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,
Peter Nolan PhD RGN RMNSenior Lecturer, School of Health Sciences, University of Birmingham,
Joaquim Soares PhDSenior Researcher, Centre for the Development of Health Services,
Sarah Thomsen MPHResearch Associate, National Institute for Psychosocial Factors and Health,
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
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).
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 &
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
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.
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
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
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
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.
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
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.
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.
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
Mental health nurses
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
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).
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).
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
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
39 49 43 32 18 16 0 3
44 42 33 39 16 15 7 4
Tiredness 22 27 32 31 34 29 12 13
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,
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