Art & science
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The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Reducing burnout in nurses and care workers in secure settings Stewart W, Terry L (2014) Reducing burnout in nurses and care workers in secure settings. Nursing Standard. 28, 34, 37-45. Date of submission: July 16 2013; date of acceptance: November 5 2013.
Abstract Aim To identify which educational interventions reduce burnout and promote wellbeing in nurses and care workers in secure settings. Method A systematic review of health, educational and criminal justice literature was undertaken to appraise relevant studies and identify educational interventions that were effective in reducing burnout. Findings There is some evidence that clinical supervision and psychological intervention training are successful in reducing burnout in nurses and care workers in secure settings. Conclusion Supportive relationships can help nurses to manage emotional stress, and continuing personal and professional development can reduce burnout in qualified nurses in secure settings.
Authors Warren Stewart Senior lecturer, School of Health Sciences, Brighton University, Brighton. Louise Terry Reader in law and ethics, Faculty of Health and Social Care, London South Bank University, London. Correspondence to: [email protected]
Keywords Burnout, clinical supervision, mental health, psychosocial interventions, reflective learning, secure settings, stress
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
‘BURNOUT’ IS DEFINED AS A ‘psychological state that is characterised by the following symptoms: emotional exhaustion, depersonalisation and a decreased perception of personal accomplishment’ (Maslach et al 1996). Burnout in the workplace results in increased financial costs in relation to staff sickness and turnover (Wright 2005), as well as reduced quality of patient care (Coffey 1999). Nurses tend to experience higher levels of occupational stress and burnout than other professionals (Aiken et al 2002, Medland et al 2004). This is an important observation because a correlation exists between burnout and poor quality of care, failure to recognise patient distress and decreased job satisfaction (Aiken et al 2002). Moreover, nursing as a career is often associated with high stress levels, which can deter individuals from becoming nurses and can also contribute to nurses leaving the profession (Medland et al 2004). Nurses and care workers in secure settings, such as prisons and forensic mental health units, experience high rates of burnout (Dickinson and Wright 2008). According to Coldwell and Naismith (1989), both the perceived threat of violence and actual physical violence contribute to high levels of stress in nursing staff in secure settings. Studies suggest that nursing and care staff can become cold and cynical as a result of burnout, thereby displaying less empathy and avoiding patient interaction (Ewers et al 2002). Bowers (2002) highlighted the difficulties carers face when trying to retain therapeutic optimism in secure settings, and questioned why some carers experience burnout and become cynical whereas others thrive in this environment. There has been an increase in the volume of literature describing the role of resilience in
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Art & science systematic review mitigating the negative effects of work-related stress (Howard 2008). Resilience can be defined as ‘the general capacity for flexible and resourceful adaptation to external and internal stressors’ (Klohnen 1996). Kinman and Grant (2011) reported that ‘interventions designed to enhance inter-personal and intra-personal emotional competencies are likely to foster resilience, which in turn, has the potential to protect the future well-being of carers’.
Aim The aim of this systematic review was to identify which educational interventions reduce burnout and promote wellbeing in nurses and care workers in secure settings. It is hoped that this information will provide guidance to inform practice and identify future research opportunities in this area.
Method Literature search
A search of the relevant health, educational and criminal justice databases was undertaken between January and May 2012 to answer the research question: ‘Which educational interventions reduce burnout among nurses and care workers in secure settings?’ A systematic review can be justified as a suitable methodological approach to answer this research question for
two reasons. First, there is a degree of uncertainty about the range of interventions that have been developed and evaluated in this area and second, it was anticipated that there would be a large number of different types of articles relating to educational interventions in secure settings. To inform the literature search, inclusion and exclusion criteria were developed using the population, intervention, comparison and outcome (PICO) formula (Sackett et al 1997) (Table 1). Table 2 summarises the databases searched during scoping searches, conducted in February 2012 to establish whether there were enough studies of suitable quality to conduct the review, and full literature searches. Electronic databases were searched using MeSH terms or appropriate permutations, for example ‘forensic mental health nursing’ and ‘reducing burnout’; ‘burnout’ and ‘prison nursing’; or ‘secure nursing’ and ‘educational interventions’ (Box 1). Care was taken to increase the sensitivity and specificity of the searches, using the most appropriate search terms to ensure that all potentially relevant articles were identified. Scoping searches retrieved a substantial number of relevant articles, therefore justifying the research question. The full search was restricted to articles based on studies published between 1991 and 2012, because this was considered a suitable timeframe in relation to policy changes in both the NHS and Her Majesty’s Prison Service.
TABLE 1 Inclusion and exclusion criteria using the population, intervention, comparison and outcome formula Study criteria
Inclusion criteria
Exclusion criteria
Population
Qualified nurses working in secure or forensic settings, or related community facilities; healthcare support workers in secure or forensic settings; qualified prison nurses; healthcare support workers in prison settings; other criminal justice care workers, for example specific prison officers; and police custody officers.
Qualified adult and child nurses in generic settings; generic mental health nurses working in areas other than secure or forensic settings; care workers in areas other than secure or forensic settings; and criminal justice workers working in generic settings.
Intervention
Educational interventions, for example clinical supervision, reflective learning, psychosocial skills training, preceptorship, study days, mindfulness and induction.
Non-relevant interventions, policy or practice changes and non-educational interventions.
Comparison
No intervention, ordinary practice.
Interventions lacking robust research evidence, for example homeopathy.
Outcome
Quantitative and qualitative data based on reduced burnout or increased wellbeing as measured qualitatively or by self-reporting scales.
Studies that did not measure a reduction in burnout qualitatively or via self-reporting scales; studies that did not assess an educational intervention and studies based in areas other than secure or forensic settings.
Type of study
Qualitative primary data studies, quantitative studies, randomised controlled studies, controlled studies and surveys.
Commentaries, systematic reviews and case studies (although these can provide useful contextual information and reference lists).
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There have been several reports and inquiries during this time, some of which advocated significant changes in educational and clinical practice (Fallon 1999, University of Central Lancashire 1999, Department of Health 2009).
Quality appraisal and data extraction
The overall quality of a research study can be influenced by several factors, such as the non-reporting of essential information or choice of method. Therefore, every effort was made to match the most appropriate appraisal tool to the individual studies. The tools selected, in the first instance, were the Critical Appraisal Skills Programme (CASP) (www.casp-uk. net) for quantitative studies and ReLIANT (Koufogiannakis et al 2006) for qualitative studies. CASP focuses on three areas: validity, results and benefits. The ReLIANT tool was developed on the basis that, because educational interventions are essentially ‘social’ interventions taking place in a social or educational setting and their effect may be moderated by the context and the person introducing them, such studies should be judged on the basis of authenticity. The ReLIANT tool assesses quality in four areas: study design, educational context, results and relevance. The use of two separate tools to assess study quality reflects the differing methodologies of the studies in the articles identified and, therefore, the heterogeneity of the sample. Two frameworks were also used to inform judgements on the quality of the studies. The framework developed by Jadad (1998) assessed relevance, internal validity, external validity,
analysis and presentation, and ethical implications for quantitative studies. The framework developed by Pawson et al (2003) assessed transparency, accuracy, purposivity, utility and propriety for qualitative studies. The articles were reviewed independently by the researcher and the research supervisor to reduce bias. The result of each appraisal was discussed until a working consensus was reached. Table 3 shows the points available using each appraisal tool or framework. The process of data extraction involved returning to the primary articles and highlighting
BOX 1 Synonyms and keywords used in the search strategy Population: Forensic nurses. Prison nurses. Correctional nurses. Healthcare workers. Intervention: Educational interventions. Training interventions. Continuing professional development. Psychosocial interventions. Comparison: No interventions. Organisational interventions. Outcome: Burnout. Reduced burnout. Stress. Stress reduction.
TABLE 2 Summary of databases searched Category of databases
Individual databases
Nursing
Medline, CINAHL Plus, British Nursing Index and PsycINFO.
Reviews
Cochrane Library and Campbell Collaboration.
Education and social care
Education Resource Information Center (ERIC), and Applied Social Sciences Index and Abstracts (ASSIA).
Criminal justice
Criminal Justice Abstracts and National Criminal Justice Reference Service.
Journals (Sage criminal justice journals)
Crime & Delinquency; Criminology and Criminal Justice; Crime, Media, Culture; Criminal Justice Review; and Criminal Justice and Behaviour.
Special searches
Home Office website and Ministry of Justice website.
London South Bank University catalogue
Books and subsequent searches based on reference lists.
Grey literature
British Library ‘Ethos’ search, Nursing and Midwifery Council (nurses or care workers working in secure settings) website, Department of Health website and Dissertation Abstracts Online.
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Art & science systematic review the relevant information to answer the research question (Bettany-Saltikov 2010). An extraction form was developed and piloted on two articles
FIGURE 1 Summary of article identification and selection process Articles identified through database searching (n =8,737)
Findings
Excluded (n=8,659), reasons: duplicates, false positives and unsuitable articles
Articles identified through database searching (n=78)
Stage 1: excluded (n=65), reasons: the wrong population or the wrong intervention was studied, or other methodological reasons
Full text articles of potentially relevant citations retrieved (n=13) Stage 2: excluded (n =8), reasons: differences between the study populations, interventions and outcomes
Final selection of articles included in the review (n =5)
that were randomly selected from the initial selection, however neither article was included in the final stage of the review. Bias was further reduced by collaborative working between the researcher and the research supervisor, and by retaining a reflexive approach – an awareness of personal values and preferences in relation to the study types, methods of data collection and results – throughout this process.
Figure 1 presents a diagrammatic summary of the article identification and selection process. The total number of retrieved articles from all searched databases was 8,737; of these, 78 articles were selected initially as being relevant to the research question. There were two further selection stages to determine the final articles to be included in the systematic review. The main reason for excluding articles from the review was that the study population (type of care worker) did not match the population under review (nurses or care workers working in secure settings) (Table 4). Several articles referred to generic nursing roles, that is, either adult or generic mental health nurses, which was not specific enough in terms of the population identified in the research question. It was originally thought that specific prison officers and police custody officers could be included in the review because it can be argued that some of these roles involve providing some social care for offenders. However, a lack of specific information was found about these professionals. At the final stage of the review process, a further eight articles were excluded on the basis of the PICO formula (Table 4). These were articles by Peacock (1991), Coffey (2000), Coffey and
TABLE 3 Points available using the relevant appraisal tool or framework Number of points available per individual category
Total number of points available for ReLIANT
Total number of points available for CASP
Total number of points available for the Jadad (1998) and Pawson et al (2003) frameworks
Qualitative rating
3 – Category considered to be of high quality
9-12
7-9
13-15
High quality: well reported and few concerns about the study.
2 – Category considered to be of medium quality
5-8
4-6
10-12
Medium quality: some concerns about the study
1 – Category considered to be of low quality
1-4
1-3
5-9
Low quality: serious concerns about the study.
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Coleman (2001), Bowers (2002), Flanagan and Flanagan (2002), Happell et al (2003), Garland and McCarty (2009) and Bennett et al (2010). However, although these articles were excluded at this stage, they did provide useful contextual information and helped to expand ideas on the subject of burnout in nurses and care workers in secure settings. Many of the eight articles rejected at this stage discussed the types of stressors faced by nurses and care workers and provided evidence of high rates of burnout, but many also failed to recommend or test interventions to reduce burnout and were, therefore, excluded from the systematic review. The majority of articles rejected at this stage recommended supportive relationships, such as clinical supervision, as a means of managing burnout. It is also notable that the five remaining articles that were included in the final analysis originated from research based in the UK, which indicates a high level of interest in this subject. Five articles were selected for the final stage of the review. Two of these (Walsh 2009, Walsh and Freshwater 2009) recommended clinical supervision and the other three articles (Ewers et al 2002, Doyle et al 2007, Redhead et al 2011) recommended psychosocial intervention (PSI) training as a protective factor against burnout. Each of the studies was assessed for quality by reading the article and using the appropriate appraisal tool or framework. Four of the five articles were of medium quality, and one article by Walsh and Freshwater (2009) was considered low quality (Table 5). Table 6 summarises useful information on these articles and associated studies, including method, interventions, findings and geographic information.
Discussion When nurses and care workers in secure settings start to develop burnout, their attitudes, the quality of their therapeutic relationships with patients, the standard of care they provide and their ability to reflect on their practice are affected. The systematic review identified some evidence supporting the use of clinical supervision and PSI training in reducing burnout among nurses and care workers in secure settings. However, there are issues with the overall validity of the studies under review, for example the quality of reporting in the qualitative studies and the weak statistical significance in the quantitative studies. These issues may compromise the generalisability of study findings to other settings. From an educational perspective, clinical supervision and PSI training are different in their
style, philosophy and purpose, and it is therefore likely that each intervention might reduce burnout in a different way. Clinical supervision is based on interpersonal relationships and reflective dialogue; its process is subjective as ‘the social world of the client is acknowledged as the basis of the developmental process’ (Brockbank and McGill 2006). Alternatively, PSI training is a more formal educational intervention that aims to increase the participant’s knowledge and understanding of severe mental disorders, and helps to develop skills and competence in this area. Interestingly, PSI appears to be beneficial when applied to trained nurses in forensic settings, whereas healthcare
TABLE 4 Reasons for excluding articles based on the population, intervention, comparison and outcome formula at selection stages 1 and 2 Reason for exclusion
Number of articles excluded at stage 1
Number of articles excluded at stage 2
Population
29
1
Intervention
13
3
Comparison
0
0
Outcome
13
3
Methodological issue
10
1
Total
65
8
TABLE 5 Appraisal tool or framework used and results of the appraisal process for articles included in the final analysis Article details
Appraisal tool or framework
Result (quality)
Ewers et al (2002) Does training in psychosocial interventions reduce burnout rates in forensic nurses?
CASP Jadad (1998) framework
Medium
Doyle et al (2007) Burnout: the impact of psychosocial interventions training.
CASP Jadad (1998) framework
Medium
Walsh (2009) The emotional labor of nurses working in her Majesty’s (HM) prison service.
ReLIANT Pawson et al (2003) framework
Medium
Walsh and Freshwater (2009) The mental well-being of prison nurses in England and Wales.
ReLIANT Pawson et al (2003) framework
Low
Redhead et al (2011) An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit.
CASP Jadad (1998) framework
Medium
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Art & science systematic review TABLE 6 Details of articles included in the final analysis Article details
Method
Intervention
Findings
Authors’ conclusions
Notes and geographic region
Ewers et al (2002) Does training in psychosocial interventions reduce burnout rates in forensic nurses?
A quantitative, quasi-experimental pre-test and post-test questionnaire; participants were randomly allocated to a control or experimental group.
A 20-day training course in psychosocial intervention (PSI).
Evidence of improvements in knowledge and attitude and in all three Maslach Burnout Inventory (MBI) sub-scales against a control group.
PSI training can protect against burnout.
Small sample size (ten participants in the experimental group and ten in the control group), therefore it is difficult to generalise findings to other settings. Results were in line with other studies. The researcher was not blinded to the sample. Study based in north west England.
Doyle et al (2007) Burnout: the impact of psychosocial interventions training.
A quantitative study involving a quasi-experimental pre-test and post-test; participants were randomly allocated to a control or experimental group.
16 three-hour PSI study sessions.
Significant increase in knowledge score in posttest results and increase in attitude score. Increase in the personal accomplishment element of the MBI.
PSI appears to have a positive effect on participants. Outlines the need for more forensic-oriented PSI training.
Not all outcome measures were independently validated. Small sample size (14 participants in the experimental group and 12 in the control group). Study based in north west England.
Walsh (2009) The emotional labor of nurses working in her Majesty’s (HM) prison service.
Qualitative, semi-structured interviews and analysis of clinical supervision sessions.
Clinical supervision as a means of developing awareness of emotional labour in prison nursing.
Evidence of the benefits of developing emotional intelligence and reflective learning.
Supportive relationships with clinical supervisors is significant. Supervision is a method of safely acknowledging emotional labour.
Small sample (nine participants in the first stage of the study and two in the final stage). No control group. Difficult to generalise findings. Study based in London prisons.
Walsh and Freshwater (2009) The mental wellbeing of prison nurses in England and Wales.
Action research followed by documentary analysis of a mixture of qualitative data sources.
Three phases of clinical supervision over a seven-year period.
Actual changes in practice such as greater use of action learning, and greater awareness of the purposes and benefits of reflective practice via clinical supervision.
Both reflective learning and clinical supervision provide a mechanism to help prison nurses manage their emotions.
Broad data set (70 participants). Few demographic details made available. Some elements of the study are transferable to other settings. Study based in England and Wales.
Redhead et al (2011) An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit.
Randomised controlled design; participants allocated to an experimental or waiting list control group.
A 16-day training course on PSI delivered over a period of eight months.
Evidence of an increase in knowledge and a decrease in the depersonalisation element of the MBI.
Highlights the benefits of PSI training and suggests the association between PSI training and a reduction in burnout is worthy of further investigation.
Small sample (22 participants in the experimental group and 20 in the control group). Includes qualified and unqualified staff. Study based in north west England.
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assistants report worsening effects on their stress levels in terms of emotional exhaustion (Redhead et al 2011). The differences between clinical supervision and PSI training are reflected in the type of methodology used to evaluate these interventions; clinical supervision is assessed using qualitative methods and PSI training using quantitative methods. There is an observable degree of homogeneity between the style of educational intervention and study designs in the articles by Walsh (2009) and Walsh and Freshwater (2009), which evaluated clinical supervision, and those of Ewers et al (2002), Doyle et al (2007) and Redhead et al (2011), which evaluated PSI training. There appears to be only two clear professional development areas to focus on: the development of reflective learning, and the improvement of knowledge, skills and attitudes to patients.
Knowledge, skills and attitudes to patients
Reflective learning
Study limitations
Reflective learning is central to clinical supervision and the acquisition, maintenance and enhancement of professional development in care work, and it has also been found to underpin successful coping in this context (Collins 2007). Reflective learning can be used to assist the analysis of difficult encounters with service users, to ameliorate cognitive or emotional dissonance, and to develop subsequent management plans. These factors highlight the value of reflection as a self-protective mechanism as well as a way of enhancing professional practice (Ruch 2009). Moreover, reflection is thought to be an integral component of emotional intelligence (Schön 1983). Emotional intelligence is defined as ‘being able to motivate oneself and persist in the face of frustrations; to control impulses and delay gratification; to regulate one’s moods and keep distress from swamping the ability to think; to emphasise hope’ (Goleman 1996). Emotional intelligence has important implications for job performance because it is associated with enhanced judgement and decision-making skills, flexibility in negotiation, and the generation of optimism, co-operation and trust in others (George 2000). In Grant and Kinman’s (2012) study, emotional intelligence was one of the strongest predictors of resilience in social work students. Indeed, Walsh (2009) stated: ‘In order to manage the emotion work inherent in prison work, it is suggested that the development of emotional intelligence through clinical supervision and reflective practice is of significant benefit to both healthcare and discipline staff.’
Both clinical supervision and PSI training promote understanding of various patient factors. In PSI training, participants are educated about causes of patients’ stress and interventions for service users with severe mental illness. Evaluation of PSI training has shown that increased knowledge can promote understanding, which can improve both attitudes and empathy towards service users (Redhead et al 2011). Empathy is an integral component of all caring relationships; it has been found to have strong positive therapeutic effects on service users’ physical, mental and social wellbeing (Morrison 2007). Doyle et al (2007) supported this view, stating: ‘it is likely that there is a link between knowledge, attitudes and burnout’. PSI training ‘engenders feelings of personal accomplishment in helping professionals’ (Morrison 2007), which can contribute to general wellbeing.
Given the small number of articles deemed suitable for inclusion in the systematic review, it may have been worth searching for articles published 25-30 years before 2012. However, any additional articles found would probably not relate to current practice given the considerable changes in both nursing and secure settings.
Internal validity and generalisability
A range of appraisal tools and frameworks was used to review the quality and reliability of the studies in the articles included in the systematic review. Data were then extracted and synthesised. Although three studies used similar designs, the selected studies represent a heterogeneous group. The quality of the studies was variable, and none of the studies was considered to be of high quality. Determining the internal and external validity of the studies has been a major theme of the work. In some of the studies, the primary researchers were not blinded to the experimental group (a possible source of researcher bias), in the quantitative studies appraisal tools were not always externally validated and in several studies important demographic information was not presented. Furthermore, data on non-participants were not discussed, which affects the representativeness of studies. In the two articles by Walsh (2009) and Walsh and Freshwater (2009), the details of how qualitative data were analysed in the studies was not made clear. External validity is important because it describes ‘how well the results can be generalised and are applicable to other circumstances’ (Jüni et al 1999). In all studies,
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Art & science systematic review the sample size was small making generalisability of findings to other settings difficult. It is, however, accepted that qualitative studies are not usually designed to be generalisable.
Recommendations for practice and research Clinical supervision is beneficial in helping some prison nurses to manage their emotions and consequently their mental wellbeing. PSI training has some beneficial effects for qualified nurses, but not for healthcare assistants. Therefore, it is suggested that managers in secure settings consider developing and implementing clinical supervision and PSI training to maintain standards of care and improve efficiency. However, because of the small number and the variable quality of the articles included in this systematic review, any recommendations should be considered carefully. A wider range of educational interventions aimed at reducing burnout should be implemented and evaluated, and future research should be more rigorous, thus increasing validity and reducing the potential for bias. Furthermore, there are implications of these findings in terms of the wider research agenda.
Several generic prison officer and police roles involve informal care-oriented activities, yet there is little published about this type of activity. Informal care is also undertaken by others, such as detainees or prisoners, so there is scope for research into informal caring in these environments. Since healthcare assistants in forensic settings show increased levels of distress after PSI training, there is a need to identify interventions to support these professionals. Recommendations for practice and research are summarised in Box 2 and Box 3 respectively.
Conclusion The aim of this systematic review was to identify not only which educational interventions reduced burnout, but also what works best for whom and in what circumstances. It was expected that a literature search would reveal a wide range of educational interventions tested both in prisons and forensic mental health settings. However, there appears to be a lack of high-quality research in this area. It is notable that different educational interventions have been tested in sub-groups within the specified population. For example, clinical supervision is
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BOX 2 Recommendations for practice Invest in the continuing personal and professional development of staff to ensure staff wellbeing and the management of burnout. Develop good quality clinical supervision in secure mental health settings. Increase the amount of psychosocial intervention training in secure mental health settings.
BOX 3 Recommendations for research Effects of clinical supervision and psychosocial intervention training in all secure settings using mixed qualitative and experimental randomised research design in a range of geographic settings over the longer term, should be explored. Other educational interventions that help to reduce burnout and enhance the resilience of nurses and care workers in prisons and forensic settings should be studied. Educational interventions that specifically address the needs of healthcare assistants should be explored.
shown to enhance psychological wellbeing in nurses and carers working in prisons, whereas PSI training has not been tested in nurses working in prisons and has only been shown to be successful with trained forensic mental health nurses. The articles included in this systematic review provide some evidence of the effectiveness of clinical supervision and PSI training in reducing burnout among nurses and care workers in secure settings. Clinical supervision helps to develop emotional intelligence, which in turn helps nurses to manage emotional stress. PSI training enhances professionals’ knowledge of patient factors, such as the behavioural aspects of severe mental illness, which can promote understanding and empathy towards service users. Although there is some evidence of a link between working in secure settings and burnout, the methods of reducing burnout are complex and require further exploration NS Free online resources For a bundle of articles on stress and burnout go to rcnpublishing.com/r/burnout. For articles on preceptorship go to rcnpublishing.com/r/ preceptorship. Available until April 30.
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kr03.pdf (Last accessed: April 2 2014.) Peacock R (1991) Stress in the Workplace: Studies of Psychiatric Nurses and Prison Service Workers. PhD Thesis, Cranfield Institute of Technology, Bedford. Redhead K, Bradshaw T, Braynion P, Doyle M (2011) An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit. Journal of Psychiatric and Mental Health Nursing. 18, 1, 59-66. Ruch G (2009) Post-Qualifying Child Care Social Work: Developing Reflective Practice. Sage Publications, London. Sackett D, Richardson WS, Rosenburg W, Haynes RB (1997) How to Practice and Teach Evidence Based Medicine. Second edition. Churchill Livingstone, Edinburgh.
Schön D (1983) The Reflective Practitioner: How Professionals Think in Action. Basic Books, New York NY. University of Central Lancashire (1999) Nursing in Secure Environments: A Scoping Study Conducted on Behalf of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London. Walsh E (2009) The emotional labor of nurses working in her Majesty’s (HM) prison service. Journal of Forensic Nursing. 5, 3, 143-152. Walsh E, Freshwater D (2009) The mental well-being of prison nurses in England and Wales. Journal of Research in Nursing. 14, 6, 553-564. Wright SG (2005) Burnout: a spiritual crisis. Nursing Standard. 19, 46, 1-24.
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If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Reducing burnout in nurses and care workers in secure settings Stewart W, Terry L (2014) Reducing burnout in nurses and care workers in secure settings. Nursing Standard. 28, 34, 37-45. Date of submission: July 16 2013; date of acceptance: November 5 2013.
Abstract Aim To identify which educational interventions reduce burnout and promote wellbeing in nurses and care workers in secure settings. Method A systematic review of health, educational and criminal justice literature was undertaken to appraise relevant studies and identify educational interventions that were effective in reducing burnout. Findings There is some evidence that clinical supervision and psychological intervention training are successful in reducing burnout in nurses and care workers in secure settings. Conclusion Supportive relationships can help nurses to manage emotional stress, and continuing personal and professional development can reduce burnout in qualified nurses in secure settings.
Authors Warren Stewart Senior lecturer, School of Health Sciences, Brighton University, Brighton. Louise Terry Reader in law and ethics, Faculty of Health and Social Care, London South Bank University, London. Correspondence to: [email protected]
Keywords Burnout, clinical supervision, mental health, psychosocial interventions, reflective learning, secure settings, stress
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
‘BURNOUT’ IS DEFINED AS A ‘psychological state that is characterised by the following symptoms: emotional exhaustion, depersonalisation and a decreased perception of personal accomplishment’ (Maslach et al 1996). Burnout in the workplace results in increased financial costs in relation to staff sickness and turnover (Wright 2005), as well as reduced quality of patient care (Coffey 1999). Nurses tend to experience higher levels of occupational stress and burnout than other professionals (Aiken et al 2002, Medland et al 2004). This is an important observation because a correlation exists between burnout and poor quality of care, failure to recognise patient distress and decreased job satisfaction (Aiken et al 2002). Moreover, nursing as a career is often associated with high stress levels, which can deter individuals from becoming nurses and can also contribute to nurses leaving the profession (Medland et al 2004). Nurses and care workers in secure settings, such as prisons and forensic mental health units, experience high rates of burnout (Dickinson and Wright 2008). According to Coldwell and Naismith (1989), both the perceived threat of violence and actual physical violence contribute to high levels of stress in nursing staff in secure settings. Studies suggest that nursing and care staff can become cold and cynical as a result of burnout, thereby displaying less empathy and avoiding patient interaction (Ewers et al 2002). Bowers (2002) highlighted the difficulties carers face when trying to retain therapeutic optimism in secure settings, and questioned why some carers experience burnout and become cynical whereas others thrive in this environment. There has been an increase in the volume of literature describing the role of resilience in
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Art & science systematic review mitigating the negative effects of work-related stress (Howard 2008). Resilience can be defined as ‘the general capacity for flexible and resourceful adaptation to external and internal stressors’ (Klohnen 1996). Kinman and Grant (2011) reported that ‘interventions designed to enhance inter-personal and intra-personal emotional competencies are likely to foster resilience, which in turn, has the potential to protect the future well-being of carers’.
Aim The aim of this systematic review was to identify which educational interventions reduce burnout and promote wellbeing in nurses and care workers in secure settings. It is hoped that this information will provide guidance to inform practice and identify future research opportunities in this area.
Method Literature search
A search of the relevant health, educational and criminal justice databases was undertaken between January and May 2012 to answer the research question: ‘Which educational interventions reduce burnout among nurses and care workers in secure settings?’ A systematic review can be justified as a suitable methodological approach to answer this research question for
two reasons. First, there is a degree of uncertainty about the range of interventions that have been developed and evaluated in this area and second, it was anticipated that there would be a large number of different types of articles relating to educational interventions in secure settings. To inform the literature search, inclusion and exclusion criteria were developed using the population, intervention, comparison and outcome (PICO) formula (Sackett et al 1997) (Table 1). Table 2 summarises the databases searched during scoping searches, conducted in February 2012 to establish whether there were enough studies of suitable quality to conduct the review, and full literature searches. Electronic databases were searched using MeSH terms or appropriate permutations, for example ‘forensic mental health nursing’ and ‘reducing burnout’; ‘burnout’ and ‘prison nursing’; or ‘secure nursing’ and ‘educational interventions’ (Box 1). Care was taken to increase the sensitivity and specificity of the searches, using the most appropriate search terms to ensure that all potentially relevant articles were identified. Scoping searches retrieved a substantial number of relevant articles, therefore justifying the research question. The full search was restricted to articles based on studies published between 1991 and 2012, because this was considered a suitable timeframe in relation to policy changes in both the NHS and Her Majesty’s Prison Service.
TABLE 1 Inclusion and exclusion criteria using the population, intervention, comparison and outcome formula Study criteria
Inclusion criteria
Exclusion criteria
Population
Qualified nurses working in secure or forensic settings, or related community facilities; healthcare support workers in secure or forensic settings; qualified prison nurses; healthcare support workers in prison settings; other criminal justice care workers, for example specific prison officers; and police custody officers.
Qualified adult and child nurses in generic settings; generic mental health nurses working in areas other than secure or forensic settings; care workers in areas other than secure or forensic settings; and criminal justice workers working in generic settings.
Intervention
Educational interventions, for example clinical supervision, reflective learning, psychosocial skills training, preceptorship, study days, mindfulness and induction.
Non-relevant interventions, policy or practice changes and non-educational interventions.
Comparison
No intervention, ordinary practice.
Interventions lacking robust research evidence, for example homeopathy.
Outcome
Quantitative and qualitative data based on reduced burnout or increased wellbeing as measured qualitatively or by self-reporting scales.
Studies that did not measure a reduction in burnout qualitatively or via self-reporting scales; studies that did not assess an educational intervention and studies based in areas other than secure or forensic settings.
Type of study
Qualitative primary data studies, quantitative studies, randomised controlled studies, controlled studies and surveys.
Commentaries, systematic reviews and case studies (although these can provide useful contextual information and reference lists).
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There have been several reports and inquiries during this time, some of which advocated significant changes in educational and clinical practice (Fallon 1999, University of Central Lancashire 1999, Department of Health 2009).
Quality appraisal and data extraction
The overall quality of a research study can be influenced by several factors, such as the non-reporting of essential information or choice of method. Therefore, every effort was made to match the most appropriate appraisal tool to the individual studies. The tools selected, in the first instance, were the Critical Appraisal Skills Programme (CASP) (www.casp-uk. net) for quantitative studies and ReLIANT (Koufogiannakis et al 2006) for qualitative studies. CASP focuses on three areas: validity, results and benefits. The ReLIANT tool was developed on the basis that, because educational interventions are essentially ‘social’ interventions taking place in a social or educational setting and their effect may be moderated by the context and the person introducing them, such studies should be judged on the basis of authenticity. The ReLIANT tool assesses quality in four areas: study design, educational context, results and relevance. The use of two separate tools to assess study quality reflects the differing methodologies of the studies in the articles identified and, therefore, the heterogeneity of the sample. Two frameworks were also used to inform judgements on the quality of the studies. The framework developed by Jadad (1998) assessed relevance, internal validity, external validity,
analysis and presentation, and ethical implications for quantitative studies. The framework developed by Pawson et al (2003) assessed transparency, accuracy, purposivity, utility and propriety for qualitative studies. The articles were reviewed independently by the researcher and the research supervisor to reduce bias. The result of each appraisal was discussed until a working consensus was reached. Table 3 shows the points available using each appraisal tool or framework. The process of data extraction involved returning to the primary articles and highlighting
BOX 1 Synonyms and keywords used in the search strategy Population: Forensic nurses. Prison nurses. Correctional nurses. Healthcare workers. Intervention: Educational interventions. Training interventions. Continuing professional development. Psychosocial interventions. Comparison: No interventions. Organisational interventions. Outcome: Burnout. Reduced burnout. Stress. Stress reduction.
TABLE 2 Summary of databases searched Category of databases
Individual databases
Nursing
Medline, CINAHL Plus, British Nursing Index and PsycINFO.
Reviews
Cochrane Library and Campbell Collaboration.
Education and social care
Education Resource Information Center (ERIC), and Applied Social Sciences Index and Abstracts (ASSIA).
Criminal justice
Criminal Justice Abstracts and National Criminal Justice Reference Service.
Journals (Sage criminal justice journals)
Crime & Delinquency; Criminology and Criminal Justice; Crime, Media, Culture; Criminal Justice Review; and Criminal Justice and Behaviour.
Special searches
Home Office website and Ministry of Justice website.
London South Bank University catalogue
Books and subsequent searches based on reference lists.
Grey literature
British Library ‘Ethos’ search, Nursing and Midwifery Council (nurses or care workers working in secure settings) website, Department of Health website and Dissertation Abstracts Online.
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Art & science systematic review the relevant information to answer the research question (Bettany-Saltikov 2010). An extraction form was developed and piloted on two articles
FIGURE 1 Summary of article identification and selection process Articles identified through database searching (n =8,737)
Findings
Excluded (n=8,659), reasons: duplicates, false positives and unsuitable articles
Articles identified through database searching (n=78)
Stage 1: excluded (n=65), reasons: the wrong population or the wrong intervention was studied, or other methodological reasons
Full text articles of potentially relevant citations retrieved (n=13) Stage 2: excluded (n =8), reasons: differences between the study populations, interventions and outcomes
Final selection of articles included in the review (n =5)
that were randomly selected from the initial selection, however neither article was included in the final stage of the review. Bias was further reduced by collaborative working between the researcher and the research supervisor, and by retaining a reflexive approach – an awareness of personal values and preferences in relation to the study types, methods of data collection and results – throughout this process.
Figure 1 presents a diagrammatic summary of the article identification and selection process. The total number of retrieved articles from all searched databases was 8,737; of these, 78 articles were selected initially as being relevant to the research question. There were two further selection stages to determine the final articles to be included in the systematic review. The main reason for excluding articles from the review was that the study population (type of care worker) did not match the population under review (nurses or care workers working in secure settings) (Table 4). Several articles referred to generic nursing roles, that is, either adult or generic mental health nurses, which was not specific enough in terms of the population identified in the research question. It was originally thought that specific prison officers and police custody officers could be included in the review because it can be argued that some of these roles involve providing some social care for offenders. However, a lack of specific information was found about these professionals. At the final stage of the review process, a further eight articles were excluded on the basis of the PICO formula (Table 4). These were articles by Peacock (1991), Coffey (2000), Coffey and
TABLE 3 Points available using the relevant appraisal tool or framework Number of points available per individual category
Total number of points available for ReLIANT
Total number of points available for CASP
Total number of points available for the Jadad (1998) and Pawson et al (2003) frameworks
Qualitative rating
3 – Category considered to be of high quality
9-12
7-9
13-15
High quality: well reported and few concerns about the study.
2 – Category considered to be of medium quality
5-8
4-6
10-12
Medium quality: some concerns about the study
1 – Category considered to be of low quality
1-4
1-3
5-9
Low quality: serious concerns about the study.
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Coleman (2001), Bowers (2002), Flanagan and Flanagan (2002), Happell et al (2003), Garland and McCarty (2009) and Bennett et al (2010). However, although these articles were excluded at this stage, they did provide useful contextual information and helped to expand ideas on the subject of burnout in nurses and care workers in secure settings. Many of the eight articles rejected at this stage discussed the types of stressors faced by nurses and care workers and provided evidence of high rates of burnout, but many also failed to recommend or test interventions to reduce burnout and were, therefore, excluded from the systematic review. The majority of articles rejected at this stage recommended supportive relationships, such as clinical supervision, as a means of managing burnout. It is also notable that the five remaining articles that were included in the final analysis originated from research based in the UK, which indicates a high level of interest in this subject. Five articles were selected for the final stage of the review. Two of these (Walsh 2009, Walsh and Freshwater 2009) recommended clinical supervision and the other three articles (Ewers et al 2002, Doyle et al 2007, Redhead et al 2011) recommended psychosocial intervention (PSI) training as a protective factor against burnout. Each of the studies was assessed for quality by reading the article and using the appropriate appraisal tool or framework. Four of the five articles were of medium quality, and one article by Walsh and Freshwater (2009) was considered low quality (Table 5). Table 6 summarises useful information on these articles and associated studies, including method, interventions, findings and geographic information.
Discussion When nurses and care workers in secure settings start to develop burnout, their attitudes, the quality of their therapeutic relationships with patients, the standard of care they provide and their ability to reflect on their practice are affected. The systematic review identified some evidence supporting the use of clinical supervision and PSI training in reducing burnout among nurses and care workers in secure settings. However, there are issues with the overall validity of the studies under review, for example the quality of reporting in the qualitative studies and the weak statistical significance in the quantitative studies. These issues may compromise the generalisability of study findings to other settings. From an educational perspective, clinical supervision and PSI training are different in their
style, philosophy and purpose, and it is therefore likely that each intervention might reduce burnout in a different way. Clinical supervision is based on interpersonal relationships and reflective dialogue; its process is subjective as ‘the social world of the client is acknowledged as the basis of the developmental process’ (Brockbank and McGill 2006). Alternatively, PSI training is a more formal educational intervention that aims to increase the participant’s knowledge and understanding of severe mental disorders, and helps to develop skills and competence in this area. Interestingly, PSI appears to be beneficial when applied to trained nurses in forensic settings, whereas healthcare
TABLE 4 Reasons for excluding articles based on the population, intervention, comparison and outcome formula at selection stages 1 and 2 Reason for exclusion
Number of articles excluded at stage 1
Number of articles excluded at stage 2
Population
29
1
Intervention
13
3
Comparison
0
0
Outcome
13
3
Methodological issue
10
1
Total
65
8
TABLE 5 Appraisal tool or framework used and results of the appraisal process for articles included in the final analysis Article details
Appraisal tool or framework
Result (quality)
Ewers et al (2002) Does training in psychosocial interventions reduce burnout rates in forensic nurses?
CASP Jadad (1998) framework
Medium
Doyle et al (2007) Burnout: the impact of psychosocial interventions training.
CASP Jadad (1998) framework
Medium
Walsh (2009) The emotional labor of nurses working in her Majesty’s (HM) prison service.
ReLIANT Pawson et al (2003) framework
Medium
Walsh and Freshwater (2009) The mental well-being of prison nurses in England and Wales.
ReLIANT Pawson et al (2003) framework
Low
Redhead et al (2011) An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit.
CASP Jadad (1998) framework
Medium
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Art & science systematic review TABLE 6 Details of articles included in the final analysis Article details
Method
Intervention
Findings
Authors’ conclusions
Notes and geographic region
Ewers et al (2002) Does training in psychosocial interventions reduce burnout rates in forensic nurses?
A quantitative, quasi-experimental pre-test and post-test questionnaire; participants were randomly allocated to a control or experimental group.
A 20-day training course in psychosocial intervention (PSI).
Evidence of improvements in knowledge and attitude and in all three Maslach Burnout Inventory (MBI) sub-scales against a control group.
PSI training can protect against burnout.
Small sample size (ten participants in the experimental group and ten in the control group), therefore it is difficult to generalise findings to other settings. Results were in line with other studies. The researcher was not blinded to the sample. Study based in north west England.
Doyle et al (2007) Burnout: the impact of psychosocial interventions training.
A quantitative study involving a quasi-experimental pre-test and post-test; participants were randomly allocated to a control or experimental group.
16 three-hour PSI study sessions.
Significant increase in knowledge score in posttest results and increase in attitude score. Increase in the personal accomplishment element of the MBI.
PSI appears to have a positive effect on participants. Outlines the need for more forensic-oriented PSI training.
Not all outcome measures were independently validated. Small sample size (14 participants in the experimental group and 12 in the control group). Study based in north west England.
Walsh (2009) The emotional labor of nurses working in her Majesty’s (HM) prison service.
Qualitative, semi-structured interviews and analysis of clinical supervision sessions.
Clinical supervision as a means of developing awareness of emotional labour in prison nursing.
Evidence of the benefits of developing emotional intelligence and reflective learning.
Supportive relationships with clinical supervisors is significant. Supervision is a method of safely acknowledging emotional labour.
Small sample (nine participants in the first stage of the study and two in the final stage). No control group. Difficult to generalise findings. Study based in London prisons.
Walsh and Freshwater (2009) The mental wellbeing of prison nurses in England and Wales.
Action research followed by documentary analysis of a mixture of qualitative data sources.
Three phases of clinical supervision over a seven-year period.
Actual changes in practice such as greater use of action learning, and greater awareness of the purposes and benefits of reflective practice via clinical supervision.
Both reflective learning and clinical supervision provide a mechanism to help prison nurses manage their emotions.
Broad data set (70 participants). Few demographic details made available. Some elements of the study are transferable to other settings. Study based in England and Wales.
Redhead et al (2011) An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit.
Randomised controlled design; participants allocated to an experimental or waiting list control group.
A 16-day training course on PSI delivered over a period of eight months.
Evidence of an increase in knowledge and a decrease in the depersonalisation element of the MBI.
Highlights the benefits of PSI training and suggests the association between PSI training and a reduction in burnout is worthy of further investigation.
Small sample (22 participants in the experimental group and 20 in the control group). Includes qualified and unqualified staff. Study based in north west England.
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assistants report worsening effects on their stress levels in terms of emotional exhaustion (Redhead et al 2011). The differences between clinical supervision and PSI training are reflected in the type of methodology used to evaluate these interventions; clinical supervision is assessed using qualitative methods and PSI training using quantitative methods. There is an observable degree of homogeneity between the style of educational intervention and study designs in the articles by Walsh (2009) and Walsh and Freshwater (2009), which evaluated clinical supervision, and those of Ewers et al (2002), Doyle et al (2007) and Redhead et al (2011), which evaluated PSI training. There appears to be only two clear professional development areas to focus on: the development of reflective learning, and the improvement of knowledge, skills and attitudes to patients.
Knowledge, skills and attitudes to patients
Reflective learning
Study limitations
Reflective learning is central to clinical supervision and the acquisition, maintenance and enhancement of professional development in care work, and it has also been found to underpin successful coping in this context (Collins 2007). Reflective learning can be used to assist the analysis of difficult encounters with service users, to ameliorate cognitive or emotional dissonance, and to develop subsequent management plans. These factors highlight the value of reflection as a self-protective mechanism as well as a way of enhancing professional practice (Ruch 2009). Moreover, reflection is thought to be an integral component of emotional intelligence (Schön 1983). Emotional intelligence is defined as ‘being able to motivate oneself and persist in the face of frustrations; to control impulses and delay gratification; to regulate one’s moods and keep distress from swamping the ability to think; to emphasise hope’ (Goleman 1996). Emotional intelligence has important implications for job performance because it is associated with enhanced judgement and decision-making skills, flexibility in negotiation, and the generation of optimism, co-operation and trust in others (George 2000). In Grant and Kinman’s (2012) study, emotional intelligence was one of the strongest predictors of resilience in social work students. Indeed, Walsh (2009) stated: ‘In order to manage the emotion work inherent in prison work, it is suggested that the development of emotional intelligence through clinical supervision and reflective practice is of significant benefit to both healthcare and discipline staff.’
Both clinical supervision and PSI training promote understanding of various patient factors. In PSI training, participants are educated about causes of patients’ stress and interventions for service users with severe mental illness. Evaluation of PSI training has shown that increased knowledge can promote understanding, which can improve both attitudes and empathy towards service users (Redhead et al 2011). Empathy is an integral component of all caring relationships; it has been found to have strong positive therapeutic effects on service users’ physical, mental and social wellbeing (Morrison 2007). Doyle et al (2007) supported this view, stating: ‘it is likely that there is a link between knowledge, attitudes and burnout’. PSI training ‘engenders feelings of personal accomplishment in helping professionals’ (Morrison 2007), which can contribute to general wellbeing.
Given the small number of articles deemed suitable for inclusion in the systematic review, it may have been worth searching for articles published 25-30 years before 2012. However, any additional articles found would probably not relate to current practice given the considerable changes in both nursing and secure settings.
Internal validity and generalisability
A range of appraisal tools and frameworks was used to review the quality and reliability of the studies in the articles included in the systematic review. Data were then extracted and synthesised. Although three studies used similar designs, the selected studies represent a heterogeneous group. The quality of the studies was variable, and none of the studies was considered to be of high quality. Determining the internal and external validity of the studies has been a major theme of the work. In some of the studies, the primary researchers were not blinded to the experimental group (a possible source of researcher bias), in the quantitative studies appraisal tools were not always externally validated and in several studies important demographic information was not presented. Furthermore, data on non-participants were not discussed, which affects the representativeness of studies. In the two articles by Walsh (2009) and Walsh and Freshwater (2009), the details of how qualitative data were analysed in the studies was not made clear. External validity is important because it describes ‘how well the results can be generalised and are applicable to other circumstances’ (Jüni et al 1999). In all studies,
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Art & science systematic review the sample size was small making generalisability of findings to other settings difficult. It is, however, accepted that qualitative studies are not usually designed to be generalisable.
Recommendations for practice and research Clinical supervision is beneficial in helping some prison nurses to manage their emotions and consequently their mental wellbeing. PSI training has some beneficial effects for qualified nurses, but not for healthcare assistants. Therefore, it is suggested that managers in secure settings consider developing and implementing clinical supervision and PSI training to maintain standards of care and improve efficiency. However, because of the small number and the variable quality of the articles included in this systematic review, any recommendations should be considered carefully. A wider range of educational interventions aimed at reducing burnout should be implemented and evaluated, and future research should be more rigorous, thus increasing validity and reducing the potential for bias. Furthermore, there are implications of these findings in terms of the wider research agenda.
Several generic prison officer and police roles involve informal care-oriented activities, yet there is little published about this type of activity. Informal care is also undertaken by others, such as detainees or prisoners, so there is scope for research into informal caring in these environments. Since healthcare assistants in forensic settings show increased levels of distress after PSI training, there is a need to identify interventions to support these professionals. Recommendations for practice and research are summarised in Box 2 and Box 3 respectively.
Conclusion The aim of this systematic review was to identify not only which educational interventions reduced burnout, but also what works best for whom and in what circumstances. It was expected that a literature search would reveal a wide range of educational interventions tested both in prisons and forensic mental health settings. However, there appears to be a lack of high-quality research in this area. It is notable that different educational interventions have been tested in sub-groups within the specified population. For example, clinical supervision is
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Dickinson T, Wright KM (2008) Stress and burnout in forensic mental health nursing: a literature review. British Journal of Nursing. 17, 2, 82-87.
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BOX 2 Recommendations for practice Invest in the continuing personal and professional development of staff to ensure staff wellbeing and the management of burnout. Develop good quality clinical supervision in secure mental health settings. Increase the amount of psychosocial intervention training in secure mental health settings.
BOX 3 Recommendations for research Effects of clinical supervision and psychosocial intervention training in all secure settings using mixed qualitative and experimental randomised research design in a range of geographic settings over the longer term, should be explored. Other educational interventions that help to reduce burnout and enhance the resilience of nurses and care workers in prisons and forensic settings should be studied. Educational interventions that specifically address the needs of healthcare assistants should be explored.
shown to enhance psychological wellbeing in nurses and carers working in prisons, whereas PSI training has not been tested in nurses working in prisons and has only been shown to be successful with trained forensic mental health nurses. The articles included in this systematic review provide some evidence of the effectiveness of clinical supervision and PSI training in reducing burnout among nurses and care workers in secure settings. Clinical supervision helps to develop emotional intelligence, which in turn helps nurses to manage emotional stress. PSI training enhances professionals’ knowledge of patient factors, such as the behavioural aspects of severe mental illness, which can promote understanding and empathy towards service users. Although there is some evidence of a link between working in secure settings and burnout, the methods of reducing burnout are complex and require further exploration NS Free online resources For a bundle of articles on stress and burnout go to rcnpublishing.com/r/burnout. For articles on preceptorship go to rcnpublishing.com/r/ preceptorship. Available until April 30.
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