Full text of DOI:10.1046/j.1365-2850.2000.00351.x

Journal of Psychiatric and Mental Health Nursing, 2000, 7, 523–528
Community mental health nurses in Wales: self-reported stressors
and coping strategies
1
2
P. BURNARD phd msc rmn rgn rnt dipn certed, D. EDWARDS mphil bsc(hons),
3
3
A. FOTHERGILL phd bsc(hons) pgce rmn rgn, B. HANNIGAN ma ba(hons) rmn
rgn dpsn(cpn) & D. COYLE med rmn rnld certed(fe)
3
1
2
3
Professor and Vice Dean, Lead Researcher and Lecturer, School of Nursing & Midwifery Studies, University of
Wales College of Medicine, Heath Park, Cardiff, CF14 4XN, Wales, UK
Correspondence:
P. Burnard
Burnard P., Edwards D., Fothergill A., Hannigan B. & Coyle D. (2000) Journal of
Psychiatric and Mental Health Nursing 7, 523–528
Community mental health nurses in Wales: self-reported stressors and coping
strategies
School of Nursing and
Midwifery Studies
University of Wales College
of Medicine
There is evidence to suggest that community mental health nurses experience stress and
burnout related to their work. Previous research has been limited by a number of method-
ological problems. One of the problems is that studies have tended to have small or unrep-
resentative samples, and many researchers have only examined mental health nurses as a
subset within their research, which limits the generalizability of the findings. The All-Wales
Community Mental Health Nurse (CMHN) Stress Study was set up in order to address
this issue. The total population of CMHNs in Wales was surveyed (N = 614) and 301
Heath Park
Cardiff
CF14 4XN
Wales
UK
(49%) responded. The questionnaire booklet contained a number of validated instruments
to measure stress, burnout, and coping, together with a demographic questionnaire. The
demographic questionnaire included three open ended-questions. These questions were
asked in order in determine the CMHNs’ own views of the sources of stress in the work-
place, and to investigate which methods they use to cope. This paper reports the findings
from the content analysis of the three questions. The results from the other measures are
reported in the companion paper (Edwards et al. 2000). The most frequently cited stres-
sors included perceived workload, excessive paperwork and administration, and a broad
spectrum of client-related issues. Coping strategies that CMHNs reported using included
peer support, a range of personal strategies such as relaxation, and belief in self and super-
vision. It appears from the findings that a range of factors such as organizational pressures
and factors related to working with patients are important in determining stress levels, and
that informal rather than formal support networks are the preferred methods of coping.
Keywords: burnout, community mental health nurses, coping strategies, occupational stress
Accepted for publication: 14 July 2000
Previous researchers have identified mental health nurses
and community mental health nurses (CMHNs) and
Introduction
There is evidence that community mental health nurses
experience stress and burnout related to their work
speech therapists as the professional groups with the
highest degree of stress within the helping professions
(Rees & Smith 1991). There is considerable documenta-
tion of the sources of stress and burnout within the nursing
(Parahoo 1991, Schafer 1992, Fagin et al. 1995, McLeod
1997, Snelgrove 1998, Drake & Brumblecombe 1999).
©
2000 Blackwell Science Ltd
523

P. Burnard et al.
profession (see, for example, Guppy & Gutheridge 1991,
Duquette et al. 1994). Sutherland & Cooper (1990) and
Dunn & Ritter (1995) suggest that mental health nurses
share many of the stressors that affect general nurses, but
that they also face a number of additional stressors.
A recent review of the literature on stress and burnout
amongst CMHNs identified a number of specific stressors.
These included increases in workload and administration,
time management, inappropriate referrals, safety issues,
role conflict, role ambiguity, lack of supervision, not having
enough time for personal study, NHS reforms, general
working conditions, lack of funding, and resources
Analysis
The responses to these questions were collated and sub-
jected to content analysis. This method of analysing the
data was based on one outlined by Burnard (1991), and
described as ‘thematic content analysis’. First, all of the
responses to each question were collated. Second, any rep-
etition of themes was removed from each of the data sets,
thus reducing the volume of the text. Third, responses were
clustered together under thematic headings with the aim of
each category heading being discrete. Fourth, the complete
data sets were revisited and coded using the category
system. The authors then diverged from Burnard’s method
in that the items under each category were counted. In the
tables that follow, each table identifies the number of ref-
erences to a particular category, and the categories are
rank-ordered by numbers of responses, and their percent-
age rating is recorded.
Given the nature of this form of analysis, care must
always be taken in reading such tables. The data are nominal
and the category system is, at least to some degree, subjec-
tive (although objectivity was sought for the construction
of the system through the involvement of two researchers).
However, the method does allow the researcher and the
reader to identify the regularity with which responses were
given and also identifies the range of responses. With this
in mind, then, the analysis used in this study echoes the
definition of content analysis offered by Clamp & Gough
(
Edwards et al. 2000).
It has been suggested that research on stress in mental
health nursing is limited by a number of methodological
problems. One of the problems is that studies tend to have
small or unrepresentative samples and many researchers
have only examined mental health nurses as a subset within
their research, which limits the generalizability of the find-
ings (Carson et al. 1996). Dunn & Ritter (1995) have sug-
gested that a number of studies have used their own research
instruments, which have not been tested for validity and reli-
ability, in order to measure stress and burnout. To address
some of the criticisms, the current study was planned to
survey the total population of CMHNs in Wales in the year
1998–9. The study has used a number of validated measures
and is the largest of its kind conducted to date.
(
1999):
Methods
‘
Content analysis: a procedure for analysing written or
Six hundred and fourteen qualified CMHNs from ten NHS
Trusts in Wales were surveyed. Three hundred and one
questionnaires were returned, representing a 49% response
rate.
verbal communication in a systematic and objective
fashion, typically with the goal of quantitatively meas-
uring variables’ (Clamp & Gough 1999, p. 228).
Detailed descriptions of the methodology and analysis
of the items included in the questionnaire are reported
elsewhere (Edwards et al. 2000). Briefly, the question-
naire booklet comprised a demographic questionnaire, the
General Health Questionnaire GHQ-12 (Goldberg &
Williams 1988), the Maslach Burnout Inventory (Maslach
et al. 1996), the modified Rosenberg Self-Esteem Scale
Results
Sources of most stress
First, respondents were asked to identify, generally, what
caused them most stress in their jobs as community mental
health nurses. A total of 691 stressors were identified.
Table 1 identifies the responses to this question. Workload
pressure and caseload pressure have been kept as separate
categories; a CMHN could have a ‘small’ caseload but still
feel pressured by the amount of work and time that this
entails.
(Wycherley 1987), the CPN Stress Questionnaire (Revised)
(Brown et al. 1995), and the PsychNurse Coping Ques-
tionnaire (McElfatrick et al. 2000).
This paper is concerned with the responses to the fol-
lowing three open-ended questions which were presented
in the demographic questionnaire:
•
•
What are the three things that cause you most stress?
What would you say was the most stressful thing that
has happened to you at work in the last month?
What factors do you feel help you to cope with your
job as a CMHN?
The category ‘client-related issues’ included, amongst
others, a range of factors relating to the following:
• admitting people to hospital;
•
• aggressive clients clients identified as ‘difficult’;
• assessing patients;
524
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Stress and coping strategies
Table 1
Table 2
The most stressful aspects of the job as a CMHN
Sources of stress in past month
Source of stress
n
%
Source of stress
n
%
Workload/time related issues
Paperwork and administration
Client-related issues
Case overload
Poor resources
Lack of supervision/support
Role-based issues
Interpersonal issues
Working with other disciplines
Isolation and loneliness
Changes
101
96
79
56
52
30
24
23
20
20
19
19
17
16
16
14
13
12
11
11
11
11
7
14.6
Client-centred issues – general
Client-centred issues – behavioural
Paperwork/administration
Concerns surrounding other agencies/disciplines
Changes in team/trust
Interpersonal problems – colleagues/managers
Covering illness/holiday
Volume of caseload
43
16.7
13.9
11.4
8.1
7.5
4.3
3.5
3.3
2.9
2.9
2.8
2.8
2.5
2.3
2.3
2.0
1.9
1.7
1.6
1.6
1.6
1.6
1.2
0.5
0.5
0.4
0.3
26
22
21
21
20
16
15
15
13
12
9
10.1
8.6
8.2
8.2
7.8
6.2
5.8
5.8
5.1
4.7
3.5
3.5
3.1
Issues concerning patients potential/actual suicide
Lack of resources
Time constraints
Staffing issues
Transport problems
Other
Managerial responsibilities
Planning for holidays, returning from sick
leave/maternity leave
9
8
Accountability and responsibility
Problems with relatives/carers
Meetings
Attitudes and working styles of managers
Problems with referrals
Other
Working with other agencies
Expectations of others
Education and training issues
Being undervalued
Not able to provide quality care
Job insecurity
Travel-related issues
7
2.7
Total
257
100.00
the nurses’ safety in certain home visits, coping with
disturbances in the home, and dealing with suicidal
behaviour.
The category other included a range of issues; amongst
others:
4
4
3
2
Worrying about other people’s problems
Weather
Total
691
100.0
•
•
•
presentation at a national conference;
recent change of job;
unsuccessful job interview;
• failure to get a new job;
• training assessments;
• working standby.
•
•
•
non-compliance with medication;
client self-harm;
crisis intervention.
The category other included a range of issues; amongst
others:
Coping strategies
•
•
•
•
•
•
dealing with housing and accommodation problems;
discharging vulnerable people;
ensuring up-to-date care places;
intense visits about distressing life events;
attending child care conferences;
key worker to a patient with a supervision order.
Third, respondents were asked to identify the factors
that helped them to cope with stress. Six hundred and
sixty-three factors were identified and these are reported in
Table 3.
Under the heading of ‘personal approaches’ there
were a number of personal qualities and methods identi-
fied that individuals used to cope with stress. These
included simply being able to relax, having confidence and
belief in one’s own abilities. Also included under this
heading were a sense of humour as a means of dispelling
stress, and having some sort of religious or spiritual
conviction.
The proportion of total respondents who cited more than
one of the top three stressors was 13%.
Sources of stress over time
Second, respondents were asked to record the source of
most stress over the month prior to completing the ques-
tionnaire. There were a total of 257 stressors identified.
Table 2 identifies the responses to this question.
The category ‘client-centred issues – general’ was con-
cerned with non-attendance, difficulties with referrals
and non-compliance with medication. The category
Discussion
The sources of stress can be divided into two broad cate-
gories: those which are related to the demands of working
with patients, and those related to other aspects of the
work. A picture seems to emerge of community mental
‘client-centred issues – behavioural’ included items such as
concerns about safety of clients, feelings of concern about
©
2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 523–528
525

P. Burnard et al.
Table 3
Stress coping strategies
vary the allocation of clients in that way, particularly in
large rural areas.
Coping strategy
n
%
When CMHNs were asked to state what had caused the
most stress in the previous month, it was difficulties arising
from relationships with clients that came out as the main
source of stress. Coffey (1999) also identified managing
difficult patients as the main cause of stress for forensic
CMHNs.
Support (colleagues/managers/other
disciplines/other agencies)
Personal approaches
Supervision
Interests and hobbies outside of work
Role as a CMHN
285
42.9
74
66
48
40
32
25
21
19
18
7
11.2
9.9
7.2
6.0
4.8
3.8
3.2
2.9
2.7
1.1
0.9
0.8
0.8
0.6
0.5
0.4
0.3
Happy home life
Good administration and organizational skills
Experience (age/maturity)
Education and training issues
Ability to switch off at the end of the day
Being able to take time out
Good knowledge of clients/area
Working part time
Good working environment
Caseload issues
Flexibility
Notable, in this section, was the reference to client
aggression. Whittington & Wykes (1992) report a series of
studies of violence amongst inpatients in a mental hospi-
tal. They found that apparently minor episodes of violence
could trigger periods of absence from work. They also
noted that social support was a strong moderator of the
adverse affects of violence. We report that respondents in
the present study often relied on such social support as a
means of moderating stress. In another study, Rix (1987)
explored the relationship between staff sickness and client
violence in a regional secure unit. He found that violence
was associated with feelings of vulnerability and frustra-
tion in nurses who also went off sick. Levels of absenteeism
in Rix’s (1987) study were moderated by complex organi-
zational and dispositional factors amongst the nurses.
Again, we report similar, although slightly different, find-
ings. It should also be noted that the findings reported by
Whittington & Wykes (1992) and Rix (1987) were from
studies carried out in inpatient settings.
Models of the stress process inform us those individual
characteristics of personality, demographic factors and the
use of various coping strategies (Cooper & Baglioni 1988,
Cooper et al. 1988) moderate the experience of stress. The
coping strategies that CMHNs reported using included
peer support, personal approaches (which included activ-
ities such as relaxation and belief in one’s own abilities),
good communication skills and receiving clinical supervi-
sion. Peer support included support from colleagues, man-
agers, other disciplines and other agencies (42% of all
strategies cited). Respondents were often complimentary
about the support they received from their managers and
colleagues but, also, having a ‘satisfactory and supportive
life outside of the job’ was often identified as a strategy for
coping with stress.
6
5
5
4
3
3
2
Financial advancement
Looking for other jobs
Total
663
100.00
health nurses who perceive themselves to be overworked,
struggling with considerable paperwork and administrative
issues, having both too many clients and serious concerns
about their client group.
The results from this study concur with the findings from
the Claybury stress study (Carson et al. 1995). Here the
authors found that caseload, paperwork/administration
and management problems were the most stressful aspects
of the job as a CMHN. Reid et al. (1999) have demon-
strated such stressors to be common to all mental health
staff, but that community staff appear to have extensive
scope for autonomous work, and feel that they are
expected to take on considerable responsibility.
One suggestion to help CMHNs with their work over-
load would be to reduce the size of their caseloads. In order
to implement care in the community effectively, Wattereus
et al. (1994) recommends that individual caseloads must
be of a manageable size, i.e. 15–20 patients (Intagliata
1992). If this is exceeded, Wattereus (1994) stresses that
there will be less time available for each patient, visits
become less frequent and the nurses become reactive rather
than proactive. However, research has shown that reduc-
ing the size of caseloads is not necessarily the answer to
reducing stress in staff; Holloway et al. (1996) recommend
that it might be helpful for staff to have more balanced
caseloads, consisting of people experiencing a mixture of
severe and less severe problems, and the facility to be able
to share the responsibility for the more difficult and wor-
rying clients. On the other hand, it may not be practical to
Being supervised was sometimes quoted a source of
de-stressing. Other coping mechanisms included having
interests away from work and a ‘happy home life’; having
good administrative and organizational skills, having had
experience of life through age and maturity and education
and further training.
Nurses tended to favour informal approaches to coping
with occupational stressors; only a small number of
CMHNs favoured clinical supervision. This finding is sup-
526
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 523–528

Stress and coping strategies
ported by findings from previous research (Trygstad 1986,
Sullivan 1993, Carson et al. 1995, Kipping & Hickey
the category system was developed and checked by two of
the researchers.
1998, Coffey 1999). The most favoured coping strategy
found in all of these studies were support from colleagues,
managers or other professionals. This support from col-
leagues refers to the day-to-day contact with other
members of the team and the ability to have impromptu
meetings to discuss difficult clients. Coffey (1999) suggests
that it is often easier to access the support of colleagues in
the office than by using more formal routes such as clini-
cal supervision. Several studies have suggested an associa-
tion between support from colleagues and increased levels
of satisfaction (Pines & Maslach 1977) and reduced ‘levels
of burnout’ (Corrigan et al. 1995).
Conclusions and recommendations
The effects on individuals of stress and inadequate methods
of coping may be problems of mental or physical health
and a reduction in job satisfaction. For the organization,
the effects of stress may be many, including high absen-
teeism, poor job performance and reduced efficiency and
effectiveness, low staff morale and high staff turnover
(Rees & Cooper 1990).
It appears from the findings that a range of factors such
as organizational pressures and factors related to working
with patients are important in determining stress levels,
and that informal rather than formal support networks are
the preferred methods of coping.
The apparent preference for informal rather than formal
support networks is an issue that warrants further inves-
tigation. While informal supervision has been identified
as being generally important in mental health nursing
One of the perceived benefits of clinical supervision is
the reduction of stress levels (Bishop 1998).
Clinical supervision might be an effective support
system in helping nurses process the many challenges
they encounter in clinical practice. The benefits of clinical
supervision have been described through out the literature.
Butterworth et al. (1998) identified that clinical super-
vision could lead to increased feelings of support and
personal wellbeing and higher staff morale and satisfac-
tion, leading to a decrease in staff sickness/absence. Clini-
cal supervision has also be identified with increased
confidence and decreased incidence of emotional strain and
burnout (Hallberg & Norberg 1993). Berg et al. (1994)
found that the introduction of clinical supervision, which
focused on the work itself, led to improvements in
creativity and reduction in burnout among nurses.
(Butterworth et al. 1998), it has not been so readily identi-
fied as a coping device in the community mental health
nursing literature. Thus, it may be useful to explore the ways
in which CMHNs make best use of these informal networks.
The current research team has planned an in-depth
qualitative study of a sample of the total population
described in this paper. It is hoped that such a study will
allow a more in-depth view of how CMHNs in Wales orga-
nize their work and manage their stress.
The reasons why clinical supervision was not favoured
in the present study therefore need further investigation,
and a series of interviews are planned to investigate this
topic in greater depth. Bishop (1998) suggests that there
are many problems in setting up clinical supervision,
including increasing workloads and time shortages. The
most common reason for difficulties in getting clinical
supervision up and running in her study was shortage of
time. This was mainly attributed to staff shortages and
increased activities in contracts.
Acknowledgments
The authors gratefully acknowledge the support of the
General Nursing Council for England and Wales Trust,
who provided the grant which enabled this project to take
place; Jerome Carson, Senior Lecturer, Institute of Psy-
chiatry, London, who acted as consultant to the study;
and the estate of the late Dr Morris Rosenberg, for per-
mission to use the Rosenberg Self-Esteem Questionnaire.
The authors wish to thank all the community mental health
nurses who participated in the study, and the individuals
in each NHS Trust who assisted the research team in
gaining access.
Limitations of the study
Although this study involved a total population of
CMHNs in Wales, the return rate was only 49%. However,
Oppenheim (1992) claims this to be a reasonable response
to a postal questionnaire.
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