Enquiring Into Healthcare Practice - Essay Example

 Enquiring Into Healthcare Practice Chapter 1 Introduction This dissertation will take the form of a literature review and will examine the subject of ‘Stress and Burnout in Forensic Psychiatric Nursing’. In undertaking the exploration of the literature the author anticipates identifying the main stressors in forensic nursing and possible ways to alleviate and reduce these. This dissertation will be presented in a logical format to aid the reader. The initial chapter will be the introduction where the reader will be advised what they might expect from each chapter. Chapter two will give the justification of the subject choice. Clifford (1997) supports this by stating that at the beginning of any research study there is a need to clarify the area of study and make a clear statement of what is seen as the research problem. It will also look at the author and his colleague’s own experience of stress. In chapter three the process of the literature search and the winnowing process will be presented. The author will examine in greater depth the issue of stress and burnout in forensic nursing. The process of the literature search will be analysed. Furthermore the rational for selecting the three articles for review in chapter four will be illustrated. Salkind (2003) support this by stating it is imperative that the writer justifies his choice of literature. Chapter four will provide the most comprehensive chapter of the dissertation. It will examine the three articles identified in chapter three in finer detail. The three selected articles appraise the subject of stress and burnout in forensic nurses from different angles. Chalder and Nolan (2000) undertake a comparative study to compare stress among forensic and acute care mental health nurses. Kirby and Pollock (1995) explore the relationship between a medium secure environment and occupational stress in forensic psychiatric nurses. Finally Happel et al (2003b) analyse stress and burnout in forensic psychiatric nursing in Australia. The main principles of undertaking the critical analysis of these three articles are according to Polit et al (2001) to cultivate critical thinking, objectively identify areas of adequacy and inadequacy, also to illuminate the papers virtues as well as its faults. Clifford (1997) also goes on to state that critical analysis also helps practicing nurses think about how study findings can be used and, sometimes, actually to plan a utilization project. Chapter five will look at all the research from the literature review and discuss the three articles in the context of wider literature and issues. The author will discuss stress and burnout in forensic psychiatric nursing taking into account all literature available on the subject, and, its application to practice. In chapter six recommendations will be identified for practice and how this can be disseminated to others. The dissertation is completed with chapter seven a conclusion. This will take the form of a personal reflective account of the author’s experience of undertaking this dissertation. To facilitate this process Boud et al’s (1985) model of reflection will be utilised. Chapter 2 Background/Rational For the purpose of this dissertation the author feels it pertinent that the terms stress and burnout are examined. Edwards (1990) describes stress as a negative discrepancy between an individual’s perceived state and desired state, provided that the individual considers the presence of this discrepancy important. Dewe (1987) goes on to suggest that definitions of stress should reflect its relationship to adaptive factors. The individual’s ability to cope with external pressures is dependant upon a cognitive appraisal of the stressor and the coping strategies the person has available to them. Stress therefore is perceived in relation to the person’s previous experience, success or failures in dealing with similar situations. Notwithstanding that burnout was first described more than thirty years ago. According to Freudenberger (1974) it is a syndrome consisting of emotional exhaustion, depersonalisation, and reduced personal accomplishment. Furthermore Schulz et al (1995) describe burnout as a negative experience that results from the interaction between the individual and the environment. Stress and burnout is something the author has witnessed first hand. Forensic psychiatric nurses work with patients who have generally exhibited aggressive behaviour. Moreover according to Coldwell and Naismith (1989) the perceived threat of, and actual physical violence is believed to contribute to high levels of stress in forensic nursing. This in turn has led the author to contemplate the link between violence and aggression and stress and burnout in forensic nursing. The author was curious to determine to what extent stress and burnout existed in forensic nursing. Moreover what could be done to reduce or alleviate it? This is highlighted by the National Health Service (NHS) Executive (1995) who expressed concern about the ability of care organizations to mange the well being of their staff. It emphasised that the damaging effects of stress on individuals have important implications for the organizations in which they work. Low levels of motivation and creativity are not commensurate with a progressive health care service. One has the impression from Western Culture that nurses who care for psychiatric patients, referred by law-enforcement (forensic psychiatric patients, including patients formerly termed ‘criminally insane’ [a contradiction in terms]), would inevitably be subject to greater risk of violence and aggression, and, stress and burnout than in any other field of nursing. Notwithstanding that it would seem pertinent to explore the nursing and medical literature with a view to determining whether that impression has any evidence basis. Moreover the main antecedent for determining stress and burnout in forensic psychiatric nursing as the subject to explore herein is due to the personal experiences of the author and his colleagues. Forensic nursing has well documented adversity. Cacciacarne et al (1986) illuminate threats from violent offenders, possible retaliatory actions and a low professional status because they work with defendants who are often seen as societal misfits. Furthermore Happel (2003a) states that poor staffing, low morale and a dangerous and unpredictable image are all problems forensic nurses face. Phillips (1983) also illustrate the conflict in the approach to dealing with the mentally ill offender may be seen in terms of whether the patient is a mentally ill person who needs to be diverted within the healthcare system for treatment or if they are first and foremost a criminal who must first expiate the sentence before their health problems can be attended to, even though they may be found not guilty by reason of insanity or unfit to stand trial. There is also wide statistical evidence to confirm the author’s personal assumption that nurses working in forensics and healthcare personnel in general are prone to stress and burnout. According to Landau (1992) 25% of all nurses suffer from burnout. Severinsson and Kamaker (1999) also go on to vent that nurses are susceptible to stress and burnout, mainly because of the nature and emotional demands of their profession. This is supported by Ploeg et al (2003) who goes on to affirm that a fifth of forensic doctors in their study were diagnosed as at risk of clinical burnout. It could be assumed that some people become nurses to replicate significant experiences from their childhood and to optimise dreams and expectations passed onto them by family members. That said according to Pompili et al (2006) these expectations are difficult to meet. This is particularly more prevalent in forensic care where according Phillips (1983) the general feeling of repulsion towards the offender and the offence committed are sometimes distracted towards those who work with these individuals. ‘How can you stand being with those criminals?’ is a question frequently asked. Given this and the absence of answers to some of the questions raised the author feels the subject warrants further inquisition. Chapter 3 Overview of Available Literature. Introduction This chapter will start with the identification of the pertinence of reading research and will outline the winnowing process. The search history undertaken by the writer will determine the type and quantity of the literature available to support this dissertation. The major reorganisation of the health care provision in the United Kingdom and pressures from the government now mean according to Clifford (1997) that health care practices are based on a sound evidence base rather than ritualistic or traditional practices. This is supported by Burns and Grove (2003) who illuminates that through nursing research, scientific knowledge can be developed to improve nursing care, patient outcomes, and the health care delivery system. In order to develop a good research report Feinstein (1973) state the author should understand the limitations of various types of research, whether analytic, experimental, cross-sectional, randomised or controlled trial. Moreover Parahoo (1997) state the author should also be able to identify the advantages and limitations of each modality, and should be able to distinguish high-and low quality research. However in order to review the literature; a search must first be conducted. According to Polit et al (2001) a literature search simply means locating and identifying the most up-to-date and relevant material. Moreover according to Burns and Grove (2003) life is now a lot easier for the researcher in terms of time spent in the library, where only a short period of time ago searching for literature meant spending a long time reviewing published indexes that were available on library shelves, only to find these indexes were inevitably out of date by the time they reached the library. Notwithstanding that Parahoo (1997) believe these items such as books should not be overlooked and are good sources that provide understanding of concepts and issues. However for the purpose of this literature review the author chose to utilize a more modern search strategy. Sources of Literature: Databases There are a large number of electronic sources now available which include JANET and TELNET, World Wide Web (www), MetLib, and AHMED (alternative therapies). Also according to Burns and Grove (2003) the most relevant nursing database is CINHAL, which contains citations of nursing literature published after 1955. Further databases commonly used by nurse researchers are illuminated by Polit et al (2001) as MEDLINE and PubMed. Libraries also subscribe to vendors who provide software such as Sliver Platte, OVID, and PaperChase. These according to Burns and Grove (2003) can be used to access multiple bibliographical databases. Since the topic of this dissertation focuses on mental health of nurses, searches were conducted on CINHAL, as the main nursing database, and PSYCHLIT as the main psychological database. The Ovid site has the facility to search the other databases within the Ovid programme thus reducing the time spent repeating the search in other databases. The author also obtained the relevant research books to support any methodological discussion. On this occasion books were not utilized for the discussion on stress and burnout as according to Blaxter et al (2001) by the time books are written, published and consulted, the research and statistical information they contain is already dated. The Literature Search: Terms and Results The search terms ‘forensic nursing’ and ‘occupational stress’ were found to be the most appropriate subject headings for both data bases. These produced thirteen articles in CINHAL and one in psycINFO. Since the number of produced articles was manageable there was no need to limit the search. The author was very disappointed with the fourteen hits identified initially. However the titles of the articles were scrutinized to assess their appropriateness to the dissertation. Parahoo (1997) states that the title of the article should be clear and concise immediately informing the reader of the aim of the study. From this the author identified that there were some appropriate articles from the search that could be utilized. The search grid in Appendix 1 provides a print out of the sear strategy and the articles retrieved. Following further assessment of the searches the three most appropriate articles were located or ordered from the British Library. The articles selected were all research articles and peer reviewed. They were also from accepted academic journals. However according to Blaxter et al (2001) the fact that an article is printed does not give it instant credibility. Therefore producing the need for critical analysis of the articles. The three selected articles for review in chapter 4 will now be identified the actual abstract from the paper will also be documented to give the reader a brief overview of each article. The rationale for selecting the articles will also be discussed. Article 1 Chalder, G., Nolan, P.W., (2000). A Comparative Study of Stress among Forensic and Acute Mental Health Nurses. British Journal of Forensic Practice. 2 (3), pp. 24-29. Abstract ‘This study sought to address one of the most critical issues that mental health professionals endure in modern health care, namely stress at work. Though it has been discussed for some time in the literature relating to mental health services, it remains one of the biggest impediments to the provision of high quality care. In this study, two groups of mental health nurses were compared: forensic and acute mental health nurses. Stress levels were ascertained using a standardized assessment tool, the Mental Health Professional Stress Scale (MHPSS). Though both groups reported high levels of stress, no significant differences were found between them. Though both groups perceived certain aspects of their work as being stressful, each group identified different causes for stress within their respective work environments. This paper discusses some of the implications of these findings and highlights the importance of protecting staff from unpropitious work environments and burnout’. Rational This article was selected, as there is a general assumption among psychiatric nurses that forensic care is the most stressful environment to work within. It seemed pertinent therefore to examine whether there was any evidence basis to this. Moreover, since the article looked at two different specialties acute and forensic care this article seemed most appropriate to examine this. The paper also applies quantitative data to its research questions. Article 2 Kirby, S.D., Pollock, P.H., (1995). The Relationship between a Medium Secure Environment and Occupational Stress in Forensic Psychiatric Nurses. Journal of Advanced Nursing 22 (5), pp. 862-867. Abstract ‘The present study investigated occupational stress levels in forensic psychiatric nurses within a medium secure unit for mentally disordered offenders and examined the possible relationships between aspects of the ward environment and identified stress levels. Data were obtained through self-reportage measures and unit statistics using a sample of 38 nurses on two secure (high and medium) wards. No significant differences in levels of occupational stress or perception of ward environment were observed between nurses on the two wards. Global ward atmosphere scores were compared with those of a maximum secure facility in the USA, showing the unit to be highly therapeutic. Occupational stress scores for all nurses were compared with normative regional data and showed elevated scores on broad view control, satisfaction and type behaviour. No demographic or ward environment variables were found to be associated with these high scores. Interpretations and implications are discussed’. Rationale This article was selected for review as it addresses the topic in hand and because it applied hard, quantitative data to its research questions. Moreover, the author is currently working within a medium secure hospital as in the paper. Therefore, it is most appropriate to his current practice. Secondly, it compares both high and medium secure wards. The author has often contemplated whether high secure is more stressful than medium secure nursing and therefore selected this paper with a view to gaining an evidence-based answer. Article 3 Happell, B., Pinikahana, J., Martin, T., (2003b). Stress and Burnout in Forensic Psychiatric Nursing. Stress and Health 19 (2), pp. 63-68. Abstract ‘The relevant literature suggests that all branches of the nursing profession are subject to high levels of stress and burnout. Forensic psychiatric nursing has been considered as an area of high risk, despite a paucity of literature in this area, particularly in Australia. This paper presents the findings of a research study undertaken with forensic nurses (n=51) and designed to measure their level of stress and burnout. The Maslach Burnout Inventory (MBI) and the Nursing Stress Scale (NSS) were the instruments used. The findings indicated that relatively few forensic nurses suffered from ‘high’ levels of burnout with considerably more forensic nurses recording ‘low’ levels of burnout. On the personal accomplishment subscale, only 17 per cent recorded a ‘high’ score. Interestingly the least reported stressor was lack of staff support for nursing activities which suggests that the amount of support received may account for lower than expected levels of stress’. Rationale This article was selected on the basis that is was one of the closest to the identified area of study in that it seeks to explore stress and burnout in forensic psychiatric nursing. Once again as in the other articles it applied hard, quantitative data to its research questions. The research is also conducted in Australia and the author was keen to see if there was any marked difference in the stress levels experienced in another country. Chapter 4 Review of the Chosen Literature Introduction This chapter will seek to critically analyse the three chosen articles. The three articles will be examined individually; to aid the process of critically analysing the papers a performa suggested by Parahoo (1997) will be utilized. The performa provides headings under title of article, abstract, literature review, methodology, results, discussions, interpretation and recommendations. The headings aid in the structure of the evaluation of research articles as it gives a clear pathway to follow in this process. This performa has been selected as it is of a similar format to the research articles for review. All articles can be found in appendix 2. Article 1 Chalder, G., Nolan, P.W., (2000). A Comparative Study of Stress among Forensic and Acute Mental Health Nurses. British Journal of Forensic Practice. 2 (8), pp. 24-29 Review of Article 1 Title, abstract, literature Review The title of the article seems on-point and appears staight forward and succinct in fulfilling the role according to Clifford (1997) of informing the reader of the aim of the study. The reader is immediately aware that the study is a comparative study, which seeks to compare the stress among forensic and acute mental health nurses. The abstract summarises the key features of the study and the research findings and sets forth their significance well. Polit et al (2001) identify that from the abstract the reader should be able to quickly assess the methodology, sample size, results and discussion. Chalder and Nolan (2000) start their study with an introduction. According to Clifford (1997) the introduction should give a historical prospective to the article. In their introduction the authors claimed that ‘stress appears to be reaching epidemic proportions in Western countries’. They also aimed to ‘compare the levels of stress experienced by nurses working in forensic services and those working in acute services. The poorly supported conclusion of the paper itself is that the difference in perceived levels of stress between forensic and acute care psychiatric nurses is minimal. The introduction therefore has no coherent explanation of the rationale for the study. A review of the literature follows. This according to Parahoo (1997) allows the researchers to state what they believe their study will contribute to the body of knowledge. The authors’ referred to previously published research however their choice of research seems slanted in favour of their initial editorial assumptions, that nurses experience a lot of stress and burnout, which is contrary to the conclusions of their article. The references are as wide-ranging and up-to-date as it is possible for the authors’ selection to be with this narrow, little researched subject. Methodology Feinstein (1978) suggest that a study group and a control group would have been superior to such uncontrolled self-reportage by questionnaire. However even a rigorous study would only have been adequate for hypothesis generation, not for definitive conclusions. The sample consisted entirely of registered mental health nurses, a control group could have been recruited amongst nursing staff from another ward that also worked with adult patients. The use of a control group helps to test causal hypotheses (Roberts, 2003). It is necessary that each group be equal with regard to participant characteristics and sampling framework, so that any differences that may be detected between the two groups can be confidently attributed to a real effect, rather than change being due to chance or extraneous variables (alternative hypotheses)( Asmundson, Norton, & Stein, 2002). The mental health nursing profession is the suspected the causal agent of stress in the study. As such, with a control group Chalder and Nolan would look to find that more stress is significantly higher in the experimental group (i.e., the mental health nurses). Overall, a control group functions to reduce measurement error and sample bias. Further, the authors chose a research methodology, the self-reportage questionnaire, which according to Sackett (1979) is inappropriate because of the inherent biases in it. These include self-selection bias, the bias that subjects exhibit in agreeing to become study-subjects, and further selection-bias or recruitment-bias, a bias that investigators exhibit in agreeing to accept study subjects. Sampling bias means that inherent bias can be attributed to how the questionnaire is used. It is important the participant selection criteria be observed to control for sample bias (Roberts, 2003). For example, as the instrument is written in English, all participants should speak English as a first language, so as to decrease the likelihood of misinterpretation of an item, and increasing the reliability of the questionnaire. The inherent bias is unlikely to be attributable to the instrument, the Mental Health Professional Stress Scale (MHPSS)(Cushingway, 1995 as cited in Chalder & Nolan, 2000). The 42 items contain an equal distribution of positive and negative wording to reduce instrument bias. The 4-point Likert scales allow respondents to report their level of disagreement with each item. Statements that are not-applicable to a participant are scored 1, while highly applicable statements are scored 4. The items are categorised into one of seven sub-categories: workload, client-related difficulties, organisational structures and processes, relationships and conflict with other professions, lack of resources, professional self-doubt, and home-work conflict. The sub-totals are added across to provide a total score between 42 and 168, higher scores indicating higher perceptions of stress. A study by Nolan et al., (1995 as cited in Chalder & Nolan, 2000) has confirmed the reliability and validity of the questionnaire. Across other studies, the MHPSS repeatedly demonstrates a strong ability for instrument to measure and predict stress (Chalder & Nolan, 2000). Also, as all nursing staffs were first level mental health nurses working with adults. It may have been more prudent that eligibility to take part in the study be based on at least two years work experience within the facility. The investigators may have been in a better position to communicate the benefits of contributing to research to the nurses had they approached a more homogenous group. The large literature on stress in other contexts suggests according to Nickel et al (2004) that a better but more expensive method to measure stress would have consisted of psychiatrists clinically evaluating a study group (and a control- group) of nurses for signs and symptoms of stress and burnout matching objective criteria. However according to Salkind (2003) one might say that it is unethical knowing that using and studying the person concerned makes them enter the testing scenario in which the study subjects will be observed and studied for a relative period of time which inevitably would intrude on their privacy. The effect is a manifestation of an unrecognized form of ‘publication bias’, whereas the phenomenon to which the writer of the dissertation refers here is the tendency of even an invalid study to bias influential policy makers, merely because it appears in publication. The authors performed no staging of subjects by severity of stress related illness or effects and therefore attempted no stratification on any such bias. The study according to LoBiondo-Wood and Harber (2001) is a cross-sectional survey. The authors collected data from subjects, who referred to their past experience of an unidentified duration. Moreover any instrument that relies on ratings of subjective personal characteristics is according to Thorndike (1998) inherently inaccurate as the ratings are affected by a marked tendency to think of oneself in general as rather good or rather inferior and to color judgements of the qualities by his general feelings. Notwithstanding that their number can be of pertinence in determining how many individuals were suffering from stress. The authors vaguely described the distribution by mail, to 60 nurses, of the instrument, the Mental Health Professional Stress Scale (MHPSS). The authors reported that the 38 nurses (63% of the total sample) who completed the instrument consisted of 23 forensic nurses (61%) and 15 acute care nurses (39%). The terminology in the MHPSS is itself biased. MHPSS personalizes some conflicts, such as ‘client-related difficulties’ and ‘relationships and conflicts with other professionals’ however depersonalises and sanitizes the nursing conflict with management, consisting of policy makers and administrators who determine budgets, staffing levels and organizational tone and culture by their conscious will, as ‘organizational structure and process’ and ‘lack of resources’. The authors omitted any consideration of the stress producing effect of nurses occupying subordinate positions, subject to orders of others. The authors omitted any mention of those biases in their study design and delineated no specific shortcomings of their study. However whatever the biases are the methodology that was used and that is the questionnaire method cannot be addressed and rated as ineffective. Indeed according to Blaxter et al (2001) a questionnaire can be a simple cost effective way of gathering information from a large sample. To add to that, the respondents answered on their own opinion and they also answered with answers they deem as the stressor for them. Disregarding all biases, Burns and Grove (2003) believe a questionnaire can be a good pendulum for this type of quantitative study. The authors chose to perform a statistical analysis using the Mann-Whitney U test, which according to White (1979) is appropriate to the extent that it is a non-parametric test for non-parametric data. However the failure of the authors to report their raw data prevents the reader from being able to assess whether the authors applied it appropriately. Results The authors failed to designate any section of the article ‘results’, however the results are presented using tables and by figures using percentage of the respondents. By presenting the facts and figures the authors have omitted the graphical presentation which according to Polit et al (2001) can greatly aid in determining the desired outcome of the study. The authors analyzed all the responding subjects in the study but because of the nebulous and biased nature of the results and the impropriety of the statistical analyses, the adequacy of the authors interpretations are not entirely valuable. The authors concluded ‘no significant differences were found between the two groups of nurses. The forensic scored highly on the ‘relationships and conflicts with other professionals’ sub scale while acute mental health nurses scored significantly more highly on the ‘lack of resources’ sub scale. The scores for five of the sub-scales (workload, client related difficulties, organizational structures and processes; professional self-doubt and home-work conflict), proved not to be statistically significant. Discussion, interpretation and recommendations The discussion section of the paper follows and according to Blaxter et al (2001) should be an opportunity to place ones own research in context and then pull out any new findings before making recommendations. While the authors claim that this study can be regarded as the first of it’s kind, one cannot deny the fact that it is lacking in details and the only saving grace of it is that the facts and figures. Quantitative method according to Parahoo (1997) is essential for this type of study in which the respondents and their numbers are an important element of this study. However we cannot disregard the fact the authors placed their results in the context of what others do in similar fields of investigation. They noted that their results were coherent with some other results and discordant with others. The conclusions and recommendations are appropriate, to the extent that the authors called for more investigation of the subject. However inappropriate according to Sackett (1979) in their failure to evaluate or even discuss the probable severe effects of the biases and other methodological defects of their study and in their rhetorical extrapolation. A major shortcoming in the presentation is the absence of original raw data. According to Davies (1987) without having access to raw data, a reader cannot be sure of an error’s importance and is justified in being sceptical of the study’s results. In place of raw data, the authors presented processed figures in table 1, which delineated ‘characteristics of study sample’ in the form of the number in each several categories and table 2, with even more processed results of statistical calculations. Furthermore according to Blaxter et al (2001) in the absence of raw data, the reader cannot verify or refute the accuracy of the authors’ statistical calculations. The wider impact of this study is unpredictable but its publication makes its influence likely to be greater than it should be. Article 2 Kirby, S.D., Pollock, P.H., (1995). The Relationship Between a Medium Secure Environment and Occupational Stress in Forensic Psychiatric Nurses. Journal of Advanced Nursing. 22 (5), pp. 862-7 Review of Article 2 Title, abstract, literature Review The article title seems on point and appears straightforward and succinct but it mislabels self-perception of occupational stress as ‘occupational stress’ when such perception may be inaccurate. It misinforms the reader of the papers content and message by suggesting that it proves definitive conclusions on the subject even though its retrospective methodology precludes the possibility that it could provide that. Notwithstanding that the abstract summarises the key features of the study, the research findings and their significance well. As in Chalder and Nolan (2000) the paper commences with an introduction. In their introduction the authors noted that little work had been done, before their articles publication, on their topic. They noted that nurses, in general have a lower life expectancy, at age 45 and higher ‘rates of suicide and suicide related death’, than do women in ‘comparative female’ occupations. They omitted the parameters for evaluation of what they considered ‘comparative’ and reviewed nothing specifically relevant to forensic psychiatric nurses or indeed male nurses. Since ‘suicide’ means ‘self killing’ the distinction the authors drew between ‘suicide and suicide related death’ seems obscure. The authors continued with a literature review which they renamed ‘theoretical approaches’. This could however prove misleading to some readers. The references are as wide ranging and up to date as it was possible for the author’s selection to be in this narrow, little researched subject at the time of publication. It fulfils its task according to Parahoo (1997) of informing the reader why the current study is important and what research if any has been carried out before. Methodology The authors chose research methodology based on two self-reportage questionnaires specifically the Ward Atmosphere Scale (WAS) and the Occupational Stress Indicator (OSI). As in article 1, such a method is inappropriate because of the same inherent biases listed there. Better would have been the physical methods cited in the review of article 1. The inclusion exclusion criteria were clear namely as many nurses who worked on the surveyed wards as possible that the authors could induce to participate in their study. This according to Polit et al (2001) is inappropriate due to the threat of the internal validity of the study being jeopardised resulting from pre-existing differences between the subjects in the study. Although the randomized controlled trial is widely accepted as the best design to investigate new interventions, conducting a trial in primary care may present researchers with many methodological problems (. The use of a randomized controlled trial would have provided a better research design, sample recruitment procedures may present methodological problems (Huiberset al., 2004). The design used by Kirby and Pollock (1995) did not include a control group, but if it had it would have increased the internal validity of the study if each of the groups had participants randomly assigned (Roberts, 2003). Hence, the statistical design was not ideal for aiding high internal validity. Importantly, it is the lack of random assignment that significantly reduces the effectiveness of he research design. Practically, the dominant concern is that to demonstrate internal validity and so establish the true effects of the treatment (e.g., the questionnaire), is to ensure that the comparison groups are equivalent in all aspects except that of the IV (e.g., stress). The absence of original raw data is a defect in this presentation as in article 1. Another is the absence in this presentation, of any proposal for any solution to stress and burnout. The study according to Parahoo (1997) is retrospective and cross sectional. The authors collected data from the subjects who referred to their past experiences of unstated and uncertain duration. The authors made no effort to follow a cohort of nurses forward in time to assess change in their circumstances, emotional reactions or levels of ‘stress’ of the 47 nurses surveyed on the wards 38 responded (89%, misstated 80% in the article). According to Clifford (1997) the good response rate lends an air of reliability to the results. However Blaxter et al (2001) argue that any instrument that relies on ratings of subjective personnel appraisal may be inaccurate. Coens and Jenkins (2000) also go on to state that most employees see themselves as excellent workers and may feel others will be disappointed with their rating and ranking if they are not at the highest level. It could therefore be said that ratings of oneself, by self reportage, on even more imprecise and dynamic qualities such as ‘stress’ and ‘burnout’ are even more futile and subject to bias. The authors have failed to mention any of those obvious biases in their study design. The study was analytic, cross sectional and retrospective and the authors divided the subjects by prior allocation to wards A and B without randomization. The small number of respondents, 38, even if they had all responded would according to Burns and Grove (2003) probably comprised too small a sample to confer sufficient power to justify any positive conclusions. To add to that, in the actual number of the respondents only 16 were nurses. The others were 14 nursing assistants, five managers, and one student nurse. The authors discussed no rationale for their sample size and type beyond their observed response-rate. The authors used outcome measures compared scores on the WAR and the OIS, between wards A and B. The authors considered theses outcome measures appropriate to their four research questions. However the point is debatable, according to Clifford (1997) considering the foregoing biases, and omission of randomization. The authors relied on prior assessments of the reliability and validity of the measures, without commenting on whether the reliability and validity could oppose each other and without mentioning any measures they took to account for or counteract that opposition. The authors chose according to Polit et al (2001) to perform a statistical analysis by one-way variance (ANOVA), comparing mean and standard deviation of each ordinal parameter in the two comparison groups, appropriate for parametric data, on their non-parametric data. However White (1979) suggests that a median and interquartile range would have been more appropriate. Results The authors presented the results clearly in two graphs. The authors analyzed all the subjects in the study however, because of the biased results, the propriety of the statistical analyses and the adequacy of the authors interpretations seem beside the point. They found no significant difference in most parameters of occupational stress in the WAS and OSI between Wards A and B. Discussion, interpretation and recommendations The authors failed to discuss the results of the study adequately, since they omitted mention of the foregoing shortcomings. However they presented a much clearer presentation than Chalder and Nolan (2000). The authors placed their results in the context of what other authors had previously found in a similar field of investigation. They noted that their results were consonant with some other results and discordant with some others. The conclusions and recommendations are appropriate, to the extent that the authors called for more investigation into the subject but inappropriate in their failure, explicitly, to discuss the probable severe effects of the biases and other methodological defects of their study. The wider impact of the study is unpredictable but its publication makes its influence likely to be greater than it should be. Article 3 Happel, B., Pinikahana, J., Martin, T., (2003b) Stress and Burnout in Forensic Psychiatric Nursing. Stress and Health. 19. pp 63-68. Review of Article 3. Title, abstract, literature Review This article starts with a title that seems on-point and straight forward and succinct. However it misinforms the reader of the papers content and message by suggesting that it proves definitive conclusions on the topic, though it cannot because of its retrospective approach. The title is expanded upon in the abstract which summaries the key features of the study, the research findings and their significance well. Thereby according to LoBiondo-Wood and Haber (2001) allowing the reader to quickly assess the study and it’s relevance to them. This would be particularly beneficial to anyone undertaking a literature review and who might be faced with a large number of articles to read. (Hart, 1998) In their introduction, the authors exaggerated and distorted facts and resorted to an extreme reference (Kendrick, 2000) an article about nurse-anaesthetists to editorialize about their theory, ‘stress has been identified as one of the major reasons why nurses fail to function at an optimum level of effectiveness’. The authors refer to no objective or testable definition of nursing ‘effectiveness’ and to no method of excluding alternative explanations for impaired nursing ‘effectiveness’, whatever that might be. In particular, for nurse-anaesthetists, stress, related to the responsibility for maintaining patients very lives during surgery and/or cumulative exposure to anaesthetic agents may have reduced nursing ‘effectiveness’. The authors referred to relevant, previously published research. However their choice of research seems slanted in the favour of their editorial position, that nurses experience a lot of stress and burnout, which is contrary to the conclusion of their article. A particularly unedifying aspect of this article is its unethical duplication, with minimal, deceptive rephrasing and juggling of the order of presentation of authors names, the same year in another journal (Happel et al, 2003a), to produce an instance of the most degenerate form of according to Feeg (1992) ‘salami-science’. There is a tendency to divide scientific work into small pieces to get as many articles as possible out of each study, ‘salami science’. When one article would do several take up precious space in journals and confuse readers about the number of reported cases in the literature. Fletcher and Fletcher (1994) also go on to state that some authors have gone so far as to submit identical, or very similar, manuscripts to more than one journal. This practice is unethical. In many countries it is also illegal: unless permission is granted, it is a copyright infringement if one journal publishes an article after another one has. The authors nefarious intent seems clear from the parallelism in their sample sizes, demographics and analyses, and in their omission, in each article, of any reference to their other article, either published or in press, despite considerable parallelism, otherwise, though not identity, between the reference lists of the two articles, the publisher of one of which is European (Happell et al, 2003a) and the other American (Happel et al 2003b). Whether those discrepancies are the author’s sincere and inadvertent errors or deliberate attempts to cover their tracks is uncertain, however the latter seems more likely. The authors according to Engel (1994) committed the fallacy of petitio principii (beginning the question, circular reasoning) in their statement that the paucity of literature on stress and burnout of forensic nurses indicates a need for research in that area. The paucity of the literature on the subject could well arise from the paucity of problems related to stress or burnout among forensic psychiatric nurses. Indeed, the poorly supported conclusions of the paper, itself is that the problem is minimal and, by comparison with results of other studies on general nurses, less than those in other nursing specialities. Methodology The authors chose a research methodology, the self-reportage questionnaire, which is inappropriate as in the previous articles because of the same inherent biases listed earlier. This is even more prevalent since the respondents also selected themselves for inclusion. As with the previous articles according to LoBiondo-Wood and Harber (2001) a study and control group would have been superior to such uncontrolled self-reportage. Again a more effective method could have consisted of psychiatrist’s clinical evaluation of the study group of nurses for signs and symptoms of stress and burnout according to objective criterion as documented in the earlier reviews. As in the previous articles a major shortcoming in the presentation is the absence of original raw data. Another defect is the absence of any elucidation of a solution to stress and burnout. The study according to Feinstein (1978) is retrospective and cross sectional. The authors collected data from the subjects, who referred to their past experience, of unstated and uncertain duration. The authors made no effort to follow a cohort of nurses forward in time to assess any change in their circumstances or emotional reactions. In their methods section, the authors vaguely described the distribution of the instruments, the Maslach Burnout Inventory (MBI) and the Nursing Stress Scale (NSS). The small number of nurses, 95, according to Clifford (1997) even if they had responded, would probably have comprised too small a sample to confer sufficient power to justify any disparate conclusions. This study was retrospective and did not compare disparate groups. The authors reported that, of the 54 percent of the sample who completed the instruments, 51 nurses completed the MBI and that 50 nurses completed most items on the NSS. Having declared that 50 nurses, at most, had completed the NSS, in their table IV, the authors claimed that 51 nurses had completed table V. The authors offered no explanation for their reported discrepancy in reported response-rate. They discussed no rationale for the size of their sample of 95 nurses, beyond their observed response rate The terminology of the NSS is itself biased. The NSS personalizes ‘conflict with other nurses’ ‘conflict with supervisors’ and ‘conflict with physicians’ but depersonalizes and sanitizes the nursing conflict with management. Such conflicts with remotely conceived administrators appear under depersonalized terminology as ‘not enough staff’, ‘lack of support’, ‘not enough time’ ‘break down of computer’ and the like. The authors omitted any mention of those obvious biases in their study-design. The authors, as did the foregoing authors, relied on prior assessments of the reliability and validity of the measures, without commenting on the likelihood that reliability and validity could tend to oppose each other and without mentioning any measures they took to account for or counteract that tendency. The authors chose to perform a statistical analysis (mean, standard deviation), appropriate for parametric data, on their non-parametric data. Instead, according to White (1979) the median and interquartile range would have been more appropriate. Results The author failed to designate a section of the article ‘results’ but they presented the results clearly in a series of tables using percentages. They omitted any use of graphical methods of presentation. The authors analyzed all the subjects in the study but, because of the nebulous and biased nature of the results, and the propriety of the statistical analyses the adequacy of the author’s interpretations seem irrelevant. Discussion, interpretation and recommendations The authors failed to discuss the results of their study adequately since they omitted mention of the foregoing shortcomings, though they cited the small sample size, which renders generalization of its results inappropriate. The authors place their results in the context of what other authors had previously found in the same field of investigation. They noted that their results were consonant with some other results and discordant with some others. The conclusions and recommendations are appropriate, to the extent that the authors called for more investigation of the subject but inappropriate in their failure, explicitly, to discuss the probable severe effects of the biases and other methodological defects of their study. They concluded that forensic psychiatric nurses experience relatively low levels of stress and burnout, compared to nurses in other specialities, but the methodological flaws seem sufficiently severe to justify dismissal of their conclusions. Conclusion Nurses are increasing expected to adopt an evidence-based practice. (Polit et al, 2001). However Parahoo’s (1997) study interestingly reports a lower rate of research utilization amongst mental health nurses in comparison to nurses in other branches, a fact that provides some rationale for this enquiry. The three articles were chosen, as they were most appropriate to the research subject. They all examine stress and burnout from different approaches. In all, the articles used are coherent with each other however do display their independence tackling different angles of this study. In the critical analysis of the papers the author has gained perspectives on the issue of stress and burnout in forensic nursing. The three papers were all mainly quantitative in their approach. Due to the minimal amount of literature available on the said subject it was difficult to locate an appropriate qualitative research article. This is contrary to the work of Cutcliffe (2000) who states there is a mutual attraction between mental health nurses and qualitative research methodology. The common trait in all papers where that they failed to discuss the severe effects of the biases and other methodological defects of their studies. Disappointingly all papers fail to give definitive solutions to the problem of stress and burnout. The authors propose only vague and unsubstantiated bromides as solutions to stress and burnout: ‘support systems’, ‘counselling’, and, ‘open and honest culture, where individuals can feel free to speak up about issues that are causing stress’. The authors provide no criteria for evaluating the availability of the above-mentioned systems, far less any mention of the presence or absence of those remedies in the localities they studied. Moreover the research suggests that there is no higher prevalence of stress and burnout in forensic nursing than in other fields. However consideration of the content has provided insight into the issue of stress and burnout in forensic nursing to inform the discussion chapter which will follow. Chapter 5 Discussion Introduction This chapter will discuss the results of the articles reviewed and their application to practice. The three articles selected for review in chapter four will be discussed initially. This will be pursued by a more general discussion addressing the wider issues regarding stress and burnout in forensic nursing. To aid this discussion further articles found in the initial literature search will be analysed. By this process of analysis and synthesis the impact of this enquiry on the authors’ own practice, both currently and in the future will be discussed. Discussion The original aim of this enquiry was to determine the extent of stress and burnout in forensic nursing, furthermore to identify ways to reduce or alleviate these. The papers reviewed in chapter four make a contribution to this however they do leave a lot of questions unanswered. As a nurse leader the author was looking to implement an evidence based solution to the problem of stress and burnout in the work place. The most logical place to seek such information would be to examine the reports for recommendations. The papers however do seem somewhat sparse as none of the articles give any clear recommendations or solutions to the problem. The work of Chalder and Nolan (2000) found that forensic nurses scored highly on the sub-scale ‘relationships and conflict with other professionals’. The client group in a forensic unit is a challenging one and difficult behaviour also brings about difficult decision-making regarding their care and management. This of course can inevitably bring about conflict of interests between staff. One such decision according to Whittington and Mason (1995) is the decision to seclude a patient if their behaviour is a risk to themselves or others. It will often be the registered nurses decision to seclude a patient in this situation. Managing a potentially violent person is a relatively unusual human experience and according to Moores and Grant (1977) is a very stressful encounter. Whittington and Mason (1995) also go on to vent the nurse has to consider the safety of the staff and other patients. Furthermore with the pertinent litigation regarding seclusion the constant apprehension whether the right decision has been made to seclude is also an issue. Their work also found that the nurse may concern oneself with what fellow practitioners would have in the same done situation and if their decision would be supported by management. Chalder and Nolan (2000) also commented that staff working in a forensic unit may have strong personalities and are prepared to be assertive. The combination of strong personalities and highly skilled professionals may at its best lead to lively debate, at worse lead to serious disagreement on occasions. Nurses’ may find it difficult to see things as objectively as some people and believe their views, based on extended patient contact is more accurate. This may or may not be the case, however it will inevitably lead to dissatisfaction amongst ward based nursing staff. This is something the author has witnessed and experienced first hand. Notwithstanding that according to Butterworth et al (1992) and Kipping (2000a) group supervision is excellent to discuss issues as a group regarding practice in an open forum. Chalder and Nolan (2000) also go on to suggest team building days and formal analysis of critical incidents are all recognized methods to improve communication with collages. This is something the author will consider implementing into the work setting. Kirby and Pollock (1995) also document that if there are more supportive and beneficial relationships, fewer mental health/stress problems were observed. They noted that staffs appear to go through a stress ‘inoculation phase’, whereby adjustment leads to longer term adaptation. The prospect of coming to work in a closed institution and deal with possibly violent, murders and rapists may lead to increased anxiety before an individual actually begins work. However once an individual realizes that most of these preconceptions are not as serious as anticipated, they go through a process of adjustment to the environment, type of patients and duties. Over the longer period short-term readjustments leads to successful or unsuccessful adaptation, and the skills to suit this environment are learnt and applied. Another issue that could be deemed as stressful in forensic nursing is maintaining control of the environment (Dooley, 1986). However Kirby and Pollock (1995) found that staff felt little need to exert excessive, repressive control methods to maintain stability on the ward. They felt confident and safe enough to rely upon the environment, its regime and their relationships with their patients to limit most disruptive behaviour. Larkin et al (1988) found that nurses working in forensic settings recognize the potential for danger in their patients and consequently place special emphasis on the need for security. Security traditionally equates with control and therefore the findings of Kirby and Pollock (1995) contradict this assumption. Kirby and Pollock (1995) utilized the OSI, which divides participants into 25 subscales. Of this type A behaviour was most prominent. The traits of this behaviour are commitment, confidence, priorities, ambition and dedication. The scores showed that there appeared to be a high proportion of well motivated, assertive, ambitious, independent thinking and proactive staff on the unit. It could be assumed that theses characteristics draw people to the demanding, high profile and challenging form of work encountered in forensics. Therefore it could be suggested that these individuals develop better stress coping strategies. Furthermore Kirby and Pollock (1995) also state it could be considered that the underlying rational behind recruitment is to select individuals who display type A behaviour. The hospitals were the author currently works; do not have any obvious selection process to look for these traits. However this is something that the author feels may need reviewing in liaison with human resources. Happell et al (2003b) found that overall forensic psychiatric nurses do not experience particularly high levels of stress. This is contrary to the work of Coffee (1999) and Coffee and Coleman (2001) who identified high levels of stress and burnout in forensic nurses. Further research would be required in order to more adequately address these differing findings. However Happell et al (2003b) did find that the primary stressor in nurses in their study was ‘workload’. Nurses found it stressful when they did not have adequate time to provide emotional support to patients or complete their day to day nursing activities or enough staff to cover the unit. This is something the author has experiences first hand where the arduous task of completing paper work can take the nurse away from providing emotional support to their patients. As a result of this the author is to meet with the senior management to try to negotiate a supernumerary day every month where nurses can complete there mandatory documentation moreover are not counted in the workforce on that particular day. The study by Happell et al (2003b) found that levels of support experienced by nurses were quite high. It is therefore possible that support is one of the primary factors in influencing levels of stress and burnout rather than the clientele for whom nurses provide care. As a nurse leader this is something the author continuously seeks to provide, it is however important according to Rix (1987) and Whittington and Wykes (1992) that this support is provided by and available to all whether formal or informal. The author will seek to maintain this level of support and instil this ethos on fellow staff. The previous discussion noted that none of the papers in chapter four gave definitive solutions to the problem of stress and burnout and since this was a pertinent component of the enquiry, the author feels that further research needs to be examined. Ewers et al (2002) conducted a study to investigate whether training in psychosocial interventions reduces burnout rates in forensic nurses. The conclusions to the study were promising and found that this did reduce burnout rates. This may be the most valuable study of all those reviewed here, to the extent that it was prospective and experimental and examined the benefits from training of the members of the study-group in coping with stress by comparing the parameters of coping of that group with those of the control-group at three junctures. However they claimed ‘[f]urther research investigating larger numbers of subjects, in different settings, and employing more rigorous methodologies is needed before any conclusions about the true value of such training can be made’. Finally the work of Cacciacare et al (1986) found that higher ranking staff reported lesser amounts of burnout. Therefore they suggested that redesigning or rotating the repetitive jobs of lower ranking staff might help reduce burnout. They advocated that nurses should have greater input into decisions made at staff or team meetings. The author is currently in the process implementing staff rotation in the work place. Staffs are encouraged to change wards every 12-18 months to rotate jobs and experience working with a different client group. This is also supported by Flanagan and Flanagan (2002) who state that staff rotation can lead to lower rates of stress and burnout, especially if someone has worked in a demanding and challenging environment such as a dangerous and severe personality disorder ward for a long period. Having discussed all the literature available the author feels it pertinent to make recommendations for practice. These will be addressed in chapter six. Chapter 6 Recommendations Initially the author feels that this is a very little researched area. Therefore further research would be warranted. Moreover in further research on the subject of stress and burnout in forensic nursing, authors should take care to avoid applying inappropriate statistical tests to their data. Complicated scenarios and situations like this needs appropriate and delicate handling of the issue such as avoiding hasty generalization on conclusions as well as focusing on a certain group like neglecting the importance of a randomised kind of survey for it hinders the number of scope and the number of respondents which results to limited output. According to Martin and Happell (2001) most professionals employed in forensic centres have graduate degrees. Some of their original intentions for entering the area of human services are self-fulfilment, personal values of justice and fairness, and a sense of wanting to help mankind. When these individuals leave the idealistic world of academia and confront reality in the work place, frustration and cynicism are likely to develop. Workers in forensic settings rarely experience the personal satisfaction of seeing their efforts culminate in concrete results. It is important therefore that forensic centres should create support systems to enable staff members to express their feelings openly and learn to deal with the frustrations. (Chalder and Nolan, 2000; Happell et al 2003b, Coffee, 1999) The author as a nurse leader will seek to foster an open and honest culture, where individuals can feel free to speak up for themselves or on behalf of others about issues that are causing stress. The hospital also provides a free confidential counselling service. However not all staff are aware of this service. The author will ensure this is readily advertised for all staff to access. The work of Ewers et al (2002) found that training in psychosocial interventions helps reduce burnout rates in forensic nurses. This is currently being considered for implementation on the young offenders’ ward of the hospital. Furthermore with this new research the author feels it will be worth discussing with senior management the possibility of equipping all staff with this training. This will not only benefit staff but also patients by having a work force equipped to deliver these therapeutic interventions. Leggett and Silvester (2003) found that formal analysis of critical incidents is extremely important. The author is fully aware that time constraints of the job do not always allow for this to happen. However the author will look to introduce a de-brief session at the end of each shift were staff will meet to discuss any issues that have arisen during the shift. The author also feels that more training is required in de-briefing of critical incidents. Given the issue of lack of time as discussed earlier the author will also look to implement a supernumerary day for all registered nurses where they can complete documentation and not to taken away from according to Kipping (2000b) the very nature of the role of a psychiatric nurse providing emotional support to their patients. Following the work of Whittington and Mason (1995) the author feels there is a need for more training in the appropriate use of seclusion, especially for newly graduated nurses. Furthermore according to Phillips (1983) forensics usually offer a higher salary to attract people into the unattractive speciality. However this can have a negative effect as the author has experienced first hand by attracting the wrong type of people, who are just there for the financial gains of the job. Notwithstanding that the work of Kirby and Pollock (1995) suggested that recruiting people with the aforementioned type A behaviour could ensure that the people recruited to the service have a more adaptive strategy to cope with the stressors of the job. This is something the author is interested in and is eager to explore further. Therefore will arrange to meet with human resources to discuss and analyse in greater detail. Finally forensic nursing is a very specialized area of nursing. Forensic psychiatric nurses must be able to demonstrate what is distinct and therapeutic about their practice. Explication of the nurse-patient relationship will be essential in this process. There is a further need for investigation of the nurse’s role in addressing offence issues within the context of the nurse-patient relationship. Furthermore according to Coffey (1999) incorporating knowledge and skills related to offending behaviour into their practice will contribute significantly to the development of forensic psychiatric nursing as a clinical speciality. Chapter 7 Conclusion Due to the reflective nature of this chapter I feel it is appropriate to write in the first person as I will be reflecting upon the process of undertaking this dissertation. Webb (1992) supports this by stating it is acceptable to write in the first person when giving a personal opinion or when one has played a crucial role in shaping the data or ideas presented. The work of Platzer et al (2000) identified that learning through reflection is more potent if there is an understanding of frameworks that encourage a structural process to guide the act of reflection. In light of this I have chosen to utilize Boud et al’s (1985) model of reflection, as it is an effective reflection tool that allows you to fully analyse the given situation. It breaks the reflection into four sections; returning to the experience, attending to feelings, re-evaluating the experience and learning from experience. Returning to the Experience The purpose of the dissertation was to enquire into stress and burnout in forensic nursing. I believe that I have undertaken this task comprehensively within this paper. I initially had trouble deciding on a subject to enquire into. However having seen collages suffering from stress and burnout I decided to see if there was anything as a nurse leader I could do to reduce or alleviate this. I initially found it difficult to balance my work and academic study; however by structuring my study time I was soon able to balance the two. Another hindrance was the difficulty in finding appropriate research articles on the said subject. Given the informal assumption that forensic nursing is stressful the quantity of literature on the subject is sparse. Notwithstanding that as my research skills and use of appropriate databases increased I was able to source more appropriate literature. Attending to Feelings Throughout this dissertation I have experienced a whole range of emotions. Initially I was very daunted by the prospect of having to complete a paper of this word count. However as I broke it down into a chapter at a time the process became more manageable. As mentioned earlier it was very frustrating initially not being able to source appropriate papers to aid the study. I began to think that I would not be able to complete this dissertation and lacked confidence in my academic ability. Furthermore as my knowledge of the research process increased through taking a systematic approach to reviewing the literature so did my confidence. Re-evaluating the Experience On reviewing the experience I realise that in hindsight I would have selected a different article to review in chapter four. Although Happell (2003b) on initial examination looked ideal in that it addressed the topic in hand. On further examination it, like the other two articles provided no definite solution to the problem of stress and burnout in forensic nursing. I feel a more appropriate article to review would have been Ewers (2002) as this actually proposed a solution to test. Given the lack of solutions proposed in the literature it has led me to contemplate if there actually are any definite solutions to the problem of stress and burnout. Furthermore whether stress is accepted as an intrinsic part of working within a forensic setting and appropriate coping techniques are devised accordingly. Learning from the Experience This has been the most academically challenging piece of work I have completed throughout my studies. I have learnt a lot not only about myself but the research process. 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