Stress in mental health nursing

International Journal of Nursing Studies 37 (2000) 207±218

www.elsevier.com/locate/ijnurstu

Stress in mental health nursing C.J. Kipping* DUAL Team, South London and Maudsley NHS Trust, Unit 7 Eros House, Brownhill Road, Catford, London, SE6 2EG, UK Received 20 April 1999; accepted 12 November 1999

Abstract Although there have been growing concerns about stress in nursing over recent years, research has primarily focused on general nurses. This paper reports on stress in mental health nursing. The data were obtained, via questionnaires, from mental health nurses at the end of their training. Four-hundred and forty-seven questionnaires were returned, an 80% response rate. Open-ended questions were asked about the nurses' experiences of stress during their time as a student, and what they anticipated would be stressful once quali®ed. A wide range of stresses were identi®ed, many similar to those reported in previous studies. The open-ended nature of the questions, however, provided greater detail about the nature of stress in mental health nursing than has been reported hitherto. This detail points to broader perspectives which might be taken in future research which, in turn, may lead to a fuller understanding of nurses' experiences of stress. Crown Copyright 7 2000 Published by Elsevier Science Ltd. All rights reserved. Keywords: Stress; Student nurses; Mental health nursing

1. Introduction Over recent years there has been growing concern about stress in nursing (e.g. Owen, 1995; O'Donnell, 1996; Dinsdale, 1998). Stress in nursing is a concern for a number of reasons. It can have an e€ect on the individual nurse, in terms of both physical and psychological health. Stress can result in ®nancial costs for employing organisations. For example, stress-related illness and absence are estimated to cost the United Kingdom (UK) £7±8 billion a year (Bryan, 1996). Moreover, compensation claims are potentially a further cost. In a recent case an out of court settlement was paid to the family of a mental health nurse who committed suicide, apparently triggered by stress at work (McMillan, 1998). Furthermore, evidence

* Tel.: +44-208-473-5753.

suggests that stress may be a reason for nurses leaving their jobs (Seccombe and Ball, 1992). As well as the impact on individual nurses and organisations stress among nurses will inevitably have an impact on patient care. Absence and high nursing turnover will result in a lack of continuity of care. Moreover, nurse±patient relationships will be damaged by `burnout', a response to chronic stress (Maslach, 1982). Burnout is characterised by emotional exhaustion, with workers no longer being able to give of themselves at a psychological level and by depersonalisation, the development of negative, cynical attitudes and feelings about patients. Although there is a growing body of research into stress in nursing, interest has primarily focused on general rather than mental health nurses, (e.g. Chiriboga et al., 1983, Cooper and Mitchell, 1990). While there may be similarities between the experiences of general and mental health nurses, it has been suggested that mental health nurses are exposed to di€erent stresses

0020-7489/00/$ - see front matter Crown Copyright 7 2000 Published by Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 0 ) 0 0 0 0 6 - 7

208

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

to the general nursing population. For example, Sutherland and Cooper (1990) note that psychiatric patients may be dangerous, unpredictable, or incapable of communication and that psychiatric nursing has a lower status than general nursing. Furthermore, Barker (1992) suggests that the interpersonal relationships which are a central feature of psychiatric nursing make the work a `potential emotional mine®eld' (p. 62). Given the potentially detrimental e€ects of stress, there is a need to understand mental health nurses' experiences of stress, so that where possible it can be avoided and, where it is unavoidable, strategies can be devised to help sta€ to cope with it more e€ectively. This paper reports on the experiences of stress of newly quali®ed mental health nurses. The data were obtained in the course of a longitudinal questionnaire survey of traditionally trained mental health nurses' careers.1 The research was commissioned by the Department of Health in response to concerns about attrition from the nursing workforce and to obtain information about mental health nursing careers at a time of considerable change in the National Health Service (NHS), nursing education and mental health care. The main aims of the study were to document the careers nurses followed after quali®cation and to explore factors that may have a bearing on career moves. As stress has been linked with attrition from the nursing workforce it has been explored from the outset of the project. The ®ndings presented here are from the ®rst questionnaire, which can be regarded as a cross-sectional survey in its own right. Before considering this study in more detail and to provide a context for the ®ndings a review of previous research on stress in mental health nursing is presented.

2. Previous research on stress in mental health nursing Several studies have identi®ed aspects of mental health nursing which are experienced as stressful. As a number of common factors have been identi®ed the methods of these studies will be outlined ®rst and then the ®ndings considered together. Taking ®rst the studies conducted outside of the UK; in an American study Trygstad (1986) interviewed 22 quali®ed nurses working in acute in-patient settings. 1 The nurses had followed `traditional' routes to gaining a certi®cate level mental health nursing quali®cation. This traditional training has now been replaced by a 3-year diploma course. Nurses who have gained certi®cate or diploma level nursing quali®cations are regarded as quali®ed nurses; unquali®ed sta€, such as nursing assistants, also work in the mental health services.

She sought to identify stresses encountered within their work and factors that increased or decreased stress, or assisted the nurses in coping. Dawkins et al. (1985), also American, sought to identify and quantify job stress. They devised a tool, the Psychiatric Nurses Occupational Stress Scale, on the basis of asking 100 nurses to identify stressful events related to their work (51 replied). Landeweerd and Boumans' (1988) study of 65 Dutch psychiatric nurses working in admissions, short stay and long stay departments, assessed satisfaction and feelings of health and stress using questionnaires. They also interviewed 15 nurses from the three departments to explore explanations for the di€erences found. Moving to the UK, Jones et al. (1987) used questionnaires to explore stress in nursing sta€ working in a special hospital. The questionnaire focused on job demands, supports and constraints. All nursing sta€, quali®ed and unquali®ed, were asked to take part, 49% (349) of whom did so. Sullivan (1993) set out to identify the stresses present in the work of nurses working in the acute admissions wards of two health authorities, to assess the e€ects of stress and identify the types of coping strategies used by the nurses. Various instruments, some standard inventories and some designed by the author, were sent to all the trained sta€; 78% (n = 61) responded. In addition 10 nurses were interviewed using a semi-structured interview format to further explore their experiences of stress and illuminate the questionnaire data. Nolan et al. (1995), as part of their work to develop a stress scale for mental health professionals, sent a battery of questionnaires (some standard inventories and others original), to 210 mental health nurses (community and hospital based). Fifty-three per cent of the nurses responded. The Claybury Stress Study (e.g. Fagin et al., 1995; Carson et al., 1995; Brown and Leary, 1995) was a large-scale study conducted in the North East Thames Regional Health Authority. The study sought to compare experiences of stress and coping strategies between community psychiatric nurses (CPNs) and ward-based psychiatric nurses (WBPNs) (quali®ed and unquali®ed). Two hundred and ®fty CPNs and 323 WBPNs took part; response rates are not reported. The study employed a wide range of standard inventories as well as the researchers' own questionnaire. Following the questionnaire phase, interviews were conducted with 21 CPNs and group discussions with 51. An additional aspect of the Claybury research was a Q-sort study in which 44 CPNs compared and ranked statements about stress and coping (Leary et al., 1995). Sources of stress identi®ed in these studies include: . patient issues, especially violence Ð Trygstad (1986), Jones et al. (1987), Sullivan (1993), Nolan et

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

al. (1995), Fagin et al. (1995) . diculties between sta€ Ð Dawkins et al. (1985), Nolan et al. (1995), Leary et al. (1995); doctors in particular have been singled out for criticism, Trygstad (1986), Sullivan (1993) . performance of other sta€ Ð Trygstad (1986), Dawkins et al. (1985), Sullivan (1993) . management style/practice of senior nurses/managers Ð Trygstad (1986), Landeweerd and Boumans (1988), Carson et al. (1995) . resource issues, such as time and stang Ð Trygstad (1986), Dawkins et al. (1985), Sullivan (1993), Nolan et al. (1995), Fagin et al. (1995) . administrative and organisational issues Ð Dawkins et al. (1985), Jones et al. (1987), Sullivan (1993), Nolan et al. (1995) . dealing with change Ð Fagin et al. (1995) . concerns regarding study/training opportunities Ð Fagin et al. (1995), Leary et al. (1995). These studies demonstrate that many aspects of the work of mental health nurses can be stressful. However, while they begin to provide some insights into why mental health nursing is a stressful occupation, they are limited in two ways. First, their perspective is rather narrow, focusing almost exclusively on the immediate work environment. Guppy and Gutteridge (1991) criticise such an approach but note that it is characteristic of most occupational stress research. Some researchers have suggested broader perspectives which might be taken to provide a fuller understanding of work stress. Latack (1989), for example, argues that career events such as career transitions, job loss and lack of upward mobility can be key sources of stress and Glowinkowski and Cooper (1985) note that stress can be linked to career stage. Handy (1990) takes a much broader perspective, arguing that people are indivisible from their social context, and that if occupational stress is to be more fully understood there is a need to consider both the wider organisation and the wider societal context. While some researchers have noted the role of the home/work interface in experiences of stress, generally occupational stress research has not taken account of the wider socio-historical context. A second way in which research into stress in mental health nursing is limited, and this is linked to the ®rst, is the acceptance of positivist assumptions which underpin models of stress and the research methods 2 These were the two main traditional routes to quali®cation. The post-registration course was a shortened course for those who already held a certi®cate in another area of nursing. The 3 year direct entry course was for people who did not hold such a certi®cate.

209

used to investigate it. While models of stress have evolved and it is increasingly recognised that stress is a subjective experience, contingent upon individual perception, there is still a lack of emphasis on understanding the meaning situations and events have for people. If nurses' experiences of stress are to be more fully understood studies are needed which take broader perspectives than have been taken hitherto and explore something of the meaning of events to individuals. Unless this is achieved it is unlikely that strategies which are designed to address nursing stress will be e€ective. The ®ndings presented in this paper add to the growing body of research into stress in mental health nursing and go some way towards presenting broader perspectives than those which have traditionally been taken. Furthermore, these ®ndings are from a particular viewpoint, that of student mental health nurses. As far as the author is aware no other studies have speci®cally focused on this groups' experiences of stress.

3. Methods 3.1. Research design A longitudinal research design was adopted to meet the aims of the careers study; this took the form of a panel study in which questionnaires have been sent to a cohort of mental health nurses at quali®cation and at 6, 18 and 36 months thereafter. The cohort was drawn from the last groups of students to complete traditional mental health nurse training. The sample was selected purposively to broadly represent all those who completed 3 year and post registration courses between January 1993 and March 1994.2 The sample was drawn from four of the regional health authorities which were in existence in England at the time the project began. Colleges of nursing within the four regions were contacted to arrange for a member of the research team to meet potential recruits to invite their participation in the study. Groups of students were visited near to the end of their course; the project was described and an explanation given of what participation would entail. Potential recruits were assured of con®dentiality. Time was allocated for questions and discussion. Names and addresses were obtained from people who indicated a willingness to participate. Of a possible 620 people, 556 (90%) agreed to take part. At the time of course completion a questionnaire was sent to each nurses' home address with a pre-paid return envelope. Reminder letters along with another copy of the questionnaire were sent to non-respondents 4 weeks after the initial mailing. A further reminder

210

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

was sent to those who had still failed to return the questionnaire after another 4 week period. Of the 556 nurses who had agreed to take part 447 returned questionnaires, an 80% response rate (72% of those eligible to take part). 3.2. Developing questions on stress Each questionnaire was developed with a pilot cohort (n = 120) recruited for the lifetime of the project. During development work for the ®rst questionnaire, as had been suggested by the literature, it became clear that stress was likely to be a key in¯uence in career decisions. Questions about stress were therefore included. Pilot work demonstrated that experiences of stress were diverse and could not adequately be captured within a closed list of options. Furthermore, closed questions would risk `leading' respondents. As little was known about mental health nurses' experiences of stress it was appropriate for the questions to be more exploratory in nature, thus an open-ended question format was adopted. Consideration was given as to whether a de®nition of stress should be provided. Although, as noted by Cox (1978), stress is a concept understood by lay people and professionals, these is no single agreed de®nition. Furthermore, while it was clear that there was a broad shared understanding of the term this could not be adequately captured in a short de®nition that was acceptable to members of the pilot cohort. Moreover this study did not adopt a particular theoretical perspective on stress. In keeping with the practice of many other researchers, therefore, respondents were allowed to interpret `stress' in their own way. Participants were asked the following questions: 1. Looking back over your psychiatric nursing experience, what, if anything, have you found stressful? 2. What, if anything, do you think you might ®nd stressful working as a newly quali®ed psychiatric nurse? 3.3. Analysis A number of texts which suggest procedures for coding the responses to open-ended questions were consulted for guidance on analysis (e.g., Moser and Kalton, 1971; Hoinville et al. 1978, Oppenheim, 1992). There was, however, little reference to the particular diculties posed by the data from this study, namely respondents had given multiple responses to each question, which, combined with the sample size produced a large volume of data. Furthermore, as the research was exploratory in nature, all issues that emerged from the data needed to be captured. A process for analys-

ing the data was, however, produced. Categories were developed from themes emerging from the data rather than being predetermined. Responses were then allocated to categories. In order to retain something of the richness of the data responses were allocated codes at two levels, a `category' and a `detail' code. A `detail' is a group of similar responses but at a lower level of abstraction than a category. Details grouped together make up categories. When all the responses had been coded the frequency of codes was counted so that the magnitude of the categories could be assessed. As Ford-Gilboe et al. (1995) suggest numbers can provide a sense of patterns emerging from qualitative data and thereby enhance understanding. Full details of the analysis method are available in Hickey and Kipping (1996). 3.4. Cohort pro®le Details of respondents' sex, age, ethnicity, edu-

Table 1 Cohort pro®le No. % Sex Male Female Age 20±24 25±29 30±34 35±39 40+ Ethnicity White British White Irish Black African, Caribbean and other black origin Mauritian Other white origin Mixed origin Indian, Pakistani, Chinese and other Asian origin No answer Educational group UKCC test Intermediate A-level plus Length of time in full-time employment No previous full-time employment < 2 years 2±5 years > 5 years Insucient information to allocate Course type Three-year Post-registration

142 305

32 68

135 148 73 31 60

30 33 16 7 13

362 26 20 11 10 9 3 6

81 6 4 2 2 2 1 1

126 156 165

28 35 37

49 89 132 155 22

11 20 30 35 5

350 97

78 22

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

cational background, years in employment and the course type they had followed to gain quali®cation are summarised in Table 1. The cohort comprised people from very diverse educational and occupational backgrounds. A range of academic and vocational quali®cations had been gained, while some respondents had no formal quali®cations others had attained Masters level degrees. The sample was categorised into three groups; 28% (126) did not have the pre-requisite quali®cations for nurse training and had therefore gained entry through an educational entrance test (known as the UKCC Ð United Kingdom Central Council Ð Test). Thirtyseven per cent (165) of respondents had attained an Alevel (or equivalent) or higher level quali®cation, and 35% (156) of respondents fell into an intermediate group. Nearly all respondents (97%, 435) had held some kind of paid employment prior to starting their mental health nursing course. Most had held full-time jobs, but length of time in employment varied (see Table 1). A wide range of types of employment had been held; 20% (90) of respondents had worked as quali®ed nurses and 27% (121) as nursing or care assistants. Other occupational groups represented included clerical and secretarial (33%, 148), personal and protective services (20%, 91) and sales (18%, 82). Occupations were classi®ed using an amended version of the system used by the Oce of Population Censuses and Surveys (OPCS, 1995). Full details of the cohort pro®le are available in Robinson et al. (1996).

4. Findings Eighteen categories emerged from responses to the question about past stress and thirteen from the question asking about anticipated stress. Although a number of the categories identi®ed were common to both past and anticipated stress the emphasis within them was often quite di€erent. Fig. 1 shows the categories identi®ed for each time period and the percentage of respondents who made comments within each category. When discussing these categories the number and percentage of respondents who made comments within each will be stated. When reporting the details within each category the number of responses will be stated. Each respondent may have made more than one response within each category. 4.1. Sources of stress Ð past only Six categories emerged which were exclusive to the past; three were about student issues (exams/assess-

211

ments/written work, placement issues and other student issues); the others were feeling unable to make a di€erence, personal issues and physical environment. Taken together student issues were mentioned by 56% (250) of respondents. 4.1.1. Exams/assessments/written work A third (149) of respondents made comments concerned with exams/assessments/written work. One hundred and eight responses were about exams, 43 mentioned assessments and 17 written work. Nineteen responses concerned the tensions between working on placements and study, and six mentioned balancing these demands with life outside work. 4.1.2. Placement issues Aspects of placements were mentioned by 28% (127) of respondents. Seventy-nine responses related to changing placements; for example, starting new placements and frequency of placement changes. One respondent wrote, `constantly changing clinical placement and having to re-orientate myself to new environments and establish working relationships with sta€ teams.' Particular clinical areas which respondents identi®ed as stressful included forensic, child psychiatry, general nursing, rehabilitation and community. Seventeen responses concerned not having one's learning needs met while on placements, for example, one nurse noted, `people expecting too much from students and on occasions not explaining procedures fully before expecting students to carry them out'. Nine responses were about being poorly treated on placements, for example, not being included as part of the team and being used for work which sta€ nurses dislike. 4.1.3. Other student issues Nineteen per cent (86) of respondents made comments about other aspects of student experiences. These included: aspects of the course (19 responses), such as disorganisation of the course and group work; perceived de®cits in training (15 responses), such as lack of preparation for physical care and lack of input regarding medication; the detrimental e€ects of change on training (12 responses), e.g. the introduction of Project 2000 and closure of school of nursing, and inadequacies of the tutors. 4.1.4. Feeling unable to make a di€erence Four per cent (18) of respondents reported feeling that at times their e€orts made little or no di€erence to patients. Responses included the `revolving door syndrome', i.e. the same patients being re-admitted, and feeling unable to meet patients' needs. For example, one respondent reported `seeing very dis-

212

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

tressed people and not being able to o€er them any real answers'. 4.1.5. Personal issues Four per cent (16) of respondents mentioned personal issues which had caused them stress. These included relationship diculties, ®nancial problems, bereavement, accommodation problems and the demands of balancing home and work life. 4.1.6. Physical environment The physical work environment was mentioned by 2% (7) of respondents. Lack of space for sta€ and patients and drab and smoky environment were among the comments made. 4.2. Sources of stress Ð past and anticipated Eleven categories emerged which were common to both the past and anticipated stress questions. 4.2.1. Patient care The largest of the past stress categories concerned aspects of patient care, 59% (262) of respondents made comments in this category. The largest number of responses related to aggression and violence (187 responses). One nurse reported, `death threats and threats of physical violence together with verbal abuse for eight solid weeks (the duration of the placement)'. Other aspects of care which were mentioned included `specialling' (38 responses), dying or the death of a patient (28), and dealing with suicidal patients (25). Particular client groups accounted for 24 responses; most frequently mentioned were the elderly. In addition to the specialling aspect of containing/controlling patients, 22 responses concerned other aspects of containing/control, for example, physical restraint/giving forced medication and detaining patients against their will. Other aspects of patient care which were identi®ed included, patients who self harm, demanding patients, dealing with distressed patients and responsibility for planning and delivery of care. Eighteen per cent (80) of respondents mentioned aspects of patient care as an anticipated stress. This encompassed a variety of aspects, some of which were very similar to those identi®ed as a stress in the past. Sixty responses related to emergency situations, for example, dealing with violent incidents, suicide attempts, restraint/giving forced medication and medical emergencies. Seventeen responses were about giving routine medication. 4.2.2. Sta€ attitudes and behaviour Sta€ attitudes and behaviour were mentioned by 34% (152) of respondents as a past stress. Many of the

comments were non-speci®c in nature, for example, sta€ relationships, and poor/bad attitudes/behaviour. However, some provided further details either regarding the personnel concerned or about the particular attitudes and behaviour. One nurse reported `Being treated badly, with plain rudeness, sarcasm, and being patronised and condescended to by the hierarchy'. Personnel who were speci®cally mentioned were managers (at ward level and above), doctors and unquali®ed sta€. One nurse complained about the `attitude of doctors, arrogant, blunt or detached Ð to myself and clients'. Eleven responses concerned the potentially detrimental e€ects of sta€ behaviour/attitudes on patient care; for example, negative attitudes to patients. Other comments included; unmotivated/lazy sta€, sta€ who gossip/bicker/bitch, lack of communication between team, institutionalised sta€, and disagreeing with other sta€. Eight per cent (37) of respondents anticipated that sta€ attitudes and behaviour would be stressful in the future. Comments included poor team work and doctors being a potential source of diculty. 4.2.3. Resource issues Resource issues were mentioned by 31% (137) of respondents as a past stress. Three main issues could be identi®ed: stang issues; detrimental e€ects on patient care, and time factors. Stang issues accounted for 124 responses; the majority of these (119) concerned inadequate stang levels. Fifty-six responses suggested that lack of resources had potentially detrimental e€ects on patients. Twenty-eight responses focused on lack of time; e.g. lack of time to complete tasks/do job properly. Eleven per cent (48) of respondents also anticipated that resource issues would be a cause of stress in the future. The same three issues were again evident with most responses concerning stang levels. Other concerns focused on de®cits in facilities required for patients; for example, bed shortages and lack of community facilities. 4.2.4. Aspects of the job Aspects of the job were mentioned by 27% (121) of respondents as having been a stress in the past. This category di€ered from aspects of patient care in that the comments included in this category were less speci®cally concerned with the nature of patient problems. Three main aspects were identi®ed: responsibilities, liaison with other disciplines, and administrative issues. The responsibility theme (65 responses) was broad but included aspects of work such as ward management and drug rounds. It also encompassed aspects of work which were likely to be new experiences for these

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

nurses; e.g. being the only quali®ed nurse on duty. The comments relating to liaison with other disciplines (22 responses) focused largely on contacts through meetings; e.g. ward rounds/multi-disciplinary team meetings. The majority of responses concerning administrative issues (12 responses) related to paperwork. `Aspects of the job' also emerged as a category from the data on anticipated stress. Five per cent (24) of respondents made comments that came within this category. These included concerns about dealing with relatives, meetings and doing paperwork/administration. 4.2.5. Thoughts/feelings/expectations of self Seventeen per cent (75) of respondents linked experiences of past stress with their own thoughts and feelings. Two main areas of concern could be identi®ed, self doubt/lack of con®dence (46 responses) and personal costs of working with patients (28 responses). One nurse expressed doubts about his lack of experience as follows, `The ®rst serious incident I was involved in on the ward was scary, I wondered if my inexperience had contributed to the incident'. It is probably not surprising that around the time of quali®cation some nurses would have doubts about their abilities. Comments associated with personal costs included dealing with one's own feelings about things that happen, having to be cheerful when having own problems, and feeling emotionally drained due to the intense nature of the work. Own expectations and fears for self were mentioned by 5% (23) of respondents as an anticipated stress. Most frequently mentioned was fear of making a drug error. 4.2.6. Lack of support/supervision Lack of support and supervision was mentioned by 14% (61) of respondents as a past stress and by 6% (28) as an anticipated stress. A variety of people from whom support and supervision was wanted and examples of some situations in which it was wanted were included. Personnel most frequently mentioned as not providing adequate support were tutors, trained sta€ and management. One nurse complained of `managers who expect me to care for patients but don't care about me as an individual'. 4.2.7. Cultural environment Issues concerning the cultural environment were mentioned by 13% (60) of respondents as something which they had found stressful in the past. The aspects that were mentioned most frequently were high workload, low morale and paperwork. Five per cent (23) of respondents mentioned similar

213

aspects of the culture which they anticipated would cause stress in the future. 4.2.8. Career issues Twelve per cent of respondents (55) identi®ed career issues that had been stressful. Some of these related to short term issues, primarily ®nding a suitable ®rst job. Others were more concerned with longer term issues, such as lack of job security and lack of long term career prospects. Career issues identi®ed as potential future stresses were mentioned by 4% (16) of respondents. The majority of these concerned lack of certainty and insecurity of employment. One post-registration student nurse feared, `starting at the bottom again, not being able to secure employment above a D grade (basic grade for quali®ed sta€) despite my previous experience and competency'. Other issues which were mentioned included diculty in getting on courses and job and/or promotion being threatened for speaking out about, for example, bad practice. 4.2.9. Conditions Aspects of employment conditions were mentioned by 11% (50) of respondents as a past stress. The majority of these were concerned with working hours (36 responses); e.g. shift work, night duty, poor rotas and early shifts. Other comments concerned non-contractual `obligations' such as missed breaks, being asked to work overtime and not leaving work on time. Conditions were mentioned as an anticipated stress by 3% (13) of respondents. Ten responses concerned aspects of working hours, in a similar vein to those mentioned as a past stress. 4.2.10. Poor care Poor care was a theme which cut across categories. If the respondent identi®ed a cause of the poor care then the response was allocated an appropriate category code, e.g. lack of resources leads to poor care was allocated a resource issues code. Other responses which concerned poor care but for which there was not an appropriate causative category were allocated to a generic poor care category. Six per cent (28) of respondents made comments concerning their past experiences of poor care and 1% (6) of respondents anticipated poor care being a stress in the future. However, for both the past and anticipated stress questions, ®ve additional categories contained comments relating to poor care. Some comments were implicit, e.g. unmotivated, lazy sta€, whereas others were more explicit, e.g. red tape resulting in poor care. 4.2.11. Change Aspects of organisational change were mentioned by

214

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

2% (9) of respondents as a past stress. These included changes in service organisation, change to trust status, and ward and hospital closures. A similar number of respondents, 3% (12), mentioned involvement in change in the future as a potential stress. Miscellaneous categories accounted for comments made by 6% (26) of respondents in relation to past stress and 4% (19) of respondents in relation to future stress. The most frequent response in the anticipated stress category was uncertainty i.e. being unsure about what would be stressful in the future. 4.3. Sources of stress Ð anticipated only 4.3.1. Change in role to quali®ed nurse The category which was exclusively about future stress concerned the change in role from being a student to a quali®ed nurse. Eighty-®ve per cent of respondents made comments in this category. Fourhundred and eighty-four responses were made about the responsibilities of being a quali®ed member of sta€ Ð with the following aspects mentioned most frequently: more/new responsibility (unspeci®ed), accountability, taking charge of ward, managing other sta€, taking responsibility for client care, delegating and being only/most senior nurse on shift. One nurse summarised her fears as follows: `Being in charge of a ward as the only quali®ed member of sta€ and being expected to make decisions about patient care which could adversely a€ect their well-being, then knowing that I will be accountable for every action and decision I take'. Another area of concern was meeting the expectations of others and doubting one's ability to do this (112 responses). Responses included others high expectations/being expected to know everything, and feeling inexperienced/lacking knowledge and skills. Some responses were particularly about the fear of making a mistake. Responsibilities in relation to junior sta€ (21 responses), such as being observed by junior sta€, supervision of more junior sta€ and teaching these sta€ were also expected to be stressful. Other comments included in this category were the transition to a new role (119 responses), working in an unfamiliar environment (thus policies, patients, colleagues etc are unknown) (58), and gaining trust/acceptance of colleagues (29).

5. Discussion These ®ndings demonstrate the great diversity of potential stresses within mental health nursing. They also provide support for the ®ndings of previous studies. In common with the research cited earlier, patient issues,

relationships between, and the performance of, other sta€, resources, administrative issues and changes were all identi®ed as stressful. As the questions were asked in an open format, however, and respondents were not constrained by being presented with a closed list of options, as is often the case in stress research, some new issues emerged. Examples include nurses' thoughts, feelings and expectations of self and feeling unable to make a di€erence. The emergence of these categories begins to illuminate the meanings which nurses attach to their work. Given that the most frequently cited source of past stress was patient issues (59%, 262 respondents) it would be helpful to know more about what it is about working with patients that makes the work stressful. An examination of the type of issues which were identi®ed con®rms the speculations of Sutherland and Cooper (1990) and Barker (1992) that mental health nurses face stresses that are unique. As might be expected, violence and aggression were mentioned most frequently; however, a range of other patient behaviours and nursing interventions were also identi®ed as stressful. These included dealing with suicidal patients, distressed patients, patients who self harm, the death of a patient, and containing and controlling patients, e.g. physical restraint, detaining people against their will and continually observing patients. While intuitively it is unsurprising that these aspects of patient care were experienced as stressful, what is less clear is what these situations mean for the nurses involved. If the interpersonal relationship between nurse and patient is at the heart of mental health nursing, as suggested by Barker (1992), then there is a need to understand more fully the meaning of this relationship to the nurse. Some insight into these meanings might be derived by drawing on a wider theoretical literature. For example, Handy (1990), observed that nurses found it dicult to integrate the control aspects of their role into their self-image as helpers because the controlling and caring aspects con¯ict. Bringing a psychodynamic approach, Dartington (1993), in her consideration of the climate and culture of nursing, suggests that nurses have unconscious anxieties about the potential sadistic abuse of absolute power that they have over patients. Mental health nurses in particular, with, for example, their power to detain patients under the provision of the Mental Health Act (1983), have considerable power over patients. Drawing on alternative explanations such as these is a radical departure from the way in which nurses' experiences of stress have traditionally been viewed. The ®ndings from this study also con®rm the bene®t of taking account of career stage/events when studying occupational stress as asserted by Latack (1989) and Glowinkowski and Cooper (1985). The ®ndings highlight the diculties experienced by students in training,

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

56% of respondents mentioned issues concerned with being a student as a past stress. They also point to the considerable anxiety which is generated when contemplating career transitions, in this case the transition from being a student to a quali®ed member of sta€; 85% (380) of respondents anticipated that this change in role would be stressful. Moreover, themes within categories such as self-doubt/lack of con®dence (in the `thoughts/feelings/expectations of self' category) and being the only quali®ed nurse on duty (`aspects of the job' category) might be anxieties which are particularly salient at this time of transition. Other career issues such as lack of job security and longer term career prospects were also identi®ed as sources of stress by respondents. A closer examination of these ®ndings also points to another dimension which it may be bene®cial to explore further. Namely that individual stresses cannot be seen in isolation. Account needs to be taken of the way in which one stressful situation can impact on another. This has been suggested in other research. Trygstad (1986), for example, found that stress was more likely to occur when the organisational climate was experienced negatively and that stress was increased when others failed to validate the importance of the situation for the individual. Sullivan (1993) found that the intensity of experiences of violence was in¯uenced by the availability of sta€ resources to deal with incidents. He also reported that nursing suicidal patients was perceived as stressful particularly when stang levels were poor and there was a lack of support. Comments made by respondents in this study highlight similar concerns. Thus lack of sta€ and lack of support when dealing with particular situations can make those situations more stressful. Particular examples provided by respondents included lack of sta€ when coping with death, and lack of support when dealing with suicidal patients, following violence and after other emergency situations. It seems reasonable to assume that these exacerbating factors may be interlinked. If there are inadequate numbers of sta€ then not only is it more likely that a violent incident will be experienced as stressful, but it is also less likely that support will be available after the event. Moreover, if sta€ relationships are poor then it is also less likely that support will be available, thus the stress inherent in mental health nursing is compounded, rather than colleagues serving to provide support for each other. It would appear, then, that while some aspects of mental health nursing might be considered to be inherently stressful, the stress they generate can be moderated or exacerbated by the context within which the event(s) takes place. Lack of resources, poor sta€ attitudes and behaviour, lack of support and supervision all of which were identi®ed as stressful in their own right may make other experiences of stress more intense.

215

Looking beyond the work context, these ®ndings also suggest that stress from outside of work can in¯uence experiences of stress within it. It is noteworthy, that personal issues, such as relationship diculties and ®nancial problems were mentioned when the focus of the question was on stress at work. Speci®c acknowledgement of the e€ect stress outside of work can have on work stress was made in some of the comments in the `thoughts/feelings/expectations of self' category, e.g. having to be cheerful despite one's own problems and dealing with issues that come up that are similar to one's own. Other comments in this category, however, suggested that stress at work might in¯uence home life, e.g. feeling emotionally drained due to the intense nature of the work. Experiences of stress then, cannot be compartmentalised into home and work domains, since the two also interact. To develop a fuller understanding of nurses' experiences of stress these interactive e€ects must be considered. The ®ndings from this study suggest a range of measures which might be considered in order to prevent or reduce stress. In terms of education and training, although as noted previously, the UK system for pre-registration training has now changed, some of the student issues mentioned are not unique to a particular course type. Exams, assessments and placements are likely to be common to any nursing course. Tutors/lecturers were one of the groups of personnel identi®ed as not always being available to provide support; they could play an important role in reducing stress by supporting students. One speci®c way in which they might provide support is by liaising with sta€ receiving students on placements, for example, clarifying what sta€ might realistically expect from students and what students might reasonably expect in terms of support and guidance while on placements. In the time since these data were collected there has been a growing recognition of the need for nurses to receive more support, particularly through the process of clinical supervision. The UKCC has recommended a period of preceptorship for newly quali®ed sta€ (UKCC, 1993) and regular clinical supervision for all nurses (UKCC, 1996). Such supervision is recognised as serving a three-fold function; formative (development of knowledge and skills), normative (concerned with quality control and the maintenance of policies and procedures) and restorative (provision of support) (Proctor, 1988). These ®ndings suggest that all three areas of need require attention. Although, as yet, there is little evidence to demonstrate that supervision will have a direct impact on stress levels, generally nurses report that they ®nd supervision helpful (e.g. White et al., 1998) and intuitively it makes sense that having the opportunity to re¯ect on work experiences and discuss them with a more experienced practitioner will render

216

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

them less threatening. There are, however, concerns about the extent to which supervision is available. Lack of supervision was a perceived stress in this study and the Mental Health Nursing Review Team (Department of Health, 1994) reported that support in the form of clinical supervision was often only available informally from peers. 5.1. Limitations This study adds to the growing body of knowledge on stress in mental health nursing. In particular it extends awareness of the range of work related experiences which nurses may perceive as stressful. Furthermore, it points to the need to understand more about the meaning of events for individuals, the role of career stage, and the way in which individual stresses might interact. The study also has a number of limitations. First, while readers may identify with the themes which emerged from the data, the ®ndings can only be generalised to a very speci®c group of nurses, namely those who were qualifying through traditional training routes at the time at which these data were collected. The changes to nurse education which have taken place in the intervening period and, indeed, the changes to the wider health care system make wider generalisation unwise. Furthermore, the data pertaining to anticipated stress is entirely speculative. While it provides an insight into the stresses which were expected in making the transition from student to quali®ed nurse until the data from the second questionnaire in the study, where nurses look back over this period, are available, it is not possible to know to what extent these fears were realised. Secondly, the data presented here comprise a small part of a much larger study. Stress was being asked about in the context of a study on careers. Not only may this have provided a particular framework within which respondents thought about their situations, but it imposed constraints on the way in which stress was explored. Thirdly, the data, while qualitative, having been obtained through open questions, were limited in their scope. This was largely because only a relatively small space was available for responses, respondents therefore provided brief statements rather than full descriptions of their experiences. Had more space been available and respondents been encouraged to be more discursive then fuller insights may have been available. 5.2. Suggestions for future research While this study adds to the literature on stress in mental health nursing there is a need for more

research. Given the attention which has been drawn to the changing nature of occupational stress over the career span by other authors and the indicators from this study that such a perspective may be important, this should be taken into account in future studies. This would best be done in a study with a longitudinal design where the same individuals can be tracked over time. Further research to speci®cally explore student nurses experiences and how these might contribute to feelings of stress would be useful. Such research would not only add to the data which have been presented here but might also point to action which could be taken to reduce stress. Transition stress might be reduced by ensuring that pre-registration education adequately prepares nurses for their roles as quali®ed practitioners. Data from elsewhere in this study of mental health nurses' careers suggested that signi®cant numbers of traditionally trained students did not feel well prepared for some aspects of their role (Robinson et al., 1996; Murrells and Robinson, 1999). Moreover Project 2000 courses have been widely criticised for their lack of attention to practical skills. Proposed changes to Project 2000 programmes, such as introducing practice skills and placements earlier and implementing a period of 3 months supervised clinical practice towards the end of the course have been recommended by the UKCC Commission for Nursing and Midwifery Education (UKCC, 1999). These changes may go some way towards improving the preparation of students and reducing the stress associated with the transition to being a quali®ed nurse. While the Commission has recommended systematic evaluation of programme changes in respect of achieving ®tness for practice, projects could also usefully consider how students' perceptions of their preparation for practice in¯uence their experiences of stress. Achieving ®tness for practice through pre-registration education will depend upon the course content being relevant to the needs of current mental health service provision. At a time when mental health services are undergoing a process of continuing and major change The Sainsbury Centre for Mental Health (1997) has recommended that core competencies for mental health workers be identi®ed. They propose that research be conducted to establish the range of skills, knowledge and attitudes required of mental health workers. The ®ndings of such research would provide important information for those involved in curriculum planning. A strategy which could help nurses prepare for, and deal with, the stresses which they encounter in their clinical work would be the introduction into the curricula of programmes to address these areas. A number of examples have been described, (e.g. Kramer, 1974;

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

Fabricius, 1991; Dartington, 1993; Lindop, 1996). Introduction of any such programmes should be the subject of rigorous evaluation. Regardless of how comprehensive pre-registration training might become it cannot be expected to prepare students to feel well-prepared for all aspects of their role (e.g. Robinson et al., 1996; Maben and Macleod Clark, 1998). Given that there will inevitably be uncertainties the provision of e€ective support through the transition from student to quali®ed nurse and a period of preceptorship after quali®cation may also be important strategies for reducing stress. These are also recommendations that have been made by the UKCC Commission for Nursing and Midwifery Education. Although there is a growing body of literature which documents transition experiences (e.g. Turner, 1991; Maben, 1995) there is a dearth of research to identify the extent to which preceptorship is available, and where it is, which aspects might make it bene®cial to the neophyte nurse. These too would be valuable areas for future research. Finally, more in-depth qualitative studies, e.g. indepth interviews, would be advantageous. Such an approach would enable greater understandings to be gained about the meaning events have for individuals. Furthermore, interviews might also provide fuller insights into the complexity of the stress process, highlighting the interplay between di€erent sources of stress and the way in which stress from work and non-work domains may interact.

Acknowledgements I should like to thank all those who participated in the study whether as members of the pilot cohort, who helped design questionnaires, or as members of the main study cohort, who ®lled them in. Thanks also to the Department of Health, for funding the research, and to colleagues on the Careers Team at the Nursing Research Unit, King's College London, who worked on the project upon which this paper is based: Sarah Robinson, Gary Hickey, Trevor Murrells, Rebecca Baker and Shelen Shah.

References Barker, P. 1992. Psychiatric nursing. In: Butterworth, T., Faugier, J. (Eds.), Clinical Supervision and Mentorship in Nursing. Chapman & Hall, London, pp. 65±79. Brown, D., Leary, J. 1995. Findings from the Claybury study for community psychiatric nurses. In: Carson, J., Fagin, L., Ritter, S. (Eds.), Stress and Coping in Mental Health Nursing. Chapman & Hall, London, pp. 115±138.

217

Bryan, S., 1996. Work-related stress: an ethical perspective. Business Ethics 5, 103±108. Carson, J., Bartlett, H., Brown, D., Hopkinson, P. 1995. Findings from the qualitative measures for community psychiatric nurses. In: Carson, J., Fagin, L., Ritter, S. (Eds.), Stress and Coping in Mental Health Nursing. Chapman & Hall, London, pp. 139±160. Chiriboga, D.A., Jenkins, G., Bailey, J., 1983. Stress and coping among hospice nurses: test of an analytic model. Nursing Research 32 (5), 294±299. Cooper, C.L., Mitchell, S., 1990. Nursing the critically ill and dying. Human Relations 43 (4), 297±311. Cox, T., 1978. Stress. Macmillan, London. Dartington, A., 1993. Where angels fear to tread: idealism, despondency, and inhibition in thought in hospital nursing. Winnicott Studies 7 (Spring), 21±41. Dawkins, J.E., Depp, F.C., Selzer, N.E., 1985. Stress and the psychiatric nurse. Journal of Psychosocial Nursing 23 (11), 9±16. Department of Health, 1994. Working in Partnership? A Collaborative Approach to Care Ð Report of the Mental Health Nursing Review Team. HMSO, London. Dinsdale, P., 1998. Pressure points. Nursing Times 94 (13), 19. Fabricius, J., 1991. Learning to work with feelings Ð psychodynamic understanding and small group work with junior student nurses. Nurse Education Today 11, 134±142. Fagin, L., Brown, D., Bartlett, H., Leary, J., Carson, J., 1995. The Claybury community psychiatric nurse stress study: is it more stressful to work in hospital or the community? Journal of Advanced Nursing 22, 347±358. Ford-Gilboe, M., Campbell, J., Berman, H., 1995. Stories and numbers: coexistence without compromise. Advances in Nursing Science 18 (1), 14±26. Glowinkowski, S.P., Cooper, C.L., 1985. Current issues in organisational stress research. Bulletin of the British Psychological Society 38, 212±216. Guppy, A., Gutteridge, T., 1991. Job satisfaction and occupational stress in UK general hospital sta€. Work & Stress 5 (4), 315±323. Handy, J., 1990. Occupational Stress in a Helping Profession. Gower, Aldershot. Hickey, G., Kipping, C.J., 1996. A multi-stage approach to the coding of data from open-ended questions. Nurse Researcher 4 (1), 81±91. Hoinville, G., Jowell, R., et al., 1978. Survey Research Practice. Heinemann, London. Jones, J.G., Janman, K., Payne, R.L., Rick, J.T., 1987. Some determinants of stress in psychiatric nursing. International Journal of Nursing Studies 24 (2), 29±144. Kramer, M., 1974. Reality Shock: Why Nurses Leave Nursing. Mosby, St Louis. Landeweerd, J.A., Boumans, N.P.G., 1988. Nurses' work satisfaction and feelings of health and stress in three psychiatric departments. International Journal of Nursing Studies 25 (3), 225±234. Latack, J.C. 1989. Work, stress and careers: a preventive approach to maintaining organisational health. In: Arthur, M.B., Hall, D.T., Lawrence, B.S. (Eds.), Handbook of Career Theory. Cambridge University Press, Cambridge, pp. 252±274.

218

C.J. Kipping / International Journal of Nursing Studies 37 (2000) 207±218

Leary, J., Gallagher, T., Carson, J., Fagin, L., Bartlett, H., Brown, D., 1995. Stress and coping strategies in community psychiatric nurses: a Q-methodological study. Journal of Advanced Nursing 21, 230±237. Lindop, E. 1996. Individual stress among nurses in training. Unpublished Ph.D. thesis, Keele University. Maben, J. 1995. Newly quali®ed Project 2000 diplomates' perceptions of their experiences of transition from student to sta€ nurse. Unpublished M.Sc. thesis, King's College, London. Maben, J., Macleod Clark, J., 1998. Project 2000 diplomates' perceptions of their experiences of transition from student to sta€ nurse. Journal of Clinical Nursing 7, 145±153. Maslach, C. 1982. Understanding burnout: de®nitional issues in analysing a complex phenomena. In: Paine, W.S. (Ed.), Job Stress and Burnout. Sage, London, pp. 29±40. McMillan, I., 1998. Settlement over suicide due to stress. Mental Health Practice 1 (7), 3. Mental Health Act, 1983. HMSO, London. Moser, C.A., Kalton, G., 1971. Survey Methods in Social Investigation. Dartmouth, Aldershot. Murrells, T., Robinson, S., 1999. Phase 1 of a longitudinal study of mental health nurses' careers: exploring relationships between pro®les, course perceptions and plans to work in the NHS. Journal of Mental Health 8 (1), 55±68. Nolan, P., Cushway, D., Tyler, P., 1995. A measurement tool for assessing stress among mental health nurses. Nursing Standard 9 (46), 36±39. O'Donnell, E., 1996. Stressing the point. Nursing Standard 10 (16), 22±23. Oce of Population Censuses & Surveys, 1995. Standard Occupational Classi®cation. Vol. 2, 2nd Ed. HMSO, London. Oppenheim, A.N., 1992. Questionniare Design, Interviewing and Attitude Measurement. Pinter, London. Owen, A., 1995. Stress reduction. Nursing Times 91 (45), 42± 43. Proctor, B. 1988. Supervision: a co-operative exercise in accountability. In: Marken, M., Payne, M. (Eds.), Enabling and Ensuring, 2nd edn. Leicester National

Youth Bureau and Council for Education and Training in Youth and Community Work, Leicester, pp. 21±34. Robinson, S., Kipping, C., Hickey, G., Murrells, T. 1996. Getting started: Phase 1 of a study of psychiatric nurses' careers. Nursing Research Unit, King's College, London University, London. Seccombe, I., Ball, J. 1992. Motivation, morale and mobility: a pro®le of quali®ed nurses in the 1990s. Institute of Manpower Studies, University of Sussex, Brighton. Sullivan, P.J., 1993. Occupational stress in psychiatric nursing. Journal of Advanced Nursing 18, 591±601. Sutherland, V., Cooper, C., 1990. Understanding Stress: A Psychological Perspective for Health Professionals. Chapman & Hall, London. The Sainsbury Centre for Mental Health 1997. Pulling Together: The Future Roles and Training of Mental Health sta€. The Sainsbury Centre for Mental Health, London. Trygstad, L., 1986. Stress and coping in psychiatric nursing. Journal of Psychosocial Nursing 24 (10), 23±27. Turner, P. 1991. Role transition experiences of a group of newly quali®ed mental health sta€ nurses: aspects of pre and post registration education and experience assisting them in new role adjustment. Unpublished B.Sc. dissertation, Leeds Polytechnic. United Kingdom Central Council 1993. The Council's position concerning a period of support and preceptorship: implementation of the post-registration time. Education and practice proposals (PREP): Registrar's letter. UKCC, London. United Kingdom Central Council 1996. Position statement on clinical supervision for nursing and health visiting. UKCC, London. United Kingdom Central Council 1999. Fitness for practice: the UKCC commission for nursing and midwifery education. UKCC, London. White, E., Butterworth, T., Bishop, V., Carson, J., Jeacock, J., Clements, A., 1998. Clinical supervision: insider reports of a private world. Journal of Advanced Nursing 28 (1), 185±192.