Problem-Solving as the Predominant Coping Strategy Among Nurses: A Cross-Sectional Study in the Second Health Cluster of Riyadh

Nursing is a cornerstone of healthcare systems and is widely recognised as a profession associated with high levels of occupational stress due to heavy workloads, emotional demands, staff shortages and complex clinical responsibilities [1]. Prolonged exposure to such stressors has been linked to burnout, reduced job satisfaction, increased turnover and compromised patient safety [2]. In Saudi Arabia, nurses face additional challenges related to cultural expectations, workforce shortages and rapid healthcare transformation aligned with Vision 2030 [3]. Coping strategies such as problem-solving, seeking social support and avoidance play a critical role in mitigating the negative effects of stress. However, limited research has explored coping strategies among nurses in the Riyadh Region. This study aims to address this gap [4]. Despite efforts to improve nursing in Saudi Arabia, significant challenges remain. One major issue is the dependence on expatriate nurses. The healthcare system relies heavily on foreign-trained nurses. However, recruiting and retaining them is difficult due to cultural differences, language barriers and adapting to the local healthcare system [5]. Additionally, geopolitical issues and visa policy changes exacerbate workforce shortages, adding pressure to the existing staff. Cultural and religious values in Saudi Arabia strongly impact the coping strategies used by nurses in the country [6]. Saudi nurses, especially women, seek emotional and spiritual support in their families as family is the core of Saudi society. Psychological comfort is also found in religious coping, e.g., praying and reciting the Quran. Saudi nurses perceive Stress with the belief of being patient and faithful, which are Islamic principles [7]. Otherwise, expatriate nurses have a higher tendency to resort to peer support because of the cultural differences and distance from home. They tend to create support groups among fellow members who have the same background to alleviate one's feeling of isolation. Expatriates can also employ more problem-focused approaches as they rely on different experiences in their work. Although there are cases of avoidant strategies, social support is one of the primary coping mechanisms among local and expatriate nurses [8,9]. Problem-solving is one of the most proactive and best coping strategies in a nursing environment. It is founded on taking the stressor as it is, rather than avoiding or postponing it. The process of problem-solving begins with the identification and definition of the stressor. In the case of nursing, a stressor might involve things such as heavy patient loads, lack of resources or the emotional nature of the stressor, such as critically ill patients [10]. Once the definition of the stressor has been established, the next step for the nurse is brainstorming possible solutions to the identified issue. If, for example, time management is a stressor, nurses might seek to implement shift-based priority lists, delegate minor tasks when possible or revise their workflow [11-13]. Therefore, this study aims to evaluate the coping strategies employed by nurses working in the Second Health Cluster of Riyadh and to examine their association with key demographic and professional characteristics. By addressing this gap, the study seeks to provide context-specific evidence that can inform targeted interventions to enhance coping capacity, improve psychological well-being and ultimately strengthen patient care outcomes.

Objective

This study aimed to evaluate the coping strategies used by nurses working in the Riyadh Region and to examine the association between these coping mechanisms and key demographic variables.

A cross-sectional, quantitative descriptive study was conducted at the second cluster hospital in Riyadh Region-(King Fahad Medical City, Prince Mohamed bin-Abdaziz, King Khalid ALMajmaah Hospital from Nursing-Staff. The study population consists of healthcare workers employed as nurses within the Second Health Cluster in Riyadh City. A total sample of 425 nurses was recruited. The sample size was calculated using Richard Geiger’s equation, based on a total nursing population of 6,300, a 95% confidence level and an assumed 50% response distribution to ensure adequate representativeness. The study utilized the Coping Strategy Indicator (CSI), an empirically derived tool used to measure coping behaviors across three domains: Problem-solving, seeking social support and avoidance. The CSI consists of 33 items rated on a three-point scale (not at all, a little, a lot), with 11 items per subscale. Higher scores reflect greater use of each coping strategy. The CSI has established content, face and construct validity and its three-factor structure has been consistently supported in international studies.

All full-time registered nurses working in major hospitals within the Second Health Cluster in Riyadh were eligible for inclusion. Nurses with a minimum of six months of clinical experience were included to ensure adequate exposure to workplace stressors and coping mechanisms. Both bedside and managerial nurses were invited to participate; however, no subgroup analysis based on role was performed. Nurses who were on leave during the data collection period, part-time or contractual staff and those with less than six months of experience were excluded. Additionally, questionnaires that were incomplete or had missing key responses were excluded from the final analysis; however, the exact number of excluded responses was not separately analyzed.

Data Collection

Ethical approval was obtained from the Institutional Review Board of the Ministry of Health and the Faculty of Nursing at Majmaah University. Eligible full-time nurses working in major hospitals within the Riyadh Region were invited to participate. The study purpose, procedures, potential risks and benefits were clearly explained and informed consent was obtained from all participants. The CSI questionnaire was provided in both paper and electronic formats to accommodate varying schedules. Research assistants were available to clarify questions without influencing responses. Completed questionnaires were anonymized, securely stored and later entered into a database for analysis.

Data Analysis

Data were analyzed using SPSS version 28. Descriptive statistics, including frequencies and percentages for categorical variables and means with standard deviations for continuous variables, were used to summarize demographic characteristics and coping strategy scores. CSI scores were categorized into low (11-18), moderate (19-25) and high (26-33) usage levels. Inferential statistics, including the Pearson Chi-square test and exact probability tests when required, were used to examine associations between coping strategies and demographic variables. A p-value of less than 0.05 was considered statistically significant.

A total of 425 nurses were included in the study. The majority were aged 20-30 years (n = 330, 77.6%), followed by 31-40 years (n = 77, 18.1%), while a smaller proportion were aged 41-50 years (n = 15, 3.5%) and over 50 years (n = 3, 0.7%). Regarding gender, 308 nurses (72.5%) were female and 117 (27.5%) were male. Regarding educational attainment, most were Bachelor of Nursing Science (BNS) graduates (n = 253, 59.5%), followed by Diploma graduates (n = 91, 21.4%), those with a Master's degree (n = 57, 13.4%) and a smaller group holding a PhD degree (n = 24, 5.6%). For work experience, a majority had less than 5 years (n = 267, 62.8%), with smaller groups reporting 5-10 years (n = 78, 18.4%), 11-15 years (n = 42, 9.9%), 16-20 years (n = 27, 6.4%) and more than 20 years (n = 11, 2.6%). Concerning work area, the highest proportion worked in the Emergency Department (ED) (n = 138, 32.5%), followed by the Intensive Care Unit (ICU) (n = 98, 23.1%), Outpatient Department (OPD) (n = 48, 11.3%) and Neonatal Intensive Care Unit (NICU) (n = 36, 8.5%). Other areas included Medical and Female Medical Wards (MMW, FMW) (n = 33, 7.8%), Maternity (MAT) (n = 31, 7.3%), Medical and Surgical Wards (MSW, FSW) (n = 24, 5.6%) and AKU (n = 17, 4.0%) (Table 1).

Table 1: Socio-Demographic Characteristics of the Nurses Working in Hospitals in Riyadh Region (N = 425)

Table 2 presents the distribution of responses on the Problem-Solving coping strategy among nurses (N = 425). A significant proportion of participants consistently reported high engagement in problem-solving behaviors, with over half indicating “a lot” of involvement in several key items. Exactly 52.9% (n = 225) reported that they had tried to solve the problem and 52.2% (n = 222) formed a plan of action in their minds. Likewise, 50.8% of participants stated that they rearranged things around them to resolve the issue, turned their full attention to solving the problem or tried different ways until they found a solution. On the other hand, a smaller percentage reported little or no engagement with problem-solving strategies, where only 7.5% (n = 32) had not thought about what needed to be done to straighten things out. The overall mean score for the problem-solving subscale was 26.1±4.6.

Table 2: Distribution of Responses on Problem-Solving Coping Strategy Among Study Nurses (N = 425)

Table 3 illustrates nurses' responses to the Seeking Social Support coping strategy (N = 425). Overall, the data reflect a moderate to high tendency to engage in support-seeking behaviors. A considerable number of participants reported frequently engaging in this strategy, with 41.2% (n = 175) seeking reassurance from those who know them best and 40.7% (n = 173) confiding fears and worries to friends or relatives. Additionally, around one-third to nearly 40% of nurses reported “a lot” of engagement in other supportive behaviors, such as talking to others about the situation (37.6%), accepting help from friends or relatives (36.0%) or going to friends for advice (35.1%). However, there was some variation in responses, with some portion reporting limited use of support-seeking strategies, where 22.6% (n = 96) indicated they had not at all gone to someone for emotional support and 18.8% (n = 80) had not confided their worries. Despite this, the overall mean score of 24.2±5.1.

Table 3: Distribution of Responses on Seeking Social Support Coping Strategy Among Study Nurses (N = 425)

Table 4 illustrates the distribution of responses related to the Avoidance coping strategy among nurses (N = 425). The data shows that avoidance coping is moderately utilized, with participants often engaging in strategies such as distracting themselves from the problem (39.5%) and daydreaming about better times (34.8%). A significant proportion also reported spending more time alone (34.6%) or watching television more than usual (27.8%), indicating a preference for disengagement or distraction from the stressor. However, there were also notable responses indicating low engagement in avoidance strategies, with 26.1% (n = 111) stating that they did not at all watch television more than usual and 24.7% (n = 105) not sleeping more than usual. Additionally, while some nurses indicated avoiding others (27.5%), a larger percentage (51.3%, n = 218) reported doing so only to a moderate extent. The overall mean score of 23.4±4.6.

Table 4: Distribution of Responses on Avoidance Coping Strategy Among Study Nurses (N = 425)

Figure 1 presents the frequency distribution of coping strategy use among study nurses (N = 425). For Problem-Solving, the majority of participants reported high use (56.2%, n = 239), with a smaller proportion engaging in moderate use (39.8%, n = 169) and only 4.0% (n = 17) reporting low use of problem-solving strategies. Regarding Seeking Social Support, the majority of nurses reported moderate use (53.6%, n = 228), with 37.6% (n = 160) engaging in high use and 8.7% (n = 37) reporting low use. As for Avoidance coping strategy, most participants reported moderate use (58.4%, n = 248), with 30.1% (n = 128) showing high use and 11.5% (n = 49) reporting low use.

Figure 1: The Frequency Distribution of Coping Strategy

Table 5 examines the relationship between demographic factors and the Problem-Solving coping strategy use among study nurses (N = 425). Age was significantly associated with problem-solving strategy use (p = 0.001). Nurses aged 31-40 years showed the highest proportion of high use of problem-solving strategies (66.2%, n = 51), compared to the younger (54.5%, n = 180) and older age groups. Nurses aged >50 years did not report high use of problem-solving strategies, with 100% (n = 3) reporting moderate use. Educational attainment was also a significant factor (p = 0.001). Nurses with a Bachelor of Nursing Science (BNS) degree showed the highest percentage of high use of problem-solving strategies (62.1%, n = 157), followed by Diploma graduates (49.5%, n = 45). In contrast, PhD graduates reported the lowest proportion of high problem-solving use (45.8%, n = 11) and Master’s degree holders had a similar trend with 45.6% (n = 26) engaging in high use. Work experience also displayed a significant relationship with problem-solving strategy use (p = 0.001). Nurses with less than 5 years of experience had the highest proportion of high use (58.4%, n = 156), followed by those with 5-10 years (60.3%, n = 47) and 11-15 years (54.8%, n = 23). Interestingly, nurses with 16-20 years of experience reported the highest proportion of moderate use (63.0%, n = 17). Work area was significantly related to the use of problem-solving strategies (p = 0.018). Nurses working in the Emergency Department (ED) had the highest percentage of high use (59.4%, n = 82) compared to other areas. Similarly, Intensive Care Unit (ICU) nurses also showed a high proportion of high use (60.2%, n = 59), while nurses in Maternity (MAT) had a slightly lower proportion (45.2%, n = 14).

Table 5: Relationship Between Demographic Factors and Problem-Solving Coping Strategy Use Among Study Nurses (N = 425)

P: Pearson X² test, ^: Exact probability test, *p<0.05 (significant)

Table 6 explores the relationship between demographic factors and the Seeking Social Support coping strategy use among study nurses (N = 425). Age was significantly associated with the use of seeking social support (p = 0.028). Nurses aged 31-40 years had the highest proportion of high use of social support (54.5%, n = 42), followed by those aged 20-30 years (34.2%, n = 113). Interestingly, nurses aged >50 years did not report high use of social support, with 100% (n = 3) engaging in moderate use. Gender did not show a significant relationship with seeking social support (p = 0.544). Both male and female nurses reported similar patterns of social support use, with females slightly more likely to report moderate use (55.2%, n = 170) compared to males (49.6%, n = 58). However, the proportions of high use were also similar, with 40.2% of males and 36.7% of females using social support extensively. Educational attainment showed no significant association with seeking social support (p = 0.263). Nurses across all educational levels (BNS, Diploma, Master’s, PhD) demonstrated similar patterns of moderate and high use, with BNS graduates reporting the highest proportion of moderate use (57.3%, n = 145). Work experience was not significantly associated with seeking social support (p = 0.361), with similar proportions of moderate use across the experience categories. However, nurses with 16-20 years of experience had the highest proportion of moderate use (63.0%, n = 17). Work area also did not show a significant association with seeking social support (p = 0.171), though nurses in areas like Maternity (MAT) reported a higher proportion of moderate use (74.2%, n = 23), compared to other areas.

Table 6: Relationship Between Demographic Factors and Seeking Social Support Coping Strategy Use Among Study Nurses (N = 425)

P: Pearson X² test, ^: Exact probability test, *p<0.05 (significant)

Table 7 examines the relationship between demographic factors and the Avoidance Coping Strategy among study nurses (N = 425). The results indicate that age did not show a statistically significant relationship with avoidance coping (p = 0.145). Nurses in the 20-30 years age group exhibited the highest proportion of moderate use of avoidance strategies (58.8%, n = 194) and a relatively high proportion of high use (30.9%, n = 102). Nurses aged 31-40 years followed a similar pattern, with moderate use at 53.2% and high use at 32.5%. The gender variable also did not demonstrate a significant relationship with avoidance coping (p = 0.703), with both male and female nurses showing similar patterns of moderate and high use. Specifically, 59.8% of male nurses (n = 70) and 57.8% of female nurses (n = 178) reported moderate use and a comparable proportion of males (27.4%) and females (31.2%) engaged in high use of avoidance strategies. Significant associations were found for educational attainment (p = 0.001), with nurses holding BNS degrees reporting the highest proportion of moderate use of avoidance coping (64.4%, n = 163), followed by Master's degree nurses at 43.9% (n = 25). Nurses with a Diploma and PhD degrees had lower proportions of moderate use. In contrast, those with BNS degrees reported the lowest proportion of low use (5.9%), compared to Diploma (20.9%) and Master’s degree nurses (19.3%). Work experience also demonstrated a significant relationship with avoidance coping (p = 0.001). Nurses with <5 years of experience reported the highest proportion of moderate use (57.7%, n = 154) and high use (35.2%, n = 94). Nurses with 5-10 years of experience showed a higher tendency for low use (23.1%, n = 18) compared to other groups, while those with 16-20 years of experience exhibited the highest proportion of moderate use (77.8%, n = 21). Regarding the work area, significant differences were observed (p = 0.031). Nurses working in areas such as the Emergency Department (ED) and Intensive Care Unit (ICU) showed high proportions of moderate use (50.7% and 67.3%, respectively), while nurses in Maternity (MAT) reported the highest proportion of high use (35.5%, n = 11). In contrast, nurses in areas like AKU and MSW and FSW showed a lower proportion of moderate use of avoidance coping.

Table 7: Relationship Between Demographic Factors and Avoidance Coping Strategy Use Among Study Nurses (N = 425)

P: Pearson X² test, ^: Exact probability test, *p<0.05 (significant)

The study aimed to investigate the coping strategies of nurses working in hospitals in the Riyadh Region, specifically how they cope with stressors and issues related to their work environments. Nursing is a demanding profession, so nurses must employ effective coping strategies to help them achieve optimal performance at work and optimise their overall well-being. This chapter contains the study findings, a comparison with the literature, unique aspects related to nursing practice and the implications for future research. The results of this study showed very specific coping strategies nurses employ when faced with stressors in their work environment [14]. The most common strategy was problem-solving, followed by moderate use of social support and low use of avoidant strategies. Problem-solving included younger and less experienced nurses due to their focus on clinical decision-making related to stressors [15]. Social support was also moderate; many nurses sought reassurance or shared concerns with colleagues or family members. Avoidance strategies were acknowledged to a lesser extent, including distraction and short withdrawal from the situation but were still used to measure acute stress. These results imply that nurses, particularly in high-stress clinical areas, like Emergency Departments (ED) and intensive care units (ICU), are positively taking an active and solutions-focused approach to managing stress [16]. However, the use of social support and avoidance behaviours also creates questions about engagement with emotional responses and potentially detrimental long-term impacts of coping strategies. Utilizing problem-solving strategies corroborates findings from past studies in Saudi Arabia and beyond, particularly in high-acuity environments [17]. Other research also supports findings that critical care nurses often use active coping strategies to cope with stressors. This study showed that nurses in the EDs and ICUs used problem-solving to deal with patient emergencies, emphasising the significance of good clinical decision-making skills for maintaining patient safety and the quality of care. The reasonable utilisation of social support proves that healthcare organisations should create systems of peer support that can be adopted [18]. Incentives: the incentives that institutional support can offer to nurses to encourage them to seek emotional support more frequently can be the benefit of institutional support, which can be in the form of mentoring programs or groupings of staff to debrief a team or any other type of support [19-22]. Regular support can alleviate emotional exhaustion and secondary traumatic stress, especially in high-stress areas such as Emergency Departments (EDs) and Intensive Care Units (ICUs). The work area also affected coping strategies. Nurses working in high-pressure areas, such as the ED and ICU, used more problem-focused strategies. In contrast, nurses working in moderate-pressure areas (such as maternity wards (MAT)) reported using more avoidant strategies [23]. The nature of the stressors nurses face in each area is likely also different. In contrast, emergency room and intensive care unit stressors are acute crises; stressors faced by staff working in maternity ward areas are likely emotional labour [24,25]. This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design limits the ability to establish causal relationships between demographic factors and coping strategies. Second, the study was conducted within hospitals of a single regional healthcare cluster in Riyadh, which may restrict the generalizability of the results to other regions or healthcare settings. Third, the use of self-reported data through questionnaires may introduce response bias, including social desirability bias. Additionally, the study included only full-time nurses, excluding part-time, contractual and rotating staff, whose coping experiences may differ. The lack of stratification by hospital and nursing role (e.g., managerial versus bedside) may also limit the assessment of variability across different work environments.

This study highlights how nurses in the Riyadh Region (Second Cluster) manage occupational stress. Problem‑solving emerged as the most prevalent strategy, with social support used at moderate levels and avoidance used least and generally for short‑term relief. Coping patterns varied by age, experience, education and clinical area, indicating that professional development and unit context shape how nurses respond to stressor mechanisms. Overall, the findings portray a workforce that primarily engages stressors directly while drawing on interpersonal support and limited, short‑term disengagement when appropriate.

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