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International Journal of Mental Health Nursing (2015) 24, 49–58 doi: 10.1111/inm.12097

Feature Article
Towards a model for understanding the
development of post-traumatic stress and general
distress in mental health nurses
Joyce Lee,1,2 Michael Daffern,1,3 James R. P. Ogloff 1,3 and Trish Martin1,3
1
Centre for Forensic Behavioural Science, Swinburne University, 2Monash Health, and 3Victorian Institute of
Forensic Mental Health, Melbourne, Victoria, Australia

ABSTRACT: In their daily work, mental health nurses (MHN) are often exposed to stressful events,
including patient-perpetrated aggression and violence. Personal safety and health concerns, as well as
concern for the physical and psychological well-being of patients, dominate; these concerns have a
profound impact on nurses. This cross-sectional study explored and compared the psychological
well-being of 196 hospital-based MHN (97 forensic and 99 mainstream registered psychiatric nurses
or psychiatric state enrolled nurses). The aim was to examine exposure to inpatient aggression and
work stress, and identify factors contributing to the development of post-traumatic stress reactions and
general distress. Multiple regression analyses indicated that working in a mainstream setting is
associated with increased work stress; however, mainstream and forensic nurses experienced similar
psychological well-being. As a group, 14–17% of mainstream and forensic nurses met the diagnostic
criteria for post-traumatic stress disorder, and 36% scored above the threshold for psychiatric
caseness. A tentative model of post-traumatic stress and general distress in nurses was developed,
illustrating the impact of aggression and stress on well-being. The present study affirms that mental
health nursing is a challenging and stressful occupation. Implications for organizations, managers, and
individual nurses are discussed.
KEY WORDS: aggression, forensic, mental health nursing, stress, trauma.

BACKGROUND is a considerable factor, with verbal abuse and threats

reported by 80–90% of mainstream and forensic unit-
Mental health nursing is a stressful occupation, with
based MHN (Nijman et al. 2005). With respect to vio-
23–44% of mental health nurses (MHN) experiencing
lence, 76% of MHN have experienced mild physical
clinical levels of psychological distress (Edwards &
violence, while 16% have encountered severe physical
Burnard 2003; Fagin et al. 1996). The causes of distress
violence resulting in major physical injury (Nijman et al.
are varied (Dickinson & Wright 2008; Edwards &
2005).
Burnard 2003), although patient-perpetrated aggression
Nurses working in a forensic setting (forensic MHN),
who interact with patients with a history of interpersonal
Correspondence: Joyce Lee, Mental Health Program, Monash violence, aggression, and antisocial behaviour, might
Health, Dandenong Hospital, 135 David Street, Dandenong, Vic. experience a different level of victimization than nurses
3175, Australia. Email: joyce.lee@monashhealth.org working in a civil setting (mainstream MHN). Forensic
Joyce Lee, BA (Hons), B.LLB (Hons), D.Psych (Clinical).
Michael Daffern, GCHE, BSc (Psych) (Hons), MPsych (Clin), PhD. MHN work in settings with patients who have committed
James R. P. Ogloff, BA, MA (Clin Psych), JD, PhD. offences or are the subject of forensic orders after having
Trish Martin, RPN, DN, MN, BAppSci (Nsing), DipAppSci
(AdvPsychNsing), CertForPsychNsing, GradCertFBS. been found incompetent/unfit to stand trial or not crimi-
Accepted July 2014. nally responsible due to mental illness. Previous studies

© 2014 Australian College of Mental Health Nurses Inc.

50 J. LEE ET AL.

have shown that forensic MHN are victimized more fre- this latter study, forensic MHN were also more satisfied
quently and severely than mainstream MHN (Gournay & with their current work situation, their involvement in
Carson 2000; Larkin et al. 1988). decision-making, and the amount of support they
Following aggression, nurses might experience anger, received. In the only known study comparing unit-based
anxiety, guilt, self-blame; shame (Needham et al. 2005), mainstream and forensic MHN, Chalder and Nolan
and ruminations, body soreness, muscle tension, fatigue, (2000) found that the two groups did not differ on level of
and fear of the perpetrator are common (Whittington & stress.
Wykes 1989). Some MHN develop post-traumatic stress Specific sources of stress frequently reported by MHN
disorder (PTSD) (Needham et al. 2005). Richter and include administrative and organizational issues, patient-
Berger (2006) reported that 17% of severely-assaulted related issues, workload, staff conflict, financial and
staff working in a mental health unit met the criteria for resource concerns, professional self-doubt, difficulty bal-
PTSD at baseline assessment, decreasing to 11% at ancing home and work, staffing issues, structural changes
6-month follow up. Additional research has found that, in the health system, and the quality of supervision
following verbal abuse or physical violence, 21% of main- (Edwards & Burnard 2003; Hamdan-Mansour et al.
stream MHN had total scores equal to or exceeding the 2011). Mainstream ward-based MHN commonly rate
threshold on the Impact of Events Scale–Revised, indi- having to manage violent and/or suicidal patients, admin-
cated that this group might meet the criteria for PTSD istrative and organizational issues, patient contact, work-
(Inoue et al. 2006). These findings indicate that a propor- load, and death/dying as frequent stressors (Cai et al.
tion of nursing staff are vulnerable to developing a 2008; Fagin et al. 1996). In the forensic context, ward-
symptom constellation sufficient to constitute PTSD fol- based MHN report stress relating to managing their
lowing aggression and violence. workload, staff conflict, lack of input in decision-making,
Mainstream ward-based MHN, who suffer more than patient supervision, and administrative work (Dickinson
one physical assault, might fall into either a violence- & Wright 2008; Happell et al. 2003b). Comparing main-
habituated or violence-distressed group (Wykes & stream and forensic ward-based MHN, Chalder and
Whittington 1998). At 1-month post-physical assault, Nolan (2000) found that MHN differed on workplace
these nurses either scored significantly better or signifi- stressors, with forensic MHN rating interprofessional
cantly worse on a variety of PTSD scales, the General conflict as more stressful than mainstream MHN, and
Health Questionnaire–28, and a measure of state anger, mainstream MHN rating resource issues as more stressful
than those nurses who were physically assaulted on one than forensic colleagues.
occasion (Wykes & Whittington 1998). Such findings
might suggest that individual differences or workplace Current study
characteristics might affect psychological reactions to vio- Previous studies have indicated that MHN employed in
lence. Little research exists on the vulnerability of foren- different settings experience considerable differences in
sic MHN to post-traumatic stress following aggression. exposure to inpatient violence and aggression, with foren-
One study found that, although forensic ward-based sic MHN encountering more frequent inpatient aggres-
MHN were exposed to more frequent physical assaults, sion, and sustaining greater injuries from such
threats, and violence than mainstream ward-based MHN, experiences, than mainstream colleagues. While a signifi-
no forensic nurse met the full criteria for a diagnosis of cant proportion of mainstream MHN might develop post-
PTSD, and a relatively low rate of post-traumatic stress traumatic stress reactions, it is unclear how forensic MHN
symptoms were reported (Lauvrud et al. 2009). differ in their reactions to patient-perpetrated aggression.
In addition to exposure to aggression, MHN experi- While MHN are known to experience a high level of work
ence considerable work stress. Findings from the few stress, differences between nurses working in forensic
known previous studies comparing work stress in forensic and mainstream settings are not well understood, and
and mainstream MHN have been largely equivocal. In previous research has not concurrently examined the level
one study, forensic ward-based MHN reported increased of work stress and inpatient aggression in the develop-
exposure to stressors and lower job satisfaction than other ment of psychological ill health in MHN.
MHN (Gournay & Carson 2000), whereas other research The current study aims to directly compare exposure
has indicated that forensic community and ward-based to inpatient aggression and work stress in mainstream and
MHN experience a lower level of burnout (emotional forensic MHN, and to develop a model to understand the
exhaustion and depersonalization) and higher job satisfac- development of psychological ill health in MHN. For
tion than non-forensic MHN (Happell et al. 2003a). In the purposes of the study, aggression was defined as

© 2014 Australian College of Mental Health Nurses Inc.

TRAUMA IN PSYCHIATRIC NURSES 51

behaviour involving ‘actual, attempted or threatened tion of their expert knowledge and inconvenience, all
harm to a person or persons’ (Webster et al. 1997, p. 24). participants were offered an A$30 shopping voucher.
Two major research questions were explored:
Instruments
1. Do mainstream and forensic ward-based MHN differ Demographic information
with regards to frequency of inpatient aggression, level The age, sex, marital status, educational level, nature and
of work stress, general distress, and post-traumatic length of nursing career, and time/type of shifts worked
stress? If so, how? It was hypothesized that forensic were recorded. Participants were asked how many hours
MHN will experience more frequent inpatient aggres- they had spent attending aggression-management courses
sion and lower levels of work stress, and demonstrate in their nursing career and in the past year, when they last
lower general distress and lower post-traumatic stress, attended a course, and to what extent these courses
than mainstream MHN. helped them to manage aggression (rated on a 7-point
2. In mainstream and forensic ward-based MHN, what Likert scale from 1 (‘not useful at all’) to 7 (‘very useful’)).
are the factors that contribute to the development of The number of hours of aggression-management courses
general distress and post-traumatic stress? It was attended in the career and in the past year, and when
hypothesized that more frequent inpatient aggression nurses last attended a course, were based on estimates
and higher levels of work stress will be associated provided by participants.
with increased general distress and increased post-
traumatic stress.
Perception of Prevalence of Aggression Scale
The Perception of Prevalence of Aggression Scale
(POPAS) is a 16-item, five-point Likert-type scale ques-
METHOD
tionnaire that provides estimates of the type, frequency,
Sample and number of 16 types of aggressive behaviour con-
Participants were 196 ward-based MHN recruited fronted or witnessed by mental health staff during the
across four sites in metropolitan Melbourne, Australia, past year of work. Specifically, the 16 types of aggressive
from June 2009 to September 2009. Ninety-nine main- behaviour are verbal aggression, threatening verbal
stream ward-based MHN were recruited from inpatient aggression, humiliating aggressive behaviour, provocative
mental health units (comprising acute, secure extended aggressive behaviour, passive-aggressive behaviour,
care, adolescent inpatient, and mother/baby and eating aggressive splitting behaviour, threatening physical
disorder units) from three major general hospitals (rep- aggression, destructive-aggressive behaviour, mild physi-
resenting a 58% response rate), and 97 forensic ward- cal violence, severe physical violence, mild violence
based MHN were recruited from a state-wide secure against self, severe violence against self, suicide attempts,
forensic mental health hospital (acute, subacute, con- successful suicides, sexual intimidation/harassment, and
tinuing care, and rehabilitation units), representing a sexual assault/rape. Based on the Likert-type scale ratings,
65% response rate. The sample was convenient in type, a total POPAS (Nijman et al. 2005; Oud 2001) score can
and only registered psychiatric nurses (those who had be computed, representing overall exposure to patient
completed a university bachelor degree) and psychiatric aggression during the past year of work. The POPAS
state enrolled nurses (those who had completed a demonstrates good internal consistency (Cronbach’s
diploma qualification through a technical institution) α = 0.86) and satisfactory face validity (findings of higher
were invited to participate. levels of severe physical violence when working with
involuntarily-admitted patients and higher levels of sexual
Procedure harassment reported by female staff), although still
This study employed a cross-sectional questionnaire requires further validation (Nijman et al. 2005). It has,
design. Ethics approval was obtained from the three however, been employed in research examining the
major general hospitals, the secure forensic mental health prevalence of inpatient aggression, as experienced by
hospital, and a university research committee (due to the MHN, by experts in the field.
study being part of doctoral research). Nurses were
invited to participate during unit meetings and via poster Lifetime trauma history
and email advertisements. Participation was voluntary Prior exposure to traumatic events outside of work was
and anonymous, and involved completing a questionnaire assessed using a list of 12 events taken from the National
booklet and separate ‘Contact Details’ form. In apprecia- Comorbidity Survey (Kesseler et al. 1995). Participants

© 2014 Australian College of Mental Health Nurses Inc.

52 J. LEE ET AL.

indicated whether they had ever experienced any of the by high correlations between the PCL and other self-
events in their life outside work, and if so, how many report measures of PTSD (Blanchard et al. 1996;
times. Weathers et al. 1993).

DeVilliers, Carson, and Leary Stress Scale General Health Questionnaire-28

The DeVilliers, Carson, and Leary (DCL) Stress Scale The General Health Questionnaire-28 (GHQ-28)
(Carson 2005; Fagin et al. 1996) is a 30-item, five-point (Goldberg & Williams 1988) is a self-administered, four-
Likert-type scale measure of work stress that was point Likert-type scale screening questionnaire designed
designed for hospital-based MHN. It comprises the five to provide an overall measure of psychological well-
subscales of patient demands (responding to unpredict- being. Participants rate how often in the past few weeks
able, violent, suicidal and problematic patients), they have experienced symptoms associated with the
organizational and managerial issues (low morale, lack of four subscales of somatization, anxiety and insomnia,
collaboration with peers and management, and general social dysfunction, and severe depression. The GHQ-28
lack of feedback), staffing (staff conflict and the impact of has been widely employed in both traumatic stress
staffing difficulties on clinical care), future concerns (job research and community surveys, both in Australia and
security and possible redundancy related to hospital internationally (Hodgins et al. 2001). Studies have indi-
restructures) and job satisfaction (remuneration and cated that items pertaining to the severe depression
career development opportunities). The DCL Stress subscale have high specificity, while items pertaining to
Scale has been frequently utilized in previous studies somatic symptoms have high sensitivity (Willmott et al.
examining the occupational experience of MHN. It has 2008).
excellent internal consistency (Cronbach’s alpha = 0.96)
(Carson 2005), high test-retest reliability, and satisfactory Data analysis
face and content validity. Data were analysed using PASW Statistics 18 (SPSS,
Chicago, IL, USA). For the PTSD diagnosis (severity
Posttraumatic Stress Disorder Checklist, Civilian Version scoring method) variable, cases were scored ‘yes’ if the
The Posttraumatic Stress Disorder Checklist (PCL) total PCL-C score was 44 or more. The GHQ-28 caseness
(Weathers et al. 1993) is a widely-employed 17-item, self- variable was coded ‘case’ if the total score was five or more
report instrument designed to assess the symptoms of (Fagin et al. 1996). To manage univariate outliers, total
PTSD. Each item corresponds directly to each of the 17 PCL-C score, GHQ-28 social dysfunction, and GHQ-28
Diagnostic and Statistical Manual–IV, Text Revision severe depression were transformed (square root, loga-
(DSM-IV-TR) criteria for a diagnosis of PTSD, with items rithm, and inverse transformations, respectively).
falling into the clusters of re-experiencing symptoms, Assumptions of analysis associated with the standard
avoidance and numbing symptoms, and hyperarousal multiple regression and moderated multiple regression
symptoms. Participants were asked to indicate on a five- were explored. Variables were generally normally distrib-
point Likert-type scale, from one (‘not at all’) to five uted, and when this was not the case, a Bonferroni
(‘extremely’), how much they had been bothered by each adjusted alpha level of 0.025 was used. Assumptions of
symptom in the past month. For the present study, the linearity and homoscedasticity were met. To reduce mul-
PCL, Civilian Version (PCL-C), which does not focus on ticollinearity between the subscales of organizational and
any specific traumatic event, but instead asks generally managerial issues and staffing, these two subscales were
about past stressful experiences, was used. Responses collapsed into one variable, termed ‘organizational and
might be summed to generate a total severity score staffing issues’. In order to identify cases to facilitate com-
(ranging from 17 to 85). Alternatively, a response of three parisons of the current sample with samples from other
or above on an item indicates individual symptom studies, proportions of nurses scoring above a threshold
endorsement (Weathers et al. 1993), with a PTSD diag- score for distress and post-traumatic stress are shown.
nosis established when one symptom from the However, regression analyses were based on continuous
re-experiencing cluster, three symptoms from the avoid- scores for these variables.
ance and numbing cluster, and two symptoms from the
hyperarousal cluster are endorsed (in accordance with the
RESULTS
DSM-IV-TR). The PCL demonstrates excellent test–
retest reliability (Cronbach’s α = 0.96), very high internal Examining the demographic characteristics of the total
consistency, and adequate construct validity, as indicated sample, mainstream and forensic nurses had a mean age

© 2014 Australian College of Mental Health Nurses Inc.

TRAUMA IN PSYCHIATRIC NURSES 53

of 40.77 years (standard deviation (SD) = 11.33); 64% of TABLE 1: GHQ-28 caseness and PTSD diagnoses by setting
the sample was female, 50% were married, and they had Setting
an average of 12.03 years of experience as an MHN Variable Mainstream Forensic Total
(SD = 10.01). In terms of highest educational level, the
GHQ-28 caseness, % (n)
majority of the total sample held a postgraduate qualifi- Case 43a (43) 29a (28) 36 (71)
cation in mental health nursing (59%), while 16% had an Non-case 57 (56) 71 (69) 64 (125)
undergraduate degree, and 15% held a hospital certifi- PTSD diagnosis (severity scoring method), % (n)†
cate. The remaining 9% were TAFE educated. As a total PTSD 18 (17) 17 (16) 17 (33)
group, participants had completed a mean of 96.12 hours No PTSD 83 (80) 83 (79) 83 (159)
of aggression-management courses in their career (range: PTSD diagnosis (symptom endorsement scoring method) % (n)
0–1000 hours), with 20.35 hours of courses in the past PTSD 16 (15) 12 (11) 14 (26)
No PTSD 85 (82) 88 (84) 87 (166)
year (range: 0–120 hours). They had attended their last
course an average of 5.71 months ago (range: 0–48 Percentages sharing a common subscript are statistically different at
months). As a total sample, nurses rated the usefulness of α = 0.05, according to a χ2-test of independence. †In the absence of a
courses as 5.02, suggesting that they found these courses designated cut-off score for PTSD diagnoses in mental health nurses, a
cut-off score of 44 (as found for motor vehicle accident and sexual
at least moderately useful, and had a mean total lifetime assault survivors) was used (Blanchard et al. 1996). GHQ-28, General
trauma history score of 1.64 traumatic events. Health Questionnaire-28; PTSD, post-traumatic stress disorder.
Comparing the demographic characteristics of forensic
and mainstream nurses, a χ2-test of independence
revealed that marital status differed significantly between These results did not differ significantly between main-
mainstream and forensic nurses (χ2(5) = 16.07, stream and forensic nurses.
P = 0.007). In comparison to mainstream nurses, forensic To explore whether nurses differed as a function of
nurses were less likely to be married, more likely to have work setting on stress, aggression, general distress, and
never married, and more likely to be divorced. An post-traumatic stress, separate standard multiple regres-
independent-samples t-test revealed that forensic nurses sion analyses were employed. Predicting future concern
had worked significantly more years as a mental health stress, the variables of setting, patient demand stress,
nurse (mean = 14.46, SD = 10.99) than mainstream organizational and staffing stress, job satisfaction stress,
nurses ((mean = 9.69, SD = 8.38), t(192) = −3.413, and frequency of aggression were entered into a regres-
P = 0.001). Independent-samples t-tests revealed that sion model (F(5, 162) = 54.91, P < 0.001). Setting
mainstream nurses had completed significantly more emerged as a significant predictor (β = −0.14, P < 0.01),
hours of courses in the past year (mean = 29.02, such that forensic nurses were exposed to lower future
SD = 20.12) than forensic nurses ((mean = 11.49, concern stress than mainstream nurses. Work stress relat-
SD = 18.66), t(186) = 6.190, P < 0.001), but that forensic ing to patient demands (β = 0.30, P < 0.001) and job sat-
nurses had attended their last course significantly more isfaction (β = 0.58, P < 0.001) were also significant
recently (mean = 3.80, SD = 5.82) than mainstream predictors of future concern stress, and the regression
nurses ((mean = 7.58, SD = 7.06), t(194) = 4.077, model accounted for 62% of the variance.
P < 0.001). No significant differences between groups Using multiple regression analyses, no other significant
were evident on other demographic variables. differences were found between mainstream and forensic
nurses, with respect to other work-stress subscales, aggres-
Comparisons between mainstream and sion, general distress, and post-traumatic stress. As such,
forensic nurses the two groups were collapsed into one group to examine
Examining general distress, Table 1 shows that 36% of all factors that predict psychological ill health in nurses.
nurses met the criteria for GHQ-28 caseness. A χ2-test of
independence revealed that the percentage of nurses who Factors predicting psychological ill health
met the criteria for caseness differed significantly Standard multiple regression analyses were conducted to
between mainstream (43%) and forensic (29%) nurses examine the direct unique contribution of work stress,
(χ2(1) = 4.50, P = 0.038). With respect to post-traumatic aggression, and demographic variables on post-traumatic
stress, 17% of the total sample met the diagnostic criteria stress, while controlling for all other variables in the
for PTSD, as determined by the severity scoring method, model. For predicting hyperarousal symptoms, work-
and 14% met the diagnostic criteria for PTSD, as deter- stress subscales, aggression, setting, age, sex, years
mined by the symptom endorsement scoring method. worked as an MHN, and lifetime trauma history were

© 2014 Australian College of Mental Health Nurses Inc.

54 J. LEE ET AL.

entered into a standard multiple regression analysis for P < 0.01) and frequent aggression (β = 0.25, P < 0.01)
mainstream and forensic nurses (F(10, 155) = 5.38, were associated with increased anxiety and insomnia,
P < 0.001). One variable, organizational and staffing stress while more hours of courses in career (β = −0.20,
(β = 0.31, P < 0.05), emerged as a significant predictor, P < 0.025) was associated with decreased anxiety and
with increased organizational and staffing stress being insomnia. The model accounted for 19% of the variance.
associated with increased hyperarousal, accounting for For predicting social dysfunction, work-stress
21% of the variance. No single predictor was found to subscales, aggression and details relating to courses, were
significantly predict re-experiencing (F(10, 155) = 4.17, entered into a model (F(9, 156) = 3.44, P < 0.01), with a
P < 0.001) or avoidance and numbing (F(10, 155) = 4.57, Bonferroni adjusted alpha of 0.025. Higher organizational
P < 0.001), using a Bonferroni adjusted alpha level of and staffing stress (β = 0.37, P < 0.025) was related to
0.025. increased social dysfunction, and more hours of courses in
Additional analyses were performed to assess for the career (β = −0.24, P < 0.01) was related to decreased
direct contribution of work-stress subscales, aggression, social dysfunction. The model accounted for 12% of the
and details relating to aggression-management courses variance.
(hours attended in career and in past year, last course
attended, and usefulness of courses) on post-traumatic
DISCUSSION
stress. For predicting hyperarousal symptoms, the model
was significant (F(9, 156) = 6.55, P < 0.001), with The present study aimed to compare work-related stress
organizational and staffing stress (β = 0.31, P < 0.05), fre- and exposure to patient-perpetrated aggression in foren-
quency of aggression (β = 0.20, P < 0.01), hours of sic and mainstream MHN, and to develop a model to
courses in career (β = −0.19, P < 0.05), and last course explain risk factors relevant to psychological ill health.
attended (β = −0.16, P < 0.05) emerging as significant Mainstream and forensic nurses reported comparable
predictors. Higher organizational and staffing stress and exposure to inpatient aggression. While this finding
frequent aggression were associated with increased appears to be at odds with some previous studies (e.g.
hyperarousal, and more hours of courses in career and Gournay & Carson 2000; Larkin et al. 1988), the total
increased time of last course attended were associated frequency of the aggression score comprised not only
with decreased hyperarousal. The model accounted for patient-perpetrated physical violence to self, others, and
23% of the variance. property ,but included patient-perpetrated verbal aggres-
With respect to general distress, for predicting anxiety sion, sexual harassment, and other types of non-physical
and insomnia, the variables of work-stress subscales, aggression. This broader definition of aggression might
aggression, setting, age, sex, years worked as an MHN, explain the lack of difference. No differences were
and lifetime trauma history, were entered into a regres- observed between mainstream and forensic MHN on
sion model (F(10, 155) = 4.88, P < 0.001), with a work stress, except that forensic nurses had lower levels of
Bonferroni adjusted alpha level of 0.025. Frequent work stress relating to future concerns than mainstream
aggression (β = 0.22, P < 0.01) was associated with nurses did. This finding indicates that forensic nurses
increased anxiety and insomnia, accounting for 19% of the report greater job security, feel less concerned about
variance. No single predictor was found to significantly redundancy, and are less worried about the impact of
predict somatization (F(10, 155) = 2.81, P < 0.01) or system-wide changes in the health service than their
social dysfunction (F(10, 155) = 2.15, P < 0.025), using a mainstream colleagues. It is possible that forensic nurses
Bonferroni adjusted alpha level of 0.025. A regression feel more secure in their roles because forensic mental
analysis predicting severe depression revealed that the health might be perceived to be an area of specialization.
model was not significant (F(10, 155) = 0.84, P = 0.59). Examining psychological well-being, mainstream and
Separate analyses were performed to examine the forensic nurses displayed similar levels of post-traumatic
unique contributions of details relating to aggression- stress reactions and general distress. Consistent with pre-
management courses on general distress. For predicting vious research indicating that a minority of nursing staff
anxiety and insomnia, the variables of work-stress develop PTSD following assault, and being mindful of the
subscales, aggression, hours of courses in career, hours of fact that the prevalence rates were not restricted to dis-
courses in past year, last course attended, and usefulness tress arising exclusively following physical assault, 36% of
of course, were entered into the model (F(9, 156) = 5.39, mainstream and forensic nurses displayed clinical levels
P < 0.001), using a Bonferroni adjusted alpha of 0.025. of general distress on the GHQ-28; this is comparable to
Higher organizational and staffing stress (β = 0.37, the results of a previous study of hospital-based mental

© 2014 Australian College of Mental Health Nurses Inc.

TRAUMA IN PSYCHIATRIC NURSES 55

health nurses (Fagin et al. 1996). This finding confirms and insomnia. With respect to risk factors for increased
that a significant proportion of mainstream and forensic anxiety and insomnia, such a finding is consistent with
hospital-based MHN experience clinical levels of distress the result reported previously; that is, that these vari-
and PTSD; in the present study, between 14% and 17% of ables (organizational and staffing stress and aggression)
MHN met criteria for PTSD. also predict increased hyperarousal symptoms of post-
Regarding those factors that might contribute to the traumatic stress. Sleep disturbances, feelings of irritabil-
development of post-traumatic stress reactions in main- ity, and generalized anxiety are common to both
stream and forensic nurses, several variables were linked GHQ-28 anxiety and insomnia and PCL-C hyperarousal.
to the hyperarousal symptom cluster. Higher levels of The finding that work stress relating to organizational
stress relating to organizational and staffing issues and and staffing issues also predicts social dysfunction is con-
frequent inpatient aggression predicted increased sistent with expectations, given that those nurses who
hyperarousal. Work stress relating to organizational and receive little positive feedback at work, feel devalued by
staffing issues might leave nurses feeling dejected and virtue of lack of consultation, and experience conflict
unvalued due to lack of consultation, lack of collabora- with colleagues, might question their ability to contrib-
tion, and ongoing staff conflict in the workplace. It is ute in a meaningful way at work. Such an experience
likely that such experiences, as well as exposure might erode a sense of purpose, achievement, and effec-
to aggression, result in hyperarousal, because the tiveness in staff, leaving individuals feeling dejected and
hyperarousal symptom cluster consists of many general demoralized.
and non-specific symptoms associated with broader dis- In examining factors that predict lower general distress
tress (as compared to the re-experiencing, and avoidance in nurses, having attended many hours of aggression-
and numbing clusters). management training over the course of one’s career pre-
Aggression-management training appears to have a dicted both decreased anxiety and insomnia and
role in reducing the development of post-traumatic stress decreased social dysfunction. It might be that attending
symptoms. Examining factors associated with resilience courses allows nurses to feel more confident in managing
and recovery, having attended more hours of aggression- workplace aggression. Alternatively, attending profes-
management training over one’s career, predicted sional development sessions might facilitate a sense of
decreased hyperarousal, as did not having attended a autonomy and initiative in nurses, enabling them to feel
course recently. It might be that staggered and regular purposeful in their roles, and further empowering nurses
training over a period of years gives nurses repeated to connect with other colleagues. It is possible that an
opportunities to rehearse aggression-management skills, increased sense of solidarity could improve general well-
thereby improving confidence. With respect to recency, it being in nurses.
might be that having attended the last course in the
distant past predicts decreased symptoms, because time A tentative model of the development of
since last completion enables nurses to regain an appro- post-traumatic stress and general distress
priate perspective on inpatient aggression. When nurses A tentative model of factors contributing to the develop-
attend or have just attended a course where the preva- ment of post-traumatic stress and general distress in
lence, cause, and management of inpatient aggression is MHN is presented in Figure 1. Bolded, solid lines repre-
discussed, they might become primed to expect aggres- sent a direct effect in the hypothesized direction. As such,
sion, and become more aroused in the short term, before frequent aggression affects post-traumatic stress reactions
experiencing decreased arousal when course information and general distress in the hypothesized direction, with
becomes assimilated with existing beliefs. more frequent exposure predicting elevated levels of
While the impact of work stress and inpatient aggres- non-specific anxious arousal. Higher organizational and
sion was limited to only one cluster of post-traumatic staffing stress predicts increased post-traumatic stress
stress symptoms (hyperarousal and not re-experiencing (hyperarousal) and increased general distress (anxiety and
or avoidance and numbing), work stress and inpatient insomnia, and social dysfunction). The role of aggression-
aggression (in addition to particular demographic vari- management training in reducing psychological ill health,
ables) predicted general distress in mainstream and with increased hours of training over one’s career predict-
forensic nurses more broadly. Work stress relating to ing decreased post-traumatic stress (hyperarousal) and
organizational and staffing issues predicted increased decreased general distress (anxiety and insomnia and
anxiety and insomnia and increased social dysfunction, social dysfunction), is highlighted in Figure 2. Increased
while frequent aggression predicted increased anxiety time since last attendance at a course is shown to predict

© 2014 Australian College of Mental Health Nurses Inc.

56 J. LEE ET AL.

Increased
Frequent
post-traumatic
inpatient
stress
aggression
reactions

High level Increased

FIG. 1: Tentative model of the develop-
of work general
distress ment of post-traumatic stress and general
stress distress.

Increased hours of Decreased

aggression- post-traumatic
management stress
courses over career reactions

Increased time since Decreased FIG. 2: Tentative model of the develop-

attendance at last general
ment of post-traumatic stress and general
aggression- distress
distress: Role of aggression-management
management course
training.

decreased post-traumatic stress (hyperarousal). It should mental health nursing. Given the role of aggression-
be noted that the Figures represent a tentative model management training in reducing the development of
only, and that relationships require further replication. post-traumatic stress reactions and general distress,
organizations need to support the regular attendance of
Implications such courses. Incorporating multiple training courses and
The current findings have several important implications. update sessions as part of onsite professional develop-
As mainstream MHN experience higher levels of stress ment, and possibly supporting staff study leave to attend
concerning job redundancy and hospital restructures than courses offsite, is essential. Individual staff members also
forensic nurses, additional support regarding this issue need to take responsibility for prioritizing regular partici-
should be provided to nurses working in mainstream hos- pation in aggression-management courses. Work stress
pitals. Administrators and managers in mainstream set- relating to low morale and a general lack of collaboration
tings might need to be more cognizant of the impact of should be decreased. Across mainstream and forensic set-
organizational changes on staff. Staff would likely benefit tings, nurses would benefit from more frequent feedback
from regular consultation and feedback from manage- from supervisors, inclusion in collaborative decision-
ment about any pending changes in the hospital system. making processes, and low levels of staff conflict. Organi-
Furthermore, to improve staff psychological well-being, zations and individual nurses might offer and seek,
incidents of inpatient aggression should be minimized in respectively, to establish regular opportunities for feed-
both mainstream and forensic settings. Support from back and collaboration, and staff might benefit from train-
management and the service more broadly is required to ing in managing interprofessional and intraprofessional
shift any cultural acceptance of violence as normal in conflict.

© 2014 Australian College of Mental Health Nurses Inc.

TRAUMA IN PSYCHIATRIC NURSES 57

Future research might seek to test the model of the Cai, Z.-X., Li, K. & Zhang, X.-C. (2008). Workplace stressors
development of post-traumatic stress and general distress and coping strategies among Chinese psychiatric nurses. Per-
developed here. Alternatively, future research efforts spectives in Psychiatric Care, 44, 223–231.
might examine whether mainstream and forensic MHN Carson, J. (2005). The Stress Process in Mental Health Workers:
Assessment and Intervention Studies (Dissertation).
have different triggers for different post-traumatic stress
London: King’s College, University of London.
symptoms.
Chalder, G. & Nolan, P. (2000). A comparative study of stress
Limitations among forensic and acute mental health nurses. British
Journal of Forensic Practice, 2, 24–29.
The current findings must be viewed in light of several
Dickinson, T. & Wright, K. M. (2008). Stress and burnout in
significant limitations. Due to the use of a self-report forensic mental health nursing: A literature review. British
questionnaire, the results might strongly reflect socially- Journal of Nursing, 17, 82–87.
desirable responses in a workplace context. It is possible Edwards, D. & Burnard, P. (2003). A systematic review of stress
that the participants might have minimized their experi- and stress management interventions for mental health
ences of victimization and denied difficulties with nurses. Journal of Advanced Nursing, 42, 169–200.
their emotional well-being. In addition, a relatively low Fagin, L., Carson, J., Leary, J. et al. (1996). Stress, coping and
response rate must be considered, and the results might burnout in mental health nurses: Findings from three
reflect a sampling bias, whereby nurses who did not take research studies. International Journal of Social Psychiatry,
part might demonstrate higher (or lower) levels of ill 42, 102–111.
health. The results might also be unable to be generalized Goldberg, D. P. & Williams, P. (1988). A User’s Guide to the
General Health Questionnaire. London: nferNelson Publish-
due to all the forensic nurses having been recruited from
ing Company Ltd.
one site, as compared to mainstream nurses who were
Gournay, K. & Carson, J. (2000). Staff stress, coping skills and
recruited from multiple hospitals. Responses from the
job satisfaction in forensic nursing. In: D. Robinson & A.
forensic sample might be influenced by systems and prac- Kettles (Eds). Nursing and Multidisciplinary Care of the
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Hamdan-Mansour, A. M., Al-Gamal, E., Puskar, K., Yacoub, M.
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Mental health nursing remains a demanding and chal- 86–94.
lenging occupation, with concerning rates of distress and
Happell, B., Martin, T. & Pinikahana, J. (2003a). Burnout and
PTSD among forensic and mainstream nurses. While job satisfaction: A comparative study of psychiatric nurses
forensic and mainstream nurses represent a largely from forensic and a mainstream mental health service. Inter-
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