S t r e s s a n d H e a l t hStress and Health 18: 203–215 (2002)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/smi.947
S t r e s s managemen t f o r men t a lh ea l t h p ro f e s s i ona l s : a r ev i ewo f e f f e c t i v e t e chn i que s
Deborah Edwards,Ł,† Ben Hannigan, Anne Fothergill and Philip Burnard
University of Wales College of Medicine, Cardiff, Wales, UK
SummaryThis paper presents the findings of a systematic review of the current evidence for the effectivenessof stress management interventions for those working in the mental health field. Research articlesfrom 1966 to 2000 which reported studies undertaken in the United Kingdom and which specificallyidentified participants as mental health workers were included in the review. Studies from otherEuropean countries and from the USA were examined as potential models of good practice. Thereview demonstrated that a great deal is known about the sources of stress at work, about how tomeasure them and about their interaction and impact on a range of outcome indicators. What wasfound to be lacking was a translation of these results into practice, into research that assessed theimpact of interventions that attempted to moderate, minimize or eliminate some of these stressors.Three papers were retrieved which reported intervention strategies for workers classified as workingwithin the mental health arena. Copyright 2002 John Wiley & Sons, Ltd.
Key Wordsmental health professionals; stress; burnout;coping; job satisfaction; intervention studies;systematic review
Background to the study
Mental health professionals are subjected to similarorganizational stressors as other workers. Theyalso face additional emotional strain by the verynature of their professions in dealing with troubledpersons over extended periods of time (Nolan,Cushway & Tyler, 1995). Stress and burnout areclearly problems for mental health workers, andthe evidence indicates that these factors not only
Ł Correspondence to: Deborah Edwards, University ofWales College of Medicine, School of Nursing andMidwifery Studies, Heath Park, Cardiff CF14 4 XN.† E-mail: [email protected]/grant sponsor: Welsh Office for Research andDevelopment.
affect the level of performance and the success ofinterventions with their patients but also their jobsatisfaction and ultimately their own health.
There have been a number of papers publishedwhich have looked at the issues of stress for men-tal health workers. Moore and Cooper (1996)presented a theoretical overview of the subject.When looking at specific members of the mentalhealth team, a number of specific stressors havebeen reported. A recent review of stress in mentalhealth professionals (Carson & Fagin, 1996) pre-sented evidence concerning stress in occupationaltherapists, psychiatrists, social workers, clinicalpsychologists, mental health nurses, case managersand community psychiatric teams. Rabin, Feldmanand Kaplan (1999) looked at intervention strategiesfor mental health workers from a variety of disci-plines and discussed the various stress reductionand stress management techniques.
It is more commonplace in psychiatric prac-tice that professionals work together in multidis-ciplinary settings, and there are many commonfactors across mental health disciplines leading to
Received 13 March 2002Copyright 2002 John Wiley & Sons, Ltd. Accepted 23 September 2002
D. Edwards et al.
chronic stress and burnout. This paper reports thefindings of a systematic review for papers whichhave classified their subjects as mental health work-ers working in multidisciplinary settings and whereresults were presented for mental health workers asa whole and not for the individual disciplines. Theresults for the individual mental health disciplineshave been reported elsewhere.
Methods of data collection
A systematic review of the effectiveness of stressmanagement interventions for mental health pro-fessionals was conducted over a 1-year periodcommencing June 2000. The University of York’sguidelines for carrying out a systematic review werereferred to for guidance (2001).
The review was conducted in two parts. The firstpart focused on stressors, moderators and stressoutcomes and included papers on stress, burnoutand job satisfaction. The second part of the reviewretrieved papers that evaluated stress managementinterventions.
Studies included in the review were researcharticles from 1966 to 2000 reporting on studiesundertaken in the United Kingdom that specificallyidentified participants as mental health workers.Studies from other European countries and from theUSA were also included in the review as potentialmodels of good practice.
A number of general (PUBMED, Excerpta MedicOnline, the Science Citation Index; the Social Sci-ence Citation Index, the Science, Technology andMedicine index) and specialist electronic databases(CINAHL–nursing and allied health, ASSIA–socialscience, PsychLit–psychology, including clinicalpsychology, Clin Psych) were searched. The searchterms Mental Health ProfessionalŁ, Mental HealthStaff, Mental Health Personnel, Mental Heath Ser-vice, Community Mental Health (EMBASE) werecombined with the terms stress, burnout, coping,job satisfaction and stress management. The elec-tronic database SIGLE (System for Informationon Grey Literature) was searched for unpublishedarticles, conference proceedings, university thesesand commissioned reports. After completing theelectronic searches, the search was drawn to a con-clusion by several stages of follow-up to identifyany further relevant articles. This was undertakenby checking reference lists of selected articles andreviews, by handsearching key journals and bywriting to key authors. A total of 98 papers were
considered potentially relevant to the review andthe papers were obtained in hard copy. Furtherassessment for relevance was made according tothe inclusion and exclusion criteria.
The inclusion criteria which were formulatedby all members of the research team were that(1) the publication should be in English, (2) itshould involve the specific professional groups con-cerned, (3) the article should be a research paper,(4) the health outcomes measured should be stres-sors, moderators or stress outcomes, and (5) thearticle should provide sufficient data. Fifty paperswere excluded from the review: foreign languagepublication (two), other professional group (20),not a primary research article (22), insufficient data(two), other outcome measures (four).
Results
Ten articles were retrieved which reported studiesconducted within the UK for groups of men-tal health professionals (Harper & Minghella,1997; Oliver & Kuipers, 1996; Onyett, Pillinger,& Mujen, 1997; Parkes & von Rabenau, 1993;Prosser et al., 1996, 1997, 1999; Reid et al.,1999a, 1999b; Wykes, Stevens & Everitt, 1997)(see Table I). These studies have all focused onthose working within community teams. Studies,which have involved mental health workers in theUK, consisted of psychiatrists, psychologists, socialworkers, nurses and occupational therapists. How-ever, US and Canadian studies also included avariety of other professional groups making anycomparisons difficult and these results have beenpresented separately (Brady, Kinnard, & Friedrich,1980; Buffum & Konick, 1982; Cacciacarne,Resnick, McArthur, & Althof, 1986; Cherniss& Egnatios, 1978a, 1978b; Corrigan & HolmesLuchin, 1995; Drude & Lourie, 1984; Finch &Krantz, 1991; Folkins, O’Reilly, Roberts, & Miller,1977; Hiscott & Connop, 1990; Hromco, Lyons,& Nikkel, 1995; Ingledew, Hardy, & Cooper,1997; Jerrell, 1983; Kirk, Koeske, & Koeske, 1993;Koeske, 1995; Koeske & Kelly, 1995; Leiter, 1988,1990; Marini, Todd, & Slate, 1995; Oberlander,1990; Pines & Maslach, 1978; Pond & Geyer,1987; Savicki & Cooley, 1987; Schulz, Green-ley, & Brown, 1995; Thornton, 1992; Webb,1980; Webster & Hackett, 1999; Wilcoxon, 1989;see Table II). The sample groups include nursingassistants, rehabilitation counsellors, rehabilitationtherapists, home care workers, psychiatric techni-cians, attendants, volunteers, recreational/activities
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002)204
Stress management for mental health professionals
Tab
leI.
Res
earc
har
ticl
esth
atco
nsid
erst
ress
ors,
mod
erat
ors
and
stre
ssou
tcom
esco
nduc
ted
inth
eU
K.
Aut
hor
(yea
r)co
untr
yPa
rtic
ipan
ts(n
D),
resp
onse
rate
,set
ting
Res
earc
hfo
cus
Mai
nfin
ding
s
Pros
ser
etal
.(1
997)
UK
nD
121,
76%
,C
omm
unit
y,H
ospi
tal
Sour
ces
ofst
ress
Incr
ease
dw
orkl
oad
Incr
ease
dad
min
istr
atio
n
Pros
ser
etal
.(1
996)
UK
nD
121,
76%
,C
omm
unit
y,H
ospi
tal
Com
pari
sons
betw
een
com
mun
ity
and
hosp
ital
staf
fon
leve
lsof
burn
out,
job
sati
sfac
tion
and
psyc
holo
gica
ldis
tres
s
Com
mun
ity
wor
kers
expe
rien
ced
high
erle
vels
ofbu
rnou
tan
dps
ycho
logi
cald
istr
ess
but
ther
ew
ere
nodi
ffer
ence
sin
leve
lsof
job
sati
sfac
tion
Har
per
&M
ingh
ella
(199
7)U
K
nD
55,
83%
,C
omm
unit
y
Sour
ces
ofst
ress
Wor
king
stru
ctur
esL
ack
ofre
sour
ces
Man
agem
ent
prob
lem
sFa
ctor
sas
soci
ated
wit
hjo
bsa
tisf
acti
onSe
eing
the
pati
ent
impr
ove
Seei
ngth
ese
rvic
eim
prov
eW
orki
ngw
ith
team
s
Ony
ett
etal
.(1
997)
UK
nD
455,
51%
,C
omm
unit
y
Sour
ces
ofst
ress
Lac
kof
reso
urce
sM
anag
emen
tpr
oble
ms
Incr
ease
dad
min
istr
atio
nFa
ctor
sas
soci
ated
wit
hbu
rnou
tC
asel
oad
size
,com
posi
tion
and
freq
uenc
yw
ith
whi
chse
rvic
eus
ers
wer
ese
enw
ere
not
asso
ciat
edw
ith
burn
out
Seei
ngpa
tien
tim
prov
eFa
ctor
sas
soci
ated
wit
hjo
bsa
tisf
acti
onW
orki
ngw
ithi
nte
ams
Rei
det
al.
(199
9a)
UK
nD
30,
Con
veni
ence
sam
ple,
Com
mun
ity,
Hos
pita
l
Sour
ces
ofst
ress
Incr
ease
dw
orkl
oad
Act
ing
aske
ywor
ker
for
pati
ents
Man
agin
gcr
ises
alon
e
Sour
ces
ofjo
bsa
tisf
acti
onW
orki
ngw
ith
pati
ents
Con
tact
wit
hco
lleag
ues
Pros
ser
etal
.(1
999)
UK
nD
120
(pha
se1)
,75%
,n
D10
0(p
hase
2),6
0%,
nD
94(p
hase
3),6
2%C
omm
unit
y,H
ospi
tal
Lev
els
ofbu
rnou
t,jo
bsa
tisf
acti
onan
dps
ycho
logi
cald
istr
ess
Com
mun
ity
wor
kers
Dec
reas
ein
psyc
holo
gica
ldis
tres
sD
ecre
ase
inE
E,D
P,In
crea
sein
job
sati
sfac
tion
Rei
det
al.
(199
9b)
UK
nD
30,
Con
veni
ence
sam
ple,
Com
mun
ity,
Hos
pita
l
Cop
ing
stra
tegi
esT
alki
ngto
colle
ague
sT
ime
man
agem
ent
Wor
kloa
dm
anag
emen
tC
linic
alsu
perv
isio
n
Wyk
eset
al.
(199
7)U
K
nD
61,
Not
stat
ed,
Com
mun
ity
Stre
ssan
dbu
rnou
tH
igh
leve
lsof
burn
out
expe
rien
ced
asa
resu
ltof
wor
kba
sed
stre
ssor
s
Oliv
er&
Kui
pers
(199
6)U
K
nD
10,
Ran
dom
ised
Con
trol
tria
l,C
omm
unit
y
Lev
els
ofex
pres
sed
emot
ion,
psyc
holo
gica
ldi
stre
ss,b
urno
utan
djo
bsa
tisf
acti
onSt
aff
disp
laye
da
high
rang
eof
expr
esse
dem
otio
nre
spon
ses
and
scor
edhi
ghly
onm
easu
res
ofst
ress
,bur
nout
and
expe
rien
ced
high
leve
lsof
job
sati
sfac
tion
Park
es&
von
Rab
enau
(199
3)U
K
nD
145,
90%
,C
omm
unit
y,H
ospi
tal
Neg
ativ
eaf
fect
ivit
y,jo
bde
man
d,jo
bdi
scre
tion
and
soci
alsu
ppor
tJo
bscl
asse
das
high
stra
inw
ere
show
nto
give
rise
toad
vers
eps
ycho
logi
calo
utco
mes
,whi
leac
tive
jobs
are
cond
uciv
eto
succ
essf
ulco
ping
,sat
isfa
ctio
n,an
dth
ede
velo
pmen
tof
mas
tery
and
com
pete
nce
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002) 205
D. Edwards et al.
Tab
leII
.R
esea
rch
arti
cles
that
cons
ider
stre
ssor
s,m
oder
ator
san
dst
ress
outc
omes
cond
ucte
din
the
USA
and
Can
ada.
Aut
hor
(yea
r)co
untr
yPa
rtic
ipan
ts(n
D),
resp
onse
rate
,set
ting
Res
earc
hfo
cus
Mai
nfin
ding
s
Tho
rnto
n(1
992)
USA
nD
234,
78%
,H
ospi
tal
Cop
ing
stra
tegi
es
Fact
ors
affe
ctin
gbu
rnou
t
Plan
ned
prob
lem
solv
ing
Wor
king
inin
pati
ent
sett
ings
Che
rnis
s&
Egn
atio
s(1
978a
)U
SA
nD
164,
94%
,22
Com
mun
ity
agen
cies
Fact
ors
affe
ctin
gjo
bsa
tisf
acti
onSe
nse
ofpe
rson
alac
com
plis
hmen
t,C
onfid
ent
inco
mpe
tenc
yto
dow
ork
Fact
ors
affe
ctin
gbu
rnou
tSt
aff
turn
over
,O
rgan
isat
iona
lqua
lity
(poo
rco
mm
unic
atio
nan
dla
ckof
orga
niza
tion
)Fo
lkin
set
al.
(197
7)U
SA
nD
114,
99%
,C
omm
unit
y
Impa
ctof
chan
ges
inph
ysic
alen
viro
nmen
ton
staf
fsa
tisf
acti
onfo
llow
ing
dece
ntra
lizat
ion
Mov
ing
into
new
surr
ound
ings
impr
oved
sati
sfac
tion
wit
hw
orki
ngco
ndit
ions
Pine
s&
Mas
lach
(197
8)U
SA
nD
76,
Not
stat
ed,
Six
Men
talh
ealt
hin
stit
utio
ns
Fact
ors
affe
ctin
gjo
bsa
tisf
acti
on,
burn
out
Hav
ing
ahi
ghpe
rcen
tage
ofpe
ople
suff
erin
gfr
omsc
hizo
phre
nia
inth
epo
pula
tion
Jerr
ell
(198
3)U
SA
nD
471,
Not
stat
ed,
Men
talh
ealt
hag
enci
es
Fact
ors
asso
ciat
edw
ith
incr
easi
ngjo
bsa
tisf
acti
onW
orki
ngin
inpa
tien
tun
its
Adu
ltcl
ient
grou
pL
ess
than
aver
age
case
load
Len
gth
ofte
nure
<1
and
>10
year
sSa
lary
leve
lIn
crea
sing
age
Wor
kgr
oup
supp
ort
Obe
rlan
der
(199
0)U
SA
nD
601,
33%
,C
omm
unit
y
Pred
icto
rsof
low
job
sati
sfac
tion
and
high
leve
lsof
stre
ssW
orki
ngw
ith
clie
nts
wit
hse
vere
men
tal
illne
ss
His
cott
&C
onno
p(1
990)
Can
ada
nD
123,
Not
stat
ed,
Hos
pita
l
Fact
ors
asso
ciat
edw
ith
incr
easi
ngem
otio
nale
xhau
stio
nB
eing
mal
eW
orki
ng12
-hsh
ifts
Fact
ors
asso
ciat
edw
ith
decr
easi
ngpe
rson
alac
com
plis
hmen
tB
eing
mal
eH
eavy
wor
kloa
dsW
orki
ngw
ith
diffi
cult
pati
ents
Dru
de&
Lou
rie
(198
4)U
SA
nD
33,
Not
stat
ed,
Hos
pita
l
Rel
atio
nshi
pbe
twee
nst
aff
perc
epti
ons
ofw
orki
ngen
viro
nmen
tand
pati
ent/
staf
frat
io
As
pati
ent/
staf
fra
tios
incr
ease
d,st
aff
wer
em
ore
likel
yto
feel
less
invo
lved
wit
han
dco
mm
itte
dto
thei
rw
ork,
whi
lepe
rcei
ving
less
supp
ort
from
both
peer
san
dsu
perv
isor
s
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002)206
Stress management for mental health professionals
Savi
cki&
Coo
ley
(198
7)U
SA
nD
95,
Not
stat
ed,
Hos
pita
l
Perc
enta
geof
tim
esp
ent
indi
rect
clie
ntco
ntac
tan
dit
sre
lati
onsh
ipto
burn
out
See
text
Ingl
edew
etal
.(1
997)
USA
nD
164,
18%
,H
ospi
tal
Stre
ssor
s,re
sour
ces
(loc
usof
cont
rol
and
perc
eive
dso
cial
supp
ort)
,co
ping
and
wel
l-be
ing
See
text
Lei
ter
(199
0)C
anad
a
nD
122,
69%
,H
ospi
tal
Bur
nout
,cop
ing
stra
tegi
es(i
ndiv
idua
land
fam
ilyre
late
d)U
seof
reso
urce
sre
late
dto
leve
lsof
burn
out.
Fam
ilyco
ping
reso
urce
sar
ela
rgel
yin
depe
nden
tof
wor
k-re
late
dco
ping
reso
urce
san
dex
tend
anin
divi
dual
’sca
paci
tyto
cope
wit
hoc
cupa
tion
alst
ress
Lei
ter
(198
8)C
anad
a
nD
34,
Not
stat
ed,
Res
iden
tial
men
talh
ealt
han
dre
habi
litat
ion
cent
re
Fact
ors
asso
ciat
edw
ith
anin
crea
sein
job
sati
sfac
tion
(loo
ked
atbu
rnou
t)
Sens
eof
pers
onal
acco
mpl
ishm
ent
Dec
reas
edle
vels
ofem
otio
nale
xhau
stio
n
Kir
ket
al.
(199
3)U
SA
nD
68(b
asel
ine)
,83%
,n
D66
(3m
onth
s),8
0%,
nD
55(1
2m
onth
s),7
5%,
nD
51(1
8m
onth
s),8
0%,
Hos
pita
l
Hea
lth
(inc
ludi
ngst
ress
and
burn
out)
and
life
sati
sfac
tion
See
text
Hro
mco
etal
.(1
995)
USA
nD
216,
21%
,H
ospi
tal
Fact
ors
asso
ciat
edw
ith
job
sati
sfac
tion
Staf
ftu
rnov
erL
ack
ofsp
ecia
list
trai
ning
Lar
ger
case
load
sK
oesk
e&
Kel
ly(1
995)
USA
Sam
esa
mpl
eas
Kir
ket
al.(
1993
)C
opin
gSe
ete
xt
Mar
inie
tal
.(1
995)
USA
nD
39,
78%
,C
omm
unit
y
Fact
ors
asso
ciat
edw
ith
incr
ease
sin
stre
ssor
sH
igh
leve
lsof
pers
onal
stai
nL
ack
ofpe
rson
alre
sour
ces
Bei
ngm
ale
Koe
ske
(199
5)U
SA
Sam
esa
mpl
eas
Kir
ket
al.(
1993
)at
the
18m
onth
tim
epo
int
Buf
feri
ngef
fect
sof
inte
rnal
locu
sof
cont
rol
Pers
onal
acco
mpl
ishm
ent
was
corr
elat
edw
ith
exte
rnal
leve
lsof
cont
rol
Job
sati
sfac
tion
was
rela
ted
toin
tern
allo
cus
ofco
ntro
lFi
nch
&K
rant
z(1
991)
USA
nD
48,
48%
,R
ehab
ilita
tion
faci
lity
Cop
ing
stra
tegi
esO
utsi
dein
tere
sts
Supp
orti
vepe
erne
twor
ksSa
tisf
acti
onde
rive
dfr
omse
eing
succ
ess
atw
ork
Wilc
oxon
(198
9)U
SA
nD
177,
Not
stat
ed,
Men
talh
ealt
hse
rvic
es
Lev
els
ofbu
rnou
tFa
ctor
sas
soci
ated
wit
hin
crea
ses
inbu
rnou
t
Mild
tom
oder
ate
Lea
ders
hip
styl
e
(con
tinu
edov
erle
af)
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002) 207
D. Edwards et al.
Tab
leII
.(C
onti
nued
).
Aut
hor
(yea
r)co
untr
yPa
rtic
ipan
ts(n
D),
resp
onse
rate
,set
ting
Res
earc
hfo
cus
Mai
nfin
ding
s
Cac
ciac
arne
etal
.(1
986)
USA
nD
133,
92%
,O
utpa
tien
tan
dre
habi
litat
ion
cent
res
(for
ensi
c)
Fact
ors
asso
ciat
edw
ith
incr
ease
sin
burn
out
Gen
der
(fem
ale)
Len
gth
ofte
nure
(3–
5ye
ars)
Cor
riga
net
al.
(199
5)U
SA
nD
51,
82%
,H
ospi
tal
Fact
ors
asso
ciat
edw
ith
incr
ease
sin
burn
out
Anx
iety
Freq
uenc
yof
illne
ssC
ontr
ary
job
atti
tude
sPo
orco
llegi
alsu
ppor
tW
ebst
er&
Hac
kett
(199
9)U
SA
nD
151,
Not
stat
ed,
Com
mun
ity
Fact
ors
asso
ciat
edw
ith
incr
ease
dE
EC
linic
alsu
perv
isio
nle
ader
ship
styl
e
Pond
&G
eyer
(199
7)U
SA
nD
226,
Not
spec
ified
,H
ospi
tal
Fact
ors
asso
ciat
edw
ith
job
sati
sfac
tion
Em
ploy
eeag
ePe
rcei
ved
wor
kal
tern
ativ
es
Schu
lzet
al.
(199
5)U
SA
nD
132,
Not
spec
ified
,43
Men
talh
ealt
hor
gani
zati
ons
Sour
ces
ofbu
rnou
tan
djo
bsa
tisf
acti
onT
eam
orga
niza
tion
stru
ctur
eL
eade
rshi
pst
yle
Che
rnis
s&
Egn
atio
s(1
978b
)U
SA
nD
174,
94%
,C
omm
unit
y
Fact
ors
asso
ciat
edw
ith
job
sati
sfac
tion
Styl
eof
clin
ical
supe
rvis
ion
Bra
dyet
al.
(198
0)U
SA
nD
21,
Not
stat
ed,
Out
pati
ent
trea
tmen
tfa
cilit
y
Fact
ors
asso
ciat
edw
ith
incr
ease
sin
job
sati
sfac
tion
Inte
ract
ion
wit
hw
ork
colle
ague
sA
uton
omy
Inno
vati
onW
ebb
(198
0)U
SA
nD
367,
65%
,T
hree
men
talh
ealt
hor
gani
zati
ons
Fact
ors
asso
ciat
edw
ith
job
sati
sfac
tion
Pay
Opp
ortu
niti
esfo
rpr
omot
ion
Buf
fum
&K
onic
k(1
982)
USA
nD
297,
Not
stat
ed,
Thr
eeho
spit
als
Fact
ors
asso
ciat
edw
ith
decr
ease
sin
job
sati
sfac
tion
Hig
hde
gree
ofpa
thol
ogy
expe
rien
ced
bypa
tien
tsM
ore
trou
bled
pati
ents
beha
viou
r
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002)208
Stress management for mental health professionals
Tab
leII
I.R
esea
rch
arti
cles
that
cons
ider
stre
ssor
s,m
oder
ator
san
dst
ress
outc
omes
cond
ucte
din
Eur
ope.
Aut
hor
(yea
r)co
untr
yPa
rtic
ipan
ts(n
D),
resp
onse
rate
,set
ting
Res
earc
hfo
cus
Mai
nfin
ding
s
Kir
kcal
dy&
Sief
en(1
991)
Ger
man
y
nD
111,
67%
,C
hild
and
adol
esce
ntho
spit
al
Job-
rela
ted
pres
sure
Bei
ngm
ale
Lon
ger
tenu
re
Job
sati
sfac
tion
Age
Gen
der
Mar
ital
stat
usG
arzo
tto
(199
2)It
aly
nD
210,
79%
,M
enta
lhea
lth
agen
cies
Fact
ors
rela
ting
tobu
rnou
tIn
crea
sein
psyc
hoso
mat
icse
lfre
port
edsy
mpt
oms
for
staf
fw
how
ere
exha
uste
d
Geu
rts
etal
.(1
998)
Net
herl
ands
nD
208,
80%
,C
omm
unit
y,ho
spit
al
Fact
ors
asso
ciat
edw
ith
inte
ntio
nto
leav
eor
gani
zati
onan
dbu
rnou
tN
egat
ive
com
mun
icat
ion
abou
tm
anag
emen
tPe
rcei
ved
ineq
uity
inem
ploy
men
tre
lati
onsh
ip
Jean
neau
&A
rmel
ius
(200
0)Sw
eden
nD
754,
Not
stat
ed,
Hos
pita
l
Bur
nout
and
its
rela
tion
ship
tose
lfim
age
Ane
gati
vese
lfim
age
was
rela
ted
tohi
gher
burn
out
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002) 209
D. Edwards et al.
therapists, mental health counsellors, case man-agers and administrators. Four studies were con-ducted in European countries (Garzotto, 1992;Geurts, Schaufeli, & DeJonge, 1998; Jeanneau &Armelius, 2000; Kirkcaldy & Siefen, 1991) andas different countries operate very different healthcare systems thus making generalizations difficult,these results have been presented separately (seeTable III).
Stressors, moderators and stressoutcomes
It is important that stress research is based on atheoretical model. Three levels of the stress processare proposed in the model developed by Carsonand Kuipers (1998). First are external ‘stressors’.These include occupation-specific stressors, every-day ‘hassles’ and ‘uplifts’ and the stress associatedwith significant life events. Five studies investigatedsources of occupational stress or job related pres-sure and/or factors associated with high levels ofstress as measured by a questionnaire. Three ofthe studies were conducted in the UK (Harper &Minghella, 1997; Prosser et al., 1997; Reid et al.,1999a), two in the USA (Marini et al., 1995; Ober-lander, 1990) and one in Germany (Kirkcaldy &Siefen, 1991).
At the second level of the stress process are‘moderators’. These include a wide range of per-sonal protectors, the possession of which help toreduce the impact of stress. These are: high levelsof self-esteem; good social support networks; har-diness; good coping skills; mastery and personalcontrol; emotional stability; and good physiologi-cal release mechanisms. Eight studies investigatedmoderators of the stress process, two in the UK(Parkes & Rabenau, 1993; Reid et al., 1996),five in the USA (Finch & Krantz, 1991; Ingledewet al., 1997; Koeske & Kelly, 1995; Leiter, 1990;Thornton, 1992) and one in Sweden (Jeanneau& Armelius, 2000). The study by Ingledew et al.(1997) was a longitudinal survey of psychiatricworkers facing redeployment and asked the ques-tion ‘Do resources bolster coping and does copingbuffer stress?’ The results indicated that stressorshad a deleterious effect on well-being and thatproblem- and emotional-focused coping strategiesare beneficial against the long-term consequencesof work-based stress with the use of avoidancecoping strategies being significantly more likely tolead to negative consequences. Problems with this
research is the small response rate and the over-representation of nurses and administrators withinthe sample.
The final level of the model is that of stressoutcomes. These include positive stress outcomessuch as psychological health and high job sat-isfaction and negative stress outcomes such aspsychological ill health, burnout and low job sat-isfaction. Burnout being described as a syndromeconsisting of three dimensions: emotional exhaus-tion (inability of individuals to give of themselvesat a psychological level), depersonalization (devel-opment of cold negative attitudes towards thosewho provide public services) and personal accom-plishment (the loss of the ability to value one’sachievements at work). Twenty studies investigatedvarious aspects of job satisfaction, four were con-ducted in the UK (Harper & Minghella, 1997;Oliver & Kuipers, 1996; Onyett et al., 1997; Ruidet al., 1999a), 15 in the USA (Brady et al., 1980;Buffum & Konick, 1982; Cherniss & Egnatios,1978a, 1978b Drude & Lourie, 1984; Folkinset al., 1977; Hromco et al., 1995; Jerrell, 1983;Koeske, 1995; Leiter, 1988; Oberlander, 1990;Pines & Maslach, 1978; Pond & Geyer, 1987;Schulz et al., 1995; Webb, 1980) and one studyin Germany (Kirkcaldy & Siefen, 2000). One fur-ther study explored the relationship between workenvironment and client contact (Savicki & Cooley,1987). The percentage of time spent in direct clientcontact was used as a variable to divide the par-ticipants into two groups. A cut-off point of 50per cent of time spent in direct contact was chosenand two groups—high contact workers (n D 53)and low contact workers (n D 24)—were created.Low contact workers who experience increasingwork pressure, have unpleasant physical surround-ings and whose work does not have any varietyor change are more likely to become emotionallyexhausted. High contact workers who received lit-tle staff support, whose work environment did notemphasize efficiency and good planning and whohad increasing work pressure were more likely tobecome emotional exhausted.
Eighteen studies explored the issue of burnout:four were conducted in the UK (Oliver & Kuipers,1996; Onyett et al., 1997; Thornton, 1992; Wykeset al., 1997), 11 in the USA (Cacciacarne et al.,1986; Cherniss & Egnatios, 1978a; Corrigan et al.,1995; Hiscott & Connop, 1990; Koeske, 1995;Leiter, 1988, 1990; Pines & Maslach, 1978;Schulz et al., 1995; Webster & Hackett, 1999;Wilcoxon, 1989), one in Italy (Garzotto, 1992),one in the Netherlands (Geurts et al., 1998) and
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002)210
Stress management for mental health professionals
one in Sweden (Jeanneau & Armelius, 2000).Prosser et al. (1997) investigated the differencesbetween hospital and community staff on levels ofpsychological distress, job satisfaction and burnout;this research was repeated over a 3-year period(Prosser et al., 1999). High staff turnover meantthat, of the 121 respondents in 1994, only 43remained in 1996.
One further study conducted in the USA reportedtheir findings in three separate articles which inves-tigated levels of burnout and coping over extendedperiods of time (Kirk et al., 1993; Koeske, 1995;Koeske & Kelly, 1995). Kirk et al. (1993) con-ducted a study on a cohort of 82 case managersnewly hired during the first year of New York’sState intensive case management programme whowere followed for 18 months. Approximately 80per cent were still employed and responded at eachtime point. Over time the workers experiencedincreasing amounts of job stress, emotional exhaus-tion and depersonalization and reported signifi-cantly more stress-related physical and depressivesymptoms. Their sense of personal accomplishmentand job satisfaction however, remained stable.
From the same study Koeske and Kelly (1995)reported on findings from the Health and DailyLiving Form, which was used to assess coping.Depending on the time frame, coping was examinedin between 39 and 51 workers. The resultsshowed that control—orientated coping strategiesclearly acted as work stress buffers and thatthose who relied exclusively on avoidance copingstrategies reported higher general levels of negativeconsequences 3 months later. Males reported moreuse of avoidance coping than females.
Again from the same study Koeske (1995)reports on findings regarding locus of controlbeliefs from this cohort at the 18-month timepoint. Counsellors with internal locus of controlbeliefs had more favourable scores in a numberof work-related variables including a greater senseof personal accomplishment as measured by theMaslach Burnout Inventory. A significant andconsistent buffering effect of internality was foundfor the intensive case mangers of SMI clients. Onlyamongst workers with external beliefs did job strainand negative work attitudes result in diminishedlife satisfaction.
Evaluated stress managementinterventions
The review retrieved three papers which reportedstress management interventions for those work-ing within the mental health professions (Bhatara,
Fuller, O’Connor-Davis, & Misra, 1996; Hun-nicutt & MacMillan, 1983; Mehr, Senteney, &Creadie, 1995; see Table IV). These interven-tions were all conducted in the USA and estab-lished that
ž Levels of burnout did not change for men-tal health workers who attended staff develop-ment workshops. However staff that attendedthe workshop accompanied by a period ofsustained consultation experienced significantlylower levels of emotional exhaustion (Hunnicutt& MacMillan, 1983).
ž Female mental health workers at risk of burnoutexperience significantly lower emotional exhaus-tion and depersonalization after participation inan intensive stress reduction programme in theform of weekend conferences and follow-up sup-port groups (Mehr et al., 1995).
ž Following a period of interdisciplinary educa-tion, mental health workers experience increasingsatisfaction with continuing education oppor-tunities and with the number of peers avail-able for professional interaction (Bhatara et al.,1996).
Limitations
Research on stressors, moderators and stress out-comes conducted in countries other than the UKgive some data which might be usefully applied tothe situation of mental health professionals here.However, the fact that different countries operatevery different health care systems means that thereare limitations in generalizing the findings of thevarious studies.
When investigating burnout all the authors usedthe Maslach Burnout Inventory (MBI) to determineburnout. When investigating stress and job satisfac-tion however, a range of tools was used and in themajority of cases the authors developed their ownquestionnaires. This makes it difficult to directlycompare findings between different studies. Theeffectiveness of stress management programmesdepends on the accuracy of the initial diagnosis.Stress in the workplace can be diagnosed in manydifferent ways—questionnaires, interviews, indi-rect observation (staff turnover, sickness records),examination of biochemical markers etc. Thereneeds to be some attempt to utilize common mea-surement approaches which will enable workers tocompare across studies.
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002) 211
D. Edwards et al.
Tab
leIV
.R
esea
rch
arti
cles
that
cons
ider
stre
ssm
anag
emen
tin
terv
enti
ons.
Aut
hor
Sett
ing,
Follo
w-u
p,R
espo
nse
rate
,
Aim
sIn
terv
enti
onM
easu
res
Hun
nicu
tt&
Mac
Mill
an(1
993)
USA
Com
mun
ity
3-ye
arfo
llow
-up
(not
stat
ed)
To
mea
sure
the
impa
ctof
ther
apeu
tic
inte
rven
tion
sup
onm
easu
red
staf
fbu
rnou
t
Staf
fde
velo
pmen
ttr
aini
ng(E
G1)
Five
wor
ksho
ps(n
D70
)
Staf
fde
velo
pmen
ttr
aini
ngan
da
seri
esof
cons
ulta
tion
s
Mas
lach
Bur
nout
Inve
ntor
yM
oos
Wor
kE
nvir
onm
ent
Scal
eW
ork
inve
ntor
yŁ
Cop
ing
scal
eŁ
Five
Wor
ksho
ps(n
D91
)C
ontr
olgr
oup
(nD
90)
Meh
ret
al.
(199
5)U
SA
Com
mun
ity
8-m
onth
follo
w-u
p(7
0%)
To
dete
rmin
eif
anin
terv
enti
onpr
ogra
mw
ould
low
erle
vels
ofst
ress
and
burn
out
To
exam
ine
the
rela
tion
ship
betw
een
subj
ect’
sre
port
sof
burn
out
and
type
sof
dayd
ream
sex
peri
ence
d
Tw
o3-
day
conf
eren
ce8
mon
ths
apar
tC
onfe
renc
e1
(nD
38)
Con
fere
nce
2(n
D27
)Fe
mal
esat
risk
ofbu
rnou
t
Mas
lach
Bur
nout
Inve
ntor
yIm
agin
alPr
oces
ses
Inve
ntor
ySc
hedu
leof
Rec
ent
Exp
erie
nce
Bha
tara
etal
.(1
996)
USA
Rur
al3-
year
follo
w-u
p(6
2%)
To
impr
ove
job
sati
sfac
tion
(and
poss
ibly
job
rete
ntio
n)th
roug
hre
duce
dpr
ofes
sion
alis
olat
ion
Inte
rdis
cipl
inar
yed
ucat
iona
lpr
ogra
mm
e40
wor
ksho
ps(n
D46
3)
Job
sati
sfac
tion
Ł
Att
itud
eto
war
dsot
her
Prof
essi
onal
sŁ
Ł Aut
hors
deve
lope
dth
eir
own
ques
tionn
aire
spec
ifica
llyfo
rth
est
udy.
Copyright 2002 John Wiley & Sons, Ltd. Stress and Health 18: 203–215 (2002)212
Stress management for mental health professionals
Conclusions
There has been much research conducted whichhas revealed an excessive level of workplace stressfor mental health workers. Mental health workersare likely to experience personal stress as a resultof working closely and intensively with patientsover an extended period of time. Even thoughdifferent countries operate different health caresystems and that the studies included a mixed rangeof mental health professionals, these professionalsare reporting the same problems of increasingworkload and administration, lack of resourcesand management problems.
Sixty-three per cent of the studies reviewedinvestigated burnout and or factors affecting jobsatisfaction which are the end processes of negativestress outcomes. Length of time in the job, beingmale, staff turnover and a number of organizationalfactors and working with a high percentage ofpatients with severe mental illness were some ofthe most frequently reported factors across studiesthat were associated with increasing levels ofburnout. Seeing patients improve, having a senseof accomplishment, working well with colleagueswere found to be associated with job satisfactionwhereas staff turnover, length of time in the job,age, large caseloads were some of the factorsinvolved with job dissatisfaction.
The second aim of this review was to inves-tigate papers that evaluated stress managementinterventions for those working within the men-tal health field. There was a lack of publishedresearch available with only three papers meet-ing the inclusion criteria. The intervention studiesreported in this review were all workplace stressmanagement strategies which were based mainlyon individual strategies. Previous reviews of occu-pational stress management programmes (DeFrank& Cooper, 1987; Newman & Beehr, 1979; vander Hek & Plomp, 1997) have reported thatinterventions have focused mainly on the individ-ual level.
The most effective way of managing stressin the workplace however, is to eliminate thestressors themselves. To achieve this, managementstrategies must be proactive rather than re-activewith respect to the organizational environment.There is a lack of research into interventions on theorganizational level. Although all interventions areintended to prevent and combat stress they producedifferent effects. It is impossible to determinewhich specific interventions or techniques are most
effective and should be recommended. Van derHek and Plomp (1997) suggest that the lackof evidence of interventions directed at stressprevention is not primarily caused by a shortageof studies, but by the considerable heterogeneity ofthe studies.
For future research there is a need to pro-vide a more longitudinal perspective. Most studieshave adopted a cross-sectional design. Longitudinalstudies will enable researchers to develop a betterunderstanding of how stress and burnout changeover time. This will in turn allow us to developappropriate intervention strategies to ensure mentalhealth workers stay healthy themselves.
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