Burnout symptoms in forensic mental health nurses: Results from a longitudinal study

Prevalence of aggression and associated factors among inpatients with mental illness at tertiary hospitals in Southwestern Uganda

BACKGROUND

In mental health treatment facilities around the world, aggression aimed towards medical personnel and other patients is a serious issue. Types of aggression include; verbal aggression, aggression towards property, self-harm/auto-aggression, and physical aggression. Studies show 1 in 5 patients admitted to acute mental health care wards in high-income countries commit an act of physical violence during admission. In Uganda, there is limited literature on aggression among patients with mental illness admitted in psychiatric wards in our setting. This study aimed to investigate prevalence, types and associated factors of aggression among patients with mental illness admitted at tertiary hospitals in southwestern Uganda.

METHODS

This was a cross-sectional study that involved 280 participants from four tertiary hospitals in southwestern Uganda. Aggression was assessed using the Modified Overt Aggression Scale. The sociodemographic and clinical characteristics were collected using a structured sociodemographic questionnaire. The prevalence of aggression was assessed using proportions and the associated factors were assessed using the multinomial logistic regression analysis.

RESULTS

The prevalence of severe aggression was 42.9% with verbal aggression being the most common type while auto aggression was the least common. Involuntary admission and having a personal history of aggression were associated with all the 3 levels of aggression: mild, moderate and severe aggression, while having a positive family history of mental illness was associated with two levels of aggression (moderate and severe aggression). Having a history of substance use was only associated with moderate aggression and having history of childhood abuse was associated with severe aggression. Coming from a rural area was associated with severe aggression.

CONCLUSION

The prevalence of aggression is high among patients with mental illness admitted at tertiary hospitals in southwestern Uganda with verbal aggression being the commonest. Mental health professionals should pay attention to aggression among patients bearing in mind that people admitted involuntary, with personal history of aggression have a high likelihood of presenting with aggression. The mental health treatment facilities should consider adopting more of voluntary admission for patients presenting with aggression and only utilize involuntary admission when it is absolutely necessary and in line with the rights and responsibilities for patients with mental illness.

Workplace stressors and mental health outcomes among personal support workers: A systematic review

BACKGROUND

Although there is a growing focus on the mental well-being of licensed clinicians, there remains a scarcity of comprehensive evidence concerning the mental well-being of personal support workers (broadly defined as direct care workers), a vital segment of the healthcare workforce, particularly for aging populations. This review aims to identify, summarize, and synthesize the literature on work-related stressors associated with mental health problems among personal support workers, while also examining the potential influence of gender or sex differences in this relationship.

METHODS

This systematic review searched the EMBASE, PsycINFO, PubMed/Medline, and Web of Science databases for relevant studies. Studies published between 1 January 2003 and 30 June 2024 were included in the review. A quality assessment of each study was conducted using the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies and the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies. Meta-analysis was not performed due to the heterogeneity of the studies' characteristics.

RESULTS

Fourteen (14) articles met the inclusion criteria. They assessed burnout, depression, and/or anxiety among personal support workers who were exposed to various work-related stressors including high workload, aggressive client behavior, insufficient resources (e.g., physical and staffing), role ambiguity, conflict, personal growth, job satisfaction, discrimination, lack of co-workers or supervisors support, emotional suppression, extended working hours, complicated grief, and organizational support or respect. Aggressive client behavior, role ambiguity, resource inadequacy, and high workload emerged as the most frequently reported stressors. Burnout was the most frequently observed outcome. These relationships persisted in many multivariable analyses, even after adjusting for potential confounders. Also, females who experienced work-related stressors were more likely than males to report burnout, depression, or anxiety.

LIMITATIONS

The considerable heterogeneity of various work-related stressors and measurements among selected studies prevented a meta-analysis.

CONCLUSIONS

Collectively, this review's results suggest a significant association between major work-related stressors and mental disorders among personal support workers, while also emphasizing notable gender/sex differences in this relationship. These findings not only guide future research into the mental well-being of personal support workers but also underscore the importance for healthcare institutions of implementing organizational interventions to mitigate stressors and cultivate a more supportive work environment.

Views of Mental Health Nurses on Responding to Clinical Aggression on General Wards

The overall aim of this study was to explore the views of mental health nurses (MHNs) about their experience of responding to workplace violence (WPV) and aggression (code greys and blacks) within acute general wards. WPV continues to pose a significant source of challenge within healthcare settings despite several initiatives that have been trialled over the years. It has the potential to impact patient care and overall staff health and well-being. Nurses play a significant role in the management of WPV; hence, it is important to understand how they respond to and manage incidents of WPV. The study design was an explorative descriptive qualitative design. Data were collected through semi-structured interviews involving n = 10 MHNs working within a mental health consultation liaison team that responds to incidents of violence and aggression (codes grey and black) in acute general wards. Participants were recruited using a convenient sampling method. Data were analysed using thematic analysis. The findings of this study highlighted the following themes: (1) Patient care (subthemes: patient frustration with hospital processes, lack of time and resources); (2) Staffing skills and confidence (subthemes: lack of adequate training, inability to intervene early and communication skills); (3) Understanding patient behaviours (subthemes: it's a psychiatry problem and zero tolerance approach). The management of WPV within acute hospital settings needs to be given due attention by healthcare services. Although a number of organisations are developing measures and guidelines to manage WPV, there is still a gap in the ability of general nursing staff to properly manage such incidences. Proper attention needs to be taken to the training of staff.

Occupational Risk Factors for Burnout Syndrome Among Healthcare Professionals: A Global Systematic Review and Meta-Analysis

Health professionals are disproportionately affected by burnout compared to other occupational groups. This study aims to systematically review and meta-analyze thirteen occupational risk factors related to burnout syndrome among health professionals globally. A comprehensive literature search was conducted in August 2023. The protocol was registered in The International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42023396081. Using a random-effects model, this meta-analysis assessed the association between occupational risk factors and burnout, reporting odds ratios (ORs) and 95% confidence intervals (CIs). The meta-analysis included 109 studies from diverse global locations. Key factors influencing burnout included workplace bullying, job stress, and poor communication, with protective factors such as supportive work environments, adequate staffing, and individual resilience. All risk factors examined showed a significant positive relationship with burnout incidence. Workplace bullying was strongly associated with increased burnout (OR 4.05-15.01, p < 0.001). Similarly, low job satisfaction and high job stress were strongly associated with burnout, with ORs of 5.05 (95% CI 3.88-6.56, p < 0.001) and 4.21 (95% CI 1.62-10.94, p = 0.003), respectively. The review findings highlight the importance of addressing these risk factors through enhanced supportive work environments and promoting personal resilience strategies.

Forensic Mental Health Nurses' Perceptions and Experiences of Trauma-Informed Care in a High-Secure Hospital

BACKGROUND

Implementation of trauma-informed care (TIC) into forensic clinical practice may contribute to positive outcomes for both patients and staff.

AIM

The current study aimed to describe forensic mental health nurses' perceptions and experiences of using TIC within a high-secure forensic hospital.

METHOD

Twenty-seven forensic mental health nurses were interviewed regarding their experiences of using TIC within a high-secure hospital.

RESULTS

Participants recognized the importance of understanding the past traumatic experiences of patients in their care but described a number of barriers to the implementation of TIC. A lack of organizational support, the negative impact of patient psychopathology on nurse well-being, and environmental factors were all perceived to negatively impact the successful delivery of TIC. Participants also discussed a widespread lack of knowledge and confidence in the application of TIC but expressed great desire for training to improve service delivery.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

The application of TIC into daily clinical practice appears to be suboptimal. To support nurse and patient well-being and contribute to a highly skilled trauma-informed workforce, further training in this area is vital.

CONCLUSION

Training in TIC may contribute to enhanced patient outcomes and promote nurse well-being and should be supported organizationally with sufficient resources.

Risk factors and consequences of mental health problems in nurses: A scoping review of cohort studies

Mental health problems in nurses are prevalent and impairing. To date, no literature has comprehensively synthesised cohort evidence on mental health among nurses. This scoping review aimed to synthesise the existing literature on the risk factors and consequences of mental health problems in nurses. A systematic search was conducted on PubMed, EMBASE, Epistemonikos database, Web of Science, CINAHL, and PsycINFO from inception to March 2023. We identified 171 cohort studies from 16 countries, mostly (95.3%) from high-income economies. This review indicated that nurses worldwide encountered significant mental health challenges, including depression, cognitive impairment, anxiety, trauma/post-traumatic stress disorder, burnout, sleep disorder, and other negative mental health problems. These problems were closely related to various modifiable risk factors such as nurses' behaviours and lifestyles, social support, workplace bullying and violence, shift work, job demands, and job resources. Moreover, nurses' mental health problems have negative effects on their physical health, behaviour and lifestyle, occupation and organisation, and intrapersonal factors. These findings provided an enhanced understanding of mental health complexities among nurses, and shed light on policy enactment to alleviate the negative impact of mental health problems on nurses. Addressing mental health among nurses should be a top priority.

Putting the usability of wearable technology in forensic psychiatry to the test: a randomized crossover trial

Introduction

Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback.

Method

In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events.

Results

Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members.

Discussion

None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

Transgressive incidents targeted on staff in forensic psychiatric healthcare: a latent class analysis

Transgressive incidents directed at staff by forensic patients occur frequently, leading to detrimental psychological and physical harm, underscoring urgency of preventive measures. These incidents, emerging within therapeutic relationships, involve complex interactions between patient and staff behavior. This study aims to identify clusters of transgressive incidents based on incident characteristics such as impact, severity, (presumed) cause, type of aggression, and consequences, using latent class analysis (LCA). Additionally, variations in incident clusters based on staff, patient, and context characteristics were investigated. A total of 1,184 transgressive incidents, reported by staff and targeted at staff by patients between 2018-2022, were extracted from a digital incident reporting system at Fivoor, a Dutch forensic psychiatric healthcare organisation. Latent Class Analysis revealed six incident classes: 1) verbal aggression with low impact; 2) verbal aggression with medium impact; 3) physical aggression with medium impact; 4) verbal menacing/aggression with medium impact; 5) physical aggression with high impact; and 6) verbal and physical menacing/aggression with high impact. Significant differences in age and gender of both staff and patients, staff function, and patient diagnoses were observed among these classes. Incidents with higher impact were more prevalent in high security clinics, while lower-impact incidents were more common in clinics for patients with intellectual disabilities. Despite limitations like missing information, tailored prevention approaches are needed due to varying types of transgressive incidents across patients, staff, and units.

Staff Turnover Intention at Long-Term Care Facilities: Implications of Resident Aggression, Burnout, and Fatigue

OBJECTIVES

Staff shortages and the high turnover rate of nursing assistants pose great challenges to long-term care. This study examined the effects of aggression from residents of long-term care facilities, burnout, and fatigue on staff turnover intention. The findings will help managers to devise effective measures to retain their staff.

DESIGN

Cross-sectional descriptive study design.

SETTING AND PARTICIPANTS

A total of 800 nursing assistants were recruited from 70 long-term care facilities using convenience sampling.

METHODS

The participants were individually interviewed and provided information about their turnover intention, resident aggression witnessed and experienced, self-efficacy, neuroticism, burnout, fatigue, and personal and facility characteristics.

RESULTS

Hierarchical multiple regression analysis revealed that the size and organizational practices of long-term care facilities were not associated with staff turnover intention. Staff who spent less time in the industry reported witnessing resident-to-resident aggression, experienced resident-to-staff aggression, reported high levels of burnout, had acute or chronic fatigue, and had low levels of inter-shift recovery were more likely than others to report a high turnover intention.

CONCLUSIONS AND IMPLICATIONS

Staff turnover poses great challenges to staff, residents, and organizations. This study identified important factors that may help support staff in long-term care facilities. Specific measures, such as person-centered care to diminish resident aggression by addressing residents' unmet needs, work-directed programs to mitigate burnout and improve staff mental health, and flexible schedules to prevent fatigue should also be advocated to prevent staff turnover.

'Fleeing' as a Strategy for Navigating Resistance in Patient Encounters within Forensic Care

The aim of this study was to describe the phenomenon of "fleeing the encounter when facing resistance" as experienced by carers working in forensic inpatient care. Qualitative analysis, namely reflective lifeworld research, was used to analyze data from open-ended questions with nine carers from a Swedish regional forensic clinic. The data revealed three meaning constituents that describe the phenomenon: shielding oneself from coming to harm or harming the other, finding one's emotional balance or being exposed, and offering the patient emotional space and finding patience. The carers described their approaches in the encounters with the patients as alternating between primitive instincts and expectant empathy in order to gain control and deal with the interaction for their own part, for that of the patient, and for that of their colleagues. The phenomenon of fleeing the encounter when facing resistance was intertwined with carers' self-perception as professional carers. Negative encounters with patients evoked feelings of shame and self-blame. A carer is a key person tasked with shaping the care relationship, which requires an attitude on the part of the carer that recognizes not only the patient's lifeworld but also their own.

Impact of COVID-19-Related Social Distancing on the Incidence of Inpatient Aggression at a Public Psychiatric Hospital

OBJECTIVE

This study explores the impact of coronavirus disease (COVID) pandemic-related social distancing measures on the incidence of inpatient aggression at a public psychiatric hospital Methods: Data was gathered from the hospital's unusual incident (UI) database for the time period ranging from January 1, 2015, to December 31, 2020. Based on the implementation of major social distancing measures, March 6, 2020, was set as a cutoff time point to categorize aggressive events into pre-COVID and post-COVID groups. Data was analyzed using Chi-square tests and general linear modeling. The p-value was set at ≤0.05.

RESULTS

After the implementation of social distancing measures, there was a decrease in the absolute number of inpatient aggressive events from 15.0/week to 12.6/week (mean difference: 2.4/week, p=0.032). However, this decrease was primarily attributable to a decrease in hospital census. There was a decrease in the proportion of seven-day and 14-day post-admission aggressive events by 5.4% and 12.1%, respectively. Concurrently, there was a 4.9% increase in recurrent aggression. Emergency psychiatric medication administration and the use of physical restraint decreased during the COVID-19 pandemic.

CONCLUSION

Consistent with previous results, this study reports a decrease in the incidence of inpatient aggression during the COVID-19 pandemic. Social distancing measures can be utilized as a tool to decrease the incidence of inpatient aggression and the use of physical restraints.

The experience of nurses moving into forensic mental health employment: A qualitative study

While forensic mental health has seen considerable growth over the last two decades, little is known about the experience of registered nurses working in these environments. This study used a qualitative descriptive approach and interviewed 11 registered nurses to explore the interpersonal experiences of transition into a forensic mental health hospital. The data revealed three themes. 'Observing what's safe' examined nurses' ability to maintain safety in the context of inconsistent practices among colleagues. 'Navigating cliques and divisions' focused on nurses' sense of belonging and adapting to professional and personal groups. Finally, 'gaining management support' reflected nurses' experiences of engagement with management. This study provides new insight into nurses' experience of adapting to employment in forensic mental health settings and highlights the importance of positive support strategies for workplace transition.

Big five model personality traits and job burnout: a systematic literature review

BACKGROUND

Job burnout negatively contributes to individual well-being, enhancing public health costs due to turnover, absenteeism, and reduced job performance. Personality traits mainly explain why workers differ in experiencing burnout under the same stressful work conditions. The current systematic review was conducted with the PRISMA method and focused on the five-factor model to explain workers' burnout risk.

METHODS

The databases used were Scopus, PubMed, ScienceDirect, and PsycINFO. Keywords used were: "Burnout," "Job burnout," "Work burnout," "Personality," and "Personality traits".

RESULTS

The initial search identified 3320 papers, from which double and non-focused studies were excluded. From the 207 full texts reviewed, the studies included in this review were 83 papers. The findings show that higher levels of neuroticism (r from 0.10** to 0.642***; β from 0.16** to 0.587***) and lower agreeableness (r from - 0.12* to - 0.353***; β from - 0.08*** to - 0.523*), conscientiousness (r from -0.12* to -0.355***; β from - 0.09*** to - 0.300*), extraversion (r from - 0.034** to - 0.33***; β from - 0.06*** to - 0.31***), and openness (r from - 0.18*** to - 0.237**; β from - 0.092* to - 0.45*) are associated with higher levels of burnout.

CONCLUSIONS

The present review highlighted the relationship between personality traits and job burnout. Results showed that personality traits were closely related to workers' burnout risk. There is still much to explore and how future research on job burnout should account for the personality factors.

Profiling health professionals' personality traits, behaviour styles and emotional intelligence: a systematic review

BACKGROUND

Non-cognitive traits have been theorised to predict characteristics, career choice and outcomes of health professionals and could represent a homogenous group. This study aims to profile and compare personality traits, behaviour styles and emotional intelligence of health practitioners across a variety of professions.

METHODS

Empirical literature was systematically reviewed. A two-concept search strategy was applied to four databases (CINAHL, PubMed, Embase, ProQuest). Title/abstract and full text articles were screened against inclusion and exclusion criteria. Methodological quality was assessed using Mixed Methods Appraisal Tool. Data was synthesised narratively and meta-aggregated where feasible.

RESULTS

Three hundred twenty-one studies representing 153 assessment tools of personality (n = 83 studies), behaviour (n = 8), and emotional intelligence (n = 62) were included. Most studies (n = 171) explored personality (medicine, nursing, nursing assistants, dentistry, allied health, paramedics), revealing variation in traits across professions. Behaviour styles were least measured with only ten studies exploring these across four health professions (nursing, medicine, occupational therapy, psychology). Emotional intelligence (n = 146 studies) varied amongst professions (medicine, nursing, dentistry, occupational therapy, physiotherapy, radiology) with all exhibiting average to above-average scores.

CONCLUSION

Personality traits, behaviour styles and emotional intelligence are all key characteristics of health professionals reported in the literature. There is both heterogeneity and homogeneity within and between professional groups. The characterisation and understanding of these non-cognitive traits will aid health professionals to understand their own non-cognitive features and how these might be useful in predicting performance with potential to adapt these to enhance success within their chosen profession.

Forensic Mental Health Nurses' Experiences of Clinical Supervision

BACKGROUND

Clinical supervision may support forensic mental health nurses with personal and professional growth in a work environment characterized by therapeutic, ethical, and practical challenges.

AIM

The aim of this study was to describe the experiences of forensic mental health nurses participating in a clinical supervision program.

METHODS

Seven forensic mental health nurses and two allied health professionals, working in a high-security forensic mental health hospital, were interviewed regarding their experiences of participating in a clinical supervision program.

FINDINGS

Participants expressed a need for clinical supervision and were motivated to participate in the program. Benefits of clinical supervision experienced by participants included improved communication with their colleagues, being supported in their career development, and developing habits and techniques to reflect on practice issues. Participants described being able to connect with their supervisor, enabled by both trust and confidence in the supervisor's expertise.

CONCLUSION

Staff showed engagement in the clinical supervision process and expressed experiencing positive outcomes related to personal and professional growth and development.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

To support nurses with the forensic mental health context-specific challenges they face, organizations should enable and promote access to clinical supervision. Considerations for forensic mental health organizations to increase uptake and effectiveness of clinical supervision include use of externally based clinical supervisors with adequate skills and experience with providing clinical supervision to clinical staff who work in a secure environment.

Wearables: An R Package With Accompanying Shiny Application for Signal Analysis of a Wearable Device Targeted at Clinicians and Researchers

Physiological signals (e.g., heart rate, skin conductance) that were traditionally studied in neuroscientific laboratory research are currently being used in numerous real-life studies using wearable technology. Physiological signals obtained with wearables seem to offer great potential for continuous monitoring and providing biofeedback in clinical practice and healthcare research. The physiological data obtained from these signals has utility for both clinicians and researchers. Clinicians are typically interested in the day-to-day and moment-to-moment physiological reactivity of patients to real-life stressors, events, and situations or interested in the physiological reactivity to stimuli in therapy. Researchers typically apply signal analysis methods to the data by pre-processing the physiological signals, detecting artifacts, and extracting features, which can be a challenge considering the amount of data that needs to be processed. This paper describes the creation of a “Wearables” R package and a Shiny “E4 dashboard” application for an often-studied wearable, the Empatica E4. The package and Shiny application can be used to visualize the relationship between physiological signals and real-life stressors or stimuli, but can also be used to pre-process physiological data, detect artifacts, and extract relevant features for further analysis. In addition, the application has a batch process option to analyze large amounts of physiological data into ready-to-use data files. The software accommodates users with a downloadable report that provides opportunities for a careful investigation of physiological reactions in daily life. The application is freely available, thought to be easy to use, and thought to be easily extendible to other wearable devices. Future research should focus on the usability of the application and the validation of the algorithms.

Defensive practices in mental health nursing: Professionalism and poignant tensions

Mental health nursing is a skilled profession, well positioned to support patients towards recovery with evidence-based therapeutic interventions. However, the profession continues to be challenged by tensions surrounding the delivery of restrictive interventions and concerns over tendencies towards defensive practices. This paper examines the ambiguity this creates within the mental health nursing role. Organizational cultures that overvalue metrics and administrative tasks create barriers for therapeutic engagement while contributing to role confusion and stress within nursing. We need to address such structural constraints on nurses as mental health nurses' well-being is crucial to service delivery and the realization of therapeutic goals. From the UK perspective, authors argue that there is a need to examine service structures that foster compassionate and transformational leadership to enable mental health nurses to exercise the agency to practice therapeutically. Education and quality nursing research have a pivotal role to play in enabling this shift.

How does burnout relate to daily work-related rumination and well-being of psychotherapists? A daily diary study among psychotherapeutic practitioners

OBJECTIVE

This is the first study to use a daily diary design to investigate the relationship between daily work-related rumination (WRR), daily well-being, and burnout symptoms among psychotherapeutic practitioners.

METHOD

In total, N = 58 psychotherapeutic practitioners participated in the study. For 4 weeks, the participants received a daily evening prompt on weekdays asking about their WRR and well-being. The burnout level of the psychotherapists was assessed using Maslach Burnout Inventory (MBI) prior to the daily diary period and afterward. The MBI measures the level of work-related distress on three subscales: emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). Two main analyses were performed: Based on the hierarchical structure of the data we performed random intercept and slopes models. These models examined the association between daily WRR and daily well-being, and the relationship between pre-burnout and daily WRR and daily mood. Secondly, linear regressions with the post-MBI subscales as criterion and the daily diary variables as predictors were calculated to assess their contribution to post-burnout.

RESULTS

The compliance rate in our study was 76.8%. Daily WRR and pre-assessment EE were associated with all aspects of reduced daily well-being: bad mood, increased nervousness, and tiredness after work. Daily tiredness and nervousness played a differential role in predicting post-burnout.

CONCLUSION

Our results indicated that daily rumination and pre-EE were associated with reduced daily well-being. As we are the first to present a daily diary study among psychotherapists, we examined the feasibility of the daily diary design in particular and ecological momentary assessment (EMA) in general in this population. Compliance rates compared well with other EMA studies, indicating that EMAs were a feasible assessment option for psychotherapeutic practitioners.

Burnout in Mental Health Care Professionals Working with Inpatients in Open or Closed Wards in Psychiatric Hospitals

Mental health care professionals are at risk of experiencing burnout. This cross-sectional study aims to investigate burnout in two settings: open and closed psychiatric wards, and two professions: registered nurses and social healthcare assistants in eight psychiatric wards in Denmark. A total of 114 professionals completed the Copenhagen Burnout Inventory and a demographic questionnaire. No statistically differences in burnout in professionals working in closed and open wards were found. However, we found professionals to score highest on personal and work-related burnout and lowest on client-related burnout. This indicates that patients may only play a minor role in burnout in health professionals.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Nursing students' experiences of violence and aggression: A mixed-methods study

BACKGROUND

Violence and aggression cause significant problems for nursing staff and students working across healthcare.

OBJECTIVES

To identify the prevalence of aggression experienced by nursing students whilst on clinical placement in one UK city, and rates and experiences of reporting of aggression.

DESIGN

A convergent mixed method design, with mixing occurring at the objective and inference stages.

PARTICIPANTS

Preregistration nursing students who had completed at least one clinical placement.

METHODS

A cross-sectional survey and concurrent focus groups were conducted between May and December 2018. Students completed the 'Students' Experiences of Violence and Aggression Survey' (SEVAS) and were separately invited to participate in focus groups.

RESULTS

There were 129 responses to the survey and 36 students participated in five focus groups. Only about a third of non-physical aggression was reported and around half of the physical aggression and sexual harassment. Very few incidents were reported to the university. Themes from the focus groups encompassed ideas of the ubiquity of violence, that students did not know what they were doing, and issues of racism, bullying, and compassion.

CONCLUSIONS

Universities have a responsibility to students; this includes preparing them adequately to manage aggression, and ensuring reporting is easy to do and adequately dealt with. A majority of students who responded to the survey had experienced non-physical aggression in the past year (81%), over half had experienced physical aggression (56%) and more than one in three had experienced sexual harassment (40%).

The impact of the second victim's experience and support on the career success of psychiatric nurses: The mediating effect of psychological resilience

AIMS

We explored the mediating role of psychological resilience in the experience and support of psychiatric nurses as the second victims and their career success.

BACKGROUND

Psychiatric nurses, as the primary victims of workplace violence, experience physical and psychological distress, which leads to high resignation rate and job burnout. However, not much is known about the mediating role of psychological resilience between the second victims of workplace violence and their career success.

METHODS

A cross-sectional study was conducted among 683 psychiatric nurses. The participants were scored according to the Chinese career success scale, Chinese version of the psychological resilience scale for nurses and Chinese version of the second victim experience and support tool. The t-test and one-way analysis of variance were used to compare the factors affecting career success.

RESULTS

Career success scores differed among nurses of different ages having different employment forms, role and working years (p < .05). Mediating effect analysis revealed that psychological resilience played a full mediating role in the experience and support of second victims and their career success.

CONCLUSION

Psychological resilience-based interventions should be developed to improve the psychological adjustment ability of psychiatric nurses and to strengthen their career success.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should create more opportunities and a harmonious working environment and enhance the management system for dealing with workplace violence.

Physiological Measurements of Stress Preceding Incidents of Challenging Behavior in People With Severe to Profound Intellectual Disabilities: Longitudinal Study Protocol of Single-Case Studies

Background

Clients with severe to profound intellectual disabilities (SPID) and challenging behavior (CB) and the professional caregivers that support them are vulnerable to high stress levels, which negatively impact their well-being and the quality of care. CB is thought to result from an increase in the intensity and frequency of clients’ stress experiences. In turn, staff members experience stress in dealing with this behavior, and stressed staff members might behave in ways that increase clients’ stress levels, contributing to the origin and maintenance of CB. Research into these dyadic interactions between clients and staff is scarce for people with SPID, especially in real-life situations. The barriers of studying stress in this population include clients’ difficulties in communicating stress experiences and the lack of an objective continuous measure of stress.

Objective

This paper presents a protocol for studying patterns of physiological stress in 15 client-caregiver dyads in the 30 minutes preceding incidents of CB compared to control periods without CB and the interplay between the stress levels of clients and professional caregivers.

Methods

We will conduct 15 single-case studies to assess patterns of physiological stress in dyads of clients with SPID and professional caregivers prior to CB in several Dutch residential institutes. Client-caregiver dyads will wear the Empatica E4 wristband for 20 sessions of 3 to 8 hours without interruptions of daily routines while caregivers report clients’ CB. The physiological measures obtained will be electrodermal activity (microsiemens) and heart rate (beats per minute). A multilevel model with repeated measures at the incident level nested within the person level will be applied, employing separate models for electrodermal activity and heart rate to compare stress levels in the 30 minutes prior to incidents with control epochs. Covariates in the models include movement, temperature, and gender. In addition, cross-recurrence quantification analyses will be performed to study the synchronization between the stress levels of clients and professional caregivers.

Results

The Ethics Committee of the Radboud University (NL-number: NL71683.091.19) approved the study on February 12, 2020. In total, 15 organizations have declared their commitment to participate in the study. The first result is expected in the spring of 2022.

Conclusions

Study results will demonstrate whether changes in patterns of electrodermal activity and heart rate are apparent in the 30 minutes preceding an incident of CB compared to baseline levels when the client does not engage in CB. The synchronization between caregivers’ and clients’ physiological stress levels will be explored with cross-recurrence quantification analyses. Insights into the physiological stress levels of clients and caregivers may contribute to a reduction of CB and an improvement of both clients’ and caregivers’ safety and well-being.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24911

Burnout among nurses: a multicentric comparative study

OBJETIVO

to identify and compare burnout levels between Portuguese, Spanish and Brazilian nurses.

METHOD

quantitative, descriptive, correlational, comparative and cross-sectional study conducted using a sample of 1,052 nurses working in hospitals and primary care centers. A sociodemographic questionnaire and the Maslach Burnout Inventory were applied to nurses in Porto, Portugal (n=306), Oviedo, Spain (n=269) and S. Paulo, Brazil (n=477). Data analysis was performed using descriptive, inferential and multivariate analysis.

RESULTS

approximately 42% of the nurses showed moderate/high levels of burnout, with no differences found between countries (Portugal and Brazil 42%, Spain 43%). Only depersonalization showed differences between countries, presenting Spain the highest level and Portugal the lowest one. Comparative analysis showed higher burnout levels in young nurses and those working by shifts. Considering job schedules, burnout was associated to shift work in Portugal, while in Spain and Brazil it was associated with fixed schedules.

CONCLUSION

these results suggest that this syndrome among nurses is a global phenomenon. The daily stressors and higher demands of the nursing profession are crucial in the preparation of nurses to deal with complex situations, to avoid burnout, and to reduce the negative impact on nurses' health and on the quality of care they provide.

Usability and Acceptance of Wearable Biosensors in Forensic Psychiatry: Cross-sectional Questionnaire Study

Background

The use of wearable biosensor devices for monitoring and coaching in forensic psychiatric settings yields high expectations for improved self-regulation of emotions and behavior in clients and staff members. More so, if clients have mild intellectual disabilities (IQ 50-85), they might benefit from these biosensors as they are easy to use in everyday life, which ensures that clients can practice with the devices in multiple stress and arousal-inducing situations. However, research on (continuous) use and acceptance of biosensors in forensic psychiatry for clients with mild intellectual disabilities and their caretakers is scarce. Although wearable biosensors show promise for health care, recent research showed that the acceptance and continuous use of wearable devices in consumers is not as was anticipated, probably due to low expectations.

Objective

The main goal of this study was to investigate the associations between and determinants of the expectation of usability, the actual experienced usability, and the intention for continuous use of biosensors.

Methods

A total of 77 participants (31 forensic clients with mild intellectual disabilities and 46 forensic staff members) participated in a 1-week trial. Preceding the study, we selected 4 devices thought to benefit the participants in domains of self-regulation, physical health, or sleep. Qualitative and quantitative questionnaires were used that explored the determinants of usability, acceptance, and continuous use of biosensors. Questionnaires consisted of the System Usability Scale, the Technology Acceptance Model questionnaire, and the extended expectation confirmation model questionnaire.

Results

Only the experienced usability of the devices was associated with intended continuous use. Forensic clients scored higher on acceptance and intention for continuous use than staff members. Moderate associations were found between usability with acceptance and continuous use. Staff members showed stronger associations between usability and acceptance (r=.80, P<.001) and usability and continuous use (r=.79, P<.001) than clients, who showed more moderate correlations between usability and acceptance (r=.46, P=.01) and usability and continuous use (r=.52, P=.003). The qualitative questionnaires in general indicated that the devices were easy to use and gave clear information.

Conclusions

Contrary to expectations, it was the actual perceived usability of wearing a biosensor that was associated with continuous use and to a much lesser extent the expectancy of usability. Clients scored higher on acceptance and intention for continuous use, but associations between usability and both acceptance and continuous use were markedly stronger in staff members. This study provides clear directions on how to further investigate these associations. For example, whether this is a true effect or due to a social desirability bias in the client group must be investigated. Clients with mild intellectual disabilities might benefit from the ease of use of these devices and their continuing monitoring and coaching apps. For these clients, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use.

Doctors and Nurses: A Systematic Review of the Risk and Protective Factors in Workplace Violence and Burnout

The present study aims analyze the risk factors that lead to high levels of burnout among nurses and physicians and the protective factors that prevent them. Thus, it is also intended to explore the possible correlation between physical and verbal violence produced at work and the symptoms derived from burnout. Methods: The search was carried out on the Scopus, PubMed and Web of Science databases between 2000 and 2019 (on which date the bibliographic search ends). Descriptive studies estimating the prevalence of workplace violence and risk and protective factors and burnout were included. An adapted version of the Downs and Black quality checklist was used for article selection. 89.6 percent of the studies analysed were in the health sector. There is a significant correlation between burnout symptoms and physical violence at work. On the one hand, the risk factors that moderate this correlation were of structural/organisational type (social support, quality of the working environment, authoritarian leadership, little autonomy or long working days, etc.) and personal type (age, gender, nationality or academic degree, etc.). On the other hand, protective factors were the quality of the working environment, mutual support networks or coping strategies. The results were analysed in-depth and intervention strategies were proposed.

Exposure to challenging behaviours and burnout symptoms among care staff: the role of psychological resources

BACKGROUND

Staff supporting individuals with intellectual disabilities are at risk of burnout symptoms. Evidence suggests an association between exposure to challenging behaviours of individuals with intellectual disabilities and burnout symptoms of staff, but the protective role of staff psychological resources in this relation has been understudied.

METHOD

We investigated the association between exposure to challenging behaviours and burnout symptoms of staff and the direct and moderating effects of several psychological resources. Staff (N = 1271) completed an online survey concerning burnout symptoms (subscale Emotional Exhaustion of the Maslach Burnout Inventory), exposure to challenging behaviours and a range of potential psychological resources. We examined main and moderating effects with multilevel analyses. In order to control for the multiple comparisons, P values corrected for false discovery rate (PFDR ) were reported.

RESULTS

We found a direct relation between exposure to challenging behaviours and increased levels of burnout symptoms in staff (b = .15, t(670) = 4.466, PFDR  < .0001). Perceived supervisor social support (b = -.97, t(627) = -7.562, PFDR  < .0001), staff self-efficacy (b = -.23, t(673) = -3.583, PFDR  < .0001), resilience (b = -.19, t(668) = -2.086, PFDR  < .05) and extraversion (b = -.20, t(674) = -3.514, PFDR  < .05) were associated with reduced burnout symptoms. None of the proposed psychological resources moderated the association between exposure to challenging behaviours and burnout symptoms of staff.

CONCLUSIONS

Of the psychological resources found to be associated with reduced risk of burnout symptoms, staff self-efficacy and access of staff to supervisor social support seem to be the factors that can be influenced best. These factors thus may be of importance in reducing the risk of developing burnout symptoms and improving staff well-being, even though the current study was not designed to demonstrate causal relations between psychological resources and burnout symptoms.

Unusual suspects: Real-time physiological evaluation of stressors during laparoscopic donor nephrectomy

INTRODUCTION

The purpose of this study was to document the variability of faculty surgeon electrodermal activity (EDA) peaks during laparoscopic donor nephrectomy (LDN) to determine the effect of case difficulty and learner expertise on the stress response.

METHODS

EDA for a single faculty surgeon was captured over 15 LDN cases using an Empatica E4 wristband. During each case, one of three transplant fellows (novice, intermediate, or expert level LDN expertise) participated. Difficulty was rated preoperatively as "low/moderate/high" by the faculty. EDA peaks were collected and analyzed; the frequency and magnitude of EDA peaks, case difficulty, and fellow expertise were compared using a two-way factorial ANOVA.

RESULTS

The main effects of learner expertise (F[2, 308]=11.27, p<0.001) and difficulty rating (F[2, 414]=15.13, p<0.001) were significant. The interaction between difficulty and expertise on faculty EDA peaks was also significant (F[3, 391]=14.29, p<0.001). The novice fellow resulted in higher faculty EDA levels compared to intermediate and expert fellows on low-difficulty cases, but not moderate- or high-difficulty cases.

CONCLUSIONS

This is the first report examining faculty surgeon EDA across cases of varying difficulty and varying learner expertise during a high-stakes operation. EDA levels were inversely proportional to the expertise of the learner and case difficulty, suggestive of a significant impact of learner autonomy on faculty stress response.

An integrative review of nursing staff experiences in high secure forensic mental health settings: Implications for recruitment and retention strategies

AIMS

To identify the experiences of nursing in high secure forensic mental health settings that may affect staff recruitment and retention.

BACKGROUND

Recruitment and retention of Registered Nurses is a vital international concern in the field of mental health. The high secure forensic setting presents unique challenges for the nurse. Studies of nurse's experiences in this setting have not previously been reviewed in the context of workforce sustainability pressures.

DESIGN

An integrative review (Whittemore and Knapfl, 2005).

DATA SOURCES

A systematic search of data sources: MEDLINE (PubMed), PsycINFO, EMBASE, CINAHL, International Bibliography of the Social Sciences, Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, ProQuest Social Sciences Premium collection (IBSS, PAIS, and Sociological Abstracts), and Web of Science from inception to December 2019.

REVIEW METHODS

Data extraction, quality appraisal, and convergent qualitative synthesis.

RESULTS

Fifteen papers were selected for inclusion in the review, describing 13 studies. Six studies were quantitative, all cross-sectional surveys. There were seven qualitative studies, using a variety of methodologies. Four themes were identified: engagement with the patient group, the ward social environment, impact on the nurse, and implications for practice.

CONCLUSION

When policymakers address workforce shortages in high secure forensic nursing they must take account of the unique features of the setting and patient group. Nurses must be adequately prepared and supported to function in an ethically and emotionally challenging environment.

IMPACT

This study identified factors affecting workforce pressures in the speciality of forensic mental health nursing. Findings are of interest to national nursing policymakers and workforce leads in mental health service provider organizations, seeking to promote forensic nursing as a career option and retain nursing staff.

Correlates of mental health in occupations at risk for traumatization: a cross-sectional study

BACKGROUND

Hospitals, police stations, and fire departments are highly demanding workplaces. Staff members are regularly exposed to various stressors including traumatic events. Correspondingly, several studies report high rates of mental health issues among these occupations. Nevertheless, despite these challenging circumstances, some staff members manage to sustain their mental health. The current study is the first to investigate three health-promoting factors simultaneously among three different, highly demanding occupations.

METHODS

The present cross-sectional survey investigated health-promoting factors (sense of coherence - SOC, trait-resilience, locus of control - LOC) and mental health outcomes (general psychopathological symptom burden, posttraumatic stress, burnout) in medical staff (n = 223), police officers (n = 257), and firefighters (n = 100).

RESULTS

Among all occupations, SOC, trait-resilience, and an internal LOC were negatively associated with general psychopathological symptoms, posttraumatic stress, and burnout symptoms. By contrast, all these outcome measures were positively correlated with an external LOC. Multiple regression models including all health-promoting factors explained 56% of the variance in general psychopathological symptoms and 27% in posttraumatic stress symptoms. Among all occupations, SOC was the strongest predictor of both general psychopathological symptom burden and posttraumatic stress symptoms. Multigroup path analyses revealed minor differences across occupations, mainly driven by a stronger influence of LOC in police officers.

CONCLUSION

Across all occupations, SOC was identified as the most important health-promoting factor. Future longitudinal studies should further examine the causal link between health-promoting factors and mental distress in different workplaces. Such studies will also allow for further development and evaluation of resilience promoting programs.

Workplace violence and health in human service industries: a systematic review of prospective and longitudinal studies

OBJECTIVES

To provide systematically evaluated evidence of prospective associations between exposure to physical, psychological and gender-based violence and health among healthcare, social care and education workers.

METHODS

The guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Medline, Cinahl, Web of Science and PsycInfo were searched for population: human service workers; exposure: workplace violence; and study type: prospective or longitudinal in articles published 1990-August 2019. Quality assessment was performed based on a modified version of the Cochrane's 'Tool to Assess Risk of Bias in Cohort Studies'.

RESULTS

After deduplication, 3566 studies remained, of which 132 articles were selected for full-text screening and 28 were included in the systematic review. A majority of the studies focused on healthcare personnel, were from the Nordic countries and were assessed to have medium quality. Nine of 11 associations between physical violence and poor mental health were statistically significant, and 3 of 4 associations between physical violence and sickness absence. Ten of 13 associations between psychological violence and poor mental health were statistically significant and 6 of 6 associations between psychological violence and sickness absence. The only study on gender-based violence and health reported a statistically non-significant association.

CONCLUSION

There is consistent evidence mainly in medium quality studies of prospective associations between psychological violence and poor mental health and sickness absence, and between physical violence and poor mental health in human service workers. More research using objective outcomes, improved exposure assessment and that focus on gender-based violence is needed.

Workplace Violence and Its Effects on Burnout and Secondary Traumatic Stress among Mental Healthcare Nurses in Japan

Workplace violence (WPV) in healthcare settings has drawn attention for over 20 years, yet few studies have investigated the association between WPV and psychological consequences. Here, we used a cross-sectional design to investigate (1) the 12-month prevalence of workplace violence (WPV), (2) the characteristics of WPV, and (3) the relationship between WPV and burnout/secondary traumatic stress among 599 mental healthcare nurses (including assistant nurses) from eight hospitals. Over 40% of the respondents had experienced WPV within the past 12 months. A multivariate logistic regression analysis indicated that occupation and burnout were each significantly related to WPV. Secondary traumatic stress was not related to WPV. Our results suggest that WPV may be a long-lasting and/or cumulative stressor rather than a brief, extreme horror experience and may reflect specific characteristics of psychological effects in psychiatric wards. A longitudinal study measuring the severity and frequency of WPV, work- and non-work-related stressors, risk factors, and protective factors is needed, as is the development of a program that helps reduce the psychological burden of mental healthcare nurses due to WPV.

Emotional intelligence as a mechanism to build resilience and non-technical skills in undergraduate nurses undertaking clinical placement

The environments in which nursing work is undertaken can be highly stressful and complex with resultant harmful outcomes for the health of both nurses and patients reported. Undergraduate nursing students are particularly challenged when on clinical placement through having only partially developed work capabilities, with wide claims that these nurses remain underprepared for work even upon graduation. Over time undergraduate nursing education has arguably not prioritized developing resilience and other non-technical skills required to respond effectively to these challenges. This paper reports findings from a qualitative study of student nurses who received training and coaching in emotional intelligence, a well-established correlate of resilience, just prior to undertaking a mental health or medical/surgical clinical placement. Of that cohort, 12 agreed to qualitative semi-structured interviews that sought to better understand how these students used the knowledge and capabilities from the training within clinical placement contexts. Four themes emerged from the thematic analysis of the interviews: (1) greater experiences of resilience; (2) responding positively to mental health consumers; (3) experiences of greater empathy and compassion; and (4) experiences of improved non-technical work skills. Implications from these findings suggest that student and patient experiences of nursing placement, and mental health nursing placements in particular, would be enhanced by pre-placement emotional intelligence training and coaching. Such training will support nursing graduates to be work-ready upon entering the workforce.

A Survey of Stress and Burnout in Forensic Mental Health Nursing

BACKGROUND

Although it is known that forensic mental health nurses (FMHNs) work in a stressful environment, their experience of stress and burnout remains largely unexplored.

AIM

The study aimed to measure levels of burnout and workplace stressors experienced by FMHNs.

METHODS

A survey of 205 FMHNs was undertaken. Respondents completed the Maslach Burnout Inventory and the Nursing Stress Scale.

FINDINGS

Fifty-seven FMHNs completed the survey, representing a response rate of 27.8%. Only five respondents (8.8%) experienced high levels of burnout across all three Maslach Burnout Inventory subscales. The most reported workplace stressors were related to "workload," "conflict with other nurses," and "conflict with physicians." A correlation between total Nursing Stress Scale score and both "emotional exhaustion" and "cynicism" were found (r = 0.45, p < 0.001, and r = 0.34, p < 0.011, respectively), indicating that FMHNs who reported higher workplace stress are at an increased risk of burnout.

CONCLUSION

Most FMHNs in the current study experienced moderate levels of burnout, although they continued to feel self-assured in their practice and found their work rewarding. Consistent with other nursing populations, the FMHNs in this study reported feeling stressed by their workload and as the result of conflict with other nurses and physicians.

IMPLICATIONS FOR CLINICAL FORENSIC NURSING PRACTICE

Reduced well-being, associated with stress and burnout, may lead to increased absences from work and the delivery of poor-quality forensic mental health consumer care. The implementation of staff well-being strategies is recommended to address stress and burnout in FMHNs.

Changes in heart rate and skin conductance in the 30 min preceding aggressive behavior

Aggressive behavior of inpatients threatens the safety and well-being of both mental health staff members and fellow patients. It was investigated whether heart rate and electrodermal activity can be used to signal imminent aggression. A naturalistic study was conducted in which 100 inpatients wore sensor wristbands during 5 days to monitor their heart rate and electrodermal activity while staff members recorded patients' aggressive incidents on the ward. Of the 100 patients, 36 displayed at least one aggressive incident. Longitudinal multilevel models indicated that heart rate, skin conductance level, and the number of nonspecific skin conductance responses per minute rose significantly in the 20 min preceding aggressive incidents. Although psychopathy was modestly correlated with displaying aggression, it was not a significant predictor of heart rate and skin conductance preceding aggression. The current findings may provide opportunities for the development of individual prediction models to aid acute risk assessment and to predict aggressive incidents in an earlier stage. The current results on the physiological indicators of aggression are promising for reducing aggression and improving both staff as well as patient safety in psychiatric mental health institutions.