Psychosocial work environment within psychiatric inpatient care in Sweden: Violence, stress, and value incongruence among nursing staff

Abstract

In psychiatric settings, as well as in other areas of working life, it is important to address the psychosocial aspects of the work environment. According to the European Agency for Safety and Health at Work (2013), the psychosocial environment for workers is crucial to deliver adequate output. This is also valid for general hospital and mental healthcare settings (Aiken et al. 2011; McTiernan & McDonald 2015) and includes appropriate management of violent threats in the workplace. Violence is a serious problem often reported in healthcare studies. Even the perceived risk of violence may cause psychological distress for both staff members and patients (Miranda et al. 2011) and a poorer quality of care (Arnetz & Arnetz 2001). An improved psychosocial work environment has shown to be an important factor when preventing violence in working life (Wikman 2014). In line with this, the psychosocial climate in an organization is often highly influenced by the values shared among colleagues and the organization. Value congruence between employees and the organization seems to be an important factor when it comes to perception of a good psychosocial work environment (Atchison 2007; Bao 2012). In psychiatric settings, research for the purpose of finding and testing different models for the management of violence has shown that to prevent violence, the problem cannot be viewed in isolation. Rather, it seems that a necessary prerequisite for successful violence prevention is a well-functioning organization that has clear values in relation to employees, patients, and their environment, and has a capacity to develop the quality of care and the psychosocial ward environment (Bowers 2014; NASMHPD 2006; Wale et al. 2011). As values, psychosocial factors, and incidents of violence are related, research on these factors can preferably be conducted simultaneously. The reduction in the number of beds in psychiatric inpatient care in the Western world has resulted in a higher proportion of inpatients with acute mental illness in psychiatric wards (Chow & Priebe 2013). For Sweden, at least, this development has, according to the National Board of Health and Welfare, had a negative impact on the care environment. There is, however, limited research comparing the work environment in psychiatry with the rest of working life (Dickinson & Wright 2008; Eriksen et al. 2003; Vaez et al. 2014), and there is a lack of knowledge regarding the perceived psychosocial work environment of psychiatric nursing staff, that is registered nurses and assistant nurses in psychiatry, compared to the views of other occupational groups in other parts of working life. Job dissatisfaction and high levels of burnout are serious problems for nurses in general. An extensive study conducted in nine countries in Europe, Asia, North America, and New Zealand indicates that the extent of the problem varies greatly depending on the country; between 20% and 60% of nurses reported to have these problems (Aiken et al. 2011). As to psychiatric nursing staff, previous studies have found high levels of burnout (Jenkins & Elliott 2004; McTiernan & McDonald 2015), a work environment characterized by high levels of occupational stress (Dickinson & Wright 2008; Edwards et al. 2000; Leka et al. 2012), and high levels of psychological job demands and low levels of social support (Leka et al. 2012). Working in psychiatric care units has been associated with a higher risk of violence (Anderson & West 2011; Kwok et al. 2012; Vaez et al. 2014), a higher risk of sick leave (Eriksen et al. 2003), and a higher risk for burnout (Dickinson & Wright 2008) compared to other settings in health care. Among some of the stressors at work mentioned by psychiatric nurses when interviewed were heavy workload, violent and aggressive behaviour, poor support from management, and fear of being blamed for things (Currid 2008). Psychiatric nurses have also reported that they are stressed by organizational issues rather than by patient-related issues (McTiernan & McDonald 2015; Pelto-Piri et al. 2012). In general, the ward environment and the organizational culture are known to be important factors for the perception of a good psychosocial work environment (Tsai 2011; Tuvesson & Eklund 2014), as well as for patient satisfaction (Tzeng et al. 2002). In a study by Eriksen et al. (2003), the most important work factors accounting for sick leave were related to the organizational culture. These factors were, for example, the perceived lack of an encouraging and supportive culture in the workplace or a culture that was perceived to be suspicious (Dickinson & Wright 2008; Eriksen et al. 2003). It has also been shown that ward managers play a major role in creating and maintaining the psychosocial work environment (Malloy & Penprase 2010; Westerberg & Tafvelin 2014). To put all these findings in a proper context, it is worthwhile noting that the psychosocial work environment can be described as the interaction between psychological and social factors, and how people react upon this interaction (Karasek & Theorell 1990). In recent years, there has been increased interest in values and their importance in relation to work factors. Values seem to be important ingredients in how the psychosocial work environment is perceived as they refer to what is desirable socially as well as personally (Thomas 2013). There are several definitions in scientific literature as to what constitutes the concept of 'values'. In this study, we have chosen to use a more operational definition suggested by Meglino and Ravlin (1998): 'a person's internalized belief about how he or she should or ought to behave'. Values held by the staff tend to influence how they interpret the patient's behaviour and how they make ethical decisions, even if this latter process is not always a conscious one (Thomas 2013). Psychiatric studies conducted in this field (Cleary 2004; Fourie et al. 2005) show that nurses in mental health care can occasionally feel such pressure from their organizations and that it can prevent them from pursuing professional nursing in a manner that matches their own expectations. This pressure was often said to be caused by contradictory and conflicting demands between institutional and therapeutic considerations, leading to a stressful work environment for the nurses (Cleary 2004; Fourie et al. 2005). When staffs are prevented from acting in accordance with their own moral and professional convictions, they may encounter what is described as stress of conscience (Glasberg et al. 2006). This stress of conscience seems to be worsened by patient aggression and violence (Tuvesson et al. 2012). Psychiatric nursing staff have described that they experience feelings of inadequacy, of not being good enough in relation to patients, of loyalty problems with stakeholders and of having a troubled conscience (Dahlqvist et al. 2009; Pelto-Piri et al. 2012). When the values held by the employee and those held by the organization do not match, there is a value incongruence (Edwards & Cable 2009; Kristof 1996). In this study, we have committed to a definition of value incongruence provided by McCoy (1986): 'Value incongruence has been defined as the difference between personal value hierarchy, and the perceived value hierarchy of a reference group or organization'. In other words, value incongruence occurs when the employee's values and priorities differ from the values and priorities of the organization they work for. Previous studies have indicated that when nurses and the organization hold similar values, there is greater job satisfaction (Verplanken 2004) and better performance at work. Furthermore, value congruence also has a positive effect on work attitudes and commitment to the workplace (Atchison 2007; Bao et al. 2013; Hunt 2014; Kristof 1996; Meglino & Ravlin 1998). On the other hand, value incongruence between nurses and their organization has shown to influence the turnover intent and frequency of burnout (Bao et al. 2013). Due to its many effects on perceived work environment, value incongruence has been studied over the past few decades in a variety of settings including health care, where value incongruence between nurses and their organizations has been subjected to a number of studies (Bao et al. 2013; Verplanken 2004). However, we have not found similar studies pertaining to the psychiatric sphere. In the field of psychiatry, people's values are usually more diverse than in other fields as psychiatry is concerned with areas of human experience and behaviour where absolute consensus concerning values are rare (Fulford et al. 2006). Accordingly, in psychiatry the question of value incongruence is even more interesting to study. Hence, this study focuses on the relationship of value incongruence on psychosocial factors as well as focusing on psychosocial factors per se. Based on what we have described above, we have chosen in this study to focus on the psychosocial factors of social interactions, leadership, and organizational culture and climate. As shown above, previous research has compared psychosocial work environment in psychiatric settings to other healthcare settings (Zampieron et al. 2010). However, there is a lack of research that has compared psychiatric clinics to other areas outside the healthcare system. In studies focusing on issues related to the work environment, it is often useful to compare the results received with those of other work units, departments, or whole areas. This comparison can be made in different ways. We wanted, in this study, to use the reference database with normal values provided by QPS Nordic (Dallner et al. 2000). By doing this, it was possible to pose the following question: 'How do the results that we received compare to a reference database comprised of a sample from the working population?'(Myhre 2015; Strandberg & Wahlberg 2007). Hence, we were not just interested in comparing the results with other areas within the healthcare system but rather with the working population. To sum up, the aim of this study was threefold: (i) to investigate the perceived psychosocial work environment among nursing staff (in this study registered nurses and assistant nurses) in psychiatric inpatient care in comparison with other professions in working life, (ii) to study perceptions of violence and stress, and (iii) to study the relationship between value incongruence and psychosocial factors among nursing staff in psychiatric inpatient care. This study was conducted using a quantitative, cross-sectional, and comparative study design. The study was conducted among the entire population of nursing staff in 10 inpatient psychiatric wards in central Sweden, situated in four different counties. The staff included all staff working in three different types of wards: general psychiatric wards, forensic psychiatric inpatient units, and one psychiatric addiction centre. The inclusion criteria required that the nursing staff included in the study should be working at the ward at the time of the study, in addition to dealing with patients on an everyday basis. A total of 1044 persons fulfilled these criteria. The managers were informed first and gave their approval for the study being conducted in the unit, and the managers, in turn, informed the staff about the study. Personal visits were also made to some of the units to provide information about the study. Self-administered questionnaires were sent to the home addresses of the staff along with a cover letter with information about the study and a pre-addressed envelope. The names were provided by the clinics taking part in the study. A reminder was sent by mail to those who did not return the questionnaires within 3 weeks. After two more weeks, an additional reminder was sent if necessary. Informed consent was given by returning the questionnaire confidentially, as is customary in medical research in Sweden and approved by the Ethical Review Board. Each questionnaire was labelled with a code number, and the code key was stored in a safe. The names and addresses were provided from some of the clinics taking part in the study, and in that case, the dispatch was administrated by the research group. Some of the clinics preferred to administrate the dispatch of the questionnaires themselves. Data were collected during spring 2014 and autumn 2015. A total of 443 questionnaires were returned, giving a response rate of 42%. Of these questionnaires returned, 353 were answered by nursing staff and 90 by other professional categories such as physicians, social workers, psychologists, occupational therapists, and ward managers. Only the results for the nursing staff are reported in this study, as the focus was to compare their work environment with other occupations. For data collection, a questionnaire called QPS Nordic 34+ was used, which is a shorter version of the General Nordic Questionnaire for Psychological and Social Factors at Work (QPS Nordic), and contains 37 questions. The QPS Nordic is a well-known questionnaire developed in the Nordic countries (Dallner et al. 2000) and is used for measuring psychological and social factors at work. The questionnaire consists of questions on individual, social, organizational, and task level within nine areas: job demands, role expectations, control at work, predictability at work, mastery at work, work centrality, social interaction, leadership, and organizational culture. It begins with background questions including year of birth, gender, workplace, title of occupation, years in present occupation, and years at present workplace. The responses to the questions in the QPS Nordic are mostly captured by an ordinal scale ranging from one (e.g. 'very seldom or never') to five (e.g. 'very often or always'). During the development of the full version of the questionnaire, validation and internal consistency was assessed showing a Cronbach's alpha value ranging between 0.60 and 0.88 (Dallner et al. 2000). The shorter version, QPS Nordic 34+, has not been psychometrically tested. As this study was using the shorter version, the Cronbach's alpha values were, therefore, calculated for the specific sample in the present study, showing a value of 0.74 for social interactions, 0.89 for leadership, and 0.80 for organizational culture and climate. However, it should be noted that the shorter version of QPS does not include all questions within each factor compared to the full version of QPS. In the questionnaire and the analysis of the study, all 37 items of the QPS 34+ were used, but in the result section, only the most interesting results can be seen. No factor analyses of individual factors were made as the shorter version of QPS Nordic does not include all questions within each factor. In addition to the original QPS Nordic questionnaire, questions about violence and bullying, as well as one specific question about value incongruence, were added. The latter, value incongruence, was measured using a direct method, by asking the staff specifically whether they believe their personal values are congruent with those held by the organization where they are working. Using this method, a congruence is said to exist as long as it is perceived to exist, regardless of whether the values between the person and the organization are the same or not (Kristof 1996). The single question used to measure the value incongruence was, 'I feel that those in my workplace/in our organization have different values than I have'. The preferred answer was marked by a cross on a scale line, a visual analogue scale, 132 mm, ranging from 'I do not agree' to 'I fully agree'. For those using the QPS Nordic, a guide is provided which contains reference data. The data for the reference database were collected for the development of the QPS Nordic questionnaire to allow for comparisons between different sets of data. It was collected from several organizations in the Nordic countries: Denmark, Finland, Norway, and Sweden. Organizations representing different sectors of working life, such as industrial production, private services, public administration, and health services, were included (Table 1). The data were collected in 1997 and 1998 (Dallner et al. 2000). Stage 1, 1997 n (%) Stage 2, 1998 n (%) Descriptive analysis was used for the demographics of the participants and for frequencies and percentages of psychosocial work environment answers. The Mann–Whitney U-test was used to test differences between the test group and the reference database regarding the psychosocial factors (Bland 2000). The analysis was made with the 5-point ordinal scale, but the tables displayed a 3-point reduced scale, 1 + 2, and + for better The analysis was with frequencies for both the test group and the reference even the results are as To the question of value incongruence, the scale line where the participants indicated their was three called and The scale line was 132 mm, and the three parts were mm, mm, and The from the the most values between the employee and their organization. were made between the question of value congruence and all the other questions in the analysis was to test the of the difference between the The analysis was also made with the whole 5-point scale, but the tables only show the reduced scale for better analysis was made to test which of the groups were different from the version and the were The study was approved by the Ethical Review Board in Sweden, participants were informed that in this study was and the questionnaires were with The demographics of the staff are in 3 the results from the QPS Nordic questionnaire and reduced scale In response to whether they support and from and from the staff to rate this as this as to 'very which is more than in the reference The organizational culture was to be rather often or always encouraging and and by of the This is better than for the reference the same the climate was perceived to be more and as well as and in comparison with the reference Of the of the group perceived between rather often to often and this is more often than in the reference A high of the staff reported that they had been to violence at their workplace. A but difference was also in of and for number of years at the workplace. people to be subjected to violence to a greater extent 1, and those with shorter time at the workplace to be to a higher of violence 1, In of perceived stress in the workplace, a of the staff reported that they stressed (Table There were differences regarding perceived stress when it to the gender, number of years in the or the number of years at the workplace. The question about value incongruence was answered by of participants answered in the of that they do not that they have the same values as their organization. There were between value incongruence and all questions in the areas of social interaction, leadership, and organizational culture (Table who a high incongruence in values between and their organization reported that they more seldom and from their also more often the work climate to be and as well as rather and by In they more often among colleagues and more seldom the at their workplace to be Previous studies have shown that working in the field of psychiatry can be with heavy violent patients (Currid and (Cleary 2004; & Wright 2008). This study also indicates several factors that make the work environment The nursing staff reported being subjected to violent and a of them reported stressed of the job during the also reported between In compared with previous this study an even higher rate of perceived stress (Leka et al. and a even higher frequency of and violence et al. 2014; et al. 2010). the same psychiatric nursing staff in our study and better than the reference database on a number of issues related to the psychosocial work environment, which indicates that there are positive factors in the work environment. of such positive factors are high of support and good support and from the Previous research has to a relationship between the of violence and a number of other negative It is known that patient aggression and violence in the ward can stress among psychiatric nursing staff & 2006; 2008; & Elliott 2004). who have been of violence are on sick leave more often or show of psychological stress or more & 2006). have negative feelings more often or are with their (Zampieron et al. 2010). A between psychosocial work climate and the of and violence has also been indicated & 2006). It has been shown that and aggressive behaviour among patients may ethical among the nursing staff, which in may cause stress of conscience (Tuvesson 2011). Factors as of stress among staff for example, lack of poor staff, and between colleagues et al. 2011). conflicting demands between and the to deliver care of high quality can also be stressful (Cleary 2004; & 2001). The results of our study show that psychiatric nurses experience between colleagues more often than from a reference database of other occupations. a of the staff indicated that they have between This among the nurses is as among colleagues are one of the for the of stress among the high proportion of staff between per that they and support from their This is more than reported in the reference of the staff indicated that they support and from their if necessary. In the same more than of the psychiatric nurses also the organizational environment as being and which was more than was in the reference from colleagues and a good social climate has been shown to be factors that job performance and stress 2004). from has also shown to be a factor when it comes to violence et al. such as these that a positive social climate to the of staff to the stressful work environment. in our study values did not those held by the organization where they work that they received support and from their colleagues or their Furthermore, they to a greater the organizational climate as suspicious and and also that they that the at work was It seems that those who do not to have similar values to their to a extent from factors in the work environment reported In this group indicated to a higher extent that they have stressed of their more than the group that they had similar values as their organization. The same to in the workplace where staff who their values to be different that they have been subjected to to a greater extent than those with similar The results of this study can be compared with research in value incongruence showing that people with similar values are more with their (Verplanken better at their have more positive job attitudes (Bao et al. 2013; Kristof and to a extent (Bao et al. 2013). Previous research has also shown that value differences within the can be a as well as creating et al. 2011). The results of this study are important people's values influence their and behaviour, and those who have similar values also in similar (Thomas 2013). In that are perceived violent or the person's values are even more the often demands that be the values are the risk for is and value within a may be a et al. 2011). The values of the organization the psychosocial work environment for the staff et al. 2005). Due to the that psychiatric inpatient care has shown to have a high frequency of violence and is often perceived as a stressful environment, the question about value incongruence is Furthermore, psychiatry to a where values are diverse and value exist (Fulford et al. 2006). In working with value questions in the organization can be a to the between values by also stress and between and the organizational climate. Working with values include the organizational values clear and and for value and among The ward has an important role in this The role has been as and the behaviour can or the within a et al. 2011). This for and of managers and for them with the necessary to as research be to the effects in for example, the perceived work environment, the frequency of violent incidents and the quality of psychiatric care and to the effects of to value and This study can research on the impact of values in psychiatric such study be to psychiatric units to work with values and to what extent this the work environment and the quality of the psychiatric care The study is limited in some ways. The reported may not be valid in other settings, and the findings be with When both the psychosocial environment and the health are reported at the same time in a questionnaire, as in this study, the results may be influenced by some of such as a positive and negative and consistency This may the results and cause et al. 2003). this study has there may be a risk that even differences can be it is important to what differences are is the low response and our to data for comparing with The results be influenced by However, to what can be a response rate in studies (e.g. & show that there has been a in the response rate the years and that mail can have response in the The study results are and valid for a defined part of central Sweden as it is on persons of working in psychiatric inpatient care in that Psychiatric inpatient care includes different types of we included both general and forensic as well as addiction psychiatric There may be differences in the psychosocial work environment between these types of settings that we have not in the present study. we to compare psychiatric inpatient care as a whole with working life in general, and to study the between value incongruence and psychosocial factors. to it is to the results of the study for the whole of Sweden, it should be noted that the work environment for those units taking part is similar Sweden when it comes to psychiatric inpatient There is also support in the literature for the results of the study. of value incongruence has been by When the questions do not the values, it is to that values are is that direct can the between the employee and the preventing their effects (Kristof 1996). The result indicates that working in inpatient psychiatric care is characterized by high frequency of violence, and stress and between colleagues in the working group were reported by of the there are also positive psychosocial work factors such as social support and support from and a positive experience of organizational culture and climate. of the staff experience they have values other than the organization. This study indicates that values and nursing staff who experience a value difference compared to the organization they work in seems to be more stressed at work, experience more among more experience adequate and experience the organizational climate as being Working with value issues can the working environment of psychiatric healthcare staff by the ward environment and patient care. This study the that values and it is from a work environment When for the work environment this knowledge about value issues can be used in to the values held by the staff and the organization. Working with value issues is one of many factors when to the work environment in psychiatric A work environment with among perceived stress, and improved organization climate the patients better care. The their to all the staff who in the psychiatric settings and the persons at the clinics who to all staff We are also to for data management and for and The study was by the for Working and