Longitudinal comparison of depression, coping, and turnover among NHS and private sector staff caring for people with dementia

BMJ 2001; 322 doi: (Published 31 March 2001) Cite this as: BMJ 2001;322:769
  1. M Margallo-Lana, specialist registrar in old age psychiatrya,
  2. K Reichelt, assistant psychologistb,
  3. P Hayes, assistant general managerc,
  4. L Lee, home managerd,
  5. J Fossey, consultant clinical psychologiste,
  6. J O'Brien, professor of old age psychiatryb,
  7. C Ballard, professor of old age psychiatry (c.g.ballard{at}
  1. a Bensham Hospital, Gateshead, Tyne and Wear NE8 4YL
  2. b Institute for the Health of the Elderly, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
  3. c Neurorehabilitation and Elderly Programme, Newcastle General Hospital
  4. d Dene Lodge Nursing Home, Denton Burn, Newcastle upon Tyne NE15 7SX
  5. e Fulbrook Centre, Churchill Hospital, Oxford OX3 7LJ
  6. f MRC Neurochemical Pathology Unit, Newcastle General Hospital
  1. Correspondence to: C Ballard
  • Accepted 22 November 2000

Relatives caring for people with dementia show high levels of psychological distress and depression.1 However, the psychological health of staff in private and NHS care facilities for people with dementia has not been evaluated. Staff turnover is often high in these facilities, and mental health could be a contributory factor.

Prevalence of stress among staff in private and NHS residential homes and stress coping mechanisms

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Active coping strategies reduce depression and psychological distress in family caregivers,2 and the same could be true for professional carers. We compared the prevalence of psychological distress among professional staff in private sector and NHS facilities and assessed the relation with coping strategies and rates of staff turnover.

Participants, methods, and results

We measured emotional wellbeing (28 item general health questionnaire) and the use of positive coping strategies (active coping, planning, seeking social support, positive reinterpretation, and acceptance-COPE3) in the care staff of private sector residential or nursing homes and NHS continuing care facilities. All nine private facilities with over 30 residents within two catchment areas and all four NHS facilities were asked to participate. Questionnaire data were discounted from one facility in each category because of the poor return rate (<25%), although the staff turnover was calculated in all 12. We compared results using the χ2 test and the Mann-Whitney U test. All data were analysed with SPSS (version 9).

A total of 225 staff completed all of the assessments (161/176 (91%) from private facilities and 64/89 (72%) from NHS facilities). There were 48 nurses (27 from NHS, 21 from private homes) and 177 care assistants or senior care assistants (37 from NHS, 140 from private homes).

Forty five (20%) respondents scored ≥5 on the general health questionnaire (the cut off point for caseness), 35 (22%) from private facilities and 10 (16%) from the NHS (χ2 =1.7, df =1, P=0.30). The table gives further details. Staff scoring below 5 on the general health questionnaire were more likely to use positive coping strategies (active coping, Z=2.1, P=0.03). Nurses used active coping (Z=2.6, P=0.008) and planning (Z=2.5, P=0.011) more than the care assistants, although the differences were not significant for private staff (table).

Seventy five (38%) staff in private facilities and 19 (16%) in NHS homes had left in the 12 months before the assessment (χ2=16.4, df=1, P<0.0001). There was no relation between staff turnover and the mean general health questionnaire score (Spearman's r=0.21, P=0.52).


We found psychological distress in about 20% of professionals caring for people with dementia in private and NHS facilities. This level is low compared with reported frequencies of 50% in other healthcare workers4 and relatives caring for people with dementia.1 Levels of stress in NHS homes were lower than in private facilities (16% v 22%), although the difference was not significant. The study did not have sufficient statistical power to detect a significant difference of this magnitude. Our study confirms previous reports that positive coping strategies protect against psychological distress and indicates that nurses are more likely to use positive coping strategies than care assistants, particularly in NHS settings. This emphasises the potentially important role of nursing staff in developing such skills in care homes.

The assumption that stress is an important factor in the high turnover of professional carers seems to be unfounded. Although staff turnover was high, particularly in the private sector, it was unrelated to the level of psychological distress within individual facilities. Possible explanations for the high turnover include the poor wages and poor career structure. The lower staff turnover rates in the NHS facilities were perhaps because staff had a better sense of “community” as they were part of a larger organisation. Promotion of better links between the NHS and private sector could increase stability and allow efficient delivery of training programmes and the development of mutually supportive staff groups.


Contributors: MM-L collected a large proportion of the data, completed the initial data analysis, and had a leading role in writing the manuscript. KR and PH helped with data collection, set up the study data base, and contributed to writing the manuscript, LL helped plan the study, contributed to data collection, and contributed to writing the manuscript. JF, JO'B, and CB took the lead in devising the original study design, recruiting study staff, and obtaining ethical approval, and all contributed to the writing of the manuscript. CB and JF trained staff; CB also supervised study staff and was responsible for the final version of the manuscript. CB will act as guarantor.


  • Funding CB's salary was paid by the Medical Research Council.

  • Competing interests None declared.


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