may make for difficulty and perhaps the work could be improved by better integration of the chapters. This is not an adverse criticism of the book. It is merely a constructive criticism for the future, for there is no doubt that this work is the most useful book on operative obstetrics today in the English language. It is also the most beautifully produced and one of the most worth-while books on obstetrics in the whole of modern medical literature. E.E.P.

The Doctor, His Patient and the Illness

Despite increased recognition of the stress experienced by hospital nursing staffs and its effects on burnout, job satisfaction, turnover, and patient care, few instruments exist that can be used to measure stress. This paper describes the development of an instrument, the Nursing Stress Scale (NSS). It consists of 34 items that describe situations that have been identified as causing stress for nurses in the performance of their duties. It provides a total stress score as well as scores on each of seven subscales that measure the frequency of stress experienced by nurses in the hospital environment. The Nursing Stress Scale was administered to 122 nurses on five hospital units. Factor analysis indicated seven major sources of stress that closely paralleled the conceptual categories of stress on which the scale was based. Test-retest reliability as well as four measures of internal consistency indicated that the Nursing Stress Scale and its seven subscales are reliable. Validity was determined by correlating the total score from the Nursing Stress Scale with measures of trait anxiety, job satisfaction, and nursing turnover hypothesized to be related to stress. In addition, the ability of the scale to differentiate hospital units and groups of nurses known to experience high levels of stress resulting in staff turnover was examined.

The Nursing Stress Scale: Development of an instrument

Stress among hospital nursing staff: Its causes and effects

Relations between working conditions and mental health status of female hospital workers were studied in a sample of 1505 women: 43% were nurses, 32% auxiliaries, and 7% ancillary staff; 13% were other qualified health care staff, mainly head nurses; 5% had occupations other than direct health care; 63% worked on the morning, 20% on the afternoon, and 17% on the night shift. Data were collected at the annual routine medical visit by the occupational health practitioner, using self administered questionnaires and clinical assessments. Five health indicators were considered: a high score to the general health questionnaire (GHQ); fatigue; sleep impairment; use of antidepressants, sleeping pills, or sedatives; and diagnosis of psychiatric morbidity at clinical assessment. Four indices of stress at work were defined: job stress, mental load, insufficiency in internal training and discussion, and strain caused by schedule. The analysis was conducted by multiple logistic regression, controlling for type of occupation, shift, number of years of work in hospital, daily travel time to work, age, marital status, number of children, and wish to move house. Sleep impairment was mostly linked to shift and strain due to schedule. For all other indicators of mental health impairment and especially high GHQ scores, the adjusted odds ratios increased significantly with the levels of job stress, mental load, and strain due to schedule. This evidence of association between work involving an excessive cumulation of stress factors and mental wellbeing should be considered in interventions aimed at improving the working conditions of hospital workers.

https://oem.bmj.com/content/oemed/47/1/20.full.pdf

Stress at work and mental health status among female hospital workers.

Although alcoholism is prevalent in both general and inpatient populations, barriers to its timely diagnosis and effective treatment exist. These are often attributed to physicians' inadequate understanding and skill development and negative attitudes toward the disease. All Johns Hopkins' medical students and house staff, during 1986 through 1987, received a self-administered survey of their attitudes, skills, perceived role responsibility, knowledge, and reported practices with regard to alcoholism. Results indicate a strong relationship between perceived role responsibility, confidence in skills, and reported screening and referral practices among students and house staff. Knowledge levels strengthened the association between skills and practices for medical students. House staff perceived less of a responsibility for screening than medical students. There was a trend toward lower confidence and more negative attitudes among house staff than medical students. The results point to areas where educational interventions can be improved to enhance quality of care and outcomes for this major chronic disease. (JAMA. 1989;261:3115-3120)

Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism.

This paper attempts to understand one of the ways in which nurses on a coronary care unit may be subjected to stress around the problem of establishing a meaningful relationship to death The themes that nurses expressed during the course of a support group which they had requested are analyzed and discussed The paper focuses on the stress felt by the nurses over responsibility for controlling illness and death which indicated an unconscious confusion between the feeling of being responsible for the care of an ill or dying patient and the feeling of being responsible for the occurrence of the patient's illness or death The possible source of this stressful confusion in medicine's and society's own relationship to death is discussed

The Relationship to Death as a Source of Stress for Nurses on a Coronary Care Unit.

A perspective on medical students' perceptions of alcoholics and alcoholism.

Two major forces mitigate against alcoholism education within the medical school curriculum. One relates to the structure and organization of academic medicine with its emphasis on disease states and pathophysiology; sophisticated and technologically complex diagnostic and treatment modalities; and an acute illness, cure-oriented focus rather than a chronic illness, adaptational approach to illness. The second constellation of factors relates to the alcoholism field's failure to identify with other issues in medical education that similarly challenge the Flexnerian curriculum; the lack of a conceptual basis for defining the physician-alcoholism specialist in relation to other medical disciplines; the clinical treatment field's competing craft and professional orientations; and the absence of a scientific vocabulary suited to the existing biopsychosocial paradigms. It is suggested that these impediments could be overcome if the alcoholism field defined the model for managing chronic illness that is implici...

Impediments to Alcohol Education.

Complex partial seizures and schizophrenia

We develop the concept of a volitional disability as an aid in understanding those patients who behave in ways that are harmful to themselves in spite of their desire to do otherwise. Using this concept enables us to describe their behavior as intentional but 'involuntary'. We demonstrate the clinical reality of such behavior by giving clinical examples of the behavior of those with phobic, compulsive, and addictive disorders. We then attempt to show how some kinds of self-harming behavior of noncompliant patients are similar to phobic and compulsive behavior. We propose use of the concept of volitional disability to make it easier for physicians to work with these noncompliant patients and thus to improve their ability to provide better care for them.

Trevor R. P. Price

Papers

The Relationship to Death as a Source of Stress for Nurses on a Coronary Care Unit.

A perspective on medical students' perceptions of alcoholics and alcoholism.

Impediments to Alcohol Education.

Complex partial seizures and schizophrenia

Volitional Disability and Physician Attitudes Toward Noncompliance