From nurse education, clinical, or workforce issues through to healthy living, Nursing Review has it covered.

Anxiety and depression are expected to be the leading causes of missed work days worldwide in the next five years. International research indicates that nurses already have higher levels of depression and anxiety than the general population. Nursing Review explores the issue.

Caring can be hazardous to your mental health.

The new Health and Safety at Work Act puts the onus on employers to eliminate or minimise risks to their workers’ health and safety – including their mental health.

Studies both here and overseas show that caring for others – who are often at their most vulnerable – in today’s fast-paced, high acuity, high workload health sector can come at a cost to the mental health and wellbeing of the carers.

It can lead to unhealthy stress levels, fatigue, emotional exhaustion, cynicism, compassion fatigue, moral distress and burnout. It can also be a trigger for anxiety and depression disorders.

But while nurses may talk about stress or feeling emotionally drained at the end of a day, it appears that few are likely to share that they have a mental health disorder like anxiety and depression.

Nursing blogger Barbara Docherty last year described depression as nurses’ “best kept secret” in a blog that went viral, attracted many social media comments and led to nurses taking the opportunity to confidentially share their stories.

It should not be a surprise that nurses suffer depression and anxiety as the 2012–13 New Zealand Health Survey found that one in six New Zealand adults (16 per cent) had been diagnosed with common mental health disorders (including depression and anxiety) at some time in their lives, and one in five New Zealand women.

Literature reviews also indicate that mental health issues are more prevalent in nursing and the other health professions than they are in the general population – probably because of the high stress and emotional demands of the work.

For example, a major review of the health and wellbeing of Britain’s NHS staff by Dr Steve Boorman released in 2009 found that sick leave taken by NHS staff was 50 per cent higher than in the private sector. About £1.3 billion of the £1.7 billion estimated annual cost could be attributed to mental health problems. 

A recent study of nearly 3,500 Chinese nurses found an estimated 38 per cent had depressive symptoms. A 2012 study of 1,171 American nurses funded by the Robert Wood Johnson Foundation found that nurses had twice the rate of depressive symptoms of the general public (18 per cent, compared with 9.4 per cent).

An Australian retrospective study found elevated rates of suicide amongst nurses and female doctors, compared with other occupations, with one explanation raised being greater exposure to work-related stressors.

These are stark statistics. What are the possible reasons behind them and how could the mental health and wellbeing of nurses be better supported?

Emotional work

“I think we should work with the assumption that all nurses at some time are going to struggle because of the emotional work we do,” believes Dr Jacquie Kidd, a researcher in the field of nursing and depression.

Kidd’s PhD research drew on the experiences of 18 Kiwi nurses experiencing mental illness while practising. She believes that if both the profession and sector acknowledged that nursing is a vulnerable workforce under high emotional stress they would be more open to providing the early intervention and support required.

“I think we would be much healthier,” says Kidd, who is also a Waikato-based senior lecturer for the University of Auckland and teaches and coordinates a mental health new graduate programme.

She says programme leaders tell nurses starting out in their first mental health jobs that after a honeymoon period all of them will hit the wall and think they are hopeless nurses and wish they’d never chosen mental health nursing as a career. But the programme leaders also reassure them that when that happens they will be supported with whatever help they need, and that they will come through it.

Kidd thinks this type of approach should be extended to nurses throughout their careers because not only does the public place “huge” expectations on nursing as a caring profession, but the profession also puts high expectations on itself.

The fear of letting their colleagues or ‘the badge’ down may be one reason few nurses are ready to speak up when they are struggling, believes Kidd.

“In the beginning, depression and anxiety can feel like you are doing something wrong … you feel you’re not quite as good or as fast as everybody else and you are struggling to cope with patients and families that your colleagues just seem to be sailing through with.”

Kidd says by covering up and putting on a brave front of ‘coping’, struggling nurses can miss the early warning signs and the opportunity for early interventions to prevent mental health issues affecting their work. Pushed nursing colleagues may also struggle to feel compassion for a struggling colleague because they are worried about the impacts on their own workloads and mental health if they offer support and help.

Dr Stacey Wilson, a mental health nurse with a research interest in emotional competency, says there is also a sense that nurses should know better, as depression is somehow seen as “quite self-absorbing or selfish” and “nurses aren’t really allowed to be like that”.

Wilson acknowledges the irony that as a profession nurses encourage clients to seek help for mental health or addiction issues and are positive about mental health recovery. But personally it may be a different story because there is still a stigma attached to disclosing mental health issues as a nurse.

“I don’t know many nurses who would say that they are off on leave because of a mental health or a drug or alcohol issue,” says Wilson. “Some might say they are on stress leave.”

Both Kidd and Wilson believe that contributing to nurses’ stress and distress is the disjoint between what draws many nurses to the profession in the first place and the reality of the modern workplace.

“My impression is that what makes us resilient is the time we spend engaging with patients and families – because that’s where we get the sense we are doing a good job,” says Kidd. But working at full capacity can leave nurses little time to foster the relationships that give them energy.

“I think we are in an ever-decreasing circle – we’ve got less and less soul-feeding happening and yet we are giving more and more.”

Wilson says constant change in the health sector is another factor, along with nurses trying to juggle the demands of work with the pressure to do postgraduate work, look after families and attempt a semblance of work/life balance.

So what steps could be taken to better care for the carers?

Healthy workplaces

“If we expect the healthcare workforce to care for patients, we need to care for the workforce.”

This quote from the National Patient Safety Foundation’s Lucian Leape Institute is one of the philosophical drivers for nurse Janice Riegen’s work.

The clinical nurse specialist in occupational health and safety is passionate about the urgent need to create healthy workplaces in the health sector, including reducing the risk factors for anxiety and depression.

“What the literature is telling us is that anxiety and depression are going to be the leading cause of workplace absence for everybody in the next five years – not just in healthcare,” says Riegen. Contributing factors to this include psychosocial risks which Riegen says are becoming one of the biggest health and safety challenges in the modern day workplace worldwide.

Riegen’s master’s research was into what contributes to a healthy workplace and she has presented on the topic internationally. Waitemata District Health Board, who Riegen works for, has created a Healthy Workplace steering group – inclusive of the main unions. Last year the DHB’s board and senior management gave the go-ahead to a Healthy Workplaces Strategy for the organisation and its staff.

The three-year programme lists 15 actions ranging from developing an age-friendly working environment to offering mindfulness and wellbeing sessions, and from supporting best practice workload management to promoting good shiftwork and fatigue management practices.

Riegen says that any healthy workplace strategy needs to be holistic and look at all work aspects that can impact on staff health and wellbeing. “Because what the evidence tells us is that one-off things are no good.” The DHB have used the World Health Organisations ‘Healthy Workplace’ (2010) definition and action model as a basis for the work, along with New Zealand’s Te Whare Tapa Whā model.

So, for example, offering mindfulness and wellbeing sessions is good – but a strategy needs to permeate an organisation’s culture and address psychosocial risks as well.

Riegen says that doesn’t mean you shouldn’t do anything in the interim – she points out that Waitemata’s strategy has been five years in the making and is still a work in progress – but that the bigger picture should always be kept in mind.

Including that there is a very good business case for investing in healthy workplaces as having healthy staff – both physically and mentally – results in less absenteeism, ‘presenteeism’ and staff turnover and leads to greater productivity.

“Also in the last few years the research about the inextricable link between staff health and wellbeing and the safety and quality of the experiences and outcomes for the patients has nearly doubled,” says Riegen.

Safe staffing is definitely one part of a healthy workplace, Riegen says, and if you talk to nurses anywhere their main safety focus is on workload pressures. Excessive workload is a psychosocial risk (according to European Agency for Safety and Health at Work) that can contribute to mental health issues, along with a lack of involvement in decision-making and a lack of support from management or colleagues.

“I used to do bureau work and I could tell how healthy the workplace was straight away after walking in – just based on how I was greeted and welcomed.”

Teamwork and managers

The nursing literature agrees that teamwork – and good managers who foster it – is a very important component of nurse wellbeing in the workplace.

For instance, the Magnet Hospital research, which distilled the common characteristics of hospitals able to attract and retain satisfied nurses during nurse shortages, found that these hospitals not only had adequate staffing, but also offered professional autonomy, participatory management styles, well-prepared leaders and teamwork.

Alison Ogier-Price, who leads the Working Well programme for the Mental Health Foundation and has been working for a number of DHBs to help develop wellness programmes, sees training and supporting managers as crucial

“I see teams that function so well,” she says, “and the heart of it is always that manager who gets it – someone who likes people and gives people a sense that they are participating in decisions that are happening around them.”

But sometimes charge nurse managers (CNMs) are in the role due to seniority or their clinical skills and don’t have the skills to run a team of people. Or they are scared to raise mental health concerns with staff because of uncertainty around what is okay to ask about and what is not. Sometimes managers themselves are affecting the mental wellbeing of their staff because of their communication styles and, on occasions, bullying behaviour.

“Sometimes bullying issues arise through lack of training – they don’t realise what they are doing,” says Ogier-Price. She says that is why it is important to invest in training managers to listen to what’s going on, acknowledge it and respond by using positive and communicative management styles. Training should include communication skills, conflict resolution and team-building skills to create cultures where teams work well together and feel free to raise issues of concern.

Kidd suggests that charge nurse managers may do well to have the ongoing support of HR, rather than HR stepping in when things go pear-shaped.

Riegen says the evidence indicates that line managers should also be trained in supporting staff at risk of mental health issues because if staff have trusting relationships with their managers then they will turn to these people first when they are struggling at work. But line managers, who can be the meat in the sandwich between staff and senior management, also need the skills and the tools to take care of themselves.

“It seems to me it doesn’t matter what position you are in the hierarchy of nursing – the level of stress and the potential for developing a mental health problem that is work-related is pretty high,” says Wilson, who provides professional supervision for nurses, from new graduates to charge nurses. “I don’t think because [managers] are at the top of the food chain that they are any more resilient to the work pressures – maybe they are even more vulnerable.”

Everyone who Nursing Review spoke to agreed that in an ideal world one-on-one professional supervision would be more widely available to help both managers and their nursing staff to critically reflect on their practices, plan their careers and work through some of the challenges facing them in their work.

Wilson says it could also help to defuse anger and conflict in a team if an issue could be resolved by confidential supervision rather than “spreading around like a virus” and infecting everybody.

Stress management, emotional competence and building resilience

So in the real world what can you do, as a nurse, to contribute to the mental wellbeing of yourself and your colleagues in a pressured work environment?

For a start, be kinder and more compassionate to yourself and be kind to your colleagues, who may be struggling around you.

“We’re a highly educated workforce that works in very difficult and challenging situations in some of the most dire times in people’s lives,” says Wilson. “We need a little reminding that nurses are valuable people and it is worth spending a little time being a little compassionate to yourself and working on your emotional competency so you are in good shape for work.”

Ogier-Price, who specialises in applying positive psychology to organisational wellbeing, agrees, saying that nurses generally don’t take good care of themselves and – strangely enough – don’t always have the information or skills to recognise when and how much support they need.

She has been offering wellbeing workshops in collaboration with the quake-challenged Canterbury DHB for the past three years, and after being called in to support other DHBs has come to believe that ‘care for the carers’ information is lacking in the health sector. In her role with the Mental Health Foundation she was commissioned to write a white paper for the Ministry of Health on the topic – something like a ‘working well’ guide for the health sector.

Ogier-Price says a health and wellbeing culture should permeate an entire organisation and include reducing the stigma of mental health illness so that people struggling with anxiety and depression feel more able to speak up.
In larger organisations this can include having access to EAP (Employee Assistance Programmes) that typically offer three free and confidential sessions with a counsellor or psychologist about personal and work issues that may be affecting workers’ productivity.

Kidd, for one, thinks that nurses could be making much more use of EAP. “Just having somebody who is paid to listen to you and talk about your woes … can really help to crystallise what you might need to do to help yourself feel better.”

Ogier-Price says organisations should also promote or offer programmes that help people to maintain and sustain their mental wellbeing.

Encouraging exercise is one example, as there is a growing body of evidence that physical exercise can be effective for people with mild to moderate depression. Programmes that can help people to relax, such as yoga, meditation or mindfulness, are also available, plus others that focus on the other important components of wellbeing, such as nutrition and sleep. Wellbeing workshops such as those offered at Canterbury DHB can teach nurses how to better care for themselves as carers.

Ogier-Price says an absolutely ‘core concept’ that she emphasises in her workshops is the need to build social networks at work, as this is where people spend so much of their lives. This includes creating a work environment where socialising can occur, such as a lunchroom, which she acknowledges can be challenging in busy wards with little private space. Finding a way for staff to get together regularly should be a priority, she says, even if it is just getting together for special morning teas once in a while.

After listening to nurses offload during wellbeing sessions, Ogier-Price is also interested in whether the idea of facilitated support groups, similar to those offered by Alcoholics Anonymous, could be helpful.
Another approach that Ogier-Price encourages in her workshops is for nurses to boost their wellbeing by “basically doing the stuff you enjoy doing”. She says that to avoid chronic stress nurses need to routinely and frequently de-stress during the working day.

“People need five minutes off every hour to de-stress so for the next hour they can function that much better.”

This may be as simple having a laugh or an enjoyable conversation. In a particularly busy day it may be just grabbing a minute to go into the corner and take some deep, calming breaths. In longer breaks it could be grabbing a chance to take a walk outside, knit or do a Sudoku puzzle – whatever helps them to relax.
Apart from stress management, Ogier-Price says other training programmes that could benefit nurses include assertiveness training and boundary setting to help them deal with both difficult patients and colleagues (see p.8 for some stress management tips).

Wilson and Kidd also believe that pre-entry and ongoing nurse education should acknowledge that nursing is emotionally draining work and help them to build the self-awareness and emotional competency skills needed to be resilient and care for themselves and others.

But it is not up to nurses alone to care for themselves – what is also needed is a health sector that cares for its carers. Creating a healthy workplace for carers – to paraphrase the World Health Organization’s healthy workplace motto – is the “smart thing, the legal thing and the right thing to do”.