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programmes
Nicola Wright, Melissa Zakarian and Holly Blake
W
A group of diverse medical and health care
ork-related stress is a challenge to public
systems, practices and products that are not
health (Health and Safety Executive
generally considered part of conventional
(HSE), 2014) and has a significant impact
medicine
on organisations, since work environments
NACCM, 2011
shown to be stressful have higher levels of
presenteeism and absenteeism (Wu et al, 2010) and a higher staff Such therapies may include massage, reflexology, Reiki,
turnover rate (Begat et al, 2005).The NHS Staff Council Health acupuncture and herbal remedies.
Safety and Wellbeing Partnership Group (2014) attributed 30% Despite high stress among nurses, workplace wellbeing
of sickness in the NHS to stress at an estimated cost of 300 initiatives are more commonly accessed by employees in office-
400 million per year. based job roles than by front-line care staff, and evaluations of
Nursing has a high prevalence of work-related stress workplace programmes accessed by nurses are limited. Little
compared with other healthcare professions (Wu et al, 2010; is known about the perceptions of nurses towards the use of
HSE, 2014) and the reasons for this are multifaceted. Nursing CATs for workplace wellbeing, although this knowledge is
demands a high level of skill, provision of 24-hour care and important for workplace health providers to better understand
the input of what is referred to by Phillips (1996) as emotional the needs of this employee group to inform the design of future
labour. Policy and organisational changes within the NHS services offered. Qualitative interviews with service users
have shown that NHS employees (from diverse occupational
groups) appreciate both the accessibility of complementary
Nicola Wright, Assistant Professor in Mental Health, School therapies offered through the workplace and the perceived
of Health Sciences, University of Nottingham, nicola.wright@ benefits they bring to health and wellbeing (Meade et al, 2009).
nottingham.ac.uk However, some nurses have expressed a lack of knowledge
Melissa Zakarin, Tissue Viability Nurse, Nottingham University about CATs coupled with a degree of skepticism towards
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Hospitals NHS Trust, Nottingham their use, which may influence their willingness to access
Holly Blake, Associate Professor, School of Health Sciences, them. Other factors may potentially hinder engagement,
University of Nottingham which are not well understood. The aim of this study was to
Accepted for publication: November 2016 explore nurses perceptions and experiences of using CATs
for workplace stress management.
Methods Findings
An exploratory qualitative research design using in-depth, semi- Analysis identified two key themes that were consistent both
structured interviews was conducted. Data collection took within and across the participant accounts. Identified themes
place between September 2011 and February 2012. All the and subthemes were agreed by a second person. Although
interviews were conducted by the second author, lasted for participants were not given the opportunity to review their
between 20 and 60minutes and were audio recorded.The data manuscripts, lay feedback and overall findings were circulated to
from the interviews were analysed using conventional qualitative all those registered with the service.The identified themes were:
thematic methods.These sought to identify themes both across perceptions of complementary therapies for stress management
and within individual accounts (Ritchie and Spencer, 1994). and engagement with workplace wellbeing initiatives. To
Approval was obtained from the local NHS Research Ethics preserve confidentiality and anonymity, participant numbers
Committee (REF: 11/EM/0081) and research governance have been used for identification purposes.
teams at the local hospital trust where the study took place.
Verbal and written information was provided to all potential Theme 1: perceptions of complementary therapies
participants and informed written consent was obtained from for stress management
those who agreed to be interviewed. Before considering their involvement in workplace stress
management initiatives, participants were asked to reflect on
Participants and setting their perceptions and experiences of CATs more generally.
Participants were registered nurses recruited from the local All participants stated that they had engaged with them for
emergency department and burns high-dependency unit of perceived stress reduction with massage being the most popular
a single site of an acute hospital trust, using a combination of form of therapy:
convenience and snowball sampling techniques.These settings
It just takes away the tension, really stops you
were selected as it has been consistently evidenced that working
feeling tense.
in these clinical areas is stressful (Helps, 1997; Negble et al, 2014;
P004
Adriaenssens et al, 2015). Ward managers and research group
leaders were asked to distribute a study information sheet to Using CATs as a mechanism for managing stress was seen
nurses in their teams.Those who wanted to participate returned to be beneficial by the majority of participants, and several
an expression of interest to the researcher.A total of 12 registered participants made references to the potential for CATs to reduce
nurses took part in the study.These included two prior users of sickness absence in hospital employees when delivered in the
the workplace therapies services who had accessed a wellness workplace setting:
unit (SenzOri Egg) and massage therapies within the workplace
I think it will reduce sickness, reduce people
setting, but infrequently accessed CATs outside of the workplace.
being irritable or upset on the wards.
The other ten participants were non-users of the workplace
P003
therapies service, and eight of them had accessed a diverse range
of CATs outside of the workplace setting, including massage However, some participants highlighted concerns about
therapies, acupuncture, aromatherapy, reflexology, and Reiki. using CATs that appeared to be twofold: a lack of a robust
Two participants had not previously accessed CATs. All of the evidence for the effectiveness of some therapies, coupled with
participants that had accessed CATs had accessed more than a conflict between the underpinning philosophy of health care
one type of CAT, whether inside or outside of the workplace. within the NHS (dominated by medicine) and the principles
All participants were female and aged 2453 years. They had of some CAT approaches:
worked at the hospital trust for between 3 and 35years.Three
It (CAT) has quite a stigma in this
of the nurses interviewed were band6 deputy sisters and nine
environment it does, of being quite wishy
were band5 registered nurses.
washy, its about trying to correlate the two,
The NHS organisation where the study was undertaken has
medicine and complementary therapy.
an established workplace wellness programme for employees,
P006
developed in 2005 and still active in 2016 at the time of
publication. This offers a wide range of services to promote For some, this conflict included a dissonance between their
and support health and wellbeing, including staff gym, exercise own cultural or spiritual beliefs and the philosophy perceived
classes and fitness challenges, staff physiotherapy service, to underlie some CATs:
and mental wellbeing (e.g. coping with stress and building
I dont do yoga because it has a bit of a
resilience). Services have evolved over time and periodically
spiritual attachment to it ... Id rather not do it
change according to staff need but are described in more
... because I dont want to compromise what I
detail elsewhere (Blake et al, 2013) and in terms of CATs, have
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believe.
included a wellness unit (SenzOriEgg), massage, aromatherapy
P003
and reflexology. The range of workplace CATs available at
the time of this study have been described in more detail In summary, the majority of participants had accessed
in other literature (Meade et al, 2009; Lee and Blake, 2009; CATs outside of the workplace, and perceived clear benefits
Blake et al, 2013). of using CATs in the workplace to manage stress. However,
Discussion should discuss alternative delivery times with nurses, and perhaps
In the UK, improving the health and wellbeing of NHS employees offer brief CATs that may be perceived to be more accessible.
remains high on public health agenda.An announcement by NHS Nurses perceived a cultural barrier to taking work breaks and felt
Englands chief executive, Simon Stevens, indicated a clear need that accessing workplace wellness services within breaks would
to reduce stress in the public health workforce (NHS England, not be supported within their work environment. Managers and
2015). The emergency department and burns units present individual nurses need to be fully informed about the risks and
particular challenges in this regard. The combination of acute costs associated with high stress within the nursing profession,
(e.g. life-or-death decision-making, violence and aggression) and the potential benefits of workplace-delivered initiatives
and chronic (e.g. high physical demands and time pressures) to prevent and manage stress. This may require a cultural shift
stressors with an unpredictability of working conditions can within hospital workplace environments to ensure that efforts
lead to nurses experiencing high levels of emotional distress to promote positive health and wellbeing for nurses are fully
and burnout (Adriaenssens et al, 2015).The consequences may recognised by all so that, where possible, break times for nurses
have an impact on both the individual concerned, and the are protected.
profession, as it has been identified that nurses experiencing When considering the implications of the study it is important
these very intense reactions may change career, or use alcohol to do so within the context of its limitations. Data collection
to cope with the stress (see, for example, Duffy et al (2015)). took place in 2011/2012 and so may be considered dated.
Given the current shortage of nurses within the healthcare However, the findings continue to have currency, given the
workforce (NHS Improvement, 2016) there is clearly a need to ongoing and increasing attention on the health and wellbeing
maintain a focus on supporting wellbeing and mangaging stress of NHS staff in contemporary literature, current policies and
in this occupational group. In this study, the authors investigated in the media. For example, the Boorman review of NHS
nurses views towards the use and implementation of CATs for health and wellbeing in 2009 recommended that trusts should
managing stress at work and found their attitudes to be very design and implement strategies for improving the physical and
positive towards inclusion of such services within workplace mental health of their staff (Boorman, 2009; Burnham, 2009).
wellness programmes, irrespective of whether they had accessed Following this, the NHS Future Forum recommended that
the services themselves. trusts should be held accountable for improving the health and
At an organisational level, the provision of CATs within wellbeing of their workforce (Ford, 2012). Nurses health and
the workplace demonstrates that employers are concerned wellbeing continue to be at the forefront of NHS employee
about staff welfare (Mackereth et al, 2005; Phillipp and Thorne, health concerns (Blake, 2014), especially given the high levels
2008) and this resonates with the views expressed by the nurses of sickness absenteeism, stress and burnout among frontline
participating in this study. Indeed, earlier evaluations have shown care staff (Wilkinson, 2015). The environments in which this
that staff opinions towards the NHS as an employer may be data was collected continue to generate high levels of stress and
improved following implementation of workplace wellness emotional burden (e.g. emergency departmentsMaddineshat
programmes incorporating CATs (Blake et al, 2014). et al (2016); burns unitsKellogg et al (2014)).
Although participants identified the positive impact from The self-selecting nature of the sampling strategy and the
treatments traditionally associated with CATs, it appeared that small number of participants mean that care needs to be taken
being able to access a quiet place if only for a few minutes was when transferring the findings to other settings.All participants
perceived to be very helpful in managing stress. This might were women and this means that the findings may not reflect
simply be a quiet room in which nurses could take a break, the experiences of male nurses. Given these limitations there is a
or self-contained wellness units offering time-out for nurses need for further research into the experience of stress for nurses
and potentially reducing perceived stress (Lee and Blake, 2009). working in different settings, the potential support mechanisms
Having a quiet place to go during breaks is not only perceived for preventing and managing workplace stress effectively and
positively by individual nurses but may have an impact on patient the barriers and facilitators to accessing these.
care and outcomes. For example, Gardner et al (2009) found
that where quiet time was implemented in clinical settings, Conclusion
patients and nurses felt more satisfied and relaxed, with patients The nurses in this small study were broadly positive about using
reporting improved sleep patterns. CATs for their own health and wellbeing, and the provision of
Nurses from high-stress clinical environments, such as the wellbeing schemes within the workplace that include CATs
emergency department and burns units, valued workplace- is seen as a positive development. Of particular importance is
delivered CATs and perceived CATs to be beneficial for the recognition this provides to nurses that they are valued by
wellbeing, although some identified uncertainty and/or stigma their employer. Some logistical and practical issues need to be
associated with their use by health professionals, which has been addressed to ensure that CATs are perceived to be accessible.
recognised previously (Peters; 2000; Furnham, 2001; Adams, Workplace culture around taking breaks needs to be further
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2006) and is often associated with a lack of robust evidence investigated to ensure that nurses feel able to take breaks and able
base (Adams, 2006). to access services, and that this is supported by their colleagues
Where relevant, workplace health and wellbeing services and managers. Healthcare employers should consider provision
need to increase awareness of the reduced cost of in-house CATs of wellbeing services within clinical settings and providing quiet
compared with external therapy services. Service providers spaces for relaxation and time out during breaks. BJN
BJN CALL FOR CLINICAL PAPERS ( 020 7738 5454 8 bjn@markallengroup.com @BJNursing
The British Journal of Nursing welcomes unsolicited articles on a range of clinical subjects
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