RESEARCH ARTICLE
EMERGENCY NURSES’ PERSPECTIVES: FACTORS AFFECTING CARING
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Authors: Carol L. Enns, MN, RN, and Jo-Ann V. Sawatzky, PhD, RN, Winnipeg, Manitoba, Canada
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Introduction: Caring is a universal phenomenon. However, as
Results: Advocacy and holistic care emerged as major themes
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in the meaning of caring for emergency nurses. Caring was affected by a number of factors, including workload, lack of time, staffing issues, shift work, and lack of self-care. However, lack of management support was the most consistent hindrance to caring identified by study participants.
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a result of higher patient acuity and staff shortages within the chaotic ED environment, caring behaviors may be in peril. The purpose of this study was to gain insight into the meaning of caring from the perspective of emergency nurses. Exploring nurses’ perspectives of caring is central to improving staffing and retention issues in this unique work environment.
Discussion: Caring continues to be a unifying concept in
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Methods: As part of a larger study, a subsample of emergency
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nurses who work in public hospitals in Manitoba, Canada (n = 17) were interviewed. A qualitative descriptive design was used to gain insight into the caring perspectives of nurses by asking them, “What does caring meaning to you?” and “What affects caring in your practice in the emergency department?” Emerging themes were extracted through analysis of audio tapes and transcripts.
nursing; however, influencing factors continue to undermine caring for emergency nurses. Caring is not subsidiary to nursing; it is the central core of nursing. Therefore, fostering a caring working environment is essential for nurses to practice holistic nursing care. It is also imperative to job satisfaction and the retention of emergency nurses.
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aring is a universal nursing phenomenon. It is understood and accepted as a fundamental value in nursing as both a discipline of knowledge and as a professional practice. 1 Nursing scholars contend that caring is the essence of nursing practice. Theorists agree that caring is central to the nursing role and have defined caring as a characteristic of nursing. 2–4 Certainly, nurses in practice view caring as relevant to their role. However, despite the vast amount of research and theoretical development with regard to caring, the meaning of caring has not been clearly established. Moreover, caring is inferred to be context specific. 5
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Carol L. Enns is Senior Instructor, Faculty of Health Sciences–College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada. Jo-Ann V. Sawatzky is Associate Professor, Faculty of Health Sciences– College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
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Funded by the Dr. Paul H.T. Thorlakson Foundation Fund, Winnipeg, Manitoba, Canada. For correspondence, write: Carol L. Enns, MN, RN, 277 Helen Glass Centre for Nursing, University of Manitoba, Winnipeg, MB, Canada R3T 2N2; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.12.003
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The emergency department is a unique nursing work environment. Factors such as the unpredictable nature of the department, increasing patient-to-nurse ratios, overcrowding, and high staff turnover rates contribute to this highly stressful contemporary work environment. 6 These factors may also influence ED nurses’ perception of caring and the ability to care. Although the meaning of caring has been explored in many areas of nursing, there is a dearth of literature specifically related to the perspectives of emergency nurses with regard to caring. Therefore, it was imperative to investigate the meaning of caring and the factors that affect caring from the emergency nurse’s point of view. Diverse theories of caring have fueled an ongoing debate among nursing theorists and researchers regarding its definition. As well, despite use of a variety of empirical methods to quantify the concept of caring, the results have been inconsistent. 7,8 However, the instruments used in these studies have attempted to define and measure different aspects of caring through the use of predetermined assessment scales. Whereas quantitative research has contributed to the body of evidence related to caring, qualitative research has also provided important contributions to our understanding of this concept. For example, in a study that explored the meaning of caring among hospital night nurses in Sweden, advocacy for patients and their relatives emerged as a major theme. 9 In another study, based on the content analysis of videotaped episodes in an
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Key words: Caring; Emergency nurses; Work environment
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Methods
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As part of a larger study described elsewhere, 18 a qualitative descriptive design was used to gain insight into the caring perspectives of emergency nurses.
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PROTECTION OF HUMAN SUBJECTS
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Ethical approval for this research was granted through a university-based research ethical review board. The regulatory body mailed written descriptions of the study, a copy of the quantitative survey, and invitations to participate in face-to-face interviews to all ED nurses within the province. Procedures included the assurance of participant confidentiality, including the use of assigned numbers. Specific interview consent forms were signed by participants prior to the interviews.
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DATA COLLECTION
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Data were collected through tape-recorded face-to-face interviews with individual participants; each interview was approximately 60 to 90 minutes in duration. Interviews were conducted between January and April 2010. The principle researcher conducted each interview using the person-centered interview approach. Participants were asked to respond, in their own words, to the following questions:
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Invitations to participate in this study were mailed to all ED nurses in the province of Manitoba, Canada, by the provincial nurses’ regulatory body. A convenience sample of registered nurses (n = 17) was selected from an overwhelmingly positive response to the request for volunteers to participate in the interviews (44%; n = 114). The sample included emergency nurses and educators who worked in urban (n = 11) and rural (n = 6) facilities. Saturation was achieved after completion of the 17 interviews.
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SAMPLE
1.What 2.What
does caring mean to you? affects caring in your practice in the emergency department?
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emergency department, the researchers described the caring nurse as open and perceptive, morally responsible, truly present, and genuinely concerned for the patient. 10 However, instrumental behavior, defined as emotionally detached but not insensitive care, predominated among the participants. Finally, Burhans and Alligood 11 used a phenomenological approach to explore the perceptions of medical and surgical nurses in the United States. Their essential themes revealed that human needs must be met through caring, empathy, and respectful interactions between nurses and patients. Factors affecting the ability to care have also been explored. In a qualitative study of surgical nurses, Enns and Gregory 12 found that factors affecting caring included lack of time, lack of caring support, tasking, increased acuity, increased workload, lack of resources, lack of continuity of care, emotional divestment, not caring for each other, and a lack of peer support. Qualitative descriptive studies have been conducted to explore caring within specialized areas of nursing practice, including intensive care and psychiatric units. 13,14 However, few studies have explored caring in the emergency department. 10,15 To date, the issue of discontent related to the inability to enact caring in the workplace persists because of staff shortages, lack of time, and workload issues. 8,12,16,17 As a result of the higher acuity of patients and nursing shortages and the chaotic work environment of the emergency department, caring behaviors may be in peril. The ability of the nurses to “care” may affect how they view their work environment and their own personal expressions of caring. Therefore, exploring the meaning of caring and the factors that affect caring for emergency nurses will facilitate the development of strategies to uphold the essence of caring in this work environment.
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DATA ANALYSIS
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The tape-recorded interviews were transcribed verbatim. Based on the work of Lincoln and Guba, 19 credibility, dependability, confirmability, and transferability were established to discern rigor and accurately represent participants’ experiences. Listening to the audio tapes (confirmability) assisted in validating the content of the interviews and corrected any discursive speech. Confirmability was also enhanced by recording notes during and after the interviews to identify essential structures to support the findings, which helped enlighten the researchers with regard to the topic of interest as each interview was conducted and analyzed. Dependability was supported through examination of the context of the findings, as well as how each interview contributed to the overall findings. Finally, transferability was established with rich descriptions that could be applied in other contexts by other researchers. Data collection and content analysis were performed concurrently. The primary researcher listened to the tape recordings and reviewed the notes after the interview. The researcher (CE) conducted the interviews and initial data analysis to maintain the credibility of the study. Each transcript was read several times by both researchers, and notes were formulated. Through discussion, themes and
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subthemes about the perspectives of caring and factors that affect caring in the emergency department were established.
support, shift work, and lack of self-care. The nurses shared the following elements that contributed to their inability to provide care for patients and their families in the emergency department.
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The Meaning of Caring: Emergency Nurses’ Perspectives
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Two major themes emerged from the nurses’ stories: patient advocacy and holistic care, including care for the patient and family. Although the meaning of “caring” is often described in the literature as an indefinable concept, the participants shared what caring meant to them:
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“…caring is being an advocate right now for patients because they are getting so lost in the system. It is helping them to get organized as they see so many different specialists all the time and they don’t have anyone that is their home person….”
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“Caring as a nurse…is taking care of my clients physically, emotionally, while maintaining the best care possible—being their advocate and being very holistic….”
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Nursing Work Environment: Factors Affecting Caring
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Participants identified factors affecting caring, including the workload, lack of time, staffing issues, lack of management
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In the emergency department, patients are assessed and cared for by nurses for a brief snapshot in time. Within this contemporary health care environment, the nurses expressed concern that patients were “lost in the system.” The participants expressed the importance of attempting to provide “whole” care for patients and their families, looking after all their needs within a specific time frame and in an often chaotic work environment. These nurses also lamented how important it was for them to feel as though they had provided “good” care.
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“Definitely it’s the workload, the assignments, the nurse to patient ratio…it’s the constant battle of priorities.”
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THEMES
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“…a lot of days you are there…you might be in the middle of triaging a patient who needs some education but then some traumas come in….”
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The unique culture and context of the workload in the emergency department was shared by all the participants. These emergency nurses conveyed feelings of displeasure in an environment where they are constantly being “pulled” in many directions.
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The study participants (n = 17) ranged in age from 26 to 61 years, with a mean age of 40 years. Work experience ranged from 3 to 37 years in the nursing profession and from 2 to 36 years in the emergency department. Ten participants had earned a diploma, and 7 had completed a baccalaureate degree; 12 were female and 5 were male. Data from the interviews revealed several themes related to expressions of caring and factors affecting ability to care. No differences in the thematic analysis were noted based on the demographic or educational background of the participants.
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The Workload. All participants painted a vivid picture of the work environment. They described a chaotic, fast-paced arena where they frequently endured difficult situations in which a heavy workload affected their “caring” capacity:
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Lack of Time. Participants described the lack of time spent with patients in the emergency department. They voiced concern that there was never enough time to address patients’ needs adequately, particularly during busy times:
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“Sometimes you can just provide very minimal care and sometimes not even that. That’s really hard to deal with because of the volume…that’s huge in caring for the new patients coming in.”
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“There is not proper follow-up for patients…they’re discharged so quickly, they don’t get patient education….”
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Participants noted that within the context of the emergency environment, patients are “revolving” through the doors of the department at an ever faster pace. They felt that the norm was “minimal” care for patients in their department. The participants expressed feelings of guilt because they did not have the time to provide quality care.
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Staffing Issues. Participants commented on staffing issues, which included staff shortages and concern about working with an increasing number of inexperienced junior staff. They shared examples of how these factors affected their ability to provide optimal nursing care, as well as their own self-care:
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“It’s a time factor; they (junior staff) don’t want to put in the time. I am finding the younger generation, they
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work hours beyond their scheduled shifts and occurs as a result of staff shortages, was clearly articulated by the participants as a barrier to care:
want to work part time, make enough to live their lifestyle…they see it as more of a job, it’s not something that you work towards…there are no more emergency nurses. When I started in emergency, you developed as an emergency nurse. Now it’s like a stepping stone to go somewhere.”
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“It might be your third or fourth 12-hour day…you have had some busy shifts and you have been working overtime…let’s say someone comes in you are just doing the basics for them…you’re trying to be friendly, considerate, but you are so tired…you have nothing left to give…you just kind of go through the motions.”
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Lack of Management Support. In order to care, all participants overwhelmingly described the need to feel supported and listened to by management. This underlying theme was the most pervasive among the participants.
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In order for these nurses to care for others, they realized the importance of caring for themselves. The increase in patient acuity, high patient turnover, and staffing issues were directly affecting their ability to provide optimal care for patients and their families.
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The participants articulated at length about the lack of support received from management and how this affected their ability to care for their patients. It was clear that the nurses wanted a manager who would listen to their work-related issues and ideas. They yearned for a manager who “validated” their concerns. Participants also believed that it was important for a manager to be visible on the unit and to assist with patient care decisions.
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“I’m not saying we have bad managers…sometimes I think the focus is so far removed from what we do that it’s hard for them to see. Our statistics are amazing… but we’re trying to tell our managers that we’re not providing the best care.”
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Shift Work. Although shift work is the norm in nursing, the participants shared the uniqueness of the emergency department in relation to caring and shift work. The “mandated overtime,” which requires nurses to
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“…you feel like you can’t even take care of yourself; you know, like making sure you eat and you drink properly.” “…you don’t feel like you’ve done a good job for your patient physically, mentally, emotionally and even for yourself…this is not the nurse that you wanted to be.”
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Lack of Self-Care. Participants described the importance of staying healthy and acknowledged that self-care is required in order to care effectively for others. Many of the participants expressed concern for their own health, as well as the general health and well-being of their peers:
“Currently our manager has been very supportive of nursing, which helps because it makes us feel validated…we have not felt validated for a long time.”
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The nurses all believed that given the context of the environment, “mandatory overtime” is unrealistic and unhealthy. Although the participants were mixed in their preference of either 8- or 12-hour work days, their major issue was being forced to work beyond scheduled shift times.
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Participants from both urban and rural institutions agreed that staff shortages were common. All participants reportedly worked overtime and extra shifts as a result of theses shortages. The more senior nurses noted that an increasing number of junior staff were working in the emergency department and that the generational differences were creating feelings of discontent among the staff. The senior nurses resented the younger generation for not being interested in working full time or developing professionally as emergency nurses. Many of the participants felt strongly that the unpredictable nature of the emergency department and the skills required to work there make it a poor work environment for newly graduated nurses.
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Discussion
The emergency nurses who participated in this study were very grateful for the opportunity to share their insights about caring in the work environment. The information elicited from this qualitative inquiry offers a distinct lens into the personal perspectives of nurses. Although findings from person-centered interviews are subject to various interpretations, the central themes were easily identified and extracted. These themes were congruent among the participants interviewed, as well as with previous research. The major elements relating to the meaning of caring for the participants included advocacy and holism. These
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Limitations
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The findings are limited to the participants interviewed and to their personal experiences. Nonetheless, the rich descriptions of caring and the factors affecting caring that emerged from the interviews provided insight into the meaning of caring for emergency nurses.
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Implications for Emergency Nurses
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Managers must be encouraged to develop strategies to create a supportive work environment that facilitates nurses’ caring perspective. As well, it is important for managers to increase their visibility and engagement with their staff. Although the nurses we interviewed lamented a loss of caring, most did not intend to leave their positions. Therefore, frontline nurses need to be supported to ensure they can perform their roles to the very best of their ability. Creating a culture of caring that is supported by the organizational and management perspective will truly enhance the nursing work experience. Moreover, further research is needed to explore the relationship between organizational factors and perceptions of caring.
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findings are consistent with a previous study of emergency nurses. 10 However, the nurses in our study also spoke of the challenges in the work environment that affected their ability to provide care. The nurses shared their interpretations of the meaning of caring, which included caring for the “whole” patient and acting as an advocate. Although the participants embraced the concept of caring in their practice, they expressed displeasure and discontent between the ideal and the reality in their workplaces. Several key factors hindered the participants’ ability to provide optimal care in the emergency department. Our findings are consistent with a study in which surgical nurses reported similar factors (ie, lack of time, lack of caring support, tasking, increased acuity, lack of continuity of care, emotional divestment, and not caring for each other) that impeded their ability to care. 12 However, in our study, the participants repeatedly stressed that the lack of support from managers was a major hindrance in their ability to care for patients. As well, the nurses discussed validation within the context of “not being listened to” by management. Participants felt disconnected from managers within the work environment. Consequently, the participants were unable to truly care for their patients. The overwhelming response rate of volunteers for the interview was congruent with a similar study 12 and affirms that these nurses want and need to be heard. Emergency nurses need to have the opportunity to voice concerns about their inability to provide “good care” in the chaotic ED work environment. Their voices lend support for previous research evidence that the high patient ratios and high acuity in the emergency department, as well as the increase in junior and inexperienced staff, contribute to poor job satisfaction, higher levels of burnout, and higher turnover rates. 20 The persistent theme of heavy workload/lack of time to provide optimal care is also supported by previous research. 15,21 A Canadian study of nurses on medical and surgical units found that discontent was present among nurses because of an imbalance between effort and reward in their work. 21 Similar to our study, workload and understaffing dominated the narratives, linking high patient acuity to the inadequacy of patient care. Although the nurses in our study enjoyed the challenge of the unique workplace, including the drama and excitement of the emergency department, they were frustrated by the perceived deficiencies in their ability to care. In summary, the 6 subthemes of heavy workload, lack of time, staffing issues, lack of management support, shift work, and lack of self-care were identified as factors affecting caring. These findings may be used to inform practice and improve the work milieu for emergency nurses. The lack of management support was particularly evident in this study.
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There is a need for ED managers to develop innovative strategies that will support an environment where nurses are able to truly care for their patients. Emergency nurses must also be supported in their need for “a voice.” Management that validates the expressions of concern from nurses will foster a positive working environment. Nurse managers need to develop strategies to support a work environment that supports nurses’ caring perspectives while also increasing their visibility and engagement with staff. Although the participants lamented a loss of caring, most did not intend to leave their positions in the emergency department. Therefore, frontline nurses need support in order to ensure they can perform their roles to the very best of their ability. It is also important for clinical nurses to continue to advocate for strategies that will have a positive impact on their ability to care. Creating a culture of caring that is supported by an organizational and management perspective will truly enhance the work experience. It will reduce physical and emotional burnout and increase job satisfaction, which in turn will have an overall favorable impact on the retention of emergency nurses.
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Nurse scholars continue to endorse the elusive concept of caring as universal and integral to nursing practice. When
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asked, “What does caring mean to you?” participants described their own perceptions and personal meanings of caring. Advocacy and holistic care were central themes in their descriptions of caring. The factors that affected their ability to care undermined their nursing practice and affected their job satisfaction. Because of the increase in acuity and complexity of our patients, the nursing shortage, and an aging population of nurses, it is particularly critical today to acknowledge the importance of caring perspectives and identify factors that enhance or deter nurses’ ability to care. Caring is central to nursing, and nurses still believe it is integral to their work.
7. Papastravou E, Efstathiou G, Charalambou A. Nurses’ and patients’ 932 perceptions of caring behaviours: quantitative systematic review of 934 comparative studies. J Adv Nurs. 2011;67(6):1191–1205. 936 8. Salimi S, Azimpour A. Determinants of nurses’ caring behaviors 938 (DNCB): preliminary validation of a scale. J Caring Sci. 940 2013;2(4):269–278. 942 9. Gustafsson C, Asp M, Fagerberg I. Municipal night nurses’ experience 944 of the meaning of caring. Nurs Ethics. 2009;16(5):599–612. 946 10. Wiman E, Wikblad K. Caring and uncaring encounters in nursing in an 948 emergency department. Iss Clin Nurs. 2004;13:422–429. 950
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11. Burhans LM, Alligood MR. Quality nursing care in the words of nurses. 952 J Adv Nurs. 2010;66(8):1689–1697. 954
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12. Enns C, Gregory D. Lamentation and loss: expressions of caring by 956 contemporary surgical nurses. J Adv Nurs. 2007;58(4):338–347. 958
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We thank the participants for their willingness to share their experiences in the interviews, as well the College of Registered Nurses of Manitoba for administrative support in this study.
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13. Cronqvist A, Lutzen K, Nystrom M. Nurses’ lived experiences of moral 960 stress support in the intensive care context. J Nurs Manage. 962 2006;14(5):405–413. 964
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19. Lincoln Y, Guba E. Naturalistic Inquiry. Beverly Hills, CA: Sage Publications. 20. Browning L, Ryan C, Thomas S, Greenberg M, Rolniak S. Nursing specialty and burnout. Psychol Health Med. 2007;12:248–254. 21. McGillis Hall L, Kiesners D. A narrative approach to understanding the nursing work environment in Canada. Soc Sci Med. 2005;61:2482–2491.
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3. Tschudin V. Ethics in Nursing: The Caring Relationship. 3rd ed. Oxford, England: Butterworth-Heinemann; 2003.
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EMERGENCY NURSES’ PERSPECTIVES: FACTORS AFFECTING CARING
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Authors: Carol L. Enns, MN, RN, and Jo-Ann V. Sawatzky, PhD, RN, Winnipeg, Manitoba, Canada
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Introduction: Caring is a universal phenomenon. However, as
Results: Advocacy and holistic care emerged as major themes
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in the meaning of caring for emergency nurses. Caring was affected by a number of factors, including workload, lack of time, staffing issues, shift work, and lack of self-care. However, lack of management support was the most consistent hindrance to caring identified by study participants.
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a result of higher patient acuity and staff shortages within the chaotic ED environment, caring behaviors may be in peril. The purpose of this study was to gain insight into the meaning of caring from the perspective of emergency nurses. Exploring nurses’ perspectives of caring is central to improving staffing and retention issues in this unique work environment.
Discussion: Caring continues to be a unifying concept in
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Methods: As part of a larger study, a subsample of emergency
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nurses who work in public hospitals in Manitoba, Canada (n = 17) were interviewed. A qualitative descriptive design was used to gain insight into the caring perspectives of nurses by asking them, “What does caring meaning to you?” and “What affects caring in your practice in the emergency department?” Emerging themes were extracted through analysis of audio tapes and transcripts.
nursing; however, influencing factors continue to undermine caring for emergency nurses. Caring is not subsidiary to nursing; it is the central core of nursing. Therefore, fostering a caring working environment is essential for nurses to practice holistic nursing care. It is also imperative to job satisfaction and the retention of emergency nurses.
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aring is a universal nursing phenomenon. It is understood and accepted as a fundamental value in nursing as both a discipline of knowledge and as a professional practice. 1 Nursing scholars contend that caring is the essence of nursing practice. Theorists agree that caring is central to the nursing role and have defined caring as a characteristic of nursing. 2–4 Certainly, nurses in practice view caring as relevant to their role. However, despite the vast amount of research and theoretical development with regard to caring, the meaning of caring has not been clearly established. Moreover, caring is inferred to be context specific. 5
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Carol L. Enns is Senior Instructor, Faculty of Health Sciences–College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada. Jo-Ann V. Sawatzky is Associate Professor, Faculty of Health Sciences– College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
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Funded by the Dr. Paul H.T. Thorlakson Foundation Fund, Winnipeg, Manitoba, Canada. For correspondence, write: Carol L. Enns, MN, RN, 277 Helen Glass Centre for Nursing, University of Manitoba, Winnipeg, MB, Canada R3T 2N2; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.12.003
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The emergency department is a unique nursing work environment. Factors such as the unpredictable nature of the department, increasing patient-to-nurse ratios, overcrowding, and high staff turnover rates contribute to this highly stressful contemporary work environment. 6 These factors may also influence ED nurses’ perception of caring and the ability to care. Although the meaning of caring has been explored in many areas of nursing, there is a dearth of literature specifically related to the perspectives of emergency nurses with regard to caring. Therefore, it was imperative to investigate the meaning of caring and the factors that affect caring from the emergency nurse’s point of view. Diverse theories of caring have fueled an ongoing debate among nursing theorists and researchers regarding its definition. As well, despite use of a variety of empirical methods to quantify the concept of caring, the results have been inconsistent. 7,8 However, the instruments used in these studies have attempted to define and measure different aspects of caring through the use of predetermined assessment scales. Whereas quantitative research has contributed to the body of evidence related to caring, qualitative research has also provided important contributions to our understanding of this concept. For example, in a study that explored the meaning of caring among hospital night nurses in Sweden, advocacy for patients and their relatives emerged as a major theme. 9 In another study, based on the content analysis of videotaped episodes in an
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Key words: Caring; Emergency nurses; Work environment
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Methods
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As part of a larger study described elsewhere, 18 a qualitative descriptive design was used to gain insight into the caring perspectives of emergency nurses.
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PROTECTION OF HUMAN SUBJECTS
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Ethical approval for this research was granted through a university-based research ethical review board. The regulatory body mailed written descriptions of the study, a copy of the quantitative survey, and invitations to participate in face-to-face interviews to all ED nurses within the province. Procedures included the assurance of participant confidentiality, including the use of assigned numbers. Specific interview consent forms were signed by participants prior to the interviews.
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DATA COLLECTION
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Data were collected through tape-recorded face-to-face interviews with individual participants; each interview was approximately 60 to 90 minutes in duration. Interviews were conducted between January and April 2010. The principle researcher conducted each interview using the person-centered interview approach. Participants were asked to respond, in their own words, to the following questions:
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Invitations to participate in this study were mailed to all ED nurses in the province of Manitoba, Canada, by the provincial nurses’ regulatory body. A convenience sample of registered nurses (n = 17) was selected from an overwhelmingly positive response to the request for volunteers to participate in the interviews (44%; n = 114). The sample included emergency nurses and educators who worked in urban (n = 11) and rural (n = 6) facilities. Saturation was achieved after completion of the 17 interviews.
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SAMPLE
1.What 2.What
does caring mean to you? affects caring in your practice in the emergency department?
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emergency department, the researchers described the caring nurse as open and perceptive, morally responsible, truly present, and genuinely concerned for the patient. 10 However, instrumental behavior, defined as emotionally detached but not insensitive care, predominated among the participants. Finally, Burhans and Alligood 11 used a phenomenological approach to explore the perceptions of medical and surgical nurses in the United States. Their essential themes revealed that human needs must be met through caring, empathy, and respectful interactions between nurses and patients. Factors affecting the ability to care have also been explored. In a qualitative study of surgical nurses, Enns and Gregory 12 found that factors affecting caring included lack of time, lack of caring support, tasking, increased acuity, increased workload, lack of resources, lack of continuity of care, emotional divestment, not caring for each other, and a lack of peer support. Qualitative descriptive studies have been conducted to explore caring within specialized areas of nursing practice, including intensive care and psychiatric units. 13,14 However, few studies have explored caring in the emergency department. 10,15 To date, the issue of discontent related to the inability to enact caring in the workplace persists because of staff shortages, lack of time, and workload issues. 8,12,16,17 As a result of the higher acuity of patients and nursing shortages and the chaotic work environment of the emergency department, caring behaviors may be in peril. The ability of the nurses to “care” may affect how they view their work environment and their own personal expressions of caring. Therefore, exploring the meaning of caring and the factors that affect caring for emergency nurses will facilitate the development of strategies to uphold the essence of caring in this work environment.
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DATA ANALYSIS
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The tape-recorded interviews were transcribed verbatim. Based on the work of Lincoln and Guba, 19 credibility, dependability, confirmability, and transferability were established to discern rigor and accurately represent participants’ experiences. Listening to the audio tapes (confirmability) assisted in validating the content of the interviews and corrected any discursive speech. Confirmability was also enhanced by recording notes during and after the interviews to identify essential structures to support the findings, which helped enlighten the researchers with regard to the topic of interest as each interview was conducted and analyzed. Dependability was supported through examination of the context of the findings, as well as how each interview contributed to the overall findings. Finally, transferability was established with rich descriptions that could be applied in other contexts by other researchers. Data collection and content analysis were performed concurrently. The primary researcher listened to the tape recordings and reviewed the notes after the interview. The researcher (CE) conducted the interviews and initial data analysis to maintain the credibility of the study. Each transcript was read several times by both researchers, and notes were formulated. Through discussion, themes and
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subthemes about the perspectives of caring and factors that affect caring in the emergency department were established.
support, shift work, and lack of self-care. The nurses shared the following elements that contributed to their inability to provide care for patients and their families in the emergency department.
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The Meaning of Caring: Emergency Nurses’ Perspectives
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Two major themes emerged from the nurses’ stories: patient advocacy and holistic care, including care for the patient and family. Although the meaning of “caring” is often described in the literature as an indefinable concept, the participants shared what caring meant to them:
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“…caring is being an advocate right now for patients because they are getting so lost in the system. It is helping them to get organized as they see so many different specialists all the time and they don’t have anyone that is their home person….”
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“Caring as a nurse…is taking care of my clients physically, emotionally, while maintaining the best care possible—being their advocate and being very holistic….”
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Nursing Work Environment: Factors Affecting Caring
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Participants identified factors affecting caring, including the workload, lack of time, staffing issues, lack of management
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In the emergency department, patients are assessed and cared for by nurses for a brief snapshot in time. Within this contemporary health care environment, the nurses expressed concern that patients were “lost in the system.” The participants expressed the importance of attempting to provide “whole” care for patients and their families, looking after all their needs within a specific time frame and in an often chaotic work environment. These nurses also lamented how important it was for them to feel as though they had provided “good” care.
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“Definitely it’s the workload, the assignments, the nurse to patient ratio…it’s the constant battle of priorities.”
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THEMES
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“…a lot of days you are there…you might be in the middle of triaging a patient who needs some education but then some traumas come in….”
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The unique culture and context of the workload in the emergency department was shared by all the participants. These emergency nurses conveyed feelings of displeasure in an environment where they are constantly being “pulled” in many directions.
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The study participants (n = 17) ranged in age from 26 to 61 years, with a mean age of 40 years. Work experience ranged from 3 to 37 years in the nursing profession and from 2 to 36 years in the emergency department. Ten participants had earned a diploma, and 7 had completed a baccalaureate degree; 12 were female and 5 were male. Data from the interviews revealed several themes related to expressions of caring and factors affecting ability to care. No differences in the thematic analysis were noted based on the demographic or educational background of the participants.
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The Workload. All participants painted a vivid picture of the work environment. They described a chaotic, fast-paced arena where they frequently endured difficult situations in which a heavy workload affected their “caring” capacity:
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Lack of Time. Participants described the lack of time spent with patients in the emergency department. They voiced concern that there was never enough time to address patients’ needs adequately, particularly during busy times:
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“Sometimes you can just provide very minimal care and sometimes not even that. That’s really hard to deal with because of the volume…that’s huge in caring for the new patients coming in.”
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“There is not proper follow-up for patients…they’re discharged so quickly, they don’t get patient education….”
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Participants noted that within the context of the emergency environment, patients are “revolving” through the doors of the department at an ever faster pace. They felt that the norm was “minimal” care for patients in their department. The participants expressed feelings of guilt because they did not have the time to provide quality care.
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Staffing Issues. Participants commented on staffing issues, which included staff shortages and concern about working with an increasing number of inexperienced junior staff. They shared examples of how these factors affected their ability to provide optimal nursing care, as well as their own self-care:
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“It’s a time factor; they (junior staff) don’t want to put in the time. I am finding the younger generation, they
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work hours beyond their scheduled shifts and occurs as a result of staff shortages, was clearly articulated by the participants as a barrier to care:
want to work part time, make enough to live their lifestyle…they see it as more of a job, it’s not something that you work towards…there are no more emergency nurses. When I started in emergency, you developed as an emergency nurse. Now it’s like a stepping stone to go somewhere.”
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“It might be your third or fourth 12-hour day…you have had some busy shifts and you have been working overtime…let’s say someone comes in you are just doing the basics for them…you’re trying to be friendly, considerate, but you are so tired…you have nothing left to give…you just kind of go through the motions.”
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Lack of Management Support. In order to care, all participants overwhelmingly described the need to feel supported and listened to by management. This underlying theme was the most pervasive among the participants.
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In order for these nurses to care for others, they realized the importance of caring for themselves. The increase in patient acuity, high patient turnover, and staffing issues were directly affecting their ability to provide optimal care for patients and their families.
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The participants articulated at length about the lack of support received from management and how this affected their ability to care for their patients. It was clear that the nurses wanted a manager who would listen to their work-related issues and ideas. They yearned for a manager who “validated” their concerns. Participants also believed that it was important for a manager to be visible on the unit and to assist with patient care decisions.
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“I’m not saying we have bad managers…sometimes I think the focus is so far removed from what we do that it’s hard for them to see. Our statistics are amazing… but we’re trying to tell our managers that we’re not providing the best care.”
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Shift Work. Although shift work is the norm in nursing, the participants shared the uniqueness of the emergency department in relation to caring and shift work. The “mandated overtime,” which requires nurses to
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“…you feel like you can’t even take care of yourself; you know, like making sure you eat and you drink properly.” “…you don’t feel like you’ve done a good job for your patient physically, mentally, emotionally and even for yourself…this is not the nurse that you wanted to be.”
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Lack of Self-Care. Participants described the importance of staying healthy and acknowledged that self-care is required in order to care effectively for others. Many of the participants expressed concern for their own health, as well as the general health and well-being of their peers:
“Currently our manager has been very supportive of nursing, which helps because it makes us feel validated…we have not felt validated for a long time.”
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The nurses all believed that given the context of the environment, “mandatory overtime” is unrealistic and unhealthy. Although the participants were mixed in their preference of either 8- or 12-hour work days, their major issue was being forced to work beyond scheduled shift times.
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Participants from both urban and rural institutions agreed that staff shortages were common. All participants reportedly worked overtime and extra shifts as a result of theses shortages. The more senior nurses noted that an increasing number of junior staff were working in the emergency department and that the generational differences were creating feelings of discontent among the staff. The senior nurses resented the younger generation for not being interested in working full time or developing professionally as emergency nurses. Many of the participants felt strongly that the unpredictable nature of the emergency department and the skills required to work there make it a poor work environment for newly graduated nurses.
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Discussion
The emergency nurses who participated in this study were very grateful for the opportunity to share their insights about caring in the work environment. The information elicited from this qualitative inquiry offers a distinct lens into the personal perspectives of nurses. Although findings from person-centered interviews are subject to various interpretations, the central themes were easily identified and extracted. These themes were congruent among the participants interviewed, as well as with previous research. The major elements relating to the meaning of caring for the participants included advocacy and holism. These
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Limitations
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The findings are limited to the participants interviewed and to their personal experiences. Nonetheless, the rich descriptions of caring and the factors affecting caring that emerged from the interviews provided insight into the meaning of caring for emergency nurses.
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Implications for Emergency Nurses
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Managers must be encouraged to develop strategies to create a supportive work environment that facilitates nurses’ caring perspective. As well, it is important for managers to increase their visibility and engagement with their staff. Although the nurses we interviewed lamented a loss of caring, most did not intend to leave their positions. Therefore, frontline nurses need to be supported to ensure they can perform their roles to the very best of their ability. Creating a culture of caring that is supported by the organizational and management perspective will truly enhance the nursing work experience. Moreover, further research is needed to explore the relationship between organizational factors and perceptions of caring.
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findings are consistent with a previous study of emergency nurses. 10 However, the nurses in our study also spoke of the challenges in the work environment that affected their ability to provide care. The nurses shared their interpretations of the meaning of caring, which included caring for the “whole” patient and acting as an advocate. Although the participants embraced the concept of caring in their practice, they expressed displeasure and discontent between the ideal and the reality in their workplaces. Several key factors hindered the participants’ ability to provide optimal care in the emergency department. Our findings are consistent with a study in which surgical nurses reported similar factors (ie, lack of time, lack of caring support, tasking, increased acuity, lack of continuity of care, emotional divestment, and not caring for each other) that impeded their ability to care. 12 However, in our study, the participants repeatedly stressed that the lack of support from managers was a major hindrance in their ability to care for patients. As well, the nurses discussed validation within the context of “not being listened to” by management. Participants felt disconnected from managers within the work environment. Consequently, the participants were unable to truly care for their patients. The overwhelming response rate of volunteers for the interview was congruent with a similar study 12 and affirms that these nurses want and need to be heard. Emergency nurses need to have the opportunity to voice concerns about their inability to provide “good care” in the chaotic ED work environment. Their voices lend support for previous research evidence that the high patient ratios and high acuity in the emergency department, as well as the increase in junior and inexperienced staff, contribute to poor job satisfaction, higher levels of burnout, and higher turnover rates. 20 The persistent theme of heavy workload/lack of time to provide optimal care is also supported by previous research. 15,21 A Canadian study of nurses on medical and surgical units found that discontent was present among nurses because of an imbalance between effort and reward in their work. 21 Similar to our study, workload and understaffing dominated the narratives, linking high patient acuity to the inadequacy of patient care. Although the nurses in our study enjoyed the challenge of the unique workplace, including the drama and excitement of the emergency department, they were frustrated by the perceived deficiencies in their ability to care. In summary, the 6 subthemes of heavy workload, lack of time, staffing issues, lack of management support, shift work, and lack of self-care were identified as factors affecting caring. These findings may be used to inform practice and improve the work milieu for emergency nurses. The lack of management support was particularly evident in this study.
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There is a need for ED managers to develop innovative strategies that will support an environment where nurses are able to truly care for their patients. Emergency nurses must also be supported in their need for “a voice.” Management that validates the expressions of concern from nurses will foster a positive working environment. Nurse managers need to develop strategies to support a work environment that supports nurses’ caring perspectives while also increasing their visibility and engagement with staff. Although the participants lamented a loss of caring, most did not intend to leave their positions in the emergency department. Therefore, frontline nurses need support in order to ensure they can perform their roles to the very best of their ability. It is also important for clinical nurses to continue to advocate for strategies that will have a positive impact on their ability to care. Creating a culture of caring that is supported by an organizational and management perspective will truly enhance the work experience. It will reduce physical and emotional burnout and increase job satisfaction, which in turn will have an overall favorable impact on the retention of emergency nurses.
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Nurse scholars continue to endorse the elusive concept of caring as universal and integral to nursing practice. When
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asked, “What does caring mean to you?” participants described their own perceptions and personal meanings of caring. Advocacy and holistic care were central themes in their descriptions of caring. The factors that affected their ability to care undermined their nursing practice and affected their job satisfaction. Because of the increase in acuity and complexity of our patients, the nursing shortage, and an aging population of nurses, it is particularly critical today to acknowledge the importance of caring perspectives and identify factors that enhance or deter nurses’ ability to care. Caring is central to nursing, and nurses still believe it is integral to their work.
7. Papastravou E, Efstathiou G, Charalambou A. Nurses’ and patients’ 932 perceptions of caring behaviours: quantitative systematic review of 934 comparative studies. J Adv Nurs. 2011;67(6):1191–1205. 936 8. Salimi S, Azimpour A. Determinants of nurses’ caring behaviors 938 (DNCB): preliminary validation of a scale. J Caring Sci. 940 2013;2(4):269–278. 942 9. Gustafsson C, Asp M, Fagerberg I. Municipal night nurses’ experience 944 of the meaning of caring. Nurs Ethics. 2009;16(5):599–612. 946 10. Wiman E, Wikblad K. Caring and uncaring encounters in nursing in an 948 emergency department. Iss Clin Nurs. 2004;13:422–429. 950
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11. Burhans LM, Alligood MR. Quality nursing care in the words of nurses. 952 J Adv Nurs. 2010;66(8):1689–1697. 954
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12. Enns C, Gregory D. Lamentation and loss: expressions of caring by 956 contemporary surgical nurses. J Adv Nurs. 2007;58(4):338–347. 958
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We thank the participants for their willingness to share their experiences in the interviews, as well the College of Registered Nurses of Manitoba for administrative support in this study.
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13. Cronqvist A, Lutzen K, Nystrom M. Nurses’ lived experiences of moral 960 stress support in the intensive care context. J Nurs Manage. 962 2006;14(5):405–413. 964
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