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QUESTION: Do mental health nurses experience occupational stress? Are stress management interventions effective?
Systematic review with narrative synthesis.
Studies were identified using PUBMED, EMBASE, SCISearch, Pascal, CINAHL, ASSIA, PsychLit, Clin Psych, Heathstar, Cochrane Library, British Nursing Index, SIGLE, and the National Research Register. Reference lists and selected nursing journals were hand searched and key authors contacted.
Eligible studies comprised primary research mainly conducted in the UK and published in English between 1966 and 2000. 7 studies completed after the search date were also included.
Data were extracted on outcome measures and scales (stressors, burnout, coping, moderators, job satisfaction, psychological disturbance) and other study findings.
77 studies were included in the review. They suggested that sources of stress for mental health nurses included workload, poor resources, role conflict, job insecurity and client issues. Lower stress was associated with a good support network (including supervision at work, a good home life, or both) and external interests. Single studies suggested that beneficial interventions might include training in behavioural therapy techniques, therapeutic skills, psychosocial interventions, relaxation, and stress management. The review found a dearth of large, high quality studies and studies about organisational interventions.
There is insufficient good quality research about stress management interventions. Results cannot be generalised due to problems with the methods of existing research including heterogeneity and low power.
Stress is experienced when demands made on us outweigh our resources. The Health Service Executive estimates that in excess of half a million workers are adversely affected by stress.1 Psychiatric nursing is implicitly stressful;2 indeed psychiatric nurses’ levels of occupational stress are remarkably high.3
Research suggests that self-fulfilment is an important motivator for mental health staff, who often have high expectations of themselves, their jobs and patients.4 The contrast between these ideals and working conditions can result in negative expectations leading to pessimism about the effectiveness of their work. More recently it has been suggested that bureaucracy and paperwork may be more significant stressors than caring for patients.5
This review focuses on the effects of stress management interventions on individual mental health nurses. However, occupational stress needs to be seen in context of the health service as a whole. Work culture, communication and workplace relationships have important effects on the emotional well-being of staff, particularly on the ways in which they manage stress. By focusing on signs and symptoms in individuals, we risk ignoring or minimising the effects of external organisational stressors. Stress management interventions for psychiatric nurses are less likely to succeed if stressful workplace conditions remain. Successful interventions for managing stress must address organizations as well as individual nurses.6
A dearth of studies; limited data on reliability and validity; and the heterogeneous nature of the original papers mar this review. Methodological limitations of the original papers means there is little reliable evidence for the effectiveness of stress management approaches for psychiatric nurses. Furthermore, I have reservations about generalising research carried out on nurses working in foreign countries, cultures and health systems to colleagues in the NHS.
Sources of funding: Wales Office of Research and Development for Health and Social Care.
Correspondence to: Deborah Edwards, School of Nursing and Midwifery Studies, Ty Dewi Sant, University of Wales College of Medicine, Health Park, Cardiff, CF14 4XN UK. email:
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