Interventions Against Burnout in Mental Health Nursing

‘Are educational interventions effective in reducing the incidence of burnout among mental health nurses?’

A critical review of the literature

Abstract

Background There is much evidence to link burnout with mental health nursing, but limited empirical evidence that examines the impact of educational interventions on the incidence of burnout in mental health nurses.

Aim The aim of this literature review was to critically evaluate the literature relating to educational interventions associated with burnout in mental health nursing using selective and comparative analysis

Method The search strategy involved the use of several electronic databases, and a library search to access relevant journals. Search terms and inclusion/ exclusion criteria are identified. Evaluative criteria (Price 2003) were applied to a critical analysis of the literature.

Findings There is limited empirical research in this area; some of it is predictive rather than evaluative.

Conclusions Despite the paucity of information, there are some strong arguments for the use of educational interventions to reduce the incidence of burnout in mental health nurses. There are implications for further research to be carried out in this area.

Background

Burnout is defined as a state of emotional exhaustion, accompanied by a sense of low self- worth (Peveler et al 2000), lack of motivation and a physical as well as emotional, sense of ill- health (Malach-Pines 2005). It tends to involve an insidious process of cumulative stress (Morrisette 2002a). Burnout is most often associated with human- service (helping) professions (Ekstedt and Fagerberg 2005) and frequently, it is those who have a high level of commitment to their work, who are most at risk (van Dierendonck D et al 2005).

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There is much evidence within the literature that links mental health nursing with burnout ( Barling 2001; Coffey 1999; Duquette et al 1994; Edwards et al 2000; Fagin et al 1995; Happell et al 2003; Harper and Minghella 1997; Kipping 2000; Prosser et al 1999a; Onyett 1997; Wykes et al 1997). Although burnout is associated with different types of nursing (Nolan and Smojkis 2003); mental health nurses in particular, are reported to be at high risk (Nolan et al 1999; Thomsen et al 1999a). Suggested reasons for this high level of vulnerability to stress and burnout are that the profession attracts people who have a predisposition to mental health difficulties themselves (Guppy and Gutteridge 1991) and that working with people with severe mental illness is so stressful that a degree of transference can occur between the patient and health professional (particularly if the latter is inexperienced) (McLeod 1997). The stressors associated with mental health nursing are further compounded if certain factors are present, such as low self- esteem; conflicting demands of home- life, inadequate coping mechanisms (Thomsen et al 1999b) and a lack of job satisfaction, which is especially associated with hospital, rather than community nurses (Prosser et al 1999b).

Many sources propose that burnout is preventable (Burnard P 1999; Figley C 2002; Jones 2003 ; Morrisette 2002b; Taormina and Law 2000). It is important therefore, to raise awareness of prevention strategies. It is possible that these could be incorporated into educational programmes and it is suggested that failure to do so can result in informally learned negative behaviours leading to maladaptive coping strategies (Thompson 2003).

Aim

The aim of this literature review is to critically evaluate the literature relating to educational interventions associated with burnout in mental health nursing using selective and comparative analysis.

Method

The search strategy involved the use of the Athens Access Management System in order to access such databases as The British Nursing Index, CINAHL, the Cochrane library, Evidence- based medicine (EBM) reviews, Embase psychiatry, internurse.com, Medline, Ovid, PsycINFO, Pubmed, ScienceDirect and TRIP database. The University library was also used in order to conduct a hand search of such relevant journals as The Journal of Psychiatric and Mental Health Nursing; The International Journal of Mental Health Nursing; Mental Health Nursing; Journal of Psychosocial Nursing and Mental Health Services, Journal of Advanced Nursing; International Journal of Nursing Studies; Nurse Researcher and Nursing Research.

The search terms and keywords used were: ‘burnout’ and ‘stress’ in combination with ‘mental health nursing’; ‘mental health nurses’; ‘nurses’ ‘education’; ‘nurse education’; ‘training’ (as it was found that this word was used quite a lot within the literature) and ‘prevention’. The search process highlighted the search terms that were most effective in accessing the relevant information using trial and error; otherwise referred to as a process of screening (Fink 2005a)

The inclusion criteria were: papers dating back to 1990, the rationale being that a lot of work on burnout was conducted during the 1990’s; some of it in relation to mental health nursing, which is still being cited by published authors; research articles addressing the concepts of ‘stress’ and ‘burnout’ as they relate to ‘mental health nursing’; research articles linking ‘burnout’ with ‘nursing’, ‘prevention’ and ‘education’ as there is limited specific information on educational interventions to prevent burnout in mental health nursing, therefore some transferable principles were applied. For the same reason (shortage of specific information) research articles from other countries were not excluded. Both quantitative and qualitative studies were included.

Exclusion criteria were any papers published before 1990; any articles not written in the English language; any articles not specifically addressing stress and burnout and articles about stress and burnout that are not related to nursing.

Evaluative criteria adapted from the framework developed by Price (2003) were broadly applied to a critical analysis of the literature. These criteria are: Do the papers address my question? Is the content accessible and comprehensible? Are the research results valid, reliable and authentic? Are there any gaps within the literature and Are there any competing perspectives/ contradictions within the literature? These criteria were supplemented by selective reference to sampling techniques used, strengths and weaknesses of the research designs, methods of data collection and analysis, ethical aspects and presentation issues (Fink 2005b).

Findings

A recurring theme that emerged from the literature in relation to burnout within the helping professions is the concept of emotional labour, and that education and training can help to make people more aware of this phenomenon and to develop strategies to manage it. Emotional labour is a form of dissonance when the practitioner feels under pressure not to display the emotions which are engendered by the nature of their work (Brotheridge and Grandey 2002). There are two levels of emotional labour; surface or deep acting (Ashkanasy et al 2006). Surface acting is when the practitioner adopts a behaviour that belies their true emotions whereas deep acting is when they struggle to feel the emotion that is expected of them.

Mann and Cowburn (2005) conducted a study that aimed to increase understanding about the links between components of emotional labour and stress in mental health nursing. 35 mental health nurses completed questionnaires which yielded information relating to 122 nurse- patient interactions. Three different published research instruments were integrated into the questionnaire; the Emotional Labour Scale, the Emotional Labour Inventory (both of which related more directly to nurse- patient interactions) and the Daily Stress inventory which addressed more general areas of stress. The use of tried- and- tested research instruments helps to ensure validity and reliability of the findings. Published research tools have often been refined several times, with the need to have excellent reliability and validity (Giles 2002). The data was analysed by using Pearson’s correlations and multiple regression techniques. The researchers concluded that emotional labour is positively correlated with both the stress that arises from interactions with patients, as well as other sources of stress; that the impact of emotional labour is dependent upon the intensity of the interaction and the range of emotions experienced throughout the interaction, and that surface acting is a more important predictor of emotional labour than deep acting. Only one psychiatric unit was involved in the study with a relatively low response rate of 29%; low response rates can introduce bias and uncertainty into a study (Smeeth 2002). What constitutes a satisfactory response rate varies according to the nature of the research, however a 60% response rate might be considered to be ‘good’, and a 50% response rate to be adequate (Sim and Wright 2000); although many researchers accept that any response rate over 40% can yield meaningful results. The authors acknowledge that generalisability of the results is limited. Interestingly it was the non- cooperation of the unit in general that adversely affected the response rate because of a lack of flexibility regarding access to respondents which influenced the methodology, in that it was not possible to obtain qualitative data relating to the lived experiences of mental health nurses in relation to emotional labour which might have been more meaningful, and an unwillingness to allow the researchers to follow- up non- responders. There is an implication here for nurses to become more research aware and for healthcare organisations to promote and support research- mindedness.

The discussion and conclusion are interesting and relevant to the link between education and burnout in relation to mental health nursing. While acknowledging the limitations of the study, the authors do however stress that the findings have important implications for nurse education in that skills training for performing emotional work should be given a higher priority; that an increased focus be placed on facilitating self- awareness skills to enable mental health nurses to become more introspective about their feelings, so that they can develop effective techniques for dealing with them. However this study does not have the scope to be able to empirically demonstrate that educational interventions are effective in preventing burnout.

The value of developing new educational strategies in relation to addressing emotional labour (in addition to other issues) for student mental health nurses was more clearly demonstrated by Turner et al (2004). The purpose of the study was to evaluate a pilot client attachment scheme for student mental health nurses. The rationale for client attachment is that it enables students to form therapeutic relationships with individual clients. This type of educational experience differs from the more traditional route of progressing through different placements. The methodology involved the use of semi- structured interviews to gain the perspectives of students (12), their supervisors (22) and clients (2). Although this is a small sample, the design was qualitative and a depth of meaningful information was obtainable, particularly from the students and the supervisors. The data was organised using thematic analysis, although this was not possible with the client data as there were only two clients and although they gave very positive feedback, the amount of information was very limited. Service user involvement in mental health research is a relatively new and developing concept (Telford and Faulkner 2004). This study is relevant to the discussion because it highlighted that different educational approaches can more effectively promote reflective skills among mental health nurses, which in turn can provide a tool for dealing with emotional labour. The researcher’s literature review revealed that many mental health student nurses report sources of stress as including not feeling part of a team, and dealing with distressing incidents involving clients. These factors lead to emotional containment, causing reduced motivation and increased stress. The client attachment scheme goes some way to addressing these issues by providing more continuity and increased supervision for mental health student nurses. Although the scope and generalisability of this study is limited, it flags up important indicators for changes to be made to the student nurse curriculum that will provide students with the skills to recognise and deal with, emotional labour, which should impact upon more effective stress management and prevention of burnout.

Another study which concludes that changes should be made to the mental health student nurse curriculum in relation to stress management was conducted by Kilfedder et al (2001). They contend that previous studies on burnout in nursing contain several methodological inadequacies, and so set out to design a more theoretical study. The study sample was drawn from nurses employed in a Scottish National Health Service (NHS) Trust which provided both acute and continuing care mental health services in both hospital and community settings. 510 nurses returned questionnaires (a response rate of 48.8%). A total of 12 published measures were used, together with one purpose- designed measure which related to non- occupational stressors. The others related to such aspects as social support, occupational stress, burnout and coping strategies. As previously highlighted, the use of published measures can enhance reliability and validity. A range of statistical tests were used to analyse the data. High levels of emotional exhaustion, depersonalisation and burnout were reported and low levels of personal accomplishment. The researchers concluded that not only should a core part of the nursing curriculum be devoted to stress management and coping skills, but also that management training should incorporate leadership skills that facilitate stress management and that all nurses should be provided with training that equips them to develop coping mechanisms. Education is very much seen by the researchers as an essential part of a comprehensive approach to prevention, which should be emphasised more than the current tendency towards ‘picking up the pieces’ after the event. This study is quite complex which tends to affect its accessibility, however its findings have important implications for stress management in mental health nurses.

Sharkey and Sharples (2003) evaluated a learning pack on risk management, developed for use with clinical mental health teams with emphasis on the impact the pack had on team members’ stress. The learning pack was made up of six sections, each one corresponding with a facilitator- led workshop. Participants were expected to carry out some reading and learning activities between workshops. Interestingly the authors identify two aspects of risk management that are potential stressors; the potential risks of the job such as dealing with violence and having to get to grips with the concept of risk management as a relatively new concept, and the systems involved. The researchers adopted a quasi- experimental approach, using pre and post measures, taken eight weeks before and after the learning intervention, in order to be able to measure any change in relation to work- related stress among the participants, as a result of following the educational programme. The researchers highlighted difficulties with not being able to conduct a controlled experiment which might have affected the outcome, as it was not possible to be certain that any change was attributable to the educational intervention, as opposed to other factors. Sampling was self- selective which might also have affected the findings, as having volunteered; the participants indicated a level of motivation which could have impacted on the effectiveness of the learning programme. The sample (42) was drawn from two mental health locality teams, which included mental health nurses. The pre and post measures used were the Occupational Stress Indicator and the Healthcare- related Work Pressure Scale. Again, these are tried and tested published instruments, the use of which should contribute to the validity and reliability of the findings. These yield quantitative data which was analysed using descriptive statistics, the paired t -test and the Wilcoxon signed rank test. Once again, it might have been of value to combine qualitative with quantitative measures, in order to gain an understanding of the participants’ experience of stress; qualitative methods allow researchers to overcome the assumptions inherent in fixed- choice questionnaires, although these also have their value for example, in relation to information about prevalence (Cummings and Galambos 2004). All 42 participants completed the pre measures( although only 32 started the programme and 27 completed it) together with the post measures. It would have been interesting to identify why almost half of the original sample did not complete the programme; whether workload and/ or stress issues contributed to this level of attrition. However it was suggested that quite intensive time commitment was required to complete the programme which might have been an inhibitory factor and there could be implications for redesigning the programme so that it can be accessed more flexibly by participants. Responses were not broken down into professional groups- this also might have yielded some important differences. In relation to the Occupational Stress Indicator, comparing pre and post scores indicated that there was a general decrease in many sources of stress. Interestingly lower means at post measures were observed for the ‘job satisfaction’ subscale which indicated reduced satisfaction. The researchers suggest that this could be due to increased knowledge and expectations as a result of the learning intervention; whether this development could be a source of stress in itself is not speculated upon even though different studies have reported a relationship between stress and reduced job satisfaction (Koslowsky 1998). Scores for the Healthcare- related work pressure scale all show a lowering of item means at post measure. Overall the researchers concluded that the learning intervention brought about positive changes in relation to the work- related stress of the participants; in some cases the impact was significant. It is suggested that the ways in which educational interventions can bring about change is by enabling participants to gain knowledge and skills within the ‘safe’ environment of the classroom. A positive outcome of this study is that the learning pack has been modified, following feedback from the pre and post measures together with evaluations from the participants, and is now in use.

Ewers et al (2002) evaluated the effect of Psychosocial Intervention Training (PSI), using a controlled experiment, in reducing burnout rates in mental health nurses working in secure units, having identified that this group is particularly at risk of developing clinical burnout syndrome. The hypothesis was that if nurses gained a better understanding of clients’ illnesses and develop more skills to be able to help clients, then they would experience lower levels of burnout within their clinical roles. A self- selecting sample of 20 volunteered to do the PSI course, but these met pre- set inclusion criteria and represented all grades of staff and all wards. 10 subjects were allocated to the experimental PSI group and 10 to the waiting list control group. Baseline measures of knowledge were taken, using a 30- item multiple choice questionnaire which had been used in previous studies; of attitudes, using a measure developed by one of the researchers and of burnout, using the Maslach Burnout Inventory. It was not clarified whether the attitude measure had been tested for reliability and validity, whereas the other two measures are tried and tested. The experimental group received 20 days of PSI training. On completion of the course all subjects were asked to complete the measure of knowledge, attitudes and burnout. The facilitator had previously received advanced training in PSIs. The course includes both practical and theoretical assessment components and a minimum attendance of 80% was required. The data was analysed using Fisher Exact tests and t– tests. The results showed that there was a significant difference in the knowledge scores for each group, with an increase in the knowledge of the experimental group. The same applied to the measurement of attitudes, which it is assumed (although not made clear by the authors) refers to an increase in positive attitudes for the experimental group. Again, the same applied to the burnout measure; this time the results are expressed more clearly in that the experimental group had moved in a positive direction along the subscales measured by the Maslach Burnout Inventory. The limitations of this study are that the results might not be generalisable to other units; as only one unit was involved in the study wherein specific factors might exist that contribute to the development of burnout. As with the previous study, the self- selecting nature of the participants might indicate that they were more highly motivated and more responsive to change. However, while acknowledging the methodological weaknesses, the researchers conclude that the significantly positive changes in knowledge, attitudes and burnout measures of participants within the experimental group are indicative of the value of educational interventions in reducing the incidence of burnout among mental health nurses working within secure units.

Ho (2007) describes a study which explored the value and meaning of a psychodynamic work discussion for mental health nurses, which is described as a method of working, learning and development in professional practice. A work discussion group can enable psychological and emotional containment for mental health nurses which can impact upon the prevention of burnout. While the work discussion group is a means of learning in itself, education about the psychodynamic processes involved is also necessary in order to unlock the potential of the group. A qualitative design was used in order to be able to explore the feelings, experiences and perceptions of the participants, which seems highly appropriate within a study of this kind. Data was collected from a focus group of 6 mental health nurses ranging from staff nurse to ward manager level. This is quite a small sample, however this is often more acceptable within qualitative research as depth rather than breadth of information is being sought. It is generally considered that the ideal composition of a focus group is between 6-12 people, however when the nature of the subject could be emotionally charged or sensitive, it is preferable to limit the size of the group to 5 or 6 (Polit and Beck 2004). The data was analysed using Bulmer’s framework, a technique derived from grounded theory in order to define meaning through focus groups. This article is quite complex but comprehension has been facilitated by the presentation, in tables and boxes, of the categories and themes within which the discussion was structured. The purpose of the focus group (which was not immediately made clear) was not to act as a work discussion group but to explore the potential for its value with mental health nurses, and the group appeared to be generally responsive to the concept. The author concludes that mental health nurses could benefit from this approach, but would need encouragement and education and that the use of the work discussion group could be integrated into nurse education. The researcher acknowledges that the potential use of this approach needs to be explored further, with larger samples from a wider area.

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Lee (2005) evaluated the effectiveness of a stress management training intervention for care assistants working in a residential home for the elderly; many of whom had dementia, having cited research which links caring for people with dementia with work- related stress. The study took place within one residential home. The training consisted of a three- day programme that aimed to create and maintain an effective work environment by managing stress and stressful situations. The researcher provides an outline of the course content but does not state how many participants there were or how she measured the effectiveness of the programme, despite including sections headed ‘methods’ and ‘findings’. She reports that the stress management training reduced the care assistants’ levels of stress and improved their ability to cope with potentially stressful situations. She also concluded that the age or experience of the care assistants did not have an impact on their stress levels or coping ability, which did not concur with the findings of a different study. This is a poorly written research article; the lack of detail reduces its value. However given the paucity of research related to educational interventions for mental health workers, it still adds to the existing body of knowledge. An interesting development is that the researcher subsequently contacted 21 residential homes and found that only 3 provided training interventions related to stress management.

Conclusions

An extensive review of the literature has revealed that there are gaps in the literature relating to educational interventions to reduce the incidence of burnout in mental health nurses; this finding is supported in a review by Edwards and Burnard (2003), who concluded that while there is evidence that stress is a problem for mental health nurses, research on interventions to address this, is insufficient. Many articles on this subject are literature reviews, drawing on broad- based research in related areas, with a definite lack of empirical studies, and these reviews have not been included here. It has been necessary to include studies which predict that educational interventions will reduce the incidence of burnout in mental health nurses as well as those which evaluate existing interventions (which are very few). There are implications for further research into this important area. However there are some interesting and valuable conclusions that can be drawn from the existing literature.

A synthesis of this review of the literature yields the following outcomes:

• There is a link between emotional labour and burnout, and adopting strategies (including educational) to enable mental health nurses to recognise and deal with emotional labour (including self- awareness and reflective skills) should impact upon the prevention of burnout.
• Educational interventions aimed at reducing the incidence of burnout should take place both within pre registration programmes and as part of continuing professional development (CPD).
• Educational interventions are an important part of a comprehensive strategy to reduce the incidence of burnout among mental health nurses.
• As well as focussing on stress management, educational interventions can also be used to enhance knowledge and skills (relating to for example, risk management and helping skills) which in turn, positively impact upon stress levels and coping skills.
• A range of educational approaches should be explored in relation to stress management, allowing for innovation and flexibility, to facilitate access for mental health nurses, who may feel inhibited by such factors as shift patterns, workload or lack of resources

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