Better than we thought

Article under review: Cramer, R., Ireland, J., Hartley, J., Long, M., Ireland, C. & Wilkins. T. (2020). Coping, mental health, and subjective well-being among mental health staff working in secure forensic psychiatric settings: Results from a workplace health assessment. Psychological Services, DOI: 10.1037/ser0000354

Summary: Working in complex and challenging environments, including where one sees and hears stories of trauma, loss, and neglect – including by perpetrators, sounds like an incredibly challenging job. Cramer and colleagues (2020) undertook a review of staff well being to examine burnout and mental health, finding some unexpected results, with cognitive and emotion-focused coping strategies demonstrating positive indications for staff in positions considered likely to cause stress.

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We often hear about the high degrees of burn-out and stress among medical professionals, particularly those working with patients who are violent or present with self-harming or suicidal behaviors. There are plenty of unique factors that may influence the work- associated stress experienced in particular by clinical mental health workers. Signifiers of this stress have been identified by a high degree of staff turnover seen in clinical organisations, plus the increased use of alcohol and cigarette as a coping strategy.

A recent pre-COVID study (Cramer, Ireland, Hartley, Long and Ireland, 2020) was designed to test several hypotheses; the first being that mental health amongst forensic medical staff would be moderate. The second hypothesis was that the same staff would have below mid-point scores for positive indicators such as life satisfaction, enthusiasm for the job, and job satisfaction with a higher level of negative indicators such as psychological exhaustion, indolence, and guilt, causing a lessened state of overall wellbeing.

This voluntary study was conducted amongst mental health workers from clinical settings including primarily nurses and nursing assistants, psychologists, psychiatrists, forensic social workers, therapists/ rehabilitation workers, and psychology assistants. The study was undertaken in both hard copy and online formats, with a total number of 170 participants. 54.5% were men and 45.3% women (one unstated).  Almost 30% had lost a patient to suicide.

The study sought to assess the coping skills, mental health, and subjective wellbeing variables of interest. The study had the dual benefits of assessing overall workforce health, while also assessing how coping-related characteristics may improve staff mental health and wellbeing.

Several models for interpreting wellbeing were considered to frame the results of the study.  Emotional Labour theory provides a useful, although somewhat limited framework for considering individual responsibility and ability to manage emotions while undertaking professional tasks. Emotional Labour theory identifies that there is a relationship between better management of emotions and reduce the impact of negative impacts of emotionally burdening work. The model proposes “deep” and “surface” coping strategies.

To extend the Emotional Labour theory, the study also considered the relevance of two emotional-relevant coping perspectives, Coping Self Efficacy and Need for Affect.  Coping Self-Efficacy refers to the presence of beliefs concerning the self-mastery of copings skills, the ability to stop negative thoughts and emotions, problem-focused coping and obtaining social support,

Need for Affect refers to the extent to which a person prefers to experience and express positive and negative emotions, composed of two subscales- NFA Avoidance and NFA Approach, reflecting proxies for emotional management strategies. NFA Approach correlates to what Emotional Labour might consider “deep” management where NFA Avoidance correlates to “surface” management. Understanding these two approaches adds value to the perspectives of the Emotional Labour model.

The study found “a better picture than hypothesized” and, found “normal” (that is, nonclinical levels) of stress, depression, anxiety, and PTS.  Further, there were low levels of psychological exhaustion, indolence, and guilt.

Assessment of the “vast majority” of participant scores indicated positive workforce mental health, and if any neutral indicators were observed, it was neutrality in job-related and general satisfaction.

Of course, limitations also apply to the study. Self-selection bias could have had an impact, as could a sense of pressure to respond in a certain way. Staff experiencing stress or anxiety may have avoided participation.  It may be the most distressed employees had also already left employment, or were absent from the workplace to be able to consider participating.  Participation was invited from several fields, but respondents were primarily nurses and this too could have had an impact on combined results.

The study also sought to identify positive contributing factors and behaviours that may have influenced what could be deemed as good results.  The study found that relationships and trust between teams and peers are important contributing factors to creating wellbeing among groups of mental health professionals.

Staff working within a strong team demonstrated peer to peer social and emotional support during times of high work-related stress, and strong teams were found to amplify positive emotions during times of non-acute work strain. One-on-one support models, such as structured supervision sessions and mentoring programs were also deemed useful.

Individual practices such as self-care and mindfulness are also recognised as contributors to wellbeing and resilience. Staff resilience is a promising attribute to be built upon in workforce health programs. The study proposes this could be done by recognising resilience “experts” who have and are willing to share resilience skills to become champions in their workplaces.

These findings indicate mental health and wellbeing can be improved by the provision of therapeutic, supportive, and reflective staff practices as well as systemic actions to improve the work environment.  This involves individual and collective activity. This study provides a useful snapshot of the wellbeing of a group of clinical professionals, gives some insight into the findings, and leaves us with suggested strategies for improving the health of our professional workforces.