient to reduce overall stress levels.
The results demonstrated statistically significant positive correlations between the Nurse Stress Scale (NSS) subscales and various coping strategies measured by the Brief-COPE. Specifically, a moderate positive correlation was observed between the Death and Dying subscale of the NSS and the Problem-Focused Coping subscale. This suggests that nurses who experience higher stress in managing patient death and dying are more likely to adopt problem-focused coping strategies, such as actively seeking solutions and support to address the emotional burden. Additionally, weaker but significant correlations were found between the Death and Dying subscale and both Emotion-Focused and Avoidant coping strategies, indicating that some nurses may rely on emotional regulation or avoidance when confronting these challenging situations. Although coping strategies are generally considered protective, the positive association observed between overall coping mechanisms and occupational stressors suggests that coping in this context may function primarily as a response to heightened stress rather than a preventive mechanism. Oncology nurses who experience greater exposure to emotionally demanding situations such as death and dying, uncertainty in treatment, and interpersonal conflict may be compelled to employ a wider range of coping strategies in an effort to manage ongoing stress. Thus, higher coping scores likely reflect increased coping efforts in response to elevated stress levels, rather than indicating effective stress reduction. This interpretation aligns with the transactional model of stress and coping, which conceptualizes coping as a dynamic process activated when individuals perceive stressors as exceeding their available resources.
The findings further revealed significant associations between conflict with physicians and all three coping Problem-Focused, Emotion-Focused, and Avoidant coping. Notably, the strongest correlation was between conflict with physicians and the overall Brief-COPE score. This highlights the complexity of nurse–physician relationships and the multidimensional coping responses nurses employ when faced with interpersonal stressors. Consistent with our results, Wang, Chen [25] reported that nurses demonstrated stronger emotional responses and were more inclined to use problem-focused strategies when dealing with workplace conflicts. In contrast, earlier findings by Li, Lambert [26] suggested that nurses tended to rely more on emotion-focused coping than problem-focused approaches. The moderate positive association between stress related to death and dying and problem-focused coping suggests that oncology nurses confronted with end-of-life care demands attempt to regain a sense of control by actively addressing stressors through planning, seeking information, or obtaining instrumental support. In oncology settings, where patient deterioration and mortality are frequent, nurses may engage in problem-focused strategies to manage clinical responsibilities and emotional demands simultaneously. However, the persistence of high stress despite the use of such strategies indicates that individual coping alone may be insufficient in the absence of adequate organizational and psychosocial support. These discrepancies may reflect cultural differences, evolving nursing roles, and institutional variations across healthcare systems.
Workload was another significant stressor in this study, showing small but statistically significant positive correlations with both problem-focused and emotion-focused coping. However, no significant relationship was found between workload and avoidant coping. These findings align with Li, Lambert [26], who identified planning as a commonly used problem-focused strategy in response to workload demands. This suggests that while oncology nurses attempt to manage heavy workloads through practical planning and emotional regulation, avoidance may not be a prevalent coping response in this context.
The concurrent associations between occupational stressors and problem-focused, emotion-focused, and avoidant coping strategies indicate that oncology nurses do not rely on a single coping approach. Instead, they appear to adopt situational and overlapping coping responses depending on the nature and intensity of the stressor. This multifaceted coping pattern reflects the complexity of oncology nursing, where nurses must balance emotional regulation, practical problem-solving, and, at times, psychological distancing to continue functioning in highly demanding clinical environments.
The current findings reinforce the understanding that oncology nurses are at heightened risk of stress-related consequences such as compassion fatigue, burnout, and moral distress. This is particularly true when nurses are required to administer treatments perceived as futile, which may prolong patient suffering at the end of life. Previous studies conducted in Jordan and the broader Middle Eastern context have consistently highlighted the influence of cultural expectations, high patient-to-nurse ratios, and limited institutional support on nurses’ stress levels [5, 15]. Our results extend this evidence by illustrating the specific coping strategies Jordanian oncology nurses employ in response to these occupational demands.
Interestingly, while problem-focused coping emerged as a significant strategy in managing stressors such as death and dying, conflict with physicians, and workload, the concurrent use of emotion-focused and avoidant strategies suggests that coping is not uniform but rather situational and multifaceted. This supports the transactional model of stress and coping, which posits that individuals adjust their coping approaches depending on the stressor and perceived control [27].
The findings underscore the urgent need to develop institutional interventions aimed at reducing occupational stress and supporting effective coping among oncology nurses in Jordan. Training programs in stress management, resilience-building, and communication skills could enhance nurses’ ability to handle emotionally intense scenarios and reduce the reliance on maladaptive coping strategies such as avoidance [28]. Furthermore, improving nurse–physician collaboration and addressing workload through better staffing policies are critical organizational strategies that could mitigate stress at its source. The finding that coping mechanisms significantly predicted occupational stressors after controlling for sociodemographic variables suggests that coping plays an important explanatory role in nurses’ stress experiences. Rather than buffering stress, higher coping engagement was associated with increased stress, reinforcing the notion that nurses intensify coping efforts when stress becomes overwhelming. This highlights the limitations of individual-level coping strategies and underscores the need for organizational interventions that address structural stressors such as workload, well-being, staffing shortages, and interprofessional conflict [29, 30].
This study has several limitations that should be acknowledged when interpreting the findings. First, the use of convenience sampling may limit the representativeness of the sample and, therefore, the generalizability of the results to all oncology nurses in Jordan. Nurses who chose to participate may differ in important ways from those who did not, potentially introducing selection bias.
Second, the unequal distribution of participants across the three hospitals resulted in asymmetry of sample sizes, which may have reduced the ability to make direct institutional comparisons. This imbalance could also have influenced the statistical power of subgroup analyses.
Finally, the reliance on self-reported questionnaires may have introduced response bias, as participants could have underreported or overreported their levels of stress and coping strategies due to social desirability or recall limitations.
Future studies are recommended to employ probability-based sampling techniques, ensure balanced recruitment across institutions, and incorporate mixed methods, including qualitative interviews, to capture richer insights into the coping experiences of oncology nurses.
Coping strategies as protective mechanisms: Oncology nurses rely on coping strategies to manage the intense occupational stressors inherent in cancer care. These strategies are essential for maintaining psychological well-being, resilience, and job satisfaction. The findings highlight the need for targeted interventions and resources that strengthen effective coping approaches while addressing the specific stressors most prevalent in oncology settings [31].Role of nursing administration: Hospital and cancer center administrations play a critical role in supporting oncology nurses’ mental health. Providing access to structured training programs on stress management, coping skills, and resilience-building can help nurses respond more effectively to the emotional demands of their roles. Leadership support and institutional policies that prioritize staff well-being are vital for sustaining a healthy workforce [29].Future directions for research and practice: To enhance generalizability and better understand causal linkages, future studies should employ diverse research designs, incorporate objective measures of stress and coping, and recruit broader, more representative samples. Establishing consistent definitions and frameworks for coping strategies will also strengthen the comparability of findings across studies and contribute to evidence-based interventions in nursing practice [32–34].
Future studies should build on the findings of this research by employing longitudinal and prospective designs to better examine the temporal relationships between coping strategies and occupational stressors among oncology nurses. Such designs would help clarify whether coping patterns change over time in response to sustained exposure to stressors related to death and dying, workload, and interprofessional conflict.
Further research is also recommended to differentiate between adaptive and maladaptive coping strategies rather than relying on aggregated coping scores. Examining individual Brief-COPE subscales may provide more nuanced insights into which coping strategies are associated with lower or higher levels of occupational stress in oncology settings. In addition, mixed-methods approaches combining quantitative surveys with qualitative interviews could deepen understanding of nurses lived experiences and contextual influences on coping behaviors.
At the individual level, integrating coping skills training into continuing professional development programs is recommended. Educational initiatives focusing on adaptive coping strategies, emotional regulation, resilience, and ethical decision-making may support nurses in managing stress associated with end-of-life care. Establishing peer support groups, mentorship programs, and debriefing sessions following emotionally challenging clinical events may further enhance psychological well-being.
In addition, healthcare institutions should consider expanding access to mental health and psychosocial support services, including counseling and stress-management resources tailored to oncology nurses. Routine assessment of occupational stress and coping patterns could be incorporated into workplace wellness programs to enable early identification of nurses at risk and facilitate timely supportive interventions. Collectively, these practice-oriented strategies may contribute to improved nurse well-being, retention, and quality of cancer care.
In conclusion, this study examined the association between occupational stressors and coping mechanisms among Jordanian oncology nurses. The findings demonstrated a statistically significant positive relationship between overall occupational stress, as measured by the Nurse Stress Scale, and the use of coping strategies assessed by the Brief-COPE. These results indicate that oncology nurses who report higher levels of occupational stress also report greater engagement in coping strategies.
Furthermore, coping mechanisms were found to be significantly associated with occupational stressors after accounting for sociodemographic characteristics, suggesting that coping strategies contribute to explaining variations in stress experiences among oncology nurses. Nurses reporting higher stress related to death and dying, conflict with physicians, and workload were more likely to report the use of problem-focused and emotion-focused coping strategies. These associations highlight the complex and dynamic nature of coping in oncology nursing practice.
Given the correlational and cross-sectional nature of the study, causal inferences cannot be drawn. Instead, the findings suggest that coping strategies may reflect nurses’ responses to ongoing occupational stressors rather than serving as definitive protective factors. Overall, the results highlight the importance of organizational and institutional support in addressing occupational stressors while promoting adaptive coping resources to enhance the psychological well-being and professional functioning of oncology nurses.