Stress Management Interventions for Mental Health Nurses

INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES
A systematic review of stress and stress management interventions for
mental health nurses
D. Edwards MPhil
Lead Researcher, School of Nursing and Midwifery Studies, University of Wales College of Medicine, Cardiff, UK
and P. Burnard MSc PhD RGN RMN RNT
Professor and Vice Dean, School of Nursing and Midwifery Studies, University of Wales College of Medicine, Cardiff, UK
Submitted for publication 7 February 2002
Accepted for publication 7 January 2003
Correspondence:
Deborah Edwards,
School of Nursing and Midwifery Studies,
Ty Dewi Sant,
University of Wales College of Medicine,
Heath Park,
Cardiff CF14 4XN,
UK.
E-mail: edwardsdj@cardiff.ac.uk
EDWARDS D
EDWARDS D. &
& BURNARD P. (2003)
BURNARD P. (2003) Journal of Advanced Nursing 42(2), 169–
200
A systematic review of stress and stress management interventions for mental health
nurses
Background. Health care professionals in the United Kingdom (UK) appear to have
higher absence and sickness rates than staff in other sectors, and stress may be a
reason for nurses leaving their jobs. These problems need to be addressed, partic-
ularly in the mental health field, if current service provision is to be maintained.
Aim. The aim was to identify stressors, moderators and stress outcomes (i.e.
measures included those related to stress, burnout and job satisfaction) for mental
health nurses, as these have clear implications for stress management strategies.
Method. A systematic review of research published in English between 1966 and
2000 and undertaken in the UK that specifically identified participants as mental
health nurses was carried out to determine the effectiveness of stress management
interventions for those working in mental health nursing. Studies from non-UK
countries were examined as potential models of good practice. The study was
limited to primary research papers that specifically involved mental health nurses,
where the health outcomes measured were stressors, moderators and stress out-
comes and where sufficient data was provided.
Results. The initial search identified 176 papers, of these 70 met the inclusion
criteria. Seven studies have been reported since the completion of the review and
have been included in this article. Sixty-nine focused on the stressors, moderators
and stress outcomes and eight papers identified stress management techniques.
Relaxation techniques, training in behavioural techniques, stress management
workshops and training in therapeutic skills were effective stress management
techniques for mental health nurses. Methodological flaws however, were detracted
from the rigour of many of the studies.
Conclusions. The review demonstrated that a great deal is known about the sources
of stress at work, about how to measure it and about the impact on a range of
outcome indicators. What was found to be lacking was a translation of these results
into practice, into research that assessed the impact of interventions that attempt to
moderate, minimize or eliminate some of these stressors.
Keywords: stress, burnout, job satisfaction, coping, stress management, mental
health nurses, systematic review
2003 Blackwell Publishing Ltd 169

Introduction
Stress in the workplace is often referred to as ‘occupational
stress’. The basic rationale underpinning the concept is that
the work situation has certain demands, and that problems in
meeting these can lead to illness or psychological distress.
Occupational stress is a major health problem for both
individual employees and organizations, and can lead to
burnout, illness, labour turnover, absenteeism, poor morale
and reduced efficiency and performance (Sutherland
Cooper 1990). Work-related stress is estimated to be the
biggest occupational health problem in the United Kingdom
(UK), after musculoskeletal disorders such as back problems
and stress related sickness absences cost an estimated £4
billion annually (Gray 2000).
Current evidence suggests that health care professionals in
the UK have higher absence and sickness rates than staff in
other sectors (Nuffield Trust 1998). Wall et al. (1997) found
that 27% of health care staff suffered serious psychological
disturbances, compared with 18% of the general working
population. It has been suggested that stress may be a reason
for nurses leaving their jobs (Seecombe Ball 1992). The
problem of retaining qualified and experienced staff has
highlighted the need to look at various aspects of work and the
work environment, which affect the level of job satisfaction
and in turn influences quality of service.
If problems with recruitment and retention are not addressed,
then there is a danger that large sections of existing UK
mental health services will not be sustainable (Sainsbury
Centre for Mental Health 2000). A Department of Health
survey in 1999 indicated that 2Æ1% of all nursing posts in
psychiatry were considered hard to fill (Department of Health
1999). Eighty-five per cent of 100 trusts surveyed by the
National Health Service (NHS) Executive reported difficulties
both in recruiting and retaining nursing staff generally and
this was a more common problem in mental health nursing
(NHS Executive 1998).
There are growing numbers of studies that have given
consideration to coping strategies and management support
issues, stress management being an umbrella term that
encompasses a wide range of different methods designed
principally to reduce stress and improve coping abilities.
Interventions can change the environment to reduce the
potential for stress, help individuals to modify their appraisal
of it, or help them to cope more effectively with stressors
(Carson Kuipers 1998). The aim of the current review
therefore was to identify stressors, moderators and stress
outcomes (i.e. measures included those related to stress,
burnout and job satisfaction) for mental health nurses, as
these have clear implications for stress management
strategies. A number of reviews (Jones 1987, Sullivan
1993a, Dunn Ritter 1995) have been conducted in the
areas of stress, coping and burnout in psychiatric nursing.
These have all looked at different perspectives but a number
of articles which we considered to be important were
excluded from these reviews, as the latter were not systematic
in nature. It was therefore decided to reassess the papers
included in previous reviews.
Methods of the review
Studies included in the review were research articles from
1966 to 2000 reporting studies undertaken in the UK that
specifically identified participants as mental health nurses.
Studies from other European countries and from the United
States of America (USA) were also included as potential
models of good practice.
Search strategy
The search strategy used the following sources:
• Computerized databases [PUBMED, Embase (Excerpta
Medic Online), SCI Search (the Science Citation Index),
SSCI Search (the Social Science Citation Index), Pascal
(the Science, Technology and Medicine Index), CINAHL
(nursing and allied health), ASSIA (social science), PsychLit
(psychology, including clinical psychology), Clin Psych,
Heathstar, Cochrane, British Nursing Index, SIGLE (Sys-
tem for Information on Grey Literature) and National
Research Register].
• Hand searching of nursing journals (selected on the basis
of being the most frequently encountered – Journal of
What is already known about this topic
• Work-related stress is estimated to be the biggest
occupational health problem in the UK.
• There are problems in the recruitment and retention of
the mental health nursing workforce.
What this paper adds
• It examines the studies that have evaluated stress
management interventions for mental health nurses
and highlights the methodological weaknesses inherent
in many of the papers reviewed.
• It discusses the role of the organization in addressing
how to improve the retention of mental health nurses
within the workforce.
D. Edwards and P. Burnard
170 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(2), 169–200

Advanced Nursing, Journal of Psychiatric and Mental
Health Nursing, International Journal of Nursing Studies,
Journal of Psychosocial and Mental Health Nursing
Services).
• Writing to key authors.
• Citations in papers identified by the above searches.
Search terms used were: Psychiatric Nur*, Mental Health
Nur*, Mental Health Professional*, Mental Health Staff,
Mental Health Personnel, Mental Health Service and Com-
munity Mental Health. These search terms were combined
with the terms stress, burnout, coping, job satisfaction and
stress management.
Results
The number of articles that were considered potentially
relevant to the review was 176. All papers identified as
potentially relevant were obtained in hard copy. Further
assessment for relevance was made according to the inclusion
criteria shown in Table 1. All references to the papers were
retrieved and stored on computer, using the reference
database program Reference Manager. Each article retrieved
for the study was assessed independently by two reviewers for
inclusion or exclusion in the review on the basis of reading
the full text. The judgements of the two reviewers were
compared and where there were differences the article was
reconsidered. Seventy articles were included in the final
review and those were excluded are shown in Table 2. Seven
studies have been reported since the completion of the review
(Kilfedder et al. 2001, Coffey Coleman 2001, Humpel
Caputi 2001, Ito et al. 2001, Tummers et al. 2001, Dallender
Nolan 2002, Ewers et al. 2002). For the purpose of
completeness these research papers have also been included in
this article, bringing the total number of articles reviewed
to 77.
Fifty-eight articles were retrieved reporting studies con-
ducted in the UK for groups of mental health nurses. Table 3
presents a summary of these. Entries in the table are arranged
alphabetically and according to the year of publication, with
information on the aims of the studies, sample and sample
size. Table 4 presents information on the measures used,
main results and details on rigour and validity. These studies
focused on mental health nurses working in a variety of
settings – community teams (n ¼ 15), forensic teams (n ¼ 6),
ward-based teams (n ¼ 31) and community- and ward-based
teams (n ¼ 6). Nineteen articles were retrieved reporting
studies conducted outside the UK and nine of these had
samples that consisted of all types of psychiatric staff, i.e.
Registered Nurses (RNs), Licensed Practical Nurses (LPNs),
nursing aides (NAs), nursing auxiliaries and ward clerks,
making comparisons with UK samples inappropriate. Details
of the aims of these studies, sample and sample size are
presented in Table 5 and details of measures used, main
results and rigour and validity are presented in the text.
Stressors, moderators and stress outcomes
It is important that stress research is based on a theoretical
model. Three levels of the stress process are proposed in the
model developed by Carson and Kuipers (1998) which are
stressors, moderators of the stress process and stress out-
comes. The model suggests that there are three major sources
of external stress. There are, firstly, specific occupational
stressors, which vary depending on the unique stress facing
each professional group. The second major source of external
stressors is major life events. The third set comes from
‘hassles’ or ‘uplifts’. These are not major events, but small
stressors that can have a cumulative effect on individuals.
Thirty-five UK studies investigated sources of occupational
stress or job-related pressure and/or factors associated with
high levels of stress as measured by a questionnaire and the
results are presented in Table 4.
From the USA, three papers examined stress-related issues.
Trygstad (1986) found that difficulties in nurse relationships
either with other RNs or head nurses, and the ability to work
together, were the most important determinants of work
stress for mental health nurses. The methods used were
purpose-designed tool and semi-structured interviews. The
sample is too small for each ward to be adequately represented
and there were no details of validity or reliability reported.
Dawkins et al. (1985) used a 78-item Psychiatric Nurses
Occupational Stress Scale developed from lists of stressful
events reported by nurses to identify and quantify stresses in
Table 1 Inclusion criteria
English language publication
Professional groups concerned
Primary research paper
Measuring stressors/moderators/stress outcomes
Table 2 Papers excluded from the review
Reasons for exclusion
Foreign language publication 17
Studies not including psychiatric nurses as subjects 31
Not a primary research article 17
Article which contained insufficient statistical data 15
Papers not examining stressors/moderators/stress outcomes 15
Duplicate publication 14
Total 106
Integrative literature reviews and meta-analyses Stress management interventions for mental health nurses
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(2), 169–200 171

Table 3 Summary of articles included in the review from studies conducted in the UK
Author Aim Study population Sample size
Response
rate (%)
Bamber (1991) To assess reasons for leaving psychiatric nursing MHNs working in a psychiatric hospital
(staff nurses)
Ns 82 (Ns)
Barton and Folkard
(1991)
To examine perceived differences in stress levels
between day and night nurses in a mental
health context
MHNs working within an independent
psychiatric hospital, UK
Ns 98 day shift (59)
28 night shift (40)
Brown et al. (1995) To discover which aspects of the role of CMHNs
were most stressful
CMHNs working in 15 health districts, UK Ns 250
Burnard et al. (1999) To explore nurses’ perceptions of job satisfaction
in a small forensic unit
FMHNs working in an interim secure unit 48 40 (83)
Burnard et al. (2000) See Edwards et al. (2000)
Carroll (2000) To explore CMHNs perceptions of occupational
stress and to identify the coping strategies they
currently use to alleviate it
CMHNs working within three CMHTs, UK 6 6 (100)
Carson et al. (1991) To devise a specific CPN Stress Questionnaire CMHNs working in four health districts, UK Ns 61 (over 90)
Carson et al. (1996) To examine whether large caseloads are associated
with higher stress levels in CMHNs
See Fagin et al. (1995) (CMHNs sample)
Carson et al. (1997a) To examine the relationship between self-esteem
and stress, coping and burnout in MHNs
See Fagin et al. (1996)
Carson et al. (1997b) To conduct an up to date survey of stress in mental
health nursing
MHNs who were members of the public sector
trade union (CMHNs and WBMHNs)
2000 473 (24)
Carson et al. (1997c) To examine the relationship between self-reported
fitness levels and mental health outcomes
in WBMHNs
Carson et al. (1998) To evaluate the effects of a social support based
intervention with MHNs using a randomized
controlled design
MHNs working within Bethlem and Maudsley
Hospitals, UK
64 Volunteers 53 (83)
27 I
26 C
Carson et al. (1999) To assess the frequency of burnout in the largest
sample of MHNs reported in the Literature
Coffey (1999) To examine levels and sources of stress and
burnout amongst FCMHNs
FCMHNs attached to 26 NHS medium secure
units in England and Wales, UK
104 80 (77)
Coffey (2000) See Coffey (2000)
Coffey and Coleman
(2001)
See Coffey (1999)
Coyle et al. (2000) See Edwards et al. (2000)
Dallender et al. (1999) To compare perceptions of immediate work
environments for psychiatrists and MHNs
and the effects it has upon them
MHNs and Psychiatrists working within five
NHS trusts (WBMHNs and CMHNs), UK
700 MHNs
123 psychiatrists
301 (43)
74 (60)
Dallender and Nolan
(2002)
To explore MHNs and psychiatrists
perceptions of their work
See Dallender et al. (1999)
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Table 3 (Continued)
Response
rate (%)
Dolan (1987) To assess the relationship between burnout
and job satisfaction on two groups of recently
qualified staff nurses from general and
psychiatric nursing
MHNs working within nine hospitals. Inclusion
criteria were based on length of service excluding
training restricted to a maximum of 5 years, Ireland
30 MHNs
30 GN
30 Admin
86 (95)
Drake and
Brimblecombe (1999)
To investigate and compare the reported stress
levels and causes in nurses working in CTTs
and in generic CMHTs
CMHNs working within two CTTs and three
CMHTs, UK
16
13
16 (100) CTTs
13 (100) CMHTs
Edwards et al. (2000) To replicate the work of the Claybury stress study CMHNs working within 10 NHS Trusts in Wales, UK 614 301 (49)
Edwards et al. (2001) See Edwards et al. (2000)
Ewers et al. (2002) To evaluate the effect of psychosocial intervention
training on the knowledge, attitudes and levels
of clinical burnout in a group of FMHNs
FMHNs working within a medium secure unit 40 Baseline 33 (83)
10 I
10 C
10 refused
Fagin et al. (1995) To examine the variety, frequency and severity
of stressors amongst CMHNs, to describe coping
strategies used by CMHNs and WBMHNs, to
compare occupational stress in CMHNs and
WBMHNs
CMHNs working in four health districts, UK
WBMHNs working in two district psychiatric hospitals, UK
Ns
Ns
245 (approx. 80)
323 (approx. 20)
Fagin et al. (1996) To examine stress in WBMHNs Combined results from three studies for WBMHNs:
Study 1 – Carson et al. (1996), Study 2 – qualified nurses
from two large asylums, Study 3 – two mental hospitals, UK
Study 1 (Ns)
Study 2 (Ns)
Study 3 (Ns)
317 (approx. 20)
145 (46)
186 (47)
Fielding and Weaver
(1994)
To compare the job perceptions of community and
hospital based MHNs, to evaluate the degree
of psychology cal strain and burnout, to explore
the relationship between job perceptions and
stress outcomes
CMHNs and WBMHNs working within two health
authorities, UK
82 CMHNs
150 WBMHNs
59 (72)
67 (45)
Fothergill et al. (2000) See Edwards et al. (2000)
Gilloran et al. (1994) To examine work satisfaction amongst nurses
across different grades from a psychogeriatric
ward
MHNs working within 121 wards from 39 NHS
Hospitals, Scotland, UK
2600 2080 (80)
Hannigan et al. (2000) See Edwards et al. (2000)
Harper et al. (1992) To investigate the job satisfaction and attitudes
of nurses working on two psychogeriatric wards
MHNs working in two psychogeriatric wards in a
hospital, UK
41 29 (71)
Humphris and Turner
(1989)
To assess staff response to job relocation MHNs working within two psychogeriatric wards
of a new unit, assessed prior to relocation (T1),
1 month after (T2) and 8 months after (T3), UK
44 T1
43 T2
46 T3
31 (70)
26 (60)
27 (59)
Jones et al. (1987) To investigate the factors that might be instrumental
in determining stress levels
MHNs working within a ‘special hospital’ – (cares
for mentally disturbed patients who are or who
have been dangers to themselves or others), UK
718 349 (49)
Kilfedder et al. (2001) To investigate burnout in MHNs using a
psychological model of stressors, moderators and stains
MHNs working within the Scottish National Health
Service, UK
1045 510 (49)
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Table 3 (Continued)
Response
rate (%)
Kirby and Pollock
(1995)
To examine the relationship between aspects
of ward environment and identified stress levels
FMHNs from a regional secure unit, UK 47 38 (81)
Kunkler and Whittick
(1991)
To introduce stress management workshops for
MHNs to help staff to identify their own sources
of stress and manage them more effectively
MHNs working on one ward invited to attend
(Workshop 1), UK
All MHNs working in a psychiatric hospital
(Workshop 2), UK
12
360
12 (100)
3 (0Æ08)
Leary et al. (1995) To evaluate ways in which MHNs themselves
define stress as well as examining the various
coping strategies that they use to alleviate stress
CMHNs working in four health districts, UK Ns 44 volunteers
Lemma (2000) To evaluate the effects of a training course on
‘Type A’ therapeutic skills designed for MHNs
on general levels of psychological distress, burnout
and related work activities
MHNs working within adult and elderly mental
health. I1 – course, I2 – course plus a 10-week
follow-up period of a weekly casework discussion group
Ns
Ns
Ns
14 – I1
13 – I2
27 – C
McCarthy (1985) To assess burnout in a sample of MHNs MHNs working in a private psychiatric
hospital, Ireland
Ns 32 (Ns)
McElfatrick et al.
(2000)
To compare the reliability and validity of two separate
measures of coping skills when used with MHNs
MHNs from various areas of Northern Ireland, UK 700 175 (25)
McLeod (1997) To test the hypothesis that higher levels of stress are
experienced by CMHNs working with clients suffering
enduring mental illness
CMHNs working within six health authorities, UK 80 71 (88)
Milne et al. (1986) To assess the factors regarded by MHNs as most
stressful
To examine the effects of an innovation involving
ward reorganization and behaviour training therapy
MHNs working on four psychogeriatric wards,
two of them defined as ‘strained (S)’ and two
‘unstrained (US)’ by the absenteeism sickness
records and the ratings of senior nursing staff, UK
MHN working on eight wards on a rehabilitation
unit that had been reorganized into areas of
specialist function, UK
26 US
30 S
65
16 (62)
5 (17)
45 (69)
Mountain et al.
(1990)
To examine the differing amounts of job satisfaction
reported by a sample of nurses working on long-stay
wards for the elderly mentally ill
MHNs from 11 wards within three long-stay
hospitals, UK
60 59 (98)
Muscroft and Hicks
(1998)
To compare levels of stress between GNs and MHNs,
to ascertain reported stress levels, the difficulties
experienced in coping with stress and to identify
potential interventions and preferred coping strategies
GNs working in an acute unit
MHNs working in one NHS trust, UK
100 GNs
100 MHNs
26 (26)
26 (26)
Nolan et al. (1995) To assess the efficacy of the scale as a tool for
measuring stress in MHNs
MHNs working within a health authority
(community and hospital based), UK
210 111 (53)
Parahoo (1991) To find out the level of job satisfaction and factors
which contribute to job satisfaction and dissatisfaction
CMHNs working within seven community
services, Northern Ireland
85 72 (91)
Parry-Jones and
Grant (1998)
To identify on the stresses and satisfactions of care
management practice among three groups of front
line workers
SWs, CNs and CMHNs working within all
health and service agencies in Wales, UK
SWs
CNs
CMHNs
276 (69)
65
62 (15)
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Burnard
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Table 3 (Continued)
Response
rate (%)
Peacock (1991) To assess subjective stress experience ad issues
relating to coping
MHNs working within psychiatric hospital
and associated sites, UK
278 110 (40)
Plant (1992) To examine levels of stress and illicit drug use across
a variety of nursing specialities
MHNs, MNs, SNs, MNs and SNs working
all acute hospitals in the Lothian region
of South-east Scotland, UK
202 MHNs
130 MNs
190 SNs
75 M and SNs
89%
Rees (1991) To examine occupational stress in all occupational
groups of health service employees
CMHNs and WBMHNs, UK Ns 12 (Ns)
42 (Ns)
Reeves (1994) To compare the incidence of neurotic symptoms
reported by MNs and MHNs
MNs from medical wards at two hospitals,
UK MHNs from department of psychiatry
in one hospital and those in community units, UK
125 MN
125 MHN
89 (72)
89 (72)
Ryan and Quayle
(1999)
To measure levels of stress among MHNs at all
grades and in all work locations, as well as
the sources of any stress reported
MHNs working in mental health services in five
catchment areas in the South-eastern
Health Board, UK
850 424 (42)
Sammut (1997) To examine the effects of a hospital closure on
MHNs’ satisfaction
MHNs working within a psychiatric institution,
surveyed at baseline (T1) before hospital closure
and at 11 months follow-up (T2) UK
201 T1
198 T2
122 (63)
111 (56)
Schafer (1992) Ns CMHNs working within one health authority,
before and after reorganization of services, UK
26 16 (62)
Sullivan (1993b) To examine occupational stress in MHNs MHNs working on eight acute admission wards
in two health authorities, UK
78 78 (100)
Snelgrove (1998) To examine similarities and differences in
the perceptions of stress and job satisfaction
of three occupational groups working in the
community sector
DNs, HVs and CMHNs working within one
district health authority, UK
DN 122
HV 122
CMHN 33
56 (47)
68 (57)
19 (58)
Watson (1986) To determine whether training in personal stress
management and relaxation techniques reduced
levels of anxiety, whether the participants coping
abilities in the work situation were influenced, and
whether these factors changed the participants’
perceptions of the stresses experienced at work
MHN participating in stress management
workshops, UK
I (Ns)
C (Ns)
12 (Ns)
20 (Ns)
Wykes and
Whittington
(1998)
To report on the effects of workplace violence in
a group of MHNs
MHNs from six acute psychiatric wards of a teaching hospital, UK
– Who had not been assaulted by a patient in previous month (time 0)
– Who had been assaulted and prospectively recruited within 10 days
of assault (time 1) followed-up 1 month after assault (time 2)
– Who had not been assaulted in past 6 months
(matched control group)
Ns
Ns
51
Ns
39 (Ns)
26 (Ns)
39 (76)
34 (Ns)
CPNs, community psychiatric nurses; CMHNs, community mental health nurses; FMHNs, forensic mental health nurses; MHNs, mental health nurses; WBMHNs, ward based mental
health nurses; SNs, surgical nurse; MNs, medical nurses, GNs, general nurse; DNs, district nurses; HVs, health visitors; CTT, community treatment team; CMHT, community mental health
teams; FCMHN, forensic community mental health nurses; SWs, social workers; CNs, community nurses; I, intervention; C, control; Ns, not specified.
Integrative
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management
interventions
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nurses

2003
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Journal
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175

Table 4 Summary of findings and rigour of studies conducted in the UK
Author Outcome measures Data collection Study findings Rigour
Bamber (1991) B,
JS
BI*
PDT
Leavers were scored significantly higher on
burnout scales
Leavers were significantly more
dissatisfied with overall job satisfaction,
quality of decisions made by managers,
amount of in service training offered
and physical working conditions
Purposive convenience sample. Limited
to staff nurses. Longitudinal study.
Following a 2-year period, respondents
were divided into ‘stayers’ (n ¼ 38)
and ‘leavers’ (n ¼ 44) Reliability and
validity of tool not discussed and no
piloting undertaken
Barton and Folkard (1991) S SC 90-R* Night as opposed to day workers report
significantly higher levels of stress and
that on the night shift, temporary as
opposed to permanent nurses reported
the highest levels. Age was found to
be an important predictor of
self-reporting levels of stress, younger
workers tending to report higher levels
than older workers
Purposive sampling, advanced statistical
analysis (regression analysis). Sample
limited to full-time workers
Brown et al. (1995) S PDT Ten factors emerged accounting for
67Æ4% of the variance. The most
dominant stress factor was issues
around support and communication
Questionnaire piloted by Carson et al.
(1991) was revised to a 66-item measure.
This was piloted again 72 CMHNs
and further revised to contain 48
items. Statistical analysis – factor
analysis. Well-documented validity
and reliability
Burnard et al. (1999) JS IWSQ Moderate levels of job satisfaction were
reported for two of the subscales – task
requirements and administration. Levels
of pay were a major area of job
dissatisfaction
Small scale study
Burnard et al. (2000) S, C SRQ The most frequently reported stressor
was workload and caseload issues
The most frequently reported coping
strategies was peer support
Same research study as reported by
Edwards et al. (2000) presenting
data from self-reported measures
from demographic questionnaire
Carroll (2000) S, C Semi-structured interviews Stressors common to all CMHNs were
aspects of client contact. Two main
coping strategies were reported – clinical
supervision and social support
Small exploratory study, very limited
generalizability
Carson et al. (1991) S,
B,
PD
PDT,
MBI,
GHQ-28
Rank order of questionnaire data determined
that not having enough facilities in the
community had the highest stress score
For mean MBI scores see Table 6
For mean GHQ-28 scores see Table 7
Pilot study, 61 items for questionnaire
generated from interviews with
16 CMHNs. Well-documented
validity and reliability
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Edwards
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P.
Burnard
176

2003
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Table 4 (Continued)
Carson et al. (1996) See Fagin et al. (1995) Large caseloads are associated with higher
levels of occupational stress.
Sample taken from Claybury CPN Stress
Study (Fagin et al. 1995). Further
analysis undertaken on caseload and
stress with the CMNH subsample
Carson et al. (1997a) See Fagin et al. (1995) Self-esteem levels were significantly higher
in staff who were happy in their life, were
fit, had job security, and had supportive
relationships with their line mangers and who
had children. Smoking and drinking were
both associated with lower levels of self-esteem.
Low self-esteem scores were correlated with
higher levels of psychological distress, higher
emotional exhaustion, lower utilization of
coping skills and lower job satisfaction
Sample taken from Claybury CPN Stress
Study (Fagin et al. 1995). Further
analysis undertaken on self-esteem
Carson et al. (1997b) S DCLSS CMHNs are no more likely to experience
higher stress than their hospital counterparts.
Rank order of questionnaire data for CMHNs
and WBMHNs determined that having too
little time to plan and evaluate treatment as
the highest stress score
Random sample. No information
provided on reliability of scale.
Basic statistic analysis. Poor
response rate
Carson et al. (1997c) See Fagin et al. (1996) The high fitness group scored significantly lower
on all subscales of the MBI and the GHQ-28,
and had significantly greater levels of job
satisfaction and utilized a great number
of coping skills
Sample taken from Fagin et al.
(1996). Further analysis undertaken
on fitness and stress. Fitness levels
were self- reported and scored on
a scale of 1 (excellent) to 4 (poor).
High fitness group responses 1 or 2
and low fitness group responses 3 or 4
Carson et al. (1998) S,
M,
B,
JS,
PD
DCLSS,
RSES, PMS, CCSS,
SOS (sv), EPQ-R (sv)
MBI
MJSS (sv)
GHQ-28
The results showed that a social support-based
programme offered no significant advantage
over a feedback only programme
Random sample. Length of sessions
2 hours everyday for a week. No
power calculation. Three participants
dropped out form the intervention
and at 6-month follow-up 17 were
reassessed (71%). Three participants
dropped out from the control group
and at 6 months follow-up 17 were
reassessed (74%). Statistical analysis
– no details of tests used. Poor attendance
at sessions (three of 25 participants
attended all five sessions). Six months
follow-up
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Table 4 (Continued)
Carson et al. (1999) B Same measures as
Carson et al. (1995)
DCLSS (for Study 2 and 3)
The high burnout group reported an unhappier
outlook on life, a self-reported lower level of
fitness, they felt less able to discuss work
problems with their colleagues and regarded
their line manager as less supportive than
the low burnout participants did. The low
burnout group scored significantly higher
on total coping skills score, job satisfaction
score, scored significantly lower for total
stress experienced and total GHQ score
**Sample taken from Fagin et al. (1996).
Further analysis undertaken on burnout.
Basic statistical analysis. Limitations
acknowledged
Coffey (1999) S,
B,
PD
CPNSQ,
MBI,
GHQ-28
that lack of facilities had the highest mean score
Basic statistical analysis (rank order),
limitations recognized, excluded
workers in own service
Coffey (2000) S, C SRQ The most frequently mentioned stressor
was concerns relating to the particular
client groups with which they worked.
The most frequently mentioned coping
strategy was receiving support of colleagues
Coffey (1999) presenting data on
self-reported measures from demographic
questionnaire
Coffey and Coleman (2001) See Coffey (1999) Authors summarize findings as statistically
significant associations were found between
caseload size and level of stress. The results
also suggest that support from managers and
colleagues were an important factor in
ameliorating the experience of stress
Same research study as reported by Coffey
(1999) presenting data on comparison
of respondent characteristic against
study measures. Multiple comparisons
conducted
Limitations recognized
Coyle et al. (2000) See Edwards et al. (2000) The mean overall coping scores were significantly
higher for females, for those who felt that they
had job security, who were older and who
had worked in the field for longer
Edwards et al. (2000) presenting
more detailed data for the PNMC.
Basic statistical analysis
Dallender et al. (1999) S,
M
PDT,
WES
For the MHNs the main source of support was
peer support. The most favoured coping
strategy was seeking a solution to the problem
Purposive convenience sample. Basic
statistical analysis. The authors are
referred to previous publication for
the validity and reliability of the tool
Dallender et al. (2002) JS SRQ Both nursing groups reported that the intrinsic
nature of the work was an item of
satisfaction and excessive administration
demands was an item of dissatisfaction
Fifty CMHNs and 50 WBMHNs
randomly selected from previous study
conducted by the authors (Dallender
et al. 1999). Sampling methods not
specified. Self-reporting factors for job
satisfaction
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Table 4 (Continued)
Dolan (1987) B,
JS
MBI,
PDT
No significant difference between GNs and
MHNs on levels of job satisfaction
Pilot study. Random sample however,
there were insufficient numbers recruited
so the inclusion criteria were extended,
control group of clerical staff. All
female sample. Basic statistical analysis.
Modified the MBI with no data on the
validity and reliability presented
Drake and Brimblecombe (1999) S CPNSQ Rank order of questionnaire data determined
that having to see inappropriate referrals
(CTT staff) and having to work with
suicidal clients alone (CMHT staff) had the
highest mean scores. No evidence to
support concerns that working in a team
providing rapid assessment and intensive
home treatment for those with severe
acute mental health problems is more
stressful that working in a generic team
Small sample size, no statistical analysis
of total score for CPNSQ. Basic statistical
analysis (rank order)
Edwards et al. (2000) S,
M,
B,
PD
CPNSQ,
PNMCQ, RSES,
MBI,
GHQ-12
that lack of facilities within the community
had the highest mean stress score
Rank order of questionnaire data determined that
having a stable home life that is kept separate from
my work life was the highest mean coping score
Mean score RSES: 18Æ8 (SD
SD 4Æ7).
For mean GHQ-12 scores see Table 7.
CMHNs who smoked, who felt that they
did not have job security, who were divorced,
widowed or separated has significantly higher
mean scores for the GHQ-12
Basic statistical analysis (rank order).
Advanced statistical analysis conducted
in a series of companion papers
Edwards et al. (2001) See Edwards
et al. (2000)
The best predictors of high stress scores were
levels of emotional exhaustion, working with
clients were severe mental illness, job in
security and alcohol consumption
Edwards et al. (2000) presenting more
detailed data for the CPNSQ. Advanced
statistical analysis (multiple regression analysis)
Ewers et al. (2002) B* MBI Staff in the experimental group showed significant
decrease in burnout rates. Staff in control
group showed a small nonsignificant increase
in burnout. For mean MBI scores see Table 6
Quasi-experimental design pre-test/post-test
design, basic statistical analysis – Fishers
exact tests taking into account small sample
size. Self-selected sample then randomly
allocated to control and intervention
groups. No follow-up period, length
of sessions – 20 one-day sessions over
a 6- month period. Limitations recognized
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Table 4 (Continued)
Fagin et al. (1995) S,
M,
B,
JS,
PD
CPN SQ (R),
OSI – CCSS, RSES,
MBI,
MJSS,
GHQ-28
not having enough facilities in the community
had the highest stress score
The highest mean coping subscore was task strategies.
For CMHNs the mean RSES score 16Æ6. 18% categorized
with low self-esteem. For WBMHNs the
mean score 16Æ9, 14Æ6% categorized with low self-esteem.
For mean MBI scores see Table 6.
For CMHNs the mean intrinsic MJSS score
was 44Æ1, extrinsic MJSS score was 16Æ4, total
score 66Æ1. For WBMHNs the mean intrinsic MJSS score
was 40Æ1, extrinsic MJSS was 16Æ5, total score 62Æ6
Claybury CPN Stress Study. Sampling
undertaken on an opportunities basis –
volunteers
Fagin et al. (1996) S,
M,
B
Same measures as Fagin
et al. (1995),
DCL SS (For Study 2 and 3)
that inadequate staffing to cover potentially
dangerous situations had the highest mean
stress score The highest mean coping subscore
for all studies was task strategies
For validity of DCLSS readers referred to
work submitted to journal in 1996. Work
still unpublished to date. Study 3 hospitals
scheduled for closure. Data from each
study are presented separately and
compared. Inadequate explanation of
statistical analysis. Data for MBI for
study for percentage of WBMHNs
with high burnout is different from
that reported from same sample by
Fagin et al. (1995)
Fielding and Weaver
(1994)
S,
B,
PD
WES,
MBI,
GHQ-12
Nurses working flexitime reported the most
negative perceptions of their work environment
and higher scores for stress related variables.
CMHNs gave higher ratings than WBMHNs
for involvement, supervisor support, autonomy,
innovation and work pressure
Inclusion criteria – professional nursing
qualification, employed at grade H,
worked full time. No post hoc testing.
No statistical data presented for
comparison of differences between
MBI scores
Fothergill et al. (2000) See Edwards et al. (2000) Factors associated with low self-esteem were
alcohol consumption and being in lower
nursing grades (D, E and F).
Factors associated with high self-esteem was
amount of time working as a CMHN
detailed data for the RSES
Giloran et al. (1994) JS PDT Staff nurses were found to have significantly
lower satisfaction and lower perception
of ward morale than nurses of other grades
Random sampling (stratified). A part
of a larger piece of research, this
paper just presents data from
comparison of staff nurses with
nurses of other grades. No data for
reliability and validity of this measure
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Table 4 (Continued)
Hannigan et al. (2000) See Edwards et al.
(2000)
Working in an urban environment and lacking a supportive
line manager were significant indicators for higher EE.
Reporting an unsupportive line manager, being male,
job insecurity and not having an elderly caseload were
significant indicators for higher DP. Not having completed
specialist training, and not working in a supervisory or
managerial position were significant indicators for lower PA
detailed data for the MBI. Abstract
and results misinterpret data presented
in table
Harper et al. (1992) JS PJSS General satisfaction reported to be higher and satisfaction with
working conditions and emotional climate same as patients
at time point T2 from Humphris and Turner (1989)
Purposive sample. Adapted validated
questionnaire, pretested for reliability.
Statistical analysis – compared findings
to Humphris and Turner (1989) but did
not undertake any statistical analysis
just ‘eyeballing’ results
Humphris and Turner (1989) JS PJSS, NSQ Statistically significant improvement in scores at Time 3
for satisfaction with working conditions and general
satisfaction. Staff turnover was associated with lower
levels of satisfaction
Quasi experimental design, two measures
used were adapted and reliability and
validity were reported. Statistical analysis –
conducted separately for staff who had
replied on all three occasions (numbers not
specified). No post hoc testing
Jones et al. (1987) S,
JS,
PD
PDT,
WJSS,
GHQ-12
Three factors emerged accounting for 45% of the variance.
The most dominant stress factor was administration
(28% of the variance) ‘Job satisfaction among this sample
is relatively low compared with some other employed
samples’. Scores on the GHQ were greater for those
who had a spouse working at the same hospital
Purpose convenience sample. Reliability
and validity of tool not discussed and
no piloting undertaken. Advanced statistical
analysis undertaken (principle components
analysis with varimax rotation). For the
WJSS no statistical data was presented
Kilfedder (2001) S,
M,
B,
PD,
JS
UPCS, RCM, RAM,
JFAQ, Psyom, PDT,
NSS, CCSS, SSM,
PANAS, MBI,
GHQ-12,
WJSS
Two per cent (n ¼ 10) of the total sample could be classified
as having high burnout. Emotional exhaustion was
increased by role conflict, nonoccupational concerns,
nursing stressors, negative affectivity and psychological
distress and was decreased by predictability of job-related
events, certainty in relation to job security, social
support, positive affectivity and job satisfaction.
Depersonalization was increased by negative
affectivity and reduced by predictability in job
related events. Personal accomplishment was
increased by control over job- related events and
positive affectivity, whilst being reduced by
being in post longer, having higher levels of job
related predictability and role ambiguity. For
mean MBI scores see Table 6
Random sampling (stratified by working
location). Advanced statistical analysis
(hierarchical regression analyses).
Developed five questions to measure
nonoccupational stressors and there is
no data for reliability and validity of
this measure
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Table 4 (Continued)
Kirby and Pollock (1995) S OSI, WES No significant differences of occupational stress or
perception of ward environment between nurses
on the two wards. When OSI was compared with
normative data the scores were elevated for the
subscales of control, satisfaction and type
‘A’ behaviour. No association between OSI
scores and demographic characteristics or work
environment variables form regression analysis
Purposive sample. Advanced statistical
analysis (regression analysis). Small
sample size in regard to type of advanced
statistical analysis undertaken
Kunkler and Whittick (1991) B,
PD
GHQ-28,
BC
All mean scores decreased over the course of
the project but the burnout scores decreased
most over the group intervention
Pilot study, length of sessions – three sessions
held once a fortnight with a fourth
follow-up session after a delay of four the
period of weeks each session lasting 1Æ5 hours
Staff did not attend sessions consistently and
did not complete questionnaires on all four
occasions. No statistical analysis undertaken
was undertaken for Workshop 1.
For Workshop 2 no statistical data is
presented. Small sample size. Sample
was self-selected from responding to
a poster on the wards
Leary et al. (1995) S,
M,
PDT,
PDT
Nine factors emerged accounting for 72Æ5%
of the total variance in total stress scores.
The most dominant stress factor was that of
feeling professionally isolated (43% of
variance). Twelve factors emerged accounting
for 76Æ2% of the total variance in total
coping score The most dominant coping
strategy was the utilization of appropriate
time management skills (37% of variance)
Sixty-one stress items developed by Carson
et al. (1991) Sixty-one coping items
generated from interviews with 21
CMHNs. Q Sort statements developed
and piloted on four CMHNs. Statistical
analysis – factor analysis. Well-documented
validity and reliability
Lemma (2000) B,
PD
MBI,
GHQ-28*
Nurses in I1 and I2 reported significantly
lower levels of psychological distress and
overall levels of burnout but at 10-week
follow-up had reverted back to their precourse
levels
Nurses in I1 reported a significant increase
in levels of PA, whereas those in I2 showed no
change. At follow-up nurses in I1 did not
maintain levels of PA
CMHNs were significantly more likely
to be scored as cases and to have
higher levels of PA
Volunteers who were then randomized
to two intervention groups and a case
matched control group. Matched on
employment capacity, place of work,
level of experience, level of previous
exposure to therapeutic skills. Length
of sessions 20 three-hour sessions. Basic
and advanced statistics (stepwise multiple
regression, logistic regression). Small
sample size for advanced statistical
techniques. Measures given at baseline,
completion of course and at 10-week
follow-up. No power calculations
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Table 4 (Continued)
McCarthy (1985) B SBSHP Nurses between the ages of 21 and 29 had
significantly higher burnout scores than
those between the ages of 29 and 59
No sampling details provided and small
sample size. Basic statistical analysis –
ANOVA
ANOVA inappropriate as very small
numbers within subgroups
McElfatrick et al. (2000) M PDT,
OSI – CSS
The authors new scale for coping was found
to be more reliable and valid when applied to
MHNs. CMHNs scored significantly higher
on both coping scales than WBMHNs. Females
were significantly more likely to use social support
and emotional comfort as a coping strategy
Low response rate. Well-documented validity
and reliability
McLeod (1997) S,
PD
PDT,
GHQ-28
The most frequently reported stressors for each
group were too many referrals/caseloads too large
(groups 1 and 2) and clerical administration (group 3).
CMHNs working with SMI are more stressed than those
working with primary or the more neurotic client group
For mean GHQ scores see Table 7
Convenience sampling used first 60
responses to obtain three equal groups
(long-term mentally ill, mixed caseload,
neurosis or primary clients). No statistical
data provided. Self-reporting of stressors
Milne et al. (1986) S,
PD
PDT, WES,
GHQ-12
Twelve items on the 98-item questionnaire strongly
discriminated between wards with high and low
levels of absenteeism sickness
The innovation was associated with reduction in
absenteeism sickness and increased
confidence and work skills
Purposive convenience sampling.
Questionnaire design. Small sample size
with no sampling details provided. Length
of sessions 1 day everyday for 1 week.
No details provided of statistical tests.
Measures given at baseline and 1 year
prior to training and 1-year follow-up
Mountain et al. (1990) JS WJSS Unqualified staff reported significantly greater satisfaction
with the job itself and working conditions than staff
or managerial grades
Random sampling (stratified by grade),
pilot study. Statistical analysis – no
post hoc testing
Muscroft (1998) S,
M
PDT More stress at work was experienced by GNs than MHNs
GNs more likely to talk to someone about their
stress in particularly colleagues and to use
professional work-based counselling services
Tools piloted for validity. Random
sampling stratified by grade. No
details of questionnaire scoring. Small
sample with poor response rate
Nolan (1995) S,
M,
PD
MHPSS, SCL-18,
CS,
GHQ-28
Stress factors were found to be overly heavy workload,
difficulties with clients, organizational structure,
interprofessional conflict, under resourcing, professional
self-doubt, home/work conflict
Most consistent predictor of poor mental health
outcomes was home/work conflict
Statistical analysis – factor analysis,
findings not supported by evidence
of the statistical process. Conclusions
reached not justified by information given.
Reader referred to authors previous work
for further details
Parahoo (1991) JS PDT Seventy per cent rated job satisfaction a high
or very high. Most frequently mentioned
factor for job satisfaction was being one’s
own manager/independent practitioner and
for job dissatisfaction paperwork/clerical duties
Reliability and validity of purpose
designed tool not discussed and no
piloting undertaken. Self-reporting of
factors. Lack of generalizability because
of particular organizational and cultural
contexts practised in the province
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Table 4 (Continued)
Parry-Jones and Grant (1998) S,
JS
PDT The research indicated increases in stress and
decreases in job satisfaction, which was
associated with increased workload and
administrative duties combined with
reduced time for the service user
and family contact
Poor sampling methods resulting in low
response rate. Reliability and validity
of purpose designed tool not discussed
and no piloting undertaken. Advanced
statistical analysis – multiple regression
analysis
Peacock (1991) S,
M,
JS,
SM
PDT For stress four factors emerged accounting for
60% of the variance. The most dominant
stress factor was staff shortages and support
(18Æ54 of the variance). Day shift workers scored
significantly higher than night shift workers
The most frequently used coping strategy appeared
to be tackling problems directly they arise
For job satisfaction five factors emerged accounting
for 66Æ7% of the variance. The most dominant
factor for job satisfaction was communications and
influence (21Æ2% of the variance). Day
shift workers scored significantly higher
than night shift workers
The most frequently used stress management
technique was relaxation training
Hospital where sample was drawn was
awaiting closure. Questionnaire piloted
on two separate samples and data on
validity and reliability presented.
Advanced statistical analysis (principle
components analysis, multiple
regression analysis)
Plant (1992) S NSS interviews The lowest mean scores were reported
for MHNs
The highest stress scores among females were
evident amongst MNs while the lowest were
reported by MHNs
Cross-sectional survey, random sample
(stratified by grade)
Respondents selected from current hospital
staff lists Statistical analysis – no post hoc
testing. Female sample
Rees (1991) S OSI Mean score OSI – sources of pressure
subscale: 210Æ6 (MHNs), 213Æ1 (CMHNs).
CMHNs ranked 1 and WBMHNs ranked
2 of 17 different professional groups
Random sampling (stratified by grade),
only results for sources of pressure
presented for MHNs, other paper
from study presents data for the
17 professional groups as a whole
Reeves (1994) PD GHQ-28 For mean scores see Table 6. Concluded
that the effects of stress on psychiatric
and medical nurses were found to be similar
GHQ scoring method, threshold greater
than 5. Subgroup analysis – Mann–
Whitney U-tests, multiple regression
analysis – however, number of variables
used was limited
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Table 4 (Continued)
Ryan and Quayle (1999) S,
M,
PD
OSI,
WOC,
GHQ-60
The most frequently reported sources of stress
related to organizational issues
The most frequently reported measure of coping was
the use of self-controlling strategies
The mean score for the GHQ60 was 4Æ74 (SD
SD
8Æ48) 7% respondents reporting stress
levels which are unlikely to remit
without intervention
Random sampling (stratified by gender
and grade)
Statistical analysis – multiple comparisons
Sammut (1997) JS PDT MHNs preferred working at the older,
more spacious psychiatric hospitals
compared with modern district general
hospitals
No data for reliability and validity of this
measure. Very specific study with little
generalizability
Schafer (1992) S,
B,
PD
CPNSQ,
MBI,
GHQ-28
that having too many interruptions in the
office (pre change), and lack of facilities
(post change) had the highest mean scores
For mean GHQ28 scores see Table 7
Small scale study. Basic statistical analysis
(rank order). Lack of statistical data
presented for any comparative analysis
Snelgrove (1998) S,
PD,
JS
PDT,
GHQ-12,
PDT
For the whole community sample four
factors emerged accounting for 38%
of the total variance. The most dominant
stress factor was that of emotional
pressure/difficulty (25% of variance).
For CMHNs the most frequently
reported stressor was quantifying work
Advanced statistical analysis (principal
component analysis with varimax
rotation). Statistical analysis – no
post hoc testing
Sullivan (1993b) S,
M,
B
PDT,
PDT,
MBI
Rank order of questionnaire items determined
that seeking social support had the highest
mean score. For mean MBI scores
see Table 6
Convenience sample. Reliability and
validity of purpose designed tool not
discussed and no piloting undertaken
The questionnaire generated a total
score and five subscales, however,
this data was not presented. Statistical
analysis (rank order)
Wykes and Whittington (1998) PD GHQ-28* Assaulted victims reported poorer mental
health than controls when compared
with baseline data. Psychological distress
was higher following assaults. For mean
GHQ scores see Table 7
Prospective design – control groups
matched for age and occupational
grade. Sample selection methods
inadequately described. Inadequate
reported of statistical analysis
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Table 4 (Continued)
Watson (1986) S,
M
SCL,
CCL
The scores after completing the course
showed that participants significantly
lowered their anxiety and improved levels
of coping compared with the control group.
There were no significant differences in the
group’s perceptions of their work-based stressors
No sampling details, no period of
follow-up Length of sessions 1
/2 day
once a week for 6 weeks, small
sample size. Statistical tests – no
details provided. Measures collected
pre-course and post-course
Outcome measures: B ¼ burnout, C ¼ coping, S ¼ stressors, M ¼ moderators, JS ¼ job satisfaction, PD ¼ psychological distress, sv, Short version. Psychometric tests: BC, Burnout
Checklist (Bailey 1985); BI, Burnout Inventory (Cherniss 1980); CCL, Coping Checklist (McLean 1979); CCSS, Cooper Coping Skills Scale (Cooper et al. 1998); CPNSQ, Community
Psychiatric Nurse Stress Questionnaire (Carson et al. 1991); CS, Coping Schedule (Moos 1984); DCL SS, The DeVilliers, Carson, Leary Stress Scale (Carson 1997); EPQ-R, Eysenck
Personality Questionnaire Short Scale (Eysenck Eysenck 1991); GHQ-12/28/60, General Health Questionnaire version 12/28/60 (Goldberg Williams 1998); IWSQ, Index of Work
Satisfaction (Slavitt et al. 1978); JFAQ, Job Future Ambiguity Questionnaire (Caplan et al. 1980); MBI, Maslach Burnout Inventory (Maslach Jackson 1986); MJSS, Minnesota Job
Satisfaction Scale (Weiss et al. 1967); MPHSS, Mental Health Professional SubScale (Cushway et al. 1996); NSQ, Nurse Satisfaction Questionnaire (Ward Felter 1979); NSS, Nursing
Stress Scale (Gray Toft Anderson 1981); NSSQ, Norbeck Social Support Questionnaire (Norbeck et al. 1983); OSI, Occupational Stress Indicator (Cooper et al. 1998); PANAS, Positive
and Negative Affectivity Scale (Watson et al. 1988); PJSS, Porters Job Satisfaction Scale (Porter 1962); PMS, Pearlin Mastery Scale (Pearlin Schooler 1978); PNMCQ, Psych Nurse
Methods of Coping Questionnaire (McElfatrick et al. 2000); Psyom, Psychosomatic Physiological Stress Symptoms (Burton et al. 1996); RAM, Role Ambiguity Measure (Caplan et al.
1980); RCM, Role Conflict Measure (Caplan et al. 1980); RSES, Rosenberg Self-Esteem Scale (Rosenberg 1965); SBS-HP, Staff Burnout Scale for Health Professionals (Jones 1980); SCL,
Stressor Checklist (McLean 1979); SCL 90-R, Symptom Checklist 90-R (Derogatis 1983); SCL-18, Symptom Check List 18 (Derogatis 1983); SOS, Significant Others Scale (Power et al.
1988); SRQ, Self-Reported Questionnaire; SSM, Social Support Measure (House Wells 1978); UPSC, Understanding, Predictability and Control Scale (Tetrick LaRocco 1987); WES,
Work Environment Scale (Moos 1986); WJSS, Warrs’ Job Satisfaction Scale (Warr 1979); WOC, Ways of Coping Questionnaire (Lazarus Folkman 1984).
*Other tools used to measure different outcome measures.
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Table 5 Summary of articles included in the review from studies conducted outside the UK
Author Aim Study population Sample size Response rate (%)
Mansfield et al. (1989) To measure nurses’ job context in
an institutional setting
Nurses who were members of a
state-wide professional
nursing association, USA
4925 985 (29) 6% psychiatry
Alexander et al. (1998) To investigate the relationship of job
satisfaction to nursing personnel’s
intention to leave and turnover
All staff (RNs, LPNs, NAs)
working within 19 long-term
psychiatric hospitals, USA
Ns 1106 (Ns)
Gordon and Goble (1986) See text
Trygstad (1986) To measure levels of stress in a
sample of MHNs
MHNs working within four units
of three private hospitals and five
units of one federal hospital, USA
Ns 22 (Ns)
Cronin-Stubbs and Rooks (1985) To identify stressors that are associated
with burnout in critical care,
psychiatric, operating room
and medical nurses
MHNs, ORNs, ICNs, MNs working
within three metropolitan medical
hospitals, USA
MHNs (Ns)
ORNs (Ns)
ICNs (Ns)
MNs (Ns)
66 (Ns)
65 (Ns)
74 (Ns)
91 (Ns)
Davis (1974) To measure intrarole conflict
and job satisfaction
MHNs working within a
psychiatric hospital, USA
Ns 17 (Ns)
Dawkins (1985) To identify and quantify job
stress as perceived by MHNs
MHNs working within a
psychiatric hospital, USA
43 43 (100)
Dorr (1980) To examine the relationship between
social climate and job satisfaction
Nursing staff (RNs, LPNs, NAs, WCs)
working within private psychiatric
hospital, USA
92 66 (72)
Farrell and Dares (1999) To examine job satisfaction in
a group of MHNs
MHNs working within acute inpatient
psychiatric unit in a large general
hospital, Tasmania
23 22 (87)
Munro et al. (1998) To examine the effects of occupational
stress in psychiatric in psychiatric
nursing on employee health well-
being in terms of job satisfaction
and mental health
MHNs working within five units of a
private inpatient facility, Australia
100 60 (60)
Humpel and Caputi (2001) To examine the relationship between
emotional competency and work
stress and the length of time
in mental health nursing
MHNs working within three mental
health inpatient units, Australia
63 52 (83)
Rump (1979) To examine the relationship between
the size of psychiatric hospital
and nurses’ job satisfaction
MHNs working within three psychiatric
hospitals (all staff), Australia
623 486 (78)
Ito et al. (2001) To examine factors which influence
nurses’ intention to leave the job
MHNs working within the Fukuka Association
of Psychiatric Hospitals, Japan
1965 1494 (76)
Integrative
literature
reviews
and
meta-analyses
Stress
management
interventions
for
mental
health
nurses

2003
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Publishing
Ltd,
Journal
of
Advanced
Nursing,
42(2),
169–200
187

Table 5 (Continued)
Author Aim Study population Sample size Response rate (%)
Astrom et al. (1990) To compare levels of empathy,
experience of burnout and attitudes
towards demented patients amongst
different categories of nursing staff
Nursing staff (RNs, LPNs, NAs)
working within a nursing home,
long-term care clinic and a
psychogeriatric clinic in
one health district, Sweden
557 358 (64)
Melchior et al. (1997a) See text
Melchior et al. (1997b) To investigate the relationship between
burnout and a number of work-related
variables
Nursing staff (ULs, PNs, NAs),
working in long stay settings,
the Netherlands
494 631 (73)
Berg and Hallberg (1999) See text
Berg et al. (1994) See text
Hallberg (1994) See text
Melchior et al. (1996) See text
Tummers et al. (2001) To examine differences in work
characteristics (autonomy,
social support and workload)
and work reactions (emotional
exhaustion and job involvement)
between GNs and MHNs
MHNs working within five wards
of a psychiatric hospital and GNs
working within five wards of a
general hospital, the Netherlands
GNs 316
MHNs 273
196 (62)
175 (64)
Landeweerd and Boumanns (1988a) To compare nurses’ work satisfaction
and feelings of health and stress
in three psychiatric departments
differing in type of work
Nurses working within three
departments of a psychiatric
hospital, the Netherlands
Long-stay 19
Short-stay 27
Admission 19
Ns
Convenience sample
Landeweerd and Boumanns (1988b) To compare nurses’ work satisfaction
and feelings of health and stress
in three psychiatric departments
differing in type of work
and two general departments
Nurses working within two
departments or a general hospital
and three departments of a
psychiatric hospital (same sample
as Landeweerd Boumanns
1988a), the Netherlands
CC 21
GS 14
Long-stay 19
Short-stay 27
Admission 19
Ns
Convenience sample
Thomsen et al. (1999) To describe the possible differences
between psychosocial work
environments of English
and Swedish MHNs
MHNs from five health trusts in UK
(randomly selected) and MHNs
from eight health districts
in Sweden (all nurses)
UK 657
Sweden 1058
296 (45)
720 (68)
Samuelsson et al. (1997) To examine suicidal feelings,
attempted suicide and aspects of
work environment and well-being
Nurses and attendants working
within in psychiatric care
243 197 (81)
RNs, Registered Nurses; LPNs, Licensed Practical Nurses; NAs, Nurses Aides; MHNs, Mental Health Nurses; ORs, Operating Room Nurses; ICNs, Intensive Care Nurses; WCs, Ward
Clerks; Uls, Unit Leaders; PNs, Practical Nurses; GNs, General Nurses; CC, Cardiac Care; GS, General Surgery.
D.
Edwards
and
P.
Burnard
188

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Ltd,
Journal
of
Advanced
Nursing,
42(2),
169–200

the lives of nurses working in a large psychiatric hospital in
the USA. The sample consisted of 43 nurses, 41 of whom were
female. Thirteen of the high stress items, including the first 11,
were classified as arising from administrative/organizational
issues. Other sources of stress were revealed to be staff
conflicts and limited resources. Mansfield (1989) conducted a
study to measure nurses’ job context in an institutional setting
with nurses from 10 different clinical specialities, 6% from
psychiatry. The scale used was the Nurse Job Context Scale,
which the authors developed, and details of this were
provided. The scale measured general pressure/uncertainty
and those working in psychiatry, paediatrics and outpatient
unit reported lowest levels of stress when compared with other
areas such as intensive care, general medicine and surgery.
In a 1988 study, Landeweerd and Boumanns compared
nurses’ work satisfaction and feelings of health and stress in
three psychiatric departments differing in type of work in the
Netherlands. The measures used were the Work Satisfaction
Questionnaire (Algera 1980) and a purpose-designed tool to
measure feelings of health and stress. Within the psychiatric
hospital, staff working in a short-stay department reported
low work satisfaction and low scores on health and stress
variables when compared with those in admission and long-
stay departments. The statistical analysis, undertaken was
basic and analysis of variance (ANOVA
ANOVA) was used to compare
three means as opposed to paired t-tests. Caution should be
exercised in generalizing from this study, given the small
sample size and the use of a purpose designed tool without
any data on validity and reliability (Landeweerd
Boumanns 1988a). At the same time the authors collected
data from nurses working on a cardiac care unit and a general
surgical ward, both in a general hospital, using the same
measures. The Cardiac Care Unit received the most positive
scores for six of seven satisfaction variables, and the short-
stay departments received the most negative scores on four of
seven satisfaction variables. Six aspects of self-reported stress
were assessed (general health, heart complaints, nervousness,
depression, irritability and stress feelings). There were
differences in relation to irritability and stress feelings, with
those working on the general surgical ward having the lowest
scores. However, these results did not stand up to post hoc
testing. The analysis was repeated by combining the data for
the general hospital with those for the psychiatric hospital
(excluding the admissions ward). Nurses in the general
hospital reported more work satisfaction and fewer health-
and stress-related problems (Landeweerd Boumanns
1988b).
The critical factor in the stress process is the moderators on
which an individual can call to help cope with external
stressors that are impinging upon them. Carson and Kuipers
(1998) identify seven such factors: high levels of self-esteem,
good social support networks, hardiness, good coping skills,
mastery and personal control, emotional stability and good
physiological release mechanisms. Possession of these buffer-
ing factors serves to minimize the effects of stress. An
individual’s self-esteem is probably one of the most important
of these moderators (Turner Roszell 1994). Those with
high self-esteem are more likely to have a greater sense of self-
efficacy and self-worth (Branden 1994), and are likely to be
more confident in dealing with stressors. Three papers gave
consideration to these issues and 17 studies investigated the
range of strategies that individuals bring to bear to deal with
stressors (see Table 4).
The final level of the model is that of stress outcomes. These
include positive stress outcomes such as psychological health
and high job satisfaction, and negative stress outcomes such as
psychological ill health, burnout and low job satisfaction.
Burnout is described as a syndrome consisting of three
dimensions: emotional exhaustion (inability of individuals to
give of themselves at a psychological level), depersonalization
(development of cold negative attitudes towards those who
provide public services) and personal accomplishment (the
loss of the ability to value one’s achievements at work).
Seventeen studies undertaken in the UK investigated various
aspects of job satisfaction and of these six reported a variety of
issues regarding job satisfaction and working with older
clients (see Table 4). Seven studies were conducted outside the
UK and these are summarized below.
In an Australian study, Munro et al. (1998) investigated
the effects of occupational stress in mental health nurses on
employee well-being (job satisfaction and mental health)
using a questionnaire based on the Job Strain Model (Dwyer
Ganster 1991), Warr Job Satisfaction Scale (Warr et al.
1979) and General Health Questionnaire (Banks 1980). The
researchers found that nurses who perceived themselves as
having greater job control and social support, both in the
workplace and their lives in general, were healthier and more
satisfied in their work. The research used advanced statistical
techniques of multiple regression analysis, but adapted
the Job Control Scale without providing any evidence of
validity. Another Australian study, by Rump (1979), aimed
to examine the relationship between the size of psychiatric
hospitals and nurses’ job satisfaction. Using a purpose-
designed tool without conducting any validity or reliability
testing, data from this large-scale study found that satisfac-
tion amongst nursing staff is related to size as defined by
number of staff.
The aim of the study by Dorr et al. (1980) was to examine
the relationship between social climate of psychiatric wards
and mental health nurses’ job satisfaction. The Ward

Atmosphere Scale (Moos 1974) was used and it was found
that job satisfaction was reliably related to views of the social
climate of the wards on nurses worked. This study used basic
statistical techniques and there were very few details on the
tool used. Davis (1974) conducted a small study of intrarole
conflict (measured using a purpose-designed questionnaire)
and job satisfaction (using a validated tool). Seventeen
psychiatric nurses completed these measures and the results
did not support the hypothesis that the higher the intrarole
conflict, the lower the job satisfaction. Farrell and Dares
(1999), using a job satisfaction questionnaire, reported that
key job satisfaction characteristics were where participants
had interesting work to do, work which gave them respon-
sibility, and good interpersonal relationships with colleagues.
However, the authors also noted that these findings did not
necessarily match respondents’ views on being interviewed,
when interviewed they reported both having little control
over decision-making and low staff morale. The study was a
small one and in a specific geographical area.
Two studies investigated issues around turnover of staff.
Alexander et al. (1998) investigated the relationship of job
satisfaction to nursing personnel’s intention to leave and
turnover using a purpose-designed tool. There were no details
provided for response rate or validity and reliability. Factors
associated with job satisfaction were workload (RNs),
autonomy (LPNs, NAs) and work hazards (LPNs, NAs). In
Japan, Ito et al. (2001) investigated factors which influenced
nurses’ intention to leave the job, and used the National
Institute for Occupational Safety and Health Job Stress
Questionnaire, which had been translated into Japanese
(Haratani 1998). Findings from logistic regression analysis
revealed that having fewer previous job changes, being
younger, having less supervisory support, lower job satisfac-
tion and having a higher perceived risk of assault influenced
nurses’ intention to leave.
Eighteen studies have investigated burnout in the UK and
17 have investigated psychological distress as a stress
outcome. Table 6 summarizes the results of studies using
the Maslach Burnout Inventory (MBI) to measure burnout
and shows that reported levels of emotional exhaustion range
from 22% to 51%, levels of depersonalization from 7% to
45% and levels of personal accomplishment between 14%
and 33%. Table 7 shows that 27–42% of psychiatric nurses
scored above the threshold for vulnerability to psychiatric
morbidity. Seven studies conducted outside the UK and one
additional study undertaken by Melchior et al. (1997a) set
out to describe the relative influence of a number of variables
on burnout among psychiatric nurses, using the technique of
meta-analysis. The results revealed that burnout was negat-
ively associated with job satisfaction, staff support and
involvement with the organization, and positively associated
with role conflict. However, not all the studies included
separate results for psychiatric nurses. A number were of
mental health professionals (Stout Posner 1984, Savicki
Cooley 1987, Leiter 1988), one presented combined results
for psychiatric and ‘mental handicap’ nurses (Firth et al.
1986), and another nursing students (Van Gorp et al. 1993).
The studies conducted outside the UK are summarized below.
Tummers et al. (2001) investigated differences in work
characteristics and work reactions, which included levels of
emotional exhaustion between general, and mental health
nurses. Emotional exhaustion was measured using the Dutch
version of the MBI and analysis revealed that mental health
nurses experienced greater levels of emotional exhaustion.
The aim of the study conducted by Cronin-Stubbs and Rooks
(1985) was to identify stressors associated with burnout in
critical care, psychiatric, operating room and medical nurses.
Purposive sampling was undertaken but the authors did not
provide details of the populations. Well-validated scales were
used and included the Life Experiences Survey (Sarason et al.
1978), Staff Burnout Scale for Health Professionals (Jones
1980), Nursing Stress Scale (Gray Toft Anderson 1981)
and Norbeck Social Support Questionnaire (Norbeck et al.
1983). Multiple regression analysis was conducted to deter-
mine the predictors of burnout. Thirty-five per cent of the
variance in burnout could be accounted for, and the predictor
variables were intensity of occupational stress, changes in life
stress (positive and negative), social support: affect, work
setting: psychiatric/mental health unit and work setting:
operating room. Multivariate analysis revealed significant
differences in occupational stress among work settings and
levels of social support. Investigating this further revealed
that critical care and medical nurses encountered occupa-
tional stressors significantly more frequently and intensely
than psychiatric and operating room nurses. Critical care
nurses experienced significantly more affirmation than psy-
chiatric nurses, and operating room nurses experienced more
aid than psychiatric nurses. There were no significant
differences in burnout among the four work settings.
The purpose of the study conducted by Thomsen et al.
(1999) was to identify and describe the possible differences
between psychosocial work environments of English and
Swedish mental health nurses. A variety of purpose-designed
tools were used to collect information on professional
fulfilment mental energy, work-related exhaustion, occupa-
tional well-being and coping, and data on reliability and
validity were presented. Self-esteem was measured using the
Rosenberg Self-Esteem Scale (Rosenberg 1965). Swedish
nurses experienced a higher level of well-being than their
British counterparts. Regression analysis was conducted for

all the nurses. Factors associated with higher psychological
well-being were lower alcohol consumption, being male,
being a clinic-based nurse and having fewer days sick leave in
the year before the study. Higher exhaustion was associated
with having taken more sick days in the last year, being
female and being under 40 years of age. Higher professional
fulfilment was associated with working full-time and taking
fewer days sick in the last year. Factors that predicted
psychological well-being were self-esteem, professional ful-
filment, workload and sick days in the last year. Factors that
Table 6 Comparison of MBI scores
Study Population Setting n EE DP PA
EE
(%)
PA
(% high)
DP
(%)
MBI manual normative scores 730 16Æ9 (8Æ90) 5Æ7 (4Æ62) 30Æ9 (6Æ37)
Dolan (1987) MHNs 30 12Æ37 (F) 5Æ47 (F) 34Æ63 (F)
17Æ13 (I) 8Æ40 (I) 34Æ50 (I)
Carson et al. (1991) CMHNs 61 19Æ07 4Æ15 32Æ40 24 39 19
Schafer (1992) CMHNs Prechange 14 19 4Æ1 32Æ5
Postchange 16 23Æ6 5Æ3 34Æ1
Sullivan (1993b) MHNs 78 20 (7Æ05) 7Æ4 (5Æ5) 30Æ9 (6Æ4) 44 14 43
Fagin et al. (1995) CMHNs 245 21Æ05 (11Æ5) 5Æ4 (5Æ3) 34Æ4 (7Æ3) 48 20 24
WBMHNs 323 20Æ4 (12) 7Æ3 (6Æ2) 32Æ3 (8Æ5) 44 48 41
Fielding and Weaver (1994) CMHNs 59 19Æ9 5Æ3 35Æ8
WBMHNs 67 17Æ5 5Æ5 35Æ1
Fagin et al. (1996) WBMHNs Study 1 317 20Æ4 (11Æ99) 7Æ4 (6Æ21) 32Æ3 (8Æ84) 31 27 17
WBMHNs Study 2 145 19Æ3 (11Æ40) 5Æ5 (5Æ41) 32Æ8 (7Æ81) 28 26 13
WBMHNs Study 3 186 21Æ3 (10Æ35) 7Æ9 (6Æ40) 32Æ8 (7Æ57) 32 26 22
Carson et al. (1998) MHNs Social support
Preintervention 27 20Æ04 (9Æ91) 8Æ37 (6Æ45) 33Æ52 (7Æ15)
Postintervention 19Æ80 (8Æ47) 8Æ28 (5Æ91) 33Æ83 (6Æ47)
Follow-up 19Æ06 (9Æ66) 7Æ72 (4Æ46) 37Æ56 (5Æ98)
MHNs Feedback
Postintervention 19Æ48 (12Æ34) 8Æ91 (5Æ38) 35Æ13 (7Æ55)
Follow-up 20Æ82 (7Æ66) 9Æ65 (4Æ18) 35Æ59 (6Æ04)
Coffey (1999) FCMHNs 80 19Æ3 (10Æ1) 5Æ7 (4Æ3) 33Æ0 (6Æ22) 44 27 24
Edwards et al. (2000) CMHNs 283 21Æ2(10Æ3) 5Æ2 (4Æ5) 34Æ8 (6Æ5) 51 14 25
Lemma (2000) MHNs Course
Preintervention 14 23 (14Æ3) 7Æ5 (6Æ2) 34Æ7 (7Æ7)
Postintervention 14 12Æ7 (9) 3Æ5 (2Æ6) 41Æ3 (5Æ7)
Follow-up 14 17Æ5 (12Æ8) 5Æ9 (6) 36Æ8 (11Æ8)
Course/follow-up
Postintervention 13 18Æ4 (12Æ8) 4Æ9 (5Æ2) 41Æ5 (6Æ7)
Follow-up 13 22Æ4 (11Æ6) 3 (2Æ5) 42Æ2 (7Æ6)
Control
Intervention 27 30Æ9 (13Æ6) 9Æ7 (7Æ1) 36Æ4 (9Æ2)
Postintervention 27 25Æ5 (14Æ1) 7Æ07 (6Æ6) 35Æ5 (8)
Follow-up 27 25Æ7 (14Æ2) 7Æ2 (6Æ2) 30Æ5 (8Æ6)
Kilfedder (2001) MHNs 510 18Æ8 (10Æ6) 4Æ9 (4Æ6) 34Æ2 (7Æ9) 21 34Æ6 7
Ewers (2002) FMHNs Experimental
Preintervention 10 13Æ53 6Æ02 35Æ37
Postintervention 10 10Æ51 2Æ04 39Æ64
FMHNs Control
Preintervention 10 18Æ82 5Æ74 35Æ81
Postintervention 10 18Æ91 5Æ96 32Æ21
EE, emotional exhaustion; DP, depersonalization; PA, personal accomplishment; F, frequency; I, intensity; MHNs, mental health nurses;
CMHNs, community mental health nurses; WBMHNs, ward-based mental health nurses; FCMNs, forensic community mental health nurses;
FMHNs, forensic mental health nurses.

Values are given as mean (SD
SD).

predicted exhaustion were professional fulfilment, work load,
self-esteem, work climate and number of sick days in the last
year.
Astrom et al. (1990) compared experience of burnout
using a number of different measures, including a burnout
scale developed by Pines et al. (1981). Basic statistical
analysis revealed that 27% of nursing staff were assessed
for risk of developing burnout, those at highest risk being
nursing aides and those at lowest risk being RNs. Melchior
et al. (1997b) conducted a study using the MBI to investigate
the relationship between burnout and a number of work-
related factors. Men were found to score higher on all three
burnout variables, but there were no differences between the
different nursing groups. The percentage variance in each of
the MBI subgroups that could be accounted for by multiple
regression was low (11–16%), suggesting that there were
many factors affecting burnout that this study did not
account for or measure. Samuelsson et al. (1997) studied
suicidal feelings, attempted suicide and aspects of work
environment and well-being in Swedish psychiatric nursing
personnel using questionnaires from previous research in
Sweden, and included a short version of the MBI along with
several other validated instruments. The study revealed that
psychiatric personnel with suicidal feelings in the last year
Table 7 Comparison of General Health Questionnaire (GHQ) scores
Study Sample n
Mean score
Threshold (%)
Scoring
method
GHQ-12 GHQ-28
Jones et al. (1987) MHNs 349 10Æ24 Likert
Carson et al. (1991) CMHNs 3Æ02 23 GHQ
Schafer (1992) Prechange 14 3Æ21 29 GHQ
Postchange 19 5Æ00 44
Fielding and Weaver (1994) CMHNs 59 11Æ8 Likert
MHNs 67 10Æ9 Likert
Reeves (1994) MHNs 89 3Æ1 (4Æ35) 27 GHQ
MNs 89 3Æ21 (4Æ75) 29 GHQ
Fagin et al. (1995) CMHNs 250 4Æ5 (5Æ8) 41 GHQ
WBMHNs 3Æ4 (4Æ8) 28 GHQ
Nolan (1995) MHNs 111 ng 37 GHQ
McLeod (1997) SMI 20 ng 40 Not stated
Mixed caseload 20 ng 20
NOPC 20 ng 20
Carson et al. (1998) MHNs
Social support 27 3Æ85 (4Æ67)
Preintervention 2Æ60 (3Æ44)
Postintervention 2Æ72 (4Æ51)
Follow-up
MHNs
Feedback 26 5Æ35 (7Æ39)
Preintervention 3Æ17 (6Æ38) GHQ
Postintervention 2Æ53 (4Æ49)
Follow-up GHQ
Snelgrove (1998) CMHNs 19 9Æ7 (4Æ5) Likert
Wykes and Whittington (1998) MHNs
Time 1 39 38 Not stated
Time 2 39 18
Coffey (1999) FCMHNs 80 3Æ8 (5Æ7) 31 GHQ
Edwards et al. (2000) CMHNs 301 2Æ6 (3Æ4) 35 GHQ
Lemma (2000) Course ng 35Æ7 GHQ
Course/follow-up 30Æ8
Control 44Æ4
Kilfedder et al. (2001) MHNs 510 ng Likert
CMHNs, community mental health nurses; SMI, severe mental illness; NOPC, neurosis and primary clients; MHNs, mental health nurses, MNs,
medical nurses; WBMHNs, ward-based mental health nurses, FCMHNs, forensic community mental health nurses; ng ¼ not given. For GHQ-
12: GHQ scoring (range 0–12) cut point 2, Likert scoring (range 0–24). For GHQ-28: GHQ scoring (range 0–28) cut point 5, Likert scoring
(range 0–84).

had significantly higher scores for emotional exhaustion,
depersonalization (as measured by the MBI), tiredness and
hopelessness than those who had never experienced suicidal
feelings. Negative work environment was associated with
burnout and depression. However, the prevalence of suicidal
feelings in the last year was lower than that found in the
general population.
Humpel and Caputi (2001) examined the relationship
between emotional competency and work stress. Emotional
competency, described as the ability to monitor one’s own
and others’ feelings and emotions, and to use this information
to guide one’s thinking and behaviour, was measured using
the Stories subtest of the Multifactor Emotional Intelligence
Scale (Mayer Salovey 1997). Work stress was measured
using three subscales of the Mental Health Professionals
subscale (Cushway et al. 1996). Those with more experience
in mental health nursing experienced less personal self-doubt
about their nursing abilities and had higher levels of
emotional competency, and this was particularly true for
female nurses. This study lacks generalizability as only part of
the stress scale was used and very basis statistical techniques
were conducted.
Stress management interventions
We identified six stress management intervention studies
conducted in the UK (Milne et al. 1986, Watson 1986,
Kunkler Whittick 1991, Carson et al. 1998, Lemma 2000,
Ewers et al. 2002), one in the Netherlands (Melchior et al.
1996) and one in the USA (Gordon Goble 1986). More
detailed information is presented in Tables 3 and 4 and, to
summarize, the studies conducted in the UK established
that:
• Training in behavioural techniques improved work satis-
faction and levels of sickness and reduced strain in psy-
chiatric nurses. The behavioural training therapy that was
provided aimed to improve nurses’ preparation for thera-
peutic tasks by helping them to develop skills and know-
ledge so that they could more effectively deal with patient
problems. The areas that the training covered included
behavioural assessment and learning and behavioural
therapy (Milne et al. 1986).
• Personal stress management relaxation techniques signifi-
cantly improved psychiatric nurses’ ability to cope with
anxiety and stress. The relaxation training used was
Jacobsen’s progressive muscle relaxation. The participants
were also introduced to other forms of relaxation, inclu-
ding clinically standardized meditation, biofeedback,
autogenics and self-hypnosis, and asked to choose
which method they felt most suitable to them. They then
used that method for the period of the study (Watson
1986).
• Stress management workshops were effective in reducing
levels of burnout for psychiatric nurses. Those offered
looked at concepts of stress and burnout, principles of
stress management and progressive muscular relaxation.
After a period of discussion, the various strategies that had
been attempted formed the basis of a further session and
participants were given the opportunity to talk through
anydifficultsituationsthattheyhadencountered(Kunkler
Whittick 1991).
• Social support-based programmes for psychiatric nurses’
offered no significant advantage over feedback only. The
intervention presented a social support model which
examined the impact of life events and stress and asked
participants to identify individuals who provide social
support and to draw up a social support network (Carson
et al. 1998).
• Levels of psychological distress and burnout significantly
decreased following attendance at a 15-week training
course in therapeutic skills. There was no further benefit
attained from attending a casework discussion group. The
aim of this intervention was to impart type A therapeutic
skills based on Egan’s three stage model of counselling, and
then to offer a safe forum for the exploration of clinical
work (Lemma 2000).
• Training a group of forensic mental health nurses in psy-
chosocial interventions had a significantly positive effect on
levels of burnout. The aim of psychosocial interventions is
to help clinicians to conceptualize their patient’s problems
within a more empathetic framework, and to train them in
the skills to intervene effectively (Ewers et al. 2002).
A study conducted in the Netherlands investigated the
effectiveness of primary nursing on levels of burnout. The
intervention involved the introduction of an innovation in
nursing care delivery, with a special focus on primary nursing.
The principles of primary nursing are that each patient is
assigned to a nurse and the nurse takes 24-hour responsibility
for that patient’s care, with care being focused on the needs of
the patient rather than the needs of the ward. Burnout was
measured using the Dutch version of the MBI 1Æ5 years before
primary nursing was introduced and then 1 year afterwards.
A random sample of 492 of a potential 725 nurses working on
35 long-stay wards from 43 psychiatric hospitals were
surveyed. The response rate was 73% (n ¼ 361). Only 161
(49%) completed the measures at all three time points and, of
those, 60 received the intervention. There were no further
details provided of how the sample was divided into the
intervention and control wards. The sample was a mixed
sample of unit leaders, mental health nurses, practical nurses

and nurses’ aides. Result showed that levels of burnout did not
change. The authors recognized the limitations of their study.
They reported that attrition was a serious problem, which
resulted in loss of participants at different time points, that the
control groups could have been affected by the interventions,
and that the period of intervention might have been too short
(Melchior et al. 1996).
One method of coping with professional frustration is
to accommodate the situation, and this has been termed
‘creative accommodation’. It is an expansion of activities that
simultaneously provide the nurse with an opportunity for an
increased sense of accomplishment and enhanced profes-
sional esteem, in addition to meeting patient and organiza-
tional needs. The purpose of the study by Gordon and Goble
(1986) was to identify the effects of this expanded activity on
nurses’ role satisfaction. In this situation the creative accom-
modation was assertiveness training with behavioural rehear-
sal in a group format. The authors did not provide any
sampling details for the seven nurses recruited to the study
and the instrument used to measure job satisfaction was a
modified version of the Job Satisfaction Inventory (Porter
1962), with no details of validity and reliability reported. For
this group of nurses, at 9 months following intervention job
satisfaction improved and they reported increased assertive-
ness and professional self-image. Because of the small sample
size, the results have to be treated with caution.
Effectiveness of clinical supervision
Three studies have been conducted in Sweden to determine
the effectiveness of 1 year of clinical supervision in relation-
ship to burnout (Berg et al. 1994, Hallberg 1994) and job
satisfaction (Berg Hallberg 1999). Hallberg (1994)
conducted a small study to investigate the effects of clinical
supervision on all nurses (n ¼ 11) on a ward for child
psychiatric care in Sweden. Data were collected using the
Tedium Measure (Pines et al. 1981) and the MBI (Maslach
Jackson 1986), and Satisfaction with Working Care Scale
(Hallberg et al. 1994), as well as a series of open-ended
questions on three occasions – baseline, 6 and 12 months
after the start of supervision. The mean score of the Tedium
measure decreased significantly over the 12 months for
mental exhaustion. Degree of burnout showed no significant
changes over time. Satisfaction with factors relating to
nursing and the job increased significantly over time, and
these factors were described as satisfaction with co-operation
and comfort at work and satisfaction with responsibility,
organization and quality of care. Berg et al. (1994) studied
creativity and innovative climate, tedium and burnout among
nurses on two wards during 1 year of systematic clinical
supervision in Sweden. This was combined with implemen-
tation of individualized care on an experimental ward
(n ¼ 19) for patients with severe dementia as compared with
a similar control ward (n ¼ 20). The intervention was
evaluated by means of the Creative Climate Questionnaire
(Ekvall et al. 1983), Tedium Measure (Pines et al. 1981), and
MBI (Maslach Jackson 1986). Tedium and burnout
decreased significantly on the experimental ward but no
change was found on the control ward. Berg and Hallberg
(1999) used a pre- and post-test design to investigate the
effects of 1 year of clinical supervision, combined with
supervised individualized planned and documented nursing
care. The effects were explored in relation to nurses’ sense of
coherence, creativity, work-related strain and job satisfac-
tion. The focus of this study was all nurses (n ¼ 22) on a
ward providing care for patients with diagnoses such as
psychotic disorder or borderline personality disorder at a
general psychiatric unit in southern Sweden. There were no
changes in nurses’ work satisfaction, job strain or sense of
coherence as a result of clinical supervision.
Methodological issues
Research on stressors, moderators and stress outcomes
conducted in countries other than the UK gives some data
which might be usefully applied to the situation of mental
health professionals here. However, the fact that different
countries operate very different health care systems means
that there are limitations in generalizing the findings.
The measurements tools used must be evaluated in terms
of the extent to which reliability and validity have been
established. There are numerous established measures which
have been shown to be valid and reliable for measuring
stressors, moderators and stress outcomes but investigators
frequently feel the need to develop new instruments.
Nineteen studies used questionnaires that had been specif-
ically designed for the study. Pilot studies and data on
reliability and validity were described in only seven of the
studies.
The majority of studies in the occupational health field
focused on psychological distress rather than psychological
health. All the studies in this review have used Goldberg’s
General Health Questionnaire for this purpose. There are
four different versions of this scale, each having a cut off
point for detecting psychiatric caseness. Caseness means a
score on the questionnaire that is characteristic of patients
with diagnosable mental disorders. On each version of the
scale there are two scoring methods – the GHQ method (0, 0,
1, 1) and the Likert Method (0, 1, 2, 3). Mean scores
obtained from the Likert Method should not be directly

compared with those obtained using the GHQ Method. Two
authors, McLeod (1997) and Kilfedder et al. (2001) do not
give the data for mean scores and the reader is left to assume
that the differences in mean scores are correct.
When investigating burnout, all the authors used the MBI
to measure this. When investigating stress and job satisfac-
tion, however, a range of tools was used and in the majority
of cases the authors developed their own questionnaires. This
makes it difficult to compare directly findings between
different studies.
The effectiveness of stress management programmes
depends on the accuracy of the initial diagnosis. Stress in
the workplace can be diagnosed in many different ways,
questionnaires, interviews, indirect observation (staff turn-
over, sickness records), examination of biochemical markers,
etc. There needs to be some attempt to utilize common
measurement approaches which will enable workers to
compare across studies.
Sample size should be determined before a study is
conducted. Sample sizes in these studies varied from 3 to
2080, an extremely large variation. The larger the sample
then the more representative of the population it is likely to
be, and small sample sizes will produce less accurate results.
Small sample sizes tend to increase the probability of
obtaining a markedly nonrepresentative sample (LoBiondo-
Woods Haber 1997). It is possible to estimate sample size
with the use of a statistical procedure known as power
analysis, but this was not undertaken for any of the studies
in this review. This issue is a particular problem in studies
that failed to detect significant differences or relationships, as
the results might be due to inadequate sample size rather than
an incorrect hypothesis (Burns Groves 2001). In the
majority of studies the sample was selected by the researcher
subjectively (purposively) or on a given date in a particular
place (convenience) and only 13 studies used a random
sampling techniques.
The statistical analyses undertaken give some cause for
concern. Two studies sought to undertake advanced statis-
tical tests (regression analysis, logistic regression) that were
inappropriate due to the small nature of the sample [Kirby
Pollock 1995 (n ¼ 38); Lemma (2000) (n ¼ 27)], and
McCarthy (1985) undertook ANOVA
ANOVA on a sample of only 32.
Analysis of variance tests whether group means differ; rather
than testing each pair of means separately, ANOVA
ANOVA considers
the variation among all groups. Post hoc analyses were
commonly performed in studies with more than two groups
when the analysis indicates that groups were significantly
different, but did not identify which group was different, as
occurs in ANOVA
ANOVA. In all the the studies that used this
approach, no post hoc analyses were performed. Five studies
did not present any statistical information at all and as a
result their conclusions cannot be accepted as valid.
It was difficult to compare the results for studies that
evaluated different interventions for a number of other
reasons. The duration of the interventions covered a range
of four to 15 sessions lasting from 1 hour to 1 day and
occurring on a daily or weekly basis for a given period of
time. It is important that after a study has finished partici-
pants are followed-up to determine whether the interventions
maintained their effectiveness. For the six studies conducted
in the UK, the period of follow-up ranged from 4 weeks to
1 year, with no follow-up in the studies by Watson (1986)
and Ewers (2002). The problem encountered in all these
studies was that participants tended to leave organization
during or after the intervention.
In conclusion, these methodological issues give rise to
problems with generalizability and rigour.
Discussion
Much research has revealed an excessive level of workplace
stress for mental health nurses, who are likely to experience
personal stress as a result of working closely and intensely with
patients over an extended period of time. When comparisons
have been made with other professional groups, mental health
nurses (hospital- and community-based) have been identified
as one of the professional groups with the highest sources of
stress (Rees Smith 1991). When compared directly with
nurses from other specialities, those experiencing significantly
greater levels of stress include medical and surgical nurses
(Plant 1992), general nurses (Muscroft Hicks 1998), and
health visitors and district nurses (Snelgrove 1998). The most
frequently reported sources of stress were administration and
organizational concerns, client-related issues, heavy workload,
interprofessional conflict, financial and resource issues, profes-
sional self-doubt, home/work conflict, staffing levels, changes
in the health service, maintenance of standards, giving talks
and lectures, length of waiting lists, and poor supervision. The
factors associated with increasing stress levels were nursing
status, job dissatisfaction, poor quality of social support,
permanent day shift work, being younger, longer length of
service, reduced time for client contact, dissatisfaction with
working conditions, level of responsibility, being female and
working occasional night shifts. Other factors associated with
increasing levels of stress for nurses working in the community
include large caseloads, reorganization of community teams,
increased workload, increased administrative duties, reduced
time for service users, and reduced time for family contact.
The most frequently reported coping strategies were social
support, having stable relationships, recognizing limitations,

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