Prior research has suggested that nurses, regardless of workplace or culture, are confronted with a variety of stressors. As the worldwide nursing shortage increases, the aged population becomes larger, there is an increase in the incidence of chronic illnesses and technology continues to advance, nurses continually will be faced with numerous workplace stressors. Thus, nurses, especially palliative care nurses, need to learn how to identify their workplace stressors and to cope effectively with these stressors to attain and maintain both their physical and mental health. This article describes workplace stressors and coping strategies, compares and contrasts cross-cultural literature on nurses' workplace stressors and coping strategies, and delineates a variety of stress management activities that could prove helpful for contending with stressors in the workplace.
Keywords: Coping, stress management activities, workplace stress
A worldwide shortage of nurses has been acknowledged by the Global Advisory Group of the World Health Organization (WHO). , As a result, nurses cannot avoid encountering an increase in workplace stressors. In addition, with the global increase in the aged population, the intensity of health care problems, the incidence of chronic illnesses and advanced technology, nurses are faced with a variety of work-related stressors. Nurses working in palliative care are no exception. Working in palliative care brings an additional set of workplace issues, such as constantly dealing with death and dying, controlling patients' pain, and helping patients and family members contend with patients' end-of-life illness.
Palliative care has been described as active total care that is designed to meet psychosocial, physical, and spiritual needs of patients.  According to the WHO, palliative care is "the active total care, by a multiprofessional team, of patients whose disease is not responsive to curative treatment."  Given these factors, it is no wonder nurses working in palliative care are confronted with a variety of workplace stressors.
Definition of workplace stress
Workplace stress can be described as the physical and emotional outcomes that occur when there is disparity between the demands of the job and the amount of control the individual has in meeting those demands. Anytime stress occurs, it is an indication that the demands placed upon the person have exceeded the person's personal resources, whether these resources are physical, emotional, economic, social, or spiritual. Thus, workplace stress occurs when the challenges and demands of work become excessive, the pressures of the workplace exceed the worker's ability to handle them, and job satisfaction turns to frustration and exhaustion.
Symptoms of workplace stress
Symptoms of stress can vary among individuals; however, according to Help Guide,  they tend to be categorized as cognitive, physical, emotional, and behavioral. Cognitive symptoms can include: memory problems, indecisiveness, inability to concentrate, poor judgment, trouble thinking clearly, seeing only the negative side of an issue, anxious or racing thoughts, constant worrying, loss of objectivity, and fearful anticipation that something will happen. Physical symptoms can include: headaches or backaches, muscle tension and stiffness, diarrhea or constipation, nausea, dizziness, insomnia, chest pain, rapid pulse, weight gain or loss, skin breakout (i.e. hives or eczema), loss of sex drive, and frequent colds. Emotional symptoms include: moodiness, agitation, restlessness, short temper, irritability, impatience, inability to relax, feeling tense, feeling overwhelmed, a sense of loneliness or isolation, and depression. Finally, behavioral symptoms can include: eating more or less, sleeping too much or too little, isolating oneself from others, procrastinating, neglecting responsibilities, using substances (i.e. alcohol, cigarettes, or drugs) to relax, nail biting, pacing, teeth grinding, jaw clenching, overdoing activities (i.e. exercising or shopping), overreacting to unexpected problems, and picking fights with others. It should be kept in mind that any of these symptoms may also be the result of other psychological or physical conditions. Therefore, it is imperative for anyone experiencing stress to see his/her health care provider to rule out a medical or psychological condition.
Chronic or long-term stress can have devastating effects. A number of medical conditions are related to, or exacerbated by, stress and include: chronic pain, migraines, ulcers, heartburn, high-blood pressure, heart disease, diabetes, asthma, obesity, premenstrual syndrome, musculoskeletal conditions, anxiety, depression, eating disorders, and substance abuse. , Thus, it is important for anyone experiencing workplace stress to bring his/her stress level under control in an effort to prevent long-term effects that can result in disruption of physical and psychological well-being.
Influence of workplace stress on productivity
The presence of workplace stress imposes a cost factor on any work setting. Costs, directly related to workplace stress, can involve absenteeism, employee turnovers, short- and long-term disabilities, medication expenses related to psychotherapeutic medications, workplace accidents, and worker's compensation claims and lawsuits. The LLuminari« Landmark Study  found, among workers examined, 1 in 5 were at risk for stress-related health problems; 2 in 5 experienced distress because of too much pressure or mental fatigue at work; 1 in 10 were so tired at the end of the work day that they did not enjoy their nonwork time; and 1 in 5 stated their work regularly interfered with responsibilities at home and kept them from spending time with their families.
In one country, it has been estimated that for a population of 303.5 million people, over 300 billion dollars is spent each year to deal with workplace stress-related issues.  While in another much less populated country (33.4 million people), the cost of workplace stress has been estimated to be 12 billion dollars annually. 
Workplace stressors most prevalent among nurses
In reviewing the literature, it can be found that a considerable amount of research has been conducted on nurses, in certain countries, regarding their workplace stressors and how they cope with these events. Interestingly, even some cross-cultural studies have been carried out to determine if nurses, regardless of country, tend to be stressed by the same factors and if they cope in similar ways.
Low job control, high job demands, low supportive relationships in the workplace ,, ; concern about quality nursing and medical care  ; dealing with death and dying , ; workload  ; being moved among different patient care units within the health care organization and being short on resources  ; being on one particular clinical unit for extended periods of time  and dealing with uncooperative family members and patients  have all been found to be stressors experienced by nurses. In addition to these work-related stressors, studies also have identified factors associated with nurses' physical and psychological wellbeing. These factors can include lack of support from others; the use of escape-avoidance as a coping mechanism; conflict with physicians and other nurses; inadequate educational preparation; uncertainty about patients treatment; workload and dealing with death and dying , ; use of problem-focused coping  ; psychological hardiness  ; poor communication  confidence in one's ability  and use of self-control and distancing as coping mechanisms. 
Cross-cultural studies conducted in China, Japan, South Korea, Thailand, the USA (Hawaii), Australia, and New Zealand have suggested a number of similarities exist among nurses regarding workplace stressors and ways of coping with these stressors. For example, hospital nurses working in China, Japan, South Korea, Thailand, and the USA (Hawaii) all indicated workload and dealing with death and dying to be the two most common workplace stressors. , Given the role and practice of nurses varies among these countries, it certainly is telling that the two major workplace stressors were found to be the same regardless of country of origin. Although research on palliative nurses' workplace stress has been limited, qualitative research has suggested workload, relationship with health professionals, the impact of sadness of the client group, and the impact of unrelieved patient suffering to be the most cited work-related stressors. ,
Definition of coping
Coping can be defined as the "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person."  Coping activities may be problem-focused in that they are directed externally and involve attempts to manage or change the problem causing the stress. On the other hand, coping activities may be emotion-focused in that they are internally directed and involve attempts to alleviate emotional distress. Examples of problem-focused coping includes problem-solving activities, recognizing one's role in solving a problem and confronting the situation by using some degree of risk-taking behavior; while emotion-focused coping includes wishful thinking, avoidance of confrontive behavior, and detachment or disengagement from the situation. According to Lazarus and Folkman,  individuals use both problem-focused and emotion-focused coping when dealing with stressful situations.
Lazarus and Folkman  have identified and described eight coping strategies people use to contend with stress. These strategies tend to be either problem-focused or emotion-focused in nature. The eight strategies include: confrontive coping, distancing, self-control, seeking social support, accepting responsibility, escape-avoidance, planful problem-solving, and positive reappraisal. Confrontive coping is described as aggressive efforts to alter a situation that involve using some degree of hostility and risk-taking behavior. Distancing is disengagement or detachment from a situation in an attempt to minimize the significance of the situation. Self-control involves efforts to regulate one's feelings and actions. Seeking social support involves efforts used to obtain informational, tangible and/or emotional support from others. Recognizing one's role in solving a problem describes accepting responsibility. Wishful thinking and behavioral efforts to avoid confronting a problem or stressful situation describes escape-avoidance. Planful problem solving involves efforts to alter the situation, including an analytic approach. Finally, positive reappraisal is described as a spiritual dimension that includes giving positive meaning to a situation by focusing on one' personal growth experience.
Coping strategies found to be most effective in dealing with nurses' workplace stressors
Of interest is how nurses cope with workplace stressors based upon country of origin. In a series of research studies involving hospital nurses, it was found that although nurses identified the top two stressors (death and dying issues and workload) to be the same, regardless of country, there were variations in coping methods. ,,,,, Lambert et al. ,, and Cheng et al. , found the three most commonly used coping strategies, in descending order of preference were: planful problem-solving, self-control, and seeking social support for Australian nurses; positive reappraisal, self-control, and planful problem-solving for Chinese nurses; self-control, seeking social support, and planful problem-solving for Japanese nurses; planful problem-solving, self-control, and seeking social support for New Zealand nurses; positive reappraisal, self-control, and seeking social support for South Korean nurses; self-control, planful problem-solving, and positive reappraisal for Thai nurses; and planful problem-solving, self-control, and positive reappraisal for USA (Hawaii) nurses. Thus, it can be seen that nurses, regardless of country, tended to prefer planful problem-solving, seeking social support, self-control, and positive reappraisal as coping strategies in the workplace. Some research has suggested coping strategies that are more problem-focused, rather than emotion-focused, tend to be associated with better mental health when dealing with workplace stress. , However, this finding tends to occur more often in Western cultures rather than in Asian cultures, where emotion-focused strategies often have been found to be positively associated with mental health. ,,
Although no comparative study could be located regarding palliative care nurses, one might speculate these nurses utilize some of the same coping mechanisms to contend with workplace stress. It would be important for researchers to conduct a study, similar to those cited, to confirm which coping strategies palliative nurses prefer when dealing with work stress.
Methods for fostering effective coping strategies
It is not possible to exist in a totally stress free environment. Regardless of how much one might want to be completely free from stress, one has to contend with some level of stress everyday in most situations. Given this fact, listed below are some stress management activities suggested by Help Guide  that might prove useful.
I. Avoid unnecessary stress . It is not possible to avoid all stressful situations, but one needs to look at the number of stressors in life that can be eliminated.
II. Alter the situation . If it is not possible to avoid a certain stressful situation, then work to alter it. This may involve changing communication patterns or the manner in which daily life is operated.
Express feelings instead of bottling them up inside. If something or someone is of concern, communicate this concern in an open and respectful manner. Failing to voice feelings causes resentment to build and the situation will likely remain the same or become worse.
III. Accept the things you cannot change . Some sources of stress are unavoidable.
One cannot prevent or change stressors, such as death of a patient or loved one. The best way to cope with stress is to accept things as they are. While acceptance may be difficult, in the long run, it is easier than trying to change that which cannot be changed.
IV. Adapt to the stressor . If the stressor cannot be changed then regain a sense of control by changing expectations and attitudes.
V. Take care of personal needs . Make healthy lifestyle choices. Take time for rest and relaxation. Nurturing ones' self is not a luxury, but a necessity.
Keep in mind no one solution for dealing with stress works for everyone. No single method works for every situation, so one has to experiment with different strategies and focus on what fosters control and calm.
This article has described workplace stressors and coping strategies, compared and contrasted cross-cultural literature on nurses' workplace stressors and coping strategies, and delineated a variety of activities that could prove helpful for contending with stress in the workplace. In seeking to identify which stress management activities work the best, it is advisable to try a number of different strategies and then determine which ones seem to be the most effective.