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Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Impact of a stress management program on stress perception of nurses

working with psychiatric patients
Gandhi Sailaxmi *, Krishnasamy Lalitha
Department of Nursing, National Institute of Mental Health & Neurosciences (INI), Hosur Road, Near Wilson Garden, Bangalore 560029, Karnataka, India

A R T I C L E I N F O A B S T R A C T

Article history: Nurses caring for psychiatric patients may have to face violent emotions and unpredictable behaviour
Received 26 August 2014 which can be quite stressful. A stress management program may equip nurses with skills to cope
Received in revised form 7 December 2014 effectively with the stress. A one group pre-test and post-test design was adopted to test this hypothesis.
Accepted 18 January 2015
Both gender nurses caring for psychiatric patients were invited to undergo 10 consecutive, one hour
Available online xxx
sessions of a stress management program. The DCL Stress scale (The De Villiers, Carson & Leary Stress
Scale; Carson et al., 1997a,b,c) was used to collect data immediately after intervention and four weeks
Keywords:
later. RM ANOVA with SPSS 16 showed that pre-intervention mean stress reduced significantly (p = 0.000)
Stress
Nurses
from 57.45  16.42 to 41.06  16.51 immediately following the intervention and 26.43  12.82 (p = 0.000)
Psychiatric patients four weeks after the intervention. The stress management strategies positively impacted on nurses’ stress
Stress management interventions levels.
ß 2015 Elsevier B.V. All rights reserved.

1. Introduction quality work environments, more effective managers, strong nurse–

Nurses working with psychiatric patients may be confronted with
intense interpersonal interactions, dynamic changes in patients,
emotional lability and psychological distress that can be very
stressful and challenging. Most studies on stress and job satisfaction
in nursing have focused on general nursing specialities, and relatively
little attention has been paid to nurses working in psychiatric units
(Cronin-Stubbs and Brophy, 1985; Dawkins et al., 1985). Although
there are educational programs in India that focus on psychiatric
nursing speciality (from diploma to doctorate programs), many
nurses caring for psychiatric patients in various psychiatric hospitals
in India may not have actually undergone a speciality training
program. When confronted by issues such as nurse shortage, violence
in the unit, advances in technology, and demands from the multi-
disciplinary team, these nurses can have high levels of stress. Worker
injuries and verbally aggressive patients are reported to be increasing
and are associated with higher rates of burnout of psychiatric nurses
(Liu and Wuerker, 2005; Flannery et al., 2007). With robust clustered
regression analysis, it was found that lower levels of psychiatric nurse
burnout among 353 nurses was significantly associated with
inpatient environments in 67 hospitals that had better overall
* Corresponding author. Tel.: +91 08026995322; fax: +91 08026564830;
mobile: +91 09902763889.
E-mail address: sailaxmi63@yahoo.com (G. Sailaxmi).
physician relationships, and higher psychiatric nurse-to-patient
staffing ratios (Hanrahan et al., 2010). Most psychiatric hospitals
in India have wards with 50–60 beds. Generally, in the morning
shift there are at least two nurses with one ward supervisor, one
nurse for the evening and one for the night shift. This inadequate
nurse–patient ratio also can contribute to stress in the nurses.
Programs for dealing with stress should be available on a routine
basis (Sorgaard et al., 2010). The present research work focuses
on testing of specific strategies to equip nurses with competen-
cies to cope with stress when working with patients with mental
illness. If this stress management program is found to be
effective, it can be advocated for nurses working in other
psychiatric hospitals in India.
1.1. Aim
To evaluate the effectiveness of a stress management program
on stress reduction in nurses working in a psychiatric hospital.
1.2. Objectives
1. To assess the level of pre-intervention perceived stress in nurses
working with psychiatric patients.
2. To develop a stress management program.
3. To evaluate the impact of the stress management program on
stress perception of nurses working with psychiatric patients.

http://dx.doi.org/10.1016/j.ajp.2015.01.002
1876-2018/ß 2015 Elsevier B.V. All rights reserved.

Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses
working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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2 G. Sailaxmi, K. Lalitha / Asian Journal of Psychiatry xxx (2015) xxx–xxx
1.3. Hypothesis
There will be a statistically significant change in the stress
perception of the nurses after under-going the stress management
program.
2. Materials & methods
2.1. Research design
A quasi-experimental one group pre test post test design.
2.2. Study population and setting
After approval by the Institutional Review Board and following
informed consent as well as detailed explanation about the risks
and benefits involved, 60 nurses working in a psychiatric hospital
at Bangalore, India were randomly selected using the Tippet’s
Random number table and invited to participate in this study. Male
and female registered nurses working with psychiatric patients for
more than one year and possessing G.N.M. (diploma) or B.Sc.
Nursing qualification (with/without additional qualifications)
were included in the study. Nurses in the supervisory capacity,
nursing trainees, nurses with chronic illness and those who had
undergone stress management courses were excluded from the
study. Of the 60 randomly selected subjects who fulfilled the
inclusion criteria, there was seven-subject mortality due to reasons
such as illness, death in the family and child’s illness. The final
sample consisted of 53 nurses, who fulfilled the inclusion/
exclusion criteria. Nurses took part in the sessions while on duty.
Since shift system was followed in this hospital, groups of
10 nurses participated in the sessions during the morning shift
and evening shift. Maximum effort was taken to meet comfort
needs, including providing refreshments. Nurses were encouraged
to contact the researchers at periods other than the intervention
sessions.
2.3. Research tools
A semi-structured, researcher constructed proforma was used
to collect socio-demographic data. The DCL (De Villiers, Carson &
Leary) Stress Scale (Carson et al., 1995, 1996, 1997a–c, 1999) was
used to measure stress levels. This is a 30 item Likert rating scale
consisting of five domains – patient demands (8 items), organiza-
tional and managerial issues (8 items), staffing (7 items), future
concerns (4 items) and job satisfaction (3 items). Cronbach’s alpha
reliability coefficient was 0.96. The test–re-test correlation
(Spearman’s Rho) was 0.91. There is high content as well as
criterion validity (with Maslach’s Emotional Exhaustion and the
GHQ – 28). Each item is scored as a Likert scale ranging from 0 to
4. Thus, the total score ranges from ‘no’ stress (score of 0) to
‘extreme’ stress (score of 120).
2.4. Stress management program
The nurses were enrolled for 10 sessions, each lasting for one
hour, on a daily basis. Five sessions in a week from Monday
through Saturday for two weeks were conducted keeping in mind
weekly off duty days. Sessions focused on stress education,
problem solving, time management, taking time off, communica-
tion skills, assertiveness training, responding to criticism, negotia-
tion skills and humour. Various teaching strategies were used such
as lecture cum discussion, brain storming, role play, group work
and behaviour rehearsal. Communication skills, assertiveness
skills, responding to criticism and negotiation skills were role
played and video graphed. These video slides also were used as
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses
working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
teaching aids. Sessions were very interactive and nurses were
encouraged to clarify doubts and participate actively. Nurses were
encouraged to prepare case scenarios based on their experience
of stressful situations in the wards and then discuss how these
stress management techniques could be implemented during
these situations. Pre-assessment was done using the socio-
demographic proforma and the DCL Stress Scale. The subjects
were then exposed to these specific strategies for ten days
continuously. Immediate post-assessment as well as assessment
four weeks later was done. The subjects were encouraged to
narrate their experiences while adopting the various techniques
taught to them. A discussion was held about the difficulties,
practicability and utility of the techniques followed by post
assessment as well as evaluation of the sessions that they had
undergone. All nurses including those who were not part of the
study were given information manuals on the stress management
interventions after the final data collection. The content validity of
this stress management program as well as the audio–visual aids
used during the sessions were determined by experts comprising
of three psychiatrists, three psychiatric nurses, two clinical
psychologists and two psychiatric social work consultants.
2.5. Analysis
It was decided to express the data obtained using descriptive
statistics and to analyze the effectiveness of intervention by
computing repeated measures ANOVA using a 0.05 level of
significance. Data analysis was performed using SPSS16.
3. Results
3.1. Descriptives
Majority of the nurses (90.57%) were female. Married nurses
comprised 84.91% of the study sample. 32.08% of the nurses were
from a joint family and the remaining 67.92% belonged to nuclear
families. 83.02% of the nurses had family support in day-to-day
activities (Table 1).
The mean age of the study sample (n = 53) was 33.19  6.90
years ranging from 24 years to 50 years. The mean basic salary was Rs.
5887.55  783.46 ranging from Rs. 5250 to Rs. 9060. The nurses
experience of working with psychiatric patients ranged from 2 years
to 29 years with a mean experience of 9.58  6.04 years (Table 2).
While 15.09% of the nurses worked in the Psychiatry special
wards, 33.96% worked in the emergency unit, 18.87% in the closed
psychiatry wards and the rest (32.08%) worked in the open
psychiatry wards. 24.53% of the nurses were professionally
Table 1
Frequency distribution of the study sample based on sex, marital status, type of
family and family support in day to day activities (n = 53).
Sample characteristics Number Percentage
Sex
Female 48 90.57
Male 5 9.43
Marital status
Married 45 84.91
Unmarried 6 11.32
Separated 2 3.77
Type of family
Joint 17 32.08
Nuclear 36 67.92
Family support in day to day activities
Yes 44 83.02
No 9 16.98
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Table 2
Frequency distribution of the study sample based on age, basic salary and duration
of experience in years (n = 53).

Sample characteristics Number Minimum Maximum Mean SD

Age 53 24 50 33.19 6.90

in years
Basic salary (Rs.) 53 5250 9060 5887.55 783.46
Duration of experience 53 2 29 9.58 6.04
in years

Table 3
Frequency distribution of the study sample based on area of working and
professional qualification (n = 53).

Sample characteristics Number Percentage

Fig. 1. Cone chart indicating the Time 0 (pre intervention), Time 1 (immediate post
Area of working
intervention) and Time 2 (4 weeks post intervention) mean scores on the DCL stress
Psychiatry special wards 8 15.09
scale.
Emergency wards 18 33.96
Psychiatry closed wards 10 18.87
Psychiatry open wards 17 32.08
(15.81  5.78) related to patient demands, in the area of organizational
Professional qualification and management issues (12.74  4.88) and about future concerns
B.Sc. nursing (including P.C.B.Sc. nursing) 13 24.53
GNM 36 67.92
(7.28  3.10) were at moderate levels. However, in the area of staffing,
GNM with diploma in psychiatric nursing 4 7.55 the mean stress level was high (14.09  4.77). The nursing shortage in
India can contribute to inadequate nurse patient ratio which may
contribute to nurses stress perception. Studies (Department of Health,
2001, 2002; Jenkins & Elliott, 2004; SCMH, 2004; Bowers et al., 2005;
qualified as B.Sc. nurses, majority (67.92%) were general nurse Richards et al., 2006) have shown that challenges faced by mental
midwives and the rest (7.55%) had attained a professional health nurses include inadequate staffing; patients who are acutely
qualification of general nurse midwife with diploma in psychiatric disturbed posing risks of violence and self-harm; bed shortages/
nursing (Table 3). occupancy rates and workload. Lack of nursing staff was found to be a
mediating variable between stress and job satisfaction (Nakakis and
3.2. Changes in stress perception of nurses following the stress Ouzouni, 2008). Hanrahan et al. (2010), found significant relationships
management program between the better nurse practice work environments and lower
psychiatric nurse reports of emotional exhaustion and depersonaliza-
There was a significant (p = 0.000) mean reduction in tion. When nurses working with psychiatric patients cope with stress in
stress perception from 57.45  16.42 at pre-intervention to an adaptive, healthy manner, other members of the multi-disciplinary
41.06  16.51 immediately after the intervention and team and also the patients themselves find the in-patient milieu more
26.43  12.82 four weeks after the intervention. Pre-intervention congenial. Moreover, nurses are role models for the patients and their
mean stress levels related to patient demands (15.81  5.78), in the family members as well as for their peers and junior workers. By
area of organizational and management issues (12.74  4.88) and turning toxic work environments into healthy workplaces, researchers
about future concerns (7.28  3.10) were at moderate levels. and nurse leaders believe that there could be improvement in
However, in the area of staffing, the mean stress level was high recruitment and retention of nurses, job satisfaction for all health
(14.09  4.77). There was a significant (p = 0.000) reduction in stress care staff, and patient outcomes – particularly those related to patient
levels in all the domains immediately after and four weeks after the safety (Department of Health, 2002). Feelings of stress may predispose
intervention (Table 4, Fig. 1). staff to other illnesses and have an adverse effect on people’s lives (Caan
et al., 2001; Norton, 2004; Richards et al., 2006). Recognizing the impact
4. Discussion that stress can have on individual staff members, their families, patients
and the NHS, the Department of Health (2001) advocated stress-
In this study, there was a gradual mean reduction in stress reduction programs and other work/life balance improvement strate-
perception from 57.45  16.42 at pre-intervention to 41.06  16.51 gies in the workplace. In India, the Indian Nursing Council can
immediately after the intervention and 26.43  12.82 four weeks after proactively advocate stress management strategies for all nurses in
the intervention with p = 0.000. Pre-intervention mean stress levels their place of work. Significant reduction in nurses’ stress perception

Table 4
Comparison of pre and post-intervention scores on the DCl stress scale (n = 53).

DCL stress scale domains Pre mean scores Post mean scores 4 weeks post mean scores F value p value
(time 0) SD (n = 53) (time 1) SD (n = 53) (time 2) SD (n = 53)

Patient demands 15.81  5.78 (50%) 11.36  5.32 (34%) 7.66  4.15 (25%) 339.04 0.000*,O,#
Organizational & 12.74  4.88 (41%) 9.43  4.67 (28%) 5.77  3.74 (19%) 341.97 0.000*,O,#
managerial issues
Staffing 14.09  4.77 (50%) 9.64  4.98 (36%) 6.47  3.73 (21%) 354.57 0.000*,O,#
Future concerns 7.28  3.10 (44%) 5.64  2.79 (38%) 3.43  2.57 (19%) 264.70 0.000*,O,#
Job satisfaction 5.53  2.24 (50%) 3.49  2.12 (33%) 2.26  1.42 (17%) 309.19 0.000*,O,#
Total scores 57.45  16.42 (48%) 41.06  16.51 26.43  12.82 471.62 0.000*,O,#
*
Time 0 vs time 1.
O
Time 0 vs time 2.
#
Time 1 vs time 2.

Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses
working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
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levels in our study indicate that stress management techniques such as
those used in this study are quite practical and feasible.
Edwards and Burnard (2003) noted that although a great deal is
known about the sources of stress at work, about how to measure it
and about the impact on a range of outcome indicators, what was
found to be lacking was a translation of these results into practice,
into research that assessed the impact of interventions that
attempt to moderate, minimize or eliminate some of these
stressors. In this study, effective stress management may have
helped to moderate nurses’ stressors. Translation of the results
of this study into practice can bring about changes in nurses well-
being which can indirectly contribute to better patient care.
This study has several limitations. The lack of a control group
prevents generalization of the study findings. There may have been
spill-over of stress from the domestic front to the occupational
area. Follow up of the subjects after a longer period of time was not
carried out. Hawthorne effect may have contributed to reduction
in stress values.
4.1. Implications
Appropriate and operationally feasible interventions such as
problem solving, time management, communicating skilfully, being
assertive, negotiating effectively and responding appropriately
to criticism which allow nurses to pursue an optimal approach to
caring for psychiatric patients are likely to produce substantial
benefits in terms of reducing the risk of burnout and consequently
positively influencing sickness absence and staff turnover. Nurses
trained in stress management are in a better position to manage not
only their own stress, but also teach patients and family members
stress management. Ensuring that pre-registration education
adequately prepares nurses for their roles as qualified practitioners
might reduce transition stress.
5. Conclusion
Stress can affect physical and mental health leading to conflicts
in the work area, frequent absenteeism due to increased
psychosomatic illness as well as high turnover. In the long run
this affects the organizations productivity. Stress management
strategies that are evolved based on the nature of nurses work can
help moderate nurses stress perception in the work place. A
practical, realistic, cost-effective and tailor-made strategy like this
could form an important component of primary and secondary
prevention by psychiatric nurses. Replication of this study using
pre post tests with control group can further enhance the validity
of this intervention. The authors recommend that stress manage-
ment strategies such as those adopted in this study be practiced
by nurses as workplace stress affects client care and outcomes.
Please cite this article in press as: Sailaxmi, G., Lalitha, K., Impact of a stress management program on stress perception of nurses
working with psychiatric patients. Asian J. Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.01.002
Acknowledgement
The authors are grateful to all the nurses who participated
in this research and the authors of the DCL Stress scale for
magnanimously giving the tool as well as permitting its use.
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