G Model
AJP-672; No. of Pages 4 Asian Journal of Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Impact of a stress management program on stress perception of nurses working with psychiatric patients Gandhi Sailaxmi *, Krishnasamy Lalitha Department of Nursing, National Institute of Mental Health & Neurosciences (INI), Hosur Road, Near Wilson Garden, Bangalore 560029, Karnataka, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 August 2014 Received in revised form 7 December 2014 Accepted 18 January 2015 Available online xxx
Nurses caring for psychiatric patients may have to face violent emotions and unpredictable behaviour which can be quite stressful. A stress management program may equip nurses with skills to cope effectively with the stress. A one group pre-test and post-test design was adopted to test this hypothesis. Both gender nurses caring for psychiatric patients were invited to undergo 10 consecutive, one hour sessions of a stress management program. The DCL Stress scale (The De Villiers, Carson & Leary Stress Scale; Carson et al., 1997a,b,c) was used to collect data immediately after intervention and four weeks later. RM ANOVA with SPSS 16 showed that pre-intervention mean stress reduced significantly (p = 0.000) from 57.45 16.42 to 41.06 16.51 immediately following the intervention and 26.43 12.82 (p = 0.000) four weeks after the intervention. The stress management strategies positively impacted on nurses’ stress levels. ß 2015 Elsevier B.V. All rights reserved.
Keywords: Stress Nurses Psychiatric patients Stress management interventions
1. Introduction Nurses working with psychiatric patients may be confronted with intense interpersonal interactions, dynamic changes in patients, emotional lability and psychological distress that can be very stressful and challenging. Most studies on stress and job satisfaction in nursing have focused on general nursing specialities, and relatively little attention has been paid to nurses working in psychiatric units (Cronin-Stubbs and Brophy, 1985; Dawkins et al., 1985). Although there are educational programs in India that focus on psychiatric nursing speciality (from diploma to doctorate programs), many nurses caring for psychiatric patients in various psychiatric hospitals in India may not have actually undergone a speciality training program. When confronted by issues such as nurse shortage, violence in the unit, advances in technology, and demands from the multidisciplinary team, these nurses can have high levels of stress. Worker injuries and verbally aggressive patients are reported to be increasing and are associated with higher rates of burnout of psychiatric nurses (Liu and Wuerker, 2005; Flannery et al., 2007). With robust clustered regression analysis, it was found that lower levels of psychiatric nurse burnout among 353 nurses was significantly associated with inpatient environments in 67 hospitals that had better overall
* Corresponding author. Tel.: +91 08026995322; fax: +91 08026564830; mobile: +91 09902763889. E-mail address: [email protected] (G. Sailaxmi).
quality work environments, more effective managers, strong nurse– physician relationships, and higher psychiatric nurse-to-patient staffing ratios (Hanrahan et al., 2010). Most psychiatric hospitals in India have wards with 50–60 beds. Generally, in the morning shift there are at least two nurses with one ward supervisor, one nurse for the evening and one for the night shift. This inadequate nurse–patient ratio also can contribute to stress in the nurses. Programs for dealing with stress should be available on a routine basis (Sorgaard et al., 2010). The present research work focuses on testing of specific strategies to equip nurses with competencies to cope with stress when working with patients with mental illness. If this stress management program is found to be effective, it can be advocated for nurses working in other psychiatric hospitals in India. 1.1. Aim To evaluate the effectiveness of a stress management program on stress reduction in nurses working in a psychiatric hospital. 1.2. Objectives 1. To assess the level of pre-intervention perceived stress in nurses working with psychiatric patients. 2. To develop a stress management program. 3. To evaluate the impact of the stress management program on stress perception of nurses working with psychiatric patients.
http://dx.doi.org/10.1016/j.ajp.2015.01.002 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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AJP-672; No. of Pages 4 G. Sailaxmi, K. Lalitha / Asian Journal of Psychiatry xxx (2015) xxx–xxx
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1.3. Hypothesis There will be a statistically significant change in the stress perception of the nurses after under-going the stress management program. 2. Materials & methods 2.1. Research design A quasi-experimental one group pre test post test design. 2.2. Study population and setting After approval by the Institutional Review Board and following informed consent as well as detailed explanation about the risks and benefits involved, 60 nurses working in a psychiatric hospital at Bangalore, India were randomly selected using the Tippet’s Random number table and invited to participate in this study. Male and female registered nurses working with psychiatric patients for more than one year and possessing G.N.M. (diploma) or B.Sc. Nursing qualification (with/without additional qualifications) were included in the study. Nurses in the supervisory capacity, nursing trainees, nurses with chronic illness and those who had undergone stress management courses were excluded from the study. Of the 60 randomly selected subjects who fulfilled the inclusion criteria, there was seven-subject mortality due to reasons such as illness, death in the family and child’s illness. The final sample consisted of 53 nurses, who fulfilled the inclusion/ exclusion criteria. Nurses took part in the sessions while on duty. Since shift system was followed in this hospital, groups of 10 nurses participated in the sessions during the morning shift and evening shift. Maximum effort was taken to meet comfort needs, including providing refreshments. Nurses were encouraged to contact the researchers at periods other than the intervention sessions. 2.3. Research tools A semi-structured, researcher constructed proforma was used to collect socio-demographic data. The DCL (De Villiers, Carson & Leary) Stress Scale (Carson et al., 1995, 1996, 1997a–c, 1999) was used to measure stress levels. This is a 30 item Likert rating scale consisting of five domains – patient demands (8 items), organizational and managerial issues (8 items), staffing (7 items), future concerns (4 items) and job satisfaction (3 items). Cronbach’s alpha reliability coefficient was 0.96. The test–re-test correlation (Spearman’s Rho) was 0.91. There is high content as well as criterion validity (with Maslach’s Emotional Exhaustion and the GHQ – 28). Each item is scored as a Likert scale ranging from 0 to 4. Thus, the total score ranges from ‘no’ stress (score of 0) to ‘extreme’ stress (score of 120). 2.4. Stress management program The nurses were enrolled for 10 sessions, each lasting for one hour, on a daily basis. Five sessions in a week from Monday through Saturday for two weeks were conducted keeping in mind weekly off duty days. Sessions focused on stress education, problem solving, time management, taking time off, communication skills, assertiveness training, responding to criticism, negotiation skills and humour. Various teaching strategies were used such as lecture cum discussion, brain storming, role play, group work and behaviour rehearsal. Communication skills, assertiveness skills, responding to criticism and negotiation skills were role played and video graphed. These video slides also were used as
teaching aids. Sessions were very interactive and nurses were encouraged to clarify doubts and participate actively. Nurses were encouraged to prepare case scenarios based on their experience of stressful situations in the wards and then discuss how these stress management techniques could be implemented during these situations. Pre-assessment was done using the sociodemographic proforma and the DCL Stress Scale. The subjects were then exposed to these specific strategies for ten days continuously. Immediate post-assessment as well as assessment four weeks later was done. The subjects were encouraged to narrate their experiences while adopting the various techniques taught to them. A discussion was held about the difficulties, practicability and utility of the techniques followed by post assessment as well as evaluation of the sessions that they had undergone. All nurses including those who were not part of the study were given information manuals on the stress management interventions after the final data collection. The content validity of this stress management program as well as the audio–visual aids used during the sessions were determined by experts comprising of three psychiatrists, three psychiatric nurses, two clinical psychologists and two psychiatric social work consultants. 2.5. Analysis It was decided to express the data obtained using descriptive statistics and to analyze the effectiveness of intervention by computing repeated measures ANOVA using a 0.05 level of significance. Data analysis was performed using SPSS16. 3. Results 3.1. Descriptives Majority of the nurses (90.57%) were female. Married nurses comprised 84.91% of the study sample. 32.08% of the nurses were from a joint family and the remaining 67.92% belonged to nuclear families. 83.02% of the nurses had family support in day-to-day activities (Table 1). The mean age of the study sample (n = 53) was 33.19 6.90 years ranging from 24 years to 50 years. The mean basic salary was Rs. 5887.55 783.46 ranging from Rs. 5250 to Rs. 9060. The nurses experience of working with psychiatric patients ranged from 2 years to 29 years with a mean experience of 9.58 6.04 years (Table 2). While 15.09% of the nurses worked in the Psychiatry special wards, 33.96% worked in the emergency unit, 18.87% in the closed psychiatry wards and the rest (32.08%) worked in the open psychiatry wards. 24.53% of the nurses were professionally Table 1 Frequency distribution of the study sample based on sex, marital status, type of family and family support in day to day activities (n = 53). Sample characteristics
Number
Percentage
Sex Female Male
48 5
90.57 9.43
Marital status Married Unmarried Separated
45 6 2
84.91 11.32 3.77
Type of family Joint Nuclear
17 36
32.08 67.92
Family support in day to day activities Yes 44 No 9
83.02 16.98
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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Table 2 Frequency distribution of the study sample based on age, basic salary and duration of experience in years (n = 53). Sample characteristics
Number
Age in years Basic salary (Rs.) Duration of experience in years
53
Minimum 24
Maximum 50
Mean 33.19
SD 6.90
53 53
5250 2
9060 29
5887.55 9.58
783.46 6.04
Table 3 Frequency distribution of the study sample based on area of working and professional qualification (n = 53). Sample characteristics
Number
Percentage
Area of working Psychiatry special wards Emergency wards Psychiatry closed wards Psychiatry open wards
8 18 10 17
15.09 33.96 18.87 32.08
Professional qualification B.Sc. nursing (including P.C.B.Sc. nursing) GNM GNM with diploma in psychiatric nursing
13 36 4
24.53 67.92 7.55
qualified as B.Sc. nurses, majority (67.92%) were general nurse midwives and the rest (7.55%) had attained a professional qualification of general nurse midwife with diploma in psychiatric nursing (Table 3). 3.2. Changes in stress perception of nurses following the stress management program There was a significant (p = 0.000) mean reduction in stress perception from 57.45 16.42 at pre-intervention to 41.06 16.51 immediately after the intervention and 26.43 12.82 four weeks after the intervention. Pre-intervention mean stress levels related to patient demands (15.81 5.78), in the area of organizational and management issues (12.74 4.88) and about future concerns (7.28 3.10) were at moderate levels. However, in the area of staffing, the mean stress level was high (14.09 4.77). There was a significant (p = 0.000) reduction in stress levels in all the domains immediately after and four weeks after the intervention (Table 4, Fig. 1). 4. Discussion In this study, there was a gradual mean reduction in stress perception from 57.45 16.42 at pre-intervention to 41.06 16.51 immediately after the intervention and 26.43 12.82 four weeks after the intervention with p = 0.000. Pre-intervention mean stress levels
Fig. 1. Cone chart indicating the Time 0 (pre intervention), Time 1 (immediate post intervention) and Time 2 (4 weeks post intervention) mean scores on the DCL stress scale.
(15.81 5.78) related to patient demands, in the area of organizational and management issues (12.74 4.88) and about future concerns (7.28 3.10) were at moderate levels. However, in the area of staffing, the mean stress level was high (14.09 4.77). The nursing shortage in India can contribute to inadequate nurse patient ratio which may contribute to nurses stress perception. Studies (Department of Health, 2001, 2002; Jenkins & Elliott, 2004; SCMH, 2004; Bowers et al., 2005; Richards et al., 2006) have shown that challenges faced by mental health nurses include inadequate staffing; patients who are acutely disturbed posing risks of violence and self-harm; bed shortages/ occupancy rates and workload. Lack of nursing staff was found to be a mediating variable between stress and job satisfaction (Nakakis and Ouzouni, 2008). Hanrahan et al. (2010), found significant relationships between the better nurse practice work environments and lower psychiatric nurse reports of emotional exhaustion and depersonalization. When nurses working with psychiatric patients cope with stress in an adaptive, healthy manner, other members of the multi-disciplinary team and also the patients themselves find the in-patient milieu more congenial. Moreover, nurses are role models for the patients and their family members as well as for their peers and junior workers. By turning toxic work environments into healthy workplaces, researchers and nurse leaders believe that there could be improvement in recruitment and retention of nurses, job satisfaction for all health care staff, and patient outcomes – particularly those related to patient safety (Department of Health, 2002). Feelings of stress may predispose staff to other illnesses and have an adverse effect on people’s lives (Caan et al., 2001; Norton, 2004; Richards et al., 2006). Recognizing the impact that stress can have on individual staff members, their families, patients and the NHS, the Department of Health (2001) advocated stressreduction programs and other work/life balance improvement strategies in the workplace. In India, the Indian Nursing Council can proactively advocate stress management strategies for all nurses in their place of work. Significant reduction in nurses’ stress perception
Table 4 Comparison of pre and post-intervention scores on the DCl stress scale (n = 53). DCL stress scale domains
Pre mean scores (time 0) SD (n = 53)
Post mean scores (time 1) SD (n = 53)
Patient demands Organizational & managerial issues Staffing Future concerns Job satisfaction Total scores
15.81 5.78 (50%) 12.74 4.88 (41%)
11.36 5.32 (34%) 9.43 4.67 (28%)
14.09 4.77 (50%) 7.28 3.10 (44%) 5.53 2.24 (50%) 57.45 16.42 (48%)
9.64 4.98 (36%) 5.64 2.79 (38%) 3.49 2.12 (33%) 41.06 16.51
* O #
4 weeks post mean scores (time 2) SD (n = 53)
F value
p value
7.66 4.15 (25%) 5.77 3.74 (19%)
339.04 341.97
0.000*,O,# 0.000*,O,#
6.47 3.73 (21%) 3.43 2.57 (19%) 2.26 1.42 (17%) 26.43 12.82
354.57 264.70 309.19 471.62
0.000*,O,# 0.000*,O,# 0.000*,O,# 0.000*,O,#
Time 0 vs time 1. Time 0 vs time 2. Time 1 vs time 2.
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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levels in our study indicate that stress management techniques such as those used in this study are quite practical and feasible. Edwards and Burnard (2003) noted that although a great deal is known about the sources of stress at work, about how to measure it and about the impact on a range of outcome indicators, what was found to be lacking was a translation of these results into practice, into research that assessed the impact of interventions that attempt to moderate, minimize or eliminate some of these stressors. In this study, effective stress management may have helped to moderate nurses’ stressors. Translation of the results of this study into practice can bring about changes in nurses wellbeing which can indirectly contribute to better patient care. This study has several limitations. The lack of a control group prevents generalization of the study findings. There may have been spill-over of stress from the domestic front to the occupational area. Follow up of the subjects after a longer period of time was not carried out. Hawthorne effect may have contributed to reduction in stress values. 4.1. Implications Appropriate and operationally feasible interventions such as problem solving, time management, communicating skilfully, being assertive, negotiating effectively and responding appropriately to criticism which allow nurses to pursue an optimal approach to caring for psychiatric patients are likely to produce substantial benefits in terms of reducing the risk of burnout and consequently positively influencing sickness absence and staff turnover. Nurses trained in stress management are in a better position to manage not only their own stress, but also teach patients and family members stress management. Ensuring that pre-registration education adequately prepares nurses for their roles as qualified practitioners might reduce transition stress. 5. Conclusion Stress can affect physical and mental health leading to conflicts in the work area, frequent absenteeism due to increased psychosomatic illness as well as high turnover. In the long run this affects the organizations productivity. Stress management strategies that are evolved based on the nature of nurses work can help moderate nurses stress perception in the work place. A practical, realistic, cost-effective and tailor-made strategy like this could form an important component of primary and secondary prevention by psychiatric nurses. Replication of this study using pre post tests with control group can further enhance the validity of this intervention. The authors recommend that stress management strategies such as those adopted in this study be practiced by nurses as workplace stress affects client care and outcomes.
Acknowledgement The authors are grateful to all the nurses who participated in this research and the authors of the DCL Stress scale for magnanimously giving the tool as well as permitting its use. References Bowers, L., et al., 2005. The nature and purpose of acute psychiatric wards, The Tompkins acute ward study. J. Ment. Health 14 (6) 625–635. Caan, W., et al., 2001. Wounded healers speak out: experience of nurses with depression. Ment. Health Pract. 8, 20–26. Carson, J., Leary, J., DeVilliers, N., Fagin, Redmall, J., 1995. Stress in mental health nurses: comparison of wards & community staff. Brit. J. Nurs. 4, 579–582. Carson, J., Brown, D., Fagin, L., Leary, J., Bartlett, H., 1996. Do larger caseloads cause greater Stress in Community Mental Health Nurses. J. Clin. Nurs. 5, 133–134. Carson, J., Fagin, L., Brown, D., Leary, J., Bartlett, H., 1997a. Self-esteem in mental health nurses: its relationship to stress, coping burnout. Nurs. Times Res. 2, 361–370. Carson, J., Wood, M., White, H., Thomas, B., 1997b. Stress in mental health nursing: findings from the mental health care survey. Ment. Health Care 1, 11–14. Carson, J., Fagin, L., Maal, S., DeVilliers, N., O’Malley, P., 1997c. Stress and fitness in ward-based mental health nurses. J. Clin. Nurs. 6, 419–420. Carson, J., Cavagin, J., Bundark, J., Maal, S., Gournay, K., Kuipers, E., Holloway, F., West, M., 1999. Effective communication in mental health nurses: did social support save the psychiatric nurse? Nurs. Times Res. 4, 31–42. Cronin-Stubbs, D., Brophy, E.B., 1985. Burnout: can social support save the psychiatric nurses? J. Psychosoc. Nurs. Ment. Health Serv. 23, 8–13. Dawkins, E.J., Depp, F., Selzer, L.E.N., 1985. Stress and the psychiatric nurse. J. Psychosoc. Nurs. 23 (11) 9–15. Department of Health (DH), 2001. Final Report by the Workforce Action Team. Department of Health, London. Department of Health, 2002. Mental Health Policy Implementation Guide: Adult Acute Inpatient Care Provision. Department of Health, London. Edwards, D., Burnard, P., 2003. A systematic review of stress and stress management interventions for mental health nurses. J. Adv. Nurs. 42 (2) 169–200, 12670386 Cit: 42. Flannery, R.B., Farley, E., Rego, S., Walker, A.P., 2007. Characteristics of staff victims of psychiatric patient assaults: 15-year analysis of the Assaulted Staff Action Program (ASAP). Psychiatr. Q. 78, 25–37. Hanrahan, N.P., Aiken, L.H., Lakeetra, M., Hanlon, A.L., 2010. Relationship between psychiatric nurse work environments and nurse burnout in acute. Care Gen. Hosp. 31 (3) 198–207, http://dx.doi.org/10.3109/01612840903200068. Jenkins, R., Elliott, P., 2004. Stressors, burnout and social support: nurses in acute mental health settings. J. Adv. Nurs. 48 (6) 622–631. Liu, J., Wuerker, A., 2005. Biosocial bases of aggressive and violent behavior – implications for nursing studies? Int. J. Nurs. Stud. 42 (2) 229–241. Nakakis, K., Ouzouni, C., 2008. Factors influencing stress and job satisfaction of nurses working in psychiatric units: a research review. Health Sci. J.1 2 (4) 183– 195. Norton, K., 2004. Re-thinking acute psychiatric inpatient care. Int. J. Soc. Psychiatr. 50 (3) 274–284. Richards, D.A., et al., 2006. The prevalence of nursing staff stress on adult acute psychiatric in-patient wards: a systematic review. Soc. Psychiatr. Psychiatr. Epidemiol. 41, 34–43. Sainsbury Centre for Mental Health, 2004. Acute Care: A National Survey of Adult Psychiatric Wards in England. SCMH, London. Sorgaard, K.W., Ryan, P., Dawson, I., 2010. Qualified and unqualified (N-R C) mental health nursing staff – minor differences in sources of stress and burnout. A European multi-centre study. BMC Health Serv. Res. 2010 10, 163, http:// dx.doi.org/10.1186/1472-6963-10-163.
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
AJP-672; No. of Pages 4 Asian Journal of Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Impact of a stress management program on stress perception of nurses working with psychiatric patients Gandhi Sailaxmi *, Krishnasamy Lalitha Department of Nursing, National Institute of Mental Health & Neurosciences (INI), Hosur Road, Near Wilson Garden, Bangalore 560029, Karnataka, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 August 2014 Received in revised form 7 December 2014 Accepted 18 January 2015 Available online xxx
Nurses caring for psychiatric patients may have to face violent emotions and unpredictable behaviour which can be quite stressful. A stress management program may equip nurses with skills to cope effectively with the stress. A one group pre-test and post-test design was adopted to test this hypothesis. Both gender nurses caring for psychiatric patients were invited to undergo 10 consecutive, one hour sessions of a stress management program. The DCL Stress scale (The De Villiers, Carson & Leary Stress Scale; Carson et al., 1997a,b,c) was used to collect data immediately after intervention and four weeks later. RM ANOVA with SPSS 16 showed that pre-intervention mean stress reduced significantly (p = 0.000) from 57.45 16.42 to 41.06 16.51 immediately following the intervention and 26.43 12.82 (p = 0.000) four weeks after the intervention. The stress management strategies positively impacted on nurses’ stress levels. ß 2015 Elsevier B.V. All rights reserved.
Keywords: Stress Nurses Psychiatric patients Stress management interventions
1. Introduction Nurses working with psychiatric patients may be confronted with intense interpersonal interactions, dynamic changes in patients, emotional lability and psychological distress that can be very stressful and challenging. Most studies on stress and job satisfaction in nursing have focused on general nursing specialities, and relatively little attention has been paid to nurses working in psychiatric units (Cronin-Stubbs and Brophy, 1985; Dawkins et al., 1985). Although there are educational programs in India that focus on psychiatric nursing speciality (from diploma to doctorate programs), many nurses caring for psychiatric patients in various psychiatric hospitals in India may not have actually undergone a speciality training program. When confronted by issues such as nurse shortage, violence in the unit, advances in technology, and demands from the multidisciplinary team, these nurses can have high levels of stress. Worker injuries and verbally aggressive patients are reported to be increasing and are associated with higher rates of burnout of psychiatric nurses (Liu and Wuerker, 2005; Flannery et al., 2007). With robust clustered regression analysis, it was found that lower levels of psychiatric nurse burnout among 353 nurses was significantly associated with inpatient environments in 67 hospitals that had better overall
* Corresponding author. Tel.: +91 08026995322; fax: +91 08026564830; mobile: +91 09902763889. E-mail address: [email protected] (G. Sailaxmi).
quality work environments, more effective managers, strong nurse– physician relationships, and higher psychiatric nurse-to-patient staffing ratios (Hanrahan et al., 2010). Most psychiatric hospitals in India have wards with 50–60 beds. Generally, in the morning shift there are at least two nurses with one ward supervisor, one nurse for the evening and one for the night shift. This inadequate nurse–patient ratio also can contribute to stress in the nurses. Programs for dealing with stress should be available on a routine basis (Sorgaard et al., 2010). The present research work focuses on testing of specific strategies to equip nurses with competencies to cope with stress when working with patients with mental illness. If this stress management program is found to be effective, it can be advocated for nurses working in other psychiatric hospitals in India. 1.1. Aim To evaluate the effectiveness of a stress management program on stress reduction in nurses working in a psychiatric hospital. 1.2. Objectives 1. To assess the level of pre-intervention perceived stress in nurses working with psychiatric patients. 2. To develop a stress management program. 3. To evaluate the impact of the stress management program on stress perception of nurses working with psychiatric patients.
http://dx.doi.org/10.1016/j.ajp.2015.01.002 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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AJP-672; No. of Pages 4 G. Sailaxmi, K. Lalitha / Asian Journal of Psychiatry xxx (2015) xxx–xxx
2
1.3. Hypothesis There will be a statistically significant change in the stress perception of the nurses after under-going the stress management program. 2. Materials & methods 2.1. Research design A quasi-experimental one group pre test post test design. 2.2. Study population and setting After approval by the Institutional Review Board and following informed consent as well as detailed explanation about the risks and benefits involved, 60 nurses working in a psychiatric hospital at Bangalore, India were randomly selected using the Tippet’s Random number table and invited to participate in this study. Male and female registered nurses working with psychiatric patients for more than one year and possessing G.N.M. (diploma) or B.Sc. Nursing qualification (with/without additional qualifications) were included in the study. Nurses in the supervisory capacity, nursing trainees, nurses with chronic illness and those who had undergone stress management courses were excluded from the study. Of the 60 randomly selected subjects who fulfilled the inclusion criteria, there was seven-subject mortality due to reasons such as illness, death in the family and child’s illness. The final sample consisted of 53 nurses, who fulfilled the inclusion/ exclusion criteria. Nurses took part in the sessions while on duty. Since shift system was followed in this hospital, groups of 10 nurses participated in the sessions during the morning shift and evening shift. Maximum effort was taken to meet comfort needs, including providing refreshments. Nurses were encouraged to contact the researchers at periods other than the intervention sessions. 2.3. Research tools A semi-structured, researcher constructed proforma was used to collect socio-demographic data. The DCL (De Villiers, Carson & Leary) Stress Scale (Carson et al., 1995, 1996, 1997a–c, 1999) was used to measure stress levels. This is a 30 item Likert rating scale consisting of five domains – patient demands (8 items), organizational and managerial issues (8 items), staffing (7 items), future concerns (4 items) and job satisfaction (3 items). Cronbach’s alpha reliability coefficient was 0.96. The test–re-test correlation (Spearman’s Rho) was 0.91. There is high content as well as criterion validity (with Maslach’s Emotional Exhaustion and the GHQ – 28). Each item is scored as a Likert scale ranging from 0 to 4. Thus, the total score ranges from ‘no’ stress (score of 0) to ‘extreme’ stress (score of 120). 2.4. Stress management program The nurses were enrolled for 10 sessions, each lasting for one hour, on a daily basis. Five sessions in a week from Monday through Saturday for two weeks were conducted keeping in mind weekly off duty days. Sessions focused on stress education, problem solving, time management, taking time off, communication skills, assertiveness training, responding to criticism, negotiation skills and humour. Various teaching strategies were used such as lecture cum discussion, brain storming, role play, group work and behaviour rehearsal. Communication skills, assertiveness skills, responding to criticism and negotiation skills were role played and video graphed. These video slides also were used as
teaching aids. Sessions were very interactive and nurses were encouraged to clarify doubts and participate actively. Nurses were encouraged to prepare case scenarios based on their experience of stressful situations in the wards and then discuss how these stress management techniques could be implemented during these situations. Pre-assessment was done using the sociodemographic proforma and the DCL Stress Scale. The subjects were then exposed to these specific strategies for ten days continuously. Immediate post-assessment as well as assessment four weeks later was done. The subjects were encouraged to narrate their experiences while adopting the various techniques taught to them. A discussion was held about the difficulties, practicability and utility of the techniques followed by post assessment as well as evaluation of the sessions that they had undergone. All nurses including those who were not part of the study were given information manuals on the stress management interventions after the final data collection. The content validity of this stress management program as well as the audio–visual aids used during the sessions were determined by experts comprising of three psychiatrists, three psychiatric nurses, two clinical psychologists and two psychiatric social work consultants. 2.5. Analysis It was decided to express the data obtained using descriptive statistics and to analyze the effectiveness of intervention by computing repeated measures ANOVA using a 0.05 level of significance. Data analysis was performed using SPSS16. 3. Results 3.1. Descriptives Majority of the nurses (90.57%) were female. Married nurses comprised 84.91% of the study sample. 32.08% of the nurses were from a joint family and the remaining 67.92% belonged to nuclear families. 83.02% of the nurses had family support in day-to-day activities (Table 1). The mean age of the study sample (n = 53) was 33.19 6.90 years ranging from 24 years to 50 years. The mean basic salary was Rs. 5887.55 783.46 ranging from Rs. 5250 to Rs. 9060. The nurses experience of working with psychiatric patients ranged from 2 years to 29 years with a mean experience of 9.58 6.04 years (Table 2). While 15.09% of the nurses worked in the Psychiatry special wards, 33.96% worked in the emergency unit, 18.87% in the closed psychiatry wards and the rest (32.08%) worked in the open psychiatry wards. 24.53% of the nurses were professionally Table 1 Frequency distribution of the study sample based on sex, marital status, type of family and family support in day to day activities (n = 53). Sample characteristics
Number
Percentage
Sex Female Male
48 5
90.57 9.43
Marital status Married Unmarried Separated
45 6 2
84.91 11.32 3.77
Type of family Joint Nuclear
17 36
32.08 67.92
Family support in day to day activities Yes 44 No 9
83.02 16.98
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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AJP-672; No. of Pages 4 G. Sailaxmi, K. Lalitha / Asian Journal of Psychiatry xxx (2015) xxx–xxx
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Table 2 Frequency distribution of the study sample based on age, basic salary and duration of experience in years (n = 53). Sample characteristics
Number
Age in years Basic salary (Rs.) Duration of experience in years
53
Minimum 24
Maximum 50
Mean 33.19
SD 6.90
53 53
5250 2
9060 29
5887.55 9.58
783.46 6.04
Table 3 Frequency distribution of the study sample based on area of working and professional qualification (n = 53). Sample characteristics
Number
Percentage
Area of working Psychiatry special wards Emergency wards Psychiatry closed wards Psychiatry open wards
8 18 10 17
15.09 33.96 18.87 32.08
Professional qualification B.Sc. nursing (including P.C.B.Sc. nursing) GNM GNM with diploma in psychiatric nursing
13 36 4
24.53 67.92 7.55
qualified as B.Sc. nurses, majority (67.92%) were general nurse midwives and the rest (7.55%) had attained a professional qualification of general nurse midwife with diploma in psychiatric nursing (Table 3). 3.2. Changes in stress perception of nurses following the stress management program There was a significant (p = 0.000) mean reduction in stress perception from 57.45 16.42 at pre-intervention to 41.06 16.51 immediately after the intervention and 26.43 12.82 four weeks after the intervention. Pre-intervention mean stress levels related to patient demands (15.81 5.78), in the area of organizational and management issues (12.74 4.88) and about future concerns (7.28 3.10) were at moderate levels. However, in the area of staffing, the mean stress level was high (14.09 4.77). There was a significant (p = 0.000) reduction in stress levels in all the domains immediately after and four weeks after the intervention (Table 4, Fig. 1). 4. Discussion In this study, there was a gradual mean reduction in stress perception from 57.45 16.42 at pre-intervention to 41.06 16.51 immediately after the intervention and 26.43 12.82 four weeks after the intervention with p = 0.000. Pre-intervention mean stress levels
Fig. 1. Cone chart indicating the Time 0 (pre intervention), Time 1 (immediate post intervention) and Time 2 (4 weeks post intervention) mean scores on the DCL stress scale.
(15.81 5.78) related to patient demands, in the area of organizational and management issues (12.74 4.88) and about future concerns (7.28 3.10) were at moderate levels. However, in the area of staffing, the mean stress level was high (14.09 4.77). The nursing shortage in India can contribute to inadequate nurse patient ratio which may contribute to nurses stress perception. Studies (Department of Health, 2001, 2002; Jenkins & Elliott, 2004; SCMH, 2004; Bowers et al., 2005; Richards et al., 2006) have shown that challenges faced by mental health nurses include inadequate staffing; patients who are acutely disturbed posing risks of violence and self-harm; bed shortages/ occupancy rates and workload. Lack of nursing staff was found to be a mediating variable between stress and job satisfaction (Nakakis and Ouzouni, 2008). Hanrahan et al. (2010), found significant relationships between the better nurse practice work environments and lower psychiatric nurse reports of emotional exhaustion and depersonalization. When nurses working with psychiatric patients cope with stress in an adaptive, healthy manner, other members of the multi-disciplinary team and also the patients themselves find the in-patient milieu more congenial. Moreover, nurses are role models for the patients and their family members as well as for their peers and junior workers. By turning toxic work environments into healthy workplaces, researchers and nurse leaders believe that there could be improvement in recruitment and retention of nurses, job satisfaction for all health care staff, and patient outcomes – particularly those related to patient safety (Department of Health, 2002). Feelings of stress may predispose staff to other illnesses and have an adverse effect on people’s lives (Caan et al., 2001; Norton, 2004; Richards et al., 2006). Recognizing the impact that stress can have on individual staff members, their families, patients and the NHS, the Department of Health (2001) advocated stressreduction programs and other work/life balance improvement strategies in the workplace. In India, the Indian Nursing Council can proactively advocate stress management strategies for all nurses in their place of work. Significant reduction in nurses’ stress perception
Table 4 Comparison of pre and post-intervention scores on the DCl stress scale (n = 53). DCL stress scale domains
Pre mean scores (time 0) SD (n = 53)
Post mean scores (time 1) SD (n = 53)
Patient demands Organizational & managerial issues Staffing Future concerns Job satisfaction Total scores
15.81 5.78 (50%) 12.74 4.88 (41%)
11.36 5.32 (34%) 9.43 4.67 (28%)
14.09 4.77 (50%) 7.28 3.10 (44%) 5.53 2.24 (50%) 57.45 16.42 (48%)
9.64 4.98 (36%) 5.64 2.79 (38%) 3.49 2.12 (33%) 41.06 16.51
* O #
4 weeks post mean scores (time 2) SD (n = 53)
F value
p value
7.66 4.15 (25%) 5.77 3.74 (19%)
339.04 341.97
0.000*,O,# 0.000*,O,#
6.47 3.73 (21%) 3.43 2.57 (19%) 2.26 1.42 (17%) 26.43 12.82
354.57 264.70 309.19 471.62
0.000*,O,# 0.000*,O,# 0.000*,O,# 0.000*,O,#
Time 0 vs time 1. Time 0 vs time 2. Time 1 vs time 2.
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
G Model
AJP-672; No. of Pages 4 G. Sailaxmi, K. Lalitha / Asian Journal of Psychiatry xxx (2015) xxx–xxx
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levels in our study indicate that stress management techniques such as those used in this study are quite practical and feasible. Edwards and Burnard (2003) noted that although a great deal is known about the sources of stress at work, about how to measure it and about the impact on a range of outcome indicators, what was found to be lacking was a translation of these results into practice, into research that assessed the impact of interventions that attempt to moderate, minimize or eliminate some of these stressors. In this study, effective stress management may have helped to moderate nurses’ stressors. Translation of the results of this study into practice can bring about changes in nurses wellbeing which can indirectly contribute to better patient care. This study has several limitations. The lack of a control group prevents generalization of the study findings. There may have been spill-over of stress from the domestic front to the occupational area. Follow up of the subjects after a longer period of time was not carried out. Hawthorne effect may have contributed to reduction in stress values. 4.1. Implications Appropriate and operationally feasible interventions such as problem solving, time management, communicating skilfully, being assertive, negotiating effectively and responding appropriately to criticism which allow nurses to pursue an optimal approach to caring for psychiatric patients are likely to produce substantial benefits in terms of reducing the risk of burnout and consequently positively influencing sickness absence and staff turnover. Nurses trained in stress management are in a better position to manage not only their own stress, but also teach patients and family members stress management. Ensuring that pre-registration education adequately prepares nurses for their roles as qualified practitioners might reduce transition stress. 5. Conclusion Stress can affect physical and mental health leading to conflicts in the work area, frequent absenteeism due to increased psychosomatic illness as well as high turnover. In the long run this affects the organizations productivity. Stress management strategies that are evolved based on the nature of nurses work can help moderate nurses stress perception in the work place. A practical, realistic, cost-effective and tailor-made strategy like this could form an important component of primary and secondary prevention by psychiatric nurses. Replication of this study using pre post tests with control group can further enhance the validity of this intervention. The authors recommend that stress management strategies such as those adopted in this study be practiced by nurses as workplace stress affects client care and outcomes.
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