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

BACKGROUND: Health care professionals in the United Kingdom (UK) appear to have higher absence and sickness rates than staff in other sectors, and stress may be a reason for nurses leaving their jobs. These problems need to be addressed, particularly in the mental health field, if current service provision is to be maintained. AIM: The aim was to identify stressors, moderators and stress outcomes (i.e. measures included those related to stress, burnout and job satisfaction) for mental health nurses, as these have clear implications for stress management strategies. METHOD: A systematic review of research published in English between 1966 and 2000 and undertaken in the UK that specifically identified participants as mental health nurses was carried out to determine the effectiveness of stress management interventions for those working in mental health nursing. Studies from non-UK countries were examined as potential models of good practice. The study was limited to primary research papers that specifically involved mental health nurses, where the health outcomes measured were stressors, moderators and stress outcomes and where sufficient data was provided. RESULTS: The initial search identified 176 papers, of these 70 met the inclusion criteria. Seven studies have been reported since the completion of the review and have been included in this article. Sixty-nine focused on the stressors, moderators and stress outcomes and eight papers identified stress management techniques. Relaxation techniques, training in behavioural techniques, stress management workshops and training in therapeutic skills were effective stress management techniques for mental health nurses. Methodological flaws however, were detracted from the rigour of many of the studies. CONCLUSIONS: The review demonstrated that a great deal is known about the sources of stress at work, about how to measure it and about the impact on a range of outcome indicators. What was found to be lacking was a translation of these results into practice, into research that assessed the impact of interventions that attempt to moderate, minimize or eliminate some of these stressors.     

Self-esteem in community mental health nurses: findings from the all-Wales stress study

The authors conducted an all-Wales survey of community mental health nurses (CMHNs) to determine their levels of stress, coping and burnout. A total of 301 CMHNs were surveyed in 10 NHS Trusts in Wales. A range of measures were used. These included the General Health Questionnaire (GHQ-12), Maslach Burnout Inventory (MBI), Rosenberg Self-Esteem Scale (SES), Community Psychiatric Nursing (CPN) Stress Questionnaire, and PsychNurse Methods of Coping Questionnaire. The findings from the Rosenberg SES are reported here. Community mental health nurses in Wales scored as having average self-esteem. When the data were divided into high and low self-esteem, a large group of CMHNs (40%) were found to have low self-esteem. Factors that are associated with low and high self-esteem were identified. Alcohol consumption and being on lower nursing grades (D, E, F) were associated with low self-esteem, whilst amount of experience working as a CMHN was associated with high self-esteem.     

不同护龄护士心理健康状态及工作倦怠调查分析

目的:探讨护龄对护士心理健康状态及工作倦怠的影响。方法:采用整群抽样的方法,选择1525名不同护龄护士进行一般状况、心理健康状态、工作倦怠、工作满意度的调查。结果:护龄对护士的心理健康及工作倦怠有影响(P0.05)。结论:不同护龄护士的心理健康状态及工作倦怠存在的差异具有统计学意义,11～20年护龄护士心理问题尤为突出,护龄是护士工作倦怠的一个非常重要的影响因素。     

Burnout in community mental health nurses: findings from the all-Wales stress study

Stress and its outcomes are significant problems for mental health workers. Questionnaires were sent to 614 community mental health nurses (CMHNs) in Wales. Three hundred and one responded (49%). Of these, 283 completed the Maslach Burnout Inventory (MBI) (Maslach et al. 1996). Half of those who responded indicated that they were emotionally overextended and exhausted by their work. One quarter of respondents were found to possess negative attitudes towards their clients, and approximately one in seven experienced little or no sense of satisfaction with their work. Working in an urban environment and lacking a supportive line manager were indicators for higher emotional exhaustion. CMHNs were significantly more likely to have negative attitudes towards their clients if they: were male; worked with an elderly care caseload; lacked job security; and had an unsupportive line manager. However, CMHNs who had worked longer within the field of community mental health were more likely to have positive attitudes towards their clients. Those CMHNs who had not completed a specialist postqualifying education course and those who did not hold a supervisory or management position were found to have a lowered sense of personal satisfaction in their work. Those CMHNs who reported that they drank alcohol were more satisfied with their sense of personal accomplishments achieved in their work.     

护士职业应激与精神卫生状况分析

[目的 ]了解护士职业应激与精神卫生状况及其相关性。 [方法 ]应用抑郁自评量表(SDS)和焦虑自评量表 (SAS)及护士职业压力源量表对 779名在岗护士进行调查。 [结果 ]护士抑郁和焦虑发生率分别为3 6.3 %和 14 .2 % ,两者并存者占 11.6% ,SDS和SAS标准分均值与国内常模比较有统计学意义 (P <0 .0 1) ;护士职业应激总分 1.97分± 0 .460分 ;精神卫生与职业应激呈高度正相关 (P <0 .0 0 1)。 [结论 ]护士群体精神卫生状况低下 ,与其职业应激密切相关。管理者应在引导护士正确认识和舒缓职业应激的同时 ,考虑到女性的社会脆弱因素及其独特的生理特征     

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. Relevance to clinical practice. 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.     

在职学历教育护士心理压力与心身健康的关系研究

目的了解在职学历教育护士心理压力现状及其与心身健康的关系。方法采用分层整群抽样法于2008年7～9月对1693名在职学历教育护士的心理压力及心身健康进行问卷调查。结果在职学历教育护士心理健康水平较差，其心理压力源从高到低依次为工作压力、家庭压力、学习压力。回归结果发现，心理压力的各个维度与在职学历教育护士的心身健康均存在相关（均P〈0．05），其中回报、技能利用和决策能力维度是保护因素，付出、心理要求、学习压力和家庭压力维度是危险因素。结论在职学历教育护士的心理压力问题应引起各级管理者的重视。     

Community mental health nurses in Wales: self-reported stressors and coping strategies

There is evidence to suggest that community mental health nurses experience stress and burnout related to their work. Previous research has been limited by a number of methodological problems. One of the problems is that studies have tended to have small or unrepresentative samples, and many researchers have only examined mental health nurses as a subset within their research, which limits the generalizability of the findings. The All-Wales Community Mental Health Nurse (CMHN) Stress Study was set up in order to address this issue. The total population of CMHNs in Wales was surveyed (N = 614) and 301 (49%) responded. The questionnaire booklet contained a number of validated instruments to measure stress, burnout, and coping, together with a demographic questionnaire. The demographic questionnaire included three open ended-questions. These questions were asked in order in determine the CMHNs' own views of the sources of stress in the workplace, and to investigate which methods they use to cope. This paper reports the findings from the content analysis of the three questions. The results from the other measures are reported in the companion paper (Edwards et al. 2000). The most frequently cited stressors included perceived workload, excessive paperwork and administration, and a broad spectrum of client-related issues. Coping strategies that CMHNs reported using included peer support, a range of personal strategies such as relaxation, and belief in self and supervision. It appears from the findings that a range of factors such as organizational pressures and factors related to working with patients are important in determining stress levels, and that informal rather than formal support networks are the preferred methods of coping.     

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.     

The clinical skills of community psychiatric nurses working with patients who have severe and enduring mental health problems: an empirical analysis

This study describes the use of reliable scales to rate the clinical skills of mental health nurses when working with individuals and families with severe mental health problems. The Cognitive Therapy Scale and the Schizophrenia Family Work Scale were adapted for the study and were shown to have good inter-rater reliability when assessing audio-taped interviews carried out by mental health nurses during their usual course of work with patients with severe mental health problems and their families. The sample of mental health nurses studied were shown to have significantly better general therapy skills than specific cognitive therapy technical skills. The implications for training are discussed.     

The relationship between emotions and stress among mental health nurses

This paper presents findings from an exploratory correlational study that examined the relationships between Emotional Competency, Trait Affectivity, Stress and Experienced Emotions among 43 mental health nurses in Australian regional hospitals. A significant relationship was found between Emotional Competency and Personal Self‐doubt in male nurses only; however, no association was found between Emotional Competency and Experienced Emotions. Trait Affectivity was found to be associated with Experienced Emotions but not Stress. Gender differences were found in Trait Affectivity and Experienced Emotions. The results of the study have implications for the retention of mental health nurses in their profession.     

A comparison of the work and values of community mental health nurses in two mental health NHS Trusts

With the reconfiguration of health services in both the primary and secondary sectors, the role of community mental health nurses (CMHNs) has become a highly contested one within mental health care. There would be great variability in the skills that CMHNs possess, the contexts in which they work and the nature of the work they do. This study sought to explore aspects of the work of those nurses who provide services at the interface between policy and practice. Two groups of CMHNs were compared, one working in an urban setting (Trust A) and the other in a rural (Trust B), focusing particularly on caseloads and client mix, the values held by CMHNs, the models of care they utilize and what they consider would improve care in the future. A specially designed 39-item questionnaire was employed, with a mix of open and closed questions, and statements to which participants were asked to respond on a three-point Likert scale. The findings raised interesting issues around collaborative working, whether CMHNs are happy to take on clients previously on their caseload, bureaucratization, autonomy, role definition within a culture of working with primary care, lack of specific models utilized by CMHNs, and the demand for greater training and educational support. The implications of the study are discussed with the aim of assisting mental health nurses determine their future roles.     

Smoking and mental health nurses: a survey of clinical staff in a psychiatric hospital

There is a lack of evidence on the prevalence of smoking among mental health nurses, and the beliefs and attitudes they hold about smoking at work. This paper describes results from a cross-sectional survey of clinical staff working in a UK specialist charitable-status psychiatric hospital and focuses on the responses of registered mental health nurses. Questionnaires specifically developed for this study were sent to all 1371 clinical employees. Completed questionnaires were returned by 167 of 429 (38.9%) registered nurses (RNs), 300 of 842 (35.6%) nursing assistants (NAs), and 123 of 200 (61.5%) other health professionals (OHPs). Twenty-nine (17.4%) RNs, 93 (31%) NAs and eight (6.5%) OHPs reported themselves as current smokers. Differences in response to attitudinal questions between groups could not be attributed to age. RN smokers were significantly more likely than RN non-smokers to state that staff should be allowed to smoke with patients, and to report therapeutic value for patients in this activity. RN smokers were less likely than RN non-smokers to report that patients should be encouraged to stop smoking. RNs were significantly more likely than OHPs to report therapeutic value for patients in smoking with staff, even after controlling for the possible confounding effect of smoking status. Implications of the survey are discussed in the context of the international literature, including the disproportionately high smoking prevalence among patients living in psychiatric institutions and current guidelines to move towards no 'smoking allowed' areas for staff working in them.     

疗养院文职护士工作压力与心理健康状况调查分析

目的调查了解疗养院文职护士工作压力和心理健康状况。方法采用护士工作压力源量表、Maslach职业倦怠调查普适表（MBI-GS）和症状自评量表（SCL-90）进行调查。结果疗养院文职护士的工作压力和倦怠情况均呈中度水平,主要在护理专业及工作问题、管理及人际关系方面和工作成就感低落方面较突出。SCL-90测评结果显示其目前心理健康状况良好。其工作成就感与护理专业及工作和管理及人际关系呈负相关（P〈0.05）;SCL-90中抑郁因子的得分与工作年限呈正相关（P〈0.05）,躯体化、焦虑、睡眠及饮食与护理专业及工作呈正相关（P〈0.05）,躯体化与工作成就感呈负相关（P〈0.05）,焦虑与情绪衰竭呈正相关（P〈0.05）。结论影响疗养院文职护士的工作倦怠和心理健康问题的主要原因是护理工作性质,还与工作年限、工作环境等因素有直接关系。个人应从自我管理方面努力调整心理状态,多方面寻求工作成就感和突破;护理管理者应充分注重以人为本的管理,积极引导和组织,提升文职护士的工作积极性。     

A grounded theory study of the role that nurses play in increasing clients' willingness to access community mental health services

ABSTRACT:  lients and caregivers frequently encounter difficulties in accessing mental health services. Early intervention to care and treatment is essential to recovery as delays can adversely affect the severity and the duration of the illness. This paper reports the factors that encouraged and deterred young adults with schizophrenia and their caregivers when trying to seek early access to community mental health services, and examines how community mental health nurses made themselves accessible to these individuals in order to increase their access to services. The findings showed that several factors simultaneously encouraged and inhibited individuals initiating contact at community mental health centres, and these had serious implications for care and treatment, and recovery. There were two client access pathways to care: a direct access pathway where an individual recognized signs of being unwell and sought help early; and an indirect access pathway where others, such as caregivers, general practitioners, police, and inpatient facilities initiated contact on an individual's behalf. Nurses used three strategies to enhance client and caregiver access to services: 'promoting favourable experiences to enhance approachability', 'using technology to promote access' and 'being available'. The findings have significance for nursing practice because they reinforce the importance of having good relationships with clients and caregivers, and the need to take account of the needs of caregivers. They highlight the benefits and drawbacks of using telecommunications to enhance accessibility, and why it is necessary to analyse nurses' workloads and time management skills.     

Influencing factors of community mental health nurses caring for people with schizophrenia in Taiwan

The purpose of this study was to explore the influencing factors in the substantive theory of home care for people with schizophrenia in Taiwan. The grounded theory of Strauss and Corbin approach was used. Semi-structured one-to-one in-depth interviews were utilized to collect data. Constant comparative analysis continued during the open, axial and selective coding processes until data saturation occurred. Participants were selected using theoretical sampling, and the final sample in this study consisted of a total of 29 community nurses (18 public health nurses and 11 home health nurses) who provided community mental health home-visiting services. The public health nurses and home health nurses both conducted a total of 16 (eight carers and eight clients) home visits. Four categories and 12 subcategories of influencing factors were identified; these factors have both positive and negative effects on nursing roles and the functions of public health nurses in the mental health home-visiting service in Taiwan. The influencing factors identified support the importance of home care services.