Whole team training to reduce burn-out amongst staff on an in-patient alcohol ward
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Whole team training to reduce burn-out amongst staff on an in-patient alcohol ward.

Hill R.G., Atnas C.I., Ryan P. et al.
Journal of Substance Use: 2010, 15(1), p. 42–50.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hill at Robert.hill@slam.nhs.uk.

Even more so than in a typical psychiatric ward, staff at a London inpatient alcohol treatment ward experienced high levels of stress and other indicators of the potential for 'burn-out'. Whole-team training seemed to help, reflected especially in feelings of greater competence in working with sometimes challenging and complex patients.

Summary Occupational stress and burn-out are common among hospital and community-based mental health staff; staff working where aggression and violence occur are at particular risk. The Maslach Burn-out Inventory is a questionnaire often used to measure these variables. It assesses feelings of emotional exhaustion, Feeling over-extended and exhausted by one's work. depersonalisation, An unfeeling and impersonal response to clients. and personal accomplishment. An individual's rating of their competence and achievement in their work with people. The results confirm high levels of stress and strain among mental health professionals, yet very little empirical work has been undertaken on ways to counter this, and the few studies there are generally had a weak research design.

The featured report derives from the EU-funded OSCAR project (Occupational Stress with Mental Health Clients in Acute Response). In five European countries, this aimed to gather information on occupational stress and burn-out among mental health workers in acute psychiatric hospital and community settings, investigate the causes, and test ways to reduce the problem. The strategy was to work with whole staff teams in order to affect team culture and introduce and 'bed down' working practices aimed at stress reduction.

In Britain the project was implemented at a mixed-sex, 16-bed inpatient ward in south east England offering generally a 28-day programme including group and individual therapy and detoxification for adults dependent on alcohol. It averaged five admissions a week. The ward had 19 staff; three quarters were women and two thirds had worked on the ward for under three years. Only one recalled in-service training on dealing with stress.

These staff completed the Maslach Burn-out Inventory. Three months later, as a team they underwent a two-day stress-reduction training course, the impacts of which were assessed by repeating the inventory a month later. The two days of the training were separated by a fortnight. Day one focused on managing stress at the individual, team and organisational levels. Day two focused on understanding the causes and consequences of aggression, involving identifying typical antecedents of violence from a comprehensive perspective, including client-related, environmental, team, and organisational factors. The team was then helped to undertake a comprehensive risk assessment along with plans for implementing effective risk management strategies.

Main findings

Four main sources of stress at work were identified. These were: group-work; dealing with complex clients; effectively evaluating the shift; and client aggression. Before training, staff scored as experiencing on average high levels of emotional exhaustion and depersonalisation, though on the latter scale only half the team had scores in the high category. Personal accomplishment scores were in the low to medium range.

After training, emotional exhaustion and depersonalisation had diminished but only slightly and not to a statistically significant degree. However, feelings of personal accomplishment had risen quite substantially and significantly to on average a high level.

The authors' conclusions

The results suggest that staff stress and burn-out on the ward were marginally higher than in-patient community and mental health psychiatric teams in the OSCAR project. This might be because alcohol problem patients can be quite forceful and demanding, and sometimes more disinhibited than those with mental health problems. Comments to staff about their work or about them personally may be experienced as more salient when they come from clients who do not have a major mental health problem. Also, the ward has a high patient turnover; new relationships are continually being established between staff and patients and among the patients themselves. The experience of detoxification is clearly challenging for clients, and can easily turn in to increased demands on staff, compounded by poor physical health which staff need to monitor. Another important factor may have been the extensive group programme patients are expected to attend and staff to facilitate, a contrast to mental health teams.

Staff who attended the training found it very effective as a team-building forum, to identify areas for change, and as a space to focus on plans for achieving this. Also, it is encouraging that the training did appear to bring about some measurable changes on the scales designed to assess stress and burn-out, in particular a positive effect on team members' feelings of competence and achievement in their work with clients. The implication is that time for the ward team to focus on their own needs in a highly demanding environment is a necessity which should be built in to the yearly working cycle.

The results cannot definitively be attributed to the training because there was no control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group who were not trained against whom the changes in the staff team's scores could be benchmarked. Also, these changes were measured only in the short term.

Last revised 02 August 2012

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