Stress in mental health nurses: comparison of ward and community staff

Support interventions for nurses working in acute psychiatric units: A systematic review

Diverse support interventions have been implemented to provide support for nurses working in acute psychiatric settings. These interventions aimed at modifying the psychological and social factors, as they either prevent stress responses or reduce its effects to improve the psychological well-being of staff. This study aimed to examine effective stress reduction interventions for nurses and to identify key elements of these successful interventions. Studies included in this review were conducted in acute psychiatric settings. A comprehensive search of electronic databases was conducted for support intervention studies between 2010 and 2021. The search yielded 315 studies that were reduced to seven studies after being reviewed by two independent reviewers. The studies were coded, and key elements were identified. Seven studies that were included consisted of a randomised controlled trial, quasi-experimental design and single-group design. Interventions included mindfulness-based stress reduction, burnout prevention programmes, communication skills, educational programme, group intervention, resilience training programme and stress management. Four key elements emerged from these interventions, namely, educational support, interpersonal skills, psychological support and adaptive coping. The findings highlighted the diverse interventions in supporting psychiatric nurses to cope with stress. However, there is a dearth of studies in acute psychiatric settings that were mostly done in emergency settings. Knowledge gained from this review may assist with practice improvement as managers can implement the identified interventions.Contribution: This is the first systematic review focusing on supportive interventions for nurses in acute psychiatric settings. The knowledge gained from this review will add to the existing research knowledge base in the field.

Challenges Encountered by Nurses Working in Acute Psychiatric Wards: A Qualitative Study in Iran

BACKGROUND

The provision of care to patients with psychiatric disorders and working in a challenging environment lead to many problems among psychiatric nurses. The aim of this study was to explore the challenges nurses faced while working in acute psychiatric wards.

DESIGN

A qualitative design using content analysis was used. Fifteen nurses working in psychiatric wards in hospitals affiliated to a university hospital in an urban area of Iran were chosen using a purposive sampling approach. Semi-structured interviews were used for data collection. An inductive content analysis method was used to analyse the collected data.

RESULTS

Four themes were developed based on the analysed data: "experiencing psycho-social challenges," "experiencing psychological challenges," "encountering catalysts causing challenges," and "employing various strategies for coping with challenges."

CONCLUSIONS

Given the importance of physical and mental well-being of nurses and the moral and professional responsibility of an organization to protect staff health, it is of prime importance to examine the inpatient psychiatric nurses' experiences to better understand them and hopefully use such knowledge so as to improve their work life.

The impact of suicide on community mental health teams: findings and recommendations

Aims and Method

The study investigated the personal impact of patient suicides on the members of community mental health teams and the sources of support utilised for coping with adverse effects.

Results

Forty-four questionnaires were returned. Eighty-six per cent of staff reported having had at least one patient suicide, with an average of 4.2 suicides. The majority of staff reported that patient suicides had significant adverse effects on their personal and professional lives. Some of the effects were long-lasting (greater than 1 month). Staff found that peer support, reviews, dedicated staff meetings and support from senior colleagues were of most value.

Clinical Implications

Staff require skilled and dedicated support following a patient suicide in order to minimise its detrimental effects on personal, professional and team functioning.

Occupational stressors, burnout and coping strategies between hospital and community psychiatric nurses in a Dublin region

Burnout negatively impacts the delivery of mental health services. Psychiatric nurses face stressors that are distinct from other nursing specialities. The research was conducted in Ireland and captured a relatively large sample of respondents. The results compared the stressors, coping strategies and burnout levels between hospital and community-based psychiatric nurses. Occupational stress can negatively impact on the well-being of psychiatric nurses, which in turn can lead to poor client care. There is a dearth of published research conducted in Ireland that examines stress within the discipline. A between-groups study, undertaken in February 2011, investigated stressors, burnout and coping strategies between hospital and community-based psychiatric nurses in a Dublin region. Sixty-nine participants (8 males and 61 females), aged between 18 to 60 years voluntarily completed the Mental Health Professional Stress Scale, the Maslach Burnout Inventory and the PsychNurse Methods of Coping Scale. The findings revealed that nurses were operating in a moderately stressful environment. Stressors focused on organizational issues as opposed to client issues. The main stressors identified were lack of resources, workload and organizational structures/processes. Both groups reported average levels of emotional exhaustion, low levels of depersonalization and average levels of personal accomplishment. A Mann-Whitney U-test and Independent Samples t-test found significant differences between hospital and community-based nurses regarding depersonalization and personal accomplishment, respectively. Hospital nurses reported higher depersonalization scores, and community nurses had a greater sense of personal accomplishment. The personal accomplishment scores of hospital nurses were below mental health professional norms. No significant differences emerged regarding coping strategies. Avoidant coping strategies were favoured by both groups. It is recommended that interventions aimed at increasing personal accomplishment be implemented for both groups of nurses. An investigation of perceived job control and the use of social support would also be insightful.

Impact of a stress management program on stress perception of nurses working with psychiatric patients

Nurses caring for psychiatric patients may have to face violent emotions and unpredictable behaviour which can be quite stressful. A stress management program may equip nurses with skills to cope effectively with the stress. A one group pre-test and post-test design was adopted to test this hypothesis. Both gender nurses caring for psychiatric patients were invited to undergo 10 consecutive, one hour sessions of a stress management program. The DCL Stress scale (The De Villiers, Carson & Leary Stress Scale; Carson et al., 1997a,b,c) was used to collect data immediately after intervention and four weeks later. RM ANOVA with spss 16 showed that pre-intervention mean stress reduced significantly (p=0.000) from 57.45±16.42 to 41.06±16.51 immediately following the intervention and 26.43±12.82 (p=0.000) four weeks after the intervention. The stress management strategies positively impacted on nurses' stress levels.

'Everything contradicts in your mind': a qualitative study of experiences of forensic mental health staff in two contrasting services

BACKGROUND

 In the theoretical literature, there is growing recognition of the psychological impact on staff of working in challenging healthcare settings. In forensic mental health (FMH) services, powerful transference and counter-transference reactions in staff-patient relationships may emerge and may even play a role in contributing to incidents of malpractice, but there is little empirical research here.

AIM

 The exploration of the experiences of FMH staff in two contrasting services.

METHOD

 Thirteen in-depth interviews were carried out with staff from a range of clinical disciplines in a mainstream National Health Service (NHS) medium secure unit (MSU), and 12 interviews were undertaken with such staff from a Personality Disorder Unit (PDU) in an MSU. All interview data were analysed independently using the grounded theory method. To synthesise the two separate analyses, a thematic analysis of both data sets was carried out, in which 'thematic units' were defined as significant points of comparison between the analyses of the two sets of interviews.

RESULTS

 The combined analysis yielded six main themes under two main headings. Themes under the first heading Experience of the Clinical Task were: 'difficulty in achieving task integration'; 'motivation to build relationships, work through difficulty and bring about change'; and 'minimal sense of risk and anxiety at the centre'. Themes under the second heading Experience of the Organisation were: 'a distant and difficult relationship with outside'; 'preoccupation with staff relationships'; and 'feeling unsafe'. The overarching concept of the combined analysis was encapsulated in the quotation: 'Everything contradicts in your mind'.

CONCLUSIONS AND IMPLICATIONS

 Clinical and organisational aspects of work seemed separate in the minds of staff, with the latter reported to be more stressful; staff support came in the form of close relationships with colleagues, who saw themselves as isolated in the context of the wider environment. Promotion of the well-being and effectiveness of FMH staff should therefore take account of clinical, organisational and societal aspects of their situation.

Qualified and Unqualified (N-R C) mental health nursing staff--minor differences in sources of stress and burnout. A European multi-centre study

BACKGROUND

Unqualified/non-registered caregivers (N-R Cs) will continue to play important roles in the mental health services. This study compares levels of burnout and sources of stress among qualified and N-R Cs working in acute mental health care.

METHODS

A total of 196 nursing staff --124 qualified staff (mainly nurses) and 72 N-R Cs with a variety of different educational backgrounds--working in acute wards or community mental teams from 5 European countries filled out the Maslach Burnout Inventory (MBI), the Mental Health Professional Scale (MHPSS) and the Psychosocial Work Environment and Stress Questionnaire (PWSQ).

RESULTS

(a) The univariate differences were generally small and restricted to a few variables. Only Social relations (N-R Cs being less satisfied) at Work demands (nurses reporting higher demands) were different at the .05 level. (b) The absolute scores both groups was highest on variables that measured feelings of not being able to influence a work situation characterised by great demands and insufficient resources. Routines and educational programs for dealing with stress should be available on a routine basis. (c) Multivariate analyses identified three extreme groups: (i) a small group dominated by unqualified staff with high depersonalization, (ii) a large group that was low on depersonalisation and high on work demands with a majority of qualified staff, and (iii) a small N-R C-dominated group (low depersonalization, low work demands) with high scores on professional self-doubt. In contrast to (ii) the small and N-R C-dominated groups in (i) and (iii) reflected mainly centre-dependent problems.

CONCLUSION

The differences in burnout and sources of stress between the two groups were generally small. With the exception of high work demands the main differences between the two groups appeared to be centre-dependent. High work demands characterized primarily qualified staff. The main implication of the study is that no special measures addressed towards N-R Cs in general with regard to stress and burnout seem necessary. The results also suggest that centre-specific problems may cause more stress among N-R Cs compared to the qualified staff (e.g. professional self-doubt).

An exploratory study of the needs of staff who care for offenders with a diagnosis of personality disorder

People with a diagnosis of personality disorder who are considered a risk to others are a current concern for public services, government and society. Healthcare provision for this group has recently increased, making it important to begin to learn about the needs of staff working in such a challenging area. An exploratory interview study with staff working in a medium secure unit for offenders with a diagnosis of personality disorder (Unit Z) is presented. Interviews were line-coded and analysed according to the grounded theory method. A model was developed from higher order categories. This related key contextual factors to areas of concern for staff. The key contextual factors were: 'complexity of the task' and 'tension in the relationship with outside'. The areas of concern were: 'desire for more meaningful contact', 'contradictory attitude towards openness', 'feeling physically safe but emotionally vulnerable', 'ambivalence towards structure and control' and 'emphasis on staff relationships'. 'Risk of isolation' formed a core category and described Unit Z staff's pervading sense of distance from the outside world. These categories are described with supporting quotations and discussed in relation to the existing literature. Their implications for clinical practice and the development of services are considered.

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.

Stressors, burnout and social support: nurses in acute mental health settings

AIMS

This paper reports a study which aims (1) to investigate and compare levels of stressors and burnout of qualified and unqualified nursing staff in acute mental health settings; (2) to examine the relationships between stressors and burnout and (3) to assess the impact of social support on burnout and stressor-burnout relationships.

BACKGROUND

Several studies have noted that the work of mental health nurses can be highly stressful, but relatively few have focused specifically on staff working in acute inpatient settings. Although many of the pressures faced by this group are similar to those in other nursing specialties, a number of demands relate specifically to mental health settings, including the often intense nature of nurse-patient interaction and dealing with difficult and challenging patient behaviours on a regular basis.

METHODS

A convenience sample of 93 nursing staff from 11 acute adult mental health wards completed the Mental Health Professionals Stress Scale, Maslach Burnout Inventory and House and Wells Social Support Scale.

RESULTS

Lack of adequate staffing was the main stressor reported by qualified staff, while dealing with physically threatening, difficult or demanding patients was the most stressful aspect for unqualified staff. Qualified nurses reported significantly higher workload stress than unqualified staff. Approximately half of all nursing staff showed signs of high burnout in terms of emotional exhaustion. A variety of stressors were positively correlated with emotional exhaustion and depersonalization. Higher levels of support from co-workers were related to lower levels of emotional exhaustion. Higher stressor scores were associated with higher levels of depersonalization for staff reporting high levels of social support, but not for those reporting low levels of support (a reverse buffering effect).

CONCLUSIONS

Qualified and unqualified nursing staff differed in terms of the prominence given to individual stressors in their work environment. The findings were consistent with the notion of burnout developing in response to job-related stressors. While staff support groups may be useful in alleviating feelings of burnout, the reverse buffering effect suggests that they should be structured in a way that minimizes negative communication and encourages staff to discuss their concerns in a constructive way.

Identifying sources and effects of carer fatigue and burnout for mental health nurses: a qualitative approach

This project aimed to: identify work-related problems to assist mental health nurses to locate the sources and effects of carer fatigue and burnout, set up a dialogue between the participants and the identified sources of stress in the workplace to address the identified problems, and make recommendations to a local Area Health Service to prevent and manage stressors in the practice of mental health nursing. In total, 20 experienced registered nurses working as mental health nurses were enlisted through a snowballing method of recruitment, and convenience sampling was used to intentionally target those research participants who were interested in identifying sources of carer fatigue and burnout in their work. Data collection was via semistructured interviews which used questions reflecting the first stage of White and Epston's (1990) method of narrative therapy, in which relative influence questioning is used to externalize the problem. The research questions related to the effect of burnout in mental health nursing across various interfaces, through the dominant story of emotional stress and fatigue. The sources of work-related problems for mental health nurses that contribute towards their experiences of carer fatigue and burnout were: employment insecurity and casualization of the work-force; issues with management and the system; difficulties with the nature of the work, inadequate resources and services, problems with doctors, aggressive and criminal consumers, undervaluing consumers and nurses, physical and emotional constraints of the work setting, and nurse-nurse relationships and horizontal violence. The effects of stress were shown in dealing with and reacting to work place stressors.

Vicarious traumatization: implications for the mental health of health workers?

It has been suggested that a unique feature of some mental heath practitioners' work is exposure through their role as therapists to clients' descriptions of and reactions to trauma, and that these experiences may actually indirectly cause distress and traumatization to the therapist. This proposed phenomenon has been termed "vicarious traumatization" (VT) and is the focus of the current review. The concept of VT, together with other related concepts such as "burnout," "compassion fatigue," "secondary traumatic stress" (STS), and "work stress" are appraised. Psychological mechanisms that might be theoretically involved in VT are considered. The measurement of VT is reviewed alongside the limited research evidence supporting its existence. Factors such as direct trauma exposure and the personal attributes of mental health workers, which have been suggested to be associated with VT, are also assessed. It is concluded that the evidence to support the existence of VT is meager and inconsistent. Future research needs to be directed at distinguishing VT from other sources of distress arising within the workplace. Finally, the organizational relevance of VT and its possible implications for the management of mental health workers are critically appraised.

Factors related to stress and coping among Chinese nurses in Hong Kong

Few empirical studies have investigated the issues linked to Hong Kong nurses work-related health. The present study investigated factors related to stress and coping among Chinese nurses in Hong Kong. The researchers employed a cross-sectional survey and made within-group comparisons of nurses' stress and coping. Using stratified random sampling the researchers selected nurses from the mailing list of a local professional organization. One hundred and sixty-eight (33.6%) nurses responded. Nurses reported lower stress levels than other workers assessed with the same measure. Paediatric nurses reported the highest stress levels. Nurses at the lower grades reported higher stress levels than nurses at the higher grades. Single nurses had marginally higher stress scores than married nurses and females had slightly higher stress scores than males. However, none of these results were statistically significant. The respondents' major sources of stress were related to nursing issues like too much work, interpersonal relationships, and dealing with hospital administration. The respondents coped with their stresses by seeking support from friends and colleagues, using different cognitive strategies and through leisure activities. There was a statistically significant link between the respondents' stress and sickness levels. The results raise issues about the nature of nurses' working experiences.

Stress and burnout in community mental health nursing: a review of the literature

There is a growing body of evidence that suggests that many community mental health nurses (CMHNs) experience considerable stress and burnout. This review aimed to bring together the research evidence in this area for CMHNs working within the UK. Seventeen papers were identified in the literature, seven of which looked at stress and burnout for all members of community mental health teams (CMHTs) and the remaining 10 papers focused on CMHNs. The evidence indicates that those health professionals working as part of community teams are experiencing increasing levels of stress and burnout as a result of increasing workloads, increasing administration and lack of resources. For CMHNs specific stressors were identified. These included increases in workload and administration, time management, inappropriate referrals, safety issues, role conflict, role ambiguity, lack of supervision, not having enough time for personal study and NHS reforms, general working conditions and lack of funding and resources. Areas for future research are described and the current study of Welsh CMHNs is announced. This review has been completed against a background of further significant changes in the health service. In the mental health field, specific new initiatives will have a significant impact on the practice of community mental health nursing. A new National Framework for Mental Health, along with a review of the Mental Health Act (1983), will undoubtedly help to shape the future practice of mental health nursing.

Job satisfaction and stress in staff working in a specialist psychiatric unit for the elderly following relocation from a traditional psychiatric hospital setting

AIM

This study examines self-reported stress and job satisfaction of staff working in a specialist psychiatric unit for the elderly (n = 79) following relocation from a traditional psychiatric hospital setting (n = 66). The levels of reported stress were examined in relation to the two staff groups before and after the relocation, and in relation to data available for similar occupational groups.

METHODS

Stress and job satisfaction levels were surveyed using the Occupational Stress Indicator. The analysis of data included t-test for independent groups.

FINDINGS

The results suggested that that there were no significant changes in the patterns of the staff groups' experience of stress at the traditional psychiatric hospital and later at the new purpose-built unit. However, it was felt that there may have been different factors contributing to staff stress at the two time-points. The staff groups in this survey reported similar, and in some areas more positive levels of occupational stress than both community and other health authority samples. However, it was felt that, due to the limited response rate of staff at both times (63 and 59%), the results may be an underestimate of stress levels. In the absence of a measure of general health and symptomatology it was not possible to assess the impact of stress levels on the psychological well-being of staff.

CONCLUSIONS

Routine audit of staff stress would be beneficial to identify potential for staff training, and individual professional development plans. This is particularly important in view of the current difficulties both locally and nationally in the recruitment and retention of qualified staff in this speciality.

Distressed and stress resistant nurses

This study examines the relative contribution of personality, coping, and family support to adaptation to stress in nursing. The sample (N = 1,043, mean age = 33.8 years) were nurses from three large public hospitals in Singapore. The findings indicated that stress resistant nurses who adapted to high work stress with good mental health status as measured by the General Health Questionnaire (GHQ-12) developed by Goldberg (1972) had a higher self-esteem and were more internal in locus of control than the distressed nurses who reported poor mental health status under high work stress. The use of negative emotion focused coping was less frequent among the stress-resistant nurses who also had greater supports from family relationships. Discriminant function analysis revealed that behavioral coping (e.g., enhancement of ability and physical health) had greater contribution to stress resistance than cognitive coping (e.g., acceptance of situations or change of perspectives). The findings were discussed with reference to the high level of performance demanded by nursing.

Coping and family relationships in stress resistance: a study of job satisfaction of nurses in Singapore

This study examined the role of coping strategies and family relationships in mitigating the negative effect of work stress on nurses. The findings indicated that nurses who adapted to work stress with high job satisfaction were more inclined to adopt approach coping methods (problem orientation, ability enhancement, and change of perspective) than those who reported low job satisfaction under high work stress. The stress-resistant nurses were also distinguished by a less frequent use of defensive or avoidance coping in handling of their emotional reactions to stress. They perceived greater family support than did the distressed nurses. Implications of the findings and limitation of the study were discussed.

Lifestyle practices and the health promoting environment of hospital nurses

Lifestyle practices and the health promoting environment of hospital nurses This paper examined the lifestyle practices of hospital nurses and the impact of specific interventions in the hospital environment. The perception of nurse as health promoter and as carer of AIDS patients was also examined. A self-administered questionnaire was used to collect data at two different time periods. The sample represented 729 nurses (at pre- and post-time periods), both qualified and student nurses. Qualified nurses reported the highest stress levels while student nurses reported more negative lifestyle practices such as smoking, alcohol consumption and drug use. A greater number of current smokers (29%) consumed alcohol and used drugs than non-smokers. The impact of intervention strategies around compliance with smoking policy and work-site walk routes reduced exposure to passive smoking at work for qualified nurses and increased exercise participation for both groups of nurses. Workplace was identified as the main source of stress which included relationships at work and demands of the job. Hospital nurses experiencing high work stress were more likely to use professional support and personal coping (discuss problems with friends/family, have a good cry and eat more) than others. Nurses believed in the importance of health promotion as part of their work; however, qualified nurses felt more confident and gave more health related information than student nurses. Student nurses perceived a lower risk of contacting AIDS through work and a higher concern/worry in caring for AIDS patients than qualified nurses.

The value of mental health nursing

In a previous issue of the British Journal of Mental Health Nursing (Vol 4(10): 571–86) we took an indepth lookat the eduction of stress in the workplace. Carson et al (1995: p. 579–82) identified the most significant stress factors for nurses as being: ack of sufficient resources, e.g. poor staffing levels; lack of facilities in the community; and having to deal with people waiting for access to services. When situations with castastrophic outcomes occur, e.g. suicide or homicide, one is always confronted with the question: ‘Would this have happened had sufficient resources been available?’