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Community mental health nurses speak out: The critical relationship between emotional wellbeing and satisfying professional practice

Community mental health nurses speak out: The critical relationship between emotional wellbeing and satisfying professional practice Jayln Rose RN, BNurs(Hons), MRCNA, PhD candidate, Southern Cross University, New South Wales Nel Glass RN, BA, MHPEd, PhD, FRCNA, FCN(NSW), Department of Nursing and Health Care Practices, Southern Cross University, New South Wales

Introduction The article reports on selected findings of a research study concerning emotional wellbeing and professional nursing practice (Rose 2002). It highlights the relationship between community mental health nurses’ and emotional wellbeing, and their capacity to provide satisfying professional nursing practice (Rose 2002). The notion of emotional wellbeing, factors that impacted upon the participants’ emotional wellbeing, and the relationship of emotional wellbeing to professional practice were revealed in the study.These findings were based on a qualitative critical feminist research inquiry and specifically, interviews with five women community mental health nurses in Australia. Whilst complex, emotional wellbeing was found to be both implicitly and explicitly linked to the participants intertwined personal and professional experiences. Four key components were identified: the nebulous notion; the stress relationship; the mind, body, spirit connection; and, inner sense of balance. In terms of emotional wellbeing and professional practice, three themes were revealed. These were: being able to speak out (or not); being autonomous (or not) and being satisfied (or not). The authors argue that the emotional wellbeing of nurses working in community mental health settings is critical to satisfying professional practice. Furthermore nursing work involves emotional work which impacts on one’s emotional wellbeing and emotional wellbeing is integrally linked to professional practice. It is recommended that health organisations must be pro-active in addressing the emotional needs of nurses to ensure the delivery of health care that is aligned to professional practice. This approach will ensure nurses will feel more recognised and validated in terms of their nursing practice. Key Words: wellbeing; nursing; professional practice; mental health.

Correspondence to: Associate Professor Nel Glass Email: [email protected]

Emotional health and professional nursing practice is an issue that has gained more explicit recognition in the literature. In particular its relationship with increased quality in health care delivery, patient recovery and patient outcomes have been documented (Bolton 2000). Yet the health care industry is experiencing significant radical change (O’Connor 2002) and its implementation has not always resulted in positive effects for both health care practitioners and recipients. In this regard, the rapidity of change in health care has lead to increased pressure being placed on nurses and the workplace climate is a ground for emotional, physical and psychological distress (Preston 2002, Taylor & Barling 2002). As such, nurses’ emotional wellbeing is now questionable and it is perceived as a critical issue in their everyday practice (Rose 2002, Glass 2003a, Walter 2003). Disturbingly, in an environment of rapid change often characterised by economic rationalisation and more limitations on the health dollar, nurses’ wellbeing is not afforded the same status or health care priority as that of their clients. This constant change is one plausible rationale for the need for nurses’ wellbeing to be comprehensively explored. However, the importance of emotional wellbeing to nurses is not entirely absent from recent literature (Arafa et al 2003, Birx 2003, Glass 2003a). The inherent benefits of nurses emotional wellbeing to their health care delivery has been identified (Glass 2003a) as has the relationship between client emotional wellbeing and their recovery (Bolton 2000). Interestingly and perhaps juxtaposed to what occurs in practice, stress and distress in nursing have been clearly acknowledged in the literature as a major point of concern (Edwards & Burnard 2003, Tully 2004). Related to this point, literature has also highlighted workplace practices that result in emotional issues such as burnout (Omdahl & O’Donnell 1999, Barling 2001, Taylor & Barling 2002, Happell et al 2003) workplace stress, violence and bullying (Farrell 1999, Farrell & Bobrowski 2003, Glass 2003b&c). Notwithstanding the significant contributions to nursing knowledge, the concept of emotional wellbeing and its specific relationship to nurses remains limited. Nursing involves emotional Collegian Vol 13 No 4 2006

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work, emotional work impacts on ones emotional wellbeing and as the results of this study revealed, emotional wellbeing is integrally linked to effective professional practice (Rose 2002).

Current literature Whilst the impact of emotional wellbeing is identified throughout national and international literature, stress and distress are often the major foci of studies, therefore forming the dominant discourse. In particular, stress and distress with novice nurses features considerably (Hinds & Harley 2001, Walter 2003, Tully 2004). A strong relationship exists between stress, distress and poor coping mechanisms for novice psychiatric nursing students in their clinical practice (Tully 2004). Notwithstanding, nursing students have their own cultural stressors which may impact on their practice, a risk to wellbeing and a potential for both physical and psychiatric illness was also revealed (Tully 2004). Novice nurses were noted to be at a greater risk of experiencing the effects of stress and disturbances to their wellbeing due to limited support in nursing practice and the increased nursing responsibilities, and they often felt overwhelmed, anxious and apprehensive (Walter 2003, Tully 2004). The pressure to conform to rigid institutional practices and the need to react quickly, and acclimatise to their new working culture in bureaucratic, impersonal institutions affected beginning nurses sense of self (Hinds & Harley 2001, Walter 2003). Furthermore, new acute care nurses endured negative experiences of professional socialisation such as harsh judgements and these culminated in ongoing stress (Hinds & Harley 2001). Workplace relations and the nursing environment was an interrelated area of research. A focus on stress, emotional competency, burnout, pressures inherent in nursing practice and dealing effectively with patient orientated issues prevailed (Carson 1997, Hopkinson et al 1998, Healy & McKay 2000, Humpel et al 2001, Foster et al 2003). Workplace pressure occurred in a climate of workplace violence and resulted in nurses being vulnerable and experiencing burnout (Glass 2001a&b). Once the pressure is sustained nurses endure a wellbeing disturbance and experience associated distress and stress (Glass 2001a&b). This in turn impacts negatively on those in their care. Furthermore as workplace environments become more competitive (Glass 2003b) the phenomena of bullying and violence proliferates in nursing (Glass 1997, Jackson et al 2002, Glass 2003b&c). In fact horizontal violence is now believed to be so common amongst nurses that many nurses perceive it as an accepted behaviour (Farrell 1999, Farrell & Bobrowski 2003). With regards to mental health nursing, burnout is linked to economic restraints and the associated pressures to effectively perform in a changing mental health system (Barling 2001, Taylor & Barling 2002). Staff shortages and inherent added responsibilities were also identified as impacting on nurses stress levels and ultimate burnout (Barling 2001, Taylor & Barling 2002). Clinical supervision and staff support also remain contentious issues. For example, Teasdale et al (2001) found no significant 28

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difference in the level of burnout between nurses who received formal clinical supervision and those who did not, however, supervised staff reported positively on support and their subsequent improved coping. The literature also addresses the significance of self healing and the overdue need to utilise strategies to deal with stressful demands (Glass 1997, O’Connor 2002, Glass 2003d, Walter 2003). Walter (2003) specifically advocated for playfulness, emotional lightness as critical strategies for emotional wellbeing and professional fulfilment. However it was Barling (2001) who argued nurses exhaustion prohibits them from dealing effectively with their own healing. Based on the literature, emotional wellbeing, professional practice and healing strategies formed the impetus for this study.

Research question and aims The specific question investigated was ‘what is the relationship between emotional wellbeing and effective functioning as a woman community mental health nurse?’ The research aims were to: explore the degree of emotional wellbeing for women community mental health nurses; identify factors that positively and negatively impact on their emotional wellbeing and professional practice; and identify the healing strategies used during their professional practice.

Methodology The theoretical framework was critical feminist methodology. Such a framework upheld the epistemological beliefs that women and nurses experience degrees of oppression and/or minimisation by both their gender and health care systems (Glass 2000, Roberts 2000). In terms of oppression, feminist scholars have claimed the silencing of women is a pervasive phenomenon (Glass & Davis 1998, Walter 2003). It was anticipated an emancipatory framework would validate the individual voices and experiences of the participants and potentially alter the disempowering effects endured by women nurses. Such factors are critical in the process towards empowerment. Utilising this methodology researchers listen to what voices women are using to describe their own experiences and may assist in ‘changing the nature and distribution of power in our society’ (Ristock & Pennell 1996 p2).

Methods In order to achieve conceptual integration (Hamilton & Clare 2004) methods were directly aligned with the research philosophical underpinnings. Fundamental objectives were to ensure rich and thick data (Davis 1998) and that the stories were characterised as information-rich cases (Patton 2002). The two methods chosen were oral narrative/storytelling and reflective journalling.

Oral narrative/storytelling Semi-structured interviews involving open-ended questions were utilised to promote conversations. Whilst some specific questions were posed to each participant, it was expected that issues raised throughout the interview process would guide subsequent questions.


Three of the main questions asked were: What does emotional wellbeing mean to you? What is the relationship between emotional wellbeing and satisfaction in your professional practice? What factors impact positively and negatively upon your emotional wellbeing in your professional practice? In terms of the interview process, ensuring emotional safety (VanderPlaat 1999, Glass 2001a) was of prime importance. Mutually agreed meeting places provided the participants with opportunities to share their thoughts and feelings in optimal environments. Such environments create additional opportunities for empowerment, thereby supporting women ‘who have been silenced to speak’ (VanderPlaat 1999 p774). Moreover, to achieve a nonhierarchical presence, the researcher remained open and honest, promoted equality and ensured reciprocity. For example, when appropriate the researcher shared relevant information or stories. Each interview was audiotaped and transcribed verbatim with copies of the transcripts returned to participants for member checking, to verify accuracy and make any necessary changes. This process ensured that credibility and authenticity were achieved.

harm and are deemed sensitive (Kavanaugh & Ayres 1998, Roberts 2002b). Following institutional ethical approval each participant was given an information sheet providing details of the study and the researcher and importantly, the ethical considerations related to their research involvement. Before data collection, clarification of any points were addressed and once satisfied, the participants consented to the research. For the purpose of maintaining anonymity the participants’ names were substituted with pseudonyms.

Results Demographics There were five women community mental health nurses in the study. Their pseudonyms were Cathy, Jana, Kym, Leigh and Sarah. Participants were drawn from Queensland and New South Wales. They ranged in age from early thirties to late forties. Their experience in nursing was from 8-30 years. Four of the women were tertiary qualified, three had nursing degrees and all had several nursing qualifications and several years experience in community mental health nursing.

Reflective journaling Journaling was used as a means of integrating intersubjectivity within the research process for the researcher and in this way she became a researcher/participant. The other participants were not required to journal. This process allowed the researcher to embed herself deeply within the research. Reflective journaling is also congruent with feminist methodology as it encourages the researcher’s own reflexivity through disclosure of emotion and experience, with the aim of the research being more equal and non-hierarchical (Walter et al 1999). To this end, the researcher intentionally enclosed excerpts from her journal with the returned transcripts to each participant. These disclosed her own perceptions of the nurse and her interview. Journaling in this study was proclaimed by the researcher to be a valuable therapeutic tool (Rose 2002). Moreover, it would be naive to suggest that undertaking such a ‘sensitive issue’ study (Kavanaugh & Ayres 1998) would not impact upon the researcher/participant’s own state of emotional wellbeing. The researcher could identify with the comment by Glass (2001a) on the benefits of journaling when she claimed, ‘it was therefore my own therapeutic conversation, and a way of de-briefing with myself particularly when the research raised issues of emotional pain’ (p174).

The meaning of emotional wellbeing It could be clearly argued that emotionally demanding and stressful situations lay at the core of the participants nursing practice. Whilst nursing involves emotional work, the results revealed that the concept of emotional wellbeing remained complex and multifactorial. Whilst the participants had difficulty defining wellbeing specifically, there were four interrelated key components identified. Those were: the nebulous notion; the stress relationship; the mind, body, spirit connection and an inner sense of balance (Rose 2002, Rose & Glass 2005). The following are examples of these components. Nebulous notion:

Source of participants A non-probability purposive convenience sampling method in conjunction with snowball sampling was chosen. The convenience sampling is frequently used in clinical nursing research (Roberts 2002a). The selection criteria ensured that the participants were women registered nurses with a minimum of two years experience in community mental health nursing.

The mind, body, spirit connection:

Ethics approval As qualitative research methods may seek to obtain intimate details of participants lives they have the potential to cause emotional

I’ve kind of got these nebulous ideas about emotional wellbeing, about feelings and where my heart is and wellbeing, being something quite grounded, solid, feeling peaceful … but it’s a whole range of things as well… a whole kind of spectrum of emotions. [Kym].

The stress relationship: I know when it is no good. The levels of stress that I feel. The ability to concentrate, memory disturbance, being disorganised, not looking forward to going to work … Not sleeping, thought racing, taking work home with me and not being able to cut it off, pre-occupation with work [Leigh]. When you’ve been nearly killed or you’ve been in a situation that is not part of the day to day world, there’s a feeling of anger and resentment ... in those kind of situations, you do take it home [Sarah]. To be emotionally well you would have to be physically well and you would have to take care of your body, you would have to take care of your spirituality, so I think it is like mind, body, spirit wellbeing for me [Sarah].

Inner sense of balance: [Balance] is always an important factor, always, and you know, I can’t imagine anybody saying that it wouldn’t be, it’s just crucial [Jana]. It’s kind of hard just to go ‘oh it’s about… feeling happy within myself, because that’s just not the way it is. The overarching thing within that is a sense of balance and a sense of solidity somewhere within myself, that I have somewhere quite sturdy within myself [but] on days when I feel emotionally wobbly — not very sturdy at all [Kym]. Collegian Vol 13 No 4 2006

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Emotional wellbeing and professional practice: The relationship In exploring professional practice all participants spoke of two interrelated aspects, those being: delivery of quality patient care and satisfaction in their nursing care. Participants were consistently explicit regarding the strong relationship between emotional wellbeing and professional practice. The following reflections illustrate this point. I think … professional practice - how you perform professionally, is so much to do with how you see yourself and how confident you feel and all those sorts of things. I think if things are going badly wrong at work then, yeah, then I would say that is quite detrimental to your emotional wellbeing [Jana]. If you are under some stress in your private life however difficult, however hard you try not to let it [a]ffect your professional practice. It does because at times you will be thinking about it and even if you try [to] stop off from it…sometimes you find that your mind’s running away from things, you’re not concentrating on what you should be doing... your professional standard might come down a bit [Cathy]. Since I’ve been doing [yoga and sport] and working within a healthy team where I get to debrief frequently I don’t use as many drugs, I don’t need to do other things that I used to do that were quite unhealthy for me, to cope… So, yeah upon reflection how has that impacted on my professional practice, yeah, I think I’m a healthy person and … I’m much more in touch with what it is that I need and what it is that I can do and boundaries… and I’m probably a more effective practitioner because I feel more ‘present’ than I ever have…for a long time. …I can actually sit with a client and be really there, be really compassionate [Kym].

Professional practice themes In terms of the relationship of emotional wellbeing to professional practice, three dual themes were identified. These were: • Being able to speak out (or not) • Being autonomous (or not) • Being satisfied (or not) The three were termed dualistic as they each had a flip side and as such, represented positive and negative aspects to each theme.

Being able to speak out (or not) The issue of speaking out (or not) at work was continually raised by the participants. Whilst it is evident that nurses generally are becoming more assertive in their practice (Staden 1998), being able to speak out at work is a complex issue (Glass 1998). The participants found if they were supported in their practice they were able to speak out but often the opposite experience occurred within their teams. They felt they were not heard, invalidated and humiliated resulting in a hesitancy to subsequently speak out or a silencing. As a result they were vulnerable. However on the ‘flip side’ they had confidence and strength to speak out but this was only if they had discerned their environment was supportive. In relation to discussing the enormity of a case load, Leigh believed as she was a new employee she had to take the assigned load and therefore was not able to say it was disproportionately large. In response to the question ‘did you feel like you had a voice while you were there in relation to your work at all’? 30


She said: Did I have a voice? No!

And it was clear she did not know who to approach or how to receive support, she said: I didn’t know who I could [turn to to say], “this is stuffed, stop, stop, stop”.

Jana spoke of an experience regarding a weekend callout where she had to implement emergency actions independently: I talked to the team about it on Monday morning meeting … and my boss, the unsupportive one, her comment was “Oh, be a good girl Jana and don’t overreact”, and that was in front of the whole team… I just felt so angry and so kind of humiliated … I thought “Well, that’s it! Never again will I display anything that could be interpreted as weakness by her”.

Researcher: So you were really silenced? Jana: Yeah! It was just so humiliating … It obviously had a big emotional impact on me at the time. I was very angry, I felt it was unfair.

In terms of the ‘flip side’, Kym related a positive experience of support in the workplace with debriefing: I feel very passionate about the work that I do and I give quite a lot of myself to it when I’m there ... We do a bit of debriefing about stuff, we try and come up with ways to deal with it, we support each other when there is no way to deal with it except just accept it. I have a punching bag at home, I go home and belt the hell out of that!

Being autonomous (or not) Central and pivotal to the community mental health nurses’ role is that of being autonomous. Autonomy has the potential to be a positive and rewarding experience and enormously satisfying (Kipping 1998). If working in an empowering structure, truly autonomous practice increases opportunities for nurses to be creative, effective and more productive (Laschinger et al 2003). However, not all Community Mental Health Nurses (CMHN) experienced such positive feelings. Attempting to meet professional role expectations, working with clients that are often described as difficult and demanding, (Leary et al 1995), exposed the existence of a dualistic struggle, between workload, resources and workplace autonomy. This finding was also supported in other research (Ryan & Quayle 1999, Barling 2001). Consequently, issues outside of their control frequently compounded their practice and blocked their satisfying autonomous role. Working under stressful circumstances the nurses spoke of conflicting pressures and a need to maintain a balance in order to achieve a constant healthy state of wellbeing. Kym raised issues that caused her frustration in her practice: The managers will run various teams understaffed, ‘cause it’s all about major blowouts, we can’t spend any more, we can’t put anyone on, so if they run teams short, then everyone in that team carries an extra load.

Kym’s balance was her autonomy with her clients: That’s the other thing that keeps me going ... the clients that I work with ... I really enjoy the work that I do when I’m out of the office.

Sarah reflected on her intense passion for her client relationships. If the office dynamics seemed intolerable she was able to strategically re-focus, utilise her ability to be autonomous and visit her clients: I think what is empowering and what is nurturing is … the connection with other people at such a deep level and I’m talking about clients. There is so much present that is not present in anything else that you do ... [W]hen I would feel really, pretty irritated with the system, pretty


‘pissed’ off and with the calibre of the people that I’m working with I [would] think well... I’ll think I’ll go and see [a client]. So I would go and get nurtured by removing myself from that space and putting myself in a different space.

Being satisfied (or not) Professional satisfaction was integrally linked to workplace clinical supervision, optimal workplace conditions and self healing strategies. When this occurred, the participants’ intense passion for their nursing practice was clearly apparent and there was a positive impact on their wellbeing. However, increased workplace demands often related to economic restraints resulted in ongoing stress, professional dissatisfaction, dialectical tension causing a disturbance to their wellbeing. In terms of supervision, it is evident that nurses satisfaction increases significantly, owing to the gained benefits, it potentially improves insight, confidence and more rewarding collegial relationships are developed (Heath & Freshwater 2000, Teasdale et al 2001). As Cathy related: having clinical supervision, I have that every week and I find that incredibly useful. It’s not something that is just offered to us. It’s just something that you have to do yourself but I find that very helpful. [A senior nurse in the hospital] has been kind enough to offer that to me, so it’s really good.

However, even though some nurses are now receiving supervision there still remains a lack of support for it. As Sarah explained: Well, a lot of it is about funding because ... it took [years] before we got clinical supervision and then it became mandatory ... Like they don’t recognise the need for any. When you ask for something as a worker [it’s] because you need it for your practice, you wouldn’t ask for it if you didn’t need it ... but [then] something happens, like there are too many deaths, or there’s too many critical incidents in the community and then all of a sudden [the organisation] decides “oh well, they must have clinical supervision because the stakes and accountability have gone up”. If they had of given it to people when they wanted it, that would have been much more supportive but oh no, that would have cost too much!

In terms of workplace conditions, dissatisfaction was explicit in their stories. Literature also supports this finding, for example Hopkinson et al (1998), Edwards et al (2000) and Cottrell (2001) reported organisational issues and general working conditions as contributing factors to work related stress for CMHNs. All participants spoke of their working environments and its impact on their wellbeing. Sarah expressed strong concerns regarding her ‘toxic’ work environment: I think the environment has a huge impact on your wellbeing as well. You know, we’d be sitting at dinner and have rocks come through the window... The air conditioning was always really, really bad and toxic, safety is a huge issue. [A colleague] was bashed up out the front mental health administrators don’t want to know about buildings, they can’t even deal with sick people.

Cathy said: We were jammed into a room... with poor ventilation and poor airconditioning... Not enough desks to go around and not enough chairs... sometimes we don’t have enough mobile [phones].

As implied above, self healing strategies were a necessity to maintain a strong sense of emotional wellbeing and professional satisfaction. The benefits of stress management strategies have a high correlation with job satisfaction in mental health nursing

(Carson et al 1997). The following comments support this theme. I’ve always been somebody who’s exercised a lot…I think jobs like mental health nursing and education, are jobs that you can take home with you in your head and removing myself physically doesn’t work but if you actually have something else that you do after work, especially something like exercise, that kind of lets you forget, perhaps get rid of some tension [Jana]. As I come home from work I really appreciate no-one being home ... I find that I have all this ‘shit’ going on in my head that I just really want to off load and I don’t really want to off load it onto anybody else … all I need is maybe 20 minutes just in my own space to listen to music and just to be … it’s just my way to cope, so that everything doesn’t reflect back on me and I don’t take it out on people around me [Cathy].

It was evident in the women’s dialogue that a strong sense of self-awareness existed. Being introspective is a critical issue in nursing practice and furthermore, essential if a person is to develop a greater understanding of the ‘self ’. As Eckroth-Bucher asserted, ‘[u]nderstanding another begins with understanding oneself ’ (2001 p34). Engagement in self caring activities provides an opportunity for nurses to achieve a greater sense of satisfaction in professional practice.

Conclusion The emancipatory process utilised in this study was considered by the participants to be particularly beneficial to their professional growth. Throughout the research the women consistently stated they felt acknowledged and validated regarding their experiences as community mental health nurses. Such a process appeared to be essential regarding the depths of their associated disclosures (Glass 2001b). The study revealed a strong relationship between satisfying professional practice and CMHNs positive emotional wellbeing and equally, dissatisfying professional practice and a negative emotional wellbeing. The authors would argue that the importance of emotional wellbeing to professional practice sets this research aside from previous studies on workplace stressors and stress related issues insofar as emotional wellbeing is pivotal to satisfying nursing practice. Whilst emotional wellbeing was portrayed as complex to explain succinctly it was evident that being emotionally calm, feeling peaceful and experiencing a healthy sense of self were critical components of effective professional practice. Nurses in this study were forthright in their comments regarding the greater need for support in their practice. Moreover, it was evident their need to be heard and listened to regarding their practice experiences irrespective or whether they felt positive or negative, was integral to their ongoing professional satisfaction. A further interrelated component was that in order to maintain their nursing passion they needed to have institutional support for their autonomous community practice whilst simultaneously shown measurable support for ongoing clinical supervision. The authors contend that nurse/client relationships are explicitly emotional, and that emotional work impacts on their emotional wellbeing. In order to support CMHNs in their practice there is a need for health care organisations to be both pro-active and reactive in their philosophical and policy directions, and their interventions. Failure to do so will jeopardise the emotional health of existing nurses, effect retention and future recruitment of nurses and of equal importance, effect quality health care delivery. Collegian Vol 13 No 4 2006

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Therefore it is argued gaining further insight into the concept of emotional wellbeing, its unique meaning to mental health nurses, and consequently the relationship between emotional wellbeing and professional practice is critical for professional satisfaction and integration. It is this that nurses need to appreciate, or be aware of, so that they may be able to deal with the emotional stressors and level of satisfaction in providing care. These factors need to be addressed comprehensively by health care employers. References Arafa M A, Nazel M W A, Ibrahim N K, Attia A 2003 Predictors of psychological …. well-being of nurses in Alesandria, Egypt. International Journal of Nursing Practice 9:313-320 Barling J 2001 Drowning but not waving: burnout and mental health nursing. Contemporary Nurse 11(2-3):247-259 Birx E 2003 Nurse, heal thyself. RN 66(1):46-48 Bolton S C 2000 Who cares? Offering emotional work as a ‘gift’ in the nursing labour process. Journal of Advanced Nursing 32(3):580-586 Carson J 1997 Self-esteem and stress in mental health nurses. Occasional Paper. Nursing Times 93 (44):55-58 Carson J, Fagin L, Maal S, de Villiers N, O’Malley P 1997 Stress and fitness in wardbased mental health nurses. Journal of Clinical Nursing 6(5):419-420 Cottrell S 2001 Occupational stress and job satisfaction in mental health nursing: focused interventions through evidence-based assessment. Journal of Psychiatric and Mental Health Nursing 9:157-164 Davis K 1998 Cartographies of rural community nursing and primary health care: mapping the in-between spaces. PhD Thesis UWS-H Australia Eckroth-Bucher M 2001 Philosophical basis and practice of self-awareness in psychiatric nursing. Journal of Psychosocial Nursing and Mental Health Services 39(2):32-41 Edwards D, Burnard P 2003 A systematic review of stress and stress management interventions for mental health nurses. Journal of Advanced Nursing 42(2):169-200 Edwards D, Burnard P, Coyle D, Fothergill A, Hannigan B 2000 Stressors, moderators and stress outcomes: findings from the All-Wales community mental health nurses study. Journal of Psychiatric & Mental Health Nursing 7(6):7-14 Farrell G 1999 Aggression in clinical settings: nurses’ views - a follow-up study. Journal of Advanced Nursing 29(3):532- 541 Farrell G, Bobrowski C 2003 Scoping Workplace Aggression in Nursing’ (SWAN). Research Report University of Tasmania Foster J, Finlayson S, Bentall R, Day J, Randall F, Wood P, Reid D, Rogers A, Healy D 2003 The perceived expressed emotion in staff scale. Journal of Psychiatric & Mental Health Nursing 10(1):109-116 Glass N 1997 Horizontal violence in nursing: celebrating conscious healing strategies. Australian Journal of Holistic Nursing 4(2):15-23 Glass N 1998 Becoming de-silenced and reclaiming voice. Women nurses speak out. In: Keleher H, McInerney F (eds) Nursing matters. Critical Sociological Perspectives. Marrickville, NSW, Churchill Livingstone Glass N 2000 Speaking feminisms and nursing. In: Greenwood J (ed) Nursing theory in Australia. Development and application, Frenchs Forest, NSW, Pearson Education Australia Glass N 2001a The dis-ease of nursing academia: putting the vulnerability ‘out there’ part one. Contemporary Nurse 10(3-4):172-177 Glass N 2001b The dis-ease of nursing academia: putting the vulnerability ‘out there’ part two. Contemporary Nurse 10(3):178-186 Glass N 2003a Studying women nurse academics: exposing workplace violence part one. Contemporary Nurse 14(2):180-186 Glass N 2003b Making a difference for nurses: professional integration as an innovative method for responding to experiences of violence. The 12th International conference of the Nursing network on violence against women. Violence against women: Evidence of difference? Rethinking current paradigms and exploring innovative approaches to ending violence Flinders University of South Australia, Adelaide, June. Glass N 2003c Studying women nurse academics: exposing workplace violence part two. Contemporary Nurse 14(2) 187-195 Glass N 2003d Validating moving on: reflections of women nurse academics experiences with violence and subsequent healing. Women Against Violence 13:49-58 Glass N, Davis K 1998 An emancipatory impulse: a feminist postmodern integrated turning point in nursing research. Advances in Nursing Science 21(1):43-52 Hamilton H, Clare J 2004 Reviewing the literature: making ‘the literature’ work for you. Collegian 11(1):8-11 Happell B, Martin T, Pinikahana J 2003 Burnout and job satisfaction: a comparative study of psychiatric nurses from forensic and a mainstream mental health service. International Journal of Mental Health Nursing 12(1):39-47 32


Healy C M, McKay M F 2000 Nursing stress: the effects of coping strategies and job satisfaction in a sample of Australian nurses. Journal of Advanced Nursing 31(3):681-688 Heath H, Freshwater D 2000 Clinical supervision as an emancipatory process: avoiding inappropriate intent. Journal of Advanced Nursing 32(5):1298-1306 Hinds R, Harley J 2001 Exploring the experiences of beginning registered nurses entering the acute care setting. Contemporary Nurse 10(1):110-116 Hopkinson P J, Carson J, Brown D, Fagin L, Bartlett H, Leary J 1998 Occupational stress and community mental health nursing: what CPN’s really said. Journal of Advanced Nursing 27:707-712 Humpel N, Caputi P, Martin C 2001 The relationship between emotions and stress among mental health nurses. Australian and New Zealand Journal of Mental Health Nursing 10:55-60 Jackson D, Clare J, Mannix J 2002 Who would want to be a nurse? Violence in the workplace-a factor of recruitment and retention. Journal of Nursing Management 10:13-20 Kavanaugh K, Ayres L 1998 “Not as bad as it could have been”: assessing and mitigating harm during research interviews on sensitive topics. Research in Nursing & Health 21:91-97 Kipping C J 1998 Exploring mental health nurses’ expectations and experiences of working in the community. Journal of Clinical Nursing 7(6):531-538 Laschinger S, Heather K, Almost J, Tuer-Hodes D 2003 Workplace empowerment and magnet hospital characteristics: making the link. Journal of Nursing Administration 33(7/8):410-422 Leary J, Gallagher T, Carson J, Fagin L, Bartlett H, Brown D 1995 Stress and coping strategies in community psychiatric nurses: a Q-methodological study. Journal of Advanced Nursing 21(2):230-237 O’Connor M 2002 Nurse leader: heal thyself. Nursing Administration Quarterly 26(2):69-79 Omdahl B, O’Donnell C 1999 Emotional contagion, empathic concern and communicative responsiveness as variables affecting nurses’ stress and occupational commitment. Journal of Advanced Nursing 29(6):1351-1359 Patton M Q 2002 Qualitative research and evaluation methods. Newbury Park, Sage Publications. Preston B 2002 Australian nurse supply and demand to 2006: a projections model and its application. National Library of Australia Cataloguing-in-Publication data, Melbourne Ristock J L, Pennel J 1996 Community research as empowerment: feminist links, postmodern interruptions. Oxford, Toronto. Roberts K 2002a Quantitative methods. In: Roberts K, Taylor B (eds) Nursing research processes: an Australian perspective 2nd edn. Nelson, Victoria Roberts K 2002b Ethics in nursing research. In: Roberts K, Taylor B (eds) Nursing research processes: an Australian perspective 2nd edn. Nelson, Victoria Roberts S J 2000 Development of a positive professional identity: liberating oneself from the oppressor within. Advances in Nursing Science 22(4):77-82 Rose J 2002 A reflective journey with community mental health nurses: exploring the relationship between emotional wellbeing and professional practice. A critical feminist research inquiry. BNurs(Hons)thesis SCU Australia Rose J, Glass N 2005 Community mental health nurses and their emotional wellbeing: is anyone listening? Australian Journal of Holistic Nursing 12(11):23-32 Ryan D, Quayle E 1999 Stress in psychiatric nursing: fact or fiction? Nursing Standard 14(4):32-35 Staden J 1998 Alertness to the needs of others: a study of the emotional labour of caring. Journal of Advanced Nursing 27(1):147-156 Taylor B, Barling J 2002 Identifying the sources and effects of carer fatigue and burnout for mental health nurses: research report. Southern Cross University Press, Lismore Teasdale K, Brocklehurst N, Thom N 2001 Clinical supervision and support for nurses: an evaluation study. Journal of Advanced Nursing 33(2):216-224 Tully A 2004 Stress, sources of stress and ways of coping among psychiatric nursing student. Journal of Psychiatric and Mental Health Nursing 11(1):43-47 VanderPlaat M 1999 Locating the feminist scholar: relational empowerment and social activism. Qualitative Health Research 9(6):773-785 Walter R 2003 Having a light attitude: an integrated postmodern feminist investigation of women graduate registered nurses and playfulness. Phd Thesis SCU Walter R, Davis K, Glass N 1999 Discovery of self: exploring, interconnecting and integrating self (concept) and nursing. Collegian 6(2):12-15

Acknowledgements

The participants who willingly gave of their time to take part in the study and who believed in the importance of this research. Southern Cross University for support of this project.