Occupational stress and community mental health nursing: what CPNs really said

Challenges for nurses who work in community mental health centres in the West Bank, Palestine

Background

Nurses in Palestine (occupied Palestinian territory) work in a significantly challenging environment. The mental health care system is underdeveloped and under-resourced. For example, the total number of nurses who work in community mental health centres in the West Bank is seventeen, clearly insufficient in a total population of approximately three million. This research explored daily challenges that Palestinian community mental health nurses (CMHNs) face within and outside their demanding workplaces.

Methods

An interpretive qualitative design was chosen. Face-to-face interviews were completed with fifteen participants. Thirty-two hours of observations of the day-to-day working environment and workplace routines were conducted in two communities’ mental health centres. Written documents relating to practical job-related policies were also collected from various workplaces. Thematic analysis was used across all data sources resulting in four main themes, which describe the challenges faced by CMHNs.

Results and conclusion

These themes consist of the context of unrest, stigma, lack of resources, and organisational or mental health system challenges. The study concludes with a better understanding of challenges in nursing which draws on wider cultural contexts and resilience. The outcomes from this study can be used to decrease the challenges for health professionals and enhance the mental health care system in Palestine.

Development and Initial Validation of the Stress of Conscience Questionnaire

Stress in health care is affected by moral factors. When people are prevented from doing ‘good’ they may feel that they have not done what they ought to or that they have erred, thus giving rise to a troubled conscience. Empirical studies show that health care personnel sometimes refer to conscience when talking about being in ethically difficult everyday care situations. This study aimed to construct and validate the Stress of Conscience Questionnaire (SCQ), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. The items were based on situations previously documented as causing negative stress for health care workers. Content and face validity were established by expert panels and pilot studies that selected relevant items and modified or excluded ambiguous ones. A convenience sample of 444 health care personnel indicated that the SCQ had acceptable validity and internal consistency (Cronbach’s alpha exceeded 0.83 for the overall scale). Explorative factor analysis identified and labelled two factors: ‘internal demands’ and ‘external demands and restrictions’. The findings suggest that the SCQ is a concise and practical instrument for use in various health care contexts.

Revalidation of the Perceptions of Conscience Questionnaire (PCQ) and the Stress of Conscience Questionnaire (SCQ)

The Perceptions of Conscience Questionnaire (PCQ) and the Stress of Conscience Questionnaire (SCQ) have previously been developed and validated within the ‘Stress of Conscience Study’. The aim was to revalidate these two questionnaires, including two additional, theoretically and empirically significant items, on a sample of healthcare personnel working in direct contact with patients. The sample consisted of 503 healthcare personnel. To test variation and distribution among the answers, descriptive statistics, item analysis and principal component analysis (PCA) were used to examine the underlying factor structure of the questionnaires. Support for adding the new item to the PCQ was found. No support was found for adding the new item to the SCQ. Both questionnaires can be regarded as valid for Swedish settings but can be improved by rephrasing some of the PCQ items and by adding items about private life to the SCQ.

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).

Mental health nursing students differ from other nursing students: Some observations from a study on stress and coping

The study reported here is taken from a wider investigation into stress among preregistration nursing students, undertaken in the nursing department of a large university in northern England. British nursing is divided into four specialties or 'branches': adult, mental health, children's, and learning disability nursing, and the aim of the study was to explore interbranch differences among the students in terms of the sources of stress they identify, the levels of stress they experience, and the ways in which they cope. A cross-sectional survey of all nursing students on the department's roll (n = 1362), using a range of self-report measures bound together in a 'questionnaire pack', was undertaken. The questionnaire pack contained formal measures of sources of stress (Student Nurse Stress Index), stress (specifically, psychological distress) (General Health Questionnaire) and coping (Coping Inventory for Stressful Situations), as well as a set of questions that enabled data on a range of pertinent variables, including the nursing branch being pursued, to be collected. The findings revealed that mental health nurses were notably different from the other three branches in terms of the quantity and characteristics of the sources of stress they faced, the levels of stress they experienced, and the ways in which they coped. These differences were largely advantageous to the students' well-being and speculations are made as to whether the concept of 'hardiness'- especially its focus on a sense of being in control - plays a role in explaining the findings.

Sources of stress and burnout in acute psychiatric care: inpatient vs. community staff

BACKGROUND

Professionals who work alone or in small teams often provide services for people with serious mental health problems in community settings. Stress is common in community teams and this may cause burnout and threaten the quality and stability of the services. This study compares levels of burnout and sources of stress among community and acute ward staff in six European centres.

METHODS

A total of 6 acute ward (N = 204) and community staff (N = 209) in 5 different European countries filled out the Maslach Burnout Inventory (MBI), the Mental Health Professional Scale (MHPSS) the Agervold Questionnaire for psychosocial work environment (QPWES) in addition to a comprehensive demographic questionnaire.

RESULTS

In the univariate analyses, except for Emotional Exhaustion (MBI), there were no differences in burnout between the two groups of staff. Community teams reported more organisational problems, higher work demands, less contact with colleagues, but also better social relations and more control over their work. The ward staff was more satisfied with the organisational structure and access to colleagues, but complained about lack of control over operating conditions at work. The multivariate analyses identified four groups of staff: (1) a Control-dissatisfied and Contact satisfied group (N = 184) with 2/3 coming from the wards. (2) A Contact-satisfied and Work-demand dissatisfied group (N = 147) with (3/4) from the community staff. (3) A Control- and Contact dissatisfied group (N = 47) with a majority from community teams, and (4) a Contact- and Work demand satisfied group (N = 37) with a majority from the wards.

CONCLUSION

Burnout as measured was not a serious problem among community and ward staff members, and did not differentiate between the two groups. Acute ward working implied lack of control but much contact with colleagues, whereas community work entailed more control but demanding work in terms of difficult task and hard-to-find-solutions.

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

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

Specialist drug misuse nurse's motivation, clinical decision-making and professional communication: an exploratory study

UK guidelines advocate a multidisciplinary shared care approach to manage drug-related problems. While general practitioners (GPs), consultants and pharmacists have been researched, there has been little research into the role of nurses in this field. This study examined nurses specialized in the field of substance misuse. It specifically explored their motivation for entering this area, interaction with other health professionals and their role in clinical decision-making. Seventeen face-to-face interviews were undertaken with nurses from the study population of the 21 nursing staff currently employed in one service. Responses were tape-recorded, transcribed and analysed using qualitative methods. The majority of nurses entered this field because of a specific interest in its patients and their problems. Various professionals interacted with nurses: specialist medical staff, who served as an expert resource and pharmacists through the dispensing of substitute drugs. GP participation in services was inconsistent forcing some nurses to take undue responsibility for clinical decision-making. It is essential that nurses entering this field have an interest in this field and positive attitudes towards drug users, and greater emphasis should be placed on this attribute when selecting new employees. If a shared care model is to be successful, it is important that all GPs accept their responsibilities and relieve pressure currently placed on specialist services. Alternatively, it may be necessary to adopt a new model of care.

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.

Downsizing and reorganization: demands, challenges and ambiguity for registered nurses

BACKGROUND

The 1990s were characterized by substantial financial cuts, and related staff redundancies and reorganizations in the Swedish health care sector. A large hospital in Sweden was selected for the study, in which downsizing had occurred between 1995 and 1997. The number of staff in the hospital was reduced by an average of 20%, and 10% were relocated to other departments.

OBJECTIVE

The aims of this study were to explore registered nurses' experiences of psychosocial 'stressors' and 'motivators', and how they handled their work situations, following a period of personnel reductions and ongoing reorganization.

METHOD

Interviews were undertaken with 14 nurses working in one Swedish hospital. Nurses were interviewed in 1997 about the recent and last round of redundancies, and were followed up 1 year later in 1998 and again in 2001. Interviews were audiotaped, transcribed and analysed for thematic content.

RESULTS

Five themes emerged in relation to nurses' perceived stressors, motivators, and coping options: 'distrust towards the employer', 'concurrent demands and challenges', 'professional ambiguity, 'a wish for collaboration', and 'efforts to gain control'. A common feature was duality and ambiguity in nurses' descriptions of the phenomena studied, meaning that identified themes had underlying sub-themes with both negative and positive dimensions.

CONCLUSIONS

The concurrence of 'ever-growing job demands' and 'work going unrewarded' contributed to a feeling of being taken advantage of by the employer. The 'waste of human resources' and 'competence drain' that followed redundancies provoked anger. Unfulfilled collaboration with doctors was a major stress producer, which related to both the downsized work organization, and the complex 'deference-dominance' doctor-nurse relationship. The well-being of nurses depends on being an equal/parallel health professional in a comprehensive team that shares knowledge and improves collaborative care of patients. A consciously formulated nursing philosophy emerged as a health-promoting resource. This study demonstrates the importance of analysing feelings relating to professional ambiguity and gaining influence in a gender-related, hierarchical environment, and the need to support professional assertiveness in relation to superiors and doctors. It is also important to stress considerations that relate to differences in the age, care philosophy, and psychosocial health conditions of nurses.

Sacrificing the personal to the professional: community mental health nurses

BACKGROUND

The study of stress in mental health nurses has almost always focused on factors intrinsic to their job roles and has neglected the interaction between work and home roles, which may also be a source of stress. Moreover, role theory has not provided an adequate account of either personal or occupational change, especially when this results from the experience of stress.

METHODS

Twenty community mental health nurses agreed to participate in semi-structured interviews about the stresses they experienced at work and at home. A grounded theory analysis disclosed the centrality of conflicts between work and home roles in participants' accounts and this provided the focus for subsequent detailed readings of the interview transcripts.

FINDINGS

Participants described how difficult and often demanding family situations were integrated with professional careers in a climate of rapid organizational change in the health service. As well as being an ongoing source of strain, these competing role demands were often described as leading to sudden changes for individual workers, such as periods of illness or re-evaluation of their work role. To assist in making sense of this process, the term 'punctuated equilibria' was adopted to illuminate the build-up of tension between work and domestic lives, which was described by some workers as leading to a sudden reformulation of their relationship to their work roles and employing organizations.

CONCLUSIONS AND LIMITATIONS

The study was small-scale and relied on retrospective self-reports. Nevertheless, it emphasized the importance of considering all the roles that individuals play and highlights the possibility that, even when staff are apparently coping with their roles at work and home, difficulties may be building up which could lead to a sudden period of absenteeism or disillusionment.

Reluctant empiricists: community mental health nurses and the art of evidence-based praxis

The National Service Framework for Mental Health (1999) emphasizes the need for a culture of evidence-based practice (EBP) in mental health care. However, there is relatively little research addressing EBP from the perspective of community mental health nurses and we are still unsure of why the uptake of this style of working has been slow. This paper suggests that rather than thinking in terms of 'barriers' to the uptake of EBP, the issue may best be conceptualized as a form of praxis on the part of nurses, as they seek to manage the diversity of ideologies and practices in their working lives. From an interview and focus group study, we identify how practitioners' narrow definition of EBP itself, their formulation of how EBP was at odds with the nurse's professional activity and the organizational constraints within which they work were perceived to inhibit access to information and offer little time and managerial support for information seeking. Those who attempt to further the involvement of community mental health staff in EBP will have to reconceptualize the reasons why staff have yet to incorporate it fully, and acknowledge that this does not occur because staff are simply 'ignorant Luddites', but that this resistance enables them to retain a sense of control over their working lives and retain a focus on work with clients. Future EBP initiatives will have to address these ideological and organizational factors in order for uptake to be accelerated. This may involve changing organizational cultures and work roles and even encouraging activism on the part of the practitioners so as to enable them to learn from each other and educate and change their work environments.

Literature review of role stress/strain on nurses: an international perspective

The presence of role stress/strain among nurses has been of concern throughout the world. However, to date, no one has conducted, from an international perspective, a literature review of research on the topic. This article assesses research from 17 countries, identifies the major areas of focus in the studies, compares and contrasts the findings, summarizes the state of the science on role stress/strain on nurses and makes recommendations for future research.

An exploration of community psychiatric nursing: a Northern Ireland perspective

The Audit Commission's (1994) report Finding a Place states that mental health problems are a major cause of disruption and difficulty in people's lives and that in any one year more than a quarter of all people suffer to some degree. The report asserts that the majority visit their general practitioner (GP) and less than half of the people concerned are recognized as having a mental health problem. Many recover over a period of weeks or months and are best served by community services. Only those with the most serious conditions need specialized care or admission to hospital. On a local level in Northern Ireland, the policy of reducing the number of long-stay patients began in the 1960s with a call for people with mental illness to be integrated into the community. This has had major implications for community mental health services and for community psychiatric nursing. The aim of this study into one community psychiatric nursing service (CPNS) in Northern Ireland is to inform managers and professionals about the nature and shape of this service and to facilitate wider discussion on how to plan and deliver it in the future.

Individual and organizational well-being in psychiatric nursing: a cross-cultural study

Although health care systems around the world are undergoing rapid changes, there is an absence of comparative studies of how these changes affect nurses' well-being and work life. The purpose of this study was (i) to identify and describe possible differences between the psycho-social work environments of English and Swedish mental health nurses, and (ii) to attempt to explain these differences. 1016 psychiatric nurses from Stockholm (Sweden) and Birmingham (England) responded to a postal questionnaire on their psycho-social work environment and feelings of professional fulfillment, mental energy and work-related exhaustion. The study was given ethical clearance in Stockholm and Birmingham. Results indicated that while the English nurses rated their organizational well-being more favourably, Swedish psychiatric nurses reported greater individual well-being than their counterparts. Multiple regression analyses indicated that self-esteem was important for explaining mental energy and work-related exhaustion, but less so for explaining professional fulfillment, which was predicted primarily by organizational factors. When controlling for self-esteem, which was higher amongst the Swedish nurses, the differences in professional fulfillment and mental health were no longer significant. Reasons for the differences in self-esteem and experiences of the workplace are discussed. Low response rate may have contributed to a selection bias.