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Occupational stress and coping in community mental health workers McDaniel, Matthew Moses 2016

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   OCCUPATIONAL STRESS AND COPING IN COMMUNITY MENTAL HEALTH WORKERS by Matthew Moses McDaniel B.A., Simon Fraser University, 2007    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS in The Faculty of Graduate and Postdoctoral Studies (Counselling Psychology)    THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) March 2016  © Matthew Moses McDaniel, 2016  ii Abstract  Community Mental Health Workers (CMHWs) support clients facing mental health challenges through work within client communities.  This study examined self-efficacy, perceived stress, coping style, and burnout in CMHWs.  One hundred and one CMHW’s were recruited from three housing, public health, and community service organizations within Vancouver. Participants completed a survey containing The General Self-Efficacy Scale, The Perceived Stress Scale, The Brief COPE, and The Maslach Burnout Inventory. It was hypothesized that (a) self-efficacy will relate differently to perceived stress regarding years of experience, (b) burnout will be related to years of experience, (c) disengagement coping strategies will correlate positively with emotional exhaustion and depersonalization, (d) disengagement coping strategies will correlate negatively with personal accomplishment, (e) engagement coping strategies will correlate positively with self-efficacy and correlate negatively with perceived stress, and (f) males and females will differ in their pattern of coping with stress.  Results indicated that self-efficacy related differently to perceived stress regarding experience and burnout was not related to years of experience, but was related to age.  Disengagement coping strategies and engagement coping strategies correlated with related variables as hypothesized.  Males and females differed in their pattern of coping with stress. Results are discussed in relation to current literature.  Implications for future research and practice are suggested.       iii Preface This thesis is an original intellectual product of the author, M. McDaniel.  All research fieldwork was supervised by Dr. Colleen Haney.  All data collection and analysis was conducted by M. McDaniel, and covered by The University of British Columbia’s Behavioural Research Ethics Board Certificate number H-15-01913, entitled “Stress and Coping in Community Mental Health Workers”.                     iv Table of Contents Abstract……………………………………………………………….…………………ii Preface………………………………………………...…………………………………iii  Table of Contents………………………………………..………………………………iv List of Tables……………………………………………...…………………………….vii Acknowledgments………….………………………...……………………...…………viii Chapter 1: Introduction………………..………………………………………………..1 Chapter 2: Literature Review………...…………………………...………………….…4 2.1  Transactional Model…….……………………….………...…...………………....4  2.2  Perceived Stress.…..…………………………….…………….........……………..5  2.2.1  Specific Sources of Stress in Community Mental Health Workers..….......7 2.3 Coping Strategies.....………….………………………….……………………......8 2.4 Distress in Community Mental Health Workers…...…………………....……….11  2.4.1 Defining Burnout…...…………………..…………………….………….11  2.4.2 Coping Strategies and Burnout…...…...…..………….………………….13  2.4.3 Self-Efficacy and Burnout…...……..……………..….………………….15  2.4.4 Work Experience and Burnout…...…………..………….…….…………18 Chapter 3: The Current Study……………….………………………………….…….20 3.1 Research Questions………….……………………………………………..…….20 3.2 Hypotheses…………………………………………………………….…………20 3.3 Qualitative Questions……………………….………………………….………...21 3.4 Research Design………………………………………………………………….21  3.4.1 Population………………………………………………………………..22   v  3.4.2 Demographics……………………………………………………………22  3.4.3 Measures…………………………………………………………………22  3.4.4 Procedure………………………………………………………………...25  3.4.5 Data Analysis…………………………………………………………….26 3.5 Ethical Considerations..……...…………………………...……………………...26 Chapter 4: Results………………….…..……………………………………………….27 4.1 Demographics……………………………………………………………………27 4.2 Measures………..……………………………………………..…………………28 4.3 Hypothesis Testing..…………………………………...…………………………28 4.4 Qualitative Data.…………………………………….……...……………………33 Chapter 5: Discussion….………………………………………………...…..…………38 5.1 General Comments on Measures.…………...………………………………...…38 5.2 Hypothesis Discussion..………..…………………………..………….…………40 5.3 Limitations..…………………..…………………………..………………...……48 5.4 Implications..…………………..…………..……………..…………….…...……48  5.4.1 Research……………….…………….……...……………………………48  5.4.2 Practice…………………….……………...….……………......................49 References….………………………………...…………………………...…..…………52 Appendix A: Demographic………………………….……..………………………….…60 Appendix B: Correlations One to Four Years Experience…………….………...…….…61 Appendix C: Correlations Five Years or More…………...………..………………….…62 Appendix D: Correlations Male Participants…….………….……………………..….…63   vi Appendix E: Correlations Female Participants……….………..…………..………….…64 Appendix F: Correlations All Participants……….….…………..…………………….…65 Appendix G: Survey……………….……….….……………..…………….………....…66 Appendix H: Information and Consent Letter…..…..…………..…………………….…71                       vii List of Tables Table 1 Mean scores and standard deviations on all measures in total, by     gender, and by years of experience………..……………………………..28 Table 2 Correlations between burnout and disengagement coping scores….....…31 Table 3 Correlations between engagement coping, self-efficacy, and perceived    stress…………………….………………………………………………..32 Table 4 Categories and example responses for question one: “What have you    found to be the most helpful in responding to workplace stress?”…........34 Table 5 Categories and example responses for question one: “What have you    found to be the least helpful in responding to workplace stress?…..…....36 Table 6 Categories and example responses for question one: “If you could change    something to reduce stress in your workplace, what would it be?”….......37 Table 7 MBI Mean Scores, Standard Deviations, and Number of Participants by    Age…………………………………………………………….………....42  Table 8 Correlations between age of participant and burnout.……………….......42            viii Acknowledgments  I’d like to thank Dr. Colleen Haney, Dr. Marv Westwood, and Dr. Alanaise Goodwill for their excellent guidance and support throughout this project.  Thank you to the organizations that graciously allowed access to their work sites and workers: Coast Mental Health, Raincity Housing, and The Lookout Society.  Thank you to the workers for the work you do, and for donating your time to this project.  The listening ear and supportive words of so many of my fellow students was a blessing, thank you.  Beyond all other the unwavering and loving encouragement of Ava Storey saw me through.  I am grateful beyond words.                 1 Chapter 1: Introduction  Stress at work is an experience shared by many.  Stress at work has been linked to a number of negative outcomes including: depression, anxiety, sleep problems, impaired memory, neck and back pain, increased alcohol consumption, flu-like symptoms, gastroenteritis, absenteeism, job turnover, and increased dissatisfaction with work (Acker, 2010b; Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). Current theories explaining the stress people feel at work focus on person-environment goodness of fit, job strain, and the cumulative building up of multiple stress risks (Evans, Becker, Zahn, Bilotta, & Keesee, 2012).  Person-environment goodness of fit theory describes the interaction between a worker’s personal characteristics and their work environment conditions.  This interaction may be between a person’s desires concerning work, and the work’s ability to provide for those desires, or between the demands of the job and the person’s ability to meet those demands (Ivancevich & Matteson, 1984). According to person-environment theories job stress is not something inherent to the work environment, but rather the result of a poor fit between the worker and the work environment.  Job strain theories point at high workload demands and low job control as responsible for producing stress within workers.  Occupations which feature a high level of active demands on workers without also allowing those workers a high level of freedom over the use of time, skills, and decision making are likely to result in stress (Karasek, 1979).  Cumulative theories describe a number of low-to-moderate personal, social, and physical risk factors as building up and overflowing into work related stress (Evans et al., 2012).     2  According to person-environment, job-strain, and cumulative theories mental health work may be considered a high stress risk occupation. Mental Health Workers (MHWs) offer their professional services with the goal of improving their client’s mental health through the treatment of mental illness.  In doing this work MHWs face a work environment with high demands, low control, and risks to their personal, social, and physical health.  They experience high job demands without feeling valued for their work (Evans et al., 2006) and a frequently changing mental health care environment featuring low levels of support at work, and conflicted work expectations (Acker, 2011). They work in an often stigmatized field featuring difficult interactions with other mental health professionals and the community, low pay, and a high caseload of traumatized, demanding, violent and abusive clients (Buchanan, Anderson, Uhlemann, & Horwitz, 2006; Padyab, Ghazinour, & Richter, 2013; Ray, Wong, White, & Heaslip, 2013; Rössler, 2012).  Considering the risks present within their workplaces, opportunities for negative occupational stress outcomes are plentiful in mental health work.  Community Mental Health Workers (CMHW) are a subset of MHWs who work directly in their client’s communities.  CMHWs are often on the frontline of mental health work and though they face similar sources of stress to MHWs, they have been found to experience higher negative outcomes in response (Salyers, Rollins, Kelly, Lysaker, & Williams, 2013).  In comparison with MHWs, CMHWs are often subject to less funding, wage compensation, benefits, and training opportunities, but also more volatile client’s, higher workloads, and increased stigma (Edwards, Burnard, Coyle, Fothergill, & Hannigan, 2000; Salyers et al., 2013).  Researchers have suggested that while research on MHWs is plentiful, additional attention to those doing community   3 based work is needed. Vancouver contains a high concentration of CMHWs.  In a 2014 report the Vancouver Sun compiled a list of 260 agencies providing social services within the city’s downtown east-side community (Culbert & McMartin, 2014).  More than 100 of these agencies are housing providers, and 30 of them are public health care providers.  These agencies are staffed primarily by people doing community based mental health work.  This makes Vancouver an ideal place to research the experiences of CMHWs, and how best to support their work.  The purpose of this study is to examine the stress and coping experienced by CMHWs.  Despite potentially high levels of occupational stress, some people are able to maintain their role as CMHWs long term, and have found healthy ways of responding to the stressors inherent in their profession.  Using Lazarus and Folkman’s (1984) person-environment transactional model of stress and coping as a theoretical background, this study will examine the interactions between perceived stress, burnout, self-efficacy, and coping style.  An increased understanding of the sources of stress CMHWs are experiencing, how they cope with that stress, what level of distress they are feeling in response, how coping is related to gender, and what relationship years of experience has on stress and coping will be gained.  Demographic information about CMHWs will be recorded.  The findings provide valuable contributions to stress and coping literature and counselling practice.       4 Chapter 2: Literature Review  This literature review will begin with an overview of the transactional model of stress and coping, and continue through a review of the literature on perceived stress, coping, and distress as it relates to CMHWs.  Highlights include: perceived stress specific to CMHWs, a conceptualization of distress in mental health work (burnout), effectiveness of coping in regards to burnout, the relationship between self-efficacy and burnout, and the relationship between years of experience and burnout. 2.1 The Transactional Model of Stress and Coping Overview  Lazarus and Folkman’s (1984) transactional model of stress and coping describes the interaction between environmental stressors, the way in which people appraise those stressors, and the strategies used to cope.  This transactional model fits within the person-environment goodness of fit theory of occupational stress.  Stress is defined as a relationship between the environment and the person, in which the person appraises a situation as taxing, exceeding their resources, or endangering their well being (Lazarus, 1993).  A person must perceive a situation as containing stressors in order to feel stress.  Each person’s unique resources and skills have an effect on this assessment of stressors. The way in which a person appraises and responds, or copes, is neither inherently good nor bad, but may be more or less effective in any given situation.  Depending on the effectiveness of a person’s coping strategy they may experience more or less resulting distress (Lazarus & Folkman, 1984).  High levels of distress have been linked low mood, mental and physical health problems, and lower overall functioning (DeLongis, Folkman, & Lazarus, 1988; Holahan, Moos, Holahan, Brennan, & Schutte, 2005; Morse et al., 2012).  Perceptions of stress, coping strategy, and distress are the key elements in this   5 transactional model.  A review of these elements and how they relate to CMHWs will be described in the following sections. 2.2 Perceived Stress  Perceived stress refers to the degree to which events are appraised as stressful (Lazaras & Folkman, 1984).  Differences in the personal situation, history, skills, self-efficacy, and resources of each person affect the amount of stress they perceived an event as containing. As a result, the same event may be appraised as stressful to one person and not stressful to another.  In 2007, in order to explore the variability in perception of stressful events, a team of researchers conducted a large scale study on reactions to Hurricane Katrina (Leon, Hyre, Ompad, DeSalvo, & Muntner, 2007).  Six months after the hurricane, they gave 1542 (1010 female and 532 male) faculty, staff and administrators at a university in New Orleans a measure of perceived stress (The Perceived Stress Scale).  Scores ranged from 0 to 16 (the maximum possible range), with a standard deviation of 3.1.  As an example of this variability, in response to the question, “In the last month, how often have you felt confident about your ability to handle your personal problems?” 29.5% of respondents indicated “Very Often”, while 27% indicated “Sometimes”.  This is may be considered a substantial degree of variability.  Results of this study provide evidence for the theory that the degree of stress perceived varies from person to person.  Variability in the appraisal of stressful events has been found across numerous populations and environments (Lee, 2012), including those doing similar work and in similar environments to CMHWs (Sohn, Kim, Kim, & Han, 2006; Ting, Jacobson, & Sanders, 2011).   6  Sohn, Kim, Kim, and Han (2006) studied the perceived stress levels of 263 Health Care Workers who had been accidentally stuck with a hypodermic needle possibly carrying HIV, Hepatitis B, or Hepatitis C while providing care for their clients.  Participants completed the Perceived Stress Scale 10-Item Version and achieved an average score of 19.20 with a standard deviation of 3.20.  Participant scores and standard deviations varied across age, education, job title, and gender.  Results of this study indicated that health care workers experiencing a similar stressful event in a similar environment experienced varying levels of resulting perceived stress.  Ting, Jacobson, and Sanders (2011) looked at the perception of stress among 285 social workers that had come into contact with either fatal or non-fatal client suicidal behaviour.  Participants completed the Perceived Stress Scale 10-Item Version and obtained an average score of 13.42 with a standard deviation of 5.42 and range of 30.  Participant scores again varied over gender, age, ethnicity, and years in practice.  Results of this study again indicate a similar variability in the perception of stress by people doing mental health work, despite a similar stressful event and environment.  These results line up well with theory behind perceived stress in that participants with differing personal factors appraised a similar occupational event as containing differing levels of stress.  Those doing mental health work perceive stress with similar variability to the general population.  In order to understand the perceived stress levels of the population sample in the current study the Perceived Stress Scale was utilized.  The use of this measure allows for comparison and contrast with similar populations and previous studies.       7 2.2.1 Specific Sources of Perceived Stress in Community Mental Health Workers  Occupational events, demands, or pressures that may be perceived as stressful are termed “work place stressors.” These work place stressors provide an opportunity for the worker to appraise the situation as manageable or overwhelming depending on their own resources and perception of the stressor.  Work place stressors experienced by those doing mental health work include unclear expectations in the workplace (Lizano & Mor Barak, 2012), conflict with service users, coworkers and supervisors (Savaya, 2014), stigma in the field and low pay (Rössler, 2012), high workloads, and low training (Coffey, 2004).  Mental health work taking place in the community has been found to share stressors with work done in an institution, but in greater number and with increased resulting distress.  In 2013, Salyers et al. completed a study exploring the differences between mental health workers at an inpatient versus community setting (Salyers et al., 2013). The researchers gave 47 female and 19 male (N=86) Veterans Health Administration (VA) staff and 58 female and 28 (N=86) male Community Mental Health Center (CMHC) staff a survey containing measures of burnout (MBI) and job satisfaction (The Job Diagnostics Survey and the Consumer Optimism scale).  The VA staff worked in a medical center, while the CMHC staff worked in a community health center.  They found that the VA staff reported greater job satisfaction and accomplishment, less emotional exhaustion and less desire to leave their jobs than the CMHC staff. The staff in a community setting was less satisfied with their work, and showed more distress as measured in terms of burnout.  The authors suggest that greater funding, with better pay, benefits, and training opportunities for VA staff may be responsible for this difference. While this study has been criticized for it’s low sample size, the authors suggestions line   8 up well with a meta-review conducted by Edwards, Burnard, Coyle, Fothergill, and Hannigan in 2000.  This review included seventeen studies with an aggregated total of 2000 nurses working on community mental health teams.  These studies included measures of distress (The CPN Stress Questionnaire, The General Health Questionnaire, and The Maslach Burnout Inventory) and asked participants to identify the specific significant demands or pressures that they perceive as stressful.  Participants identified confusion around role and responsibility, a lack of supervision, increases in workload and administration, time management, inappropriate referrals, safety around volatile, violent and suicidal clients, and higher levels of client trauma as significant stressors in their workplaces.  The authors in both of these studies suggest that in order to best support CMHWs an increase in research looking at the challenges they face is needed.  This study seeks to respond to this suggestion through investigating what workers are finding stressful, and how they are responding to this stress. 2.3 Coping Strategies  Once a situation has been perceived as stressful a person chooses how to respond, and this response is defined as a coping strategy.  In 1980, Folkman and Lazarus undertook an exploration of the strategies people use in coping, and presented a measure cataloguing sixty-eight ways that a person may respond to a stressor (The Ways of Coping Checklist).  They broadly split the ways that people respond and cope into two categories: problem-focused and emotion-focused.  Problem-focused strategies seek to manage the source of stress while emotion-focused strategies seek to manage the resulting distress.  Examples of problem-focused strategies include, “Made a plan of action and followed it” and “Got the person responsible to change his or her mind.”   9 Examples of emotion-focused strategies include, “Tried to forget the whole thing” and “Accepted sympathy and understanding from someone.”  This measure was given to 100 community members.  The authors found that coping strategy employment is not limited to one strategy or type of strategy; rather, the majority of participants employed a combination of strategies.  In the presence of an event perceived to be stressful a person will use a variety of coping strategies, sometimes at the same time, in order manage the stressful event.  Seeking to refine the categorization of coping strategies presented by Lazarus and Folkman (1980), Tobin (1989) applied hierarchical factor analysis to an adaptation of the Ways of Coping Checklist.  Two hundred and eight males and three hundred and sixteen females (N= 524) completed the measure.  Two tertiary factors were found: Engagement and Disengagement, and four secondary factors: Problem Engagement, Emotional Engagement, Problem Disengagement, and Emotional Disengagement.  In this conceptualization Engagement strategies seek to address the stressor, problem solve, or make a change, while Disengagement strategies seek to distance physically or emotionally from the problem (Tobin, 1989).  Engagement approaches include problem solving, cognitive restructuring, expressing emotions, and seeking social support.  Disengagement approaches include problem avoidance, wishful thinking, self-criticism and social withdrawal.  This Engagement/Disengagement encapsulation of coping strategies is commonly utilized in studying coping, and will be used in this study.  Coping strategies are not considered to be inherently good nor bad, rather they are evaluated based upon their effectiveness in reducing distress.  In evaluating the effectiveness of coping strategies, researchers have found a general trend towards a   10 positive correlation between disengagement coping strategies and higher levels of distress.  To investigate the relationship between coping strategy and distress Glass et al. (2009) gave 228 adult survivors of Hurricane Katrina a measure of coping strategies (The Brief COPE) and measures of psychological distress and PTSD symptoms (The Brief Symptoms Inventory and The Impact of Event Scale-Revised) (Glass, Flory, Hankin, Kloos, & Turecki, 2009).  Participants who used disengagement coping strategies had higher levels of psychological distress and PTSD symptoms.  The relationship found between disengagement coping and distress was stronger than the relationships between any other variables included in the study.  These results suggest that the use of disengagement coping strategies is not an effective method in mitigating distress.   The strong relationship between distress and disengagement found by Glass et al. (2009) is borne out in research on Mental Health Workers.  Chang et al. (2007) administered surveys to 320 nurses.  These surveys contained a measure of workplace stress (The Nursing Stress Scale), coping strategy (The Ways of Coping Questionnaire), and both physical and mental health indicators (SF-36 Health Survey Version 2).  A strong positive correlation was found between escape-avoidance coping strategies and poor mental health.  Using stepwise regression, it was found that poor physical and mental health scores were predicted by escape-avoidance coping strategies.  Escape-avoidance falls within the disengagement categorization of coping strategies.  The results of this study indicate that among those doing work similar to Mental Health Workers a link between disengagement coping and distress exists.  In a similar study, Acker (2010) gave 591 social workers a measure of coping strategy (Problem Focused and Emotion Focused Coping Scales adapted from Lazarus and Folkman, 1988) and distress (The   11 Maslach Burnout Inventory).  A strong relationship between emotion-focused coping and distress was found.  The author describes emotion focused coping as escape and avoidance efforts.  This description lines up with the Disengagement category of coping strategies (e.g. problem avoidance, wishful thinking) and put the results of this study in line with similar past studies.  People doing mental health that are using more disengagement coping strategies also experience higher levels of distress.  Considering the strong link observed by research between disengagement coping strategies and distress, it is expected that the CMHW participants in this study will display a similar pattern of coping and distress. 2.4 Distress in Community Mental Health Workers  In mental health and helping work distress is conceptualized as Burnout (Maslach & Jackson, 1981).  Distress/Burnout is the long-term negative outcome of prolonged perceived stress.  This section will define Burnout and discuss three factors that have a relationship with Burnout: (a) the effectiveness of a chosen coping strategy, (b) a person’s self-efficacy, and (c) the amount of work experience a person possesses.  2.4.1 Defining Burnout.  Maslach and colleges defined Burnout as the manifestation of the feeling of being depleted of one’s resources, cynicism and detachment towards interpersonal relationships, and a lack of achievement and productivity (Maslach, Leiter, & Schaufeli, 2009).  These symptoms are categorized into three primary features: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA).  EE describes a loss of feeling, concern and energy.  DP describes negative or inappropriate attitudes towards clients, irritability, loss of idealism, withdrawal, and an increase of these symptoms over time.  PA describes a negative   12 response towards oneself and one’s personal accomplishments.  Aside from these three primary features, burnout has been associated with increased depression, anxiety, sleep problems, impaired memory, neck and back pain, alcohol consumption, flu-like symptoms, and gastroenteritis (Acker, 2010b; Peterson et al., 2008).     In a meta-review of burnout in mental health workers, Morse et al. (2012) found that across 4 studies with over one thousand participants, between 21 and 67% of mental health workers experience high levels of burnout.  Participants included CMHWs, directors of community mental health centers, social workers, and forensic mental health workers, and burnout was primarily measured using the MBI.  The most significant of the studies reviewed is Siebert's (2005) survey of 751 social workers.  Participants were given a 7-item version of the emotional exhaustion subscale of the Maslach Burnout Inventory.  Thirty-four percent of respondents scored above the high burnout threshold score of 16 on this modified subscale.  These results indicate that nearly 1 in 3 of the participants surveyed were experiencing a high level of Burnout.  This prevalence level has been found to be higher in populations doing community focused work.  In 1999, Webster and Hacket gave 151 CMHWs the Maslach Burnout Inventory.  Fifty-four percent of participants scored above the 21-point cutoff for high burnout on the emotional exhaustion scale, and 38% scored above the 9-point cut off for high burnout on the depersonalization scale.  These results indicate that 1 in 2 participants were highly emotionally exhausted, and 1 in 3 were experiencing high levels of depersonalization towards their clients.  The high prevalence levels found in these studies mark burnout as a common result of stress within mental health worker populations.   13  Burnout and negative stress outcomes have been found to be higher in CMHWs than in mental health workers (Edwards et al., 2000; Lasalvia et al., 2009; Prosser et al., 1996; Salyers et al., 2013).  The increased levels of burnout symptoms within CMHWs mark them as population in high need of researchers’ attention.  The research that does exist is inadequate to meet CMHW needs, and has been criticized as inconsistent and frequently suffering from methodological issues such as low response rates, low participant numbers, and inconsistent choice of dependent variables (Onyett, 2011).  This study will attempt to begin addressing this research need through large sample size, and the inclusion of coping and self-efficacy measures.   On an organizational level, burnout has been associated with reduced commitment and negative attitudes toward the employing organization, absenteeism, high turnover, job dissatisfaction, low staff group morale, sick leave, and reduced adherence to evidence based practices (Morse et al., 2012).  Burnout has been shown to increase worker’s negative feelings towards clients, resulting in distancing, rejection, and reduced service provided to clients (Holmqvist & Jeanneau, 2006).   Burnout takes out a large toll on people, organizations, and the mental health system as a whole.  Considering general estimates of Burnout prevalence within mental health work, it is expected that the CMHW population sample in this study will report high levels of burnout symptoms.  2.4.2 Coping Strategies and Burnout.  Researchers have observed a positive relationship between disengagement coping strategies and distress (see previous section within this lit review).  This association between disengagement coping strategies and distress is maintained in research on how coping affects Burnout.   14  Shin et al. (2014) completed a meta-analysis looking at the relationship between coping and burnout in healthcare, mental health, and service populations.  The researchers included 36 studies completed in North America, Europe, and China that utilized the Maslach Burnout Inventory, a measure of coping, and a correlation coefficient between the two.  Total participants numbered in the thousands.  Coping strategies were divided between problem focused and emotion focused with descriptions of these strategies matching problem focused into engagement strategies, and emotion focused into disengagement.  Results indicated that problem-focused coping correlated negatively, and emotion-focused coping correlated positively, with burnout.  This relationship held across all professions and work environments with the strongest (problem focused coping/burnout positive) relationship present amongst participants identifying as nurses.  This result is reflected in a similar study of social workers stationed primarily in a community setting (Gilla M Acker, 2010a).  The author gave 591 participants a survey containing measures of self-efficacy (MPSC), problem-focused coping strategies (The Problem-Focused Coping Strategy Scale), emotion-focused coping strategies (The Emotion-Focused Coping Strategy Scale), burnout (MBI), and somatic symptoms (flu-like symptoms and gastroenteritis).  The author describes emotion-focused coping as escaping/avoiding, putting these strategies in a disengagement category.  A relationship between emotion-focused (disengagement) coping and Burnout was found. The author noted that participants reporting lower levels of Burnout and high levels of self-efficacy also used less coping in general.  It is suggested that this may be due to participants reporting higher levels of self-efficacy perceiving less stress, and requiring less use of coping strategy.  The author (Acker, 2010a) suggests a study including   15 measures of self-efficacy, perceived stress, coping strategy, and distress as an area for future research.  As research has indicated higher levels of burnout in participants who use disengaging coping strategies, it is hypothesized that those within the CMHW population sampled in this study who report high disengagement coping use will also report higher burnout levels.  2.4.3 Self-Efficacy and Burnout. Self-efficacy is defined as a person’s judgment of their capability to organize and execute actions necessary to achieve desired goals (Bandura, 1982).  Self-efficacy is theorized to have an effect on the levels of stress and motivation people feel in taxing situations (Bandura, 1989).  This increase in self-efficacy may cause a person to perceive a stressor as a manageable challenge, rather than a distressing obstacle, and therefor approach that stressor with more effective engaging coping strategies.  In order to study how self-efficacy interacts with perceived stress and distress, Ventura et al. (2015) surveyed 460 schoolteachers (258 female and 202 male), and 596 (268 female and 328 male) users of information and communication technology (Ventura, Salanova, & Llorens, 2015).  Their survey contained a measure of self-efficacy (The General Self-Efficacy Scale), job demands (The Hindrance and Challenge Demand Scale), burnout (MBI), and engagement with work (The Utrecht Work Engagement Scale).  It was found that participants who reported high levels of self-efficacy also reported perceiving the demands of their work places as challenges to be overcome, rather than obstacles hindering their progress.  Those who reported low levels of self-efficacy also reported higher levels of hindering demands at work, and higher levels of   16 burnout.  The authors suggest this result as evidence that workers with high self-efficacy engage with stressors directly and are more effective in managing the distress they feel.  Similar results regarding the effect of self efficacy has been found in people doing mental health work.  Aftab et al. (2012) surveyed 40 female and 40 male physicians (N=80) who primarily work in hospitals. The survey contained a measure of burnout (MBI) and a measure of self-efficacy (The General Self-Efficacy Scale).  Participants reporting high levels of self-efficacy also reported low levels of burnout symptoms.  In other words, participants who perceived themselves as being capable of doing their job experienced less work related distress.  In a similar study, Acker and Lawrence (2009) surveyed 126 female and 14 male social workers (N=140) working primarily in a community setting. The survey included a measure of emotional exhaustion (MBI), role stress (The Role Conflict Scale), perceived self-efficacy (The Management Behavioral Health Care Provider Self-perceived Competence Scale (MPSC)), involvement with clients with severe mental illness (The Involvement with Clients with Severe Mental Illness scale), and social support in the workplace (The Social Support from Supervisor and Coworker scales).  Participants who reported high levels of self-efficacy also reported lower levels of role stress and symptoms of burnout.  Using hierarchical regression analysis self-efficacy was found to be a stronger predictor of burnout than client’s characteristics, workload, or social support.  Further investigating this self-efficacy relationship in mental health work, Acker completed 2 survey based studies (2010a, 2010b) with a sample of 590 (472 female and 118 male) social workers.  The first study (Acker, 2010b) looked at self-efficacy (MPSC), burnout (MBI), somatic symptoms (flu-like and gastroenteritis), involvement with clients with severe mental illness (The   17 Involvement with Clients with Severe Mental Illness Scale), social support (The Social Support from Supervisor and Co-workers Scales), and opportunities for professional development (The Opportunities for Professional Development Scale). Participants who reported higher levels of self-efficacy also reported lower burnout levels, and less somatic symptoms.  These results indicate a link between reduced burnout and increased self-efficacy.  The authors second study (Acker, 2010a) looked at self-efficacy (MPSC), problem-focused coping strategies (The Problem-Focused Coping Strategy Scale), emotion-focused coping strategies (The Emotion-Focused Coping Strategy Scale), social support at the workplace (The Social Support from Supervisor and Coworkers Scale), burnout (MBI), and somatic symptoms (flu-like symptoms and gastroenteritis).  Participants reporting high self-efficacy also reported lower levels of burnout, and somatic symptoms.  In addition, participants reporting high self-efficacy also used emotion focused coping strategies less often.  The description of emotion focused and problem focused coping strategies mirror disengagement and engagement coping strategy descriptions respectively.  These results indicate a link between increased self-efficacy and increased engagement coping strategies.  Both of these studies demonstrate links between high self-efficacy, distress/burnout, and selection of coping strategy in people doing mental health work.   Previous research has shown a negative relationship between self-efficacy, perceived stress, and distress.  It is expected that the CMHW population members sampled in this study will report relationships with self-efficacy that are similar to past research.   18  2.4.4 Work experience and burnout.  Early research on burnout found that as age and experience increase levels of burnout decrease (Maslach & Jackson, 1981).  In their original article Maslach and Jackson administered the Maslach Burnout Inventory to 1025 human service workers in a wide range of occupations.  Participants aged 17-29 scored an average of 3.52 on emotional exhaustion, 2.48 on depersonalization, and 4.90 on personal accomplishment.  Participants aged 59 and over scored 2.49 on emotional exhaustion, 0.78 on depersonalization, and 5.21 on personal accomplishment.  These results indicate that younger participants scored higher on depersonalization and emotional exhaustion, while older participants scored higher on the positive personal accomplishment subscale.  Participants from each age category reported higher burnout as that category increased in age.  It was theorized that burnout is likely to occur within the early years of one’s career, and therefor people with more years of experience have found effective ways to cope with job stresses and reduce burnout within themselves.  This explanation is in line with theory stating that as a person’s belief in their ability to do their job increases, their distress levels decrease (Bandura, 1989).   Current studies with populations doing mental health related work back up this early link between advanced age and reduced burnout.  Ray, Wong, White, and Heaslip (2013) gave 169 frontline mental health care professionals the Maslach Burnout Inventory (Ray et al., 2013).  While they did not report the participant’s mean scores according to experience in the field, they did report a significant negative correlation between experience and emotional exhaustion (r=-.19, p<.01).  As the authors describe frontline mental health care professionals as doing work similar to community mental health workers the results from this study suggest that mental health workers experience   19 reduced burnout as they gain experience in their profession.  Lizano and Mor Barak (2012) completed a three wave longitudinal study examining the effect of workplace demands on Emotional Exhaustion and Depersonalization (Lizano & Mor Barak, 2012).  335 Public Child Welfare Workers were given the Maslach Burnout Inventory at six-month intervals.  A negative correlation was found between years of experience at work and Emotional Exhaustion.  Using growth curve analysis and with all other variables constant, a one-unit increase in years of experience resulted in a decrease of 0.27 in Emotional Exhaustion scores.  The authors suggest that as the time workers have spent at work increases they either burnout and leave work, or adapt their coping to keep burnout at a manageable level.  This result suggests that workers with similar demands (the welfare of client’s in their home environment and community) experience a relationship comparable with other populations between burnout and years of experience. In Acker’s 2010 study (Acker, 2010b) 591 social workers in the New York area were given the Maslach Burnout Inventory.  The author in this study reported that younger and less experienced participants reported higher levels of depersonalization and lower levels of personal accomplishment.  This result indicates that those doing work similar to CMHWs display a pattern of experience and burnout that matches theory and early research.   Previous research has shown a link between increased age and burnout. It is expected that the CMHW population sample in this study will report a relationship between age and years of experience that is similar to past research.      20 Chapter 3: The Current Study  The purpose of the current study is to investigate stress and coping within a Community Mental Health Worker population. Six research questions and six hypotheses are proposed.  3.1 Research Questions  Research Question 1.  What is the stress level of participants as measured by the Perceived Stress Scale?  Research Question 2.  What levels of self-efficacy exist within the participants as measured by the General Self-Efficacy Scale?  Research Question 3.  How is self-efficacy related to perceived stress, coping strategy, and burnout symptoms?  Research Question 4.  What coping strategies are being utilized by this sample as measured by the Brief Cope?  Research question 5.  What burnout levels are present within the sample as measured by the Maslach Burnout Inventory?   Research Question 6.  How is coping strategy related to burnout as measured by the Brief Cope and the Maslach Burnout Inventory? 3.2 Hypothesis   Hypothesis 1.  Self-efficacy (as measured by the General Self-Efficacy Scale) will relate differently to Perceived Stress (as measured by the Perceived Stress Scale) depending on years of experience.  Hypothesis 2.  Burnout (as measured by the Maslach Burnout Inventory) will be related to years of experience.   21  Hypothesis 3.  Disengagement coping strategies will correlate positively with Emotional Exhaustion and Depersonalization as measured by the Brief Cope and Maslach Burnout Inventory.  Hypothesis 4.  Disengagement coping strategies will correlate negatively with Personal Accomplishment as measured by the Brief Cope and Maslach Burnout Inventory.  Hypothesis 5.  Engagement coping strategies will correlate positively with self-efficacy and correlate negatively with perceived stress as measured by the Brief Cope, General Self-Efficacy Scale and Perceived Stress Scale.  Hypothesis 6.  It is expected that males and females will differ in their pattern of coping with stress. 3.3 Qualitative Questions  Question 1.  What have you found to be most helpful in responding to workplace stress?  Question 2.  What have you found to be least helpful in responding to workplace stress?  Question 3.  If you could change something to reduce stress in your workplace, what would it be?  Responses to these questions will be used in discussion, and provide possible avenues for future exploration. 3.4 Research Design and Method  A cross sectional survey design was employed in investigating the research questions.   22  3.4.1 Population  One hundred and one participants were recruited from the employees of three non-profit mental health, housing, and public health organizations within Vancouver: Coast Mental Health, The Lookout Society, and Rain City Housing.  Inclusion criteria was those working directly with marginalized, addicted, or mental health challenged populations as housing, outreach, case management, safe injection site, and home support employees.  Job duties included: efficient, effective and professional response in crisis situations, taking notice of and responding to behaviour that may indicate de-compensation, maintain the cleanliness and security of residential sites, advocating with other service providers on behalf of clients, performance of first aid services, engendering a sense of community by getting to know all clients and engaging with them on a daily basis.   3.4.2 Demographics   Demographic information, including age, gender, ethnicity, education levels, length of employment, current position, and time spent within that position was submitted by participants.  3.4.3 Measures  The Perceived Stress Scale (PSS) was used to measure the amount of stress CMHWs perceive themselves to be under.  The PSS is a 14-item scale measuring the degree to which situations are appraised as stressful, and is the most commonly used scale in assessing the stressfulness of events (Sheldon Cohen, Kamarck, & Mermelstein, 1983; Leon et al., 2007).  The PSS contains 7 items considered negative, and 7 considered positive.  Examples of negative items include: In the past month, have often   23 have you “…been upset by something happening un-expectantly?” “…felt unable to control the important things in your life?” and “…felt that difficulties were piling up so high that you could not overcome them?”.  Examples of positive items include: in the past month, how often have you “…dealt successfully with day-to-day problems and annoyances?” “…felt that things are going your way?” and “felt on top of things?”.  Each item is rated on a five point Likert-type scale (0 = never to 4 = very often).  With a sample of 208 male and 299 female college students and members of a smoking cessation program (N=507) the PSS achieved a reliability coefficient of .85, test-retest of .85 and a correlates at .49 with the impact of life events (Sheldon Cohen et al., 1983).  The scale has previously been used to determine the perceived stress levels of mental health workers (Sohn et al., 2006).  The items will be edited to indicate an at work context (“In the past month have you been upset by something happening un-expectantly at work?”).  The General Self-Efficacy Scale (GSE) (Scholz, Doña, Sud, & Schwarzer, 2002) was used to measure the perceived self-efficacy of the population sample.  The GSE is a 10-item scale with responses made on a 4-point scale from 1 (not true at all) to 4 (exactly true).  Items include, “I am confident that I can deal efficiently with unexpected events”, and “When I am confronted with a problem, I can usually find several solutions”.  Scores are summed with a range of 10 to 40 with higher scores indicating higher self-efficacy.  In a sample of 180 male and 187 female Canadian participants (N=367) the GSE attained an item-total correlation of .88.  It is theorized that Self-efficacy is not age dependent, and is stable across time.  In addition the GSE correlates positively with optimism, and negatively with anxiety and depression.  The GSE has been modified to indicate a work   24 context in the past (Ventura et al., 2015).  Items will be similarly modified in this study, for example: “I am confident I can deal efficiently with unexpected events at work.”   The Brief Cope was used to identify which coping strategies the CMHW sample used.  The Brief Cope is derived from the longer COPE inventory and contains 28-items rated on a 4-point Likert scale (1 = I haven’t been doing this at all to 4 = I’ve been doing this a lot).  The scale contains 14 subscales of 2 items each allowing for categorization of coping strategy.  The 14 subscales are: Active Coping, Planning, Positive Reframing, Acceptance, Humor, Religion, Using Emotional Support, Using Instrumental Support, Self-Distraction, Denial, Venting, Substance Use, Behavioral Disengagement, and Self-Blame.  In a sample of 111 female and 57 male community residents that had been seriously affected by Hurricane Andrew (N=168), the Brief Cope achieved reliability coefficients above .60 for all subscales except Denial (.54) and Venting (.50) (Carver, 1997).    Brief COPE scales were combined into two coping strategy categories: Engagement Coping and Disengagement Coping.  This categorization is based upon the hierarchical factor analysis completed by Tobin (1989).  Tobin (1989) lists the following scales as loading onto Engagement Coping: Problem solving, Cognitive restructuring, Seeking Social Support, and Expressing Emotions. The Brief COPE equivalents are: Active Coping, Planning, Positive Reframing, Acceptance, Humor, Emotional Support, and Instrumental Support.  Tobin (1989) lists the following scales as loading onto Disengagement Coping: Problem avoidance, Wishful Thinking, and Self-criticism, and Social Withdrawal.  The Brief COPE equivalents are: Self-distraction, Denial, Substance use, behavioral disengagement, Venting, and Self Blame.  The Religion subscale was   25 divided between the Engagement and Disengagement according to theory.  The item, “I’ve been trying to find comfort in my religion or spiritual beliefs” was added to the Engagement category according to its active nature.  The item, “I’ve been praying or meditating” was added to the Disengagement category according to its passive nature.  The Maslach Burnout Inventory (MBI) was used to measure distress.  The MBI contains 22 items and three scales measuring emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) (Maslach & Jackson, 1981).  The frequency of each item is rated on a 6 point Likert type scale (0=never to 6=every day).   In a meta-analysis of 84 studies for reliability information for the MBI (Wheeler, Vassar, Worley, and Barnes (2011) a value of .87 was found for EE, .71 for DP, and .76 for PA.  The MBI has been used widely with a variety of populations and allows for normative score comparisons with similar populations.  3.4.4 Procedure  Letters were sent to target organizations containing information on the purpose and goals of the study, and requesting permission to proceed.  The researcher visited each organization’s work sites with survey packets and information on the study.  Survey packets included a cover letter with details about the study and a questionnaire.  In addition participants were provided with a separate sheet to indicate if they would like to receive information on the completed results of the study and/or be entered into a draw for one of three $10 Starbucks cards as a thank you for their participation.  Drop boxes were placed at each site to facilitate survey collection.  Participation was anonymous, and confidential.  Completed survey packages were collected, and drop boxes emptied, weekly for four weeks.    26  3.4.5 Data Analysis  Descriptive demographic data provides a valuable introduction to this subset of the MHW population.  Means and standard deviations are reported for each measure in relation to both gender and years of experience.  ANOVAs are used to explore relationships among the dependent variables (Perceived Stress, Self-Efficacy, Coping, and Burnout), years of experience, and the differences between male and female participants.  A correlation matrix is utilized to understand the relationships and patterns among the variables.  3.5 Ethical Considerations  Responses to the survey may be influenced by social desirability bias.  Despite confidentiality and anonymity, participants may have been wary of reporting actual levels of stress and distress.  To address this possible bias, it was made known to participants that the aim of this study is not to expose any individual’s confidential responses, but to explore the data as a group.   It is possible that in considering the stress, coping, and distress felt at work, participants experienced some distressing emotions within themselves.  In consideration of this possibility, the names of available staff supports and counselling resources were included within survey packets.  It is also possible that identifying the stress and coping experienced at work in the context of an attempt to improve conditions provided a valuable debrief opportunity for participants.      27 Chapter 4: Results 4.1 Demographics  A total of one hundred and sixty four packages were distributed to twenty-seven work sites belonging to three non-profit mental health, housing, and public health organizations within Vancouver, British Columbia.  One hundred and two packages were returned resulting in a 62.1% response rate. One survey package was incomplete and withdrawn from analysis. Sixty-two participants reported as female and 39 reported as male.  Thirty-seven percent of participants were between 20 and 29 years of age, 27% were between 30 and 39 years of age, 16% were between 40 and 49 years of age, and 20% were over 50 years of age.  Participants reported primarily as Caucasian (66.30%), with 17.9% reporting as Other, and the remaining as Indigenous (6.9%), South Asian (4%) and East Asian (5%).  The majority of participants had completed an undergraduate degree (58.4%). Eleven percent had completed a diploma or certificate alone, 10% had completed high school alone and 10% had completed a graduate degree. Nine percent did not indicate their education and 2% had not completed high school.  Five percent of participants had been working in the mental health field for less than a year, 42% had worked between 1 and 4 years, and 54% had worked for 5 years or more. Seventy-eight percent of participants had been in their current position less than 3 years, 10% had been in their current position for 3 to 6 years, 9% had been in their current position for 6 to 10 years, and 3% had been in their current position for more than 10 years.  A detailed description of the sample’s demographics is presented within Appendix A.     28 4.2 Measures  The mean scores for each measure in total, by gender and by years of experience are reported in table 1.  Table 1 Mean Scores and Standard Deviations on All Measures in Total, by Gender, and by Years of Experience.     Total Male Female 1 to 4 years 5 Years and Greater Mean SD Mean SD Mean SD Mean SD Mean SD PSS 23.45 7.92 23.44 8.45 23.45 7.64 24.24 8.27 23.11 7.89 GSE 31.94 5.17 32.29 5.20 31.73 5.18 30.69 5.20 32.78 5.10 EE 24.52 11.71 23.85 11.31 24.94 12.02 24.76 12.51 24.62 11.48 DP 9.18 6.50 10.05 7.11 8.63 6.08 9.96 6.77 8.94 6.34 PA 35.70 7.26 35.75 7.71 35.67 7.03 34.58 7.94 36.49 6.92 Engagement 39.03 7.91 38.91 9.06 39.11 7.17 38.69 8.27 39.34 7.95 Disengagement 24.79 6.34 24.86 5.91 24.74 6.65 24.41 6.04 24.77 6.50 Note. N = 101 PSS: Perceived Stress Scale. GSE: General Self Efficacy Scale. EE: Emotional Exhaustion. DP: Depersonalization. PA: Personal Accomplishment.  4.3 Hypothesis Testing  Hypothesis One.  The first hypothesis stated that self-efficacy will relate differently to perceived stress regarding years of experience.  Participants were divided into two categories: those with between one and four years experience, and those with five years experience or more.  Participants with less than one year of experience were removed from the analysis, as the number of participants was low (N=5) and those with less than a year of experience are learning what the job entails, and not yet understanding what is expected of them.     Participants with one to four years experience achieved a mean of 24.24 on the PSS and 30.69 on the GSE, while participants with five years experience or more scored 23.11 on the PSS and 32.78 on the GSE (Table 1).  A one-way ANOVA was conducted   29 to compare the effect of years of experience on PSS scores.  An analysis of variance showed that the effect of years of experience on PSS scores was not significant, [F (1, 94)=.462, p=.50].  A one-way ANOVA was conducted to compare the effect of years of experience on GSE scores.  An analysis of variance showed that the effect of years of experience on GSE scores was significant, [F (1, 94)=3.908, p=.05].  This result indicates that participants with 5 or more years experience experienced higher levels of self-efficacy than participants with one to four years of experience.    Correlation analysis showed a significant negative correlation between Self-Efficacy and Perceived Stress scores for participants with one to four years experience (r=-.551, p<0.01) and with five years experience or more (r=-.420, p<0.01) (Appendix B and C).  This result indicates that as Self-Efficacy increased Perceived Stress decreased for both groups.   Hypothesis Two.  The second hypothesis stated that Burnout will be related to years of experience.  Participants with one to four years experience reported mean scores of 24.76 on the Emotional Exhaustion subscale, 9.96 on Depersonalization, and 34.58 on Personal Accomplishment (Table 1).  Participants with five years experience or more reported mean scores 24.62 on the Emotional Exhaustion subscale, 8.94 on Depersonalization, and 36.94 on Personal Accomplishment (Table 1).  This result indicates that participants with one to four years experience reported higher levels of Emotional Exhaustion and Depersonalization, and lower levels of Personal Accomplishment than participants with five years experience or more.  One-way ANOVAs were completed to compare the effects of years of experience on Emotional Exhaustion, Depersonalization, and Personal Accomplishment.  An analysis of variance   30 showed that the effect of years of experience on Emotional Exhaustion [F (1, 94)=.00, p=.95], Depersonalization [F (1, 94)=.57, p=.45], and Personal Accomplishment [F (1,94)=1.59, P=.210] was not significant.  These results indicate that while participants with one to four years experience reported higher levels of Burnout, the difference between their scores and the scores of participants with five years of experience or more was non-significant.    Hypothesis Three.  The third hypothesis stated that Disengagement coping strategies will correlate positively with Emotional Exhaustion and Depersonalization.  Correlational analysis showed a positive relationship between Disengagement coping and EE scores (r=.423, p<0.01) and between Disengagement and DP scores (r=.518, p<0.01) (Table 2). This result indicates that using more Disengagement coping strategies, such as denial or substance abuse, was related to more Emotional Exhaustion and Depersonalization.             31 Table 2 Correlations between Burnout and Disengagement Coping Scores.  EE DP PA Disengagement EE  1 .707** -.498** .423** DP   1 -.545** .518** PA    1 -.364** Disengagement     1      Note: N = 101 **p < 0.01 EE: Emotional Exhaustion DP: Depersonalization PA: Personal accomplishment.   Hypothesis Four.  The fourth hypothesis stated that Disengagement coping strategies will correlate negatively with Personal Accomplishment.  Correlational analysis showed a negative relationship between Disengagement coping and Personal Accomplishment scores (r=-.36, p<0.01) (Table 2).  This result indicates that more disengagement coping strategies are related to experienced less personal accomplishment and confirm hypothesis four.  Hypothesis Five.  The fifth hypothesis stated that Engagement coping strategy scores will correlate positively with Self-Efficacy scores and correlate negatively with Perceived Stress scores.  Correlational analysis showed a positive relationship between Engagement coping strategies and Self-Efficacy scores (r=.31, p<0.01) (Table 3).  This result indicates that participants using engagement coping strategies, such as planning or instrumental support, also scored high on Self-Efficacy.  Correlational analysis showed a non-significant relationship between Engagement coping strategies and PSS scores (r=-  32 .19, p=0.61) (Table 3).  This result does not indicate a relationship between reported Engagement coping strategy scores and PSS scores. Table 3 Correlations Between Engagement Coping, Self-Efficacy, and Perceived Stress.   Engagement GSE PSS Engagement  1 .306** -.187 GSE   1 -.469** PSS     1     Note: N = 101 ** p < 0.01 GSE: General Self-Efficacy PSS: Perceived Stress Scale.    Hypothesis Six.  The sixth hypothesis stated that males and females will differ in their pattern of coping in response to stress.  Mean scores on all measures divided by gender are reported in Table 1.  No significant differences in reported means between genders was found.  All significant correlations between variables were similar in direction across gender (Appendix D, Appendix E).  A difference in the significance of correlations between variables across genders was found in six instances.  Females participants reported significant correlations while males did not between the following variables: Perceived Stress and Engagement coping strategies (negative relationship), Self-Efficacy and Engagement coping strategies (positive relationship), Emotional Exhaustion and Engagement coping strategies (negative relationship), Personal Accomplishment and Engagement coping strategies (positive relationship), and Self-Efficacy and Emotional Exhaustion (negative relationship).  Males reported a significant relationship between Self-Efficacy and Disengage coping strategies (negative relationship) while females did not.  See Appendixes D and E.    33 4.4 Qualitative Data  Qualitative data were analyzed and grouped into categories. An independent investigator provided a category check.  There was 91% agreement between investigators. Amendments were discussed until consensus was achieved.   Question One.  Question one was, “What have you found to be the most helpful in responding to workplace stress?”  Response categories included self-care (N=48), Social Support (35), and Other (N=12) (Table 4).   An example of the self-care category is, “Finding balance in my life with other opportunities—yoga, time with friends, running, weekend getaways.”  An example of the social support category is, “Being able to debrief or talk about what has happened, having coworkers to discuss and brainstorm with.”  An example of the other category is, “A secure office.”               34 Table 4 Categories and example responses for question one: “What have you found to be the most helpful in responding to workplace stress?” Category N   (%) Responses Self-Care 48  (51%) -Finding balance in my life with other opportunities—yoga, time with friends, running, weekend getaways. -Talking and self-care. Family, walks in the woods. -Meditation and buddhist study. Compassion. Leaving work at work. Letting shit go. Exercise.  Social Support 35   (37%) -Being able to debrief or talk about what has happened, having coworkers to discuss and brainstorm with. -Support from co-workers and management. -Discussing with it with colleagues and sharing similar situations. Other 12  (13%) -A secure office.   Question Two.  Question two was, “What have you found to be least helpful in responding to workplace stress?  Response categories included: internalization/avoidance (N=36), negative interactions with coworkers (N=35), substance use (n=9), and other (N=20) (Table 5).  An example of the internalization/avoidance category is, “Thinking about it constantly, without doing anything about it.”  An example of the negative   35 interactions with co-workers category is, “Paying attention to the people at work around me who think negatively, poorly, and not optimistic about situations.”  An example of the substance abuse category is, “Drugs and Alcohol.”  An example of the other category is, “Frustrating, arguing, trying to be reasonable with clients who are in denial.”                      36 Table 5 Categories and example responses for question one: “What have you found to be the least helpful in responding to workplace stress?” Category N  (%) Responses Internalization/Avoidance 36 (36%) -Thinking about it constantly without doing anything about it. -Pretending it doesn’t exist on my time off but then I end up thinking about it more. -Living with it and keeping things to yourself. Negative Interactions with Coworkers 35  (35%) -Paying attention to the people at work around me who think negatively, poorly, and not optimistic about situations. -Non-receptive colleagues. -Venting in negative ways that just get me more wound up. Substance Use 9  (9%) -Drugs and Alcohol. -Drinking too much. Partying or attempting to party the stress away. -Substances. Other 20 (20%) -Frustrating, arguing, trying to be reasonable with clients who are in denial.       37  Question Three.  Question three was, “If you could change something to reduce stress in your workplace, what would it be?” The most dominant categories of response were: management support, and staffing.  An example from the management support category is, “More communication between staff and management, better chances to debrief.”  An example from the staffing category is, “More staff to help share the bad.”  Table 6 Categories and example responses for question one: “If you could change something to reduce stress in your workplace, what would it be?” Category N  (%) Responses Management Support 44 (41%) -More communication between staff and management, better chances to debrief. -More management support in solving problems. More immediacy in solving problems. -More direction from management/admin and clear guidelines. Less inconsistency. Staffing 35 (36%) -More staff to help share the bad. -More pay/time off. -I would include more training and education. Other 17 (18%) -Not worrying about my client so much that sometime it worries me.       38 Chapter 5: Discussion  The purpose of this study was to investigate the occupational stress and coping of Community Mental Health Workers within Vancouver.  A comparison of relevant participant mean scores with similar populations and cut offs, and the results of hypotheses testing will be discussed in the following section. 5.1 General Comments on Measures  As Community Mental Health Workers are an under-researched population (Morse et al., 2012) and there are no known studies on the specific Community Mental Health Worker population in Vancouver sampled by the current study, discussion regarding how the current sample compares with similar populations and measure cut offs is warranted.  Perceived Stress was measured by the Perceived Stress Scale 14 item version (PSS) (Sheldon Cohen et al., 1983).  The PSS does not produce cut offs for levels of Perceived Stress (low, medium, high), but does allow for comparison with other populations.  Participants in the current study reported a mean score of 24.45 (Table 1).  This score is higher than the American normative sample reported by the measure’s authors (19.62 N=2387) (Cohen & Williamson, 1988) and indicates that the current study participants are experiencing higher than normal levels of Perceived Stress.    Self-Efficacy was measured by the General Self-Efficacy Scale (GSE) (Scholz et al., 2002).  The GSE does not produce cut offs for levels of Self-Efficacy (low, medium, high), but does allow for comparison with other populations.  Participants in the current study reported a mean score of 31.94 (table 1).  This score is similar to the score attained by measure’s authors using a Canadian sample (31.19, N=367) (Scholz et al., 2002) and   39 indicates that the current study participants are experiencing levels of Self-Efficacy similar to other populations.   Burnout was measured by the Maslach Burnout Inventory (Maslach & Jackson, 1981).  The measure’s authors created low, medium, and high cut offs using an American normative sample (N=11067) (Maslach, Jackson, & Leiter, 1996).  Participants in the current study reported means of 24.52, 9.18, and 35.70 on the Emotional Exhaustion, Depersonalization, and Personal Accomplishment subscales respectively (table 1).  This puts participants in the current study within the high Burnout range regarding Emotional Exhaustion and Depersonalization (high range cut offs: EE>21, DP>8), but in the medium range regarding Personal accomplishment (medium range: PA>28). Similar populations have reported corresponding high levels of Emotional Exhaustion and Depersonalization with medium levels of Personal Accomplishment.  A sample of 460 American mental health service providers reported means of 19.64, 5.42, and 39.16 on the Emotional Exhaustion, Depersonalization, and Personal Accomplishment subscales respectively (Acker, 2008).  A sample of 123 women’s shelter workers reported means of 18.23, 4.82, and 37.22 on the Emotional Exhaustion, Depersonalization, and Personal Accomplishment subscales respectively (Baker, O’Brien, & Salahuddin, 2007).  A sample of 151 American Community Mental Health workers reported means of 23.20, 7.10, and 40.30 on the Emotional Exhaustion, Depersonalization, and Personal Accomplishment subscales respectively (Webster & Hackett, 1999).  It has been previously suggested that the act of helping those in need may be responsible for the relatively higher levels of Personal Accomplishment (Baker et al., 2007).  A participant in the current study responded that “taking pride in my work, doing my best, and shining   40 bright” was the most helpful at work.  It is possible that even when feeling disconnected from clients and emotionally exhausted the satisfaction generated through altruistic work prevails.  5.2 Hypothesis Discussion  Hypothesis One.  The first hypothesis was that Self-Efficacy will relate differently to Perceived Stress regarding years of experience.  A significant difference was found between each group’s reported GSE scores with workers with 5 years of experience or more reporting a higher GSE mean.  In addition, both groups reported a significant negative relationship between Self-Efficacy and Perceived Stress.The relationship between Self-Efficacy and Perceived Stress discovered by the current study matches the results of previous research on those doing mental health work (Acker, 2010a; Aftab, Shah, & Mehmood, 2012; Ventura et al., 2015).  These studies administered measures of Self-Efficacy and Perceived Stress/Distress to participants and discovered a negative relationship similar to the relationship found by the current study.  The significant difference in reported GSE means between more experienced and less experienced workers found by the current study is in line with theory stating that Self-Efficacy increases with years of experience, and that this increase in Self-Efficacy decreases stress levels (Bandura, 1989; Maslach & Jackson, 1981).  Maslach and Jackson (1981) further theorize that it is possible that those who do not find self-efficacious ways of coping with stress become overwhelmed and leave their jobs before the five-year mark.  This explanation may apply to the current population sample; a future study investigating CMHW’s reasons for leaving the profession could assist in confirming this   41 line of reasoning.  The results of this hypothesis represent a novel contribution to the literature in that the effect of years of experience in CMHWs is an under-researched area. Hypothesis Two.  The second hypothesis was that Burnout will be related to years of experience.  Participants with five years of experience or more reported higher levels of Burnout, but the analysis of variance did not find a significant difference between the means.  This finding is not in line with previous research and theory regarding the interaction between experience and burnout.  In comparing the relationship between years in the profession and MBI results Ray, Wong, White, and Heaslip (2013) found a significant negative relationship between experience and Emotional Exhaustion in a similar population.  Similarly, using a longitudinal design Lizano and Mor Barak (2012) found a significant negative relationship between Emotional Exhaustion and experience.  Finally, Maslach and Jackson’s (1981) original article found that as age of participant increased reported burnout levels decreased.    Based upon Maslach and Jackson’s (1981) findings, a post hoc mean, variance, and correlational analysis was completed to examine the relationship between participant age and burnout.  Participants were separated into age categories by decade as in Maslach and Jackson’s study. Participant Emotional Exhaustion and Depersonalization means were found to decrease as age increased, while Personal Accomplishment means increased as age increased (table 7).  One-way ANOVAs were conducted to compare the effect of age on Burnout subscale scores.  Analysis of variance showed that the effect of age on Emotional Exhaustion [F (3, 96)=3.47, p=.02], Depersonalization [F (3, 96)=4.01, p=.01], and Personal accomplishment [F (3, 96)=2.66, p=.05] was significant.  Correlational analysis found a significant negative relationship between age and   42 Emotional Exhaustion (r=-.31, p<0.01) and Depersonalization (r=-.29, p<0.01), and a significant positive relationship between age and Personal Accomplishment (r=.20, p<0.05).  These results indicate that as age of participants increased burnout levels decreased, and is in line with Maslach and Jackson’s (1981) original finding.  Table 7  MBI Mean Scores, Standard Deviations, and Number of Participants by Age.   20-29 30-39 40-49 50+ Mean SD N Mean SD N Mean SD N Mean SD N EE 27.82 10.88 37 26.07 11.47 27 23.25 11.20 16 18.10 11.66 20 DP 10.87 6.62 37 10.81 6.97 27 5.88 2.99 16 6.80 6.26 20 PA 33.46 6.63 37 36.07 7.61 27 39.31 7.26 16 36.24 7.18 20 Note. EE: Emotional Exhaustion, DP: Depersonalization, PA: Personal Accomplishment  Table 8 Correlations between age of participant and burnout.  Age EE DP PA Age  1 -.305** -.288** .198* EE   1 .707** -.498** DP    1 -.545** PA     1      Note: N = 101 **p < 0.01 *p < 0.05 EE: Emotional Exhaustion DP: Depersonalization PA: Personal accomplishment Experience: years of experience.    The results of this study have indicated that age is significantly related to Burnout, but years of experience are not.  A possible explanation for the lack of significant relationship found between years of experience and Burnout may be the number of participants included.  Participant Burnout means did increase with years of experience as expected by theory and past research and theory, and it is possible that with more   43 participants this increase would be significant.  Another possibility is that the experience workers are gaining is not positive experience.  This experience is not adding to their ability to more effectively cope with workplace stress.  Perhaps older workers are bringing an effective wisdom and richness learned through a lifetime to their interaction with work place stressors.  A follow up study including a larger sample and utilizing a longitudinal design is suggested in order to further investigate the relationship between experience, age, and Burnout in Community Mental Health Workers.  Tracking of participants who leave their profession would increase understanding of how burnout and age/experience interact.  A measure that provides information on the life experience of participants would provide a contract between age and experience.   Hypothesis Three.  Hypothesis three stated that Disengagement coping strategies will correlate positively with Emotional Exhaustion and Depersonalization. Correlational analysis showed positive relationships between Disengagement coping strategies and Emotional Exhaustion, and Disengagement coping strategies and Disengagement and confirmed this hypothesis.  This finding matches those observed by Acker (2010a), in which the author studied the use of coping strategy and Burnout.  The finding showed a positive relationship between Disengagement coping and Burnout in a sample of American Social Workers.  This finding is also supported by the results of a meta-analysis completed by Shin et al. (2014) in which across 36 studies Disengagement coping strategies were found to correlate positively with Burnout. The results of the current study provide further evidence for the links between Disengagement coping strategies, Emotional Exhaustion, and Depersonalization.  The Community Mental Health Worker participants sampled in the current study related disengagement coping   44 strategies, emotional exhaustion, and depersonalization in similar ways to previously studied populations.  Interestingly, qualitative data gathered in the current study generated a similar theme; the most common response category to the qualitative question, “What have you found to be least helpful in response to workplace stress?” was Internalization/Avoidance.  Specific participant responses included,  “Thinking about it constantly, without doing anything about it.”, “Pretending it doesn’t exist on my time off but then I end up thinking about it more.”, and “Avoidance.”.  Hypothesis Four.  Hypothesis four stated that Disengagement coping strategies will correlate negatively with Personal Accomplishment. Correlational analysis found a negative relationship between Disengagement coping strategies and Personal Accomplishment (table 2), and provided confirmation for this hypothesis.  The results of the current research match those found by Acker (2010a) in which a negative relationship was found between Personal Accomplishment and Disengagement coping strategies in a sample of American Social Workers.  The results is also supported by the meta-analysis completed by Shin et al. (2014) in which Disengagement coping strategies was found to be related to less Personal Accomplishment across 36 studies on healthcare, mental health, and service populations.  The results of the current study provide further evidence for the link between Disengagement coping strategies and a reduced sense of Personal Accomplishment.    Hypothesis Five.  Hypothesis five stated that Engagement coping strategies will correlate positively with Self-Efficacy and correlate negatively with Perceived Stress.  Correlational analysis showed a significant positive relationship between Engagement   45 coping strategies and Self-Efficacy, but no significant relationship between Engagement coping strategies and Perceived Stress (table 4).    Participants in the current study that reported high levels of Self-Efficacy were more likely to report the use of Engagement coping strategies.  High Self-Efficacy is theorized to increase the likelihood that a person will perceive a stressor as a manageable change (Bandura, 1989), and actively approach and engage with the stressor.  Matching the current study’s finding is the positive relationship between Self-Efficacy and Engagement strategies found by Ventura et al. (2015).  Further support for this finding is provided by Acker’s (2010a) study linking high Self-Efficacy and increased Engagement coping strategies in a population of American Social Workers.    As high Self-Efficacy has been found to increase the likelihood of a stressor being perceived as a manageable challenge (Ventura et al., 2015), it was hypothesized that if there was a positive relationship between Self-Efficacy and Engagement coping strategies there would also be a negative relationship between Engagement coping strategies and Perceived Stress.  Though the current study did not find a significant relationship between Perceived Stress and Engagement coping strategies, the direction of the non-significant correlation was negative as expected.  It is possible that with a larger sample size this relationship may become significant.   Hypothesis Six.  Hypothesis six stated that a difference in the pattern of coping between males and females is expected.  There were no significant differences in the reported means between genders.  This finding matches the results of a meta-analysis reviewing 183 studies and including participants across a large variety of occupations including but not limited to those doing mental health work in which no major difference   46 was found in Burnout levels across gender (Purvanova & Muros, 2010).  The comparison of the current finding with previous gender related findings in Community Mental Health Workers specifically is limited by a lack of reporting regarding gender differences.  Perhaps reflecting a disparity between the number of females versus males working in the field, the population sampled in previous studies has often been above 80% female (Acker, 2010b; Baker et al., 2007; Strozier & Evans, 2010; Travis, Lizano, & Barak, 2015).  As Acker (2010b) suggests, a largely homogenous sample makes gender comparisons difficult.  Despite this difficulty, researchers continue to highlight the need for exploration of gender differences regarding stress, coping, and mental health work (Onyett, 2011; Shin et al., 2014).  The findings of this study represent a response to this need.   While no difference in significance of measure means was found, differences in the significance of correlations between certain variables were found.  Males did not report any significant correlations with Engagement coping strategies while females reported a significant relationship between Engagement coping and all variables except for Depersonalization (Appendix D, Appendix E).  This result suggests that males may not be using Engagement coping strategies in a way that correlates with any other variables.  It is possible that males feel less comfortable engaging with and talking about the stress they perceive at work.  As a result their use of engagement coping strategies may not be following a pattern discernable within this study.  It is also possible that with more male participants a significant relationship between Engagement coping and other variables would be discovered.    47  Male participants reported a significant negative relationship between Self-Efficacy and Disengagement coping strategies (Appendix D).  This result suggests that when experiencing high levels of Self-efficacy males may also be using less Disengagement coping.  Female participants reported a significant negative relationship between Self-Efficacy and Emotional Exhaustion.  This result suggests that when experiencing high levels of Self-Efficacy females may also experience less Emotional Exhaustion.  It is possible that this result is illuminating a difference in the way males and females interact with Self-Efficacy.  However, as with the non-significant Engagement coping strategy correlations reported by male participants, it is possible that with a larger sample size this difference in significance found between these variables across gender may be reduced.  It is interesting to note that though the relationships were not significant, the correlations between Engagement coping strategies and both Emotional Exhaustion and Depersonalization were reported in the opposite direction across gender (Appendix D, Appendix E).  Males reported positive relationships between Engagement coping and both Emotional Exhaustion and Depersonalization while Females reported negative relationships.  Lack of significance prevents any conclusions from being drawn about this difference in direction of relationship, however it would be of value to discover if the direction of these relationships gain significance with a larger sample size.   In general, the result of the current study would be strengthened, and differences in significance would be best tested through future study with a larger sample size.     48 5.3 Limitations  Though steps to assure participants that survey responses are confidential and anonymous, a social desirability bias may have caused an under-reporting of accurate stress and coping levels. Additionally, the lack of significance among certain variables may have been due to the sample size and lack of equal numbers across years of experience, and male and female participants.  It is possible that a larger sample containing equal diversity regarding experience and gender may have resulted in more variability within the data.   5.4 Implications   5.4.1 Research  The current research meets the suggestion made by Acker (2010a) that the inclusion of a measure of Perceived Stress would allow for a closer look at how Self-Efficacy and coping strategy selection relate to each other.  The current finding that Self-Efficacy is negatively correlated with perceived stress and positively correlated with Engagement coping strategies in Community Mental Health Workers could be extended upon through a follow up study of longitudinal design.  This design would allow for investigation of the long-term interactions between Self-Efficacy, Perceived Stress, and coping strategy selection, as well as the implications of this interaction on the experience of Burnout.  A better long-term understanding of this interaction would allow for the design of more effective Burnout interventions.  The current research also meets the suggestion by Salyers et al. (2013) that more research is needed into the stress faced by CMHWs, and how they meet this stress.  Two   49 of the current findings meet this need and suggest further research directions. They are: age/experience, and gender difference.  The current study found that Self-Efficacy increases with age/experience, and that there is a negative correlation between Self-Efficacy and both Perceived Stress and Burnout.  This finding is backed up by previous research (Acker, 2010a; Aftab, Shah, & Mehmood, 2012; Maslach & Jackson, 1981; Ventura et al., 2015) and points to the need for a longitudinal study investigating contributions to the increase in Self-Efficacy and decrease in Perceived Stress/Burnout. Tracking of workers who leave the profession during this study would add valuable information on the cause of their departure and its possible connection with stress and coping.  An understanding of how these variables are connected in long terms would allow for improved Self-Efficacy and Burnout interventions.  The current study found no significant relationship between engagement coping and other variables in male participants.   This suggests a possible difference in the way that males utilize engagement coping and warrants further study.  A qualitative study focusing on how and why males use engagement would provide valuable insight on how to best support engagement within males.  In addition, a similar study with a larger population sample containing more equal numbers of male and female participants would allow for further investigation of these non-significant correlations.  5.4.2 Practice  Several suggestions for practice spring from the current findings. The finding that workers reporting higher Self-Efficacy also reported less Perceived Stress and more    50 Engagement coping strategy use speaks to the need for support that raises worker’s Self-Efficacy.  The opportunity for regular training and development could aid in raising Self-Efficacy among workers.  This suggestion matches the qualitative participant suggestion that “more training and education” would help reduce stress.   The finding that a relationship exists between age/experience, Self-Efficacy, Perceived Stress, and Burnout reveals a strong resource in workers with age/experience.  The implication that experienced workers have found adaptive ways to cope with stress mark them as potential mentors for younger and less experienced workers.  Counsellor assistance in setting up programs that pair older and more experienced workers with those that are younger and newly hired under a peer-supervision model would allow for the utilization of this human resource.  Further, counsellor assistance in the creation of debriefing groups that mix workers across age/experience would allow for additional support.  This suggestion is in line with the qualitative identification of social support as most helpful in responding to workplace stress.  Having masters level counsellors and counselling students lead these groups would assist in maintaining a positive debriefing environment.  Training older workers to provide peer leadership within these groups over time would empower workers to support themselves, and prevent prohibitive financial support costs.  In general, future research on the culture of support in community mental health work places with a focus on how to practically assist in this support is needed.  Tracking stress and coping levels within workers during the creation and maintenance of mentorship and group debriefing programs would allow for continued tailoring of these programs to workers’ needs.   51  The finding of a possible difference in the way that males utilize engagement coping strategies suggests that the development of support strategies taking into account client gender may be needed.  The creation of counsellor led training programs that take into account the possible difference in use of engagement between genders would assist in this regard.  Framing engagement in language and concepts that males feel most comfortable with according to a cross-cultural framework may assist in providing these training programs.  The results of a future explorative qualitative study focused on engagement coping within males would best inform these approaches.  Approaches that help males feel more comfortable speaking about their experiences with stress, and increase their engagement with stressors, may ultimately assist males in effectively managing stress.    This research provides valuable demographic information on the Community Mental Health Worker population in Vancouver, as well as what levels of Perceived Stress, Self-Efficacy, and Burnout exist, and what coping styles are being used in responding to this Perceived Stress.  This information may be used by the organizations employing these workers in improving work place conditions and supports.           52 References Acker, G. M. (2008). 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Educational and Psychological Measurement, 71(1), 231–244. doi:10.1177/0013164410391579                      60 Appendix A: Demographics   N Percent Gender Male 39 38.6% Female 62 61.4% Age 20-29 37 37.0% 30-39 27 27.0% 40-49 16 16.0% 50+ 20 20.0% Ethnicity Caucasian 67 66.3% Indigenous 7 6.9% South Asian 4 4.0% East Asian 5 5.0% Other 18 17.8% Education High School 10 9.9% Some High School 2 2.0% Undergrad 59 58.4% Graduate School 10 9.9% Diploma or Certificate 11 10.9% Not Indicated 9 8.9% Time Spent in Current Position Less than 3 Years 78 78.0% 3 to 6 Years 10 10.0% 6 to 10 years 9 9.0% More than 10 Years 3 3.0% Years of Experience 1 to 4 Years 42 41.6% 5 Years or More 54 53.5% Less than 1 year 5 5.0%                 61 Appendix B: Correlations Between all Variables for Participants with One to Four Years Experience.   PSS GSE EE DP PA Engagement Disengagement PSS  1 -.551** .742** .684** -.685** -.397** .611** GSE   1 -.521** -.510** .553** .398** -.424** EE    1 .814** -.762** -.523** .568** DP     1 -.661** -.355* .687** PA      1 .456** -.518** Engagement       1 -.089 Disengagement        1         Note: N = 42 ** p < 0.01 * p<0.05 PSS: Perceived Stress Scale GSE: General Self-Efficacy EE: Emotional Exhaustion DP: Depersonalization PA: Personal Accomplishment.                         62 Appendix C: Correlations Between All Variables for Participants With Five Years Experience or More.   PSS GSE EE DP PA Engagement Disengagement PSS   1 -.420** .635** .393** -.321* -.027 .277* GSE    1 -.339* -.270* .461** .228 -.185 EE     1 .612** -.256 .128 .355** DP      1 -.426** .168 .454** PA       1 .148 -.282* Engagement        1 .450** Disengagement        1         Note: N = 54 ** p < 0.01 * p<0.05 PSS: Perceived Stress Scale GSE: General Self-Efficacy EE: Emotional Exhaustion DP: Depersonalization PA: Personal Accomplishment.                          63 Appendix D: Correlations Between All Variables for Male Participants   PSS GSE EE DP PA Engagement Disengagement PSS   1 -.564** .601** .650** -.603** -.009 .364* GSE    1 -.309 -.438** .517** .112 -.405* EE     1 .856** -.483** .117 .425** DP      1 -.483** .122 .420** PA        1 .177 -.496** Engagement        1 .240 Disengagement          1         Note:  N = 39 ** p < 0.01 * p<0.05 PSS: Perceived Stress Scale GSE: General Self-Efficacy EE: Emotional Exhaustion DP: Depersonalization PA: Personal Accomplishment.                           64 Appendix E: Correlations Between All Variables for Female Participants   PSS GSE EE DP PA Engagement Disengagement PSS   1 -.405** .722** .409** -.394** -.358** .394** GSE    1 -.462** -.373** .510** .465** -.225 EE     1 .628** -.511** -.385** .424** DP      1 -.602** -.250 .593** PA       1 .390** -.288* Engagement        1 .172 Disengagement        1         Note: N = 62 ** p < 0.01 * p<0.05 PSS: Perceived Stress Scale GSE: General Self-Efficacy EE: Emotional Exhaustion DP: Depersonalization PA: Personal Accomplishment.                        65 Appendix F: All Participant Correlation Matrix   PSS GSE EE DP PA Engagement Disengagement PSS   1 -.469** .672** .513** -.484** -.187 .381** GSE    1 -.406** -.391** .512** .306** -.288** EE     1 .707** -.498** -.169 .423** DP      1 -.545** -.073 .518** PA       1 .291** -.364** Engagement        1 .196* Disengagement        1         Note: N = 101 ** p < 0.01 * p<0.05 PSS: Perceived Stress Scale GSE: General Self-Efficacy EE: Emotional Exhaustion DP: Depersonalization PA: Personal Accomplishment.                     66 1Stress and Coping in Community Mental Health WorkersThank you for your participation in this survey. Please answer the following questions to the best of your ability. All answers are anonymous and confidential. This survey will take approximately 30 minuets to complete.The following questions ask you about your feelings and thoughts about work during the last month. In each case, please indicate which number best fits according to the following scale:0 = Never  1 = Almost Never 2 = Sometimes 3 = Fairly Often 4 = Very Often 1. In the last month, how often have you been upset because of something that happened unexpectedly at work?c 0 c 1 c 2 c 3 c 42. In the last month, how often have you felt that you were unable to control the important things at work? c 0 c 1 c 2 c 3 c 43. In the last month, how often have you felt nervous and “stressed” at work? c 0 c 1 c 2 c 3 c 44. In the last month, how often have you dealt successfully with irritating work hassles? c 0 c 1 c 2 c 3 c 45. In the last month, how often have you felt that you were effectively coping with important changes that were occurring at work? c 0 c 1 c 2 c 3 c 46. In the last month, how often have you felt confident about your ability to handle your work problems?c 0 c 1 c 2 c 3 c 47. In the last month, how often have you felt that thing were going your way at work? c 0 c 1 c 2 c 3 c 48. In the last month, how often have you found that you could not cope with all the things you had to do at work?c 0 c 1 c 2 c 3 c 49. In the last month, how often have you been able to control irritation at work? c 0 c 1 c 2 c 3 c 410. In the last month, how often have you felt that you were on top of things at work? c 0 c 1 c 2 c 3 c 411. In the last month, how often have you been angered because of things that were outside of your control at work?c 0 c 1 c 2 c 3 c 412. In the last month, how often have you found yourself thinking about things that you have to accomplish at work?c 0 c 1 c 2 c 3 c 413. In the last month, how often have you been able to control the way you spend your time at work?c 0 c 1 c 2 c 3 c 414. In the last month, how often have you felt difficulties were piling up so high at work that you could not overcome them?c 0 c 1 c 2 c 3 c 4 Appendix G: Survey                                    67  2Please read each of the following statements carefully and decide if you ever feel this way about your job. If you have never had this feeling, check the number “0” (zero) beside the statement. If you have had this feeling, indicate how often you feel it by checking the number (from 1 to 6) that best describes how frequently you feel that way.How often: 0 = Never1 = A few times a year or less 2 = Once a month or less3 = A few times a month4 = Once a week5 = A few times a week6 = Every day1. I feel emotionally drained from my work. c 0 c 1 c 2 c 3 c 4 c 5 c 62. I feel used up at the end of the workday. c 0 c 1 c 2 c 3 c 4 c 5 c 63. I feel fatigued when I get up in the morning and have to face another day on the job.c 0 c 1 c 2 c 3 c 4 c 5 c 64. I can easily understand how my residents/clients/participants/members feel about things.c 0 c 1 c 2 c 3 c 4 c 5 c 65. I feel I treat some residents/clients/participants/members as if they were impersonal objects.c 0 c 1 c 2 c 3 c 4 c 5 c 66. Working with people all day is really a strain for me. c 0 c 1 c 2 c 3 c 4 c 5 c 67. I deal very effectively with the problems of my residents/clients/participants/members.c 0 c 1 c 2 c 3 c 4 c 5 c 68. I feel burned out from my work. c 0 c 1 c 2 c 3 c 4 c 5 c 69. I feel I’m positively influencing other people’s lives through my work. c 0 c 1 c 2 c 3 c 4 c 5 c 610. I’ve become more callous toward people since I took this job. c 0 c 1 c 2 c 3 c 4 c 5 c 611. I worry that this job is hardening me emotionally. c 0 c 1 c 2 c 3 c 4 c 5 c 612. I feel very energetic. c 0 c 1 c 2 c 3 c 4 c 5 c 613. I feel frustrated by my job. c 0 c 1 c 2 c 3 c 4 c 5 c 614. I feel I’m working too hard on my job. c 0 c 1 c 2 c 3 c 4 c 5 c 615. I don’t really care what happens to some residents/clients/participants/members. c 0 c 1 c 2 c 3 c 4 c 5 c 616. Working with people directly puts too much stress on me. c 0 c 1 c 2 c 3 c 4 c 5 c 617. I can easily create a relaxed atmosphere with my residents/clients/participants/members.c 0 c 1 c 2 c 3 c 4 c 5 c 618. I feel exhilarated after working closely with my residents/clients/participants/members.c 0 c 1 c 2 c 3 c 4 c 5 c 619. I have accomplished many worthwhile things in this job. c 0 c 1 c 2 c 3 c 4 c 5 c 620. I feel like I’m at the end of my rope. c 0 c 1 c 2 c 3 c 4 c 5 c 621. In my work, I deal with emotional problems very calmly. c 0 c 1 c 2 c 3 c 4 c 5 c 622. I feel residents/clients/participants/members blame me for some of their problems. c 0 c 1 c 2 c 3 c 4 c 5 c 6  68  3Please indicate how true each of the following statements are for you based upon this scale. 1 = Not at all true   2 = Hardly true   3 = Moderately true   4 = Exactly trueI can always manage to solve difficult problems if I try hard enough. c 1 c 2 c 3 c 4If someone opposes me, I can find the means and ways to get what I want. c 1 c 2 c 3 c 4It is easy for me to stick to my aims and accomplish my goals. c 1 c 2 c 3 c 4I am confident that I could deal efficiently with unexpected events. c 1 c 2 c 3 c 4Thanks to my resourcefulness, I know how to handle unforeseen situations. c 1 c 2 c 3 c 4I can solve most problems if I invest the necessary effort. c 1 c 2 c 3 c 4I can remain calm when facing difficulties because I can rely on my coping abilities. c 1 c 2 c 3 c 4When I am confronted with a problem, I can usually find several solutions. c 1 c 2 c 3 c 4If I am in trouble, I can usually think of a solution. c 1 c 2 c 3 c 4I can usually handle whatever comes my way. c 1 c 2 c 3 c 4The following items look at the ways you’ve been coping with the stress in your workplace.  Please write down a specific stressful situation that you experienced within the last 6 months:  69  4There are many ways to try to deal with problems. These items ask what you’ve been doing to cope with the one you have written above.  Obviously, different people deal with things in different ways, but I’m interested in how you’ve tried to deal with this one. Each item says something about a particular way of coping. I want to know to what extent you’ve been doing what the item says.  How much or how frequently. Don’t answer on the basis of whether it seems to be working or not—just whether or not you’re doing it.  Use these response choices, and mark each answer in the black space provided. Try to rate each item separately in your mind from the others.  Make your answers as true FOR YOU as you can.  1 = I haven’t been doing this at all   2 = I’ve been doing this a little bit   3 = I’ve been doing this a medium amount   4 = I’ve been doing this a lot1. I’ve been turning to work or other activities to take my mind off things.   c 1 c 2 c 3 c 42. I’ve been concentrating my efforts on doing something about the situation I›m in.  c 1 c 2 c 3 c 43. I’ve been saying to myself “this isn’t real.”.  c 1 c 2 c 3 c 44. I’ve been using alcohol or other drugs to make myself feel better.  c 1 c 2 c 3 c 45. I’ve been getting emotional support from others.  c 1 c 2 c 3 c 46. I’ve been giving up trying to deal with it.  c 1 c 2 c 3 c 47. I’ve been taking action to try to make the situation better.  c 1 c 2 c 3 c 48. I’ve been refusing to believe that it has happened.  c 1 c 2 c 3 c 49. I’ve been saying things to let my unpleasant feelings escape.  c 1 c 2 c 3 c 410. I’ve been getting help and advice from other people.  c 1 c 2 c 3 c 411. I’ve been using alcohol or other drugs to help me get through it.  c 1 c 2 c 3 c 412. I’ve been trying to see it in a different light, to make it seem more positive.  c 1 c 2 c 3 c 413. I’ve been criticizing myself.  c 1 c 2 c 3 c 414. I’ve been trying to come up with a strategy about what to do.  c 1 c 2 c 3 c 415. I’ve been getting comfort and understanding from someone.  c 1 c 2 c 3 c 416. I’ve been giving up the attempt to cope.  c 1 c 2 c 3 c 417. I’ve been looking for something good in what is happening.  c 1 c 2 c 3 c 418. I’ve been making jokes about it.  c 1 c 2 c 3 c 419. I’ve been doing something to think about it less, such as going to movies,   watching TV, reading, daydreaming, sleeping, or shopping. c 1 c 2 c 3 c 420. I’ve been accepting the reality of the fact that it has happened.  c 1 c 2 c 3 c 421. I’ve been expressing my negative feelings.  c 1 c 2 c 3 c 422. I’ve been trying to find comfort in my religion or spiritual beliefs.  c 1 c 2 c 3 c 423. I’ve been trying to get advice or help from other people about what to do. c 1 c 2 c 3 c 424. I’ve been learning to live with it.  c 1 c 2 c 3 c 425. I’ve been thinking hard about what steps to take.  c 1 c 2 c 3 c 426. I’ve been blaming myself for things that happened.  c 1 c 2 c 3 c 4  70  527. I’ve been praying or meditating.  c 1 c 2 c 3 c 428. I’ve been making fun of the situation. c 1 c 2 c 3 c 4Please take your time and write as much as you would like in response to the following questions.What is your biggest source of stress at work?What have you found to be most helpful in responding to workplace stress?What have you found to be least helpful in responding to workplace stress?If you could change something regarding stress in your workplace, what would it be?We aren’t looking at specific individuals, but knowing what type of people have taken this survey will help us address the stressors in your workplace.Please indicate your:Age ______________________________Gender ___________________________Ethnicity___________________________Highest Degree or Training Achieved ____________________________________________________________________Degree or Training title _______________________________________________________________________________Length of employment in your current field ______________________________________________________________Current position _____________________________________________________________________________________Time spent in your current position ________________________  71 Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education Version 2: August 6, 2015 1 of 2 !a place of mind THE $UNIVERS ITY $OF $BR IT ISH $COLUMBIA $ ! !! Dear%Research%Participant,%%% We%are%asking%you%to%complete%this%anonymous%survey%package%to%help%explore%occupational%stress%in%mental%health%work.%%% The%purpose%of%the%study%is%to%identify%stresses%experienced%by%Community%Mental%Health%Workers%in%their%daily%duties,%and%coping%strategies%they%use%to%cope%with%those%stressors.%This%is%your%opportunity%to%share%your%experiences%as%mental%health%workers%working%on%frontlines,%and%contribute%to%the%research%on%psychological%health%and%well%being%of%mental%health%workers.%%% It%is%expected%that%the%survey%package%will%take%approximately%30F40%minuets%to%complete.%Please%do%not%put%your%name%on%any%of%the%surveys%to%insure%your%anonymity.%The%University%of%British%Columbia%(UBC)%researchers%will%collect%sealed%survey%packages%and%no%individual%information%will%be%disclosed%to%anyone.%The%only%people%that%will%have%access%to%the%information%will%be%the%research%team%at%UBC.%%% All%information%resulting%from%this%study%will%be%kept%strictly%confidential.%Documents%will%be%identified%by%code%number%and%kept%in%a%locked%filing%cabinet%once%they%have%been%collected.%No%participants%will%be%identified%during%the%research%and%in%any%reports%of%the%completed%study.%Your%decision%to%participate%or%not%to%participate%will%have%no%impact%on%your%employment.%%%% If%you%have%any%questions%about%the%study%you%may%contact%Dr.%Colleen%Haney%in%the%Department%of%Education%and%Counselling%Psychology%at%UBC%(604F822F4639)%or%Matthew%McDaniel,%Master’s%student%researcher%in%the%Department%of%Education%and%Counselling%Psychology%at%UBC%(778F316F9854).%This%study%is%graduate%research,%and%is%being%completed%as%a%part%of%the%master’s%student’s%thesis%requirement.%%% %If%you%have%any%concerns%or%complaints%about%your%rights%as%a%research%participant%and/or%your%experiences%while%participating%in%this%study,%contact%the%Research%Participant%Complaint%Line%in%the%UBC%Office%of%Research%Ethics%at%604F822F8598%or%if%long%distance%eFmail%RSIL@ors.ubc.ca%or%call%toll%free%1F877F822F8598%FREE.%%% You%may%refuse%to%participate%in%this%study%at%any%time.%If%you%complete%the%survey%it%is%assumed%that%consent%for%participation%has%been%given.%After%you%complete%the%survey%package%please%put%it%back%into%the%envelope%provided,%seal%and%placed%in%the%box%marked%“UBC%Study”%which%will%be%placed%in%the%mailroom%at%your%work%location.%You%can%also%hand%your%responses%directly%to%Matthew%McDaniel,%Master’s%student%researcher%in%the%Department%of%Education%and%Counselling%Psychology%at%UBC.%%%% %%%Faculty(of(Education((Department(of(Educational(and(Counselling(Psychology,(and(Special(Education(2125$Main$Mall$Vancouver,$BC$$$Canada$$$V6T$1Z4$$Phone$$604$822$0242$Fax$$604$822$3302$$Appendix H: Information and Consent Letter                                   72  Counselling Psychology ● Human Development, Learning and Culture Measurement, Evaluation and Research Methodology ● School Psychology ● Special Education Version 2: August 6, 2015 2 of 2 !a place of mind THE $UNIVERS ITY $OF $BR IT ISH $COLUMBIA $ %%%%% %% In%addition,%you%may%fill%out%the%sheet%marked%“Request%for%Results%and%Thank%You%Draw%”%if%you%would%like%to%receive%information%on%the%results%of%this%study,%and/or%be%entered%into%a%draw%for%one%of%three%$10%Starbucks%cards%as%a%thank%you%for%your%participation.%Please%deposit%this%into%the%box%separately%from%your%survey%package.%%% If%you%find%yourself%upset%by%any%of%the%questions%asked%in%this%survey%you%may%contact%your%organizations%staff%support%department,%or%access%affordable%counselling%services%with%Family%Services%of%Greater%Vancouver%at%604F874F2938.% Faculty(of(Education((Department(of(Educational(and(Counselling(Psychology,(and(Special(Education(2125$Main$Mall$Vancouver,$BC$$$Canada$$$V6T$1Z4$$Phone$$604$822$0242$Fax$$604$822$3302$$

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