https://dx.doi.org/10.14528/snr.2017.51.1.122 2017. Obzornik zdravstvene nege, 51(1), pp. 9–23. ABSTRACT Introduction: Evidence suggests that stressful situations are frequent in the field of psychiatry and that professionals working in this speciality are more prone to stress. Stressful situations may be compounded by ignoring the principles and strategies of therapeutic communication in all interactions with patients. The purpose of the research was to determine the presence of stress among the nursing team members. Methods: The research is based on a quantitative methodology; the data were collected using a semi-structured questionnaire. The sample consisted of 73 nurses working in a special social welfare institution (n = 37) and in a psychiatric hospital (n = 36). The survey was conducted in the first half of the year 2016. Descriptive statistics and chi-square test were used. Results: The list of stress factors most frequently reported by the participants include low pay (n = 40, 55 %), poor interpersonal relationships in the workplace (n = 23, 32 %), and the sense of insecurity due to unpredictable behaviour of patients (n = 32, 44 %). One fifth of the respondents are regularly subjected to patient physical violence and psychological abuse in the workplace (n = 14, 19 %) and a large majority (n = 53, 72.5 %) are frequently exposed to dangerous situations. The respondents are not fully aware of the crucial importance of therapeutic communication with the patients (n = 38, 52 %). Discussion and conclusion: It is impossible to completely avoid stressful situations in psychiatric settings. Psychiatric nurses should possess good communication skills and the ability to develop good interpersonal relationships. IZVLEČEK Uvod: Na področju psihiatrije so pogosto prisotne različne stresne situacije, zato so osebe, ki obravnavajo paciente z duševnimi motnjami, stresu bolj podvržene. Stresne situacije potencira tudi slabo poznavanje terapevtske komunikacije. Namen raziskave je bil ugotoviti prisotnost stresa med člani negovalnega tima. Metode: Raziskava je temeljila na kvantitativni metodologiji, podatki so bili zbrani z delno strukturiranim vprašalnikom. V raziskavo je bilo vključenih 73 članov negovalnih timov, in sicer 37 članov iz posebnega socialnovarstvenega zavoda in 36 iz psihiatrične bolnišnice. Podatki so bili zbrani v prvi polovici leta 2016. Za analizo je bila uporabljena opisna statistika ter hi-kvadrat test. Rezultati: Za anketirane so najbolj stresni dejavniki slabo nagrajevanje za opravljeno delo (n = 40, 55 %), slabi odnosi med sodelavci (n = 23, 32 %) in zmanjšan občutek varnosti ob nepredvidljivih pacientih (n = 32, 44 %). Na delovnem mestu se vsakodnevno srečujejo s fizičnim ali psihičnim nasiljem pacientov (n = 14, 19 %), pri čemer so bili anketirani že večkrat ogroženi (n = 53, 72,5 %). Anketirani na terapevtsko komunikacijo včasih pozabljajo (n = 38, 52 %). Diskusija in zaključek: Stresnim situacijam se na področju psihiatrije ni mogoče popolnoma izogniti. Za medicinsko sestro, ki deluje v zdravstveni negi na področju psihiatrije, je pomembno, da dobro obvlada komunikacijske spretnosti in veščine za vzpostavljanje medsebojnih odnosov. Key words: workplace; burnout; patient violence; therapeutic communication; stress factors Ključne besede: delovno mesto; izgorelost; nasilje pacientov; terapevtska komunikacija; dejavniki stresa Urška Nemec, RN; General hospital Murska Sobota, Rakičan, Ulica dr. Vrbnjaka 6, 9000 Murska Sobota, Slovenia Correspondence e-mail/ Kontaktni e-naslov: nemec.urska@gmail.com Senior Lecturer Klavdija Čuček Trifkovič, PhD, MSc, BSc, RN; University of Maribor, Faculty of Health Sciences, Žitna ulica 15, 2000 Maribor, Slovenia Original scientific article/Izvirni znanstveni članek Stress among employees in psychiatric nursing Stres med zaposlenimi na področju psihiatrične zdravstvene nege Urška Nemec, Klavdija Čuček Trifkovič The article is based on the diploma work of Urška Nemec Stress among nursing team members in the psychiatric field, in the clinical environment and in special social welfare institutions (2016)./Članek je nastal na osnovi diplomskega dela Urške Nemec Stres med člani negovalnega tima na psihiatričnem področju, v kliničnem okolju in v posebnem socialno-varstvenem zavodu (2016). Received/Prejeto: 15. 9. 2016 Accepted/Sprejeto: 22. 1. 2017 Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.10 Introduction Previous studies have indicated a probable high prevalence of stress in nursing staff worldwide (Weinberg & Creed, 2000). The nursing employees spend a large portion of their lives in the workplace (Kramli, 2007). Responsibility, an essential component of professional nursing practice, and the heavy, responsible and demanding workload require that nurses develop the necessary characteristics, such as compassion, reliability, understanding, readiness to help other people, and tolerance (Thaler, 2007, p. 56). Nursing employees claim that they are burdened with expanding responsibility and that the team work is practically non-existent due to hierarchical relationship within nursing. For the majority of nurses exercising the profession has become just a job to earn one's living and a constant source of stress. In the field of psychiatric nursing, 70 % of employees have reported perpetual threats from patients, work overload, and physical fatigue (Čuk & Gnezda, 2007). Stressful situations in mental health settings have become a norm in everyday work. Several nursing studies have confirmed that a constant stress is due to the demanding and responsible work and life of the employees (Weinberg & Creed, 2000; Peterka Novak, et al., 2010; Bregar, et al., 2011; Rössler, 2012; Berring, et al., 2016). The frequent stressful situations in psychiatric settings are mainly due to specific pathologies of patients. The involuntary admission to a psychiatric facility, the patients' violent behaviour and severe staff shortage in one shift may adversely affect employee work performance. Additional stress may be generated by insufficient use and knowledge regarding therapeutic communication. It is therefore of key importance that health workers are involved and engage in continuing professional education and training (Kržišnik & Čuk, 2010). Health workers tend to ignore therapeutic communication in order to avoid work-related emotional stress. They therefore deny and avoid the patients' problems and limit their communication with the patients to the basic necessities. They adopt impersonal attitudes and maintain personal distance in order to protect themselves from emotional distress (Čuk & Gnezda, 2007). Due to the unique nature of the psychiatric profession, the employees may incur injuries or experience tension, insecurity, psychological pressure, stress and also the risk for burnout (Čuk & Gnezda, 2007; Kramli, 2007; Čuk, 2010; Lapanja, 2010). Beyond the effects of the above stressors, the employees have to cope also with difficult interactions with other health professionals as part of multidisciplinary teams (Kindy, et al., 2005; Peterka Novak, et al., 2010; Bregar, et al., 2011; Rössler, 2012). Peterka Novak and colleagues (2010) conducted a research in six psychiatric facilities at a secondary and tertiary level of health care to determine the causes and incidence of stress and burnout. Consistent with the findings of other research studies, the present study indicates that the psychiatric staff have to endure also the harassment or emotional and psychological pressure by co-workers, employee grouping leading to strained interpersonal relationships within a healthcare and nursing team (inter- and intraprofessional conflicts), insincerity among employees, unsatisfied individuals, stressful meetings with superiors, and compromises in inter-professional cooperation in the pursuit of common goals. The psychiatric nurses also report poor work environment, not clearly defined responsibilities, great responsibility for patients, non- participation in organisation of work, poor prospects for career advancement, work shifts, and adverse and unpredictable situations (Čuk & Gnezda, 2007, p. 31), pace of work and intensity, high physical and psychological demands of workload, shortage of staff (Zeller, et al., 2009; Peterka Novak, et al., 2010; Bregar, et al., 2011; Ferri, et al., 2016; Lantta, et al., 2016). The list of stressors includes also long bedside visits, constant hurry, a large number of concurrent interventions and the triage during on-call time, acting against patients' will, non-voluntary admission, physical restraint of patients, involuntary treatment, incidents (e.g. suicide attempt), demolished biorhythm, etc. (Lapanja, 2010, pp. 50−51). Typical of psychiatric settings, especially in clinical environment and social welfare institutions, is an increased risk of patient aggression, hetero-aggression and auto-destructiveness (Peterka Novak, et al., 2010; Bregar, et al., 2011). Zeller and colleagues (2009) argue that the major stress factors for employees are the challenges and burdens of patient aggressive behaviour, especially verbal threats and insults, and physical violence (e.g. kicks and bites). Other studies (Reininghaus, et al., 2007) confirmed that violence presents the primary work-related stress. Ferri and colleagues (2016) concluded that workplace violence against health professionals is a major global public health issue with an increasing incidence and that all health workers, especially nurses, are at risk of suffering aggressive assaults. It has also been established that organizational factors of the inpatient psychiatric environments are associated with psychiatric nurse burnout (Hamaideh, 2011). Burnout was first identified in nurses and other professional caregivers (Schmiedel, 2011) and it is also the main cause of changing the job. A great majority of psychiatric employees (90 %) define their job as stressful and burdensome, and feel to be at risk of job burnout (Čuk & Klemen, 2010). Aims and objectives The aim of the study was to determine the occurrence rate and the extent of work-related stress among psychiatric nurses in a clinical setting and in a special Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 11 social welfare institution. Accordingly, the following objectives were set: to identify the most common sources of work-− related stress among psychiatric nursing employees; to establish the consequences of work-related stress − on the private life of psychiatric nursing employees; to determine the incidence of adverse events and the − patient psychological and physical violent behaviour in psychiatric settings; and to assess the frequency of use of therapeutic − communication among psychiatric nurses. The research questions addressed the following topics: Which events and situations are the biggest − determinants of stress and how work-related stress affects the private life of employees? How often are the nursing team members faced − with the patient physical and psychological violent behaviour and which are the forms of patient aggression directed toward nurses in a workplace or on duty? Accordingly, the following hypotheses were proposed: H1: The psychiatric nursing team members have not yet been on sick leave due to work overload. H2: The employees are satisfied with their work position and environment. H3: The employees regularly use therapeutic communication in their interaction with patients. Methods The study was based on a non-experimental quantitative descriptive research method. Description of the research instrument For the purposes of the present study a questionnaire was designed on the basis of relevant literature review (Peterka Novak, et al., 2010; Schmiedel, 2011; Lipovšek, 2012). It consisted of ten closed- ended, three semi-structured and four open-ended questions. The questions were classified into four thematic sections. The first section comprised standard sociodemographic data, such as gender, age, educational level and years of employment in a psychiatric setting. The second section consisted of statements related to stressogenic factors in the field of psychiatric care, where the respondents rated each item using the following criteria: 0 − strongly disagree, 1 − neutral/no opinion, 2 − strongly agree. The third section included questions regarding the perceived safety at work, the prevalence of violent events, the use of therapeutic communication, the frequency of patient physical and psychological violent acts, the employees' personal history of victimisation, their tolerance levels, the lack of confidence in their skills and expertise in performing nursing interventions. The fourth section inquired into the impact of work- related stress on private life of employees, using the same grading scale as in the third section. The reliability of the research instrument was tested with the Cronbach's alpha coefficient. It ranged from 0.70 to 0.90, which indicates a strong internal consistency (UC Regents, 2016). Description of the research sample The total of 140 questionnaires were administered to the nursing employees of one of the psychiatric hospitals (n = 70) and the nursing employees of a special social welfare institution (n = 70), both situated in the northeastern part of Slovenia. Just over half of the questionnaires (n = 73) were completed and returned (36 from the hospital and 37 from a social welfare institution). The majority of the respondents have completed secondary school education (n = 51, 70 %) and only four (5 %) study participants have university education. Most of the participants involved in the research were female (n = 59, 80.5 %). Nearly half of the respondents (n = 33, 45.5 %) constituted the age group from 30 to 40 years (n = 33, 45.5 %), and only one respondent (1.5 %) belonged to the group of less than 20 years of age. The majority of the respondents had up to 20 years of employment in the field of psychiatric care (n = 26, 35.5 %), and the smallest proportion of the cohort had up to 40 years of employment in this field (n = 8, 11 %). Description of the research procedure and data analysis An oral ethical approval was obtained from the relevant authorities in both institutions prior to commencing the study, collecting the data and recruiting the participants. The study was conducted in accordance with the principles of research ethics. The research was conducted from March to May, 2016, in collaboration with the heads of nursing teams of the participating departments. All the participants were informed with the aim of the study and the content of the questionnaire ahead of time. Participation was voluntary and the participants were assured of the confidentiality of their responses. The data collected were statistically analysed using Microsoft Word 2007, Microsoft Excel 2007 and SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). The descriptive statistics was used to establish the differences between the variables. The chi- square test (χ2) was employed to test the null hypotheses regarding the participants' sick-leave due to work overload, the workers' job satisfaction, and the use of therapeutic communication in their interaction with patients. Results The study aimed to explore the events and situations causing work-related stress. The list of stressors was Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.12 limited to the following sources: easy fatigability, constant lack of time for meals, insincere relationship among co-workers, uneasiness in the presence of superiors, a fast-paced work environment, short terms to meet the goals, multiple duties in one work shift, unpredictable situations, three-shift work, not feeling comfortable in providing care for unpredictable psychiatric patients, lack of support and understanding by the superiors, insincere communication with other professionals, low pay, dishonesty among co- workers, patient aggressive behaviour and reactions, implementation of special preventive measures, and the feeling of being overburdened with duties in comparison to other employees. The percentages given in the result section represent the proportion of subjects who strongly agree with a given statement. A significant difference was established between the employees from the two participating institutions regarding the sources of stress. A certain level of agreement was, however, established in both institutions regarding the low pay, which was reported by 15 (41 % ) respondents from a special social welfare institution and 25 (69 %) respondents from a psychiatric hospital. Another common stress factor identified was also dishonesty among co-workers, which was reported by 14 (38 %) respondents from a special social welfare institution and 22 (61 %) respondents from a psychiatric hospital. The multiplicity of safety concerns due to unpredictable behaviour of patients is the third most frequently reported stressful situation in a special social welfare institution (n = 15, 40.5 %), while the patient physical violence was the third stressor reported by the respondents from a psychiatric hospital (n = 17, 47 %). Nearly half of all the respondents (n = 34, 46.5 %) reported a history of physical and psychological violence several times per month. In a special social welfare institution 30 % (n = 11) of employees encounter patient physical and psychological violence on a daily basis, 30 % (n = 11) several times per week, and 40 % (n = 14) several times per month. In a psychiatric hospital, on the other hand, 8 % (n = 3) of respondents encounter patient physical and psychological violence on a daily basis, 36 % (n = 13) several times per week and 53 % (n = 19) several times per month. One of the respondents (3 %) never experienced patient violence. A good half of the respondents from a special social welfare institution (n = 23, 62 %) claim that their safety in the workplace was at risk, manifesting as residents' unpredictable physical assaults (n = 12), aggressive behaviour (n = 6), and verbal threats (n = 10). In a psychiatric hospital, on the other hand, 83 % (n = 30) of the respondents specified that their risks to safety were manifested as verbal aggression, such as threats, insults, profane language, and spitting (n = 16), physical aggression, such as punching, kicks and bites (n = 12), and the attempted physical assaults (n = 11). The study addressed also the issue of patient safety and the implementation of preventive measures to enhance the safe psychiatric environment. Half of the Table 1: Effects of work-related stress on the wellbeing of respondents outside their work Tabela 1: Vpliv stresa na delovnem mestu na položaj oz. počutje anketiranih izven delovnega mesta Strong agreement with the statements/ Popolno strinjanje s trditvami Research results for a special social welfare institution/ Rezultati raziskave za posebni socialnovarstveni zavod Research results for a psychiatric hospital/ Rezultati raziskave za psihiatrično bolnišnico Average of both research samples/ Povprečje obeh raziskovalnih vzorcev n % n % n I often anticipate stressful situations on my way to work. 11 30 7 19 18 25 I frequently revolve around my work duties even outside working hours. 10 27 4 11 14 19 I practise relaxation techniques. 6 16 8 22 14 19 I do not socialise with my friends as much as I used to. 5 14 7 11 12 13 I believe I deserve a better working environment. 5 14 6 17 11 16 I often share my work-related problems with others. 1 3 2 5 3 4 When I am not at work I often feel tired. 1 3 3 8 4 6 I would like to change my work environment. 2 5 3 8 5 7 I find it very difficult to relax. 2 5 1 3 3 4 My annual leave is not long enough to recover from stressful work conditions and renew my strength. 4 11 9 25 13 18 Legend/Legenda: % – percentage/odstotek; n – number/število; – average/povprečje Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 13 respondents from the psychiatric hospital (n = 18, 50 %) believe that patient safety and the prevention of injuries from violent acts were well provided for, while the other half (n = 18, 50 %) claim the contrary. Nonetheless, 17 (47 %) respondents from a psychiatric hospital report frequent occurrence of violent acts. A large majority of respondents from a special social welfare institution (n = 30, 81 %) affirm that patient safety and the prevention of injuries from violent acts were secured, although 13 (35 %) respondents report frequent occurrence rate of violent acts. It is interesting to note the lack of a relation between the self-reported experience of assault and injury and the perception of physical threat. The respondents were also questioned about their lack of confidence in their skills and expertise in performing nursing interventions. All of the respondents from the psychiatric hospital (n = 36, 100 %) maintain that they are never in doubt about their professional competence. In a special social welfare institution, the majority of the respondents are fully confident in their professional skills and expertise, 19 % (n = 7) occasionally doubt their ability to perform certain nursing interventions, and one respondent regularly experiences such doubts. Several studies have stressed the impact of work- related stress and the well-being of employees also outside work. In the current study, the respondents from a special social welfare institution often anticipate stressful situations already on their way to work (n = 11, 30 %), they frequently revolve around their work obligations even outside working hours (n = 10, 27 %), while the respondents from a psychiatric hospital opine that the annual leave is not long enough to repose and renew one's strength (n = 9, 25 %). The results of the remaining items are presented in Table 1. Testing of hypotheses The first null hypothesis (Ho) 'The psychiatric nursing team members have not yet been on sick leave due to work overload.' was tested against the following statements: 'I take sick leave several times per month because of work overload.' and 'I take sick leave several times per year because of work overload.' According to the results, none of the participants (n = 73, 100 %) agrees with the first statement, while 72 respondents do not agree with the second statement, and one participant strongly agrees with the second statement. The chi-square test of independence revealed no statistically significant difference (χ2 = 0.001, p = 0.987). Therefore the hypothesis was accepted and the following conclusion was drawn: the members of the psychiatric nursing team in the clinical setting and in a special social welfare institution did not take sick leave because of the work overload. The second null hypothesis (Ho) 'The employees are satisfied with their work position and work environment.' was tested against the following two statements: 'I would like to change my work environment.' and 'I believe I deserve a better working environment.' The majority of the participants (n = 44, 60 %) do not agree with first statement, 24 (34 %) participants occasionally agree, and 5 (7 %) participants strongly agree with the first statement. A good half of the participants (n = 40, 55 %) do not agree with the second statement, 22 (30 %) participants occasionally agree, and 11 (15 %) participants strongly agree with the second statement. The results show a statistically significant difference for both statements (χ2 = 73.397, p < 0.001). The hypothesis that the employees are satisfied with their work position and environment is rejected. According to the results, the employees would like to change their work place and believe that they deserve a better work environment. The third null hypothesis (Ho) 'The employees regularly use therapeutic communication in their interaction with patients.' was tested with the adverbs denoting frequency of occurrence. Over half of the participants (n = 34, 53 %) always use therapeutic communication, 38 (46 %) use it frequently and one respondent (1.1 %) is not familiar with therapeutic communication. The results show a statistically significant difference (χ2 = 234.349, p < 0.001). The null hypothesis that the employees regularly use therapeutic communication in their interaction with patients is rejected. Instead, an alternative hypothesis that the employees do not always use therapeutic communication in their interaction with patients could be accepted. Discussion Nursing has long been recognised as one of the most stressful professions due to the pressures that are central to the nurses' work. These responsibilities and the excessive workload may translate into significant stress levels among nurses, especially in psychiatric facilities. The patients with mental health conditions may need institutional short or long-term care in special social welfare institutions or psychiatric units. Caregivers provide the necessary mental health assistance to acute and chronic psychiatric patients who are admitted and treated on their own accord or on an involuntary basis. The current study into problematic work environments was focused on the stress levels experienced by the nursing employees. This study produced results which corroborate the findings of a great deal of previous research which indicate that psychiatric nurses are more prone to experience work- related stress than are those in other occupations. Prior studies have provided evidence that a strong relationship exists between the incidence of stress and workplace experiences in psychiatric nursing. The work-related stress my affect the employees' quality of work and their everyday life (Reininghaus, et al., Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.14 2007; Dickinson & Wright, 2008; Weinberg & Creed, 2000; Čuk, 2010; Čuk & Klemen, 2010; Hanrahan, et al., 2010; Peterka Novak, et al., 2010; Hamaideh, 2011; Lombardo & Eyre, 2011; Rössler, 2012; Berring, et al., 2016; Ferri, et al., 2016; Lantta, et al., 2016). As pressure in the workplace is unavoidable due to the demands of the contemporary work environment, the employees have to develop and use healthy coping strategies to manage stress, and meet as well as enjoy professional challenges. It should be reminded that not everyone responds to stressful events in the same way and that all coping responses have limitations. On the question of safety, the study results reveal different views among the respondents from the participating institutions. The majority of study participants from the special social welfare institution claim that measures to optimize patient safety and to minimize the effects of violence on staff are being implemented. Some of the respondents, however, report frequent violent incidents in the workplace. The respondents from the psychiatric hospital, on the other hand, do not all agree that safety in the workplace is ensured. As regards the prevalence of violent incidents, there was more agreement among these respondents than in the sample from the special social welfare institution. It can be concluded that the general safety in the unit decreases the number of incidents perpetrated by patients. Čuk and Gnezda (2007) further report that poor working conditions can be a major source of stress. Hanrahan and colleagues (2010) highlighted that the safety of employees depends on general quality of work and efficient leadership. The inpatient mental health facilities and social welfare institutions should impose adequate measures to reduce the potential for violence and the risks to safety of patients and staff. Working with mentally disturbed or behaviourally compromised patients requires adequate staffing coverage, especially nurses, the ongoing safety assessment in the psychiatric milieu and the training for the management of patient aggression. Prior studies (Černoga, 2013) have provided evidence that permanent staff education and training plays a crucial role in ensuring and maintaining a safe environment. Bregar (2012) reported that there are critical shortages of highly qualified nurses (80 %) to perform advanced nursing tasks. Such a shortage may have a significant negative impact on the quality of work and safety of patients. Recent estimates suggest that the number of nurses should be increased by 20 % to meet the current health needs of the population. Kindy and colleagues (2005) investigated the impact of severe nursing shortages and confirmed that serious work- related hazards exist in psychiatric facilities and they also provided insight into possible remedies. According to the study results, the respondents do not utilise therapeutic communication in their daily contacts with patients or residents, which was contrary to our expectations. Therapeutic communication skills are essential to today's nurse, especially in contacts with mentally ill and behaviourally compromised patients (Gorše Muhič, 2000). Therapeutic communication facilitates the development of therapeutic (help and/ or care) relationship, which is a key ingredient and the cornerstone of mental health nursing, The quality of the relationship or the therapeutic alliance is one of the common factors for predicting the success or failure of therapy (Lambrette, 2015). In their work with patients, the psychiatric nurses often apply the theory/model of interpersonal relations developed by Hildegard E. Peplau (1991). One of the major concepts of this theory is that nursing is an interpersonal process because it involves interaction between two or more individuals with a common goal. Another conceptual model commonly used in psychiatric nursing is the one developed by Virginia Henderson (1998), which categorises nursing activities into 14 components based on human needs. One of these components refers to the patients' needs to communicate with others and express their emotions, needs, fears, or opinions. This psychological component of nursing is fundamental in psychiatric inpatient facilities. Permanent education and training is therefore necessary to avoid automated care in mental health nursing. The staff should acquire and apply therapeutic communication strategies based on theories and research evidence to reduce their emotional distress and foster behavioural change of patients. A great majority of the respondents are fully confident in their ability to competently perform nursing tasks and interventions. Any doubt in one's professional competence may be a major source of daily stress in psychiatric nursing. The work in psychiatric nursing may entail various negative effects on the private life of nurses (Kindy, et al., 2005; Augusto Landa, et al., 2008; Berring, et al., 2008; Bregar, et al., 2011; Lipovšek, 2012; Ferri, et al., 2016). The study therefore aimed to determine the extent to which the respondents' professional responsibilities interfere with their family life. Nearly one third of respondents from the special social welfare institution report the experience of anticipatory stress and anxiety on their way to work, and feel the weight of their job responsibilities outside work. The study conducted by Kržišnik and Čuk (2010) presents valuable insights into the work-family balance and how the effects of fatigue and stress experienced at work can affect family life at home. One fourth of the respondents from a psychiatric hospital claim that their annual leave is not sufficient to recover from stressful work conditions and recuperate their strength even though their annual leave is longer than that of other nursing employees. The perceived stress and coping responses for stress depend on individual personal characteristics. The respondents from both samples agree that the major sources of stress are low pay and dysfunctional, non- supportive relationships among co-workers. Similar findings were reported by Longo (2007), Dickinson Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 15 and Wright (2008), Čuk and Klemen (2010), Bregar and colleagues (2011) and Rössler (2012). The study conducted by Lipovšek (2012) indicates that more than half of the study participants are not satisfied with their pay in psychiatric nursing, and that the main reason why they stay in a job under given conditions is financial security. Physical and psychological violence in mental health settings and in social welfare institutions cannot be avoided. All the respondents from the special social welfare institution have been subjected to patient violent acts during their career, either on a daily basis or several times per week or month. Similar results were established for the respondents from a psychiatric hospital. Lantta and colleagues (2016) concluded that patient violence against health care personnel at work is a widespread global concern, particularly in the fields of mental health care and, more specifically, psychiatric nursing. In the USA, for instance, about 40 % of all nurses have been exposed to physical violence and 70 % to violence of a non-physical type. Černoga (2013) reported that nearly all psychiatric employees experienced patient-on- professional aggression involving direct verbal abuse, or they witnessed patient violent behaviours towards objects in their environment (e.g. throwing or breaking objects, causing mayhem). The same author also noted that the incidence of patient physical violence against psychiatric health care professionals was increasing. According to Perne (2005), psychiatric nurses working with behaviourally compromised patients report among the highest violent victimization rates among all types of healthcare providers. Patient aggressive and unpredicted behaviour is also one of the major sources of stress (Bregar, et al., 2011). Čuk and Gnezda (2007) reported that 70 % of nurses working in psychiatric settings feel threatened and that the critical issue of nurse safety has not been properly addressed. The current research yielded equal results (n = 53, 73 %,), which indicate that nurses are exposed to similar safety hazards in their work environment, and that caring for those who care still remains the main concern of psychiatric and welfare institutions. The findings of the present study also reveal a very high level of the respondents' tolerance towards psychiatric patients (n = 72, 98.5 %), although their frequent violent behaviour adds to the work-related stress. The members of the psychiatric nursing teams in both participating institutions do not need to take sick leave because of stress and work overload. A small percent of the surveyed employees (n = 5, 7 %) would like to leave their current job and believe that they deserve a better working environment (n = 11, 15 %). The results of the study provide an overview of some aspects of work environment in two different psychiatric settings. Limitations of the study included a small sample size (n = 73) and a relatively poor response rate. For this reason, these findings cannot be generalized to the larger population of psychiatric settings where nurses provide care to patients with mental conditions and developmental issues. Further comprehensive research with larger population is required to determine the extent to which our findings can be generalized. Conclusion The major cause of stress of the present day is the modern lifestyle, with sometimes overwhelming job and home demands and expectations. Experiencing high levels of stress may put one's health and the entire well- being at risk. The way people cope with stress depends on their stress recognition and coping strategies - how they take charge of their lifestyle, thoughts, emotions and challenges so that they do not compound the problems. They may avoid unnecessary stress, alter the situation, adapt to the stressors or accept the things they cannot change. The caregivers in psychiatric settings are especially at risk for stress due to their work conditions and the type of patients they care for. Stress in clinical settings and social welfare institutions may also be caused by the perceived or actual threat to safety and patient violence against healthcare workers. The anticipation and elimination of potential safety hazards should be considered, but work in these facilities is not always entirely safe and free of risk. The compromised behaviour and violent acts of patients directed towards the nursing staff cannot be avoided and the violence rates have not decreased. Several respondents of the present study experienced some kind of patient aggression on a daily basis or several times per week or month. To alleviate the overall stress, the employees should strive for better interpersonal relations within the team of co-workers. One skill of great importance to workplace violence prevention is the use of therapeutic communication in caregivers' contact with patients. It should become an integral part of psychiatric nursing, which residents and patients expect and need. The current research was presented to the representatives of both participating institutions. It was generally agreed that the study findings may have important implications for the implementation of changes, employee work satisfaction and better quality of work performance. They are also aware that the specifics of psychiatric nursing require more collegial and supervisory support. They suggested that further research be conducted on the impact of the environmental and job-specific factors on the health and wellbeing of psychiatric nursing employees. Slovenian translation/Prevod v slovenščino Uvod Po vsem svetu je stres v zdravstveni negi prisoten v veliki meri (Weinberg & Creed, 2000). Zaposleni v zdravstveni negi na delovnem mestu preživijo pretežni del svojega življenja (Kramli, 2007). Poklic medicinske Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.16 sestre je izredno odgovoren, naporen in zahteven, zato so za ta poklic potrebne lastnosti, kot so: humanost, odgovornost, razumevanje, sposobnost pomoči in tolerantnosti (Thaler, 2007, p. 56). Zaposleni v zdravstveni negi menijo, da imajo preveč odgovornosti, o odnosu v negovalnem in zdravstvenem timu pa, da je preveč hierarhičen in da tim v pravem pomenu sploh ne obstaja. Posledično medicinskim sestram poklic v večini pomeni samo sredstvo za preživetje in obremenjujočo situacijo. Na področju psihiatrije ogroženost, obremenjenost in fizično utrujenost občuti 70 % zaposlenih (Čuk & Gnezda, 2007). Stresne situacije na področju psihiatrije so postale stalnica in vsakdan. Raziskave zdravstvene nege na področju psihiatrije pričajo, da je stres nenehni spremljevalec zahtevnega dela in življenja zaposlenih (Weinberg & Creed, 2000; Peterka Novak, et al., 2010; Bregar, et al., 2011; Rössler, 2012; Berring, et al., 2016). Pogostost stresnih situacij povečujejo značilnosti pacientov na psihiatriji, saj imajo svojo specifično simptomatiko. Sprejem pacienta proti volji, nasilno vedenje pacienta in premajhno število kadra v izmeni pomembno vplivajo na kakovost dela. Obremenitve se dodatno pojavljajo zaradi nezadostnega znanja o terapevtski komunikaciji. Zaradi teh razlogov ima v zdravstvu poseben pomen permanentno izobraževanje zaposlenih (Kržišnik & Čuk, 2010). Zdravstveni delavci pozabljajo na terapevtsko komunikacijo, saj bi se radi izognili čustvenim obremenitvam na delovnem mestu. Tako zanikajo probleme pacientov, se jim izogibajo, zmanjšujejo komunikacijo na najmanjšo mero, imajo brezoseben odnos do pacientov ter vzdržujejo osebnostno razdaljo; s tem se želijo zaščititi pred čustveno prizadetostjo (Čuk & Gnezda, 2007). Zaradi specifike delovnega področja v zdravstveni negi se zaposleni pogosteje srečujejo s poškodbami, napetostjo, negotovostjo, psihičnimi pritiski, stresom in tudi z izgorevanjem (Čuk & Gnezda, 2007; Kramli, 2007; Čuk, 2010; Lapanja, 2010). Značilnosti dela pomembno vplivajo na pojavnost stresa tudi na področju psihiatrije. Med temi izstopajo zlasti medsebojni odnosi (Kindy, et al., 2005; Peterka Novak, et al., 2010; Bregar, et al., 2011; Rössler, 2012). Iz raziskave, ki so jo izvedli Peterka Novak in sodelavci (2010) v šestih psihiatričnih zavodih na sekundarni in terciarni zdravstveni dejavnosti, je razvidno, da zaposlene na področju psihiatrije med drugim bremenijo tudi mobing oz. emocionalni in psihični pritiski sodelavcev, slabi odnosi med sodelavci, grupiranje kadra in posledično slabi odnosi v zdravstvenem in negovalnem timu, neodkritost med sodelavci, nezadovoljni posamezniki, sestanki z nadrejenimi, medpoklicno sodelovanje, ki zahteva prilagajanje za doseganje skupnega cilja. Pri medicinskih sestrah na področju psihiatrije so dejavniki stresa iz delovnega okolja med drugim tudi slabi delovni pogoji, nejasne meje poklicne odgovornosti, velika odgovornost za paciente, slaba možnost udeležbe pri organizaciji dela, slabe možnosti napredovanja, delo v turnusih, obremenitve, kot so neželene in nepredvidljive situacije (Čuk & Gnezda, 2007, p. 31), hiter tempo dela, dežurstvo, prevelik obseg dela, pomanjkanje kadra (Zeller, et al., 2009; Peterka Novak, et al., 2010; Bregar, et al., 2011; Ferri, et al., 2016; Lantta, et al., 2016), dolge vizite, veliko število sprejemov skozi dan, sprejem proti volji pacienta, neprestano hitenje, veliko število hkratnih intervencij in njihova triaža v času dežurstva, delovanje proti volji pacienta, fizično oviranje pacienta, aplikacija terapije proti volji pacienta, incidenti (npr. poskus samomora), porušen bioritem ipd. (Lapanja, 2010, pp. 50−51). Značilnost na področju psihiatrije, npr. v kliničnem okolju in v posebnem socialnovarstvenem zavodu, so tudi pacienti, ki lahko izražajo agresijo, heteroagresijo in avtoagresijo (Peterka Novak, et al., 2010; Bregar, et al., 2011). Zeller in sodelavci (2009) navajajo, da je za zaposlene najbolj stresni dejavnik agresivno vedenje pacientov, predvsem verbalne grožnje (žalitve) in izvedeno fizično nasilje (brce, ugrizi). Reininghaus in sodelavci (2007) so ugotovili, da je prav nasilje v največji meri povezano s stresom na delovnem mestu. Ferri in sodelavci (2016) pa navajajo, da je nasilje nad zdravstvenimi delavci s strani pacientov postalo globalni problem in da se bo pojavnost še večala, in trdijo, da so predvsem medicinske sestre postavljene pred tveganje za agresivne napade pacientov. Za zdravstveno nego na področju psihiatrije je značilna tudi visoka stopnja poklicne izgorelosti (Hamaideh, 2011), h kateri pomembno prispevata način dela kot tudi psihične in fizične obremenitve, ki izhajajo iz dela s pacienti. Poklicna izgorelost se je prvotno pojavila prav pri medicinskih sestrah oz. v skrbstvenih poklicih (Schmiedel, 2011). Izgorevanje v psihiatriji je tudi glavni razlog za menjavo delovnega mesta. Zaposleni na področju psihiatrije v 90 % menijo, da je delo stresno ter obremenjujoče, in pri sebi opažajo simptome izgorevanja (Čuk & Klemen, 2010). Namen in cilji Namen raziskave je bil raziskati prisotnost stresa med člani negovalnega tima na področju psihiatrije, in sicer v kliničnem okolju bolnišnice in v posebnem socialnovarstvenem zavodu, ter ugotoviti njegovo razsežnost. V skladu s tem so bili cilji: ugotoviti najpogostejše vzroke za nastanek stresa med − člani negovalnega tima na področju psihiatrije, ugotoviti posledice stresa v zasebnem življenju − članov negovalnega tima na področju psihiatrije, ugotoviti pojavnost neželenih incidentov in − psihičnega ter fizičnega nasilja pacientov na področju psihiatrije, ugotoviti pogostost uporabe terapevtske − komunikacije pri članih negovalnega tima na področju psihiatrije. V okviru raziskovalnih vprašanj nas je zanimalo: Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 17 Kateri so dogodki in situacije, ki negovalnemu timu − na področju psihiatrije predstavljajo stres, in kako se stres na delovnem mestu odraža v njihovem zasebnem življenju? Kako pogosto se člani negovalnega tima na področju − psihiatrije srečujejo s fizičnim in psihičnim nasiljem pacientov in s čim pacienti ogrožajo varnost članov tima? Postavljene so bile naslednje hipoteze: H1: Člani negovalnega tima na področju psihiatrije še niso imeli bolniškega staleža, katerega vzrok bi bila preobremenjenost zaposlenih na delovnem mestu. H2: Zaposleni so zadovoljni s svojim delovnim mestom. H3: Zaposleni ob stiku s pacientom vedno uporabljajo terapevtsko komunikacijo. Metode Za raziskovanje smo uporabili neeksperimentalno kvantitativno opisno raziskovalno metodo. Opis instrumenta Za potrebe raziskave smo po pregledu literature (Peterka Novak, et al., 2010; Schmiedel, 2011; Lipovšek, 2012) razvili vprašalnik, ki je vseboval 17 vprašanj: 10 vprašanj zaprtega tipa, 3 vprašanja polodprtega tipa in 4 vprašanja odprtega tipa. Vprašanja so bila razdeljena na štiri vsebinske sklope. Prvi sklop je vseboval socialnodemografske podatke, in sicer vprašanja o spolu, starosti, stopnji izobrazbe in delovni dobi na področju psihiatrije. Drugi sklop je zajemal trditve, ki so predstavljale stresogene dejavnike na področju psihiatrije – anketiranci so trditve ocenili od 0 do 2, kjer je pomenilo 0 – »sploh se ne strinjam«, 1 – »ne morem se opredeliti«, 2 – »popolnoma se strinjam«. Tretji sklop je zajemal vprašanja, s katerimi smo želeli ugotoviti mnenje anketiranih o varnosti v njihovi ustanovi, kako pogosto se srečujejo z incidenti, kako pogosto uporabljajo terapevtsko komunikacijo pri pacientih, kako pogosto se srečujejo s fizičnim in psihičnim nasiljem pacientov, ali so jih pacienti že ogrožali na delovnem mestu, ali imajo do pacientov potrpljenje in ali dvomijo vase pri opravljanju intervencij zdravstvene nege. Četrti sklop je zajemal trditve, s katerimi smo odkrivali, kako stres na delovnem mestu vpliva na zasebno življenje anketiranih. Anketiranci so trditve ocenili od 0 do 2 na enak način kot pri tretjem sklopu. Zanesljivost vprašalnika je bila preverjena s Cronbachovim koeficientom alfa; le-ta se je gibal od 0,70 do 0,90, kar kaže na dobro zanesljivost konstrukta (UC Regents, 2016). Opis vzorca Vprašalnik je bil razdeljen med člane negovalnega tima v eni od psihiatričnih bolnišnic v severovzhodnem delu Slovenije in med člane negovalnega tima v posebnem socialnovarstvenem zavodu v severovzhodnem delu Slovenije. V vsaki instituciji smo razdelili 70 anket. V posebnem socialnovarstvenem zavodu smo dobili vrnjenih 37 anket, v psihiatrični bolnišnici pa 36 anket. V raziskavi je sodelovalo 73 zaposlenih v zdravstveni negi. Največ med njimi jih je imelo srednješolsko (n = 51, 70 %) in najmanj univerzitetno izobrazbo (n = 4, 5 %). Večina anketiranih je bila žensk (n = 59, 80,5 %). Največ anketiranih je bilo v starostnem obdobju od 30 do 40 let (n = 33, 45,5 %), najmanj v starostnem obdobju do 20 let (n = 1, 1,5 %). Večji delež so predstavljali anketirani, ki so imeli na področju psihiatrije delovno dobo do 20 let (n = 26, 35,5 %), najmanjši delež pa anketirani, ki so imeli na področju psihiatrije delovno dobo do 40 let (n = 8, 11 %). Opis poteka raziskave in obdelave podatkov Pred anketiranjem smo pridobili ustno soglasje vodstva psihiatrične bolnišnice in posebnega socialnovarstvenega zavoda. Raziskavo smo izvajali v sodelovanju s strokovnimi vodji zdravstvene nege posameznih oddelkov. Vprašalnik je bil anonimen, ob pristopu so bile jasno navedene informacije o namenu anketne raziskave. Udeleženci raziskave so prostovoljno pristopili k izpolnjevanju vprašalnika. Pri izvedbi raziskave smo upoštevali etična načela raziskovanja. Izvedba raziskave je potekala od marca do maja 2016. Rezultate vprašalnika smo obdelali z računalniškimi programi Microsoft Word 2007, Microsoft Excel 2007 in SPSS verzija 20.0 (SPSS Inc., Chicago, IL, USA). Pri analizi je bil poleg opisne statistike uporabljen tudi hi-kvadrat test (χ2), s katerim smo testirali ničelne hipoteze (Ho) o bolniških staležih, katerih vzrok je preobremenjenost na delovnem mestu, o zadovoljstvu anketiranih na delovnem mestu in o uporabi terapevtske komunikacije ob stiku s pacientom. Rezultati V raziskavi smo želeli ugotoviti, kateri so dogodki in situacije, ki anketiranim predstavljajo stres na delovnem mestu – pri tem smo se omejili na določene stresne situacije, kot so: hitra utrujenost pri delu, konstantno pomanjkanje časa za malico, nezaupljivi odnosi med sodelavci, nelagoden občutek ob nadrejenih, hitenje pri delu, kratki časovni roki za izpolnitev danega cilja, obilica delovnih nalog v izmeni, nepredvidljive situacije, triizmensko delo, zmanjšan občutek varnosti ob nepredvidljivih pacientih, pomanjkanje pomoči in razumevanja s strani nadrejenih, nepristna komunikacija med sodelavci, slabo nagrajevanje za opravljeno delo, nepoštenost med sodelavci, agresivni odzivi pacientov, izvajanje posebnih varovalnih ukrepov in občutek opravljanja večjega števila delovnih nalog v primerjavi s sodelavci. Navedeni strukturni deleži v rezultatih predstavljajo delež anketiranih, Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.18 ki se popolnoma strinjajo z določeno trditvijo ali vprašanjem. Ugotovili smo, da na anketirane v posebnem socialnovarstvenem zavodu in na anketirane v psihiatrični bolnišnici določeni stresni dejavniki delujejo zelo različno. Obema raziskovalnima vzorcema je skupno, da najpogostejše stresne situacije na delovnem mestu predstavljata slabo nagrajevanje za opravljeno delo, kar meni 41 % (n = 15) anketirancev v posebnem socialnovarstvenem zavodu in 69 % (n = 25) anketirancev v psihiatrični bolnišnici, ter nepoštenost med sodelavci, kar meni 38 % (n = 14) anketirancev v posebnem socialnovarstvenem zavodu in 61 % (n = 22) anketirancev v psihiatrični bolnišnici. V posebnem socialnovarstvenem zavodu je med najpogostejšimi tremi stresnimi situacijami še zmanjšan občutek varnosti ob nepredvidljivih pacientih (n = 15, 40,5 %), v psihiatrični bolnišnici pa fizično nasilje pacientov (n = 17, 47 %). S psihičnim in fizičnim nasiljem pacientov se večkrat mesečno srečuje skoraj polovica (n = 34, 46,5 %) vseh anketiranih. V posebnem socialnovarstvenem zavodu se s psihičnim in fizičnim nasiljem pacientov kar 30 % (n = 11) anketiranih srečuje vsak dan, 30 % (n = 11) se jih s tem pojavom sooči večkrat tedensko in 40 % (n = 14) večkrat mesečno. S fizičnim in psihičnim nasiljem pacientov se v psihiatrični bolnišnici vsak dan sreča 8 % (n = 3) anketiranih, 36 % (n = 13) jih je v taki situaciji večkrat tedensko, 53 % (n = 19) pa večkrat mesečno, en anketiranec (3 %) se ni srečal z nasiljem, ki bi ga izvedel pacient. V posebnem socialnovarstvenem zavodu 62 % (n = 23) anketiranih trdi, da so jih stanovalci že ogrožali na delovnem mestu. Pri tem so bili največkrat navedeni predvidljivi fizični napadi (n = 12), agresivno vedenje stanovalca (n = 6) in verbalne grožnje (n = 10). V psihiatrični bolnišnici 83 % (n = 30) anketiranih trdi, da so jih pacienti že ogrožali na delovnem mestu. Oblike nasilja, ki so bile pri tem največkrat izpostavljene, so verbalna agresija, kot so grožnje, kletvice, pljuvanje (n = 16), izvedena fizična agresija, kot so udarci, brce, ugrizi (n = 12), in poskusi fizičnega napada (n = 11). V raziskavi smo anketirane povprašali glede mnenja o varnosti pacientov in preprečevanju incidentov v njihovi ustanovi. Polovica (n = 18, 50 %) anketiranih v psihiatrični bolnišnici meni, da je v njihovi ustanovi za varnost in preprečevanje incidentov dobro poskrbljeno – druga polovica (n = 18, 50 %) anketiranih pa meni, da je v njihovi ustanovi za to slabo poskrbljeno, pri tem pa skoraj polovica (n = 17, 47 %) vseh anketiranih v psihiatrični bolnišnici meni, da se z incidenti srečujejo pogosto. Da je v posebnem socialnovarstvenem zavodu za varnost pacientov in preprečevanje incidentov dobro poskrbljeno, meni 81 % (n = 30) anketiranih – pri tem 35 % (n = 13) anketiranih meni, da se v ustanovi z incidenti srečujejo pogosto. Anketirane smo povprašali tudi o tem, ali pri opravljanju intervencij zdravstvene nege kdaj dvomijo vase. V psihiatrični bolnišnici vseh 36 (100 %) anketiranih zatrjuje, da pri opravljanju intervencij zdravstvene nege vase ne dvomijo. V posebnem socialnovarstvenem zavodu večina (n = 29, 78 %) anketiranih pri opravljanju intervencij zdravstvene nege vase ne dvomi, 19 % (n = 7) jih vase dvomi včasih, Tabela 1: Vpliv stresa na delovnem mestu na položaj oz. počutje anketiranih izven delovnega mesta Table 1: Effects of work-related stress on the wellbeing of respondents outside their work Popolno strinjanje s trditvami/ Strong agreement with the statements Rezultati raziskave za posebni socialnovarstveni zavod/ Research results for a special social welfare institution Rezultati raziskave za psihiatrično bolnišnico/ Research results for a psychiatric hospital Povprečje obeh raziskovalnih vzorcev/ Average of both research samples n % n % n Pogosto pomislim, kako stresen bo dan, medtem ko se odpravljam v službo. 11 30 7 19 18 25 Premišljujem o službi, tudi ko nisem na delovnem mestu. 10 27 4 11 14 19 Uporabljam tehnike za sprostitev. 6 16 8 22 14 19 S prijatelji se ne družim več veliko. 5 14 7 11 12 13 Menim, da si zaslužim boljše delovno okolje. 5 14 6 17 11 16 Drugim pogosto razlagam o problemih na delovnem mestu. 1 3 2 5 3 4 Ko nisem v službi, sem pogosto utrujen. 1 3 3 8 4 6 Želim si zamenjati svoje delovno okolje. 2 5 3 8 5 7 Zelo težko se sprostim. 2 5 1 3 3 4 Letni dopust mi ne zadostuje, da bi se spočil/-a in si nabral/-a nove energije. 4 11 9 25 13 18 Legenda/Legend: % − odstotek/percentage; n – število/number; – povprečje/average Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 19 eden (3 %) izmed vprašanih pa vase dvomi. Stres na delovnem mestu vpliva na položaj oz. počutje izven delovnega mesta v največji meri tako, da anketiranci v posebnem socialnovarstvenem zavodu pogosto pomislijo, kako stresen bo dan, medtem ko se odpravljajo v službo (n = 11, 30 %), ter pogosto premišljujejo o službi, tudi ko niso na delovnem mestu (n = 10, 27 %), v psihiatrični bolnišnici pa menijo, da jim letni dopust ne zadostuje, da bi se spočili in si nabrali nove energije (n = 9, 25 %). Ostali rezultati so prikazani v Tabeli 1. Preverjanje hipotez Testirali smo ničelno hipotezo (Ho) s trditvama »Mesečno imam večkrat bolniški stalež zaradi preobremenjenosti na delovnem mestu« – nestrinjanje s to trditvijo je izrazilo vseh 73 (100 %) anketiranih – in »Letno imam večkrat bolniški stalež zaradi preobremenjenosti na delovnem mestu« – s tem se 72 anketiranih ne strinja, en anketirani pa se popolnoma strinja. Hi-kvadrat test kaže, da statistične razlike ni (χ2 = 0,001, p = 0,987), zato hipotezo potrdimo in sprejmemo sklep: člani negovalnega tima na področju psihiatrije, in sicer v kliničnem okolju in v posebnem socialnovarstvenem zavodu, še niso imeli bolniškega staleža, katerega vzrok bi bila preobremenjenost zaposlenih na delovnem mestu. Pri drugi hipotezi smo testirali ničelno hipotezo (Ho) s trditvama »Želim si zamenjati svoje delovno okolje«, s čimer se 44 (60 %) anketiranih ne strinja, 24 (34 %) anketiranih se včasih strinja in 5 (7 %) anketiranih se popolnoma strinja, in »Menim, da si zaslužim boljše delovno mesto«, s čimer se 40 (55 %) anketiranih ne strinja, 22 (30 %) anketiranih se včasih strinja in 11 (15 %) anketiranih se popolnoma strinja. Za obe trditvi obstaja statistično značilna razlika (χ2 = 73,397, p < 0.001). Hipotezo, da so zaposleni zadovoljni s svojim delovnim mestom, zavržemo, saj si le-ti želijo zamenjati svoje delovno okolje in menijo, da si zaslužijo boljše delovno mesto. Pri tretji hipotezi smo testirali ničelno hipotezo (Ho), da zaposleni vedno uporabljajo terapevtsko komunikacijo. Hipotezo smo testirali glede na ponujene možne odgovore: »vedno« (n = 34, 53 %), »pogosto« (n = 38, 46 %) in »ne vem, kaj je terapevtska komunikacija« (n = 1, 1 %). Rezultat je pokazal statistično značilno razliko (χ2 = 234,349, p < 0.001). Ničelno hipotezo (Ho), da zaposleni vedno uporabljajo terapevtsko komunikacijo, zavrnemo oz. sprejmemo alternativno hipotezo, da zaposleni ne uporabljajo terapevtske komunikacije vedno. Diskusija Pogosto pozabljamo na to, da so stresni dogodki odvisni od vsakega posameznika posebej. Osebe z motnjami v duševnem zdravju in razvoju v zdravstveni negi srečamo v posebnem socialnovarstvenem zavodu, ki je njihov dom, v katerem za njihove potrebe skrbijo izobraženi zdravstveni delavci in sodelavci, in v psihiatrični bolnišnici, kamor je pacient zaradi akutnega ali kroničnega duševnega obolenja sprejet prostovoljno ali proti svoji volji. Rezultati naše raziskave so pokazali, da je med anketiranimi člani negovalnega tima na področju psihiatrije, in sicer v kliničnem okolju in v posebnem socialnovarstvenem zavodu, stres prisoten. Tudi iz raziskav, ki so jih izvedli številni drugi avtorji (Reininghaus, et al., 2007; Dickinson & Wright, 2008; Weinberg & Creed, 2000; Čuk, 2010; Čuk & Klemen, 2010; Hanrahan, et al., 2010; Peterka Novak, et al., 2010; Hamaideh, 2011; Lombardo & Eyre, 2011; Rössler, 2012; Berring, et al., 2016; Ferri, et al., 2016; Lantta, et al., 2016), je razvidno, da se zaposleni na področju psihiatrije soočajo s stresom na delovnem mestu, ki vpliva na njihovo delovno storilnost in vsakdanje življenje. Stresu se ne moremo izogniti, zato se ga moramo naučiti obvladati, da nam bo delo kasneje v izziv in zadovoljstvo. Iz naše raziskave lahko razberemo, da anketirani v posebnem socialnovarstvenem zavodu v večji meri menijo, da je v njihovem delovnem okolju dobro poskrbljeno za varnost, in v manjši meri, da se pogosto srečujejo z incidenti, medtem ko si anketirani v psihiatrični bolnišnici glede vprašanja o varnosti v ustanovi niso enotni, glede pogostosti incidentov pa se s trditvijo strinjajo v večji meri kot prva skupina. Sklepamo lahko, da večja varnost v ustanovi zmanjšuje število incidentov, ki jih povzročajo pacienti. Čuk in Gnezda (2007) navajata, da so med vzroki za stres na delovnem mestu tudi slabi delovni pogoji, Hanrahan in sodelavci (2010) pa so izpostavili, da na varnost zaposlenih vplivata tudi splošna kakovost dela in učinkovito vodstvo. Zaradi različnih duševnih motenj mora biti na področju psihiatrije, npr. v kliničnem okolju in v posebnem socialnovarstvenem zavodu, dobro poskrbljeno za varnost pacientov oz. stanovalcev. Če je dobro poskrbljeno za varnost pacientov oz. stanovalcev, se lahko s tem zmanjšuje število incidentov. Pomemben dejavnik za zmanjševanje incidentov so tudi izobraženi zdravstveni delavci in sodelavci, ki ne bi smeli biti v pomanjkanju, kar v zdravstveni negi predstavlja resno problematiko – s tako problematiko se zaposleni v zdravstveni negi srečujejo vsakodnevno. Černoga (2013) navaja, da večina zaposlenih v zdravstveni negi na področju psihiatrije meni, da na zmanjševanje incidentov in varnost zaposlenih vpliva tudi permanentno izobraževanje zaposlenih. Bregar (2012) ugotavlja, da za obravnavo najzahtevnejših pacientov v zdravstveni negi primanjkuje za kar 80 % medicinskih sester z visoko izobrazbo – tako pomanjkanje pa lahko bistveno vpliva na kakovost in varnost obravnave pacientov. Dnevno se izvajalci zdravstvene nege srečujejo z več kot 20-% pomanjkanjem kadra. Z enako problematiko se srečujejo tudi v tujini (Kindy, et al., 2005). Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.20 Anketirani terapevtske komunikacije pri pacientu oz. stanovalcu ne uporabljajo vedno. Takih rezultatov nismo pričakovali, saj je posebnost v zdravstveni negi na področju psihiatrije prav terapevtska komunikacija in odnos z osebo, ki ima duševno motnjo (Gorše Muhič, 2000). Ena izmed glavnih prvin kakovostnega odnosa med medicinsko sestro in pacientom je terapevtska komunikacija, z njo lahko napovemo uspeh ali morebiten neuspeh zdravljenja (Lambrette, 2015). Prav na področju psihiatrije je nastala teorija oz. model medsebojnih odnosov, ki ga je razvila teoretičarka Hildegard E. Peplau (1991), ki ga pogosto uporabljamo v interakciji s pacientom. Zanimivo je tudi, da prav pri osebah z duševno motnjo velikokrat zaznamo potrebe po odnosih z ljudmi, izražanju čustev, občutkov in potreb, kar povzema 10. temeljna življenjska aktivnost po konceptualnem modelu Virginie Henderson (1998). Zatorej predpostavljamo, da bi bilo še posebej v zdravstveni negi na področju psihiatrije potrebno permanentno izobraževanje o komunikacijskih veščinah s poudarkom na terapevtski komunikaciji. Ugotovili smo tudi, da večina anketirancev pri opravljanju intervencij zdravstvene nege ne dvomi vase. Menimo, da tovrsten dvom pri delu potencira stresne dejavnike v zdravstveni negi na področju psihiatrije. Delo v zdravstveni negi na področju psihiatrije lahko negativno vpliva na zasebno življenje zaposlenih (Kindy, et al., 2005; Augusto Landa, et al., 2008; Berring, et al., 2008; Bregar, et al., 2011; Lipovšek, 2012; Ferri, et al., 2016). Zato nas je zanimalo, ali anketiranci obremenjenost v delovnem okolju nosijo domov in jo prenašajo na svoje delovanje v zasebnem življenju. Skoraj tretjina anketiranih v posebnem socialnovarstvenem zavodu pogosto pomisli, kako stresen bo dan, medtem ko se odpravljajo v službo, in pogosto premišljujejo o službi, tudi ko niso na delovnem mestu. Tudi iz raziskave, ki sta jo izvedla Kržišnik in Čuk (2010), je razvidno, da večina anketiranih o težavah na delovnem mestu razmišlja tudi doma. V psihiatrični bolnišnici se največ (četrtina) vprašanih strinja s trditvijo, da jim letni dopust ne zadostuje, da bi se spočili in si nabrali nove energije, čeravno imajo zaradi specifičnih potreb pacientov na področju psihiatrije dodeljenih več dni dopusta kot ostali zdravstveni delavci na področju zdravstvene nege. Od vsakega posameznika je odvisno, kako se bo na stres odzval in kako ga bo ovrednotil. Obema raziskovanima vzorcema pa je skupno, da anketirancem največ stresa predstavljata slabo nagrajevanje za opravljeno delo ter slabi medsebojni odnosi med sodelavci – podobne ugotovitve navajajo tudi Longo (2007), Dickinson in Wright (2008), Čuk in Klemen (2010), Bregar s sodelavci (2011) ter Rössler (2012). Tudi Lipovšek (2012) je v raziskavi navedla, da več kot polovica anketiranih s svojim zaslužkom v zdravstveni negi na področju psihiatrije ni zadovoljnih in da anketirani opravljajo svoje delo zaradi finančne varnosti. Trdimo lahko, da se fizičnemu in psihičnemu nasilju na področju psihiatrije, v kliničnem okolju in v posebnem socialnovarstvenem zavodu, ni moč izogniti. V posebnem socialnovarstvenem zavodu se je vsak anketirani srečal s psihičnim in fizičnim nasiljem stanovalcev, doživijo pa ga vsakodnevno, večkrat tedensko ali večkrat mesečno. Enako lahko rečemo za psihično in fizično nasilje pacientov nad anketiranimi v psihiatrični bolnišnici. Lantta in sodelavci (2016) navajajo, da je v tujini nasilje nad zaposlenimi v zdravstveni negi postalo globalen problem, še posebej v zdravstveni negi na področju psihiatrije, kjer je 40 % medicinskih sester že bilo izpostavljenih fizičnemu nasilju in 70 % poskusu fizičnega nasilja. Černoga (2013) v svoji raziskavi navaja, da so bili že skoraj vsi zaposleni v zdravstveni negi na področju psihiatrije verbalno napadeni s strani pacienta, prav tako so skoraj vsi bili priča pacientovemu nasilnemu vedenju do predmetov (primeri razbijanja, premetavanja stvari ipd.). Ista avtorica poudarja, da se število fizičnih napadov v zdravstveni negi na področju psihiatrije povečuje. Perne (2005) navaja, da je ob pacientu z duševno motnjo največ časa prisotno negovalno osebje in da je prav to razlog, zakaj so verbalnemu in fizičnemu nasilju pacientov največkrat izpostavljene prav medicinske sestre. Tudi Bregar in sodelavci (2011) trdijo, da agresivno vedenje pacientov velja za zelo stresen dejavnik. Čuk in Gnezda (2007) navajata, da se 70 % zaposlenih v zdravstveni negi na področju psihiatrije počuti ogrožene. Če povzamemo povprečje iz naše raziskave (n = 53, 73 %), ugotovimo, da pacienti in stanovalci nič manj ne ogrožajo zaposlenih kot pred leti, ko sta raziskavo izvedla Čuk in Gnezda (2007). Kljub temu da značilnosti pacientov na področju psihiatrije potencirajo stresne dejavnike, so anketirani (98,5 %, n = 72) strpni do pacientov z duševnimi motnjami. Stres na delovnem mestu zdravstvene nege na področju psihiatrije sicer ni tako velik, da bi terjal bolniški stalež zaradi preobremenjenosti na delovnem mestu, vendar bi nekateri anketirani (n = 5, 7 %) radi zamenjali svoje delovno mesti in menijo (n = 11, 15 %), da si zaslužijo boljše delovno mesto. Pridobljeni rezultati dajejo vpogled v značilnosti dela in delovnega okolja v dveh različnih okoljih zdravstvene nege na področju psihiatrije. V raziskavi niso sodelovali vsi zaposleni iz zdravstvene nege na področju psihiatrije, zato rezultatov ne moremo posplošiti na vse ustanove, v katerih se lahko srečujemo s pacienti z duševnimi motnjami ali s pacienti z motnjami v duševnem razvoju. Omejeni smo bili tudi na zelo majhen vzorec. Zaključek V večini je vzrok stresa današnji hiter tempo in sodoben način življenja, kjer so zahteve postavljene zelo visoko. Nezavedno nas stres lahko privede do različnih obolenj. Kako bodo stresorji delovali na posameznika, je odvisno od njega samega, od Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 21 njegovega prepoznavanja samega stresa in soočanja z njim. Menimo, da mora biti v ustanovi, kjer se nahajajo osebe z duševnimi obolenji ali z motnjami v duševnem razvoju, zelo dobro poskrbljeno za varnost, saj se prav z varnostjo lahko zmanjšuje pojavnost incidentov. Sklepamo tudi, da se nasilju s strani pacientov in stanovalcev na področju psihiatrije, npr. v kliničnem okolju in v posebnem socialnovarstvenem zavodu, ni mogoče izogniti, saj se veliko zaposlenih s takim nasiljem srečuje vsakodnevno, občutek ogroženosti zaposlenih pa se skozi leta ni spremenil. Na delovnem mestu bi morali izboljšati odnose med sodelavci, pri pacientu pa ne bi smeli pozabiti na terapevtsko komunikacijo. Prav odnosi so namreč tisti, ki so za zaposlene najbolj stresni. Razvidno je tudi, da zaposleni pozabljajo na terapevtsko komunikacijo, ki je v zdravstveni negi na področju psihiatrije zelo pomembna. Menimo, da bi bilo treba obnavljati znanje o terapevtski komunikacije vse do te mere, da bi jo vsak zaposleni ponotranjil, saj jo pacienti z duševno motnjo zelo potrebujejo ter tudi pričakujejo. Naša raziskava je bila predstavljena vodilnim predstavnikom v obeh sodelujočih institucijah. Vodilni so mnenja, da jim bodo rezultati pomagali pri načrtovanju sprememb za zadovoljstvo zaposlenih in pri doseganju boljše kakovosti dela, ter se zavedajo, da je področje psihiatrije specialno področje prakse zdravstvene nege in da morajo namenjati pozornost in podporo tudi zaposlenim. V nadaljnjih raziskavah bi se zanimali, ali ima zaposlenost v zdravstveni negi na področju psihiatrije negativen vpliv na zdravje medicinskih sester. Conflict of interest/Nasprotje interesov The authors declare that no conflicts of interest exist./Avtorici izjavljata, da ni nasprotja interesov. Funding/Financiranje The study received no funding./Raziskava ni bila finančno podprta. Ethical approval/Etika raziskovanja The study was conducted in accordance with the Helsinki-Tokyo Declaration (World Medical Association, 2013) and the Code of Ethics for Nurses and Nurse Assistants of Slovenia (2014)./Raziskava je pripravljena v skladu z načeli Helsinško-Tokijske deklaracije (World Medical Association, 2013) in v skladu s Kodeksom etike v zdravstveni negi in oskrbi Slovenije (2014). Author contributions/Prispevek avtorjev The co-author contributed to manuscript preparation of all structural parts of the article written by the author (Introduction, Methods, Results, Discussion and Conclusion) with guidance and advice./ Soavtor je z nasveti in pojasnili sodeloval pri vseh strukturnih delih članka, ki jih je napisal avtor (Uvod, Metode, Rezultati, Diskusija in Zaključek). Literature/Literatura Augusto Landa, J.M., Lopez-Zafra, E., Berrios Martos, M.P., Aguilar-Luzon, M.C., 2008. The relationship between emotional intelligence, occupational stress and health in nurses: a questionnaire survey. International Journal of Nursing Studies, 45(6), pp. 888–901. https://doi.org/10.1016/j.ijnurstu.2007.03.005 PMid:17509597 Berring, L.L., Pedersen, L., Buus, N., 2016. Coping with violence in mental health care settings: patient and staff member perspectives on de-escalation practices. Archives of Psychiatric Nursing, 30(5), pp. 499–507. https://doi.org/10.1016/j.apnu.2016.05.005 PMid:27654228 Bregar, B., 2012. Kadrovske stiske zaposlenih v bolnišnični zdravstveni negi – vidik kakovosti in varnosti. In: B. Skela - Savič, S. Hvalič Touzery, K. Skinder Savić & J. Zurc, eds. Kakovostna zdravstvena obravnava skozi izobraževanje, raziskovanje in multiprofesionalno povezovanje – prispevek k zdravju posameznika in družbe: 5. mednarodna konferenca s področja raziskovanja v zdravstveni negi in zdravstvu. Ljubljana: Visoka šola za zdravstveno nego Jesenice, pp. 440–450. Bregar, B., Peterka Novak, J. & Možgan, B., 2011. Doživljanje stresa pri zaposlenih v zdravstveni negi na področju psihiatrije. Obzornik zdravstvene nege, 45(4), pp. 253–262. Available at: http://www.obzornikzdravstvenenege.si/2011.45.4.253 [20. 11. 2016] Černoga, A., 2013. Analiza varnosti zaposlenih v zdravstveni negi s področja mentalnega zdravja pri obravnavi nasilnega vedenja pacienta: magistrsko delo. Kranj: Univerza v Mariboru, Fakulteta za organizacijske vede, pp. 34–91. Čuk, V., 2010. Obvladovanje neželenih dogodkov v zdravstveni negi v psihiatričnih bolnišnicah. Obzornik zdravstvene nege, 44(1), pp. 21–26. Available at: http://www.obzornikzdravstvenenege.si/2010.44.1.21 [20. 11. 2016] Čuk, V. & Gnezda, S., 2007. Izgorevanje in delovne obremenitve medicinskih sester. In: R. Trampuž, ed. Izgorevanje – stiska ali izziv: zbornik prispevkov, Ajdovščina, 24. marca 2007. Nova Gorica: Društvo medicinskih sester in zdravstvenih tehnikov, pp. 16–33. Čuk, V. & Klemen, J., 2010. Izgorevanje osebja v zdravstveni negi na psihiatričnem področju. Obzornik zdravstvene nege, 44(3), pp. 179–187. Available at: http://www.obzornikzdravstvenenege. si/2010.44.3.179 [20. 11.2016] Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23.22 Dickinson, T. & Wright, K.M., 2008. Stress and burnout in forensic mental health nursing: a literature review. British Journal of Nursing, 17(2), pp. 82–87. https://doi.org/10.12968/bjon.2008.17.2.28133 PMid:18414278 Ferri, P., Silvestri, M., Artoni, C. & Di Lorenzo, R., 2016. Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross- sectional study. Journal of Psychology Research and Behavior Management, 23(9), pp. 263–275. https://doi.org/10.2147/PRBM.S114870 PMid:27729818; PMCid:PMC5042196 Gorše Muhič, M., 2000. Komunikacija v zdravstveni negi. In: B. Kogovšek & R. Kobentar, eds. Priročnik psihiatrične zdravstvene nege in psihiatrije: za medicinske sestre in zdravstvene tehnike. Ljubljana: Psihiatrična klinika, pp. 15–26. Hamaideh, S.H., 2011. Burnout, social support, and job satisfaction among Jordanian mental health nurses. Issues in Mental Health Nursing, 32(4), pp. 234–242. https://doi.org/10.3109/01612840.2010.546494 PMid:21355758 Hanrahan, N.P., Aiken, L.H., McClaine, L. & Hanlon, A., 2010. Relationship between psychiatric nurse work environments and nurse burnout in acute care general hospitals. Issues in Mental Health Nursing, 31(3), pp. 198–207. https://doi.org/10.3109/01612840903200068 PMid:20144031; PMCid:PMC2856615 Henderson, V., 1998. Osnovna načela zdravstvene nege. Ljubljana: Zbornica zdravstvene nege Slovenije, pp. 19–88. Kindy, D., Petersen, S. & Parkhurst, D., 2005. Perilous work: nurses‘ experiences in psychiatric units with high risks of assault. Archives of Psychiatric Nursing, 19(4), pp. 169–175. https://doi.org/10.1016/j.apnu.2005.05.002 PMid:16088855 Kodeks etike v zdravstveni negi in oskrbi Slovenije in Kodeks etike za babice Slovenije, 2014. Ljubljana: Zbornica zdravstvene in babiške nege Slovenije – Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije. Kramli, M., 2007. Medicinska sestra med domom, družino in službo. In: R. Trampuž, ed. Izgorevanje – stiska ali izziv: zbornik prispevkov, Ajdovščina, 24. marca 2007. Nova Gorica: Društvo medicinskih sester in zdravstvenih tehnikov, pp. 12–15. Kržišnik, K. & Čuk, V., 2010. Obremenitve in izgorevanje zdravstveno negovalnega osebja v psihiatriji. In: B. Bregar & J. Peterka Novak, eds. Kako zmanjšati stres in izgorevanje na delovnem mestu: zbornik prispevkov z recenzijo. Ljubljana, Slovenija: Zbornica zdravstvene in babiške nege – Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, Sekcija medicinskih sester in zdravstvenih tehnikov v psihiatriji, pp. 30–46. Lambrette, G., 2015. The relationship, a key ingredient of care. Soins Psychiatrie, (36)301, pp. 38–40. https://doi.org/10.1016/j.spsy.2015.09.007 PMid:26564492 Lantta, T., Anttila, M., Kontio, R., Adams, C.E. & Välimäki, M., 2016. Violent events, ward climate and ideas for violence prevention among nurses in psychiatric wards: a focus group study. International Journal of Mental Health Systems, 10, p. 27. https://doi.org/10.1186/s13033-016-0059-5 PMid:27051463; PMCid:PMC4820948 Lapanja, A., 2010. Doživljanje in soočanje medicinske sestre s stresom na intenzivnem psihiatričnem oddelku. In: B. Bregar & J. Peterka Novak, eds. Kako zmanjšati stres in izgorevanje na delovnem mestu: zbornik prispevkov z recenzijo. Ljubljana: Zbornica zdravstvene in babiške nege Slovenije – Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, Sekcija medicinskih sester in zdravstvenih tehnikov v psihiatriji, pp. 47–56. Lipovšek, M., 2012. Stres med člani negovalnega tima na psihiatričnem področju: diplomsko delo univerzitetnega študija. Maribor: Univerza v Mariboru, Fakulteta za zdravstvene vede, pp. 43–59. Lombardo, B. & Eyre, C., 2011. Compassion fatigue: a nurse's primer. Online Journal of Issues in Nursing, 16(1), p. 3. Longo, J., 2007. Factors affecting registered nurses job satisfaction and intent to leave: doctoral thesis. Boca Raton: Atlantic University, p. 64. Peplau, H.E., 1991. Interpersonal relations in nursing: a conceptual frame of reference for psychodynamic nursing. New York: Springer, pp. 3–119. Perne, D., 2005. Uporaba Brøsetove lestvice za napoved nasilnega vedenja pacientov. Urgentna medicina – izbrana poglavja: zbornik. Dvanajsti mednarodni simpozij o urgentni medicini, Portorož, Slovenija, 15.–18. junij 2005. Ljubljana: Slovensko združenje za urgentno medicino, pp. 67–72. Peterka Novak, J., Bregar, B., Možgan, B. & Vajda, A., 2010. Dejavniki, ki povzročajo stres pri zaposlenih v psihiatrični zdravstveni negi. In: B. Bregar & J. Peterka Novak, eds. Kako zmanjšati stres in izgorevanje na delovnem mestu: zbornik prispevkov z recenzijo. Ljubljana: Zbornica zdravstvene in babiške nege Slovenije – Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, Sekcija medicinskih sester in zdravstvenih tehnikov v psihiatriji, pp. 24–29. Reininghaus, U., Craig, T., Gournay, K., Hopkinson, P. & Carson, J., 2007. The high secure psychiatric hospitals' nursing staff stress survey 3: identifying stress resistance resources in the stress process of physical assault. Personality and Individual Differences, 42(3), pp. 398–408. https://doi.org/10.1016/j.paid.2006.07.013 Nemec, U. & Čuček Trifkovič, K., 2017. / Obzornik zdravstvene nege, 51(1), pp. 9–23. 23 Rössler, W., 2012. Stress, burnout, and job dissatisfaction in mental health workers. European Archives of Psychiatry and Clinical Neuroscience, 262(2), pp. 65–69. https://doi.org/10.1007/s00406-012-0353-4 PMid:22926058 Schmiedel, V., 2011. Izgorelost: ko nas delo, družina in vsakdanjik izčrpavajo. Maribor: Mettis bukvarna, pp. 11–30. Thaler, D., 2007. Pomen supervizije pri oblikovanju poklicne distance. In: R. Trampuž, ed. Izgorevanje – stiska ali izziv: zbornik prispevkov, Ajdovščina, 24. marca 2007. Nova Gorica: Društvo medicinskih sester in zdravstvenih tehnikov, pp. 56–61. UC Regents, 2016. SPSS FAQ: What does Cronbach’s alpha mean? Available at: http://www.ats.ucla.edu/stat/spss/faq/alpha.html [22. 11. 2016]. Zeller, A., Hahn, S., Needham, I., Kok, G., Dassen, T. & Halfens, R., 2009. Aggressive behavior of nursing home residents toward caregivers. Geriatric Nursing, 30(3), pp. 174–187. https://doi.org/10.1016/j.gerinurse.2008.09.002 PMid:19520228 Weinberg, A. & Creed, F., 2000. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet, 355(9203), pp. 533–537. https://doi.org/10.1016/S0140-6736(99)07366-3 World Medical Association, 2013. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Journal of the American Medical Association, 310(20), pp. 2191–2194. Avaliable at: http://www.wma.net/en/20activities/10ethics/10h elsinki/DoH-Oct2013-JAMA.pdf [23. 11. 2016]. Cite as/Citirajte kot: Nemec, U. & Čuček Trifkovič, K., 2017. Stress among employees in psychiatric nursing. Obzornik zdravstvene nege, 51(1), pp. 9−23. https://dx.doi.org/10.14528/snr.2017.51.1.122