The experience and meaning of stress in nurses working in acute mental health wards.
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Thomas Currid, PGCE, MA, BSc, RMN, is senior lecturer in mental health and learning disabilities, London South Bank University.
Currid, T. (2008) Experience of stress in acute mental health nurses. This is an extended version of the article published in Nursing Times; 104: 2, 39-40.
A recent survey by Nursing Times found that 70% of nurses said they suffered from physical or mental health problems associated with work-related stress (Vere-Jones, 2007).
To capture the lived experience and meaning of stress in nurses working in acute mental health wards.
The study used a hermeneutical phenomenological methodology.
The findings reveal that participants experience a lack of resources, poor home/work balance and difficulties in professional recognition.
The meanings attached to this were that they were unable to deliver the standards of care they wanted thus prompting attributions of being undervalued.
Stress in acute mental health nursing is an area that requires immediate attention for the benefit of many.
Over the last two decades considerable evidence has emerged that all health professionals experience stress (Jenkins and Elliott, 2004; McVicar, 2003). This scenario is evident worldwide, resulting in increased interest in the well-being of healthcare staff.
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 report from NHS Employers (2006) estimated that up to 30% of staff absence is due to workplace stress, costing the NHS £400 million a year.
The aim of this study 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.
Rationale for the study
In recent years a number of publications (Bowers et al, 2005; Sainsbury Centre for Mental Health, 2004; Department of Health, 2001) have raised concerns about standards of care and environments in acute mental health settings. While these publications document unacceptable levels of care and culture on acute wards, they also report on unacceptable levels of stress in nurses.
Acute mental health nursing poses many challenges against a backdrop of poorly resourced and structured environments. Studies (Richards et al, 2006; Bowers et al, 2005; Jenkins and Elliott, 2004; SCMH, 2004; DH, 2001) have shown that such challenges include:
- Inadequate staffing;
- Patients who are acutely disturbed posing risks of violence and self-harm;
- Bed shortages/occupancy rates;
While challenges may have some positive effects – such as bringing stimulation, excitement and enthusiasm to the workforce – the challenges described may become counterproductive, especially if they are seen as beyond nurses’ control or threatening their well-being. In turn, they can become stressors and lead to stress.
Feelings of stress may predispose staff to other illnesses and have an adverse effect on people’s lives (Richards et al, 2006; Norton, 2004; Caan et al, 2001). Recognising the impact that stress can have on individual staff members, their families, patients and the NHS, the DH (2000) advocated stress-reduction programmes and other work/life balance improvement strategies in the workplace.
One mechanism to tackle staff stress in acute mental health nurses may be to address the paucity of research in this area. While Edwards and Burnard (2003) detailed the variables and sources of stress, the real paucity lies in the meaning and the experience that it holds for individual nurses (Lambert and Lambert, 2001). This study used a qualitative paradigm to capture the experience and meaning that stress has for acute mental health nurses.
Occupational stress in nursing has been the focus of much research over the last 20 years. However, studies on stress in mental health nursing have been slower to emerge. Of the studies to date (for example, Jenkins and Elliott, 2004; Kilfedder et al, 2001), many have been quantitative in nature and sought to ascertain the levels of stress or the variables that accounted most for stress. Findings indicate that lack of adequate staffing levels (Jenkins and Elliott, 2004); levels of support at work and from family and friends; and emotional exhaustion, depersonalisation and lack of personal accomplishment (Kilfedder et al, 2001) are frequently cited as either stressors or indicators of stress in mental health settings.
Although many pressures faced by nurses in different specialties may be similar, generalising findings to a whole profession may be difficult due to different variables such as specialty and emotional demands of the job. Supporting this, McVicar (2003) stated that: ‘Commonality of sources of distress…cannot be assumed, even for nurses within the same practice area.’ Therefore it may be argued that studies specific to each specialty are needed to ascertain a more detailed and representative view of stress and stressors in the workplace.
In a recent systematic review on the prevalence of nurses’ stress on adult acute psychiatric inpatient wards, Richards et al (2006) identified 13 studies directly relating to acute mental health inpatient areas. Although only 13 studies were identified, the review included 21 other studies specific to other non-specified ward-based samples.
Of the 13 identified, six included occupational stress as a primary outcome. Of these six, four drew their sample from acute wards, while the other two compared forensic and acute staff, and general nurses and acute mental health nurses. The seven other studies sought to investigate burnout, job satisfaction, staff attitudes, sickness and turnover. Based on the small number of studies and methodological weaknesses, Richards et al (2006) asserted that this area is poorly researched and it is difficult to draw conclusions.
Sullivan (1993) sought to describe various stressors in psychiatric nurses’ work in the acute admission wards of two district health authorities. Findings from his sample of 78 participants (of all grades) cited violent incidents, observations practice and potential suicide as the most frequent stressors to patient care. Other factors of significance were manpower resources and lack of support and understanding from organisational management. Despite this study being carried out over 14 years ago, these issues still prevail in recent publications (Jenkins and Elliott, 2004; DH, 2002) and are supported elsewhere.
Service delivery, organisational transition, national and local policy, finances and changes in the client profile have all had an impact on mental health nurses’ role. These factors, while adding further to the burden of care, pose challenges to staff and may result in their feeling overwhelmed by the structural changes and job demand (Gelsema et al, 2006). Compounding these feelings is the loss of control they experience in their work environments. This loss is determined by issues such as lack of resources, workload, difficulties with management and lack of staff support.
Thomsen et al (1999), in comparing Swedish and English mental health nurses, found that English nurses rated their work environment higher but experienced lower individual well-being than their Swedish counterparts. Regression analyses revealed that English nurses reported a much higher workload and rated their self-esteem much lower than the Swedish nurses. Thomsen et al (1999) suggested that the lower perceived status of mental health nurses in England results in higher amounts of work being allocated. To further explain this they drew a comparison between both cohorts in terms of hierarchical professional structure. They argued that Swedish nurses hold a more central and higher status in the mental health workforce than that of their English colleagues. It appears Swedish nurses are better represented as a profession, have higher self-esteem and a lower workload, leading to a more positive view. These findings may suggest that the high workload of mental health nurses in England is not just related to their environments, but is influenced by hierarchical status.
As may be seen from this, there is sound evidence that mental health nurses experience stress in their work influenced by several variables. From the perspective of nurses working in acute mental health, the evidence is less well documented. The real dearth of evidence in this area is the absence of literature that uses qualitative methodologies to capture the meaning and lived experience of stress from acute mental health nurses’ perspectives.
A qualitative approach, underpinned by a phenomenological paradigm based on hermeneutic phenomenology, was used in this study. 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 (Laverty, 2003).
Hermeneutic phenomenology is concerned with investigating, interpreting and giving voice and meaning to human experience as it is, rather than drawing inference or making law-like statements. In hermeneutic phenomenology, the ontological (nature of being) premise is that understanding is brought about by a number of experiences and influences. These include one’s culture, traditions, race, ethnicity, language and presence (Laverty, 2003).
Eight participants from acute mental health units in a London mental health trust working at different grades took part. The participants’ demographics showed that they had between six months and 10 years’ experience working in acute metal health settings. Five male and three female nurses were interviewed. Of these eight, six were graded (salary scale) at band five while two were graded at band six. In terms of their role within the units, 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.
Data collection and analysis
The interviews were tape recorded and then transcribed verbatim. In the case of hermeneutic phenomenology, unstructured interviews are used when the researcher knows little about the topic, whereas semi-structured interviews are used when the researcher has an idea of the topic and knows what questions to ask (Roberts et al, 2006; Whitehead, 2004). As I have experience of the topic, I used semi-structured interviews.
Interpretative phenomenological analysis (IPA) was used in the analysis of the data collected. IPA is concerned with trying to understand the meanings that experiences hold for individuals. It explores personal perception of an event, as opposed to trying to record an objective record of the event. As a means of validating my interpretation of the interviews, respondents were consulted several times to check for accuracy of interpretations. Quality criterion and a framework were used to guide me in constituting quality within the research.
Experience of stress
The experience of stress was captured by asking a number of questions about participants’ understanding, definition, experience and the holistic feelings that they experienced from stress in the workplace. Some staff members related their definition in relation to their experience of stressors on the ward (for example, proving oneself, pressure from managers), while others gave a more refined definition (such as a stimuli where you have difficulty coping) that would be reflective of the literature (McVicar, 2003). While the definitions offered varied, common themes did emerge of their experience in relation to stress, namely:
- Home/work balance;
- Professional recognition and value;
- Lack of resources.
Home/work balance With the exception of one participant, all talked about being unable to stop thinking about work when they had finished their shift. They reported they found it difficult to ‘switch off’ from the pressure of work when at home or outside of work.
Professional recognition and value Participants reported they felt management and others within the multidisciplinary team did not listen to them and that their professional opinions were not taken into account. They also reported that they were unable to use their professional skills and do the job they had trained to do. Rather, there seemed to be more emphasis put on paperwork and administrative duties than interaction with patients.
Lack of resources All respondents talked about their experience of working in an environment where resources were scarce, 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, thereby creating very busy environments that were not conducive to either patient or staff well-being.
The stressors identified were:
- Workload/lack of staff;
- Violence and aggression;
- Poor team-working practices.
All participants reported on these four main themes. Most gave direct examples of when the stressors were present and why they were identified as stressors.
Workload Workload was very closely aligned with lack of resources. Participants felt that, due to inadequate levels of staff within their units, their workload was overwhelming and constant.
Violence and aggression Violent and aggressive behaviours by patients were seen as one of the major stressors. These outbursts were against both patients and staff. Some reported that along with the physical act of aggression, they found some patients to be quite intimidating. Acts of aggression included verbal threats, physical assault and racist comments.
Poor team-working practices
Poor team-working among staff members contributed to stress. Considering the environment and the many demands within it, staff felt that other team members 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 to the whole of the interviews and some are captured within sections of dialogue from the interview. In essence, meanings are constructed from both specific detail (statements) and from the general overall feeling of the interviews. 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 that they were not doing their job properly or felt they were offering a service that conflicted with their belief that patients come first. These meanings were drawn from participants’ experiences of working within financial constraints, where they felt finances were given priority over patient care and were closely related to lack of resources.
For some participants, working with 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. In the interviews, participants talked about the dangers in the environment for patients and staff and the potential for something serious to occur.
In the process concerning the verification of meanings with participants, they asserted that many government policies and guidelines that were intended to assist staff with duties had little bearing on mental health services. Many gave examples such as calling the police to the ward when they had been assaulted and being told there was nothing the police could do. Other examples were when they called for police assistance to deal with a violent incident and the police did not respond.
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; Sullivan, 1993).
Findings from this study reflect and accord with previous studies. Difficulties with home/work balance are an issue that has 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 for staff members to ‘switch off’ from work may be a result of the high number of serious incidents that have occurred nationally and the reported feelings of being blamed or criticised for not doing their job properly (Higgins et al, 1999). This may bring a sense of heightened sensitivity for participants about the ever-present risks in the environment and the potential for other incidents to occur. In addition, as found in a number of studies (Cottrell 2001; Berg and Hallberg, 2000), it may be that staff do not feel supported by management and feel that, if something should go wrong, they would not be given understanding and solace.
Professional recognition and lack of consultation are also themes that emerged within this study. These two issues were also found in Sullivan`s (1993) study – similar to that, the participants in this study were dealing with a number of changes at local, regional and national level that potentially have an impact on their work environment. In times of change and restructuring, consultation is particularly important with the workforce to facilitate transition and reduce any staff anxieties (Greenglass et al, 2002). Otherwise 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 team-working practices. These are supported by many other studies (for example, Jenkins and Elliott, 2004; Edwards et al, 2001). Furthermore, it may be argued that while these stressors are closely related to participants’ experiences, there is an interrelationship among them, with one being seen to compound the other.
Within this study, meaning has been derived from the experiences and stressors that participants talked about in their interviews and is the evidence of their interrelationship between stressors (situation) and experiences (contexts).
The meaning of participants’ experiences may initially be construed as being negative in nature and one that reflects negative views about the organisation, environment and role in which participants are engaged. However, meanings attached to the experience and situations may in fact reflect participants’ desires to deliver ideal care, set against constraints in which they find themselves. In turn, this may create feelings of ambivalence.
Participants spoke about not being able to meet patients’ needs so it could be argued that meanings relate strongly to providing the best patient-centred care possible. These meanings could also be understood in the context of participants’ passion for caring for patients, set against moral dilemmas, idealism and the lack of resources that they experience.
From the results it may be concluded that experience of stress and stressors compound each other and give rise to meanings that are set in context to the situations that participants face every day. The meanings that participants attach to these experiences may reflect their ideal view of their role, their commitment to patients or, as argued earlier, their passion for caring. It may, as other studies have suggested, be a coping mechanism to deal with the turbulence faced at ward, organisational and national level. Without such meanings, participants may give up arguing for better conditions and resign themselves to feelings of hopelessness about changing current failing systems. It could be these very meanings that give staff the impetus to recognise that changes are needed and give rise to critical reflection.
Implications for practice
A number of documents (SCMH, 2004; DH, 2002) have made recommendations for improvements within acute wards, such as increasing staff levels, increasing leadership within acute areas and a more robust multidisciplinary team approach to patient care.
There are a number of implications for practice that are worth advocating. Staff need to be aware of their own well-being and how it may impact on quality of patient 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 – therefore, it is an issue that needs to be embedded within health and safety policies and one that should be given equal standing to more traditional health and safety concerns such as infection control or musculoskeletal disorders. 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/index.htm) as a guide to implementing best practice to reduce and deal with stress in the workplace.
Limitations of the study
This study has its limitations. 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, with the current financial climate in the NHS, where staff face possible redundancies, it may not have been the most appropriate time for this study to take place.
Lastly, as frameworks were used to demonstrate trustworthiness and rigour, it could be argued that this form of objectivity is not in keeping with the hermeneutic process (Brown et al, 2003).
Despite the limitations of this study, based on the findings of this and previous studies, stress in acute mental health nursing is an area that needs immediate attention. Further studies of a longitudinal design, using larger samples and across trusts, may give a greater insight into nurses’ experiences across an extended period. While there are many studies focusing on stress levels using quantitative designs, there are still relatively few that have used qualitative methodologies. Future qualitative studies may yield vital information in directing effective strategies to deal with this issue.
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