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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631 623
R. Jenkins and P. Elliott
(Constable & Russell 1986, Kaufmann & Beehr 1986, Jones acute adult mental health wards at four hospitals in London
et al. 1987, Hare & Pratt 1988, Chappell & Novak 1992). and the south-east of England. A total of 240 questionnaires
were distributed and 93 were returned completed, represent-
Differences between qualified and unqualified nursing staff ing a response rate of 39%.
Both the prominence of particular stressors and the incidence
of burnout can vary as a function of nursing rank or grade.
Questionnaire
Nurses in charge of wards have reported higher adminis-
trative demands than less senior grades (Jones et al. 1987), We designed a self-report questionnaire consisting of four
while greater levels of emotional exhaustion and deperson- sections: background information, levels of stressors, burnout
alization have been found among nursing assistants (Hare & and social support.
Pratt 1988). Nursing assistants may be more vulnerable to the
development of burnout because they deliver a high propor- Background information
tion of direct care services to patients (Novak & Chappell Personal details were obtained on participants’ job titles,
1994). In the present study we sought to investigate differ- length of employment on current ward, length of employ-
ences in the stressor and burnout profiles of qualified and ment in the nursing profession, gender and age.
unqualified nursing staff. The experiences of unqualified staff
are worthy of particular attention, given the increasing Stressors
importance of their role during the last decade. Following the A major criticism of previous research on occupational stress
introduction of the Project 2000 scheme of nurse education among mental health nurses has been the lack of a reliable and
and training in the UK (UKCC 1986), nursing or healthcare valid scale that encompasses the specific problems faced by
assistants now provide much of the direct patient care pre- this group. For example, only 11 of the 78 items comprising
viously delivered by student nurses (MacPherson 1993). the Psychiatric Nurses Occupational Scale in the study by
Dawkins et al. (1985) were specific to the work in mental
Buffering health settings. To address this deficiency, we used the Mental
While the main effects of social support on the incidence of Health Professionals Stress Scale (MHPSS). This was devel-
burnout (i.e. negative correlations between these two variables) oped by Cushway et al. (1996) and originally tested with a
are well documented, few studies have investigated the buff- sample of 154 clinical psychologists and 111 mental health
ering phenomenon among nursing staff (Constable & Russell nurses. It demonstrated good discriminant validity (differ-
1986, Kaufmann & Beehr 1986, Chappell & Novak 1992). ences between the two groups in terms of the main sources of
stress), concurrent validity (relationships with a range of cri-
terion measures including a symptom check list, job satisfac-
The study
tion, self-reported stress and social support) and internal
consistency (Cronbach’s a ¼ 0Æ94 for mental health nurses).
Aims
The MHPSS consists of 42 items which are grouped into
The aims of the study were: seven subscales: workload; client-related difficulties; organ-
• to investigate and compare the levels of stressors and burn- izational structure and processes; relationships and conflicts
out experienced by qualified and unqualified nursing staff; with other professionals; lack of resources; professional self-
• to examine relationships between stressors and burnout for doubt; and home–work conflict. Each item is answered on a
the sample as a whole; four-point scale. The original form of the MHPSS uses only
• to assess the impact of social support on burnout (main an end-point labelling system, where a score of 0 represents
effect) and stressor–burnout relationships (buffering). ‘does not apply to me’ and 3 represents ‘does apply to me’.
However, in line with the stress and coping paradigm
(Lazarus & Folkman 1984) that formed the basis of our
Design
present study, we replaced this with a response scale that
A survey design was adopted. would make more explicit the notion of individuals apprais-
ing events as difficult to cope with: 0, never or rarely a
problem; 1, sometimes a problem; 2, often a problem and 3,
Participants
very often a problem. Reliability coefficients (Cronbach’s
These were a convenience sample of full-time qualified nurses alpha) for the MHPSS subscales in the present study are
and nursing assistants identified from the staff lists of 11 shown in Table 1.
624 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
Nursing and health care management and policy Nurses in acute mental health settings
Table 1 Reliability coefficients (Cronbach’s a), mean values and Table 2 Frequency distribution of MBI burnout scores by staff group
standard deviations of Mental Health Professionals Stress Scale
(MHPSS) subscales Staff group
Burnout ‘somewhat true’ and ‘very true’). The reliability coefficient for
The Maslach Burnout Inventory (MBI) (Maslach et al. 1996) the House and Wells scale in the present study was 0Æ84.
consists of 22 items grouped into three subscales: emotional
exhaustion, depersonalization and personal accomplishment.
Data collection
Each item is answered on a seven-point response scale, scored
0–7 (‘never’, ‘a few times a year’, ‘once a month or less’, The study was conducted between April and July 2000. The
‘a few times a month’, ‘once a week’, ‘a few times a week’ Directors of Nursing or General Managers of mental health
and ‘every day’). Responses are summed to give separate services at the selected hospitals were contacted to request
scores for each of the three subscales, which can then be permission to conduct the study and obtain staff lists. Each of
categorized as low, average or high degrees of burnout the acute adult mental health wards was then visited by the
according to normative data. The categorization of scores in researcher (R.J.) following an introductory letter to the ward
the present study (see Table 2) was based on normative data manager explaining the nature of the study and requesting
from a sample of 730 mental health workers (Maslach et al. the participation of nursing staff. Questionnaires were
1996). Reliability coefficients for the MBI subscales in the distributed to nursing staff with a covering letter outlining
present study were 0Æ90 (emotional exhaustion), 0Æ75 the study and ensuring confidentiality of responses. Stamped
(depersonalization) and 0Æ76 (personal accomplishment). addressed envelopes were enclosed for the return of
questionnaires to the researcher. A written reminder to
Social support complete the questionnaire was sent to all staff via their ward
This was assessed using the four-item scale devised by House managers after 3 weeks.
and Wells (1978), which measures social support from the
immediate supervisor (e.g. ward or line manager), co-work-
Ethical considerations
ers, spouse/partner and friends and relatives. The first two
items relate to all four sources of support and the third to the The study was approved by the ethics committee of the
two work-related sources (supervisor and co-workers). For Department of Psychology at the University of Southampton.
these items, participants rate the extent to which each source As an audit of occupational stress and burnout, however,
fulfills a particular supportive function; a four-point response the study did not require permission from National Health
scale is used, scored 0–3 (‘not at all’, ‘a little’, ‘somewhat’ and Service Local Research Ethics Committees. Completion and
‘very much’). The final item has three statements about the return of the questionnaire was taken as evidence of
participant’s supervisor, which require a rating of their the individual giving informed consent to participate in the
truthfulness, scored 0–3 (‘not at all true’, ‘a little true’, study.
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631 625
R. Jenkins and P. Elliott
a whole were examined by computing Pearson correlation Analyses at the univariate level showed that qualified nurses
coefficients for normally distributed data and Spearman’s rho scored significantly higher than nursing assistants on the
correlation coefficients for non-parametric data. For each set of ‘workload’ subscale [F (1, 91) ¼ 5Æ52, P ¼ 0Æ021].
correlations, the required level of statistical significance was
subject to a Bonferroni correction to control for type 1 errors.
Burnout
To test for a buffering effect of social support in the
relationship between stressors and burnout, a series of hierar- The frequency distribution of MBI scores categorized accord-
chical multiple regressions was employed. The procedure ing to degree of burnout (low, average or high) for each
normally involves entering each stressor variable followed by group is shown in Table 2. Chi-square analyses revealed no
each social support variable, then a series of interaction terms significant associations between staff group and degree of
for each combination of stressor and support variable, with emotional exhaustion (v2 ¼ 0Æ44, d.f. ¼ 2, P ¼ 0Æ802),
each dimension of burnout as the criterion variable (Constable depersonalization (v2 ¼ 0Æ88, d.f. ¼ 2, P ¼ 0Æ646) or
& Russell 1986). Given the sample size of the present study and personal accomplishment (v2 ¼ 2Æ58, d.f. ¼ 2, P ¼ 0Æ275).
statistical power considerations, however, the number of
predictor variables was limited to include only the total
Relationships between stressors, social support and
stressor and social support scores, together with a total
burnout
stressor/social support interaction term. The buffering hypoth-
esis predicts that there will be a significant interaction between Correlations between MHPSS, social support and MBI scores
stressors and social support, which is indicated by a significant are shown in Table 3. Scores on six of the seven MHPSS
change in the amount of variance in the criterion variable subscales (excluding ‘lack of resources’) were positively
(scores on each dimension of burnout). correlated with MBI emotional exhaustion scores. Scores on
four of the MHPSS subscales (excluding ‘workload’, ‘organ-
izational structure and processes’ and ‘lack of resources’)
Results
were positively correlated with MBI depersonalization scores.
Thus, higher stressor scores were associated with higher
Participants
levels of emotional exhaustion and depersonalization,
The sample comprised 57 qualified nurses and 36 nursing respectively. There were no significant correlations between
assistants. The mean length of work experience on the MHPSS and MBI personal accomplishment scores. With
current ward for all staff was 2Æ8 years (SD ¼ 2Æ8) and mean regard to relationships between levels of social support and
length of work experience in the nursing profession was burnout, there was a significant negative correlation between
9Æ3 years (SD ¼ 6Æ9). Sixty-two of the participants were co-worker support and MBI emotional exhaustion scores,
female (66Æ7%) and 31 were male (33Æ3%). Their mean age with higher levels of co-worker support associated with lower
was 37Æ1 years (SD ¼ 10Æ0). levels of emotional exhaustion (r ¼ 0Æ32, P ¼ 0Æ002).
Stressors Buffering
Descriptive statistics for scores on the MHPSS subscales are Given the absence of any significant correlations between
shown in Table 1. The order of prominence given to stressors and personal accomplishment, hierarchical multiple
626 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
Nursing and health care management and policy Nurses in acute mental health settings
MBI, Maslach Burnout Inventory; MHPSS, Mental Health Professionals Stress Scale.
Scores on these subscales were not normally distributed. Correlation analyses involved the
computing of Spearman’s rho coefficients.
*P < 0Æ01, **P < 0Æ001 with Bonferroni correction.
regressions were performed on only the MBI emotional F (1, 46) ¼ 3Æ779, P ¼ 0Æ058]. This pattern indicated an
exhaustion and depersonalization scores (see Table 4). A total opposite or reverse buffering effect. Higher stressor scores
MHPSS-social support interaction term did not explain a were associated with higher levels of depersonalization for
significant increase in the variance of emotional exhaustion nurses reporting high levels of support, but not for nurses
scores [R2 change ¼ 0Æ003, F (1, 89) ¼ 0Æ392, P ¼ 0Æ533]. reporting low levels of support.
However, the interaction term did explain a significant
increase in the variance of depersonalization scores
Discussion
[R2 change ¼ 0Æ035, F (1, 89) ¼ 4Æ061, P ¼ 0Æ047]. To
determine the nature of this interaction, the sample was split In this study we sought to clarify the nature of occupational
into low and high social support groups using the median stress among nursing staff on acute adult mental health wards
value of the total social support variable (1Æ92). Deperson- by measuring levels of stressors and burnout experienced by
alization scores were then regressed on the total MHPSS qualified nurses and nursing assistants, relationships between
scores for each group. Total MHPSS scores significantly stressors and burnout, and the impact of social support on
predicted depersonalization in the high support group burnout (main effect) and stressor–burnout relationships
[adjusted R2 ¼ 0Æ398, F (1, 43) ¼ 30Æ041, P < 0Æ001], (buffering).
but not for the low support group [adjusted R2 ¼ 0Æ056, The main stressor cited by qualified staff was a lack of
adequate staffing, which is consistent with the findings of a
Table 4 Hierarchical regression analyses of emotional exhaustion number of previous studies of mental health nurses (Carson
and depersonalization scores et al. 1995, Cushway et al. 1996). Dealing with physically
Step B SE B b
threatening, difficult or demanding patients was rated as the
most problematic source of stress by nursing assistants. The
Emotional exhaustion
prominence of both these stressors may reflect, in part,
1. Total stressors 14Æ653 2Æ313 0Æ574**
changes in the patient population that have characterized
2. Total social support 1Æ958 1Æ649 0Æ105
3. Stressor–social support interaction 0Æ657 1Æ049 0Æ054 acute inpatient settings in recent years. Staffing levels have
Depersonalization been a major cause for concern for much of the last two
1. Total stressors 7Æ031 1Æ369 0Æ511** decades as a result of the reduction in the number of mental
2. Total social support 1Æ372 0Æ976 0Æ137 health nursing students in this period (Department of Health
3. Stressor–social support interaction 1Æ251 0Æ621 0Æ191*
1994). However, the demands posed by an increasingly
*P < 0Æ05, **P < 0Æ001. diverse mix of inpatients may have intensified the concerns of
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631 627
R. Jenkins and P. Elliott
qualified nurses over the adequacy of staffing by contributing in the completion of work tasks. They are also likely to be
to a feeling of being over-stretched. It is perhaps not more accessible for support than the nurse’s immediate
surprising that these same demands were rated as the greatest supervisor (e.g. ward manager). A previous study involving
source of stress by nursing assistants, given that over half of mental health nurses noted that when faced with a work-
their day-to-day work involves direct contact with patients related problem, 85% of staff said they would seek the
(Higgins et al. 1999). The higher rating of workload stress by support of their immediate colleagues compared with 75%
qualified nurses can be interpreted in terms of another of the who would consult their manager (Dallender et al. 1999).
key themes noted by Higgins et al. (1999), namely an We found no significant buffering effect of social support in
increasing volume of administrative duties. the relationships between stressors and emotional exhaustion
Qualified nurses and nursing assistants did not differ (i.e. higher levels of support did not weaken these relation-
significantly in terms of the degree of reported burnout. ships). However, total level of support did act as a buffer in
Compared with the findings of Sullivan (1993), a greater the relationship between stress and depersonalization,
proportion of all nursing staff in our study were categorized although in the opposite direction to the one normally found
as experiencing a high degree of emotional exhaustion (Constable & Russell 1986, Chappell & Novak 1992). This
(51Æ6% compared with 45%) and a lower percentage reverse buffering effect was characterized by a significant
reported feelings of high depersonalization (37Æ6% compared positive relationship between stressors and depersonalization
with 43%). It is interesting to note that in both studies less for staff reporting higher levels of support, but not for those
than a quarter of staff experienced a high degree of burnout reporting lower levels. One explanation of this phenomenon
in terms of reduced personal accomplishment. In other proposed by Beehr (1985) concerns the content of commu-
words, most nurses were judging their work performance in nications between staff when discussing work-related issues:
a positive manner. One possible explanation of this finding colleagues may alter an individual’s perception of a situation
relates to the challenges posed by the acute inpatient setting. from positive to negative or accentuate an already negative
Landeweerd and Boumans (1988) found higher levels of appraisal (i.e. things are actually worse than they first
work satisfaction among staff working on acute wards thought). For example, a colleague’s discussion of a particular
compared with other mental health settings (e.g. long-stay). patient may dwell on the difficulties encountered during their
Interviews with nursing staff revealed that work on the acute nursing care, such as management of problem behaviours. It is
wards was seen by many as representing ‘real psychiatry’, possible that this negative appraisal may then later manifest
posing demands that fully used the nurse’s skills. itself in the form of a higher level of depersonalization.
A variety of aspects of the work environment were
associated with levels of emotional exhaustion and deper-
Limitations
sonalization. Of all the stressors documented, workload
showed the strongest relationship with emotional exhaustion. Due to the cross-sectional nature of the data, no definitive
This is consistent with the findings of a review of 36 studies statements can be made about causal relationships among the
(Duquette et al. 1994), which identified workload as one of variables. While the pattern of results is consistent with the
the main correlates of burnout among nursing staff. How- notion of burnout developing in response to chronic occupa-
ever, no significant relationships were found between any of tional stressors, it is equally plausible that as a result of
the stressors and the personal accomplishment dimension of feeling burnt-out, nursing staff may have appraised their
burnout in the present study. According to Glass and work environment as more demanding and problematic.
McKnight (1996), feelings of competence at work may be Similarly, while lower levels of support may have contributed
better explained in terms of an ‘aspiration–achievement gap’ to feelings of emotional exhaustion, these same feelings may
or unfulfilled career expectations. have resulted in poorer supportive relationships through
With regard to social support, we found evidence of both withdrawal from others or other attitudinal changes.
main effects and buffering. Main effects were confined to The use of convenience sampling may have yielded
only one of the four sources of support measured, with higher unrepresentative findings as a result of a self-selection bias.
levels of support from co-workers associated with lower Many of the nurses who participated may have done so
levels of emotional exhaustion. This pattern can be explained because they felt particularly distressed by their work
in terms of the breadth and immediacy of support from co- environment and wished to make their feelings known,
workers. Work colleagues are able to provide a greater range leading to an inflation of reported stress and burnout levels.
of supportive behaviours for dealing with work-related Alternatively, the most burnt-out staff may have felt too
problems than external sources, such as practical assistance exhausted and disaffected to participate in the study or have
628 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
Nursing and health care management and policy Nurses in acute mental health settings
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