Emergency Nursing

The Emergency Department (ED) in a Health care facility deals with life threatening conditions that calls for immediate medical attention. The Department handles exacerbations of various critical conditions like myocardial infarction, trauma and COPD, which demands training, not only in handling the equipments but also in handling patients, who, usually arrive unstable with an unknown medical history, allergy reactions or blood group. Hence, emergency nurse care is stressful.

The Federal Emergency Medical Treatment and Active Labor Act, also known as the Patient Anti-Dumping Law commonly referred to as EMTALA passed in 1986 warrants proper emergency attention in USA and the emergency departments of most hospitals operate around the clock. With a lower staffing levels at night, there is a concern recently on the work-related stress and on emergency nurse burn out as evidenced by various reports and published literature.

What Is Nurse Burnout?

Nurse burnout is a condition where a nurse experiences chronic fatigue, exhaustion, tiredness, anger, irritability, frequent headaches, gastrointestinal disturbances, abnormal weight gain or loss, depression, insomnia and breathing difficulties on account of work stress affecting professional performance. Burnout presents three basic features namely, Emotional Exhaustion, Depersonalization and Personal Achievement (Aleandri et.al, 2006).

ED Nurses, by duty, have to act quickly and effectively with minimal information and hence, are more prone to professional stress and burnout. A nurse burnout has serious consequences on account of the medical errors that can occur in an emergency department.

 

Is Nurse Burnout A Reality?

A review of the published sources reveals that nurse burn out is a physiological reality and not a psychological myth.

A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care center in Vancouver has shown that such burnouts even result in violence and verbal abuse in the work place (Christopher, 1999).

A study to assess the physiological relationship between the salivary cortisol levels and work stress in emergency department nurses has shown that ED nurses have high levels of work stress as indicated by morning salivary cortisol levels (Yang et.al, 2001).

Greater endocrine reactions have been shown during and after the handling of patients in direct life threatening situations during morning hours compared to the handling of patients who were not in direct life threatening situations in a study done to investigate the neuroendocrine reactions in emergency caregivers during emergency situations ( Sluiter et.al, 2003).

A recent study has elucidated the role of work stressors and shown that depersonalization and reduced personal accomplishment are two important dimensions of nurse burnout (Sabine Stordeur et.al, 2001).

Aleandri et.al (2006), have shown that a significant relationship exists between emotional exhaustion and depersonalization in nurses working in an emergency department using the Maslach Burnout Inventory. Patti et.al. have recently studied the prevalence of depression and anxiety in emergency department staff and also investigated the influence of gender or professional role on depression and anxiety.

Mark Gillespie and Vidar Melby (2003) in their quantitative and qualitative study on emergency nurse burnout using the Maslach Burnout Inventory conclude that stress and burnout have far reaching effects both for nurses in their clinical practice and personal lives.

A qualitative study undertaken using hermeneutic phenomenology involving a representative sample of 25 emergency nurses has shown that work related stress symptoms are associated with poor social support, staff to staff support and supervisors or managerial support (Anders Jonsson, 2006).

The Remedy

John A. Schriver et.al (2003) have elucidated the current and future roles of the emergency nurse highlighting the need to improve the emergency nurse-to-patient ratios, staff scheduling, increasing nursing wages, recognizing contributions of emergency nurses with financial reward, developing internships for nurses new to emergency nursing and to invest in nursing education.

Kathleen Dracup et.al, (2005) has also highlighted the need for an improved staff scheduling to reduce nurse burnout. She has rightly pointed out that it is difficult for nurses to perform without errors with a break time of less than 30 minutes in a 12-hours shift. Rogers et.al (2004), have statistically shown that nurses who worked more than 12.5 consecutive hours were 3 times more likely to make an error due to fatigue especially at the end of a shift and when trying to finish a multitude of tasks, complete charting, and report to the incoming nurse.

Lockley et.al (2004), have also reported the importance of reducing the work hours and need of enough sleep in effective patient care. Joanne et.al. (1999) have demonstrated that 12-hour shifts are associated with reduction in nurse performance.

California passed the first legislation in the United States to establish minimum staffing levels in hospitals for registered nurses (RNs) and licensed vocational nurses in 1999 (Spetz, Joanne, 2004).

Age, vocational education and years of practice are important variables having an influence on staff burnout (Koivula et.al,2000). Recently "System complexity" has been introduced as a viable and technically feasible measurement for monitoring and managing surge capacity in the ED (Daniel J. France et.al, 2006).

 

Although the measure actually quantifies the uncertainty of demands on system resources, the measure has been modified to quantify both workload and uncertainty to produce a single integrated measure of system state in the ED. Specific minimum nurse-to-patient ratios is yet another measure that will reduce burnout (Spetz et.al, 2004).

A Victorian model that mandates minimum staffing of five nurses to 20 patients has been critically evaluated recently (Gerdtz et.al, 2007).

 

The 2003 regulations by the Accreditation Council for Graduate Medical Education to limit residents hours on duty to a maximum of 80 hours per week, or 24 hours per continuous shift has greatly contributed towards reduction of fatigue (Kathleen Dracup, 2005).

The regulations also stipulate that the residents also must have 1 day off every 7 days and 10 hours of rest between scheduled clinical or educational obligations. These regulations are more relevant in emergency nursing.

Conclusion

Loke (2001) explains job satisfaction as a pleasurable or positive emotional state resulting from the appraisal of one's own job or job experience. Paula Greco (2006) identifies poor working conditions in nursing work environments as a major cause of burnout among nurses. Leiter and Maslach (1999) identify six areas of nurse work life, namely, workload, control, reward, community, fairness and values that need to be taken care to avoid burn out that seriously affects employee's attitudes relating to job satisfaction and organizational commitment.

Nurse retention, performance, job satisfaction, nursing skill, experience and change strategies are the predominant issues in emergency nursing today on account of nurse burnout. Nurse burnout is nurse in distress. There is an urgent need to improve nurse-working conditions to retain the existing work force and attract nurses into emergency nursing. A failure to do so will result in an acute emergency nurse shortage.

References

Aleandri A, Sansoni J. (2006). Nurses and burnout: a survey in an Emergency Department in the Lazio Region. Prof Inferm. 59(3): 165-70.

Anders Jonsson. (2006). Work related post-traumatic stress as described by Jordanian emergency nurses, Accident and Emergency Nursing , 14(2); 89-96.

Catharina Eriksson and Britt-Inger Saveman. (2002). Nurses' experiences of abusive/non-abusive caring for demented patients in acute care settings. Scandinavian Journal of Caring Sciences.16 (1 ): 79-85.

Christopher M.B. Fernandes,, France Bouthillette, Janet M. Raboud,, Linda Bullock, , Catherine F. Moore, James M. Christenson, Eric Grafstein, , Sandra Rae, , Leisa Ouellet, Clay Gillrie and Michele Way.(1999). Violence in the emergency department: a survey of health care workers, CMAJ, 161;10.

Daniel J. France and Scott Levin, 2006, System Complexity As a Measure of Safe Capacity for the Emergency Department, Acad Emerg Med published online before print June 28.

J K Sluiter, A J van der Beek, M H W Frings-Dresen. (2003). Medical staff in emergency situations: severity of patient status predicts stress hormone reactivity and recovery. Occupational and Environmental Medicine; 60:373-375.

Jackson D,Clare J and Mannix J.(2002).Who would want to be a nurse? Violence in the workplace: a factor in recruitment and retention. Journal of Nursing Management.10, 13-20.

Joanne M. Fitzpatrick,Alison E. While & Julia D. Roberts>(1999). Shift work and its impact upon nurse performance: current knowledge and research issues. Journal of Advanced Nursing. 29 (1);18-27.

John A. Schriver, Robin Talmadge, Roberta Chuong, and Jerris R. Hedges.(2003). Emergency Nursing: Historical, Current, and Future Roles. Acad Emerg Med. 10(7); 798-804.

Kathleen Dracup and Christopher W. Bryan-Brown (2005). First, Do No Harm. American Journal of Critical Care. 14: 99-101.

Koivula, Paunonen , &Laippala.(2000). Burnout among nursing staff in two Finnish hospitals. Journal of Nursing Management. 8(3); 149-158.

Leiter, M.P. and C. Maslach.( 1999). "Six Areas of Worklife: A Model of the Organizational Context of Burnout." Journal of Health and Human Services Administration: 472-89.

Loke, J.C.F. (2001). "Leadership Behaviours: Effects on Job Satisfaction, Productivity and Organizational Commitment." Journal of Nursing Management 9(4): 191-204.

Mark Gillespie and Vidar Melby.(2003). Professional issues in clinical nursing,Burnout among nursing staff in accident and emergency and acute medicine: a comparative study, Journal of Clinical Nursing 12( 6); 842-851.

Patti, E., Acosta, J., Chavda, A., Verma, D., Marker, M., Anzisi L. Prevalence of Anxiety and Depression Among Emergency Department Staff. www.newyorkmedicaljournal.org/Articles/patti9-07.htm.

Paula Greco, Heather K. Spence Laschinger, Carol Wong. (2006). Leader Empowering Behaviours, Staff Nurse Empowerment and Work Engagement/Burnout. Nursing Leadership (CJNL), 19(4): 41-56.

Sabine Stordeur , William D'Hoore & Christian Vandenberghe.(2001). Leadership, organizational stress, and emotional exhaustion among hospital nursing staff. Journal of Advanced Nursing. 35(4); 533-542.

Spetz, Joanne. ( 2004). California's Minimum Nurse-to-Patient Ratios: The First Few Months. Journal of Nursing Administration. 34(12): 571-578.

Yang, Yong; Koh, David, Vivian; Lee, Francis Chun Yue; Chan, Gregory, Dong, Fang; Chia, Sin Eng.(2001). Salivary Cortisol Levels and Work-Related Stress Among Emergency Department Nurses. Journal of Occupational & Environmental Medicine. 43(12): 1011-1018.

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