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Factors influencing stress and job satisfaction of nurses working in psychiatric units: a research review

Nakakis Konstantinos*, Ouzouni Christina

Lecturer in Nursing, Technological Educational Institute of Lamia

*Corresponding Author:
Nakakis Konstantinos
Department of Nursing
Technological Educational Institute of Lamia
3rd Km Old National Road
Lamia-Athens 35100 Lamia, Greece
Tel: +30 22310 60352
Mob: + 30 6977379125
E-mail: knakakis@teilam.gr
 
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Abstract

Background: Mental health nursing has been reported as a stressful speciality, with low job satisfaction. Method: An extensive literature search was performed aiming to identify and review research studies that investigate variables which influence stress and job satisfaction of nurses working in mental health settings. Results: This review shows that a variety of factors influence stress and job satisfaction of mental health nurses. Among these, clinical leadership and quality inter-professional collaboration between nurses and doctors and amongst nurses are particularly important. Nurses’ job satisfaction was found to be influenced primarily by psychological stress and the quality of clinical leadership. Conclusions: The influence of the quality of collaboration amongst nurses and between nurses and doctors on nurses’ job satisfaction is uncertain. A strong negative relationship was found between clinical leadership, inter-professional collaboration, stress and job satisfaction. Although a positive relationship between clinical leadership and nurses' job satisfaction was found, the association between clinical leadership and quality of inter-professional collaboration is unclear. The association between these variables and job satisfaction is positive but tenuous. In addition, a positive but weak relationship was revealed between the clinical leadership and the quality of relationships amongst nurses. Organisational issues, lack of nursing staff and patient care were found to be related to ward type mental health nurses’ stress emerged as mediating variables between stress and job satisfaction. A hypothetical model of the relationships between these variables is presented for testing at a future study.

Keywords

job satisfaction, stress, mental health nurses/nursing, psychiatric nursing/nurses.

Introduction

Nursing has been identified by a number of studies as a stressful occupation [1-5]. Stress has a cost for individuals in terms of health, well-being and job dissatisfaction, as well as for organizations in terms of absenteeism and turnover, which in turn may impact upon the quality of patient care [6-9]. Research studies on stress in nursing have identified a variety of stressors that depend upon the clinical speciality. However, some common stressors across nursing specialities include poor working relationships between nurses and doctors and other health care professionals, demanding communication and relationships with patients and relatives, emergency cases, high workload, understaffing and lack of support or positive feedback from senior nursing staff [10,11]. Most studies on stress and job satisfaction in nursing have focused on general nursing specialities, and relatively little attention has been paid to nurses working in psychiatric units [7,12]. A better understanding of these factors in mental health nursing may allow identification of strategies to improve the working conditions for these nurses with resulting benefits for the quality of nursing care.

This research review investigates the factors influencing nurses' stress and job satisfaction in psychiatric units as well as the potential relationships amongst these and mediating variables. A hypothetical model of the relationships between these variables is presented that has been subsequently tested in an empirical study which has yet to be reported.

Method

Computerized literature searches using CINAHL, Medline and Psyinfo database were undertaken, using the key words ‘stress’, ‘stressors’, ‘mental health nursing or nurses’, ‘psychiatric nursing or nurses’, ‘job satisfaction’. As articles were retrieved their references' were reviewed for potential studies to be included in the review.

Selected for inclusion within the review were research studies written in English language that were related to occupational stress and job satisfaction of mental health nurses.

Studies of stress in mental health nursing.

Research studies show that nurses perceive various type of stressors depending on their speciality and characteristics of the ward or work environment [1]. In general, studies on stress in psychiatric nursing take one of two approaches: there are those that compare mental health nurses with nurses in other nursing specialities [7,13-15] and those that investigate stress solely in different types of mental health nurses.

Comparison of psychological stress in mental health nurses and other specialities

Studies comparing mental health nurses with other group of nurses have found that mental health nurses are less stressed than other specialities [16,17]. However, most stressors identified are common to both mental health and general nurses, and stress seems to arise from the overall complexity of nurses’ work, rather than specific tasks required within hospital settings [13,15,16,18].

Dolan [13] identified significantly lower levels of burnout in psychiatric nurses compared with general nurses. She suggests that this is so because psychiatric nurses have the opportunity to express their opinion in a multidisciplinary team whereas general nurses have fewer opportunities to do this. Thus, this aspect of their work appears to protect mental health nurses from the levels of stress and burnout experienced by their general nursing counter parts.

Dolan [13] found that burnout was negatively correlated with job satisfaction. The negative influence of stress on job satisfaction has been noted also in a number of studies [19,29,21,22].

Cronin-Stubbs and Brophy’s [7] comparative study of psychiatric nurses and nurses working in theatres, intensive care and general medicine, using a random sample of 269 female nurses found that psychiatric nurses experienced intense interpersonal involvement and stated that frequent conflicts with patients, families, physicians and colleagues took place in their working environment. This study demonstrated that interpersonal relationships were the most frequent sources of undesirable personal stress for psychiatric nurses and that it had a greater impact on them than on nurses of other specialities.

The authors suggested that psychiatric nurses were vulnerable to burnout because of less social support and less on–job and off–job affirmation compared with nurses from other specialities. However, the above findings conflict with Dolan’s [13,23] conclusion that psychiatric nurses are protected from stress through social support from the multi-disciplinary team.

Studies examining stress in different nursing sub-specialities have used stress assessment instruments validated in general but not mental health nurses. Cronin-Stubbs and Brophy’s [7] for example use the Nursing Stress Scale [20]. These studies found that individual stressors varied according to speciality, for example access to drugs and medication was a major stressor for psychiatric nurses, but not for other specialities. This raises questions about the validity of such measurements of stress for mental health nurses who might be exposed to different stressors than general nurses [24].

Stress in different types of psychiatric nurses

Research studies in mental health nursing have been carried out in different countries and have identified several sources of stress. Trygstad [25] in America used semi-structured interviews to examine stress and coping in a sample of 22 female staff registered psychiatric nurses working in four acute units in three private hospitals.. She found that problems with patients accounted for 13% of overall stressors that psychiatric nurses encountered. In particular, patients’ chronicity and recidivism were identified as sources of stress. She found that difficulties in relationships among staff nurses and their ability to work together were the most important determinants of stress experienced by these nurses. One of every three stressors that psychiatric nurses discussed were related with working relationships and performance of co-worker nurses and other unit staff such as nursing assistants and psychiatric technicians. Problems with such relationships included inadequate or ineffective communication and in-fighting between individuals and groups in the unit.

Relationships between nurses and physicians accounted for only 9% of the stressors identified. Relationships with physicians were considered as a stressor by nurses when the former ignored nurses’ input and made unilateral decisions. Trygstad [25] also found that the role of the ward sister was pivotal when staff friction and in-fighting and/or staff non performance of duties occurred in the work environment. From the stressors identified, 17% involved the ward sister’s poor supervisory attitudes and practices, such as insufficient positive reinforcement or support for staff, and lack of clinical or administrative expertise. Trygstad [25] pointed out that ward sisters were often described by their staff as contributing to staff friction, and as fighting and hindering rather than facilitating. However, staff nurses reported that support of the ward sister, or their clinical supervisors, was more effective than in resolving work problems. Trygstad [25] concluded that the relationship between staff nurses and their ward sister and their ability to work together was an important determinant of the work stress experienced by psychiatric nurses. Findings from the data analysis were checked with the sub sample of the participants to increase credibility of the findings and hence the value of this study. However, the small sample size and the combination of hospital settings (namely private hospitals and a federal hospital) from which the sample was derived raises questions about the extent to which the stressors identified are applicable to wards with different characteristics and policies.

Jones et al [26] used a self report instrument to measure stress in nurses’ working in a special psychiatric hospital. They conceptualised the outcomes of psychological distress, anxiety and depression as the result of the relationship between job demands, support, and constraints. Their study revealed three main types of job demands: administration demands (such as “contribution to conference meetings” and “report patients’ progress to medical staff”), patient supervision (“continually observe patients” and adverse demands (such as being required to “undertake work I consider unnecessary” and “work with patients I am afraid of”). Patient supervisory demands were high compared with administrative and adverse demands but nurses were not stressed by these demands, possibly because this was the primary function of many psychiatric nurses and one that they have been prepared for. There was a strong positive correlation between frequent adverse demands and stress. The sample of psychiatric nurses reported relatively high levels of stress overall compared with previous studies. Interestingly, Jones et al. [26] found that higher job demands such as patients’ supervision are not necessarily related to high levels of stress in psychiatric nurses. However, the findings of this study are difficult to generalise in other areas of psychiatric nursing because it was carried out in only one specialised psychiatric hospital.

Dawkins et al. [8] developed the Psychiatric Nurses Occupational Stress Scale (PNOSS) to identify sources of stress specifically in psychiatric nurses. In a telephone survey of 43 psychiatric nurses randomly selected from the workforce of a large psychiatric hospital they found that negative patient characteristics accounted for 9% of stressors and physical threats from patients were also very stressful for nurses (n=43. . 21% of the stressors that psychiatric nurses (n= 43) reported were related to staff conflicts. The highest stressors were ‘working with poorly motivated staff’, ‘working with persons who resent new ideas’ and ‘having a doctor who fails to notify staff of changes in patient’s order’ as well as ‘convincing doctors to order adequate medication’. In addition, some of the items that the authors included in the subscale of ‘staff performance’ can be considered also to relate with professional relationships. For instance, ‘dealing with a hassle that occurs when you try to take action against incompetent staff’ was rated highly as a stressor by psychiatric nurses. This study is valuable because it highlights some sources of stress encountered by nurses who work in a public mental hospital. However, its results should be accepted cautiously because of the small and heterogeneous sample. Most subjects were in supervisory roles and thus were involved more with administration rather than directly with patient care. Therefore, it is uncertain whether the same stressors apply to direct psychiatric nursing staff. Data that compare the views of direct care with supervisory staff are not reported.

In contrast, Sullivan [27] who examined occupational stress and burnout in 78 psychiatric nurses working in eight acute admissions wards in the UK found that violent incidents, potential suicide and observation are the most frequent stressors in relation to patient care. He also found that the intensity of such stressful experiences was influenced by two factors: lack of manpower resources to maintain observations at a safe level, and psychiatric nurses’ perception of lack of understanding and support from hospital management. The findings of this study suggest that the type of patient care that psychiatric nurses provide may be a major source of stress. The results may be explained by the fact that Sullivan’s [27] study was carried out in acute psychiatric admission wards where unpredictable violent episodes and the need for observation occur more frequently that on chronic long-stay wards.

On the “managerial support” subscale of the PSI [27], most respondents were found to receive only a low level of managerial support. An interview revealed that management perceived to be general management at unit level; at a lower level the ward sister/charge nurse was perceived to be supportive. Sullivan [27] found a positive correlation (r=0.6; p<0.05) between lack of management support and emotional exhaustion.

In contrast with previous research, Sullivan’s [27] study found that interpersonal conflict, including conflict among nursing staff, as well as between nurse and medical staff was rare. However, when problems with interpersonal relationships did occur they invariably resulted in major problems that were experienced as stressful. Similarly, Cushway et al [19] found that the score on the relationships and conflicts with other professionals subscale, (which included relationships between psychiatric nurses and doctors and amongst nurses) were relatively low indicating that it was not an important source of stress. Notwithstanding, the general nursing literature reports that there is significant stress and dissatisfaction associated with the relationship between doctors and nurses in the practice environment of the hospital [28]. Devereux [29] pointed out that a lot of nurses, especially younger ones, express discontent with the lack of respect they perceive from other health professionals, primarily physicians, and the lack of collaboration in decision making with regard to patient management.

Handy30 in an in-depth case study examined stress in psychiatric nursing in England from a different perspective. She used qualitative techniques to collect data of nurses working in two wards within a large psychiatric hospital and a community psychiatric nursing unit attached to the same hospital. She found that stress in psychiatric nurses occurs due to the contradictory therapeutic role which is attributed to the concept psychiatric care and the control-oriented practice which is used to organise daily activities. However, nurses failed to understand that in order to increase their understanding - particularly on occupational stress- they need to consider the factors affecting the organisation as well as the social context of psychiatric wards. Thus, nurses -especially the young ones- who haven’t developed defensive mechanisms feel frustrated when their attempt to improve patients’ quality of life is unsuccessful. Hence, Handy [30] concluded that nurses through that process are dissatisfied and the effort to recreate the formed system in the ward causes stress and dissatisfaction to psychiatric nurses.

Callaghan [31] studied stress and job satisfaction in relation to organizational factors such as role ambiguity, role overload, non-participation, and patients’ psychopathology in mental health nurses based in acute psychiatric wards. He found that these organisational factors were associated with stress and low job satisfaction.

The Claybury Stress Study [32-34] was a large survey of 323 ward based mental health nurses and 250 community psychiatric nurses (CPNs) working in a Regional Health Authority in UK and found that the latter were more stressed than the former. The study sought to compare stress and coping strategies between community psychiatric nurses and ward based qualified as well as unqualified psychiatric nurses. The study revealed that organisational factors, lack of resources (including staff shortage and manpower resources) and poor interpersonal relationships were the main stressors identified by the hospital based psychiatric nurses.

Kipping’s [35] was the first study carried out in England which explored stress as it is perceived by student mental health nurses. She adopted a longitudinal research design asking open-ended questions to a cohort of nurses about their experiences of stress during the time they were students, as well as what they anticipated to be stressful once they qualified. Of a possible sample of 620 nurses, finally 447 returned the postal questionnaires (80% response rate).

Mental health nurses reported that during their training, sources of stress were the exams, stressors related with the change of placements, problems with the organisation of the course and other student issues, feeling unable to meet patients’ needs, personal issues (relationship difficulties, financial problems, bereavement, accommodation) whereas only 2% commented that physical environment (lack of space, smoky environment) was a source of stress.

Nurses reported 11 additional sources of stress such as patient care (aggression, violence), staff attitudes and behaviour, resources issues (understaffing, lack of time), aspects of the job (inter-professional relationships, administrative issues), thoughts/ feelings/expectations of self, lack of support/supervision, cultural environment (high workload, low morale and paperwork), career issues, conditions of work (shift work, night duty, missed breaks), poor care and organisational change. The category which dealt exclusively with future stress was the changing role of qualified nurses (including difficulties related to unspecified responsibility, inter-professional relationships, their personal leadership ability and insufficient knowledge and skills) which the majority of respondents (85%) reported.

In fact, Kipping’s [35] study confirmed some of the stressors cited in earlier studies such as patients related issues, professional relationships, performance of self and other staff, administrative issues, and changes.

Melchior et al.'s [36] meta-analysis of variables related to burnout in psychiatric nursing found that burnout was negatively associated with job satisfaction, staff support, involvement with the organisation and positively associated with role conflict. This supports Blegen’s [37] meta-analysis of job satisfaction studies which found that the best negative correlate of job satisfaction in nurses is stress or burnout.

More recently, Kilfedder et al. [38] conducted a cross-sectional mail survey to ascertain burnout of 510 randomly selected psychiatric nurses (response rate 48,8%) working in one Scottish Trust which provided both acute and continuing care psychiatric services in a range of hospital and community based care. Their study revealed that the respondents reported low and average levels of emotional exhaustion, depersonalisation and personal accomplishment, respectively. It is noteworthy that only 2.0% of the study sample could be categorised as having high burnout. Of the stressors, the nursing stress scale made the greatest contribution to emotional exhaustion whereas job satisfaction was negatively correlated with burnout, which is in accordance with Melchior et al.’s36 study. Kilfedder et al.’s38 study also revealed that higher emotional exhaustion and depersonalisation were associated with less available social support in their study.

Robinson et al. [39] found psychiatric nurses to be experiencing high level of emotional exhaustion (high burnout).

The diversity of stressors found in different psychiatric nursing specialities (e.g. acute care setting, secure psychiatric hospital and psychiatric hospital for the chronically ill), as well as in student psychiatric nurses mean that it is difficult to generalise stressors from one setting to another. However, the sources of stress that the above studies revealed can be grouped as follows:

• Difficulties that arise from inter-professional relationships namely amongst nurses as well as between nurses and doctors [7,8,13,25,27,33].

▪ The clinical leadership ability of ward managers [25,33,35,40].

▪ Stressors related to psychiatric patients care (mainly violent incidents) [13,25,26,27,35].

▪ Organisational issues such as dealing with change [33], administrative demands [26], organisational structure [13], cultural environment of their work place.

Job satisfaction in mental health nurses

Studies of job satisfaction carried out in general nursing settings have found a diversity of factors which influence job satisfaction. Thus, there is little consensus between studies. More recent studies support conclusion that when the same variables are tested in more than one study different influencing variables are identified in each one [21]. With regard to mental health nurses, relatively few studies have examined influences on job satisfaction. Most of the studies have sought to describe the negative relationship between stress and job satisfaction rather than identify specific factors which have an impact on it [19,41]. Other studies have examined the relationship between intra-role conflict and job satisfaction in psychiatric units [42], job satisfaction of psychiatric aids [43] nurse/psysician collaboration and its relationship to nurses’ stress and job satisfaction [44], psychiatric nurses’ job satisfaction after closure of a custodial psychiatric hospital [45], have compared ward based and community psychiatric nurses’ job satisfaction33 and finally, Farrell and Dares46 examined the level as well as the factors influencing job satisfaction.

Davis’s [42] small scale survey of psychiatric nurses, other staff members, patients and doctors examined whether there exists an intra-role conflict among the expectations of mental health workers, of nurses’ participation in decision making, and how these expectations are related to nurses’ job satisfaction. The nurse group was found to have the highest mean expectancy to be involved in decision making regarding individual therapy and co-therapy while the doctors had the lowest expectations for nurses’ involvement. Overall, no relationship was found between intra-role conflict and job satisfaction in psychiatric nurses. This study suggests that nurses’ job satisfaction is not influenced by other professionals’ expectations, such as doctors, with regard to nurses’ participation in patient therapy. However, the staff samples were small and all drawn from a single hospital. Therefore, those findings are questionable with respect to mental health care today.

Interestingly, Floyd’s [43] was the only identified study examining job satisfaction in 213 psychiatric aids in Texas and found that 80% of the respondents surveyed reported that good relationship with doctors was a major source of satisfaction for them. In addition, 97% of the respondents reported that their relations with co-workers, especially peers, influenced their job satisfaction. Moreover, half of the respondents rated professional relationships with members of different professions as very important to their satisfaction. Nursing aids in particular valued “communication of ideas” and teaching among medical and nursing staff (67%) because they were dissatisfied with other academic opportunities which were -for them- limited. The quality of professional relationships between nurses and doctors as an important contributory factor of nurses’ job satisfaction was supported by Stamps et al. [46] who examined job satisfaction in health professionals.

Cronin-Stubbs & Brophy [7] carried out a study in America to examine the relationship between social support and burnout in four nursing specialities, and found that psychiatric nurses experience less affirmation and support than intensive care nurses. The authors explained this finding in terms of the different nature of nurses’ work in a psychiatric ward and in an intensive care unit. For instance, the outcomes of the therapeutic interaction between the psychiatric nurse and a patient are less visible due to the mental illness and consequently psychiatric nurses get less affirmation for their job. In contrast, the outcomes from the patient-nurse interaction in an intensive care unit are more concrete and give more job affirmation to those nurses.

The fact that psychiatric nurses get less affirmation from their role raises difficulties for nurses in this speciality to give each other positive feedback for their work. In addition, Cronin-Stubbs & Brophy [7] found that psychiatric nurses received less aid or direct assistance from colleagues than other specialities, explaining that interdependence is not required by the psychiatric team work.

Landeweerd & Bouman’s [48] survey of psychiatric nurses in Netherlands examined whether differences in the work setting in three different types of psychiatric departments were reflected in nurses’ work satisfaction and reported health and stress. The three types of departments were: the admission ward, in which patients were hospitalized for no more than 30 days; the short-stay department, in which patients were admitted for psychotherapeutic support with a maximum period of hospitalization of 24 months; and the long-stay unit, which provided a ‘sheltered home’ for the chronic mentally ill patients. Landeweerd & Boumans [48] found that psychiatric nurses in all units were satisfied with their work, and that admission unit staff were most satisfied. The investigators attribute this to the relatively quick results of the nurses' efforts with patients which made success observable. In addition, the researchers found that in the admission department the nurses felt that their work was valuable and meaningful. Their work required regular contact with other nurses and the members of the interdisciplinary team, which they found stimulating. They appreciated the resultant opportunities to learn and to express their opinions and feelings in an open atmosphere but were least satisfied with the clarity of their role and supervision.

Landeweerd & Boumans [48] also found that there was little positive feedback from patients for nurses working in short-stay and long-stay departments because there was little hope of a total cure for patients, and relatively few patients showed improvement in their psychiatric state. Also there were few opportunities for positive feedback from nursing colleagues because nurses in these departments worked with patients on one-to-one basis. This finding is similar to Cronin-Stubbs and Brophy’s [7] assertion that a source of low level of satisfaction for psychiatric nurses working in short and long-stay psychiatric wards was the limited interaction with other colleagues as well as with the interdisciplinary team.

In America, Eliadi44 tested the relationship between nurse/physician collaboration and its relationship to nurses’ stress and job satisfaction in different nursing specialities including psychiatric nurses. She found that nurses in all specialities were dissatisfied with their relationships with physicians, indicating on the one hand a negative association between inter-professional collaboration and nurses’ job satisfaction but on the other hand a negative association between inter-professional collaboration and stress. The results of this study were valid taking into consideration that the sample was randomly selected and relatively large (n=100) compared to previous studies. This study suggests that nurses were dissatisfied with the relationships with the unit doctors, which indicates that the quality of professional relationships influences nurses’ satisfaction.

Carson et al. [33] surveyed in the UK a sample of 323 ward based psychiatric nurses to examine job satisfaction and found a strong positive association between supportive line nurse manager and psychiatric nurses’ job satisfaction. This study showed that ‘the supportive line manager’, ‘the emotional exhaustion level’, ‘happiness with current life’, ‘personal accomplishment level’, ‘age and job security’ were high predictors of job satisfaction. The positive contribution of this study is the finding that the supportive role of the line manager (or ward sister) is related to nurses' job satisfaction. In addition, the large sample size of nurses surveyed working in acute psychiatric departments makes the results significant and to some extent representative of this area, therefore more generalisable.

From a different aspect, Sammut [45] investigated job satisfaction in psychiatric nurses who changed working environment to a district general hospital after the closure of a traditional psychiatric hospital. He found that nurses were more satisfied when working in the older psychiatric hospital than in psychiatric units of general hospitals. Furthermore, nurses reported that factors such as ‘lack of support’, ‘poor availability and communication with doctors’, ‘small space’ and ‘violent incidents’ contributed to low job satisfaction.

More recently, Farrell and Dares [46] assessed the level of job satisfaction of 22 psychiatric nurses working in a psychiatric unit attached in a general hospital in Australia. They used both questionnaires and interviews in order to assess nurses’ satisfaction with their current work. Overall, respondents were found to be mildly dissatisfied with their work. From the interviews it has been revealed that there was a feeling of lack of teamwork between peers as well as amongst the multidisciplinary team of the unit. In particular, respondents expressed that lack of autonomy, undervalue by the medical staff and nurse managers, lack of opportunities for professional development, lack of support from managers for professional development, lack of recognition and low morale were factors related to nurses’ job satisfaction.

It is apparent from this review that the number of studies which have examined job satisfaction in mental health is limited. In addition, most of these studies present methodological drawbacks such as small, non-random sample of psychiatric nurses working in different types of psychiatric wards. Therefore, any attempt to generalise those factors found to contribute to job satisfaction in any psychiatric setting is uncertain. Nevertheless, it is worth noticing that the factors contributing to the job satisfaction which nurses experience working in this speciality are similar to those reported in Blegen’s [37] meta-analysis of variables related to nurses’ job satisfaction. Especially, the current review revealed the following main contributory factors to mental health nurses’ job satisfaction:

▪ Issues related to inter-professional working mostly between nurses and doctors [42,43,44,46], as well as amongst nurses [7,43,45,46,48].

▪ The type of the psychiatric ward (acute, admission, short-/long-stay) as well as patients characteristics (acute phase, chronic patients) [48].

▪ The supportive line manager [33,45,46].

▪ Nurses’ individual characteristics such as happiness with current life, personal accomplishment level, age, job security [33].

▪ Autonomy [46].

Conclusions and modelling

Poor professional relationships have been identified as a frequent stressor for mental health nurses working in hospitals. Problems in professional relationships are manifest in the lack of collaboration between doctors and mental health nurses, conflicts between nurses and doctors and lack of doctors’ respect for nurses’ opinions and their participation in decision making about patients’ care. Mental health nurses are also stressed by difficulties in relationships and conflicts with other staff nurses they work with. From the studies discussed in this review, we concluded that there is a negative relationship between stress and good professional relationships between nurses and doctors, and also amongst mental health nurses. Thus, nurses who have low levels of stress will have collaborative relationships with doctors and other nurses, and those with high stress scores will have poor relationships with colleagues. Stress and clinical leadership of ward line managers have not been examined specifically in relation to each other in previous studies, but clinical leadership has been found to be a major influence on the stress of mental health nurses. The role of the ward sister has emerged from previous studies as of paramount importance in establishing a cooperative working environment which fosters low stress and high job satisfaction for the staff. In addition, the literature stresses that lack of a skilled ward sister to resolve conflicts amongst nurses and to be supportive is an influential factor that increases mental health level of stress. Lack of these skills has a negative relationship with mental health nurses’ occupational stress. In addition, it seems from the literature that the team building skills of the ward sister is positively associated with the quality of professional relationship amongst nurses.

Stressors related to psychiatric patients care - mainly violent incidents - were found to have a positive relationship with stress. Moreover, lack of nursing staff was found to have a negative relationship with mental health nurses’ stress. Furthermore, organisational issues were found to be related with stress.

Although few studies have been conducted, it seems that there is a consensus in the literature with respect to the strong negative association between stress and job satisfaction in mental health nurses. Studies report that different sources of stress are perceived by nurses in the work environment and that stress decreases nurses’ job satisfaction.

The factors influencing job satisfaction in registered mental health and auxiliary nurses are uncertain because of the limited empirical investigation in this field. The few studies that have examined job satisfaction in these groups report contradictory findings and the small, non-random samples drawn by most of the studies limit the generalisability of their findings to mental health and assistant nurses working in different care settings. In addition, it seems that nurses’ level of satisfaction or dissatisfaction varies according to the type of unit they work in. In one study, psychiatric nurses were satisfied working in an acute care psychiatric unit48 and in another study they were dissatisfied [45]. In addition, it seems that autonomy is positively correlated with nurses’ job satisfaction whereas employees’ specific characteristics such as happiness with current life, personal accomplishment level, age and job security are moderators to mental health nurses’ job satisfaction.

The findings of the studies examining job satisfaction in psychiatric assistants are more congruent with the predictors of job satisfaction reported by general nurses. For example, factors relating to the quality of professional relationships between nurses and doctors and amongst nurses’ co-workers and supervisors appear to contribute to nurses’ job satisfaction. In addition, the leadership ability of the head nurse and his/her relationships with the nursing team emerge as an important factor in predicting job satisfaction of mental health nurses working in acute care settings; these studies show a strong positive association between a supportive line nurse manager and nurses’ job satisfaction. Thus, the literature shows a positive relationship between inter-professional working, clinical leadership and job satisfaction. However, with the exception of the clinical leadership, which seems to have a strong association with job satisfaction, other variables do not have straightforward associations. Overall, we have only limited knowledge about the factors that contribute to mental health nurses’ job satisfaction.

The findings of this review suggest a possible model for stress and job satisfaction in psychiatric nursing for testing in future research. This model shown in Fig. 1 depicts the expected relationships between the variables that influence stress and job satisfaction in nurses working in psychiatric units. Therefore, the expected directions between the variables are described either with the solid arrows which represent strong relationships between them as supported by the literature, or with the dotted arrows indicating possible associations less obvious in previous research. The plus sign indicates that the variables are expected to be positively related and the minus sign indicates that an inverse association is expected. The absence of a sign indicates that the direction of this relationship between variables has not been established by previous research.

hsj-satisfaction-mental-health

Figure 1: Proposed model of the variables related to stress and job satisfaction of mental health and assistant nurses

The model shows occupational stress to be negatively related to job satisfaction, the clinical leadership of the ward manager, the quality of professional relationships amongst nurses and between nurses and doctors. Job satisfaction is positively related to the quality of professional relationships amongst nurses, and between nurses and doctors as well as the clinical leadership of the ward manager. In addition, job satisfaction is positively related to nurses’ autonomy. Furthermore, the clinical leadership of the ward manager is related positively to professional relationships amongst nurses working in a psychiatric speciality.

Organisational issues, lack of nursing staff and patient care were found to be related to mental health nurses’ stress. The type of psychiatric ward emerged as a mediating variable between stress and job satisfaction. Moreover, autonomy and employee characteristics were found to be related to mental health nurses’ job satisfaction.

In summary, relationships between stress and job satisfaction, the clinical leadership of the ward manager, quality of collaboration between nurses and doctors as well as collaboration amongst nurses receive support from the literature. However, the relationships between job satisfaction and collaboration between nurses and doctors, collaboration amongst nurses and clinical leadership of the ward sister are uncertain and require further investigation

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