A systematic review of stress and stress management interventions for mental health nurses

Yoga and qigong in the psychological prevention of mental health disorders: a conceptual synthesis

The study proposes to explore two alternative medicine therapies-qigong and yoga for balancing the essential duo of holistic mind-body and consequently offer a solution for stress, uncertainty, anxiety and depression. Qualitative research methods have been used to create a conceptual synthesis of yoga and qigong. It is suggested that an increased sense of control is the interface between these two modalities. This conceptual congruence of qigong and yoga is thought to be a selective, curative method, a prescription for ideal living and a ground of human essence existence. Furthermore, this essence is thought to enhance the mind's self-regulatory processes and prevent mental health disorders. The two alternative therapies can prevent mental health disorders such as anxiety, depression and, minimize mental health disruptions such as stress and poor quality of life. It is suggested that patients and/or clients can benefit from this fusion.

A randomised controlled trial of clinical supervision: selected findings from a novel Australian attempt to establish the evidence base for causal relationships with quality of care and patient outcomes, as an informed contribution to mental health nursing practice development

This paper reports on selected findings from a novel randomised controlled trial (RCT) conducted in mental health settings in Queensland, Australia. Several national and state reports recently revealed the sub-optimal state of Australian mental health service provision which have direct implications for mental health nursing, including the privately experienced cost of working and coping in these settings. Clinical supervision (CS), a structured staff support arrangement, has shown promise as a positive contribution to the clinical practice development agenda and is now found reflected in health policy themes elsewhere in the world. However, CS is underdeveloped in Australia and the empirical evidence base for the informed implementation of CS, per se, has remained elusive. Within the overall context of a RCT design, therefore, and supplemented by other data collection methods, this large and generously funded study attempted to make an incremental contribution to better understanding this demanding substantive domain. Whilst the substantive insights and theoretical propositions reported here were derived from, and may be limited by, a sub-specialty of nursing and a single geographic location, they were earthed in the personal self-reported experience of those directly involved with a clinical practice innovation. They may resonate with counterparts beyond mental health nursing and Queensland, Australia, respectively, therefore, and may assist in both conceptualising and operationalising CS research, education, management, policy and clinical practice development decision making in the future.

Improving hospital care for young children in the context of HIV/AIDS and poverty

Paediatric wards in South African government hospitals are occupied predominantly by children with HIV and AIDS-related illnesses. Although access to anti-retroviral treatment for adults is being scaled up, it is likely to be many years before South Africa achieves anywhere near universal access for children. Currently, most children living with HIV or AIDS are identified only when they become acutely or chronically ill and/or hospitalized, if at all. In the absence of treatment, the stress of caring for ill and hospitalized HIV-positive children often results in emotional withdrawal among both health professionals and caregivers. The demoralizing cycle of repeated admissions, treatment failure and death also affect the quality of the care given to HIV-negative children in over-burdened wards. This article describes the development of simple, low-cost and context-relevant interventions to improve the care environment for young hospitalized children within the context of the HIV/AIDS epidemic and poverty.

Front-line management, staffing and nurse–doctor relationships as predictors of nurse and patient outcomes. A survey of Icelandic hospital nurses

OBJECTIVE

To investigate aspects of nurses' work environments linked with job outcomes and assessments of quality of care in an Icelandic hospital.

BACKGROUND

Prior research suggests that poor working environments in hospitals significantly hinder retention of nurses and high quality patient care. On the other hand, hospitals with high retention rates (such as Magnet hospitals) show supportive management, professional autonomy, good inter-professional relations and nurse job satisfaction, reduced nurse burnout and improved quality of patient care.

METHODS

Cross-sectional survey of 695 nurses at Landspitali University Hospital, Reykjavík. Nurses' work environments were measured using the nursing work index-revised (NWI-R) and examined as predictors of job satisfaction, the Maslach burnout inventory (MBI) and nurse-assessed quality of patient care using linear and logistic regression approaches.

RESULTS

An Icelandic adaptation of the NWI-R showed a five-factor structure similar to that of Lake (2002). After controlling for nurses' personal characteristics, job satisfaction, emotional exhaustion and nurse rated quality of care were found to be independently associated with perceptions of support from unit-level managers, staffing adequacy, and nurse-doctor relations.

CONCLUSIONS

The NWI-R measures elements of hospital nurses' work environments that predict job outcomes and nurses' ratings of the quality of patient care in Iceland. Efforts to improve and maintain nurses' relations with nurse managers and doctors, as well as their perceptions of staffing adequacy, will likely improve nurse job satisfaction and employee retention, and may improve the quality of patient care.

Clinical supervision for nurses working in mental health settings in Queensland, Australia: a randomised controlled trial in progress and emergent challenges

Abstract

Several national and state-based inquiry documents have reported long-standing and major concerns about mental health service provision in Australia. In particular, accounts of the difficult circumstances that surround the recruitment and retention of high-quality mental health nurses have clearly emerged, independent of jurisdiction. However, the privately experienced cost of working and coping in contemporary mental health settings, especially when the resilience of nursing staff is tested remains poorly understood. Clinical supervision (CS), a structured staff support arrangement, has shown promise as a positive contribution to the clinical governance agenda and is now found reflected in central policy themes elsewhere in the world. However, the concept of CS remains underdeveloped in Australia. The background to a unique randomised controlled trial (RCT), currently in progress in Queensland, Australia, has been described in this study. The efficacy of the most widely adopted model of CS that may address the promotion of standards and clinical audit issues, the development of skills and knowledge and the personal well-being of the supervisee will be tested. This study, funded by the Queensland Treasury/Golden Casket Foundation, will focus not only on the outcomes for individual mental health nurses but also examine the quality of care they provide and the effects of both on patient outcomes. This study will seek to establish a sustainable, strategically significant contribution to the knowledge base both for the mental health nursing workforce in Queensland (and beyond) and the patients they seek to serve.

Facing inadequacy and being good enough: psychiatric care providers' narratives about experiencing and coping with troubled conscience

The aim of this study is to illuminate the meaning of encounters with a troubled conscience among psychiatric therapists. Psychiatric care involves ethical dilemmas which may affect conscience. Conscience relates to keeping or losing a sense of personal integrity when making judgments about one's actions. Ten psychiatric therapists were interviewed in June 2006. The interviews were tape-recorded, transcribed verbatim and interpreted using a phenomenological-hermeneutic method. Two themes 'Facing inadequacy' and 'Struggling to view oneself as being 'good enough'' are presented. In the therapists interviewed, awareness of their use of power, a sense of powerlessness and a sense of blame gave rise to feelings of betrayals and shameful inadequacy. By sharing their inadequacy with co-workers, they managed to endure the sense of their inadequacy which otherwise would have threatened to paralyse them. Finding consolation in sharing wearing feelings, becoming realistic and attesting their worthiness, they reached reconciliation and found confirmation of being good enough. The findings are interpreted in light of Lögstrup's ethics of trust, according to which conscience alerts us to silent but radical ethical demand and the risk of self-deception.

Self-care strategies for nurses: A psycho-educational intervention for stress reduction and the prevention of burnout

The purpose of this project is to develop and evaluate a psycho-educational program that assists nurses to develop stress management plans. Discussion of nursing-specific risk factors, practice with relaxation techniques, and exploration via art are used as interventions. Quantitative and qualitative measures of stress and burnout are conducted pre- and postcourse using the Maslach Burnout Inventory, Draw-a-Person-in-the-Rain Art Assessment, and wellness plans. Descriptive statistics are used, and preliminary analysis indicates that the course is useful in impacting levels of emotional exhaustion. There are opportunities for evolving the program so that more enduring change in self-care is generated.

Nurses' Experiences of Practicing the HeartTouch Technique for One Month

Stress plays a significant role in almost every aspect of health. Appraisal (thoughts and feelings) of a situation determines the level of stress experienced. Purpose: To describe the nurses' experiences of practicing the HeartTouch (HRTT) technique, an internal tool designed to help nurses change their thoughts and feelings, especially in stressful situations. Method: After an education session discussing the effects of thoughts and feelings on stress and health, nurses learn HRTT. After practicing HRTT for 1 month during their daily life, 48 nurses answer 7 open-ended questions about their experience. Content analysis is used to analyze the data. Findings: Nurses notice physical, mental, and emotional benefits for themselves, patients, colleagues, and family members. Nurses feel less stressed and experience an increased sense of control and ability to notice and change their thoughts and feelings. Nurses also discuss meaningful connections with self, others, and a Higher Power and greater work satisfaction.

Maintaining equilibrium: a theory of job satisfaction for community mental health nurses

This study aimed to explore what was satisfying in the role of community mental health nurse (CMHN). Previous studies have emphasized sources of dissatisfaction but the emphasis on satisfaction allowed the researchers to explore positive aspects of the role which have been largely neglected in previous studies and to explore how these nurses managed to sustain satisfaction. This study used a grounded theory, and the primary source of data was in-depth interviews collected over a 1-year period with 12 CMHNs. Data were analysed using the constant comparative method and theoretical sampling. The therapeutic relationship (being therapeutic, knowing oneself, knowing how) was identified as the most significant source of satisfaction for the CMHNs, but this was mediated by three properties associated with role performance - working for the organization, belonging to a team and maintaining a personal life. The properties associated with role performance affected the participants' experience of the therapeutic relationship which determined whether the CMHNs found their job satisfying. This process of balance and counter-balance is best explained by the core category maintaining equilibrium which accounts for the dynamic interaction that occurs between the therapeutic relationship properties and the role performance properties. As a core category maintaining equilibrium describes the process in which the participants were impelled towards satisfaction.

Workplace stressors and coping strategies among Chinese psychiatric nurses

PURPOSE

This study was conducted with Chinese psychiatric nurses to identify their workplace stressors and coping strategies, as well as the relationships between their demographics, workplace stressors, and coping strategies.

DESIGN AND METHODS

This survey was conducted, with the use of three questionnaires, on 188 psychiatric nurses recruited via convenient sampling in central China.

FINDINGS

The findings indicated that (a) workload and dealing with death/dying were the greatest workplace stressors; (b) positive coping strategies were the most often used coping strategies; and (c) a series of correlation results occurred. PRACTICE APPLICATION: Understanding the relationship between workplace stressors, effective and ineffective coping, and demographics can contribute to designing less stressful environments and more constructive coping strategies.

Assisting persons with multiple disabilities to move through simple occupational activities with automatic prompting

The present study assessed the possibility of assisting four persons with multiple disabilities to move through and perform simple occupational activities arranged within a room with the help of automatic prompting. The study involved two multiple probe designs across participants. The first multiple probe concerned the two participants with blindness or minimal vision and deafness, who received air blowing as a prompt. The second multiple probe concerned the two participants with blindness and typical hearing who received a voice calling as a prompt. Initially, all participants had baseline sessions. Then intervention started with the first participant of each dyad. When their performance was consolidated, new baseline and intervention occurred with the second participant of each dyad. Finally, all four participants were exposed to a second intervention phase, in which the number of activities per session doubled (i.e., from 8 to 16). Data showed that all four participants: (a) learned to move across and perform the activities available with the help of automatic prompting and (b) remained highly successful through the second intervention phase when the sessions were extended. Implications of the findings are discussed.

Psychiatric nurse reports on the quality of psychiatric care in general hospitals

Although acute inpatient psychiatric care has changed dramatically over the past 2 decades, little is known about how these changes have affected the quality of care, psychiatric nurse staffing, or patient outcomes. The purpose of this report is to explore the quality of care, quality of the practice environment, and adverse events as assessed by psychiatric nurses in the general hospital setting. The study sample consisted of 456 registered nurses permanently assigned to psychiatric units, compared with a larger sample of 11,071 registered nurses who work permanently on medical, surgical, or medical-surgical units. Compared with nonpsychiatric nurses, psychiatric nurse characteristics reveal an older, more experienced workforce, with a higher proportion of male nurses. Nurses rated quality of patient care lower in the psychiatric specialty than in the medical-surgical specialty. Furthermore, psychiatric nurses reported significant concern about the readiness of patients for discharge and higher incidence of adverse events. They also experienced more verbal abuse, physical injuries, and complaints from patients and families. Collectively, the results from this study underscore the organizational problems and quality-of-care issues that cause psychiatric nurses in general hospital settings to evaluate their work environments negatively.

Emotions and Their Cognitive Precursors

This study used Smith and Lazarus's appraisal model to explore nurses' emotional reactions to self-identified distressing work situations. Key situations reported typically involved time or interpersonal pressure, coping with errors at work, difficulties with patients, and managerial conflict. The strongest emotions experienced were anger and frustration. Anxiety and sadness were less endorsed. Most nurses felt able to cope emotionally and problem-solve solutions to the problems they faced. The findings were generally supportive of Smith and Lazarus's theory, with the exception of the emotion of sadness. The implications of the results are discussed.

Dealing with stress: patterns of self-comfort among healthcare students

Stress among healthcare students is a growing problem. As self-comfort is assumed to be a way of coping with stressful emotions, the aim of this study was to describe the patterns of self-comforting actions that healthcare students usually use in distress. One hundred and sixty-eight healthcare students volunteered to write down accounts of what they do when they comfort themselves. Their accounts were analysed using qualitative content analysis. The findings reveal two themes: Ingressing and Transcending. Ingressing comprises the sub-themes Unloading, Distracting, Nurturing oneself, Withdrawing and Reassuring. Transcending comprises the sub-themes Opening up and Finding new perspectives. These findings are in line with some stress-reducing strategies described in the literature on stress management. Winnicott's theory about the phenomenon of transition is used to interpret the findings. In the light of Winnicott's theory, self-comforting measures can be comprehended as the ability to transfer early childhood experiences of being nurtured and comforted into well-adapted strategies to effect relaxation and gain strength.

Impact on HIV test providers of giving a positive test result

The provision of a positive HIV antibody test result and the direction and support given to the test recipient are critical components of care and prevention. There has been little research that describes what happens in such interactions between recipient and provider. The impact on the test provider of delivering the HIV test result is an important issue to consider. The discomfort experienced by some health providers in giving a positive test result may have adverse effects on the client interaction or may carry over into subsequent client interactions. Utilizing a thematic analysis on interview data from 24 HIV test providers, we describe the impact of delivering a positive test result on HIV test providers, identify the factors that influence this impact, and describe strategies used to manage the impact. As with other health care professionals communicating "bad news,"HIV test providers experience a variety of impacts. While a small number of providers indicated little or no impact of delivering the HIV positive test result because the diagnosis is ''not the end of the world,'' most indicated it was difficult as it was anticipated that the test recipient would (or did) find the news distressing. Several coping strategies were identified.

A survey of role stress, coping and health in Australian and New Zealand hospital nurses

BACKGROUND

Previous research has identified international and cultural differences in nurses' workplace stress and coping responses. We hypothesised an association between problem-focused coping and improved health, emotion-focused coping with reduced health, and more frequent workplace stress with reduced health.

OBJECTIVES

Test the above hypotheses with Australian and New Zealand nurses, and compare Australian and New Zealand nurses' experience of workplace stress, coping and health status.

PARTICIPANTS AND SETTINGS

Three hundred and twenty-eight New South Wales (NSW) and 190 New Zealand (NZ) volunteer acute care hospital nurses (response rate 41%) from randomly sampled nurses.

DESIGN AND METHOD

Postal survey consisting of a demographic questionnaire, the Nursing Stress Scale, the WAYS of Coping Questionnaire and the SF-36 Health Survey Version 2.

RESULTS

Consistent with hypotheses, more frequent workplace stress predicted lower physical and mental health. Problem-focused coping was associated with better mental health. Emotion-focused coping was associated with reduced mental health. Contrary to hypotheses, coping styles did not predict physical health. NSW and NZ scored effectively the same on sources of workplace stress, stress coping methods, and physical and mental health when controlling for relevant variables.

CONCLUSIONS

Results suggest mental health benefits for nurses who use problem-solving to cope with stress by addressing the external source of the stress, rather than emotion-focused coping in which nurses try to control or manage their internal response to stress. Cultural similarities and similar hospital environments could account for equivalent findings for NSW and NZ.

The psychosocial and health effects of workplace reorganisation. 1. A systematic review of organisational-level interventions that aim to increase employee control

OBJECTIVE

Systematic review of the health and psychosocial effects of increasing employee participation and control through workplace reorganisation, with reference to the "demand-control-support" model of workplace health.

DESIGN

Systematic review (QUORUM) of experimental and quasi-experimental studies (any language) reporting health and psychosocial effects of such interventions.

DATA SOURCES

Electronic databases (medical, social science and economic), bibliographies and expert contacts.

RESULTS

We identified 18 studies, 12 with control/comparison groups (no randomised controlled trials). Eight controlled and three uncontrolled studies found some evidence of health benefits (especially beneficial effects on mental health, including reduction in anxiety and depression) when employee control improved or (less consistently) demands decreased or support increased. Some effects may have been short term or influenced by concurrent interventions. Two studies of participatory interventions occurring alongside redundancies reported worsening employee health.

CONCLUSIONS

This systematic review identified evidence suggesting that some organisational-level participation interventions may benefit employee health, as predicted by the demand-control-support model, but may not protect employees from generally poor working conditions. More investigation of the relative impacts of different interventions, implementation and the distribution of effects across the socioeconomic spectrum is required.

What makes a good midwife? An integrative review of methodologically-diverse research

AIM

This paper reports an integrative review aimed at answering the question: 'What makes a good midwife?'

BACKGROUND

A research-based definition of a good midwife which can be used as an operational definition in research and as a basis for curriculum development could not be found. Research in nursing has identified that patients and nurses may give different responses when asked about the most important aspects of nurses' contribution to care. It is also possible that views of how to define a good midwife might differ.

METHODS

A four-stage systematic review process was used, consisting of protocol development, carrying out the search, appraisal/analysis of the papers retrieved, and synthesis of the information. The initial search covered the period from 1993 and used the keywords 'midwi*', 'nurse-midwi*' and 'good'. This was later extended to include the terms 'exemplary', 'excellent' and 'superb' as synonyms of 'good', and 'bad' as its antonym. The integrative review was descriptive and focussed on extracting from the papers the findings that contributed to answering the research question.

FINDINGS

Thirty-three research-based papers were included in the review, and these had used a range of approaches and methods. Eight key concepts were derived from the data: attributes of a midwife, education, research, what a midwife does, care organization, other professionals, partners and an international perspective.

CONCLUSION

Having good communication skills made the greatest contribution to being 'a good midwife', while being compassionate, kind, supportive (affective domain), knowledgeable (cognitive domain) and skilful (psychomotor domain) also made major contributions. Being involved in education and research were necessary requirements, and midwives' abilities to treat women as individuals, adopt a caring approach, and 'be there' for women were essential. A good midwife can compensate for poor management systems, but women should be able to choose who provides their care, and partners should be involved in this care.

Expressed emotion and burnout: the experience of staff caring for men with learning disability and psychosis in a medium secure setting

This study examines the level of expressed emotion (EE) and burnout in staff caring for people with learning disabilities on a medium secure unit. The study aims to develop a baseline measure of EE and burnout in staff on the unit to be used for future service evaluation and to underpin interventions in the developing service based on psychosocial interventions. Ten staff participated in an audiotaped interview and completed a questionnaire. The Five Minute Speech Sample and Maslach Burnout Inventory were completed. High EE was evident in 31% of responses based on critical comments and negative relationships. Expressed emotion was higher in male staff and in Health Care Support Workers. No staff met all components for high burnout, but low personal accomplishment, high emotional exhaustion and high depersonalization were evident for some staff. There is evidence of high EE and some elements of high burnout within the staff team. A significant relationship was found between the level of high EE and the depersonalization element of burnout.

Community mental health nurses speak out: the critical relationship between emotional wellbeing and satisfying professional practice

The article reports on selected findings of a research study concerning emotional wellbeing and professional nursing practice (Rose 2002). It highlights the relationship between community mental health nurses' and emotional wellbeing, and their capacity to provide satisfying professional nursing practice (Rose 2002). The notion of emotional wellbeing, factors that impacted upon the participants' emotional wellbeing, and the relationship of emotional wellbeing to professional practice were revealed in the study. These findings were based on a qualitative critical feminist research inquiry and specifically, interviews with five women community mental health nurses in Australia. Whilst complex, emotional wellbeing was found to be both implicitly and explicitly linked to the participants intertwined personal and professional experiences. Four key components were identified: the nebulous notion; the stress relationship; the mind, body, spirit connection; and, inner sense of balance. In terms of emotional wellbeing and professional practice, three themes were revealed. These were: being able to speak out (or not); being autonomous (or not) and being satisfied (or not). The authors argue that the emotional wellbeing of nurses working in community mental health settings is critical to satisfying professional practice. Furthermore nursing work involves emotional work which impacts on one's emotional wellbeing and emotional wellbeing is integrally linked to professional practice. It is recommended that health organisations must be pro-active in addressing the emotional needs of nurses to ensure the delivery of health care that is aligned to professional practice. This approach will ensure nurses will feel more recognised and validated in terms of their nursing practice.

Assessing morale in community mental health professionals: a pooled analysis of data from four European countries

BACKGROUND

While there is a need to assess morale in community mental health professionals, it still remains to be determined how to obtain and interpret data in a sound and meaningful way. The aims of the present study were to assess the extent to which levels of morale are sensitive to differences between professional groups and health care systems, and identify factors influencing morale across groups and settings.

METHODS

A literature search of electronic databases was undertaken to identify studies measuring morale in different groups of community mental health professionals. Data was subjected to a pooled analysis. Differences between groups and sites were tested using factorial ANOVA and respective effect sizes were estimated based on Cohen's [1] work.

RESULTS

Data of four studies and a total of 723 professionals (from Austria, Germany, Italy and United Kingdom) were combined in a pooled analysis. Significant differences of morale levels were found between professional groups and study sites, and differences between professional groups varied significantly by study site. Effect sizes estimated for differences between particular groups of different health care systems ranged from small to large. Age was found to be a factor independently associated with morale.

CONCLUSIONS

Staff in community mental health care show substantial differences in morale levels depending on the professional group and context. These differences can often be identified even if in sample sizes of only 30 participants per group. Levels of morale need to be established specifically for different professional groups and context, and age should be controlled as an influential factor. The findings show a discriminant validity of assessment instruments for staff morale in community mental health care, and underline the rationale for such assessments in research and routine care.

A randomized clinical trial of a population- and transtheoretical model-based stress-management intervention

Stress has been associated with a variety of chronic and acute conditions and with higher use of health care services. This research reports on 18-month outcomes of a randomized clinical trial of a stress-management program based on the transtheoretical model (TTM; J. O. Prochaska & C. C. DiClemente, 1986). A national sample of 1,085 individuals participated (age range = 18-91 years, M = 55.33; 68.9% female, 31.1% male; 84.8% Caucasian; 15.2% non-Caucasian). Both the treatment and control groups received assessments at 0, 6, 12, and 18 months. In addition to the assessments, the treatment group received 3 individualized reports (0, 3, 6 months) and a manual. The 18-month assessment was completed by 778 individuals (72%). A random effects model indicated that participants completing the study in the treatment group had significantly more individuals reporting effective stress management at follow-up time points than did completers in the control group. Results also indicate that the intervention had significant effects on stress, depression, and specific stress-management behaviors. Results provide evidence for the effectiveness of this TTM population-based stress-management intervention.

Personal and professional impact of a course on contemplative practices in health and illness

A nursing graduate course focused on the impact of alternative healing modalities, particularly those that are contemplative in nature, on their professional and personal lives demonstrated that up to 4 years later students found the content to be of value. Suggestions for incorporation of CAM in mainstream nursing courses are shared.

Testing the relationship between job stress and satisfaction in correctional nurses

BACKGROUND

Correctional nurses function in a high stress environment due to the nature of their clients and the primacy of environmental security. Job stress and satisfaction are theorized relational concepts that influence intent to stay and turnover as described in the anticipated turnover model. An increased understanding of the nature and sources of stress and satisfaction provides necessary information about correctional nursing.

OBJECTIVE

To (a) replicate an earlier study of correctional nurses to determine whether similar findings could be duplicated in a study of prison nurses from another state and (b) test the concepts of stress and satisfaction as represented in the anticipated turnover model.

METHODS

Using the Index of Work Satisfaction and the Nurse Stress Index, a correlational mail survey was designed to assess job stress and satisfaction among 454 nurses in a northeastern state prison system.

RESULTS

Overall stress scores were not significantly different from the original study despite differences in demographic characteristics. Highest to lowest mean scores on actual sources of satisfaction include physician-nurse interaction, autonomy, professional status, task requirements, organizational policies, and pay. Satisfaction scores were significantly higher in the original study. An inverse relationship exists between job stress and satisfaction among correctional nurses. Job stress was a significant predictor of job satisfaction, supporting the theorized conceptual relationship between job stress and job satisfaction as described in the anticipated turnover model.

DISCUSSION

Stress levels and the top two sources of stress were essentially the same for both groups of correctional nurses. Sources of satisfaction are ranked similarly but subscale and overall scores indicate that the nurses in the replication study were more dissatisfied. Findings validate the theoretical proposition in the anticipated turnover model that job stress is a major predictor variable in explaining job satisfaction.

Change on the horizon: issues and concerns of neophyte advanced healthcare practitioners

AIMS AND OBJECTIVES

The aim was to interview new entrants to a Master's level programme of educational preparation for advanced healthcare practice roles. The objectives were to gain an understanding of their issues and concerns as they looked ahead to their future development and to illuminate issues concerning their experiences as students and as employees.

BACKGROUND

As advanced practice roles become more widespread in the United Kingdom and abroad, nurses and other healthcare professionals are becoming more involved in innovation and service development and experiencing greater autonomy in many areas, particularly in regard to clinical examination and diagnosis.

DESIGN

A qualitative design was employed to illuminate issues and concerns of new students on a Master's degree programme of educational preparation for advanced healthcare practitioners.

METHODS

Two focus group interviews were conducted in 2004. Sixteen students from two programme cohorts participated in the two groups.

FINDINGS

Two main themes were outlined. These were: 'opportunities for development' and 'time pressures'. Subcategories within these two themes are also discussed.

CONCLUSIONS

Students undertaking Master's level preparation for advanced healthcare practitioner roles perceive personal and professional benefits and opportunities to develop innovative services to improve patient care as accruing from the programme. These opportunities and benefits were related to the United Kingdom national health policy agenda. Some role difficulties were experienced. The additional burdens that the programme of study provided were an issue for some, but these were perceived as a temporary problem, worth undergoing for the likely long-term benefits.

RELEVANCE TO CLINICAL PRACTICE

Students undertaking educational preparation for advanced practice roles see themselves as innovators, specifically aiming to develop and improve aspects of service provision. Education for advanced practice roles should not be undertaken lightly, but can equip students with various skills, particularly regarding clinical assessment, and these skills should underpin practitioners' autonomy.

Clinical supervision and burnout: the influence of clinical supervision for community mental health nurses

AIMS

The aim of this study was to establish the degree to which clinical supervision might influence levels of reported burnout in community mental health nurses in Wales, UK.

METHODS

The research instruments used were the Maslach Burnout Inventory and the Manchester Clinical Supervision Scale. At the time of the survey 817 community mental health nurses were reported to work within Wales. Two hundred and sixty (32%) community mental heath nurses working in 11 NHS Trusts responded to the survey.

RESULTS

One hundred and eighty-nine (73%) community mental heath nurses had experience of clinical supervision in their present posts and 105 (40%) in their previous posts. The findings from the Maslach Burnout Inventory indicated high levels of emotional exhaustion for 36%, high levels of depersonalization for 12% and low levels of personal accomplishment for 10% of the community mental heath nurses surveyed. Univariate analysis showed that those community mental heath nurses who were younger, male and who had not experienced six or more sessions of clinical supervision were more likely to report cold negative attitudes towards their clients as indicated by higher scores on the depersonalization subscale of the Maslach Burnout Inventory. One hundred and sixty-six community mental heath nurses had experienced six or more sessions of clinical supervision and had completed the Maslach Burnout Inventory. Higher scores on the Manchester Clinical Supervision Scale were also associated with lower levels of measured burnout, with significant negative correlations between the total Manchester Clinical Supervision Scale score and the emotional exhaustion subscale (r = -0.148, P = 0.050) and the depersonalization subscale (r = -0.220, P = 0.003) of the Maslach Burnout Inventory. These findings suggest that if clinical supervision is effective then community mental heath nurses are likely to report lower levels of emotional exhaustion and depersonalization.

CONCLUSIONS

The findings from this study suggest that if clinical supervision is effective then community mental heath nurses report lower levels of burnout. Further research is required to determine the long-term benefits of implementing clinical supervision and to determine which other factors have an influence on levels of burnout for this group of nurses. Health service organizations have a responsibility for ensuring that all individual practitioners have access to effective clinical supervision and the Nursing and Midwifery Council could extend the registered nurses personal accountability to include - to seek clinical supervision as and when necessary.

Students' Self-Concepts: Implications for Promoting Self-Care Within the Nursing Curriculum

An important component of encouraging self-care among nursing students is the development of a self-concept that is aligned with valuing personal health. Dimensions of self-concept have been found to correlate with health behaviors and responses to health promotion information. In this study, 300 undergraduate students in a health course completed measures regarding their self-concept, health behaviors, and responses to a health promotion message. Students reported little overlap between their descriptions of themselves and of people they liked and respected and their descriptions of people who are healthy and take care of themselves. In addition, various self-concept ratings were related to self-reported involvement with smoking, alcohol consumption, and exercise, as well as to their responses to a health promotion message. This study offers suggestions for addressing the complexity of students' self-concepts in the nursing curriculum to foster a self-identity that includes valuing self-care at this key developmental stage.

Workplace bullying in nursing: towards a more critical organisational perspective

Workplace bullying is a significant issue confronting the nursing profession. Bullying in nursing is frequently described in terms of 'oppressed group' behaviour or 'horizontal violence'. It is proposed that the use of 'oppressed group' behaviour theory has fostered only a partial understanding of the phenomenon in nursing. It is suggested that the continued use of 'oppressed group' behaviour as the major means for understanding bullying in nursing places a flawed emphasis on bullying as a phenomenon that exists only among nurses, rather than considering it within the broader organisational context. The work of Foucault and the 'circuits of power' model proposed by Clegg are used to provide an alternative understanding of the operation of power within organisations and therefore another way to conceive bullying in the nursing workforce.

Taking a lead on stress: rank and relationship awareness in the NHS

Recent legislation from the Health and Safety Executive will have a significant impact on the expectations of how an organization manages stress. This paper considers the need for more awareness of risk assessment and risk management that takes into account the systemic antecedents of stress. It is suggested that assessment of organizational stress levels should include qualitative and quantitative methods of data collection to analyse the cumulative wear and tear on staff that contributes to the experience of workplace stress. This paper explores the importance of leadership within organizational hierarchies. Rank and status dynamics are identified as a potentially significant source of workplace stress. It is proposed that training in rank dynamics and relationship awareness are potential mediators in reducing workplace stress. The National Health Service could be a leader in establishing organizational well-being through patterns of leadership and relationship that tackles the growing epidemic of workplace stress.

Psychoneuroendocrine effects of cognitive-behavioral stress management in a naturalistic setting--a randomized controlled trial

It is assumed that chronic or extensive release of cortisol due to stress has deleterious effects on somatic and psychological health, making interventions aiming to reduce and/or normalize cortisol secretion to stress of interest. Cognitive-behavioral stress management (CBSM) has repeatedly been shown to effectively reduce cortisol responses to acute psychosocial stress. However, the effects of CBSM on psychoneuroendocrine responses during "real-life" stress have yet not been examined in healthy subjects. Eight weeks before all subjects took an important academic exam, 28 healthy economics students were randomly assigned to four weekly sessions of cognitive behavioral stress management (CBSM) training or a waiting control condition. Psychological and somatic symptoms were repeatedly assessed throughout the preparation period. Salivary cortisol (cortisol awakening response and short circadian cortisol profile) was repeatedly measured at baseline and on the day of the exam. In addition, cognitive appraisal was assessed on the day of the exam. Subjects in the CBSM group showed significantly lower anxiety and somatic symptom levels throughout the period prior to the exam. On the day of the exam, groups differed in their cortisol awakening stress responses, with significantly attenuated cortisol levels in controls. Short circadian cortisol levels did not differ between groups. Interestingly, groups differed in their associations between cortisol responses before the exam and cognitive stress appraisal, with dissociation in controls but not in the CBSM group. The results show that CBSM reduces psychological and somatic symptoms and influences the ability to show a cortisol response corresponding to subjectively perceived stress. In line with current psychoneuroendocrine models, the inability to mount a cortisol response corresponding to the cognitive appraisal in controls could be a result of a dysregulated HPA axis, probably as a consequence of longlasting stress.

The prevalence of nursing staff stress on adult acute psychiatric in-patient wards. A systematic review

BACKGROUND

Concerns about recent changes in acute in-patient mental health care environments have led to fears about staff stress and poor morale in acute in-patient mental health care staff.

AIM

To review the prevalence of low staff morale, stress, burnout, job satisfaction and psychological well-being amongst staff working in in-patient psychiatric wards.

METHOD

Systematic review.

RESULTS

Of 34 mental health studies identified, 13 were specific to acute in-patient settings, and 21 were specific to other non-specified ward-based samples. Most studies did not find very high levels of staff burnout and poor morale but were mostly small, of poor quality and provided incomplete or non-standardised prevalence data.

CONCLUSIONS

The prevalence of indicators of low morale on acute in-patient mental health wards has been poorly researched and remains unclear. Multi-site, prospective epidemiological studies using validated measures of stress together with personal and organizational variables influencing staff stress in acute in-patient wards are required.

Factors influencing the effectiveness of clinical supervision

Clinical supervision is widely accepted as an essential prerequisite for high quality nursing care. This paper reports findings from a study that aims to identify the factors that may influence the effectiveness of clinical supervision for community mental health nurses (CMHNs) in Wales, UK. Two hundred and sixty (32%) CMHNs from an estimated total population of 817 completed the Manchester Clinical Supervision Scale (MCCS) and a demographic questionnaire. The MCCS is a 36-item questionnaire measuring the quality and effectiveness of the supervision received. Three-quarters of CMHNs reported having participated in six or more sessions of supervision in their current posts. Clinical supervision was more positively evaluated where sessions lasted for over one hour, and took place on at least a once-monthly basis. Perceived quality of supervision was also higher for those nurses who had chosen their supervisors, and where sessions took place away from the workplace. These findings have important implications for the organization and delivery of mental health nursing services.

Clinical supervision, burnout, and job satisfaction among mental health and psychiatric nurses in Finland

This paper presents the findings from a survey of Finnish mental health and psychiatric nurses. The aim of the study was to describe and evaluate the current state of clinical supervision, and ascertain the levels of burnout and job satisfaction experienced by these health care professionals. Clinical supervision was found beneficial for mental health and psychiatric health care professionals in terms of their job satisfaction and levels of stress. The findings seem to demonstrate that efficient clinical supervision is related to lower burnout, and inefficient supervision to increasing job dissatisfaction.

Emotional labour and stress within mental health nursing

For many within the nursing profession, the work role involves a great deal of emotional work or 'emotional labour'. Such emotional work can be performed through 'surface acting' in which the individual simply feigns an appropriate emotion, or through 'deep acting' in which they actually try to feel the required emotion. The current study aims to aid understanding of the complex relationship between components of emotional labour and stress within the mental health nursing sector. Thirty-five mental health nurses completed questionnaires relating to a total of 122 nurse-patient interactions. Data were collected in relation to: (1) the duration and intensity of the interaction; (2) the variety of emotions expressed; (3) the degree of surface or deep acting the nurse performed; and (4) the perceived level of stress the interaction involved. Nurses also completed Daily Stress Indicators. Results suggest that: (1) emotional labour is positively correlated with both 'interaction stress' and daily stress levels; (2) the deeper the intensity of interactions and the more variety of emotions experienced, the more emotional labour was reported; and (3) surface acting was a more important predictor of emotional labour than deep acting. Implications for mental health nurses are outlined.

Role stress in nurses: Review of related factors and strategies for moving forward

The aim of this paper was to review the literature on factors related to role stress in nurses, and present strategies for addressing this issue based on the findings of this review while considering potential areas for development and research. Computerized databases were searched as well as hand searching of articles in order to conduct this review. This review identified multiple factors related to the experience of role stress in nurses. Role stress, in particular, work overload, has been reported as one of the main reasons for nurses leaving the workforce. This paper concludes that it is a priority to find new and innovative ways of supporting nurses in their experience of role stress. Some examples discussed in this article include use of stress education and management strategies; team-building strategies; balancing priorities; enhancing social and peer support; flexibility in work hours; protocols to deal with violence; and retention and attraction of nursing staff strategies. These strategies need to be empirically evaluated for their efficacy in reducing role stress.

Improving the psychosocial work environment

AIM

This paper reports a pilot project to evaluate the effectiveness of a participatory organizational intervention to improve the psychosocial work environment in one long-term care unit.

BACKGROUND

Since the early 1990s, health care institutions in Quebec have been constantly changing in order to improve the efficiency of the health care system. These changes have affected the work environment and have contributed to higher rates of burnout and absenteeism among nurses and other health care workers.

METHOD

The study participants were health care workers in a long-term care unit (n = 60). The participatory organizational intervention was based on a contract and carried out by a work team. Work constraints were identified, and an action plan implemented, The effectiveness of the intervention was evaluated by pre- and postintervention questionnaires: the Job Content Questionnaire, Effort-Reward Imbalance Questionnaire and Psychiatric Symptom Index.

RESULTS

There was a significant increase in reward (P < or = 0.01) and a significant decrease in Effort-Reward Imbalance (P < or = 0.01) following the intervention. Absenteeism rates decreased from 8.26% to 1.86% over the study period, but in the rest of the institution remained the same. However, there was a significant decrease in social support from supervisors (P < 0.05) at post-test.

CONCLUSION

Participation by health care workers and action plans targeting problematic aspects of the psychosocial work environment are key elements in interventions to improve their health. However, such interventions present challenges, such as the involvement of managers, involvement of all relevant participants, and re-establishment of trust within work teams. Recognition and respect must be re-established, and supervisors must engage with health care workers and give support at all stages of the intervention.

Relaxation training methods for nurse managers in Hong Kong: a controlled study

Nurse managers are under increased stress because of excessive workloads and hospitals' restructuring which is affecting their work tasks. High levels of stress could affect their mental health. Yet, few stress management training programmes are provided for this population. The purpose of this study was to apply stretch-release relaxation and cognitive relaxation training to enhance the mental health for nurse managers. A total of 65 nurse managers in Hong Kong were randomly assigned to stretch-release relaxation (n = 17), cognitive relaxation (n = 18), and a test control group (n = 35). Mental health status was assessed using the Chinese version of State-Trait Anxiety Inventory and the Chinese version of the General Health Questionnaire. Participants were assessed at the pretreatment session, the fourth posttreatment session, and at the 1-month follow-up session. The results revealed both the stretch-release and cognitive relaxation training enhanced mental health in nurse managers in Hong Kong. The application of relaxation training in enhancing mental health status for nurses and health professionals is discussed.

Developing Lecturer Practitioner roles using action research

BACKGROUND

Lecturer Practitioner roles are well established in the United Kingdom. The national literature demonstrates that these staff are valuable to National Health Service trusts and universities however, their roles are busy and demanding, with conflicting expectations from the two employers. In addition, their role in addressing the theory-practice gap - a major reason for their establishment - is at best unclear. Although a number of qualitative studies have explored the topic, there have been no systematic attempts to develop the role or to quantify the effects on postholders.

AIM

This paper reports a study that aimed to develop aspects of Lecturer Practitioners' work roles, examine the effects of this on individuals at one English university, and to quantify Lecturer Practitioners' occupational stress and burnout.

METHODS

A flexible, 'spiral' action research framework and 'collaborative group approach' were used, with mixed methods of data collection. Data were collected through focus groups, meetings and participant feedback, and participants' reflective diaries. A questionnaire using previously validated psychological attitude rating scales was also used to measure occupational stress and burnout, the extent to which the project influenced these, and the influence of Lecturer Practitioners' experience and qualifications. Six null hypotheses were constructed to measure these ideas. Findings from qualitative and quantitative perspectives were triangulated to give depth to the analysis.

FINDINGS

Five themes emerged from the focus groups: personal motivation, workload pressures, role clarity, preparation and support, and gains from the role. Specific policies and documentation were developed as a result of this initial project planning work. The findings from the questionnaire indicated that Lecturer Practitioners were no more stressed or burnt out than comparable workers. Synthesis of findings indicated, broadly speaking, that these LPs were 'thriving rather than just surviving'.

CONCLUSION

Action research was an effective methodology for uncovering new knowledge, and bringing about organizational change in this project.