Nursing Reasrch-Article Crtique -Article On Attachment File

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Article

Abstract: Emergency departments are high-stress environments for patients and clinicians. As part of the clinical team, nurses experience this stress daily and are subject to high levels of burnout, which has been shown to lead to hypertension, depression, and anxiety. Presence of these diseases may also contribute to burnout, creating a cycle of stress and illness. This prospective qualitative study used a phenomenological approach to better understand factors associated with burnout among emergency department nurses. Burnout manifests itself in multiple modes, can affect nurses’ decisions to leave the profession, and must be addressed to mitigate the phenomenon.

Keywords: emergency response, occupational hazards, occupational health and safety team, continuous quality improvement, management

emergency departments (EDs) are high-stress environments for patients and health care workers. Emergency department nurses are at risk for developing burnout due to the nature of their fast-paced and demanding field (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010). According to García- Izquierdo, ED nurses with burnout can develop hypertension, depression, and anxiety. Lack of empathy and medication errors are associated with burnout (García-Izquierdo & Ríos-Rísquez, 2012). A recent study reviewed factors identified to be associated with burnout among ED staff for over 25 years (Adriaenssens, De Gucht, & Maes, 2015). However, the encounters that contribute to burnout have not been adequately described. The aim of this study was to use a phenomenological approach to better understand lived experiences and factors that may lead to burnout among ED nurses.

Background Caregiver burnout is one of the most prevalent problems in

health care today (Adriaenssens et al., 2015). Burnout is a syndrome characterized by emotional exhaustion, lack of

empathy, and low self-esteem (Maslach & Jackson, 1982), which can lead to a variety of physical, emotional, and social problems including substance abuse, depression, medication errors, and job-related shortages as these nurses either decide to explore other areas in nursing or leave the profession altogether. Nurses are particularly afflicted by this phenomenon as they experience unpredictable work environments, heavy workloads, long shifts, exposure to traumatic events, overcrowding, lack of support, violence, and patients who have experienced acute trauma, illnesses, or injuries.

A phenomenological approach to studying nursing can improve understanding of the relationship among life experiences; this study is focused on ED nurses who have experienced burnout, and burnout has affected their health and overall quality of life (Pratt & Gibbons, 2012). Although burnout is an acknowledged phenomenon within health care (Adriaenssens et al., 2015), additional research is needed to understand the experiences of nurses who have actually experienced burnout in the ED. Phenomenological research allows the researchers to gain a rich, thick description of the experience (i.e., allowing for a detailed description of the setting, characteristics, and findings of a study that may not be allowable in quantitative research), leading to a better understanding of lived experience (Merriam, 2002).

Method This prospective, qualitative study was designed to better

understand external factors associated with burnout in ED nurses. A phenomenological approach with purposive sampling was used to better understand emergency nurses’ experiences. Five interviews were conducted, transcribed, coded, and analyzed. During the fourth and fifth interviews, several responses were repetitive, and no new information was gathered which suggested saturation had been reached.

Participants Participants were recruited using purposive sampling and the

snowball technique (Merriam, 2002). Purposeful sampling is useful

705669WHSXXX10.1177/2165079917705669Workplace health & safetyWorkplace health & safety research-article2017

Situational Factors Associated With Burnout Among Emergency Department Nurses Jose andres rozo, BSN, rN, ccrN1, DaiWai M. olson, phD, rN2, Hlaing (Sue) thu, BSN, rN2, and Sonja e. Stutzman, phD2

DOI: 10.1177/2165079917705669. From 1Parkland Health and Hospital System, Dallas, TX, USA, and 2The University of Texas Southwestern Medical Center, Dallas, TX, USA. Address correspondence to: DaiWai M. Olson, PhD, RN, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8897, USA; email: DaiWai.Olson@ UTSouthwestern.edu. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2017 The Author(s)

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in qualitative research because the investigator identifies participants who have experienced the phenomenon of interest (Creswell, 2007). Participants were included in the study if they had ED nursing experience, reported work-related stress, were English speaking, and were above the age of 18 years. A waiver of consent was approved by the Institutional Review Board (Record Number: STU 022015-013); therefore, verbal consent was given by each nurse, which further protected confidentiality and anonymity. All participant names were changed to protect their identities.

Data Collection Data were collected from current and former ED nurses via a

demographic self-report form and one-on-one interviews. Prior to each interview, a short description of the study, procedures, interview protocol, and concept of burnout were discussed with each participant. Interviews lasted approximately 1 hour and were audio recorded. Interview questions addressed nurses’ experiences with work-related traumatic events within the ED (Figure 1); additional probing questions were used as necessary.

Rigor Validation strategies included triangulation, peer review, and

rich, thick descriptions via interviewer journaling. In triangulation, different outside sources were used to corroborate the information collected (Creswell, 2007). Peer review process included presenting the information to other nurses in other areas including current and former ED nurses and nurse managers (Creswell, 2007). Finally, rich and thick descriptions were composed after each interview, detailing a summary of the interview as well as generating new ideas and meanings (Creswell, 2007).

Data Analysis This qualitative design used a hermeneutic approach.

Creswell (2007) refers to hermeneutical phenomenology as “research oriented toward lived experience” (Creswell, 2007) p. 59). Data analysis was conducted at the completion of each

interview. Field notes were written by the interviewer throughout the interview. Immediately after each interview, the interviewer journaled about the interview. The audiotape was transcribed verbatim by a member of the research team after each interview.

For coding, the researcher read over the transcript without taking notes or coding. Then reread the transcript and highlighted important quotes that could potentially be identified as codes. The researcher read through the codes and chunked the codes into groups to form three or four themes. The data analysis was completed by composing a table using the identified codes and themes. Field notes were matched with themes and added to the data analysis table. As a final step in individual interview analysis, the researcher identified three to four remarkable quotes that could potentially be used to support themes in the final presentation of the data. After the completion of data analysis for all individual interviews, the researcher began cross analysis of interview codes by compiling codes and themes across all interviews, creating a combined data analysis table and determining overall themes that emerged in the data analysis process.

Results Study results illuminated the development of burnout among

ED nurses. Transcription and coding uncovered four main themes: (a) work environment, (b) perception, which was supported by the subthemes of internal and external perceptions, (c) workplace violence, and (d) moral distress (Figure 2). Work environment was the most supported theme; 13 codes supported this theme.

Work Environment The environment of the ED is fated to be somewhat chaotic.

Several codes in this study supported that overcrowding was the main stressor in EDs. Overcrowding, due to the constant flow of patients into and out of the department was one significant source

Figure 1. Participant interview questions.

Figure 2. Themes and subthemes.

Applying Research to Practice The emergency department is a demanding and dynamic environment. Burnout is high across the nursing profession, but factors contributing to burnout vary by nursing specialty. This study identified work environment, workplace violence, moral distress, and perceptions (internal and external) as themes associated with emergency nurse burnout. Understanding the underpinnings of these themes will allow for nurses, managers, and administrators to identify strategies aimed at reducing burnout. Identifying and separating the themes is vital to provide researchers a platform to test targeted interventions aimed to treat one or more factors rather than struggling to find a one-size-fits-all approach to reducing burnout.

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of burnout. In addition, inadequate staffing was reported to be an issue as it led to extra shifts, longer shifts and assuming extra responsibilities that added to workload. Participants also identified alarm fatigue, lack of supplies, and physical demands (e.g., walking demanded by larger EDs). Of the five nurses interviewed, three nurses had left the ED due to high levels of burnout.

Scott, who worked as an emergency room nurse for 2 years recalled, “At the end of the day, you are driving home and your mind doesn’t stop. You hear the bells, the whistles as you’re driving home.” Diane reported that there were times she had to shift between being a bedside nurse and a charge nurse within a shift, which caused her additional stress. Tina, who currently works as an ED nurse, recounted the impact of understaffed shifts, “I think it (burnout) happens more often when we’re short staffed and then we end up picking up overtime and not really having time off.” She also verbalized her frustration at the lack of help she encounters when she has a heavy workload, “A lot of times, we have our 4 (patients) and no extra help.” Thomas described long shifts, constantly standing and walking, and lack of proximity of services (e.g., x-ray, CT scanners) and supplies as barriers to patient service coordination and major contributors to stress in the workplace.

Perceptions Nurses’ perceptions of their work environment (internal) as well

as others’ perceptions of emergency nurses (external) were also reported to affect burnout. Internal perceptions, those experienced by ED nurses, included feeling unappreciated, depersonalizing patients due to excessive work flow, being unable to meet job expectations, and lacking the time to properly perform their duties. Eve often felt unappreciated and noticed nurses becoming “mean and bitter” over time. Laura verbalized her frustration when patient acuity levels were low, which made her feel like a “refreshment administrator.” Thomas reported how stress was “part of the job.” He also reported not being able to fully interact with patients, but instead felt he was “just doing tasks.”

External perceptions included negative patient attitudes toward nurses. Nurses reported that patients wanted tasks completed on their time schedules, which was not always possible. In addition, patients did not always understand the triage process leading to patient dissatisfaction, which patients projected onto their nurses. Eve articulated,

Because everybody had a complaint, we didn’t take care of everybody fast enough. We didn’t do everything that everybody wanted at the same time and it didn’t seem to matter whether we saved somebody’s life or didn’t save somebody’s life. Nobody was ever happy with us.

Workplace Violence Workplace violence is a top priority for ED nurses and

administration (American Organization of Nurse Executives and Emergency Nurses Association, 2015). Violent experiences, the constant fear of the unknown, and lack of administrative support in maintaining safe EDs were all reported contributors to burnout. Diane said she had experienced “verbal violence”

almost once a shift. “I’ve been spit on, grabbed and kicked, you name it.” She recalled a particular experience of physical violence committed by a patient that left her with physical and emotional scars “I still have nerve damage. I do carry that experience with me.” Laura described being the target of violence from both patients and coworkers, stating that she was hazed by coworkers when she began working in the ED.

Moral Distress Nurses in this study described experiencing moral distress as

part of the burnout process. Some described sadness over the death of a patient, dealing with patients who return to the ED due to suicide attempts, and not having “official” ways to decompress when stressful situations occur. Often these nurses wondered if they would like to continue in their roles as ED nurses, switch specialties, or leave the profession altogether.

Eve reported “experiencing sadness due to seeing people dying from accidents or experiencing pain.” She mentioned that seeing the same people return to the ED was draining and eventually she left the profession altogether. Scott recalled dealing with the death of an infant.

One of the first deaths that I experienced was a child, an infant . . . It impacted me . . . I felt saddened for the child who obviously would not grow up, for the family members who had lost their loved one.

Thomas stated, “If a patient dies, and you are a part of that, you don’t get to talk about it . . . and you carry that with you.” Thomas, Diane, and Eve had all considered, or had actually left the ED due to moral distress.

Discussion Burnout is prevalent in the nursing profession. Previous

literature has found that burnout is the outcome of contributory factors such as excessive workload, lack of support, and workplace violence (García-Izquierdo & Ríos-Rísquez, 2012). This study supported these previous responses. Studies dating back to the early 1980s have looked at factors associated with burnout (Adriaenssens et al., 2015). This study found that burnout continues to occur and nurses continue to leave the ED because of factors such as workplace violence, workload and staffing, and perceptions of administrative support.

In this sample, communication and interaction with physicians were not associated with burnout. This finding is congruent with recent literature suggesting that physician-nurse communication is often positive (Van Bogaert et al., 2017). Similarly, although an ED study found that nurses had moral distress from following physician orders, this finding appears to be driven by orders nurses consider to be unnecessary (Zavotsky & Chan, 2016).

This study adds to the literature as it uncovered the importance of moral distress and nurses’ perceptions. This study also found a relationship between moral distress and burnout that was enhanced by lack of administrative support (MacKusick & Minick, 2010). According to Kirwan, Matthews,

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and Scott (2013), “Nurses perceive their work environment to be supportive of patient safety outcomes.”

Limitations Although this study adequately describes the experiences of

some nurses who developed burnout in the ED, it is not without limitations. As with all qualitative research, the purpose was to generate hypotheses and therefore lacks generalizability to all nurses’ experiences in the ED. The researchers acknowledge that questions were formulated specifically about burnout and that not all ED nurses experience burnout or have had the same experiences as the participants in this study. The coding of this study was conducted by one researcher, which presents both benefits and potential bias. Future studies could employ multiple coders to analyze interview content.

Implications for Practice It is well established that nursing practice can be taxing.

Burnout can be described as a product of stress, workplace violence, and lack of support. This study demonstrated that these factors also resonated with nurses working in the ED. The findings of this particular qualitative study indicate that work environment, violence, and moral distress play a significant role in burnout. Strategies to assist ED nurses in coping with these factors include support groups where nurses are allowed to share their experiences and listen to others with the same experiences (Braunschneider, 2013). Another study highlighted the benefits of mindfulness training as a tool to decrease burnout and promote well-being among ER nurses (Westphal et al., 2015). Additional studies may be needed to improve support among bedside nurses as well as from nurse administrators. The themes also indicated that nurses need rest breaks, unit based support groups, time away from the unit and patients, and reprieve from the ED.

Conclusion The findings of this qualitative study revealed that

emergency nurses experience burnout due to unhealthy, stressful, and sometimes violent environments. Therefore, quantitative research is needed to explore strategies to eliminate burnout among ED nurses as well as nurse administrators. This study raises awareness of burnout risk and can proactively generate ideas to mitigate burnout and improve quality of care to ED patients and their families.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Jose Andres Rozo is currently a bedside nurse in the critical care unit at Parkland Hospital.

DaiWai M. Olson is an associate faculty at the University of Texas Southwestern Medical Center and a bedside nurse in the neuroscience intensive care unit.

Hlaing (Sue) Thu is a bedside nurse in the imaging department at the University of Texas Southwestern Medical Center.

Sonja E. Stutzman is the Clinical Research Manager at the University of Texas Southwestern Medical Center.