Burning bright: Psychiatric
nurses feel burden of care
"I've experienced loss of interest in the work, a feeling of apathy
and exhaustion: of not knowing what to do or how to change things, and
not being heard or understood no matter how hard I try."
"I felt I was reacting to patients more, and personalizing more;
becoming more negative toward the behaviour. I lost sight of the illness
affecting patient behaviour because I was tired."
While many psychiatric nurses find their work rewarding, others, like
the two Toronto nurses quoted above, are seriously affected by the stresses
associated with caring for people with mental illness. The work of these
two nurses centres around containing the fear, anger and disbelief that
often accompany mental illness. They chose psychiatric nursing over other
specialities because they welcomed the close interaction -- the observing,
listening and talking -- that the job brings. But they are candid about
the physical and emotional costs that may come with working in the mental
health field.
A large body of research on stress in nursing shows that nurses in general
are susceptible to stress and to a syndrome commonly known as occupational
"burnout." A 2001 study led by Dr. Linda Aiken, director of
the Center for Health Services and Policy Research at the University of
Pennsylvania School of Nursing, found that 36 per cent of Canadian nurses
reported having experienced symptoms of burnout -- the same percentage
recorded in England and slightly lower than in the United States. Seventeen
per cent of Canadian nurses said they intend to leave the profession within
a year, and 57 per cent said they do not receive enough institutional
support.
This research points to high levels of stress, a precursor to burnout,
among nurses. Three key components of burnout identified by researchers
are emotional exhaustion, depersonalization and reduced personal accomplishment.
In lay terms, this means feeling stressed or depressed, experiencing an
inability to empathize with clients and exhibiting lower general job performance.
Emotional exhaustion is the most significant defining characteristic of
burnout, and studies have shown that it remains constant in people who
are burned out, even in the absence of the other two factors. Linda Nasato,
a nurse at the William Osler Health Centre's Mental Health Clinic in Brampton,
Ontario, describes burnout as "a chronic, pessimistic attitude and
jaded thinking. Not giving the job one hundred per cent."
Burnout exacts a price at many levels. It leads to suffering, not only
among nurses, but also among clients and their families, who feel the
consequences of nurse attrition or poorer client care. In fact, an Academy
of Health Services Research and Health Policy study found that: "The
same work environment characteristics that explain higher nurse satisfaction
in Ontario hospitals also result in higher patient satisfaction."
Absenteeism is also a substantial problem: The Canadian Labour and Business
Centre reports that in any given week, 7.4 per cent of all registered
nurses are absent from work because of injury, illness, burnout or disability
-- a rate that is 80 per cent higher than the Canadian average. It also
reports that absenteeism among psy- chiatric nurses is higher than for
other specialities, though exact statistics are not yet available.
Burnout undoubtedly affects health care organizations and the nursing
profession itself. According to research carried out by the Canadian Policy
Research Networks, health professionals are the least likely of all workers
to rate their work environment as healthy. Only 15.5 per cent of health
care workers strongly agreed that their job allowed them to balance work
and family or personal life.
Workload is a significant contributor to burnout. Nurses' workload is
going up, because numbers of staff positions are going down. According
to the Canadian Institute for Health Information, in 1980, the ratio of
nurses per head in the general population was 1: 109. In 2001, the ratio
had gone down to 1:135. Various recent studies and policy documents note
that downsizing and layoffs, leading to this lower nurse-client ratio,
have adversely affected nurses' own assessments of the quality of their
working life and have also led to decreased levels of client care. Forty-four
per cent of Canadian nurses polled in Aiken's study reported not having
had enough time to "comfort patients" during their last shift,
and 47 per cent reported not having had the time to plan client care.
Dr. Judith Shamian, executive director of Nursing Policy for Health Canada,
says that these are real factors in causing burnout. She notices a "growing
recognition that the gap between effort and reward leads to ill health."
"Nurses are treated as a "stop/go" commodity," says
Doris Grinspun, executive director of the Registered Nurses Association
of Ontario (RNAO). They are expected to work overtime or frequently work
alongside agency nurses brought in to cover staffing gaps. "This
is very emotionally and professionally detrimental and a stressor that's
totally linked with burnout," says Grinspun.
While psychiatric nurses face many of the same institutional pressures
as their peers in other specialities, they experience a range of unique
challenges that, arguably, put them at even greater risk for burnout.
Dr Leonard Fagin, a consulting psychiatrist and clinical director of
the North East London Mental Health NHS Trust in the United Kingdom, says
that psychiatric nursing in the United Kingdom is becoming an increasingly
stressful occupation for three reasons. To begin, he says that inpatient
nursing has changed dramatically since the shift from institutionalizing
clients in psychiatric hospitals toward integrating people with mental
health problems into community and general hospital contexts. "Patients
are closer to home, but in the new, less geographically-isolated settings
there is more responsibility on the nurse to contain patient anxiety in
the community."
Also, with the growing awareness that clients may present with co-occurring
problems, such as a concurrent drug use and mental health problem, treatment
regimens and symptom management become more complex and outcomes less
predictable.
Lastly, Fagin feels that in the British psychiatric nursing context,
working conditions have not improved and nurses are inadequately supported.
The result? "Recruitment is going down and we have fewer nurses and
higher absenteeism," says Fagin. His work has shown that burnout
is a significant problem for psychiatric nurses in Britain.
Extrapolating Fagin's remarks to the Canadian context is a complex task,
because there are institutional, economic and social differences between
the two countries. Like Britain, Canada too shifted its focus away from
large specialist psychiatric institutions toward mainstream care, but
clear data on resulting changes to working conditions are not available.
Similarly, the impact of drug use on client numbers and behaviour is not
as clear in Canada as it has been in Britain. However, nursing advocates
say that working conditions and support levels are declining in Canada,
as they have been in Britian. This is the result of lower numbers of nurses
and higher workloads.
In addition to these broad working environment factors, psychiatric nursing
involves a host of unique stressors that nurses may experience more directly
on a daily basis.
Empathy for the client's situation is part of the job -- it lies at the
heart of what nurses do -- but it can also be dangerous. A study published
in a 1998 issue of the Journal of Advanced Nursing found that "emotional
contagion," experiencing emotions with the client, can lead to burnout.
And a study published in a 2001 issue of the same journal found that emotional
exhaustion was higher among psychiatric nurses than general nurses. Psychiatric
nurses work more closely and intensively with clients over an extended
period of time than general nurses do. The frequent, close contact with
severe illness and prolonged exposure to intense emotional suffering can
take its toll. Remaining objective in the face of client distress is a
difficult, and sometimes exhausting, balance to achieve.
Psychiatric nurses are also faced with the reality that many clients
have relatively little chance of recovery or resocialization. And uncertainty
of outcome, not knowing whether a client's health will improve, may be
discouraging. A study by Melchior et al in a 1997 issue of the Journal
of Psychiatric and Mental Health Nursing found that unrealistic expectations
among nurses about clients' potential for rehabilitation may lead to an
imbalance between efforts and rewards. And seeing little improvement in
clients' health and functioning may give nurses a restricted sense of
personal accomplishment.
Another common stressor in psychiatric nursing is the very real risk
of injury from unpredictable, troubled clients. Grinspun of the RNAO says:
"Acute care psychiatric nursing is extreme in its unpredictability.
You don't know how your patients will react emotionally. Will they become
violent? You're physically and intellectually on high alert." A study
published in a 1999 issue of the Journal of Advanced Nursing found
that clients often transfer feelings, either affectionalte or hostile,
onto nurses -- a dynamic that may be particularly stressful for nurses
working with clients who are aggressive.
The social stigma of mental illness also plays a part in job stress for
nurses. Understanding stigma is a big challenge for psychiatric nurses,
yet they too feel its taint. Nasato at the William Osler clinic agrees:
"Mental health nurses are looked at with as much stigma as the mentally
ill themselves. We get told: 'You're not doing real nursing,' because
we don't do as many medical procedures, such as giving injections or changing
dressings. We also face this attitude from nurses in other specialities."
Nasato adamantly feels, that "Nursing in this country is perceived
as a profession of procedures, as opposed to one with a psychosocial or
spiritual side."
Many studies of psychiatric nursing have pointed to role ambiguity --
the "wearing of many hats" throughout the course of any given
work shift -- as a significant stressor. Nurses may be called upon to
do administrative work, such as answering the phone, and housekeeping
work, such as packing a client's belongings, arranging for broken equipment
to be fixed or carrying meal trays, leaving little time for more complex
-- and critical -- client care work.
However complex the causes of burnout may be, nurses, managers and administrators
alike believe there is a need to take occupational stress much more seriously,
and to implement policies to both understand and combat it. Fagin agrees:
"Measures should be taken to ensure that staff are well supported.
Support from managers and peer support are both key."
While the nature of the work can be emotionally draining, nurses can
be taught to ease the stress of working with people with mental health
problems. In a study of forensic nurses published in a 2002 issue of the
Journal of Advanced Nursing, Ewers et al found that providing nurses
with a better understanding of serious mental illness and training them
in a broader range of interventions helped nurses become more positive
in their attitudes toward clients and lowered their stress levels. Similarly,
a 2000 study published in the same journal revealed that effective empathic
skills and communication decreased the likelihood of burnout. The Centre
for Addiction and Mental Health in Toronto offers courses to help staff
better understand and deal with clients, including a seminar on preventing
and managing aggressive behaviour.
Many institutions that employ psychiatric nurses offer seminars that
focus not only on upgrading professional competence and clinical skills,
but also on developing time management skills, stress management interventions
and teamwork skills, so staff, including nurses, can deal with their work
stress with greater confidence and efficiency.
Despite the challenges and shortcomings of the nursing work environment,
Aiken's study found that three-quarters of all nurses are satisfied with
their career choice. If this dedication is strengthened with proper coping
strategies and institutional support, psychiatric nurses can help make
a difference in their clients' lives without compromising their own health.
By Abigail Pugh
Measuring burnout
The Maslach Burnout Inventory
The most commonly used measure of occupational burnout in the caring professions.
It measures three criteria for burnout: emotional exhaustion, depersonalization
and lack of personal accomplishment.
The Copenhagen Burnout Inventory
This tool has been developed to replace the Maslach Inventory and has
been found to measure burnout accurately in Danish nurses and firefighters.
It measures burnout in all types of workers, not just those in "people"
professions, and it also examines the following: "personal"
burnout (in a domestic, not just professional, context), "work"
burnout (according to occupation) and "client" burnout (according
to the type of client).
Understanding burnout
Burnout is not a straightforward phenomenon. Physical injuries in the
workplace are easy to measure, but psychosocial damage is more elusive
and difficult to quantify. And physical hazards, once identified, are
often easily fixable -- yet the many components of burnout are less amenable
to quick solutions. Even defining the term is a complex task. After all,
feeling "burned out" can mean anything from healthy exhaustion
at the end of a tiring, but satisfying day to a crippling depletion of
coping skills or even to a decision to leave the job altogether. Measuring
burnout is also very difficult. Consider the following two behaviours:
heavy cigarette and alcohol consumption and a lack of engagement and interest
in one's job. These have both been shown by researchers to be factors
in causing burnout, but they are also effects of burnout. Determining
which came first is a difficult task.
Caring for the carer
- Burnout is a recognized psychological phenomenon whose main cause
is excessive workplace stress. It can be chronic, but there are ways
to break the cycle. The following techniques can help reduce workplace
stress:
- Take care of your body
- Eat regularly and healthily.
- Get enough sleep.
- Find the right physical exercise for you, and do it at least twice
a week.
- Take yoga classes.
- Treat yourself: take a weekend break or plan a relaxing vacation.
- If your budget permits, schedule a regular massage or shiatsu treatment.
Take care of your mind
- Unburden with friends and family. Let them in on your fears, frustrations
and plans.
- Write your thoughts and feelings in a journal.
- Make time for activities you enjoy.
- Guard your spare time: don't reflexively say "yes" to every
new responsibility.
- Make time for simple things: a walk, meditation, playing an instrument
or listening to music.
- If you can't remember the last time you sang or danced, rectify this!
- Make use of your employee assistance program.
- Find a therapist or counsellor and meet regularly.
Take care of your professional relationships
- Learn conflict management techniques.
- Participate in professional development activities.
- Nurture good communication among your colleagues.
- Address conflict as it arises.
- See communication mistakes as learning opportunities -- not as disasters.
- Praise your colleagues when you see they're doing good work.
Source: Registered Nurses Association of British Columbia
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