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Research

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Experience of stress in acute mental health nurses

Author Thomas Currid, PGCE, MA, BSc, RMN, is senior lecturer in mental health and learning disabilities, London South Bank University.
Abstract Currid, T. (2008) Experience of stress in acute mental health nurses. Nursing Times; 104: 2, 39–40.
A recent NT survey found that 70% of nurses said they suffered from physical or mental health problems associated with work-related stress (Vere-Jones, 2007). This study aimed to capture the experience and meaning of stress for nurses working in acute mental health wards. The findings reveal that participants experience a lack of resources, a poor home/work balance and difficulties in professional recognition. Stress in acute mental health nursing is an area that requires immediate attention.

Introduction
Over the past two decades, considerable evidence has emerged signifying that all health professionals experience stress (Jenkins and Elliott, 2004). Evidence from the Healthcare Commission’s NHS staff survey (2004) showed that 36% of staff suffered from work-related stress. More recently, evidence from the RCN (2006) workplace survey revealed that nurses reported their jobs as ‘very stressful’, and are exposed to higher-than-average levels of stress.
A literature review was carried out for this study – for details see nursingtimes.net.

Aim and method
The aim was to explore the lived experiences of individual mental health nurses in acute mental health wards to ascertain the main stressors and to gain an insight into the meaning that these experiences hold for them.
A qualitative approach, underpinned by a phenomenological paradigm based on hermeneutic phenomenology, was used. Phenomenology is, essentially, the study of lived experience with an emphasis on the life and understanding of the person as a unique individual, rather than an objective scientific reality.
Eight individuals on different grading levels at acute mental health units in a London mental health trust took part. Five male and three female nurses were interviewed. Two were junior staff nurses, four were senior staff nurses, one was a charge nurse and the other was a ward manager.
Ethical approval for this study was granted by the local ethics committee and the trust’s research and development department. Participants were assured of confidentiality.
Semi-structured interviews were undertaken with the participants. These were then transcribed verbatim.
Interpretative phenomenological analysis (IPA) was used in the data analysis. As a means of validating my interpretation of the interviews, respondents were consulted several times to check that interpretations were accurate.

Results
Experience of stress
The nature of stress was captured by asking questions about participants’ understanding and definition of stress, and the feelings they experienced as a result of stress in the workplace. While the definitions varied, common themes did emerge, namely:

  • Home/work balance;

  • Professional recognition and value;

  • Lack of resources.

Home/work balance All but one participant talked about being unable to stop thinking about work after finishing their shift. They reported finding it difficult to ‘switch off’ from the pressure of work when at home or outside work.
Professional recognition and value Participants reported they felt management and others in the multidisciplinary team did not listen to them and that their professional opinions were not taken into account. They also reported being unable to use their professional skills and do the job they had been trained to do, with more emphasis being put on paperwork and administrative duties than on interaction with patients.
Lack of resources All respondents talked about scarce resources, particularly in relation to staffing levels. They gave accounts of feeling they could not perform their duties to meet clients’ needs, and described situations where finances seemed to take precedence over patient care.

Stressors
The stressors identified were:

  • Workload/lack of staff;

  • Violence and aggression;

  • Poor teamworking practices.

All participants reported on all of these main themes. Most gave direct examples of when the stressors were present and why they were identified as stressors.


Workload/lack of staff Workload levels were very closely aligned with a lack of resources. Participants felt that, because staff levels in their units were inadequate, workloads were overwhelming and constant.
Violence and aggression Violent and aggressive behaviours by patients were seen as major stressors. These were against both patients and staff. Some reported that, along with the physical act of aggression, they found some patients quite intimidating. Acts of aggression included verbal threats, physical assault and racist comments.
Poor teamworking practices Poor teamworking among staff contributed to stress. Considering the environment and the many demands within it, staff felt that other workers were not always helpful. Situations included feeling left alone to carry out work, unhelpful comments being made by colleagues and staff ideas being opposed.

Meaning of the experience
Meanings are set in context of the whole of the interviews. Some are captured within sections of dialogue from the interview.
The main meaning that emerged is that, as nurses, participants are undervalued in terms of their professional abilities and what they can offer to patient care. This is mainly brought about by what they perceive as other organisational aspects being given priority over patient care.
Other meanings were that participants were being professionally compromised in terms of the standard to which they had been trained. Being asked or having pressure placed on them to discharge patients before they were ready meant they felt they were not doing their job properly or were offering a service that conflicted with their belief that patients come first.
For some participants, a lack of resources meant they were working in a dangerous environment, where they may have been putting other staff or patients at risk. Some anticipated that adverse events might result from this lack of resources.

Discussion
This study set out to ascertain the lived experience of stress and stressors in acute mental health wards or units. While studies on stress in mental health nurses have been carried out previously (Kilfedder et al, 2001), this study is among the few that are specific to acute mental health nurses (Jenkins and Elliott, 2004).
Findings from this study reflect and accord with previous studies. Difficulties with home/work balance have been found elsewhere.
In addition, some research has found that home/work conflict is associated with anxiety and insomnia as well as being related to poor social support. The inability of staff to ‘switch off’ from work may be
a result of the high number of serious incidents concerning service users that have occurred nationally and the reported feelings of being blamed or criticised for not doing their job properly.
Themes of professional recognition and lack of consultation emerged in this study. In times of change and restructuring, staff consultation is important to facilitate transition and reduce anxieties – if this is not done, change may give rise to adverse psychological effects in terms of control and job satisfaction (Gelsema et al, 2006). While this may partially apply to the results of this study, lack of consultation was related more to professional recognition and value, particularly in relation to clinical decisions. It would seem that participants do not feel their professional judgement is valued or their professional role recognised.
The stressors identified were workload, violence and aggression and poor teamworking practices. These findings are supported by many other studies (for example, Jenkins and Elliott, 2004). While these stressors are closely related to experience, there are relationships between them, with one seen to compound another.
The meaning of participants’ experiences may initially be construed as being negative. However, meanings attached to the experience and situations may reflect participants’ desires to deliver ideal care, set against constraints. In turn, this may create feelings of ambivalence.
Experience of stress and stressors compound each other and give rise to meanings in the context of situations faced by participants every day. The meanings that participants attach to experiences
may reflect their ideal view of their role, commitment to patients or passion for caring. It could be these very meanings that give staff the impetus to recognise that changes are needed and give rise to critical reflection.

Limitations of the study
The number participating in the study was small. The possibility that participants answered questions in a manner they felt might have been appeasing cannot be ruled out. In addition, given the financial climate in the NHS, where staff may face redundancy, it may not have been the most appropriate time for this study to have taken place.

Conclusion
Despite the limitations, based on the findings of this and previous research, stress in acute mental health nursing needs immediate attention. Future qualitative studies may yield vital information in directing strategies to deal with this issue.

references
Gelsema, T. et al (2006) A longitudinal study of job stress in the nursing profession: causes and consequences. Journal of Nursing Management;
14: 289–299.
Healthcare Commission (2004) NHS National Staff Survey 2004: Summary
of Key Findings. London:
Healthcare Commission.
www.healthcarecommission.org.uk
Jenkins, R., Elliott, P. (2004) Stressors, burnout and social support: nurses in acute mental health settings. Journal of Advanced Nursing; 48: 6, 622–631.
Kilfedder, C. et al (2001) Burnout in psychiatric nursing. Journal of Advanced Nursing; 34: 3, 383–396.
RCN (2006) At Breaking Point? A Survey of the Wellbeing and Working Lives
of Nurses in 2005. London: RCN.
www.rcn.org.uk
Vere-Jones, E. (2007) Harming the healers. Nursing Times; 103: 27, 16–17.

Implications for practice

  • Staff need to be aware of their well-being and how it may affect quality of care. They may need to raise and discuss these issues at trust board level and take a proactive and collaborative approach to tackling stress.

  • Tackling stress needs to be seen as everyone’s responsibility, not just
    that of the employer. As such, it needs to be embedded within health and safety policies.

  • Risk assessments may be necessary to determine the severity of a threat or hazard – not just as a yardstick but also to determine the best approach in dealing
    with stressors.

Staff may wish to use the advice of the Health and Safety Executive (www.hse.gov.uk/stress) to reduce and deal with stress in the workplace.

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