stress management for mental health professionals: a review of effective techniques

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



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)


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



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


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



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.


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.



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.

References

Bhatara, V.S., Fuller, W.C., O’Connor-Davis, L., &Misra, L.K. (1996). Improving job satisfaction of ruralSouth Dakota mental health providers through education:a pilot study. South Dakota Journal of Medicine, 49,93–96.

Brady, C.A., Kinnard, K.L., & Friedrich, W.N. (1980). Jobsatisfaction and perception of social climate in amental health facility. Perception and Motor Skills, 51,559–564.

Buffum, W., & Konick, A. (1982). Employees’ job satisfaction,residents’ functioning and treatment progress in psychiatricinstitutions. Health and Social Work, 7, 320–326.

Cacciacarne, M., Resnick, P.J., McArthur, C., & Althof, S.E.(1986). Burnout in forensic psychiatric staff. Medical Law,5, 303–308.

Carson, J., & Fagin, L. (1996). Stress in mental healthprofessionals: a cause for concern or an inevitable part of thejob? (editorial). International Journal of Social Psychiatry,42, 79–81.

Carson, J., & Kuipers, E. (1998). Stress managementinterventions. In S., Hardy J., Carson & B., Thomas (Eds)Occupational stress: personal and professional approaches(pp. 157–174). Cheltenham: Stanley Thornes.

Cherniss, C., & Egnatios, E. (1978a). Is there job satisfactionin community mental health? Community Mental HealthJournal, 14, 309–318.

Cherniss, C., & Egnatios, E. (1978b). Clinical supervisionin community mental health. Social Work, 23,219–223.

Corrigan, P.W., & Holmes Luchin, E.P.D. (1995). Burnoutand collegial support in state psychiatric hospital staff.Journal of Clinical Psychology, 51, 703–710.

DeFrank, R.S., & Cooper, C.L. (1987). Worksite stressmanagement interventions. Journal of ManagerialPsychology, 2, 4–10.

Drude, K.P., & Lourie, I. (1984). Staff perceptions of workenvironment in a state psychiatric hospital. PsychologicalReports, 54, 263–268.

Finch, E.S., & Krantz, S.R. (1991). Low burnout in a high-stress setting: A study of staff adaptation at Fountain House.Psychosocial Rehabilitation Journal, 14, 15–26.

Folkins, C., O’Reilly, C., III, Roberts, K., & Miller, S. (1977).Physical environment and job satisfaction in a communitymental health center. Community Mental Health Journal,13, 24–30.


D. Edwards et al.

Garzotto, N. (1992). The syndrome of burn-out amongmental health professionals in Verona (Italy). NewTrends in Experimental Clinical Psychology, 8,113–118.

Geurts, S., Schaufeli, W., & DeJonge, J. (1998). Burnout andintention to leave among mental health-care professionals: Asocial psychological approach. Journal of Social and ClinicalPsychology, 17, 341–362.

Harper, H., & Minghella, E. (1997). Pressures and rewards ofworking in community mental health teams. Mental HealthCare, 1, 18–21.

Hiscott, R.D., & Connop, P.J. (1990). The health andwellbeing of mental health professionals. Canadian Journalof Public Health, 81, 422–426.

Hromco, J.G., Lyons, J.S., & Nikkel, R.E. (1995). Mentalhealth case management: characteristics, job function, andoccupational stress. Community Mental Health Journal, 31,111–125.

Hunnicutt, A.W., & MacMillan, T.F. (1983). Beatingburnout: findings from a three-year study. Journal of MentalHealth Administration, 10, 7–9.

Ingledew, D.K., Hardy, L., & Cooper, C.L. (1997). Doresources bolster coping and does coping buffer stress? Anorganisational study with longitudinal aspect and control fornegative affectivity. Journal of Occupational Psychology, 2,118–133.

Jeanneau, M., & Armelius, K. (2000). Self image and burnoutin psychiatric staff. Journal of Psychiatric and Mental HealthNursing, 7, 399–407.

Jerrell, J.M. (1983). Work satisfaction among rural mentalhealth staff. Community Mental Health Journal, 19,187–200.

Kirk, S.A., Koeske, G.F., & Koeske, R.D. (1993). Changes inhealth and job attitudes of case managers providing intensiveservices. Hospital and Community Psychiatry, 44, 168–173.

Kirkcaldy, B.D., & Siefen, G. (1991). Occupational stressamong mental health professionals. The relationshipbetween work and recreational pursuits. Social Psychiatryand Psychiatric Epidemiology, 26, 238–244.

Koeske, G.F. (1995). Direct and buffering effects of internallocus of control among mental health professionals. Journalof Social Services Research, 20, 3–4.

Koeske, G.F., & Kelly, T. (1995). The impact of overinvolvement on burnout and job satisfaction. AmericanJournal of Orthopsychiatry, 65, 282–292.

Leiter, M.P. (1988). The impact of family resources, controlcoping, and skill utilization on the development of burnout:A longitudinal study. Human Relations, 43, 1067–1083.

Leiter, M.P. (1990). Burnout as a function of communicationpatterns: A study of a multidisciplinary mental health team.Group and Organisational Studies, 13, 111–128.

Marini, I., Todd, J., & Slate, J.R. (1995). Occupational stressamong mental health employees. Journal of RehabilitationAdministration, 19, 123–130.

Mehr, M.L., Senteney, A., & Creadie, T.M. (1995).Daydreams, stress and burn-out in women mental healthworkers: A preliminary clinical report. Imagination,Cognition and Personality, 14, 105–115.

Moore, K.A., & Cooper, C.L. (1996). Stress in mental healthprofessionals: A theoretical overview. International Journalof Social Psychiatry, 42, 82–89.

Newman, J.E., & Beehr, T.A. (1979). Personal andorganisational strategies for handling job stress: a reviewof research and opinion. Personnel Psychology, 32, 1–43.

Nolan, P., Cushway, D., & Tyler, P.A. (1995). A measurementtool for assessing stress among mental health nurses. NursingStandard, 9, 36–39.

Oberlander, L.B. (1990). Work satisfaction amongcommunity-based mental health service providers: theassociation between work environment and worksatisfaction. Community Mental Health Journal, 26,517–532.

Oliver, N., & Kuipers, E. (1996). Stress and its relationshipto expressed emotion in community mental healthworkers. International Journal of Social Psychiatry, 42,150–159.

Onyett, S., Pillinger, T., & Mujen, M. (1997). Job satisfactionand burnout among members of community mental healthteams. Journal of Mental Health, 6, 55–66.

Parkes, K.R., & von Rabenau, C. (1993). Work characteristicsand well being among psychiatric health care staff.Journal of Community and Applied Social Psychology, 3,243–249.

Pines, A., & Maslach, C. (1978). Characteristics of staffburnout in mental health settings. Hospital and CommunityPsychiatry, 29, 233–237.

Pond, S.B., & Geyer, P.D. (1987). Employee age as amoderator of the relation between perceived workalternatives and job satisfaction. Journal of AppliedPsychology, 72, 552–557.

Prosser, D., Johnson, S., Kuipers, E., Dunn, G., Szmukler, G.,& Reid, Y. (1999). Mental health, ‘burnout’ and jobsatisfaction in a longitudinal study of mental healthstaff. Social Psychiatry and Psychiatric Epidemiology, 34,295–300.

Prosser, D., Johnson, S., Kuipers, E., Szmukler, G., Bebbing-ton, P., & Thornicroft, G. (1996). Mental health, ‘burnout’and job satisfaction among hospital and community-basedmental health staff. British Journal of Psychiatry, 169,334–337.

Prosser, D., Johnson, S., Kuipers, E., Szmukler, G., Bebbing-ton, P., & Thornicroft, G. (1997). Perceived sources of workstress and satisfaction among hospital and community men-tal health staff, and their relation to mental health, burnoutand job satisfaction. Journal of Psychosomatic Research,43, 51–59.

Rabin, S., Feldman, D., & Kaplan, Z. (1999). Stress andintervention strategies in mental health professionals. BritishJournal of Medical Psychology, 72, 159–169.

Reid, Y., Johnson, S., Morant, N., Kuipers, E., Szmukler, G.,& Bebbington, P. (1999b). Improving support for mentalhealth staff: a qualitative study. Social Psychiatry andPsychiatric Epidemiology, 34, 309–315.

Reid, Y., Johnson, S., Morant, N., Kuipers, E., Szmukler, G.,& Thornicroft, G. (1999a). Explanations for stress andsatisfaction in mental health professionals: a qualitativestudy. Social Psychiatry and Psychiatric Epidemiology, 34,301–308.

Savicki, V., & Cooley, E. (1987). The relationship of workenvironment and client contact to burnout in mental healthprofessionals. Journal of Counselling and Development, 65,249–252.

Schulz, R., Greenley, J.R., & Brown, R. (1995). Organization,management, and client effects on staff burnout.Journal of Health and Social Behaviour, 36,333–345.

The University of York NHS Centre for Reviews andDissemination. (2001). Undertaking Systematic Reviews ofResearch on Effectiveness. CRD Report Number 4 (2ndedn.). York: University of York.

Thornton, P.I. (1992). The relation of coping, appraisal, andburnout in mental health workers. Journal of Psychology,126, 261–271.

van der Hek, H., & Plomp, H.N. (1997). Occupationalstress management programmes: a practical overview



of published effect studies. Occupational Medicine, 47,133–141.

Webb, L. (1980). Employees’ satisfaction among workers inmental health settings. Psychological Reports, 47, 30.

Webster, L., & Hackett, R.K. (1999). Burnout and leadershipin community mental health systems. Administrative Policyfor Mental Health, 26, 387–399.

Wilcoxon, S.A. (1989). Leadership behaviour and therapistburnout, a study of rural agency settings. Journal of Ruraland Community Psychology, 10, 13–14.

Wykes, T., Stevens, W., & Everitt, B. (1997). Stress incommunity care teams: will it affect the sustainabilityof community care? Social Psychiatry and PsychiatricEpidemiology, 32, 398–407.


stress management for mental health professionals: a review of effective techniques

Documents