Full text of DOI:10.1046/j.1365-2850.2000.00359.x

Journal of Psychiatric and Mental Health Nursing, 2000, 7, 529–537
Stressors, moderators and stress outcomes: findings from the All-
Wales Community Mental Health Nurse Study
D. EDWARDS1 mphil bsc(hons), P. BURNARD2 phd msc rmn rgn rnt dipn certed, D. COYLE3
med rmn rnld certed(fe), A. FOTHERGILL3 phd bsc(hons) pgce rmn rgn & B. HANNIGAN3
ma ba(hons) rmn rgn dpsn(cpn)
1Lead Researcher, 2Professor and Vice Dean and 3Lecturer, School of Nursing & Midwifery Studies, University of
Wales College of Medicine, Heath Park, Cardiff, CF14 4XN, Wales, UK
Correspondence:
D. Edwards
EDWARDS D., BURNARD P., COYLE D., FOTHERGILL A. & HANNIGAN B. (2000)
Journal of Psychiatric and Mental Health Nursing 7, 529–537
Stressors, moderators and stress outcomes: findings from the All-Wales
Community Mental Health Nursing Study
School of Nursing and
Midwifery Studies
University of Wales College
of Medicine
The All-Wales Community Mental Health Nurse Stress Study was the largest study under-
taken in the UK to date to investigate stress, burnout and coping amongst the CMHN
workforce. The aim of the study was to examine the variety, frequency and severity of stres-
sors, to describe coping strategies used to reduce work-based stress, and to determine stress
outcomes. Questionnaires were sent out to 614 CMHNs from ten NHS Trusts throughout
Wales. The response rate was 49% (n = 301). The measures used included the Maslach
Human Services Survey, the CPN Stress Questionnaire, the Psychnurse Methods of Coping
Questionnaire, the Rosenberg Self-Esteem Scale and the General Health Questionnaire
GHQ-12. Community mental health nurses indicated that trying to maintain a good quality
service in the midst of long waiting lists, poor resources, and having too many interrup-
tions while trying to work in the office were particularly stressful items. The coping strat-
egies that CMHNs utilized the most were having a stable home life and looking forward
to going home at the end of the day, having outside interests and hobbies and talking to
people that they got on well with. Forty per cent of CMHNs tended to view themselves
negatively, feeling that others did not hold much respect for them. The GHQ-12 measure
indicated that 35% of CMHNs had crossed a threshold of psychiatric caseness. Measured
against a normative sample of mental health workers, 51% of CMHNs were experiencing
high levels of long-term emotional exhaustion. Twenty-four per cent were suffering from
high levels of depersonalization burnout and were not relating well to clients, whilst 14%
were experiencing severe long-term feelings of lack of personal accomplishment. The results
from the study provided us with a picture of stress and coping in CMHNs in Wales.
Addressing these factors may help to reduce levels of experienced stress and burnout.
Heath Park
Cardiff
CF14 4XN
Wales
UK
Keywords: burnout, community mental health nurses, coping strategies, occupational stress
Accepted for publication: 7 August 2000
ing a range of agencies and professions. In 1996, in the
most recent quinquennial community mental health
Introduction
In the mental health field, care is increasingly being pro-
vided in community settings involving workers represent-
nursing survey, the total community mental health nursing
workforce in England and Wales was estimated at just
© 2000 Blackwell Science Ltd
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P. Burnard et al.
under 7000 (Brooker & White 1997). Community mental
health nurses (CMHNs) play a key role in providing and
co-ordinating a variety of services to people experiencing
mental health problems, including those suffering from
severe and enduring mental illness, such as schizophrenia.
In recent years there has been much concern over the job-
related satisfactions and difficulties of mental health nurses
working in the community setting (Kipping & Hickey
1998). Increasing workloads, increasing administration and
lack of resources have been indicated as sources of increas-
ing stress and burnout for health professionals working as
part of community mental health teams (Edwards et al.
2000). It has been suggested that this is particularly true for
CMHNs (Brown et al. 1994). There is a growing body of
evidence that indicates that many CMHNs experience stress
and burnout (For example, Parahoo 1991, Schafer 1992,
Carson et al. 1995, Fagin et al. 1995, McLeod 1997, Parry-
Jones et al. 1998, Snelgrove 1998, Drake & Brumblecombe
1999). The consequences of stress and burnout in the work-
place impact both on the individual and the organization.
This affects not only the level of performance and success
of interventions of mental health workers, but also job
satisfaction and ultimately their own mental and physical
health (Carson & Fagin 1996). From the literature, poor
quality work, taking longer over tasks, and making more
errors are some of the behavioural signs ascribed to
stress, together with increased smoking, increased alcohol
consumption and absenteeism. Other signs are cognitive
changes, especially with regard to poor memory and
concentration and impaired decision-making skills (Cooper
1984, Duckworth 1986).
self-esteem, mastery, personal control, emotional stability
and physiological release mechanisms to the model. The
final factor in the model is stress outcomes. Those staff with
poor stress outcomes will experience psychological ill-
health, low job satisfaction, and burnout (Fagin et al. 1996).
Whilst there are similarities in the organization and
focus of mental health services in England and Wales, dif-
ferences also exist. Key documents produced by the Welsh
Office emphasize the community focus of mental health
care (Welsh Office 1996). There has, however, been no
formal adoption of the care programme approach (CPA)
in Wales, while in England it is now the cornerstone of
mental health care (DoH 1995).
The environment within which Welsh CMHNs work is
therefore distinct from the environment within which their
English counterparts work. In England, previous research,
beginning with the Claybury stress study, has established
that many CMHNs experience considerable stress (Carson
et al. 1995, Fagin et al. 1995, Leary et al. 1995). The only
survey conducted in Wales to date is the Mental Health
Care survey, which indicated that mental health nurses in
Wales had higher levels of stress than nurses surveyed
in England (excluding London) (Carson et al. 1997).
However, only 24% of CMHNs responded to the ques-
tionnaire, limiting generalizability of these findings.
The overall aim of the all-Wales stress study was to repli-
cate the work of the Claybury stress survey, using the
total population of CMHNs working in Wales. The spe-
cific objectives were: to examine the variety, frequency, and
severity of stressors amongst CMHNs working in Wales;
to describe coping strategies used by CMHNs to reduce
work based stress; and to determine stress outcomes. The
All-Wales Community Mental Health Nurse Stress Study
was the largest single UK survey undertaken to date that
used a number of validated instruments to survey the total
CMHN workforce in Wales in relation to stress, burnout
and coping. This paper will present an overview of all
the findings from the all-Wales stress study. More detailed
discussion on each of the scales and the demographic
questionnaire will be reported elsewhere.
Carson et al. (1997) have reported that studies which
attempt to identify the specific occupational stressors con-
fronting mental health nurses should also try to locate
these stressors within an empirically derived, field-tested
model of the stress process.
Duquette and colleagues, in a three-tier model of
burnout, suggest that burnout is the end result of organi-
zational stressors not adequately buffered by the key
moderators of hardiness, social support and coping skills
(Duquette et al. 1994).
Carson & Kuipers (1998) have proposed a similar model
of the stress process, which incorporates the idea of stres-
sors, moderators, and stress outcomes. Stressors are seen as
arising from three main sources: those relating to one’s occu-
pation, major life events and hassles, and uplifts. The criti-
cal factor in the model the mediating or buffering factors
which individuals can call upon to help them. These stres-
sors will only lead to negative stress outcomes if the indi-
vidual has insufficient resources to manage them. Carson &
Kuipers (1998) propose a greater number of factors at this
level than Duquette et al. (1994), and have further added
Method
Three hundred and one qualified CMHNs from ten NHS
Trusts in Wales returned questionnaires. This represented
a 49% response rate. The following research measure-
ments were included in a questionnaire booklet:
Welsh CMHN Stress Study Demographic
Questionnaire
This was a 19-item measure covering issues such as case-
load size, client group, and team location. It also included
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Community mental health nurse stress study
Table 1a
Characteristics of the sample
Variable
n1
Mean
SD
Minimum
Maximum
Caseload size
Age
Hours per week
Number of months in current position
Number of years in field
Days off sick in past year
293
291
296
292
293
299
37.9
40.4
36.4
78.5
16.9
9
16.7
7.2
4.5
67.5
7.6
17.2
3
23
18.35
1
1
0
110
63
50
300
40
120
1n refers to the number of respondents supplying the relevant information.
open-ended questions on stress and coping. This was
devised especially for the study.
a total score for each subscale and a categorical rating as
high, moderate or low burnout. The subscales are emo-
tional exhaustion, depersonalization, and personal accom-
plishment (Maslach et al. 1996).
Maslach Human Services Demographic Data Sheet
This is a 15-item measure covering issues such as gender,
age, martial status, and experience, and was used in con-
junction with the Maslach Burnout Inventory (Maslach et
al. 1996).
CMHN Stress Questionnaire (Revised) This is a 48-item
questionnaire which subjects were asked to score on a 5-
point scale, from 0, ‘this item causes me no stress’, to 4,
‘this causes me extreme stress’ (Brown et al. 1995).
Results
Not all the respondents answered all the items on each
measure. Where this was the case the subjects were
excluded from the analysis for that particular measure. The
characteristics of the sample as determined by the demo-
graphic questionnaire are presented in Tables 1a and 1b.
The majority of CMHNs were grades E (27%), F (13%)
and G (49%). Further investigation of client group
revealed that of those who worked with a specific client
group, 66 (34%) worked with the elderly, and 94 (49%)
worked with severe mental illness and rehabilitation. The
findings from the individual scales are presented in the next
section.
PsychNurse Methods of Coping Questionnaire
This is a 35-item questionnaire on which subjects were
asked to score on a 5-point scale the extent to which strat-
egies are used to deal with stress, from 1, ‘never’, to 5, ‘all
the time’. This coping indicator provides information on
six types of coping strategy. These are diverting one’s atten-
tion away from work, self-regulation and self-attitude,
social support at work, positive attitude towards one’s role
at work, and emotional comfort (McElfatrick et al. 2000).
CPN Stress Questionnaire (Revised)
The average CPN Stress score was 65.1 (SD 28.8, range
13–144). The results from all 48 items on the completed
CPN Stress Questionnaire were analysed by ranking the
overall average value of the Likert (0–4) score for each
item. Brown & Leary (1995) employed this method of
ranking. Rankings of the ten most stressful and least stress-
ful item are presented in Tables 2 and 3, respectively.
Rosenberg Self-Esteem Scale
The modified version of Rosenberg’s (1965) scale was used
(Wycherley 1987). Scores vary between 10 and 40, and low
scores indicate better self-esteem.
General Health Questionnaire GHQ-12
Rosenberg Self-Esteem Questionnaire
The GHQ-12 is a scale that measures psychological dis-
tress. Two scores are obtained. These are firstly, the total
GHQ score, which ranges from 0 to 12 when using a
binary coding method (Goldberg & Williams 1988), and
secondly, a ‘caseness’ score. A rating of caseness is made
on scores of 2 or more on this version.
The average score for CMHNs was 18.8 (SD 4.7, range
10–33). The interpretation of the modified Rosenberg
scores is recorded in Table 4.
Coping strategies
Ninety-three per cent of CMHNs felt that they could
discuss their work-related problems with their work col-
leagues, and this was a means of alleviating work-related
stress. In reply to the question ‘how would you describe
Maslach Burnout Inventory
This is a human services burnout measure comprising three
subscales, for which two types of scores can be obtained,
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 529–537
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P. Burnard et al.
Table 1b
Characteristics of the sample
the attitude of your line manager toward you?’, 86% of
CMHNs considered that their line managers supported
them. Table 5 gives the average scores for CMHNs on the
five subscales of the coping strategies measure.
The results from all 35 items on the completed Psych-
nurse Methods of Coping Questionnaire were analysed
by ranking the overall average value of the Likert (1–5)
score for each item. Rankings of the ten most and least
used coping methods are presented in Tables 6 and 7,
respectively.
Variable
n
%
Position
Staff member
Supervisor/Manager
Smoking
Yes
No
Alcohol
Yes
223
72
76
24
95
205
68
32
252
46
15
84
No
Geographical location
Urban
Rural
Mixed
150
134
13
50
45
4
General Health Questionnaire GHQ-12
Specialist course
Yes
No
Job security
Yes
No
The average GHQ-12 score was 2.6 (SD 3.4, range 0–12).
Thirty-five per cent of the CMHNs in the sample crossed
the threshold of ‘psychiatric caseness’ on the GHQ, scoring
2 or above.
121
177
41
59
237
59
80
20
The mean scores for this measure were significantly
higher for those who smoked, those who felt that they
did not have job security, and those who were divorced,
widowed or separated. These results are presented in
Table 8.
There was a significant positive correlation between
GHQ-12 scores and the MBI emotional exhaustion sub-
scale (r = 0.497, P < 0.01), the MBI depersonalization
Gender
Male
Female
Marital status
Single
Married/Living with partner
Divorced/widowed/separated
Client group
Specific
Mixed
112
185
38
62
27
231
32
9
78
11
187
114
62
38
Table 2
Rankings from the CPN Stress Questionnaire: the ten most stressful items
Rank
Item
Mean stress score (range 0–4)
1
2
3
4
Not having facilities in the community that I can refer my clients on to
Trying to keep up good quality care in my work
Having too many interruptions when I am trying to work in the office
Knowing that there are likely to be long waiting lists before my clients can get
access to services, e.g. to see a psychologist
2.20
2.02
2.00
1.94
5
6
7
8
9
Having to keep detailed records/notes on clients
Having to visit unsafe areas
Feeling that other people expect too much from me as a CPN
Not being informed of treatment affecting my client, e.g. changes in medication
Having to deal with suicidal clients on my own
1.89
1.79
1.76
1.73
1.73
1.72
10
Feeling that there is not sufficient hospital back-up
Table 3
Rankings from the CPN Stress Questionnaire: the ten least stressful items
Rank
Item
Mean stress score (range 0–4)
1
2
3
4
5
6
Not feeling that I can rely on the support of my CPN colleagues
Having to carry drugs around
0.50
0.63
0.65
0.70
0.79
0.79
Feeling that there is a communication problem with my colleagues
Having to receive supervision that I do not find helpful
Having to obtain a suitable caseload/experience for students
Having problems getting to some client’s homes, e.g. having to go into big
housing estates
7
8
9
Feeling that the management style within our department is inflexible
Having to drive a lot in the course of a week
Feeling that other people underestimate my skills as a CPN
Having to put up with interruptions when seeing clients at home
0.94
0.96
0.99
0.99
10
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Community mental health nurse stress study
Table 4
Interpretation of Rosenberg Self-Esteem scores
Score
Interpretation
n
%
10–13
14–16
17–20
21–25
You see yourself very positively, as a competent and valuable person
You generally have a positive view of yourself
You have an average, fairly balanced view of yourself as having both good and bad points
You tend to be somewhat negative and self-critical
49
45
86
104
14
16
15
29
35
5
Above 25
You generally see yourself very negatively, as less valuable and competent than others
Table 5
Mean scores for coping strategies from the Psychnurse Method of Coping Questionnaire
Coping strategy
Mean
SD
5.7
3.4
2.8
4.1
5.0
Minimum
Maximum
Diverting one’s attention away from work
Self-regulation and self-attitude
Emotional comfort
Social support at work
Positive attitude towards one’s role at work
Psychnurse overall score
35
22
19
20
32
16
12
10
10
16
76
70
30
25
30
14
128
16.5
169
n = 299, as data was unavailable for two cases.
Table 6
The ten most-used coping items, as rated by the Psychnurse Coping Questionnaire
Rank
Item
Mean coping score (range 0–4)
1
2
3
4
5
6
7
8
9
Having a stable home life that is kept separate from my work life
Knowing that my life outside work is healthy, enjoyable and worthwhile
Talking to people I get on well with
Looking forward to going home at the end of each day
Having pastimes and hobbies outside of work
Being able to draw upon my own knowledge and experience when necessary
Discussing problems with colleagues as they arise at work
Having a steady partner to turn to
Detaching myself from work matters when necessary
Taking a mature view of the situation
4.35
4.17
4.15
4.15
4.14
4.13
3.93
3.93
3.88
3.84
10
Table 7
The ten least-used coping items, as rated by the Psychnurse Coping Questionnaire
Rank
Item
Mean coping score (range 0–4)
1
2
3
4
5
6
7
8
9
Having team supervision
2.81
3.07
3.19
3.21
3.28
3.30
3.38
3.49
3.53
3.53
Having confidential ‘one-to-one’ supervision
Reminding myself that others have placed their trust in me
Having a satisfying sex life
Having support from my line manager
Reminding myself that the work I do is being appreciated
Finding out how others have coped in the same situation
Having a good, positive atmosphere around me at work
Managing my time efficiently
10
Sleeping restfully
subscale (r = 0.233, P < 0.01) and the total Rosenberg
Self-Esteem score (r = 0.454, P < 0.01).
Maslach Burnout Inventory
There was a significant negative relationship between
the GHQ-12 scores and the total Psychnurse Methods
of Coping Questionnaire (r = –0.315, P < 0.01) and the
personal accomplishment subscale (r = -0.369, P <
0.01).
Two hundred and eighty-three CMHNs completed the 22-
item Maslach Burnout Inventory (MBI). Respondents were
asked to rate items such as ‘I feel emotionally drained from
my work’ on a scale of 0, ‘never’, to 6, ‘everyday’. From
these frequencies, mean scores were obtained for each of
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 529–537
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P. Burnard et al.
Table 8
Significant results of t-tests for the General Health Questionnaire and demographic variables
95% CL
Lower
0.15
Variable
n
Mean
SD
t
d.f.
256
Upper
2.62
P
Marital status
2.21
0.028
Divorced/widowed/separated
Married/with partner
32
226
3.8
2.4
3.3
3.7
Job security
No
Yes
Smoker
Yes
No
2.17
2.08
287
291
0.0098
0.0047
2.05
1.70
0.031
0.039
57
232
3.5
2.4
3.7
3.3
92
201
3.2
2.3
3.6
3.2
Table 9
Data on the subscales of the Maslach Burnout Inventory
MBI subscale (range)
n
Mean
SD
Minimum
Maximum
Emotional exhaustion (0–78)
Depersonalization (0–96)
Personal accomplishment (0–84)
283
283
283
21.2
5.2
34.8
10.3
4.5
6.5
0
5
1
24
48
48
Table 10
Categorization of MBI scores
Low burnout
Average burnout
High burnout
MBI subscale
n
%
n
%
n
%
Emotional exhaustion (EE)
Depersonalization (DP)
Personal accomplishment (PA)
68
162
166
24
57
59
70
51
77
25
18
27
145
70
40
51
25
14
EE: Low (13, average 14–20, high ≥ 21); DP: low (4, average 5–7, high ≥ 8); PA: low ≥ 34, average 33–39, high (28).
the three subscales. For the emotional exhaustion and
depersonalization subscales, high mean scores reflect high
levels of burnout, whilst for the personal accomplishment
subscale, low scores reflect high levels of burnout. Data
relating to mean scores on these subscales of the MBI are
presented in Table 9. These mean subscale scores were
compared with normative scores for the corresponding
subscales for the ‘mental health’ occupational subgroup
contained within the current edition of the Maslach
Burnout Inventory Manual (Maslach et al. 1996). On the
basis of this comparison, respondents were allocated to a
‘high burnout’, ‘average burnout’ or ‘low burnout’ cat-
egory for each of the three subscales. Data relating to
the categorization of MBI scores into ‘high’, ‘average’ and
‘low’ for each of the three subscales are presented in Table
10.
experiencing high levels of stress. As well as indicating the
severity of stress experienced, the responses from the CPN
stress questionnaire can be utilized to determine the nature
of particular stressors. This measure revealed that organi-
zational factors, as opposed to negative patient character-
istics, were major sources of stress for CMHNs in Wales,
UK. Community mental health nurses indicated that trying
to maintain a good quality service in the midst of long
waiting lists and poor resources, and having too many
interruptions while trying to work in the office, were par-
ticular stressful items. Parry-Jones et al. (1998), in a small
study of social workers, community nurses and CMHNs
in Wales, found that since the implementation of the
NHS and Community Care Act 1990, levels of stress had
increased, and levels of job satisfaction had decreased. The
heart of the problem was revealed to be increased work-
load and administrative duties combined with reduced time
for service-user and family contact. It is clear from the
literature that CMHNs in Wales are not alone with these
problems. These findings are similar to those found in the
Claybury Study (Brown & Leary 1995), and in studies on
forensic community mental health nurses (Coffey 1999),
ward based psychiatric nurses (Cronin-Stubbs & Brophy
Discussion
The stress model outlined by Carson & Kuipers (1998)
underpinned this study. This model comprises three tiers:
stressors, moderators and stress outcomes. The results of
the CPN stress questionnaire indicate that CMHNs are
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Community mental health nurse stress study
1985, Dawkins et al. 1995, Jones 1987), and general
nurses (McGrath et al. 1989).
Just over one in three CMHNs have crossed the thresh-
old of ‘psychiatric caseness’. It is difficult to make com-
parisons with other studies on this measure because of
the range of different scoring methods used. This study
adopted the simplest approach to scoring, as described in
the GHQ-12 handbook, in order to avoid ‘middle users’.
A number of studies have utilized the simple Likert scoring
method with cut points of 3–4 (Fielding & Weaver 1994)
and 4–5 (Snelgrove 1998, Prosser et al. 1996). The mean
scores for these studies ranged from 9.7 to 11.8 (possible
range 0–24). However, for studies that have utilized
the GHQ-28 scoring method (Schafer 1992, Fagin et al.
1995, Oliver & Kuipers 1996, McLeod 1997, Drake &
Brumblecombe 1999), 20–44% of CMHNs were identified
as ‘cases’, i.e. describing symptoms which would be classi-
fied as mild psychiatric morbidity. McGrath et al. (1989),
in a sample of nurses in Northern Ireland found that
the GHQ-12 and the GHQ-28 revealed similar findings,
with 23% (GHQ-12) and 27% (GHQ-28) of nurses being
classed as cases.
Community mental health nurses with poor stress
outcomes (high GHQ-12 scores) are more likely to be
divorced, widowed or separated, to smoke, and to feel
insecure in their present job. These CMHNs are also more
likely to have higher burnout scores on all subscales of the
Maslach Burnout Inventory, have lower self-esteem, and
make poor use of coping strategies that are available to
them.
The long-term emotional effects of stress can be demon-
strated for CMHNs in that one in two were experiencing
high levels of the long-term effects of emotional exhaus-
tion. One fifth of CMHNs felt that they did not relate well
to their clients and just over one in ten CMHNs felt dis-
satisfied with their work and had no sense of personal
achievement, as indicated by the MBI depersonalization
and personal accomplishment subscales.
It appeared that CMHNs in the all-Wales stress study
were frustrated because in their opinion patients were not
receiving the best quality care, due to lack of facilities and
long waiting lists. This is supported by the work of Kipping
& Hickey (1998), who identified large caseloads as a factor
that CMHNs felt inhibited care provision. This limited the
time available for each individual patient.
The critical factor in the model is the mediating
or buffering factors which individuals can call upon to
help them. Potential stressors will only lead to negative
stress outcomes if the individual has insufficient resources
(coping strategies) to manage them. Carson & Kuipers
(1998) proposed self-esteem to be an important moderat-
ing factor in their model. In the present study it was found
that the CMHNs had healthy self-esteem. The average
score from the Rosenberg Self-Esteem Scale indicated that,
at the time of the study, the CMHNs had a fairly well
balanced view of self, encompassing both good and bad
points. This finding, however, is masked by the fact that
40% of the sample were experiencing low self-esteem, in
that they tended to view themselves negatively, feeling that
others did not hold much respect for them. This is a
concerning finding and will be explored in more depth in
a separate paper.
The rankings from the Psychnurse Stress Questionnaire
on different methods of coping indicated that CMHNs
favoured informal approaches to cope with work-based
stress. Having a stable home life, looking forward to going
home at the end of the day, having outside interests and
hobbies, and talking to people that they got on well with
were some of the top ranking items. Only a small number
favoured supervision (group or one-to-one basis) or having
support from their line manger. However, the Psychnurse
instrument does not have the ability to distinguish between
those who did not receive supervision and those who did
not use it as a coping strategy. This issue will be addressed
by further qualitative research, to be undertaken in the
second phase of this study.
The study revealed that nurses appear to value the pres-
ence of their colleagues in terms of the support they derive
from proximity, but that this proximity can, however, bring
with it practical problems in day-to-day working. This
is consistent with findings from previous studies (Coffey
1999).
Conclusions
Overall, we conclude that CMHNs in Wales are experi-
encing high levels of stress. The GHQ-12 measure indi-
cated that 35% of CMHNs had crossed a threshold of
so-called psychiatric caseness. Measured against a norma-
tive sample of mental health workers, 51% of CMHNs
were experiencing high levels of long-term emotional
exhaustion. Twenty-four per cent were suffering from high
levels of depersonalization burnout and not relating well
to clients, whilst 14% were experiencing severe long-term
feelings of a lack of personal accomplishment.
The final factor in the model is stress outcomes, and
individuals will experience either good or poor stress out-
comes depending on the effectiveness of the moderating
factors. The results from the GHQ-12 and the Maslach
Burnout Inventory can be utilized to determine stress
outcomes.
It appears from the findings of this study that a range of
factors such as organizational pressures, and factors relat-
ing to working with patients, are important in determin-
© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 529–537
535

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reduce levels of experienced stress and burnout. The
authors plan to conduct further research into the area of
stress management interventions, and their effectiveness in
relation to mental health professionals.
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Acknowledgments
The authors acknowledge, gratefully, 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 permission
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.
Fagin L., Carson J., Leary J., De Villiers N., Bartlett H.,
O’Malley P., West M., McElfatrick S. & Brown D. (1996)
Stress, coping and burnout in mental health nurses: findings
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