Edwards 2003

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: E D W A R D S D . & B U R N A R D P . ( 2 0 0 3 ) Journal of Advanced Nursing 42(2), 169–

Deborah Edwards, 200
School of Nursing and Midwifery Studies, A systematic review of stress and stress management interventions for mental health
Ty Dewi Sant,
nurses
University of Wales College of Medicine,
Background. Health care professionals in the United Kingdom (UK) appear to have
Heath Park,
Cardiff CF14 4XN,
higher absence and sickness rates than staff in other sectors, and stress may be a
UK. reason for nurses leaving their jobs. These problems need to be addressed, partic-
E-mail: edwardsdj@cardiff.ac.uk 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

D. Edwards and P. Burnard
1999). Eighty-five per cent of 100 trusts surveyed by the

What is already known about this topic National Health Service (NHS) Executive reported difficulties
• Work-related stress is estimated to be the biggest both in recruiting and retaining nursing staff generally and
occupational health problem in the UK. this was a more common problem in mental health nursing
• There are problems in the recruitment and retention of (NHS Executive 1998).
the mental health nursing workforce. There are growing numbers of studies that have given
consideration to coping strategies and management support
issues, stress management being an umbrella term that
What this paper adds encompasses a wide range of different methods designed
• It examines the studies that have evaluated stress principally to reduce stress and improve coping abilities.
management interventions for mental health nurses Interventions can change the environment to reduce the
and highlights the methodological weaknesses inherent potential for stress, help individuals to modify their appraisal
in many of the papers reviewed. of it, or help them to cope more effectively with stressors
• It discusses the role of the organization in addressing (Carson & Kuipers 1998). The aim of the current review
how to improve the retention of mental health nurses therefore was to identify stressors, moderators and stress
within the workforce. 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
Introduction
1993a, Dunn & Ritter 1995) have been conducted in the
Stress in the workplace is often referred to as ‘occupational areas of stress, coping and burnout in psychiatric nursing.
stress’. The basic rationale underpinning the concept is that These have all looked at different perspectives but a number
the work situation has certain demands, and that problems in of articles which we considered to be important were
meeting these can lead to illness or psychological distress. excluded from these reviews, as the latter were not systematic
Occupational stress is a major health problem for both in nature. It was therefore decided to reassess the papers
individual employees and organizations, and can lead to included in previous reviews.
burnout, illness, labour turnover, absenteeism, poor morale
and reduced efficiency and performance (Sutherland &
Methods of the review
Cooper 1990). Work-related stress is estimated to be the
biggest occupational health problem in the United Kingdom Studies included in the review were research articles from
(UK), after musculoskeletal disorders such as back problems 1966 to 2000 reporting studies undertaken in the UK that
and stress related sickness absences cost an estimated £4 specifically identified participants as mental health nurses.
billion annually (Gray 2000). Studies from other European countries and from the United
Current evidence suggests that health care professionals in States of America (USA) were also included as potential
the UK have higher absence and sickness rates than staff in models of good practice.
other sectors (Nuffield Trust 1998). Wall et al. (1997) found
that 27% of health care staff suffered serious psychological
Search strategy
disturbances, compared with 18% of the general working
population. It has been suggested that stress may be a reason The search strategy used the following sources:
for nurses leaving their jobs (Seecombe & Ball 1992). The • Computerized databases [PUBMED, Embase (Excerpta
problem of retaining qualified and experienced staff has Medic Online), SCI Search (the Science Citation Index),
highlighted the need to look at various aspects of work and the SSCI Search (the Social Science Citation Index), Pascal
work environment, which affect the level of job satisfaction (the Science, Technology and Medicine Index), CINAHL
and in turn influences quality of service. (nursing and allied health), ASSIA (social science), PsychLit
If problems with recruitment and retention are not addressed, (psychology, including clinical psychology), Clin Psych,
then there is a danger that large sections of existing UK Heathstar, Cochrane, British Nursing Index, SIGLE (Sys-
mental health services will not be sustainable (Sainsbury tem for Information on Grey Literature) and National
Centre for Mental Health 2000). A Department of Health Research Register].
survey in 1999 indicated that 2Æ1% of all nursing posts in • Hand searching of nursing journals (selected on the basis
psychiatry were considered hard to fill (Department of Health of being the most frequently encountered – Journal of
170 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(2), 169–200
Integrative literature reviews and meta-analyses Stress management interventions for mental health nurses
Advanced Nursing, Journal of Psychiatric and Mental this article, bringing the total number of articles reviewed
Health Nursing, International Journal of Nursing Studies, to 77.
Journal of Psychosocial and Mental Health Nursing Fifty-eight articles were retrieved reporting studies con-
Services). ducted in the UK for groups of mental health nurses. Table 3
• Writing to key authors. presents a summary of these. Entries in the table are arranged
• Citations in papers identified by the above searches. alphabetically and according to the year of publication, with
Search terms used were: Psychiatric Nur*, Mental Health information on the aims of the studies, sample and sample
Nur*, Mental Health Professional*, Mental Health Staff, size. Table 4 presents information on the measures used,
Mental Health Personnel, Mental Health Service and Com- main results and details on rigour and validity. These studies
munity Mental Health. These search terms were combined focused on mental health nurses working in a variety of
with the terms stress, burnout, coping, job satisfaction and settings – community teams (n ¼ 15), forensic teams (n ¼ 6),
stress management. 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
Results
samples that consisted of all types of psychiatric staff, i.e.
The number of articles that were considered potentially Registered Nurses (RNs), Licensed Practical Nurses (LPNs),
relevant to the review was 176. All papers identified as nursing aides (NAs), nursing auxiliaries and ward clerks,
potentially relevant were obtained in hard copy. Further making comparisons with UK samples inappropriate. Details
assessment for relevance was made according to the inclusion of the aims of these studies, sample and sample size are
criteria shown in Table 1. All references to the papers were presented in Table 5 and details of measures used, main
retrieved and stored on computer, using the reference results and rigour and validity are presented in the text.
database program Reference Manager. Each article retrieved
for the study was assessed independently by two reviewers for
Stressors, moderators and stress outcomes
inclusion or exclusion in the review on the basis of reading
the full text. The judgements of the two reviewers were It is important that stress research is based on a theoretical
compared and where there were differences the article was model. Three levels of the stress process are proposed in the
reconsidered. Seventy articles were included in the final model developed by Carson and Kuipers (1998) which are
review and those were excluded are shown in Table 2. Seven stressors, moderators of the stress process and stress out-
studies have been reported since the completion of the review comes. The model suggests that there are three major sources
(Kilfedder et al. 2001, Coffey & Coleman 2001, Humpel & of external stress. There are, firstly, specific occupational
Caputi 2001, Ito et al. 2001, Tummers et al. 2001, Dallender stressors, which vary depending on the unique stress facing
& Nolan 2002, Ewers et al. 2002). For the purpose of each professional group. The second major source of external
completeness these research papers have also been included in stressors is major life events. The third set comes from
‘hassles’ or ‘uplifts’. These are not major events, but small
Table 1 Inclusion criteria stressors that can have a cumulative effect on individuals.
English language publication
Thirty-five UK studies investigated sources of occupational
Professional groups concerned stress or job-related pressure and/or factors associated with
Primary research paper high levels of stress as measured by a questionnaire and the
Measuring stressors/moderators/stress outcomes results are presented in Table 4.
From the USA, three papers examined stress-related issues.
Table 2 Papers excluded from the review Trygstad (1986) found that difficulties in nurse relationships
either with other RNs or head nurses, and the ability to work
Reasons for exclusion
together, were the most important determinants of work
Foreign language publication 17 stress for mental health nurses. The methods used were
Studies not including psychiatric nurses as subjects 31 purpose-designed tool and semi-structured interviews. The
Not a primary research article 17 sample is too small for each ward to be adequately represented
Article which contained insufficient statistical data 15
and there were no details of validity or reliability reported.
Papers not examining stressors/moderators/stress outcomes 15
Duplicate publication 14 Dawkins et al. (1985) used a 78-item Psychiatric Nurses
Occupational Stress Scale developed from lists of stressful
Total 106
events reported by nurses to identify and quantify stresses in
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(2), 169–200 171
172
Table 3 Summary of articles included in the review from studies conducted in the UK
Response
Author Aim Study population Sample size rate (%)
Bamber (1991) To assess reasons for leaving psychiatric nursing MHNs working in a psychiatric hospital Ns 82 (Ns)
(staff nurses)
Barton and Folkard To examine perceived differences in stress levels MHNs working within an independent Ns 98 day shift (59)
(1991) between day and night nurses in a mental psychiatric hospital, UK 28 night shift (40)
health context
Brown et al. (1995) To discover which aspects of the role of CMHNs CMHNs working in 15 health districts, UK Ns 250
were most stressful
Burnard et al. (1999) To explore nurses’ perceptions of job satisfaction FMHNs working in an interim secure unit 48 40 (83)
in a small forensic unit
Burnard et al. (2000) See Edwards et al. (2000)
Carroll (2000) To explore CMHNs perceptions of occupational CMHNs working within three CMHTs, UK 6 6 (100)
stress and to identify the coping strategies they
currently use to alleviate it
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 See Fagin et al. (1995) (CMHNs sample)
with higher stress levels in CMHNs
Carson et al. (1997a) To examine the relationship between self-esteem See Fagin et al. (1996)
and stress, coping and burnout in MHNs
Carson et al. (1997b) To conduct an up to date survey of stress in mental MHNs who were members of the public sector 2000 473 (24)
health nursing trade union (CMHNs and WBMHNs)
Carson et al. (1997c) To examine the relationship between self-reported See Fagin et al. (1996)
fitness levels and mental health outcomes
in WBMHNs
Carson et al. (1998) To evaluate the effects of a social support based MHNs working within Bethlem and Maudsley 64 Volunteers 53 (83)
intervention with MHNs using a randomized Hospitals, UK 27 I
controlled design 26 C
Carson et al. (1999) To assess the frequency of burnout in the largest See Fagin et al. (1996)
sample of MHNs reported in the Literature
Coffey (1999) To examine levels and sources of stress and FCMHNs attached to 26 NHS medium secure 104 80 (77)
burnout amongst FCMHNs units in England and Wales, UK
Coffey (2000) See Coffey (2000)
Coffey and Coleman See Coffey (1999)
(2001)
Coyle et al. (2000) See Edwards et al. (2000)
Dallender et al. (1999) To compare perceptions of immediate work MHNs and Psychiatrists working within five 700 MHNs 301 (43)
environments for psychiatrists and MHNs NHS trusts (WBMHNs and CMHNs), UK 123 psychiatrists 74 (60)
and the effects it has upon them
Dallender and Nolan To explore MHNs and psychiatrists See Dallender et al. (1999)
(2002) perceptions of their work
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 42(2), 169–200

Table 3 (Continued)
Response
Dolan (1987) To assess the relationship between burnout MHNs working within nine hospitals. Inclusion 30 MHNs 86 (95)
and job satisfaction on two groups of recently criteria were based on length of service excluding 30 GN
qualified staff nurses from general and training restricted to a maximum of 5 years, Ireland 30 Admin
psychiatric nursing
Drake and To investigate and compare the reported stress CMHNs working within two CTTs and three 16 16 (100) CTTs
Brimblecombe (1999) levels and causes in nurses working in CTTs CMHTs, UK 13 13 (100) CMHTs
and in generic 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 FMHNs working within a medium secure unit 40 Baseline 33 (83)
training on the knowledge, attitudes and levels 10 I
Integrative literature reviews and meta-analyses
of clinical burnout in a group of FMHNs 10 C

10 refused
Fagin et al. (1995) To examine the variety, frequency and severity CMHNs working in four health districts, UK Ns 245 (approx. 80)
of stressors amongst CMHNs, to describe coping WBMHNs working in two district psychiatric hospitals, UK Ns 323 (approx. 20)
strategies used by CMHNs and WBMHNs, to
compare occupational stress in CMHNs and
WBMHNs
Fagin et al. (1996) To examine stress in WBMHNs Combined results from three studies for WBMHNs: Study 1 (Ns) 317 (approx. 20)
Study 1 – Carson et al. (1996), Study 2 – qualified nurses Study 2 (Ns) 145 (46)
from two large asylums, Study 3 – two mental hospitals, UK Study 3 (Ns) 186 (47)
Fielding and Weaver To compare the job perceptions of community and CMHNs and WBMHNs working within two health 82 CMHNs 59 (72)

(1994) hospital based MHNs, to evaluate the degree authorities, UK 150 WBMHNs 67 (45)
of psychology cal strain and burnout, to explore
the relationship between job perceptions and
stress outcomes
Fothergill et al. (2000) See Edwards et al. (2000)
Gilloran et al. (1994) To examine work satisfaction amongst nurses MHNs working within 121 wards from 39 NHS 2600 2080 (80)
across different grades from a psychogeriatric Hospitals, Scotland, UK
ward
Hannigan et al. (2000) See Edwards et al. (2000)
Harper et al. (1992) To investigate the job satisfaction and attitudes MHNs working in two psychogeriatric wards in a 41 29 (71)
of nurses working on two psychogeriatric wards hospital, UK
Humphris and Turner To assess staff response to job relocation MHNs working within two psychogeriatric wards 44 T1 31 (70)
(1989) of a new unit, assessed prior to relocation (T1), 43 T2 26 (60)
1 month after (T2) and 8 months after (T3), UK 46 T3 27 (59)
Jones et al. (1987) To investigate the factors that might be instrumental MHNs working within a ‘special hospital’ – (cares 718 349 (49)
in determining stress levels for mentally disturbed patients who are or who
have been dangers to themselves or others), UK
Kilfedder et al. (2001) To investigate burnout in MHNs using a MHNs working within the Scottish National Health 1045 510 (49)
psychological model of stressors, moderators and stains Service, UK
Stress management interventions for mental health nurses
173
Table 3 (Continued)
174
Response
Kirby and Pollock To examine the relationship between aspects FMHNs from a regional secure unit, UK 47 38 (81)
(1995) of ward environment and identified stress levels
Kunkler and Whittick To introduce stress management workshops for MHNs working on one ward invited to attend 12 12 (100)
(1991) MHNs to help staff to identify their own sources (Workshop 1), UK 360 3 (0Æ08)
of stress and manage them more effectively All MHNs working in a psychiatric hospital
(Workshop 2), UK
Leary et al. (1995) To evaluate ways in which MHNs themselves CMHNs working in four health districts, UK Ns 44 volunteers
define stress as well as examining the various
coping strategies that they use to alleviate stress
Lemma (2000) To evaluate the effects of a training course on MHNs working within adult and elderly mental Ns 14 – I1
‘Type A’ therapeutic skills designed for MHNs health. I1 – course, I2 – course plus a 10-week Ns 13 – I2
on general levels of psychological distress, burnout follow-up period of a weekly casework discussion group Ns 27 – C
and related work activities
McCarthy (1985) To assess burnout in a sample of MHNs MHNs working in a private psychiatric Ns 32 (Ns)
hospital, Ireland
McElfatrick et al. To compare the reliability and validity of two separate MHNs from various areas of Northern Ireland, UK 700 175 (25)
(2000) measures of coping skills when used with MHNs
McLeod (1997) To test the hypothesis that higher levels of stress are CMHNs working within six health authorities, UK 80 71 (88)
experienced by CMHNs working with clients suffering
enduring mental illness
Milne et al. (1986) To assess the factors regarded by MHNs as most MHNs working on four psychogeriatric wards, 26 US 16 (62)
stressful two of them defined as ‘strained (S)’ and two 30 S 5 (17)
To examine the effects of an innovation involving ‘unstrained (US)’ by the absenteeism sickness 45 (69)
ward reorganization and behaviour training therapy 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 65
specialist function, UK
Mountain et al. To examine the differing amounts of job satisfaction MHNs from 11 wards within three long-stay 60 59 (98)
(1990) reported by a sample of nurses working on long-stay hospitals, UK
wards for the elderly mentally ill
Muscroft and Hicks To compare levels of stress between GNs and MHNs, GNs working in an acute unit 100 GNs 26 (26)
(1998) to ascertain reported stress levels, the difficulties MHNs working in one NHS trust, UK 100 MHNs 26 (26)
experienced in coping with stress and to identify
potential interventions and preferred coping strategies
Nolan et al. (1995) To assess the efficacy of the scale as a tool for MHNs working within a health authority 210 111 (53)
measuring stress in MHNs (community and hospital based), UK
Parahoo (1991) To find out the level of job satisfaction and factors CMHNs working within seven community 85 72 (91)
which contribute to job satisfaction and dissatisfaction services, Northern Ireland
Parry-Jones and To identify on the stresses and satisfactions of care SWs, CNs and CMHNs working within all SWs 276 (69)
Grant (1998) management practice among three groups of front health and service agencies in Wales, UK CNs 65
line workers CMHNs 62 (15)

Table 3 (Continued)
Response
Peacock (1991) To assess subjective stress experience ad issues MHNs working within psychiatric hospital 278 110 (40)
relating to coping and associated sites, UK
Plant (1992) To examine levels of stress and illicit drug use across MHNs, MNs, SNs, MNs and SNs working 202 MHNs 89%
a variety of nursing specialities all acute hospitals in the Lothian region 130 MNs
of South-east Scotland, UK 190 SNs
75 M and SNs
Rees (1991) To examine occupational stress in all occupational CMHNs and WBMHNs, UK Ns 12 (Ns)
groups of health service employees 42 (Ns)
Reeves (1994) To compare the incidence of neurotic symptoms MNs from medical wards at two hospitals, 125 MN 89 (72)
reported by MNs and MHNs UK MHNs from department of psychiatry 125 MHN 89 (72)
in one hospital and those in community units, UK
Ryan and Quayle To measure levels of stress among MHNs at all MHNs working in mental health services in five 850 424 (42)
(1999) grades and in all work locations, as well as catchment areas in the South-eastern
the sources of any stress reported Health Board, UK
Sammut (1997) To examine the effects of a hospital closure on MHNs working within a psychiatric institution, 201 T1 122 (63)
MHNs’ satisfaction surveyed at baseline (T1) before hospital closure 198 T2 111 (56)
and at 11 months follow-up (T2) UK
Schafer (1992) Ns CMHNs working within one health authority, 26 16 (62)
before and after reorganization of services, UK
Sullivan (1993b) To examine occupational stress in MHNs MHNs working on eight acute admission wards 78 78 (100)
in two health authorities, UK

Snelgrove (1998) To examine similarities and differences in DNs, HVs and CMHNs working within one DN 122 56 (47)
the perceptions of stress and job satisfaction district health authority, UK HV 122 68 (57)
of three occupational groups working in the CMHN 33 19 (58)
community sector
Watson (1986) To determine whether training in personal stress MHN participating in stress management I (Ns) 12 (Ns)
management and relaxation techniques reduced workshops, UK C (Ns) 20 (Ns)
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
Wykes and To report on the effects of workplace violence in MHNs from six acute psychiatric wards of a teaching hospital, UK Ns 39 (Ns)
Whittington a group of MHNs – Who had not been assaulted by a patient in previous month (time 0) Ns 26 (Ns)
(1998) – Who had been assaulted and prospectively recruited within 10 days 51 39 (76)
of assault (time 1) followed-up 1 month after assault (time 2) Ns 34 (Ns)
– Who had not been assaulted in past 6 months
(matched control group)
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.
175
Table 4 Summary of findings and rigour of studies conducted in the UK
176
Author Outcome measures Data collection Study findings Rigour
Bamber (1991) B, BI* Leavers were scored significantly higher on Purposive convenience sample. Limited
burnout scales to staff nurses. Longitudinal study.
JS PDT Leavers were significantly more Following a 2-year period, respondents
dissatisfied with overall job satisfaction, were divided into ‘stayers’ (n ¼ 38)
quality of decisions made by managers, and ‘leavers’ (n ¼ 44) Reliability and
amount of in service training offered validity of tool not discussed and no

and physical working conditions piloting undertaken
Barton and Folkard (1991) S SC 90-R* Night as opposed to day workers report Purposive sampling, advanced statistical
significantly higher levels of stress and analysis (regression analysis). Sample
that on the night shift, temporary as limited to full-time workers
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
Brown et al. (1995) S PDT Ten factors emerged accounting for Questionnaire piloted by Carson et al.
67Æ4% of the variance. The most (1991) was revised to a 66-item measure.
dominant stress factor was issues This was piloted again 72 CMHNs
around support and communication 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 Small scale study
reported for two of the subscales – task
requirements and administration. Levels
of pay were a major area of job
dissatisfaction
Burnard et al. (2000) S, C SRQ The most frequently reported stressor Same research study as reported by
was workload and caseload issues Edwards et al. (2000) presenting
The most frequently reported coping data from self-reported measures
strategies was peer support from demographic questionnaire
Carroll (2000) S, C Semi-structured interviews Stressors common to all CMHNs were Small exploratory study, very limited
aspects of client contact. Two main generalizability
coping strategies were reported – clinical
supervision and social support
Carson et al. (1991) S, PDT, Rank order of questionnaire data determined Pilot study, 61 items for questionnaire
that not having enough facilities in the generated from interviews with
community had the highest stress score 16 CMHNs. Well-documented
B, MBI, For mean MBI scores see Table 6 validity and reliability
PD GHQ-28 For mean GHQ-28 scores see Table 7

Table 4 (Continued)
Carson et al. (1996) See Fagin et al. (1995) Large caseloads are associated with higher Sample taken from Claybury CPN Stress
levels of occupational 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 Sample taken from Claybury CPN Stress
in staff who were happy in their life, were Study (Fagin et al. 1995). Further
fit, had job security, and had supportive analysis undertaken on self-esteem
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
Carson et al. (1997b) S DCLSS CMHNs are no more likely to experience Random sample. No information
higher stress than their hospital counterparts. provided on reliability of scale.
Rank order of questionnaire data for CMHNs Basic statistic analysis. Poor
and WBMHNs determined that having too response rate
little time to plan and evaluate treatment as
the highest stress score
Carson et al. (1997c) See Fagin et al. (1996) The high fitness group scored significantly lower Sample taken from Fagin et al.
on all subscales of the MBI and the GHQ-28, (1996). Further analysis undertaken

and had significantly greater levels of job on fitness and stress. Fitness levels
satisfaction and utilized a great number were self- reported and scored on
of coping skills 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, DCLSS, The results showed that a social support-based Random sample. Length of sessions
M, RSES, PMS, CCSS, programme offered no significant advantage 2 hours everyday for a week. No
B, SOS (sv), EPQ-R (sv) over a feedback only programme power calculation. Three participants
JS, MBI For mean MBI scores see Table 6 dropped out form the intervention
PD MJSS (sv) For mean GHQ-28 scores see Table 7 and at 6-month follow-up 17 were
GHQ-28 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
177
178
Table 4 (Continued)
Carson et al. (1999) B Same measures as The high burnout group reported an unhappier **Sample taken from Fagin et al. (1996).
Carson et al. (1995) outlook on life, a self-reported lower level of Further analysis undertaken on burnout.
DCLSS (for Study 2 and 3) fitness, they felt less able to discuss work Basic statistical analysis. Limitations
problems with their colleagues and regarded acknowledged
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
Coffey (1999) S, CPNSQ, Rank order of questionnaire data determined Basic statistical analysis (rank order),
B, MBI, that lack of facilities had the highest mean score limitations recognized, excluded
PD GHQ-28 For mean MBI scores see Table 6 workers in own service
For mean GHQ-28 scores see Table 7
Coffey (2000) S, C SRQ The most frequently mentioned stressor Same research study as reported by
was concerns relating to the particular Coffey (1999) presenting data on
client groups with which they worked. self-reported measures from demographic
The most frequently mentioned coping questionnaire
strategy was receiving support of colleagues
Coffey and Coleman (2001) See Coffey (1999) Authors summarize findings as statistically Same research study as reported by Coffey
significant associations were found between (1999) presenting data on comparison
caseload size and level of stress. The results of respondent characteristic against
also suggest that support from managers and study measures. Multiple comparisons
colleagues were an important factor in conducted
ameliorating the experience of stress Limitations recognized
Coyle et al. (2000) See Edwards et al. (2000) The mean overall coping scores were significantly Same research study as reported by
higher for females, for those who felt that they Edwards et al. (2000) presenting
had job security, who were older and who more detailed data for the PNMC.
had worked in the field for longer Basic statistical analysis
Dallender et al. (1999) S, PDT, For the MHNs the main source of support was Purposive convenience sample. Basic
M WES peer support. The most favoured coping statistical analysis. The authors are
strategy was seeking a solution to the problem 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 Fifty CMHNs and 50 WBMHNs
nature of the work was an item of randomly selected from previous study
satisfaction and excessive administration conducted by the authors (Dallender
demands was an item of dissatisfaction et al. 1999). Sampling methods not
specified. Self-reporting factors for job
satisfaction

Table 4 (Continued)
Dolan (1987) B, MBI, No significant difference between GNs and Pilot study. Random sample however,
JS PDT MHNs on levels of job satisfaction there were insufficient numbers recruited
For mean MBI scores see Table 6 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 Small sample size, no statistical analysis
that having to see inappropriate referrals of total score for CPNSQ. Basic statistical
(CTT staff) and having to work with analysis (rank order)
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
Edwards et al. (2000) S, CPNSQ, Rank order of questionnaire data determined Basic statistical analysis (rank order).
M, PNMCQ, RSES, that lack of facilities within the community Advanced statistical analysis conducted
B, MBI, had the highest mean stress score in a series of companion papers
PD GHQ-12 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 4Æ7).
For mean MBI scores see Table 6
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
Edwards et al. (2001) See Edwards The best predictors of high stress scores were Same research study as reported by
et al. (2000) levels of emotional exhaustion, working with Edwards et al. (2000) presenting more
clients were severe mental illness, job in detailed data for the CPNSQ. Advanced
security and alcohol consumption statistical analysis (multiple regression analysis)
Ewers et al. (2002) B* MBI Staff in the experimental group showed significant Quasi-experimental design pre-test/post-test
decrease in burnout rates. Staff in control design, basic statistical analysis – Fishers
group showed a small nonsignificant increase exact tests taking into account small sample
in burnout. For mean MBI scores see Table 6 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
179
Table 4 (Continued)
180
Fagin et al. (1995) S, CPN SQ (R), Rank order of questionnaire data determined Claybury CPN Stress Study. Sampling
M, OSI – CCSS, RSES, not having enough facilities in the community undertaken on an opportunities basis –
B, MBI, had the highest stress score volunteers
JS, MJSS, The highest mean coping subscore was task strategies.
PD GHQ-28 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
Fagin et al. (1996) S, Same measures as Fagin Rank order of questionnaire data determined For validity of DCLSS readers referred to
M, et al. (1995), that inadequate staffing to cover potentially work submitted to journal in 1996. Work
B DCL SS (For Study 2 and 3) dangerous situations had the highest mean still unpublished to date. Study 3 hospitals
stress score The highest mean coping subscore scheduled for closure. Data from each
for all studies was task strategies study are presented separately and
For mean MBI scores see Table 6 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 S, WES, Nurses working flexitime reported the most Inclusion criteria – professional nursing
(1994) B, MBI, negative perceptions of their work environment qualification, employed at grade H,
PD GHQ-12 and higher scores for stress related variables. worked full time. No post hoc testing.
CMHNs gave higher ratings than WBMHNs No statistical data presented for
for involvement, supervisor support, autonomy, comparison of differences between
innovation and work pressure MBI scores
Fothergill et al. (2000) See Edwards et al. (2000) Factors associated with low self-esteem were Same research study as reported by
alcohol consumption and being in lower Edwards et al. (2000) presenting more
nursing grades (D, E and F). detailed data for the RSES
Factors associated with high self-esteem was
amount of time working as a CMHN
Giloran et al. (1994) JS PDT Staff nurses were found to have significantly Random sampling (stratified). A part
lower satisfaction and lower perception of a larger piece of research, this
of ward morale than nurses of other grades paper just presents data from
comparison of staff nurses with
nurses of other grades. No data for
reliability and validity of this measure

Table 4 (Continued)
Hannigan et al. (2000) See Edwards et al.Working in an urban environment and lacking a supportive Same research study as reported by
(2000) line manager were significant indicators for higher EE. Edwards et al. (2000) presenting more
Reporting an unsupportive line manager, being male, detailed data for the MBI. Abstract
job insecurity and not having an elderly caseload were and results misinterpret data presented
significant indicators for higher DP. Not having completed in table
specialist training, and not working in a supervisory or
managerial position were significant indicators for lower PA
Harper et al. (1992) JS PJSS General satisfaction reported to be higher and satisfaction with Purposive sample. Adapted validated
working conditions and emotional climate same as patients questionnaire, pretested for reliability.
at time point T2 from Humphris and Turner (1989) 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 Quasi experimental design, two measures
for satisfaction with working conditions and general used were adapted and reliability and
satisfaction. Staff turnover was associated with lower validity were reported. Statistical analysis –
levels of satisfaction conducted separately for staff who had
replied on all three occasions (numbers not
specified). No post hoc testing
Jones et al. (1987) S, PDT, Three factors emerged accounting for 45% of the variance. Purpose convenience sample. Reliability
JS, WJSS, The most dominant stress factor was administration and validity of tool not discussed and
PD GHQ-12 (28% of the variance) ‘Job satisfaction among this sample no piloting undertaken. Advanced statistical

is relatively low compared with some other employed analysis undertaken (principle components
samples’. Scores on the GHQ were greater for those analysis with varimax rotation). For the
who had a spouse working at the same hospital WJSS no statistical data was presented
Kilfedder (2001) S, UPCS, RCM, RAM, Two per cent (n ¼ 10) of the total sample could be classified Random sampling (stratified by working
M, JFAQ, Psyom, PDT, as having high burnout. Emotional exhaustion was location). Advanced statistical analysis
B, NSS, CCSS, SSM, increased by role conflict, nonoccupational concerns, (hierarchical regression analyses).
PD, PANAS, MBI, nursing stressors, negative affectivity and psychological Developed five questions to measure
JS GHQ-12, distress and was decreased by predictability of job-related nonoccupational stressors and there is
WJSS events, certainty in relation to job security, social no data for reliability and validity of
support, positive affectivity and job satisfaction. this measure
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
181
Table 4 (Continued)
182
Kirby and Pollock (1995) S OSI, WES No significant differences of occupational stress or Purposive sample. Advanced statistical
perception of ward environment between nurses analysis (regression analysis). Small
on the two wards. When OSI was compared with sample size in regard to type of advanced
normative data the scores were elevated for the statistical analysis undertaken
subscales of control, satisfaction and type
‘A’ behaviour. No association between OSI
scores and demographic characteristics or work

environment variables form regression analysis
Kunkler and Whittick (1991) B, GHQ-28, All mean scores decreased over the course of Pilot study, length of sessions – three sessions
PD BC the project but the burnout scores decreased held once a fortnight with a fourth
most over the group intervention 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, PDT, Nine factors emerged accounting for 72Æ5% Sixty-one stress items developed by Carson
M, PDT of the total variance in total stress scores. et al. (1991) Sixty-one coping items
The most dominant stress factor was that of generated from interviews with 21
feeling professionally isolated (43% of CMHNs. Q Sort statements developed
variance). Twelve factors emerged accounting and piloted on four CMHNs. Statistical
for 76Æ2% of the total variance in total analysis – factor analysis. Well-documented
coping score The most dominant coping validity and reliability
strategy was the utilization of appropriate
time management skills (37% of variance)
Lemma (2000) B, MBI, Nurses in I1 and I2 reported significantly Volunteers who were then randomized
PD GHQ-28* lower levels of psychological distress and to two intervention groups and a case
overall levels of burnout but at 10-week matched control group. Matched on
follow-up had reverted back to their precourse employment capacity, place of work,
levels level of experience, level of previous
Nurses in I1 reported a significant increase exposure to therapeutic skills. Length
in levels of PA, whereas those in I2 showed no of sessions 20 three-hour sessions. Basic
change. At follow-up nurses in I1 did not and advanced statistics (stepwise multiple
maintain levels of PA regression, logistic regression). Small
CMHNs were significantly more likely sample size for advanced statistical
to be scored as cases and to have techniques. Measures given at baseline,
higher levels of PA completion of course and at 10-week
For mean MBI scores see Table 6 follow-up. No power calculations

Table 4 (Continued)
McCarthy (1985) B SBSHP Nurses between the ages of 21 and 29 had No sampling details provided and small
significantly higher burnout scores than sample size. Basic statistical analysis –
those between the ages of 29 and 59 ANOVA inappropriate as very small
numbers within subgroups
McElfatrick et al. (2000) M PDT, The authors new scale for coping was found Low response rate. Well-documented validity
OSI – CSS to be more reliable and valid when applied to and reliability
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
McLeod (1997) S, PDT, The most frequently reported stressors for each Convenience sampling used first 60
PD GHQ-28 group were too many referrals/caseloads too large responses to obtain three equal groups
(groups 1 and 2) and clerical administration (group 3). (long-term mentally ill, mixed caseload,
CMHNs working with SMI are more stressed than those neurosis or primary clients). No statistical
working with primary or the more neurotic client group data provided. Self-reporting of stressors
For mean GHQ scores see Table 7
Milne et al. (1986) S, PDT, WES, Twelve items on the 98-item questionnaire strongly Purposive convenience sampling.
PD GHQ-12 discriminated between wards with high and low Questionnaire design. Small sample size
levels of absenteeism sickness with no sampling details provided. Length
The innovation was associated with reduction in of sessions 1 day everyday for 1 week.
absenteeism sickness and increased No details provided of statistical tests.
confidence and work skills 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 Random sampling (stratified by grade),
with the job itself and working conditions than staff pilot study. Statistical analysis – no
or managerial grades post hoc testing
Muscroft (1998) S, PDT More stress at work was experienced by GNs than MHNs Tools piloted for validity. Random
M GNs more likely to talk to someone about their sampling stratified by grade. No
stress in particularly colleagues and to use details of questionnaire scoring. Small
professional work-based counselling services sample with poor response rate
Nolan (1995) S, MHPSS, SCL-18, Stress factors were found to be overly heavy workload, Statistical analysis – factor analysis,
M, CS, difficulties with clients, organizational structure, findings not supported by evidence
PD GHQ-28 interprofessional conflict, under resourcing, professional of the statistical process. Conclusions
self-doubt, home/work conflict reached not justified by information given.
Most consistent predictor of poor mental health Reader referred to authors previous work
outcomes was home/work conflict for further details
Parahoo (1991) JS PDT Seventy per cent rated job satisfaction a high Reliability and validity of purpose
or very high. Most frequently mentioned designed tool not discussed and no
factor for job satisfaction was being one’s piloting undertaken. Self-reporting of
own manager/independent practitioner and factors. Lack of generalizability because
for job dissatisfaction paperwork/clerical duties of particular organizational and cultural
contexts practised in the province
183
184
Table 4 (Continued)
Parry-Jones and Grant (1998) S, PDT The research indicated increases in stress and Poor sampling methods resulting in low
JS decreases in job satisfaction, which was response rate. Reliability and validity
associated with increased workload and of purpose designed tool not discussed
administrative duties combined with and no piloting undertaken. Advanced

reduced time for the service user statistical analysis – multiple regression
and family contact analysis
Peacock (1991) S, PDT For stress four factors emerged accounting for Hospital where sample was drawn was
M, 60% of the variance. The most dominant awaiting closure. Questionnaire piloted
JS, stress factor was staff shortages and support on two separate samples and data on
SM (18Æ54 of the variance). Day shift workers scored validity and reliability presented.
significantly higher than night shift workers Advanced statistical analysis (principle
The most frequently used coping strategy appeared components analysis, multiple
to be tackling problems directly they arise regression analysis)
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
Plant (1992) S NSS interviews The lowest mean scores were reported Cross-sectional survey, random sample
for MHNs (stratified by grade)
The highest stress scores among females were Respondents selected from current hospital
evident amongst MNs while the lowest were staff lists Statistical analysis – no post hoc
reported by MHNs testing. Female sample
Rees (1991) S OSI Mean score OSI – sources of pressure Random sampling (stratified by grade),
subscale: 210Æ6 (MHNs), 213Æ1 (CMHNs). only results for sources of pressure
CMHNs ranked 1 and WBMHNs ranked presented for MHNs, other paper
2 of 17 different professional groups from study presents data for the
17 professional groups as a whole
Reeves (1994) PD GHQ-28 For mean scores see Table 6. Concluded GHQ scoring method, threshold greater
that the effects of stress on psychiatric than 5. Subgroup analysis – Mann–
and medical nurses were found to be similar Whitney U-tests, multiple regression
analysis – however, number of variables
used was limited

Table 4 (Continued)
Ryan and Quayle (1999) S, OSI, The most frequently reported sources of stress Random sampling (stratified by gender
M, WOC, related to organizational issues and grade)
PD GHQ-60 The most frequently reported measure of coping was Statistical analysis – multiple comparisons
the use of self-controlling strategies
The mean score for the GHQ60 was 4Æ74 (SD
8Æ48) 7% respondents reporting stress
levels which are unlikely to remit
without intervention
Sammut (1997) JS PDT MHNs preferred working at the older, No data for reliability and validity of this
more spacious psychiatric hospitals measure. Very specific study with little
compared with modern district general generalizability

hospitals
Schafer (1992) S, CPNSQ, Rank order of questionnaire data determined Small scale study. Basic statistical analysis
B, MBI, that having too many interruptions in the (rank order). Lack of statistical data
PD GHQ-28 office (pre change), and lack of facilities presented for any comparative analysis
(post change) had the highest mean scores
For mean GHQ28 scores see Table 7
Snelgrove (1998) S, PDT, For the whole community sample four Advanced statistical analysis (principal
PD, GHQ-12, factors emerged accounting for 38% component analysis with varimax

JS PDT of the total variance. The most dominant rotation). Statistical analysis – no
stress factor was that of emotional post hoc testing
pressure/difficulty (25% of variance).
For CMHNs the most frequently
reported stressor was quantifying work
Sullivan (1993b) S, PDT, Rank order of questionnaire items determined Convenience sample. Reliability and
M, PDT, that seeking social support had the highest validity of purpose designed tool not
B MBI mean score. For mean MBI scores discussed and no piloting undertaken
see Table 6 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 Prospective design – control groups
health than controls when compared matched for age and occupational
with baseline data. Psychological distress grade. Sample selection methods
was higher following assaults. For mean inadequately described. Inadequate
GHQ scores see Table 7 reported of statistical analysis
185
186
Table 4 (Continued)
Watson (1986) S, SCL, The scores after completing the course No sampling details, no period of
M CCL showed that participants significantly follow-up Length of sessions 1/2 day
lowered their anxiety and improved levels once a week for 6 weeks, small
of coping compared with the control group. sample size. Statistical tests – no
There were no significant differences in the details provided. Measures collected
group’s perceptions of their work-based stressors 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.

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 Nurses who were members of a 4925 985 (29) 6% psychiatry
an institutional setting state-wide professional
nursing association, USA
Alexander et al. (1998) To investigate the relationship of job All staff (RNs, LPNs, NAs) Ns 1106 (Ns)
satisfaction to nursing personnel’s working within 19 long-term
intention to leave and turnover psychiatric hospitals, USA
Gordon and Goble (1986) See text
Trygstad (1986) To measure levels of stress in a MHNs working within four units Ns 22 (Ns)
sample of MHNs of three private hospitals and five
units of one federal hospital, USA
Cronin-Stubbs and Rooks (1985) To identify stressors that are associated MHNs, ORNs, ICNs, MNs working MHNs (Ns) 66 (Ns)
with burnout in critical care, within three metropolitan medical ORNs (Ns) 65 (Ns)
psychiatric, operating room hospitals, USA ICNs (Ns) 74 (Ns)
and medical nurses MNs (Ns) 91 (Ns)
Davis (1974) To measure intrarole conflict MHNs working within a Ns 17 (Ns)
and job satisfaction psychiatric hospital, USA
Dawkins (1985) To identify and quantify job MHNs working within a 43 43 (100)
stress as perceived by MHNs psychiatric hospital, USA
Dorr (1980) To examine the relationship between Nursing staff (RNs, LPNs, NAs, WCs) 92 66 (72)
social climate and job satisfaction working within private psychiatric

hospital, USA
Farrell and Dares (1999) To examine job satisfaction in MHNs working within acute inpatient 23 22 (87)
a group of MHNs psychiatric unit in a large general
hospital, Tasmania
Munro et al. (1998) To examine the effects of occupational MHNs working within five units of a 100 60 (60)
stress in psychiatric in psychiatric private inpatient facility, Australia
nursing on employee health well-
being in terms of job satisfaction
and mental health
Humpel and Caputi (2001) To examine the relationship between MHNs working within three mental 63 52 (83)
emotional competency and work health inpatient units, Australia
stress and the length of time
in mental health nursing
Rump (1979) To examine the relationship between MHNs working within three psychiatric 623 486 (78)
the size of psychiatric hospital hospitals (all staff), Australia
and nurses’ job satisfaction
Ito et al. (2001) To examine factors which influence MHNs working within the Fukuka Association 1965 1494 (76)
nurses’ intention to leave the job of Psychiatric Hospitals, Japan
187
188
Table 5 (Continued)
Author Aim Study population Sample size Response rate (%)
Astrom et al. (1990) To compare levels of empathy, Nursing staff (RNs, LPNs, NAs) 557 358 (64)
experience of burnout and attitudes working within a nursing home,
towards demented patients amongst long-term care clinic and a
different categories of nursing staff psychogeriatric clinic in
one health district, Sweden

Melchior et al. (1997a) See text
Melchior et al. (1997b) To investigate the relationship between Nursing staff (ULs, PNs, NAs), 494 631 (73)
burnout and a number of work-related working in long stay settings,
variables the Netherlands
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 MHNs working within five wards GNs 316 196 (62)
characteristics (autonomy, of a psychiatric hospital and GNs MHNs 273 175 (64)
social support and workload) working within five wards of a
and work reactions (emotional general hospital, the Netherlands
exhaustion and job involvement)
between GNs and MHNs
Landeweerd and Boumanns (1988a) To compare nurses’ work satisfaction Nurses working within three Long-stay 19 Ns
and feelings of health and stress departments of a psychiatric Short-stay 27 Convenience sample
in three psychiatric departments hospital, the Netherlands Admission 19
differing in type of work
Landeweerd and Boumanns (1988b) To compare nurses’ work satisfaction Nurses working within two CC 21 Ns
and feelings of health and stress departments or a general hospital GS 14 Convenience sample
in three psychiatric departments and three departments of a Long-stay 19
differing in type of work psychiatric hospital (same sample Short-stay 27
and two general departments as Landeweerd & Boumanns Admission 19
1988a), the Netherlands
Thomsen et al. (1999) To describe the possible differences MHNs from five health trusts in UK UK 657 296 (45)
between psychosocial work (randomly selected) and MHNs Sweden 1058 720 (68)
environments of English from eight health districts
and Swedish MHNs in Sweden (all nurses)
Samuelsson et al. (1997) To examine suicidal feelings, Nurses and attendants working 243 197 (81)
attempted suicide and aspects of within in psychiatric care
work environment and well-being
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.

the lives of nurses working in a large psychiatric hospital in (1998) identify seven such factors: high levels of self-esteem,
the USA. The sample consisted of 43 nurses, 41 of whom were good social support networks, hardiness, good coping skills,
female. Thirteen of the high stress items, including the first 11, mastery and personal control, emotional stability and good
were classified as arising from administrative/organizational physiological release mechanisms. Possession of these buffer-
issues. Other sources of stress were revealed to be staff ing factors serves to minimize the effects of stress. An
conflicts and limited resources. Mansfield (1989) conducted a individual’s self-esteem is probably one of the most important
study to measure nurses’ job context in an institutional setting of these moderators (Turner & Roszell 1994). Those with
with nurses from 10 different clinical specialities, 6% from high self-esteem are more likely to have a greater sense of self-
psychiatry. The scale used was the Nurse Job Context Scale, efficacy and self-worth (Branden 1994), and are likely to be
which the authors developed, and details of this were more confident in dealing with stressors. Three papers gave
provided. The scale measured general pressure/uncertainty consideration to these issues and 17 studies investigated the
and those working in psychiatry, paediatrics and outpatient range of strategies that individuals bring to bear to deal with
unit reported lowest levels of stress when compared with other stressors (see Table 4).
areas such as intensive care, general medicine and surgery. The final level of the model is that of stress outcomes. These
In a 1988 study, Landeweerd and Boumanns compared include positive stress outcomes such as psychological health
nurses’ work satisfaction and feelings of health and stress in and high job satisfaction, and negative stress outcomes such as
three psychiatric departments differing in type of work in the psychological ill health, burnout and low job satisfaction.
Netherlands. The measures used were the Work Satisfaction Burnout is described as a syndrome consisting of three
Questionnaire (Algera 1980) and a purpose-designed tool to dimensions: emotional exhaustion (inability of individuals to
measure feelings of health and stress. Within the psychiatric give of themselves at a psychological level), depersonalization
hospital, staff working in a short-stay department reported (development of cold negative attitudes towards those who
low work satisfaction and low scores on health and stress provide public services) and personal accomplishment (the
variables when compared with those in admission and long- loss of the ability to value one’s achievements at work).
stay departments. The statistical analysis, undertaken was Seventeen studies undertaken in the UK investigated various
basic and analysis of variance (ANOVA ) was used to compare aspects of job satisfaction and of these six reported a variety of
three means as opposed to paired t-tests. Caution should be issues regarding job satisfaction and working with older
exercised in generalizing from this study, given the small clients (see Table 4). Seven studies were conducted outside the
sample size and the use of a purpose designed tool without UK and these are summarized below.
any data on validity and reliability (Landeweerd & In an Australian study, Munro et al. (1998) investigated
Boumanns 1988a). At the same time the authors collected the effects of occupational stress in mental health nurses on
data from nurses working on a cardiac care unit and a general employee well-being (job satisfaction and mental health)
surgical ward, both in a general hospital, using the same using a questionnaire based on the Job Strain Model (Dwyer
measures. The Cardiac Care Unit received the most positive & Ganster 1991), Warr Job Satisfaction Scale (Warr et al.
scores for six of seven satisfaction variables, and the short- 1979) and General Health Questionnaire (Banks 1980). The
stay departments received the most negative scores on four of researchers found that nurses who perceived themselves as
seven satisfaction variables. Six aspects of self-reported stress having greater job control and social support, both in the
were assessed (general health, heart complaints, nervousness, workplace and their lives in general, were healthier and more
depression, irritability and stress feelings). There were satisfied in their work. The research used advanced statistical
differences in relation to irritability and stress feelings, with techniques of multiple regression analysis, but adapted
those working on the general surgical ward having the lowest the Job Control Scale without providing any evidence of
scores. However, these results did not stand up to post hoc validity. Another Australian study, by Rump (1979), aimed
testing. The analysis was repeated by combining the data for to examine the relationship between the size of psychiatric
the general hospital with those for the psychiatric hospital hospitals and nurses’ job satisfaction. Using a purpose-
(excluding the admissions ward). Nurses in the general designed tool without conducting any validity or reliability
hospital reported more work satisfaction and fewer health- testing, data from this large-scale study found that satisfac-
and stress-related problems (Landeweerd & Boumanns tion amongst nursing staff is related to size as defined by
1988b). number of staff.
The critical factor in the stress process is the moderators on The aim of the study by Dorr et al. (1980) was to examine
which an individual can call to help cope with external the relationship between social climate of psychiatric wards
stressors that are impinging upon them. Carson and Kuipers and mental health nurses’ job satisfaction. The Ward
Atmosphere Scale (Moos 1974) was used and it was found involvement with the organization, and positively associated
that job satisfaction was reliably related to views of the social with role conflict. However, not all the studies included
climate of the wards on nurses worked. This study used basic separate results for psychiatric nurses. A number were of
statistical techniques and there were very few details on the mental health professionals (Stout & Posner 1984, Savicki &
tool used. Davis (1974) conducted a small study of intrarole Cooley 1987, Leiter 1988), one presented combined results
conflict (measured using a purpose-designed questionnaire) for psychiatric and ‘mental handicap’ nurses (Firth et al.
and job satisfaction (using a validated tool). Seventeen 1986), and another nursing students (Van Gorp et al. 1993).
psychiatric nurses completed these measures and the results The studies conducted outside the UK are summarized below.
did not support the hypothesis that the higher the intrarole Tummers et al. (2001) investigated differences in work
conflict, the lower the job satisfaction. Farrell and Dares characteristics and work reactions, which included levels of
(1999), using a job satisfaction questionnaire, reported that emotional exhaustion between general, and mental health
key job satisfaction characteristics were where participants nurses. Emotional exhaustion was measured using the Dutch
had interesting work to do, work which gave them respon- version of the MBI and analysis revealed that mental health
sibility, and good interpersonal relationships with colleagues. nurses experienced greater levels of emotional exhaustion.
However, the authors also noted that these findings did not The aim of the study conducted by Cronin-Stubbs and Rooks
necessarily match respondents’ views on being interviewed, (1985) was to identify stressors associated with burnout in
when interviewed they reported both having little control critical care, psychiatric, operating room and medical nurses.
over decision-making and low staff morale. The study was a Purposive sampling was undertaken but the authors did not
small one and in a specific geographical area. provide details of the populations. Well-validated scales were
Two studies investigated issues around turnover of staff. used and included the Life Experiences Survey (Sarason et al.
Alexander et al. (1998) investigated the relationship of job 1978), Staff Burnout Scale for Health Professionals (Jones
satisfaction to nursing personnel’s intention to leave and 1980), Nursing Stress Scale (Gray Toft & Anderson 1981)
turnover using a purpose-designed tool. There were no details and Norbeck Social Support Questionnaire (Norbeck et al.
provided for response rate or validity and reliability. Factors 1983). Multiple regression analysis was conducted to deter-
associated with job satisfaction were workload (RNs), mine the predictors of burnout. Thirty-five per cent of the
autonomy (LPNs, NAs) and work hazards (LPNs, NAs). In variance in burnout could be accounted for, and the predictor
Japan, Ito et al. (2001) investigated factors which influenced variables were intensity of occupational stress, changes in life
nurses’ intention to leave the job, and used the National stress (positive and negative), social support: affect, work
Institute for Occupational Safety and Health Job Stress setting: psychiatric/mental health unit and work setting:
Questionnaire, which had been translated into Japanese operating room. Multivariate analysis revealed significant
(Haratani 1998). Findings from logistic regression analysis differences in occupational stress among work settings and
revealed that having fewer previous job changes, being levels of social support. Investigating this further revealed
younger, having less supervisory support, lower job satisfac- that critical care and medical nurses encountered occupa-
tion and having a higher perceived risk of assault influenced tional stressors significantly more frequently and intensely
nurses’ intention to leave. than psychiatric and operating room nurses. Critical care
Eighteen studies have investigated burnout in the UK and nurses experienced significantly more affirmation than psy-
17 have investigated psychological distress as a stress chiatric nurses, and operating room nurses experienced more
outcome. Table 6 summarizes the results of studies using aid than psychiatric nurses. There were no significant
the Maslach Burnout Inventory (MBI) to measure burnout differences in burnout among the four work settings.
and shows that reported levels of emotional exhaustion range The purpose of the study conducted by Thomsen et al.
from 22% to 51%, levels of depersonalization from 7% to (1999) was to identify and describe the possible differences
45% and levels of personal accomplishment between 14% between psychosocial work environments of English and
and 33%. Table 7 shows that 27–42% of psychiatric nurses Swedish mental health nurses. A variety of purpose-designed
scored above the threshold for vulnerability to psychiatric tools were used to collect information on professional
morbidity. Seven studies conducted outside the UK and one fulfilment mental energy, work-related exhaustion, occupa-
additional study undertaken by Melchior et al. (1997a) set tional well-being and coping, and data on reliability and
out to describe the relative influence of a number of variables validity were presented. Self-esteem was measured using the
on burnout among psychiatric nurses, using the technique of Rosenberg Self-Esteem Scale (Rosenberg 1965). Swedish
meta-analysis. The results revealed that burnout was negat- nurses experienced a higher level of well-being than their
ively associated with job satisfaction, staff support and British counterparts. Regression analysis was conducted for
Table 6 Comparison of MBI scores
EE PA DP
Study Population Setting n EE DP PA (%) (% high) (%)
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 ).
all the nurses. Factors associated with higher psychological female and being under 40 years of age. Higher professional
well-being were lower alcohol consumption, being male, fulfilment was associated with working full-time and taking
being a clinic-based nurse and having fewer days sick leave in fewer days sick in the last year. Factors that predicted
the year before the study. Higher exhaustion was associated psychological well-being were self-esteem, professional ful-
with having taken more sick days in the last year, being filment, workload and sick days in the last year. Factors that
Table 7 Comparison of General Health Questionnaire (GHQ) scores
Mean score
Scoring
Study Sample n GHQ-12 GHQ-28 Threshold (%) method
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).
predicted exhaustion were professional fulfilment, work load, burnout variables, but there were no differences between the
self-esteem, work climate and number of sick days in the last different nursing groups. The percentage variance in each of
year. the MBI subgroups that could be accounted for by multiple
Astrom et al. (1990) compared experience of burnout regression was low (11–16%), suggesting that there were
using a number of different measures, including a burnout many factors affecting burnout that this study did not
scale developed by Pines et al. (1981). Basic statistical account for or measure. Samuelsson et al. (1997) studied
analysis revealed that 27% of nursing staff were assessed suicidal feelings, attempted suicide and aspects of work
for risk of developing burnout, those at highest risk being environment and well-being in Swedish psychiatric nursing
nursing aides and those at lowest risk being RNs. Melchior personnel using questionnaires from previous research in
et al. (1997b) conducted a study using the MBI to investigate Sweden, and included a short version of the MBI along with
the relationship between burnout and a number of work- several other validated instruments. The study revealed that
related factors. Men were found to score higher on all three psychiatric personnel with suicidal feelings in the last year
had significantly higher scores for emotional exhaustion, used that method for the period of the study (Watson
depersonalization (as measured by the MBI), tiredness and 1986).
hopelessness than those who had never experienced suicidal • Stress management workshops were effective in reducing
feelings. Negative work environment was associated with levels of burnout for psychiatric nurses. Those offered
burnout and depression. However, the prevalence of suicidal looked at concepts of stress and burnout, principles of
feelings in the last year was lower than that found in the stress management and progressive muscular relaxation.
general population. After a period of discussion, the various strategies that had
Humpel and Caputi (2001) examined the relationship been attempted formed the basis of a further session and
between emotional competency and work stress. Emotional participants were given the opportunity to talk through
competency, described as the ability to monitor one’s own any difficult situations that they had encountered (Kunkler &
and others’ feelings and emotions, and to use this information Whittick 1991).
to guide one’s thinking and behaviour, was measured using • Social support-based programmes for psychiatric nurses’
the Stories subtest of the Multifactor Emotional Intelligence offered no significant advantage over feedback only. The
Scale (Mayer & Salovey 1997). Work stress was measured intervention presented a social support model which
using three subscales of the Mental Health Professionals examined the impact of life events and stress and asked
subscale (Cushway et al. 1996). Those with more experience participants to identify individuals who provide social
in mental health nursing experienced less personal self-doubt support and to draw up a social support network (Carson
about their nursing abilities and had higher levels of et al. 1998).
emotional competency, and this was particularly true for • Levels of psychological distress and burnout significantly
female nurses. This study lacks generalizability as only part of decreased following attendance at a 15-week training
the stress scale was used and very basis statistical techniques course in therapeutic skills. There was no further benefit
were conducted. 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
Stress management interventions
then to offer a safe forum for the exploration of clinical
We identified six stress management intervention studies work (Lemma 2000).
conducted in the UK (Milne et al. 1986, Watson 1986, • Training a group of forensic mental health nurses in psy-
Kunkler & Whittick 1991, Carson et al. 1998, Lemma 2000, chosocial interventions had a significantly positive effect on
Ewers et al. 2002), one in the Netherlands (Melchior et al. levels of burnout. The aim of psychosocial interventions is
1996) and one in the USA (Gordon & Goble 1986). More to help clinicians to conceptualize their patient’s problems
detailed information is presented in Tables 3 and 4 and, to within a more empathetic framework, and to train them in
summarize, the studies conducted in the UK established the skills to intervene effectively (Ewers et al. 2002).
that: A study conducted in the Netherlands investigated the
• Training in behavioural techniques improved work satis- effectiveness of primary nursing on levels of burnout. The
faction and levels of sickness and reduced strain in psy- intervention involved the introduction of an innovation in
chiatric nurses. The behavioural training therapy that was nursing care delivery, with a special focus on primary nursing.
provided aimed to improve nurses’ preparation for thera- The principles of primary nursing are that each patient is
peutic tasks by helping them to develop skills and know- assigned to a nurse and the nurse takes 24-hour responsibility
ledge so that they could more effectively deal with patient for that patient’s care, with care being focused on the needs of
problems. The areas that the training covered included the patient rather than the needs of the ward. Burnout was
behavioural assessment and learning and behavioural measured using the Dutch version of the MBI 1Æ5 years before
therapy (Milne et al. 1986). primary nursing was introduced and then 1 year afterwards.
• Personal stress management relaxation techniques signifi- A random sample of 492 of a potential 725 nurses working on
cantly improved psychiatric nurses’ ability to cope with 35 long-stay wards from 43 psychiatric hospitals were
anxiety and stress. The relaxation training used was surveyed. The response rate was 73% (n ¼ 361). Only 161
Jacobsen’s progressive muscle relaxation. The participants (49%) completed the measures at all three time points and, of
were also introduced to other forms of relaxation, inclu- those, 60 received the intervention. There were no further
ding clinically standardized meditation, biofeedback, details provided of how the sample was divided into the
autogenics and self-hypnosis, and asked to choose intervention and control wards. The sample was a mixed
which method they felt most suitable to them. They then sample of unit leaders, mental health nurses, practical nurses
and nurses’ aides. Result showed that levels of burnout did not supervision in Sweden. This was combined with implemen-
change. The authors recognized the limitations of their study. tation of individualized care on an experimental ward
They reported that attrition was a serious problem, which (n ¼ 19) for patients with severe dementia as compared with
resulted in loss of participants at different time points, that the a similar control ward (n ¼ 20). The intervention was
control groups could have been affected by the interventions, evaluated by means of the Creative Climate Questionnaire
and that the period of intervention might have been too short (Ekvall et al. 1983), Tedium Measure (Pines et al. 1981), and
(Melchior et al. 1996). MBI (Maslach & Jackson 1986). Tedium and burnout
One method of coping with professional frustration is decreased significantly on the experimental ward but no
to accommodate the situation, and this has been termed change was found on the control ward. Berg and Hallberg
‘creative accommodation’. It is an expansion of activities that (1999) used a pre- and post-test design to investigate the
simultaneously provide the nurse with an opportunity for an effects of 1 year of clinical supervision, combined with
increased sense of accomplishment and enhanced profes- supervised individualized planned and documented nursing
sional esteem, in addition to meeting patient and organiza- care. The effects were explored in relation to nurses’ sense of
tional needs. The purpose of the study by Gordon and Goble coherence, creativity, work-related strain and job satisfac-
(1986) was to identify the effects of this expanded activity on tion. The focus of this study was all nurses (n ¼ 22) on a
nurses’ role satisfaction. In this situation the creative accom- ward providing care for patients with diagnoses such as
modation was assertiveness training with behavioural rehear- psychotic disorder or borderline personality disorder at a
sal in a group format. The authors did not provide any general psychiatric unit in southern Sweden. There were no
sampling details for the seven nurses recruited to the study changes in nurses’ work satisfaction, job strain or sense of
and the instrument used to measure job satisfaction was a coherence as a result of clinical supervision.
modified version of the Job Satisfaction Inventory (Porter
1962), with no details of validity and reliability reported. For
Methodological issues
this group of nurses, at 9 months following intervention job
satisfaction improved and they reported increased assertive- Research on stressors, moderators and stress outcomes
ness and professional self-image. Because of the small sample conducted in countries other than the UK gives some data
size, the results have to be treated with caution. 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
Effectiveness of clinical supervision
that there are limitations in generalizing the findings.
Three studies have been conducted in Sweden to determine The measurements tools used must be evaluated in terms
the effectiveness of 1 year of clinical supervision in relation- of the extent to which reliability and validity have been
ship to burnout (Berg et al. 1994, Hallberg 1994) and job established. There are numerous established measures which
satisfaction (Berg & Hallberg 1999). Hallberg (1994) have been shown to be valid and reliable for measuring
conducted a small study to investigate the effects of clinical stressors, moderators and stress outcomes but investigators
supervision on all nurses (n ¼ 11) on a ward for child frequently feel the need to develop new instruments.
psychiatric care in Sweden. Data were collected using the Nineteen studies used questionnaires that had been specif-
Tedium Measure (Pines et al. 1981) and the MBI (Maslach & ically designed for the study. Pilot studies and data on
Jackson 1986), and Satisfaction with Working Care Scale reliability and validity were described in only seven of the
(Hallberg et al. 1994), as well as a series of open-ended studies.
questions on three occasions – baseline, 6 and 12 months The majority of studies in the occupational health field
after the start of supervision. The mean score of the Tedium focused on psychological distress rather than psychological
measure decreased significantly over the 12 months for health. All the studies in this review have used Goldberg’s
mental exhaustion. Degree of burnout showed no significant General Health Questionnaire for this purpose. There are
changes over time. Satisfaction with factors relating to four different versions of this scale, each having a cut off
nursing and the job increased significantly over time, and point for detecting psychiatric caseness. Caseness means a
these factors were described as satisfaction with co-operation score on the questionnaire that is characteristic of patients
and comfort at work and satisfaction with responsibility, with diagnosable mental disorders. On each version of the
organization and quality of care. Berg et al. (1994) studied scale there are two scoring methods – the GHQ method (0, 0,
creativity and innovative climate, tedium and burnout among 1, 1) and the Likert Method (0, 1, 2, 3). Mean scores
nurses on two wards during 1 year of systematic clinical obtained from the Likert Method should not be directly
compared with those obtained using the GHQ Method. Two did not present any statistical information at all and as a
authors, McLeod (1997) and Kilfedder et al. (2001) do not result their conclusions cannot be accepted as valid.
give the data for mean scores and the reader is left to assume It was difficult to compare the results for studies that
that the differences in mean scores are correct. evaluated different interventions for a number of other
When investigating burnout, all the authors used the MBI reasons. The duration of the interventions covered a range
to measure this. When investigating stress and job satisfac- of four to 15 sessions lasting from 1 hour to 1 day and
tion, however, a range of tools was used and in the majority occurring on a daily or weekly basis for a given period of
of cases the authors developed their own questionnaires. This time. It is important that after a study has finished partici-
makes it difficult to compare directly findings between pants are followed-up to determine whether the interventions
different studies. maintained their effectiveness. For the six studies conducted
The effectiveness of stress management programmes in the UK, the period of follow-up ranged from 4 weeks to
depends on the accuracy of the initial diagnosis. Stress in 1 year, with no follow-up in the studies by Watson (1986)
the workplace can be diagnosed in many different ways, and Ewers (2002). The problem encountered in all these
questionnaires, interviews, indirect observation (staff turn- studies was that participants tended to leave organization
over, sickness records), examination of biochemical markers, during or after the intervention.
etc. There needs to be some attempt to utilize common In conclusion, these methodological issues give rise to
measurement approaches which will enable workers to problems with generalizability and rigour.
compare across studies.
Sample size should be determined before a study is
Discussion
conducted. Sample sizes in these studies varied from 3 to
2080, an extremely large variation. The larger the sample Much research has revealed an excessive level of workplace
then the more representative of the population it is likely to stress for mental health nurses, who are likely to experience
be, and small sample sizes will produce less accurate results. personal stress as a result of working closely and intensely with
Small sample sizes tend to increase the probability of patients over an extended period of time. When comparisons
obtaining a markedly nonrepresentative sample (LoBiondo- have been made with other professional groups, mental health
Woods & Haber 1997). It is possible to estimate sample size nurses (hospital- and community-based) have been identified
with the use of a statistical procedure known as power as one of the professional groups with the highest sources of
analysis, but this was not undertaken for any of the studies stress (Rees & Smith 1991). When compared directly with
in this review. This issue is a particular problem in studies nurses from other specialities, those experiencing significantly
that failed to detect significant differences or relationships, as greater levels of stress include medical and surgical nurses
the results might be due to inadequate sample size rather than (Plant 1992), general nurses (Muscroft & Hicks 1998), and
an incorrect hypothesis (Burns & Groves 2001). In the health visitors and district nurses (Snelgrove 1998). The most
majority of studies the sample was selected by the researcher frequently reported sources of stress were administration and
subjectively (purposively) or on a given date in a particular organizational concerns, client-related issues, heavy workload,
place (convenience) and only 13 studies used a random interprofessional conflict, financial and resource issues, profes-
sampling techniques. sional self-doubt, home/work conflict, staffing levels, changes
The statistical analyses undertaken give some cause for in the health service, maintenance of standards, giving talks
concern. Two studies sought to undertake advanced statis- and lectures, length of waiting lists, and poor supervision. The
tical tests (regression analysis, logistic regression) that were factors associated with increasing stress levels were nursing
inappropriate due to the small nature of the sample [Kirby status, job dissatisfaction, poor quality of social support,
& Pollock 1995 (n ¼ 38); Lemma (2000) (n ¼ 27)], and permanent day shift work, being younger, longer length of
McCarthy (1985) undertook ANOVA on a sample of only 32. service, reduced time for client contact, dissatisfaction with
Analysis of variance tests whether group means differ; rather working conditions, level of responsibility, being female and
than testing each pair of means separately, ANOVA considers working occasional night shifts. Other factors associated with
the variation among all groups. Post hoc analyses were increasing levels of stress for nurses working in the community
commonly performed in studies with more than two groups include large caseloads, reorganization of community teams,
when the analysis indicates that groups were significantly increased workload, increased administrative duties, reduced
different, but did not identify which group was different, as time for service users, and reduced time for family contact.
occurs in ANOVA . In all the the studies that used this The most frequently reported coping strategies were social
approach, no post hoc analyses were performed. Five studies support, having stable relationships, recognizing limitations,
dealing with problems immediately they occur, fitness levels, the lack of evidence of interventions directed at stress
peer support, personal strategies, supervision, good home life prevention is not primarily caused by a shortage of studies,
with family and partner and interests outside of work. but by their considerable heterogeneity. The next step would
Factors associated with increased use of coping skills are be to minimize the negative effects of stress via education and
being female, particularly for social support and emotional management strategies, and the last step would be to assist
comfort, more experience in the field, being older, job individuals who are experiencing the effects of stress. Gray
security and work setting. (2000), in the report Mental Health in the Workplace:
Sixty-two per cent of the studies investigated burnout Tackling the Effects of Stress, suggests that organizations
and or factors affecting job satisfaction, and psychological need to recognize and accept that mental health is an
distress which are the end processes of negative stress important issue and that the Health and Safety Executive in
outcomes. The reasons associated with leaving psychiatric the UK recommends that a mental health policy should be an
nursing were low overall job satisfaction, dissatisfaction with integral part of any organization’s health and safety policy.
the perceived quality of decisions made by those in mana- This should not just be limited to large corporate organiza-
gerial positions, dissatisfaction with the amount of in service tions, but should also be developed within the NHS with the
training offered, dissatisfaction with physical working con- intention of addressing the issue of retaining mental health
ditions, burnout, type A personality and being younger, less nurses in the workforce.
experienced and more highly qualified. Burnout has been
shown to be positively associated with role conflict, lack of
Acknowledgements
staff support, lack of involvement with the organization, poor
job satisfaction and number of days taken off sick. Increased This study was undertaken with the support of the Wales
levels of emotional exhaustion were associated with patient Office of Research and Development for Health and Social
care, work environment, and lack of support. Decreased Care.
levels of personal accomplishment were associated with
dissatisfaction with the organization. The factors associated
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INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

A systematic review of stress and stress management interventions for

and P. Burnard MSc PhD RGN RMN RNT

Submitted for publication 7 February 2002

Correspondence: E D W A R D S D . & B U R N A R D P . ( 2 0 0 3 ) Journal of Advanced Nursing 42(2), 169–

Keywords: stress, burnout, job satisfaction, coping, stress management, mental

2003 Blackwell Publishing Ltd 169

1999). Eighty-five per cent of 100 trusts surveyed by the

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

of clinical burnout in a group of FMHNs 10 C

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

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

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

amount of in service training offered validity of tool not discussed and no

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

Author Outcome measures Data collection Study findings Rigour

higher levels of psychological distress, higher

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

Author Outcome measures Data collection Study findings Rigour

their line manager as less supportive than

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

Author Outcome measures Data collection Study findings Rigour

support concerns that working in a team

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

mean score 16Æ9, 14Æ6% categorized with low self-esteem.

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

Author Outcome measures Data collection Study findings Rigour

not undertake any statistical analysis

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

scores and demographic characteristics or work

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

Author Outcome measures Data collection Study findings Rigour

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

Author Outcome measures Data collection Study findings Rigour

administrative duties combined with and no piloting undertaken. Advanced

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

Author Outcome measures Data collection Study findings Rigour

compared with modern district general generalizability

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

Author Outcome measures Data collection Study findings Rigour

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

Author Aim Study population Sample size Response rate (%)

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

Author Aim Study population Sample size Response rate (%)

one health district, Sweden

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

Table 6 Comparison of MBI scores

Table 7 Comparison of General Health Questionnaire (GHQ) scores

Jones et al. (1987) MHNs 349 10Æ24 Likert

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