A comparative study of the perceptions of British mental health nurses and psychiatrists of their work environment

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  • A comparative study of the perceptionsof British mental health nursesand psychiatrists of their work environment

    Janie Dallender MScResearch Associate, School of Health Sciences, University of Birmingham,

    Birmingham

    Peter Nolan PhD RGN RMNSenior Lecturer, School of Health Sciences, University of Birmingham,

    Birmingham, England

    Joaquim Soares PhDSenior Researcher, Centre for the Development of Health Services,

    Stockholm

    Sarah Thomsen MPHResearch Associate, National Institute for Psychosocial Factors and Health,

    Stockholm

    and Bengt Arnetz MD PhDProfessor of Psychosocial Medicine, National Institute for Psychosocial Factors

    and Health, Stockholm, Sweden

    Accepted for publication 21 January 1998

    DALLENDER J., NOLAN P., SOARES J., THOMSEN S. & ARNETZ B. (1999) Journal of

    Advanced Nursing 29(1), 3643

    A comparative study of the perceptions of British mental health nurses

    and psychiatrists of their work environment

    This comparative study of the perceptions of mental health nurses and

    psychiatrists about aspects of their work environment was undertaken in the

    West Midlands in England. The aim of the study was to ascertain the extent to

    which the environment in which mental health professionals' work impacts on

    their own mental and physical well-being. Seventy-four psychiatrists and 301

    mental health nurses responded to a postal questionnaire. Analysis of data

    indicated that signicant differences exist between nurses and psychiatrists in

    their working conditions, their physical working environment, their sources of

    support with a work-related problem, and the effects of their work on their own

    mental and physical health. The main recommendation derived from this study

    was to improve communication between mental health professionals and their

    managers by giving more structured feedback and guidance about one's work

    performance. This may help to alleviate the mental strain many mental health

    professionals experience in their work.

    Correspondence: Janie Dallender, School of Health Sciences,

    The Medical School, Edgbaston, Birmingham B15 2TT, England.

    Journal of Advanced Nursing, 1999, 29(1), 3643 Experience before and throughout the nursing career

    36 1999 Blackwell Science Ltd

  • Keywords: mental health professionals, work environment, mental well being,

    job satisfaction, work-related stress

    INTRODUCTION

    At a time when radical changes are taking place in health

    services, it appears that work-related stress is on the

    increase (Sutherland & Cooper 1990). Evidence is accruing

    that the effects of these changes can result in reduced job

    satisfaction, absenteeism, somatic complaints and mental

    health problems (Cartwright 1979, Price & Mueller 1981).

    Not only are these changes affecting professionals person-

    ally, but they are also affecting how they undertake their

    professional duties. It has been shown that prolonged

    exposure to stressors in the health care environment not

    only impairs care delivery, but may also be instrumental

    in the development of negative and cynical attitudes

    towards patients and colleagues (Maslach & Jackson 1982).

    LITERATURE REVIEW

    An extensive literature is being generated about the

    environment in which health professionals work and the

    impact it has on them both personally and professionally.

    Traditionally, the selection, training and education of

    professionals have tended to focus primarily on the

    imparting of specialist knowledge and the acquisition of

    appropriate skills, but relatively little attention has been

    paid to the environment in which these skills are

    practised. In the eld of mental health care particularly,

    studies into the `social climate' or `therapeutic

    environment' have been undertaken largely to assess the

    impact of the environment on patients and clients, but

    relatively few have examined its effects on professionals

    themselves (Rothman 1971, Aubry et al. 1996).

    Those studies which have examined the effects of

    environment on professional practice have tended to

    centre on doctors and nurses in physical health care,

    which is understandable since they form the largest and

    most visible groups in health care (Cushway et al. 1996).

    In comparison, relatively little work has been done with

    mental health professionals whose work has been tradi-

    tionally seen as less glamorous and less visible (Jones

    1989). One reason for the paucity of research in this area

    may be due to the prevailing assumption that health care

    professionals can cope, and have high expectations of

    their abilities to help others (Sutherland & Cooper 1993).

    Changes in working practices have had a greater impact

    upon mental health professionals than upon their col-

    leagues in general health care due to the different and

    more severe nature of the stressors (Blachly et al. 1968).

    Further evidence of this is provided by Russell et al.

    (1975) who found that psychiatrists had the highest

    suicide rate among doctors and that trainee psychiatrists

    had high levels of mental health problems as well as high

    drop-out rates from training. Merklin & Little (1967) found

    that junior psychiatrists experienced high levels of neu-

    rotic symptoms and psychosomatic disturbances during

    their training and concluded that this was an inevitable

    part of their education.

    Health care professionals differ signicantly from other

    workers in that they have frequent close contact with

    severe illness and death and are expected to alleviate the

    distressing situation in which some patients and their

    carers nd themselves (Maslach & Jackson 1982). They are

    exposed to intense physical and emotional suffering and

    are frequently the focus of primitive transference reactions,

    both affectionate and hostile (Mowardi 1983). Despite

    well-dened selection criteria for admission into the

    health care professions, great variation has been found in

    how individuals respond to stress and suffering (Keinan &

    Melamed 1987). Heim (1991) observed the anomaly that

    factors identied as stressful by some respondents were

    seen by others as those contributing most to job satisfac-

    tion. Professionals who have doubts about being able to

    cope are more likely to experience an impulse to disengage

    from potentially difcult situations even though social or

    other constraints prevent them from doing so (Carver &

    Scheier 1988).

    Arnetz (1991), in a study of physicians, found that this

    extended to avoiding social activities, meeting friends or

    even interacting socially with their own families. In the

    same study, 25% of respondents stated that they felt unable

    to unwind after work, while 8% acknowledged that they

    relied on the consumption of excessive amounts of alcohol

    in order to relax. He concluded that the work environment

    and the way in which work was organized were closely

    linked to stress over which respondents felt they had little

    control. Nonetheless, Heim (1991) found that 97% of

    doctors stated that their job satisfaction was high.

    Similarly, studies of nurses' work have also identied a

    number of stressors such as role conict, work load,

    relations with senior colleagues, anxiety about death and

    dying and conicts between home and work which affect

    the personal and professional functioning of nurses (Hin-

    gley & Harris 1986). Guppy & Gutteridge (1991) estimated

    that 85% of stress in nurses was due to heavy workload,

    55% was associated with poor relationships with senior

    staff, and 43% was related to poor relationships with

    colleagues. Patterns of connection and relationship were

    also identied in a study by Westmoreland (1993) as

    constituent features of what made work meaningful to

    hospital nurse managers.

    Experience before and throughout the nursing career Perceptions of mental health nurses

    1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 3643 37

  • The conclusion arrived at by Duquette et al. (1994), after

    reviewing 300 studies, is that nursing is a particularly

    stressful occupation. They found the best correlates of

    burnout and stress in nursing to be role ambiguity,

    workload, age and social support. However, Cash (1988)

    has pointed to the difculty of trying to draw inferences

    from this kind of meta-analysis due to studies having

    different aims, deploying different instruments, and

    conceptualizing stress and burnout in different ways.

    Furthermore, studies have been conducted on different

    nursing groups working in a variety of environmental

    contexts.

    In a large scale study of nurses and the work environ-

    ment, Petterson et al. (1995) found that more than 90% of

    nurses were satised with their jobs, although female

    nurses were more satised than males. Despite the high

    levels of reported satisfaction, however, 45% of nurses

    had seriously considered leaving the profession at some

    time in their career.

    The reasons given were low salary, unchallenging and

    repetitious work, lack of skills and poor career prospects.

    The study also showed that 90% of nurses considered the

    psychosocial environment in which they worked to be

    important and more than 80% reported high levels of

    mental strain in their jobs. Whilst most felt free to make

    suggestions that would improve their working environ-

    ment, a signicant number felt that these suggestions

    would not be acted upon. When asked to identify how

    their work environment could be altered so that the

    quality of care could be improved, respondents listed the

    acquisition of psychosocial skills, and skills for handling

    crises, and improved management and clinical supervi-

    sion. One of the most signicant ndings of this study was

    that nurses who developed stress-related problems were

    those who received least support and frequently ended up

    working by themselves.

    Despite the limited nature of the research into stress in

    mental health nursing, evidence suggests that many of the

    stressors which affect general nurses are also shared by

    mental health nurses (Dawkins et al. 1985). There are,

    however, signicant factors that relate specically to

    mental health nurses (Dunn & Ritter 1995). Cronin-Stubbs

    & Brophy (1984) observed that the nature of mental health

    care may predispose some professionals to burnout

    because of the necessity of intense interpersonal

    involvement with clients and their carers. This study

    further suggests that staff who experience severe burnout

    tend to avoid close contact with their families, thus

    minimizing the potential positive effects of a supportive

    home environment. Various studies have conrmed that

    violence is another major source of stress in mental

    health nurses regardless of the context in which they

    work (Dunn & Ritter 1995, Carson et al. 1995).

    Mental health nurses may also be disadvantaged in that

    their work tends to be less visible than that of their general

    nursing colleagues, and consequently they experience less

    conrmation of their worth (Jones 1989).

    From the research undertaken thus far, it appears that

    the work environment of health care professionals can

    have adverse effects on their physical and mental well-

    being. The consequences of this both in terms of cost to

    the individual and to the health service can be consider-

    able. The Royal College of Nursing has informed the NHS

    Efciency Task Force that Trusts could save millions each

    year if they boosted staff morale, prevented back injuries,

    and addressed absenteeism and high staff turnover (Royal

    College of Nursing 1997). More effort is required in order

    to produce valid and reliable measures of occupational

    stress, its causes and how it might be alleviated.

    Whilst there have been studies that have examined the

    impact of the work environment either on psychiatrists or

    mental health nurses, few comparative studies, to date,

    have involved both groups. The aim of this study there-

    fore, was to compare psychiatrists' and mental health

    nurses' perceptions of their immediate work environment

    and the effects it has upon them. Our main hypothesis was

    there will be no signicant difference between psychia-

    trists' and nurses' perceptions of their work environment.

    METHOD

    Setting and subjects

    Between November 1996 and March 1997, psychiatrists

    (qualied and trainee) and rst level mental health nurses

    working in a cross-section of National Health Service

    Trusts in the West Midlands, England, were surveyed

    using a postal questionnaire. The sample was drawn from

    stafng lists of qualied mental health workers held by the

    personnel (human resources) managers of ve NHS Trusts.

    A cross-section of employees working in the eld of

    mental health responded to the questionnaire (Table 1).

    The overall response rate was 47%, accounting for 375

    employees. The response rate for psychiatrists was 60%

    (n 74) and for nurses, 45% (n 301).

    Table 1 Number and percentage in sample by professional

    category

    Professional category

    Number of

    employees

    replying

    Percentage

    of sample

    Consultant psychiatrist 46 12%

    Senior psychiatric registrar 4 1%

    Trainee psychiatrist 24 6%

    Community psychiatric nurse 95 26%

    Hospital-based nurse 201 54%

    Unknown category 5 1%

    Total 375 100%

    J. Dallender et al.

    38 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 3643

  • Measurements

    The questionnaire contained 32 items which sought to

    elicit data about the following areas: physical work

    environment; psychosocial work environment; social cli-

    mate; social support; coping; personal characteristics of

    the respondent. No identication code was used as a

    means of tracing respondents or non-respondents. The

    instrument was comprised of items that had already been

    validated elsewhere (Arnetz 1997).

    Sub-scales within the instrument were used either in

    their original form or revised to enable them to measure

    aspects of the work environment relevant to mental health

    workers.

    Procedure

    Questionnaires and covering letters were sent to psychi-

    atrists, trainee psychiatrists and mental health nurses in

    their workplace via their personnel managers. The infor-

    mation to the respondents regarding the survey was

    outlined in the covering letter. The letter stated that we

    were interested in obtaining the views of nurses and

    psychiatrists regarding their work environment and that

    the results of the study would be utilized to identify

    working environments that are conducive to the provision

    of good quality mental health care. The letter also stated

    that the results would be completely condential and

    anonymous and that their trust would receive a report

    summarizing the main ndings of the study.

    Stamped addressed envelopes were enclosed for return

    of questionnaires which were to be sent directly back to the

    researcher. Four weeks after the initial mailing, a reminder

    was sent to all subjects via their personnel managers.

    Throughout the study condentiality and anonymity were

    guaranteed, and permission to distribute the question-

    naires was sought from senior managers. Respondents

    were assured that once data had been analysed, the

    questionnaires would be destroyed. The researcher had

    no direct contact with the respondents and was unknown

    to the respondents prior to and during the study.

    Statistical analyses

    SPSS for Windows (version 61) software package wasused to input and analyse the data. Chi-square tests were

    employed to analyse the differences in responses between

    the professional categories. All tests were two-tailed and

    statistical signicance was assumed at P

  • tended to work signicantly more overtime than nurses,

    43% and 27%, respectively (v2(3) 82, P < 005). Fur-thermore, psychiatrists were more likely to state that they

    `never' or `rarely' have time to complete their work (45%)

    compared to nurses (29%, v2(4) 193, P < 001), al-though there was no signicant difference between the

    two groups in terms of having `too much work' to do.

    Table 3 shows the coping responses of psychiatrists and

    nurses when they had `too much work'.

    The table illustrates how both psychiatrists and nurses

    favoured `active' coping strategies when faced with `too

    much work to do'. However, psychiatrists were more

    likely to adopt the `passive' coping strategy of `keeping the

    problem to themselves', whilst the nurses were more

    likely to actively `seek help and support' (P < 001).Differences were found in the level of supervisory

    duties between nurses and psychiatrists. A signicantly

    higher proportion of psychiatrists supervised staff on a

    weekly basis whereas a greater proportion of nurses who

    had supervisory duties tended to supervise on a monthly

    basis (v2(4) 193, P < 001, see Table 4). When asked:`How hard must you work in order to accomplish your

    daily tasks?', a higher proportion of nurses (61%) than

    psychiatrists (47%) stated they worked `hard' to accom-

    plish their daily tasks (v2(2) 84, P < 005). Sixteen percent of psychiatrists and nurses reported that they `did not

    work very hard'. A higher percentage of psychiatrists

    (59%) felt dissatised with their salaries compared to

    nurses (38%, v2(3) 175, P < 005).

    Physical working environment

    Perceptions of the degree of exposure to adverse factors in

    the physical environment of work were explored and

    signicant differences were found between the two

    groups.

    Eighteen per cent of nurses compared to 3% of psychi-

    atrists regularly had to lift heavy objects (v2(3) 219,P < 001). Nurses were often exposed to `too much noise'(16%) which was not a problem for any of the psychia-

    trists (v2(3) 201, P < 001). However, psychiatrists weremore likely to work in poorly ventilated surroundings

    than nurses (65% v 53%, v2(3) 99, P < 005) and weremore likely to engage in sedentary work (86% v 72%)

    (v2(3) 359, P < 001). No signicant difference wasfound between psychiatrists and nurses in terms of

    exposure to insufcient light.

    Social climate

    No signicant differences were found between psychia-

    trists' and nurses' perceptions of the social climate at

    work. Over 70% of psychiatrists and nurses reported that:

    there was a pleasant atmosphere at work; that their

    colleagues were supportive; that they got on well with

    senior colleagues; and that people worked well as a team.

    Support climate

    There were no signicant differences in the amount of

    support received by nurses and psychiatrists from their

    managers and colleagues. Most psychiatrists (83%) and

    nurses (66%) felt that they had the support of their

    managers `sometimes', `often' or `always'. Similarly, 62%

    of psychiatrists and 70% of nurses felt they `often' or

    `always' had the support of work colleagues.

    When confronted with a work-related problem, how-

    ever, most psychiatrists said they would turn to either

    their colleagues or their partners for support. This was

    similar for nurses, although a signicantly higher propor-

    tion would turn to their line managers or a therapist

    (P 001, Table 5). Overall, just over half of all nursesand psychiatrists were satised with the amount of

    support they received with work-related problems.

    Psychosocial work environment

    A third of nurses and 23% of psychiatrists rated their

    work as `always' psychologically taxing whilst 46% and

    53%, respectively, said it was `often' taxing. Nevertheless,

    most mental health workers were satised with their

    work. Fifty-eight per cent of psychiatrists were satised `to

    some degree' and 20% `to a great degree'. Less than 1% of

    psychiatrists reported that they were `not at all satised'.

    Similarly, two out of three nurses were satised with their

    Table 5 Sources of sought support for a work-related problem.

    *P < 005

    Sources of

    sought support

    Psychiatrists

    n (%)

    Mental health nurses

    n (%)

    Colleagues 64 (90) 280 (85)

    Partner 50 (70) 216 (74)

    Manager 46 (64) 217 (75)*

    Friends 46 (64) 168 (59)

    Family 30 (13) 142 (51)

    Therapist 6 (9) 36 (13)*

    Table 4 Extent of supervisory duties. P < 0001

    Frequency of

    supervisory duties Nurses Psychiatrists

    None 57 (193) 12 (162)Daily 122 (414) 35 (473)Weekly 49 (166) 26 (351)Monthly 67 (227) 1 (14)

    J. Dallender et al.

    40 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 3643

  • work `to some degree', 13% `to a great degree' and less

    than 1% were `not at all satised'. There were no signi-

    cant differences in these responses between the groups.

    Two-thirds of psychiatrists and nurses perceived that

    they had less inuence over their work than they wished

    and a large percentage felt that they rarely received clear

    work directives from their line managers. A third of nurses

    and 47% of psychiatrists `never' or `rarely' received clear

    information as to what was expected of them. Over half of

    nurses and two-thirds of psychiatrists `never' or `rarely'

    received positive feedback when they had `done a good

    job'. Thirty-one per cent of nurses `often' or `always'

    received feedback when they had done a poor job com-

    pared to only 1% of psychiatrists (v2(4) 203, P < 001).

    Mental well-being

    Although there were no signicant differences between

    psychiatrists and nurses in the frequency with which they

    reported irritation, emotional exhaustion, physical

    exhaustion and tiredness at the thought of doing their

    job, Table 6 serves to illustrate the degree of negative

    mental well-being for both groups. This table also shows

    that the only signicant differences between nurses and

    psychiatrists was the frequency with which they felt

    `restless', with a higher proportion of psychiatrists feeling

    `restless' daily than nurses (v2(4) 103, P < 005), andmore nurses `not caring about the results of their work (v2

    (4) 119, P < 005).

    DISCUSSION

    The response rate (47%) to this survey was fairly low. One

    reason may be due to the growing number of surveys being

    targeted at service providers in a bid to improve efciency

    as stipulated in recent health and social welfare reforms.

    Health professionals are perhaps becoming increasingly

    disinclined to ll in yet another questionnaire, especially

    if they feel that imparting information about one's

    workplace could be used to justify staff reductions. Whilst

    the overall response rate was low, the response rate from

    psychiatrists (60%) was good. This may be because

    psychiatrists feel less threatened or that they perceive

    their work environment to be an important issue. Those

    who did respond tended to have been in their profession

    for over 10 years which may indicate a sense of security in

    their post or, if near retirement, a perception that they

    have little to lose by frank disclosures in questionnaires.

    The majority of questions in the survey were completed by

    respondents, suggesting that the questions were compre-

    hensible and relevant.

    One of the most interesting results relates to the number

    of hours worked by psychiatrists compared to nurses.

    Despite working, on average, 20 hours a week more than

    nurses, psychiatrists were more likely to state that they

    `never' or `rarely' had time to complete their duties. This

    may be linked to having more frequent supervisory duties

    than nurses or to the fact that psychiatrists appear less

    likely to seek help when they have too much work to do.

    This perceived lack of time by psychiatrists to complete

    their duties raises issues about the training they receive in

    skills such as time management and delegation, as well as

    about the number of patients they are expected to see.

    However, no overall signicant differences were found

    between hours worked, length of service and other aspects

    of the work environment.

    Most mental health workers were engaged in a high

    level of sedentary work which tended to be carried out in

    poorly ventilated conditions. This was especially so for

    psychiatrists who apparently spend a lot of time in their

    ofces either seeing patients or writing reports. This

    implies that the amount of time they spend outside

    their ofces either meeting other health professionals or

    in their local community is fairly limited. However,

    within their workplace most of the respondents reported

    that they enjoyed favourable relations with their col-

    leagues and managers. This contrasts starkly with the

    Table 6 Mental well being

    Well-being

    Per week (%) Per month (%) Per year (%) Never (%)

    indicators Medics Nurses Medics Nurses Medics Nurses Medics Nurses

    Irritation 54 41 32 46 13 12 1 1

    Restlessness 28 32 39 27 19 32 14 9

    Emotional

    exhaustion

    39 49 43 32 18 16 0 3

    Physical

    exhaustion

    44 42 33 39 16 15 7 4

    Tiredness 22 27 32 31 34 29 12 13

    Not caring

    about work

    2 7 8 8 37 19 53 66

    Works calmly 84 89 11 8 4 2 1 1

    Experience before and throughout the nursing career Perceptions of mental health nurses

    1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 3643 41

  • work of Guppy & Gutteridge (1991) who found that 50% of

    the stress in their general hospital subjects was account-

    able to poor work relationships.

    Although most mental health workers in this survey

    found their job psychologically taxing, the results reported

    for nurses were much lower than those found by Petterson

    et al. (1995). Similarly, respondents reported a high

    degree of satisfaction with their work although again not

    quite as high as that reported in previous studies (Heim

    1991, Petterson et al. 1995). Unfortunately, no information

    was readily available about the actual client morbidity

    levels in the different districts which may have helped to

    cast light on the self-reported levels of mental well-being

    and job satisfaction.

    Communication between psychiatrists, nurses and their

    managers appeared limited, especially with regard to

    positive feedback. Most respondents stated that, in addi-

    tion to not receiving constructive feedback from their

    seniors, they also received little guidance in the carrying

    out of their duties. Psychiatrists, in particular, received

    less feedback than nurses from their managers about their

    work. This lack of communication combined with

    assumptions that health care professionals can cope has

    serious implications for staff morale and could account

    for the high levels of mental health problems among

    psychiatrists found in earlier studies (Russell et al. 1975,

    Merklin & Little 1967). The extent of mental and physical

    strain experienced daily by both groups was found in our

    survey to be considerable. This supports previous research

    indicating high levels of mental stress found in mental

    health professionals (Blachly et al. 1968).

    Although both groups of respondents regarded commu-

    nication in their work environment to be poor, neverthe-

    less, the majority of respondents felt they had the support

    of their managers and colleagues. This is important when

    considering the ndings of Petterson et al. (1995) who

    stated that nurses who developed stress-related problems

    were those who received least support. As well as

    respondents perceiving they had the support of their

    managers and colleagues, they also reported there was a

    pleasant atmosphere at work, that they got on well with

    their seniors, and worked well as a team.

    Yet, even in such favourable conditions the level of

    mental and physical strain was still fairly high. This

    suggests that whilst support and good relations with

    colleagues are important as previous studies have

    indicated, these of themselves are not sufcient. It is

    the quality of communication between staff and their

    managers that is the crucial issue in alleviating stress. This

    entails providing staff with regular constructive feedback

    and guidance about how they are performing in their work

    The challenge to managers is that, in addition to providing

    cost-effective services, there is an overwhelming need to

    create working environments structured in a way which

    allows conrmation of the value of staff and the

    contribution they make to health care to be regularly

    communicated. Further research is required on how con-

    structive feedback and guidance can be best communicated

    to staff by their managers in the current climate.

    Therefore the null hypothesis may be rejected as

    signicant differences were found between psychiatrists'

    and mental health nurses' perceptions of their work

    environment with regard to their working conditions,

    physical working environment, and mental well-being.

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