NURSING AND HEALTH CARE MANAGEMENT AND POLICY

Stressors, burnout and social support: nurses in acute mental health

settings
Richard Jenkins BA MSc
Researcher, FOCUS, College Research Unit, Royal College of Psychiatrists, London, UK

Peter Elliott BA MSc CPsychol AFBPsS

Programme Director (Academic and Training), Doctorate in Clinical Psychology, Department of Psychology, University
of Southampton, Southampton, UK

Submitted for publication 25 November 2003

Accepted for publication 28 April 2004

Correspondence: J E N K I N S R . & E L L I O T T P . ( 2 0 0 4 ) Journal of Advanced Nursing 48(6), 622–631

Richard Jenkins, Stressors, burnout and social support: nurses in acute mental health settings
FOCUS, Aims. This paper reports a study which aims (1) to investigate and compare levels
College Research Unit,
of stressors and burnout of qualified and unqualified nursing staff in acute mental
The Royal College of Psychiatrists,
health settings; (2) to examine the relationships between stressors and burnout
83 Victoria Street,
London SW1H 0HW,
and (3) to assess the impact of social support on burnout and stressor–burnout
UK. relationships.
E-mail: rjenkins@cru.rcpsych.ac.uk Background. Several studies have noted that the work of mental health nurses can
be highly stressful, but relatively few have focused specifically on staff working in
acute inpatient settings. Although many of the pressures faced by this group are
similar to those in other nursing specialities, a number of demands relate specifically
to mental health settings, including the often intense nature of nurse–patient
interaction and dealing with difficult and challenging patient behaviours on a
regular basis.
Methods. A convenience sample of 93 nursing staff from 11 acute adult mental
health wards completed the Mental Health Professionals Stress Scale, Maslach
Burnout Inventory and House and Wells Social Support Scale.
Results. Lack of adequate staffing was the main stressor reported by qualified staff,
while dealing with physically threatening, difficult or demanding patients was the
most stressful aspect for unqualified staff. Qualified nurses reported significantly
higher workload stress than unqualified staff. Approximately half of all nursing staff
showed signs of high burnout in terms of emotional exhaustion. A variety of
stressors were positively correlated with emotional exhaustion and depersonaliza-
tion. Higher levels of support from co-workers were related to lower levels of
emotional exhaustion. Higher stressor scores were associated with higher levels of
depersonalization for staff reporting high levels of social support, but not for those
reporting low levels of support (a reverse buffering effect).
Conclusions. Qualified and unqualified nursing staff differed in terms of the
prominence given to individual stressors in their work environment. The findings
were consistent with the notion of burnout developing in response to job-related
stressors. While staff support groups may be useful in alleviating feelings of burnout,
the reverse buffering effect suggests that they should be structured in a way that
minimizes negative communication and encourages staff to discuss their concerns in
a constructive way.

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2004 Blackwell Publishing Ltd

Nursing and health care management and policy
Keywords: occupational stress, stressors, burnout, social support, mental health
nursing, acute mental health
Introduction
Occupational stress in the nursing profession has been the
focus of much research over the last 20 years (Gray-Toft &
Anderson 1981, Packard & Motowidlo 1987, Dewe 1989,
Foxall et al. 1990, Tyler & Ellison 1994, Brown & Edelmann
2000). However, Dunn and Ritter (1995) have noted that
relatively few studies have investigated mental health nurses.
Although many of the pressures faced by this group are
similar to those reported by staff in other nursing specialities
(Riding & Wheeler 1995), a number of demands relate
specifically to mental health settings. These include the often
intense nature of nurse–patient interaction (Cronin-Stubbs &
Brophy 1985) and the confrontation of difficult and challen-
ging behaviours on a regular basis (Sullivan 1993).
While in recent years there has been an increase in the
number of studies examining occupational stress among
community mental health nurses (Harper & Minghella 1997,
McLeod 1997, Coffey 1999, Drake & Brumblecombe 1999,
Burnard et al. 2000), the experiences of staff in acute
inpatient settings, providing 24-hour care for people with
serious mental illness, have received less attention. An
investigation of acute mental health nursing commissioned
for the United Kingdom’s (UK) Department of Health
(Higgins et al. 1997) has highlighted the need for further
research in this area. An increasingly diverse patient popu-
lation (acute psychiatric episodes, compulsory detentions,
and alcohol- and drug-related emergency admissions), a
growing volume of administrative duties, weakness in multi-
disciplinary team working, and a mismatch between the skills
learned in training and those now required by the current
work environment have been identified as posing particular
problems for nursing staff (Higgins et al. 1999).
Stressors, burnout and social support
According to the ‘stress and coping’ paradigm developed by
Lazarus and Folkman (1984), people will experience stress if
they appraise an event as stressful and perceive the demands
posed by that event as exceeding their ability to cope. This
paradigm has featured in a number of studies of occupational
stress in the nursing profession (Boyle et al. 1991, Sullivan
1993, Tyler & Cushway 1995), and forms the basis for the
current study.
Previous studies of mental health nurses have identified a
variety of stressors in the work environment. These include

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
Nurses in acute mental health settings
administrative and organizational issues such as the volume of
paperwork and lack of consultation over work-related changes
(Dawkins et al. 1985), inadequate staffing (Carson et al. 1995),
dealing with potentially violent and/or suicidal patients
(Sullivan 1993) and conflict between staff (Trygstad 1986).
Long-term exposure to job-related stressors can lead to
burnout (Schaufeli et al. 1993). Maslach and Jackson (1981)
have defined this as the experience of emotional exhaustion
(depletion or draining of one’s emotional resources), deper-
sonalization (development of negative, callous and cynical
attitudes towards patients) and reduced personal accomplish-
ment (tendency to appraise one’s work-related behaviour and
performance in a negative manner). Burnout in mental health
nursing has been associated with a number of stressors.
Sullivan (1993) found positive correlations between the level
of emotional exhaustion and various aspects of patient care
(violent incidents and continuous one-to-one observation)
and the work environment (staffing, administrative duties
and workload). A study by Firth et al. (1987) found that
unclear expectations of the nursing role were associated with
higher levels of burnout.
The experience of burnout can be alleviated by the
availability of coping resources, one of which is social
support (Melchior et al. 1997). Support can be emotional,
such as the action of caring or listening sympathetically, or
instrumental, involving tangible assistance such as help with
a work task (Fenlason & Beehr 1994). High levels of support
have been associated with low levels of burnout in a number
of mental health nursing studies (Cronin-Stubbs & Brophy
1985, Firth et al. 1986, Sullivan 1993, Kilfedder et al. 2001).
Two models have been proposed to explain the mechanism
by which social support may have a beneficial effect on health
outcomes such as burnout. According to the ‘main effects’
model, social support is beneficial to well-being, regardless of
the level of stressors to which individuals are exposed, by
meeting important human needs for security, social contact,
approval, belonging and affection (House 1981). In contrast,
the ‘buffering’ hypothesis proposes that social support mod-
erates the effects of stressors (Wheaton 1985). Relationships
between stressors and burnout will be stronger for people with
low levels of support than for those with high levels.
Occupational stress in nursing
A number of additional issues were identified from previous
studies of occupational stress in the nursing profession
623
R. Jenkins and P. Elliott
(Constable & Russell 1986, Kaufmann & Beehr 1986, Jones
et al. 1987, Hare & Pratt 1988, Chappell & Novak 1992).
Differences between qualified and unqualified nursing staff
Both the prominence of particular stressors and the incidence
of burnout can vary as a function of nursing rank or grade.
Nurses in charge of wards have reported higher adminis-
trative demands than less senior grades (Jones et al. 1987),
while greater levels of emotional exhaustion and deperson-
alization have been found among nursing assistants (Hare &
Pratt 1988). Nursing assistants may be more vulnerable to the
development of burnout because they deliver a high propor-
tion of direct care services to patients (Novak & Chappell
1994). In the present study we sought to investigate differ-
ences in the stressor and burnout profiles of qualified and
unqualified nursing staff. The experiences of unqualified staff
are worthy of particular attention, given the increasing
importance of their role during the last decade. Following the
introduction of the Project 2000 scheme of nurse education
and training in the UK (UKCC 1986), nursing or healthcare
assistants now provide much of the direct patient care pre-
viously delivered by student nurses (MacPherson 1993).
Buffering
While the main effects of social support on the incidence of
burnout (i.e. negative correlations between these two variables)
are well documented, few studies have investigated the buff-
ering phenomenon among nursing staff (Constable & Russell
1986, Kaufmann & Beehr 1986, Chappell & Novak 1992).
The study
Aims
The aims of the study were:
• to investigate and compare the levels of stressors and burn-
out experienced by qualified and unqualified nursing staff;
• to examine relationships between stressors and burnout for
the sample as a whole;
• to assess the impact of social support on burnout (main
effect) and stressor–burnout relationships (buffering).
Design
A survey design was adopted.
Participants
These were a convenience sample of full-time qualified nurses
and nursing assistants identified from the staff lists of 11
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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
acute adult mental health wards at four hospitals in London
and the south-east of England. A total of 240 questionnaires
were distributed and 93 were returned completed, represent-
ing a response rate of 39%.
Questionnaire
We designed a self-report questionnaire consisting of four
sections: background information, levels of stressors, burnout
and social support.
Background information
Personal details were obtained on participants’ job titles,
length of employment on current ward, length of employ-
ment in the nursing profession, gender and age.
Stressors
A major criticism of previous research on occupational stress
among mental health nurses has been the lack of a reliable and
valid scale that encompasses the specific problems faced by
this group. For example, only 11 of the 78 items comprising
the Psychiatric Nurses Occupational Scale in the study by
Dawkins et al. (1985) were specific to the work in mental
health settings. To address this deficiency, we used the Mental
Health Professionals Stress Scale (MHPSS). This was devel-
oped by Cushway et al. (1996) and originally tested with a
sample of 154 clinical psychologists and 111 mental health
nurses. It demonstrated good discriminant validity (differ-
ences between the two groups in terms of the main sources of
stress), concurrent validity (relationships with a range of cri-
terion measures including a symptom check list, job satisfac-
tion, self-reported stress and social support) and internal
consistency (Cronbach’s a ¼ 0Æ94 for mental health nurses).
The MHPSS consists of 42 items which are grouped into
seven subscales: workload; client-related difficulties; organ-
izational structure and processes; relationships and conflicts
with other professionals; lack of resources; professional self-
doubt; and home–work conflict. Each item is answered on a
four-point scale. The original form of the MHPSS uses only
an end-point labelling system, where a score of 0 represents
‘does not apply to me’ and 3 represents ‘does apply to me’.
However, in line with the stress and coping paradigm
(Lazarus & Folkman 1984) that formed the basis of our
present study, we replaced this with a response scale that
would make more explicit the notion of individuals apprais-
ing events as difficult to cope with: 0, never or rarely a
problem; 1, sometimes a problem; 2, often a problem and 3,
very often a problem. Reliability coefficients (Cronbach’s
alpha) for the MHPSS subscales in the present study are
shown in Table 1.
Nursing and health care management and policy Nurses in acute mental health settings

Table 1 Reliability coefficients (Cronbach’s a), mean values and Table 2 Frequency distribution of MBI burnout scores by staff group
standard deviations of Mental Health Professionals Stress Scale
(MHPSS) subscales Staff group

Qualified nurses Nursing assistants All staff

Staff group
MBI subscale score* (n ¼ 57) (n ¼ 36) (%)
Qualified Nursing
Emotional exhaustion
MHPSS subscale Cronbach’s a nurses assistants
Low (£13) 16 9 26Æ9
Workload 0Æ71 1Æ43 (0Æ57) 1Æ13* (0Æ68) Average (14–20) 11 9 21Æ5
Client-related difficulties 0Æ66 1Æ26 (0Æ51) 1Æ38 (0Æ61) High (‡21) 30 18 51Æ6
Organizational structure 0Æ82 1Æ29 (0Æ64) 1Æ19 (0Æ82) Depersonalization
and processes Low (£4) 25 16 44Æ1
Relationships/conflicts 0Æ80 0Æ92 (0Æ53) 0Æ87 (0Æ73) Average (5–7) 12 5 18Æ3
with other professionals High (‡8) 20 15 37Æ6
Lack of resources 0Æ68 1Æ47 (0Æ51) 1Æ34 (0Æ73) Personal accomplishment
Professional self-doubt 0Æ81 0Æ97 (0Æ51) 0Æ82 (0Æ72) Low (‡34) 38 18 60Æ2
Home–work conflict
0Æ79 0Æ71 (0Æ58) 0Æ73 (0Æ67) Average (29–33) 11 10 22Æ6
Total MHPSS score 0Æ92 1Æ15 (0Æ36) 1Æ07 (0Æ55) High (£28) 8 8 17Æ2


Scores on this subscale were not normally distributed. Comparison MBI, Maslach Burnout Inventory.
of the group mean values was made using the Mann–Whitney U-test. *Categorization of low, average and high burnout according to
*P < 0Æ05. normative data (Maslach et al. 1996).

Burnout
The Maslach Burnout Inventory (MBI) (Maslach et al. 1996)
consists of 22 items grouped into three subscales: emotional
exhaustion, depersonalization and personal accomplishment.
Each item is answered on a seven-point response scale, scored
0–7 (‘never’, ‘a few times a year’, ‘once a month or less’,
‘a few times a month’, ‘once a week’, ‘a few times a week’
and ‘every day’). Responses are summed to give separate
scores for each of the three subscales, which can then be
categorized as low, average or high degrees of burnout
according to normative data. The categorization of scores in
the present study (see Table 2) was based on normative data
from a sample of 730 mental health workers (Maslach et al.
1996). Reliability coefficients for the MBI subscales in the
present study were 0Æ90 (emotional exhaustion), 0Æ75
(depersonalization) and 0Æ76 (personal accomplishment).
Social support
This was assessed using the four-item scale devised by House
and Wells (1978), which measures social support from the
immediate supervisor (e.g. ward or line manager), co-work-
ers, spouse/partner and friends and relatives. The first two
items relate to all four sources of support and the third to the
two work-related sources (supervisor and co-workers). For
these items, participants rate the extent to which each source
fulfills a particular supportive function; a four-point response
scale is used, scored 0–3 (‘not at all’, ‘a little’, ‘somewhat’ and
‘very much’). The final item has three statements about the
participant’s supervisor, which require a rating of their
truthfulness, scored 0–3 (‘not at all true’, ‘a little true’,
‘somewhat true’ and ‘very true’). The reliability coefficient for
the House and Wells scale in the present study was 0Æ84.
Data collection
The study was conducted between April and July 2000. The
Directors of Nursing or General Managers of mental health
services at the selected hospitals were contacted to request
permission to conduct the study and obtain staff lists. Each of
the acute adult mental health wards was then visited by the
researcher (R.J.) following an introductory letter to the ward
manager explaining the nature of the study and requesting
the participation of nursing staff. Questionnaires were
distributed to nursing staff with a covering letter outlining
the study and ensuring confidentiality of responses. Stamped
addressed envelopes were enclosed for the return of
questionnaires to the researcher. A written reminder to
complete the questionnaire was sent to all staff via their ward
managers after 3 weeks.
Ethical considerations
The study was approved by the ethics committee of the
Department of Psychology at the University of Southampton.
As an audit of occupational stress and burnout, however,
the study did not require permission from National Health
Service Local Research Ethics Committees. Completion and
return of the questionnaire was taken as evidence of
the individual giving informed consent to participate in the
study.

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631 625
R. Jenkins and P. Elliott
Data analysis
Differences between qualified and unqualified nursing staff on
the MHPSS subscales (with the exception of ‘home–work
conflict’) were examined using multivariate analysis of vari-
ance (MANOVA ). A Kolmogorov–Smirnov test showed that
scores on the ‘home–work conflict’ subscale were not normally
distributed, and so between-group differences were analysed
using a Mann–Whitney U-test. Between-group comparisons of
the incidence of burnout in terms of low, average and high
degrees were performed using chi-square tests. Relationships
between stressors, social support and burnout for the sample as
a whole were examined by computing Pearson correlation
coefficients for normally distributed data and Spearman’s rho
correlation coefficients for non-parametric data. For each set of
correlations, the required level of statistical significance was
subject to a Bonferroni correction to control for type 1 errors.
To test for a buffering effect of social support in the
relationship between stressors and burnout, a series of hierar-
chical multiple regressions was employed. The procedure
normally involves entering each stressor variable followed by
each social support variable, then a series of interaction terms
for each combination of stressor and support variable, with
each dimension of burnout as the criterion variable (Constable
& Russell 1986). Given the sample size of the present study and
statistical power considerations, however, the number of
predictor variables was limited to include only the total
stressor and social support scores, together with a total
stressor/social support interaction term. The buffering hypoth-
esis predicts that there will be a significant interaction between
stressors and social support, which is indicated by a significant
change in the amount of variance in the criterion variable
(scores on each dimension of burnout).
Results
Participants
The sample comprised 57 qualified nurses and 36 nursing
assistants. The mean length of work experience on the
current ward for all staff was 2Æ8 years (SD ¼ 2Æ8) and mean
length of work experience in the nursing profession was
9Æ3 years (SD ¼ 6Æ9). Sixty-two of the participants were
female (66Æ7%) and 31 were male (33Æ3%). Their mean age
was 37Æ1 years (SD ¼ 10Æ0).
Stressors
Descriptive statistics for scores on the MHPSS subscales are
shown in Table 1. The order of prominence given to
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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
individual stressors differed for the staff groups although
significant between-group differences were limited to only
one source of stress. The main stressors were ‘lack of
resources’ in the case of qualified nurses and ‘client-related
difficulties’ in the case of nursing assistants. Individual item
analysis within each of these subscales revealed that the
stressors rated as most problematic by qualified nurses were
‘lack of adequate staffing’ (M ¼ 2Æ23, SD ¼ 0Æ82) and ‘lack of
adequate cover’ (M ¼ 1Æ79, SD ¼ 0Æ92). For nursing assist-
ants, ‘physical threats from patients’ (M ¼ 2Æ08, SD ¼ 0Æ91)
and ‘difficult and/or demanding patients’ (M ¼ 1Æ97,
SD ¼ 0Æ88) were perceived as the main sources of stress.
Analyses at the univariate level showed that qualified nurses
scored significantly higher than nursing assistants on the
‘workload’ subscale [F (1, 91) ¼ 5Æ52, P ¼ 0Æ021].
Burnout
The frequency distribution of MBI scores categorized accord-
ing to degree of burnout (low, average or high) for each
group is shown in Table 2. Chi-square analyses revealed no
significant associations between staff group and degree of
emotional exhaustion (v2 ¼ 0Æ44, d.f. ¼ 2, P ¼ 0Æ802),
depersonalization (v2 ¼ 0Æ88, d.f. ¼ 2, P ¼ 0Æ646) or
personal accomplishment (v2 ¼ 2Æ58, d.f. ¼ 2, P ¼ 0Æ275).
Relationships between stressors, social support and
burnout
Correlations between MHPSS, social support and MBI scores
are shown in Table 3. Scores on six of the seven MHPSS
subscales (excluding ‘lack of resources’) were positively
correlated with MBI emotional exhaustion scores. Scores on
four of the MHPSS subscales (excluding ‘workload’, ‘organ-
izational structure and processes’ and ‘lack of resources’)
were positively correlated with MBI depersonalization scores.
Thus, higher stressor scores were associated with higher
levels of emotional exhaustion and depersonalization,
respectively. There were no significant correlations between
MHPSS and MBI personal accomplishment scores. With
regard to relationships between levels of social support and
burnout, there was a significant negative correlation between
co-worker support and MBI emotional exhaustion scores,
with higher levels of co-worker support associated with lower
levels of emotional exhaustion (r ¼
0Æ32, P ¼ 0Æ002).
Buffering
Given the absence of any significant correlations between
stressors and personal accomplishment, hierarchical multiple
Nursing and health care management and policy Nurses in acute mental health settings

Table 3 Correlations between MHPSS,

MBI subscale
social support and MBI scores
Emotional Personal
MHPSS/social support subscale exhaustion Depersonalization accomplishment

Workload 0Æ51** 0Æ31 0Æ18

Client-related difficulties 0Æ42** 0Æ39**
0Æ05
Organizational structure and processes 0Æ42** 0Æ09 0Æ11
Relationships/conflicts with other professionals 0Æ46** 0Æ39** 0Æ07
Lack of resources 0Æ27 0Æ21 0Æ09
Professional self-doubt 0Æ38** 0Æ40**
0Æ18
Home–work conflict
0Æ46** 0Æ33*
0Æ05
Total MHPSS score 0Æ60** 0Æ43** 0Æ03
Support from supervisor

0Æ15 0Æ02
0Æ09
Support from co-workers

0Æ32* 0Æ04
0Æ10
Support from spouse/partner

0Æ09
0Æ09 0Æ16
Support from friends & relatives

0Æ09
0Æ07 0Æ18
Total social support score
0Æ28*
0Æ01
0Æ001

MBI, Maslach Burnout Inventory; MHPSS, Mental Health Professionals Stress Scale.


Scores on these subscales were not normally distributed. Correlation analyses involved the
computing of Spearman’s rho coefficients.
*P < 0Æ01, **P < 0Æ001 with Bonferroni correction.

regressions were performed on only the MBI emotional
exhaustion and depersonalization scores (see Table 4). A total
MHPSS-social support interaction term did not explain a
significant increase in the variance of emotional exhaustion
scores [R2 change ¼ 0Æ003, F (1, 89) ¼ 0Æ392, P ¼ 0Æ533].
However, the interaction term did explain a significant
increase in the variance of depersonalization scores
[R2 change ¼ 0Æ035, F (1, 89) ¼ 4Æ061, P ¼ 0Æ047]. To
determine the nature of this interaction, the sample was split
into low and high social support groups using the median
value of the total social support variable (1Æ92). Deperson-
alization scores were then regressed on the total MHPSS
scores for each group. Total MHPSS scores significantly
predicted depersonalization in the high support group
[adjusted R2 ¼ 0Æ398, F (1, 43) ¼ 30Æ041, P < 0Æ001],
but not for the low support group [adjusted R2 ¼ 0Æ056,
Table 4 Hierarchical regression analyses of emotional exhaustion
and depersonalization scores
Step B SE B b
Emotional exhaustion
1. Total stressors 14Æ653 2Æ313 0Æ574**
2. Total social support
1Æ958 1Æ649
0Æ105
3. Stressor–social support interaction 0Æ657 1Æ049 0Æ054
Depersonalization
1. Total stressors 7Æ031 1Æ369 0Æ511**
2. Total social support 1Æ372 0Æ976 0Æ137
3. Stressor–social support interaction 1Æ251 0Æ621 0Æ191*
*P < 0Æ05, **P < 0Æ001.
F (1, 46) ¼ 3Æ779, P ¼ 0Æ058]. This pattern indicated an
opposite or reverse buffering effect. Higher stressor scores
were associated with higher levels of depersonalization for
nurses reporting high levels of support, but not for nurses
reporting low levels of support.
Discussion
In this study we sought to clarify the nature of occupational
stress among nursing staff on acute adult mental health wards
by measuring levels of stressors and burnout experienced by
qualified nurses and nursing assistants, relationships between
stressors and burnout, and the impact of social support on
burnout (main effect) and stressor–burnout relationships
(buffering).
The main stressor cited by qualified staff was a lack of
adequate staffing, which is consistent with the findings of a
number of previous studies of mental health nurses (Carson
et al. 1995, Cushway et al. 1996). Dealing with physically
threatening, difficult or demanding patients was rated as the
most problematic source of stress by nursing assistants. The
prominence of both these stressors may reflect, in part,
changes in the patient population that have characterized
acute inpatient settings in recent years. Staffing levels have
been a major cause for concern for much of the last two
decades as a result of the reduction in the number of mental
health nursing students in this period (Department of Health
1994). However, the demands posed by an increasingly
diverse mix of inpatients may have intensified the concerns of

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631 627
R. Jenkins and P. Elliott
qualified nurses over the adequacy of staffing by contributing
to a feeling of being over-stretched. It is perhaps not
surprising that these same demands were rated as the greatest
source of stress by nursing assistants, given that over half of
their day-to-day work involves direct contact with patients
(Higgins et al. 1999). The higher rating of workload stress by
qualified nurses can be interpreted in terms of another of the
key themes noted by Higgins et al. (1999), namely an
increasing volume of administrative duties.
Qualified nurses and nursing assistants did not differ
significantly in terms of the degree of reported burnout.
Compared with the findings of Sullivan (1993), a greater
proportion of all nursing staff in our study were categorized
as experiencing a high degree of emotional exhaustion
(51Æ6% compared with 45%) and a lower percentage
reported feelings of high depersonalization (37Æ6% compared
with 43%). It is interesting to note that in both studies less
than a quarter of staff experienced a high degree of burnout
in terms of reduced personal accomplishment. In other
words, most nurses were judging their work performance in
a positive manner. One possible explanation of this finding
relates to the challenges posed by the acute inpatient setting.
Landeweerd and Boumans (1988) found higher levels of
work satisfaction among staff working on acute wards
compared with other mental health settings (e.g. long-stay).
Interviews with nursing staff revealed that work on the acute
wards was seen by many as representing ‘real psychiatry’,
posing demands that fully used the nurse’s skills.
A variety of aspects of the work environment were
associated with levels of emotional exhaustion and deper-
sonalization. Of all the stressors documented, workload
showed the strongest relationship with emotional exhaustion.
This is consistent with the findings of a review of 36 studies
(Duquette et al. 1994), which identified workload as one of
the main correlates of burnout among nursing staff. How-
ever, no significant relationships were found between any of
the stressors and the personal accomplishment dimension of
burnout in the present study. According to Glass and
McKnight (1996), feelings of competence at work may be
better explained in terms of an ‘aspiration–achievement gap’
or unfulfilled career expectations.
With regard to social support, we found evidence of both
main effects and buffering. Main effects were confined to
only one of the four sources of support measured, with higher
levels of support from co-workers associated with lower
levels of emotional exhaustion. This pattern can be explained
in terms of the breadth and immediacy of support from co-
workers. Work colleagues are able to provide a greater range
of supportive behaviours for dealing with work-related
problems than external sources, such as practical assistance
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2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
in the completion of work tasks. They are also likely to be
more accessible for support than the nurse’s immediate
supervisor (e.g. ward manager). A previous study involving
mental health nurses noted that when faced with a work-
related problem, 85% of staff said they would seek the
support of their immediate colleagues compared with 75%
who would consult their manager (Dallender et al. 1999).
We found no significant buffering effect of social support in
the relationships between stressors and emotional exhaustion
(i.e. higher levels of support did not weaken these relation-
ships). However, total level of support did act as a buffer in
the relationship between stress and depersonalization,
although in the opposite direction to the one normally found
(Constable & Russell 1986, Chappell & Novak 1992). This
reverse buffering effect was characterized by a significant
positive relationship between stressors and depersonalization
for staff reporting higher levels of support, but not for those
reporting lower levels. One explanation of this phenomenon
proposed by Beehr (1985) concerns the content of commu-
nications between staff when discussing work-related issues:
colleagues may alter an individual’s perception of a situation
from positive to negative or accentuate an already negative
appraisal (i.e. things are actually worse than they first
thought). For example, a colleague’s discussion of a particular
patient may dwell on the difficulties encountered during their
nursing care, such as management of problem behaviours. It is
possible that this negative appraisal may then later manifest
itself in the form of a higher level of depersonalization.
Limitations
Due to the cross-sectional nature of the data, no definitive
statements can be made about causal relationships among the
variables. While the pattern of results is consistent with the
notion of burnout developing in response to chronic occupa-
tional stressors, it is equally plausible that as a result of
feeling burnt-out, nursing staff may have appraised their
work environment as more demanding and problematic.
Similarly, while lower levels of support may have contributed
to feelings of emotional exhaustion, these same feelings may
have resulted in poorer supportive relationships through
withdrawal from others or other attitudinal changes.
The use of convenience sampling may have yielded
unrepresentative findings as a result of a self-selection bias.
Many of the nurses who participated may have done so
because they felt particularly distressed by their work
environment and wished to make their feelings known,
leading to an inflation of reported stress and burnout levels.
Alternatively, the most burnt-out staff may have felt too
exhausted and disaffected to participate in the study or have
Nursing and health care management and policy
What is already known about this topic
• Mental health nursing staff experience a variety of
stressors in their work environment.
• Many of these stressors are associated with the devel-
opment of burnout (feelings of emotional exhaustion,
depersonalization and reduced personal accomplish-
ment).
• Burnout can be alleviated by the availability of coping
resources such as social support.
What this paper adds
• Qualified and unqualified nursing staff differ in terms of
the prominence given to individual stressors in acute
mental health settings.
• Social support impacts on burnout in a variety of ways,
having a main effect on emotional exhaustion and a
reverse buffering effect in the relationship between
stressors and depersonalization.
already left their jobs, resulting in an underestimation of the
real trends.
Only 39% of the eligible sample completed the question-
naire, although similar response rates have been reported in
previous occupational stress research involving hospital-
based nurses (Tyler & Cushway 1995, Stordeur et al.
2001). However, introductory meetings with ward managers
at one of the four hospitals revealed that staff had recently
participated in a questionnaire survey on an unrelated topic.
This may have contributed to a greater level of participant
apathy than would otherwise have been the case.
Conclusions
Although significant differences between qualified nurses and
nursing assistants were limited to only one source of stress,
the order of prominence given to individual stressors differed
for each staff group. The Mental Health Professionals Stress
Scale (Cushway et al. 1996) offers an effective method of
documenting the concerns of staff in acute mental health
settings. The pattern of subscale scores can provide a focus
for subsequent stress-management programmes by highlight-
ing the most prominent sources of stress for different grades
of nursing staff.
The reduction of workload stress should be a priority for
action, given the strength of its association with the
emotional exhaustion dimension of burnout. While feelings
of emotional exhaustion may, to a certain extent, be an

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(6), 622–631
Nurses in acute mental health settings
inevitable consequence of working in the highly demanding
acute ward environment, appropriate interventions are
necessary to avoid a number of potential consequences of
burnout. These include absenteeism, turnover and decreases
in the quality and quantity of work performance (Cordes &
Dougherty 1993). For example, Cronin-Stubbs and Brophy
(1985) found that mental health nurses with high levels of
burnout were more likely to use prescription drugs to calm
patients, and spent less time in direct contact with them.
There is a need for further research into relationships
between burnout and its consequences.
The positive relationship between levels of support from
fellow nurses and emotional exhaustion indicates that staff
support groups have an influential role to play in alleviating
some of the effects of occupational stress. However, the
reverse buffering phenomenon has important implications for
the success of such intervention strategies. As Beehr (1985)
has suggested, the discussion of work-related issues may
sometimes lead to a more negative appraisal of the work
environment. If staff support groups are to be used success-
fully as part of a stress management package, they need to be
structured in such a way that minimizes negative communi-
cation and encourages staff to discuss their concerns in a
constructive way.
Acknowledgements
We would like to thank the nursing staff and their managers
for participating in the study. Thanks also go to the following
people for their valued advice and support: Anne Waters,
David Daley, Mark van Vugt (University of Southampton),
Deanna Buick and Jane Clatworthy (University of Brighton).
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