ship building with drawing

Running head: LITERATURE REVIEW 1

Literature Review: How to Reduce Stress in Emergency Nurses and Prevent Burnout

Thuy-Van T. Pham

West Coast University Orange County

NURS 540 Research Utilization

Dr. Orel Ramirez

September 27, 2020

LITERATURE REVIEW 2

Research Proposal: How to Reduce Stress in Emergency Nurses and Prevent Burnout

Literature Review

Emergency nursing is one of the crucial departments and practices in the healthcare

sector. The department deals with different, challenging and severe health conditions daily. The

medical approach utilized and exercised in the department includes immediate care and

emergency care since most of the patient health conditions are life-threatening. Evidence

supports that the emergency department often has the mandate of handle exacerbation of various

critical situations, such as myocardial infarction, cardiovascular disorder, and trauma, among

others (Ahwal & Arora, 2015). Some studies highlight that emergency department nurses require

a new and excellent level of expertise and training since the environmental conditions often

expose the practitioners to stress and burnout, among other psychological issues. Nurse burnout

is a condition where nurses are exposed to chronic fatigue, emotional exhaustion, irritability,

weight loss or gain, or depression, among other signs and symptoms (Melby & Harkin, 2014). It

has and is becoming a significant issue in the healthcare sector since it affects efficient and

effective care delivery. While there is no permanent confirmation on a percentage of emergency

nurses experiencing burnout due to research gap and data variation as per constraints such as

regions, emergency nursing age and experience, and the intensity of the workload: The topic still

creates a lot of concern since the emergency department is one of the vital departments that

influences and promotes acute care to the public.

Statistical Analysis

Over the years, there have been many studies composed in qualitative or quantitative

research approaches concerning nurse stressors that lead to burnouts. Besides, a series of these

studies have been organized to explore work-stress among health professionals, particularly

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those working in the emergency departments. Several studies have been highlighted that

emergency department nurses and other professionals are often exposed to burnout syndrome

due to excess workload and high demand for emergency care and treatment. A study conducted

by Moukarzel et al. (2019), indicated that alterations in work environments and medical

situations are often linked with the increasing prevalence of mental risks that might expose the

nurses to physical and mental health issues. The same study supported that some of the

significant issues related to nurse burnout include musculoskeletal disorders and work-

driven/related psychological problems. Among the three, burnout syndrome accounts for roughly

7% of all the psychological issues affecting the physicians working emergency departments in

the United States. In other words, in nations such as the U.S. and France, roughly 6.8% of the

nurses working in the medical emergency department often show burnout syndrome (Moukarzel

et al., 2019). In other terms, the study strengthens the topic by highlighting that emergency

department nurses are among the vulnerable healthcare provider groups due to extensive and

excessive workload.

Emotional Exhaustion

A study conducted by Harkin and Melby (2014) supported Moukarzel et al.’s position on

the topic by confirming that burnout syndrome has enhanced the prevalence of emergency nurses

that experience higher levels of emotional exhaustion than other medical professionals in the

same department. Additionally, the same study reflected that the majority of emergency nurses

showed higher de-personalization levels than other medical personnel working in the emergency

department, among other sectors. Nonetheless, Harkin and Melby (2014) strengthened their

hypothesis by highlighting that out of the thirty-nurses interviewed, 56% of them experienced

higher burnout levels than the emergency nurses that recorded only 20%. Nevertheless, the

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scholars highlighted that emergency nurses are considered vulnerable and at-risk than other

nurses. The same studies also indicated that most of the affected emergency nurses confront their

stressors, for example, overcrowding, noises, complaints from the patients, and abuses, by

seeking for group or individual intervention programs. Fortunately, these nurses are equipped

with the right skills and knowledge to handle such issues (Harkin & Melby, 2014; Moukarzel et

al., 2019). The study contributed to the topic by stating that ancient studies correlated burnout

with the practitioner or nurses working in emergency departments; for instance, younger

inexperienced emergency stationed nurses experience higher burnout episodes than older

experienced nurses.

Nevertheless, Ahwal and Arora (2015) focused their attention on understanding

workplace stress for nurses stationed in the emergency sector. The study supports Harkin &

Melby’s and Moukarzel et al.’s studies by highlighting that the emergency department

environments expose nurses to a series of stressors that affect them both mentally and physically.

According to the scholars, the workload was not the primary cause of burnout among nurses, but

the highly challenging work nurses are exposed to. The scholars raised several issues; some

include, norms of the work environment that had low accountability, uncontrolled working shift

schedules, inadequate frequencies at which the practitioners rotate, traumatic situations, and poor

leadership and management skills. Some of the other stressors that were not mentioned by

Harkin and Melby (2014) included lack of teamwork, increased mortality rates, traumatic deaths,

or dealing with major incidents. Furthermore, the scholars highlighted that most critically ill

patients exposed young and inexperienced emergency nurses to stress and burnouts. The

evidence stated that emergency department staff had been tasked with the obligations to cope up

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with the acute and chronic stressors daily (Ahwal & Arora, 2015). The same team needs to

explore other options by seeking assistance to manage the workplace effectively.

Environmental Factors

Moustake and Constantinidis (2010) implemented theories deduced by McGrath to

establish primary reasons why emergency department nurses are often victims of stress and

burnout than other nurses assigned to different healthcare departments. The study stretched by

stating that the environment status threatens to pull the practitioner’s capabilities, and the

professional does so if he/she receives the little reward in the everyday practice (Ahwal & Arora,

2015). Besides, the same study highlighted that an individual’s fear is what he/she cannot

predict, for example, the future, since it is often associated with low self-esteem and stress.

Nevertheless, there are contradicting theories used in understanding the norms of pressure, for

instance, some hypothesis suggests that it is different from one practitioner to another; others

believe that its primary cause is a stressful situation that lasts for a long time. Due to these

theories, Moustake and Constantinidis thought that the major causes of burnout among nurses

working in healthcare emergency departments include, working environment, interpersonal

relationships, nature of the practice, organizational factors, and role attributes (2010).

Burnout among emergency department nurses is a broad topic. Dyrbye et al. (2019)

adhere to the premise since the act can cause mental and physical health issues among the nurse

attendants at the emergency setup. Dyrbye et al. (2019), narrowed their study and focused on the

correlation between absenteeism and job performance with nurse burnout experiences.

According to the study, the scholars reported that professional burnout affects roughly 35-40% of

U.S. nurses. Besides, the scholars defined burnout as a syndrome often experienced through

exhaustion that is directly influenced by the cynicism of their duties and often limits or reduces

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one professional efficacy (Moukarzel et al., 2019). Furthermore, the study indicated that

excessive work and low working environments are generally universal contributors to nurse

burnout. A study reflects that burnout syndrome is the primary cause of a series of health issues

in the emergency department and, if not addressed, often leads to the nurses getting involved in

absenteeism (Dyrbye et al., 2019). Almost all healthcare communities try to establish strategies

to curb burnout. Fortunately, most of these medical setups have invested in various norms of

limiting burnout among the nurses. In this case, they successfully contain and solve the issues

related to burnouts; then, they often obtain a positive return on the investment.

Psychological and Physical Prospects of Burnout

While some studies understand occupational burnout as a physical issue due to workout,

some studies correlate it as a psychological issue. The same studies have linked burnout with

employment turnover intentions associated with workplace violence. According to a survey

conducted by Hamdan and Hamra (2017), like the developed nations such as France and the

U.S., Palestinian hospitals, particularly the emergency department health, face higher levels of

burnouts among their nurses. One of the signs and symptoms used identifying burnout is the

emotional exhaustion among the nurses, and it is often associated with health issues and at times

negatively affects the well-being of professional by exposing them to anxiety, depression and

low self-esteem (Hamdan & Hamra, 2017; Harkin & Melby, 2014). Nonetheless, studies indicate

that emotional exhaustion is highly correlated to excessive workload, anxiety/stress, and lack of

control over the emergency environment. Unfortunately, there are no universal scales used in

understanding the percentage of emergency nurses affected since the range differs from hospital

to hospital, expertise, age, and management levels over the entire work environment.

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Psychological studies have deduced that emotional exhaustion often arises during times

of anxiety or stress. Other triggers of emotional exhaustion include being a caregiver, chronic

medical condition, and working in environments that experience high pressure from the

management and patients. The evidence also reflects that the percentage of nurses affected by

emotional exhaustion often experience physical and emotional impacts that affect their cognitive

response to situations. According to an extensive study on the mental changes when experiencing

emotional exhaustion, nurses often experience mood shifts that usually affects their relationship

with other co-workers and patients (Ahwal & Arora, 2015). Change of mood is often highlighted

by the emergency nurses' cynical approaches towards situations or when socializing with their

colleagues. Nonetheless, emotional exhaustion affects the nurses' critical thinking capabilities,

such as exposing them to confusing and mixing up ideas, difficulty concentrating, and lack of

imagination. Due to burnout, most nurses are often exposed to a decline in executive function,

attention, and memory. Nonetheless, these nurses often experience sleeping disorder issues

(Hamdan & Hamra, 2017). Nevertheless, emotional exhaustion manifests into physical impacts

such as appetite alterations, headaches, weight loss, and cardiovascular problems. Such

environments disable the capabilities of the nurses to perform their duties.

Burnout Mitigation Programs

While some literature such as Ahwal and Arora (2015), Moukarzel et al., (2019), and

Harkin and Melby (2014) advocate on the causes and adverse impacts of burnout among

emergency nurses, some have dedicated their time and resources addressing on how best to

prevent and manage burnout. A series of studies in this field have proposed a series of solutions

to emergency nurse burnout. Still, only a few of these approaches have been implemented in an

actual emergency department. According to a study conducted by de Oliveira et al. (2019), the

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authors suggested a series of skills and plans used in preventing and managing burnout and stress

based on the emergency nurse attributes, resilience, and the ability to cope. According to the

study, one of the significant issues affecting emergency nurses is the resilience to cope with all

the activities and horrific events experienced in the department. According to de Oliveira et al.

(2019), nurses need continuous and repetitive resilience delineating training that would reduce

stress levels. Additionally, the same study highlighted that attributes such as resilience could be

taught, mainly to deal with cognitive behavior and adapt to the profession's ever-changing

demand.

Studies highlighted that building resilience is more of a mental practice than just a

theoretical approach used to understand challenging situations. It is a practice that needs

adequate preparation, both mentally and spiritually, to foster wellness. According to literary

studies, nurses working in emergency departments are often faced with lots of challenges. To

some extent, they lack time to enhance and focus on self-care. Evidence support that the best

approach towards becoming resilient is by taking care of one-self. It is a mental process that

helps establish resilience; for example, nurses who promote a healthy and positive lifestyle such

as adequate sleep, hydration, regular exercise, and proper nutrition adapt to stress easily and are

often not affected by burnout. A second discussion proposed implementing mindfulness such as

journaling, yoga, and other spiritual meditation process to build a connection with consciousness

to restore hope. Such an approach is often used in accepting positive reflection that is important

in deducing models that assist in managing stress. Besides, resilience training is a model that

helps nurses find their purpose in helping others, being proactive, setting daily goals and

attaining them, and searching for opportunities for self-discovery.

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In a systematic review by Aryankhesal et al. (2019), the authors accepted that a larger

percentage of emergency department nurses are exposed to stress and burnout. Unfortunately,

such a situation exposes the patients and the entire department of healthcare issues that might

affect the whole setup. The systematic review highlighted that these nurses could only maintain

consistent, effective performance if they receive internal or external assistance. According to

Aryankhesal et al. (2019), many healthcare organizations have deduced many interventions to

assist curb burnout syndrome. These programs have often been established based on the purpose

of enhancing psychological health for emergency nurses. The plans include motivational

initiatives, effective communication models, therapeutic approaches, and combined strategies. In

a general perspective, motivational programs are often established to gratify the emergency

department nurses and appreciate their work. The program is usually initiated by using

professional identity programs that are structured to equip and strengthen the nurses’ beliefs on

their duties. The study also indicated that these programs had registered 100% success rates in

minimizing burnouts among emergency nurses (Aryankhesal et al., 2019). Unlike the norms of

training resilience that is more of a psychological and practical process that lacks a universal

guide, communication is a tool that is essential in this sector. It can be trained on various

occasions.

The approach that has a higher success rate towards burnouts management include the

norms of practical communication skills by either implementing verbal, non-verbal, or

technology-based gestures. Effective communication is an approach that promotes the criteria of

coming into consensus with other nurses or patients. It is a means of establishing a new system

of practice that supports two-way means of communication; for example, team-based and

participatory programs assist in reducing signs and symptoms of stress and enhance mental

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health since it supports dual-discussion approach. Two-way communication between emergency

department nurses helps them establish joint operations that are positively linked to managing

symptoms such as irritation, anger, and anxiety. Nonetheless, Aryankhesal et al., (2019) agreed

with de Oliveira et al. (2019) that psychiatric mitigation plans such as yoga, mindful journaling,

and meditation are essential prospects that can reduce burnouts and enhancing mental well-

being. Also, most studies have confirmed the importance of copying techniques to assist

emergency nurses in reducing burnout rates among emergency nurses. Indeed, a series of studies

have reflected the importance of coping strategies. Still, medical facilities do not recommend it

since the approach accumulates lots of time and resources before the emergency nurses are ready

to comply and continue with their duties.

It is a fact that humans and their immediate environments interact daily, so do the nurses

and the emergency department. The presence of environmental stimuli that surpass human ability

is harmless towards the survival of well-being. It causes essential reactions in the evolution, the

maintenance and balance between well-being and ecological concern. One of the critical issues

revolving the circumstance includes chronic psychological stress experienced by nurses working

in emergency departments (Bagheri et al., 2019). Studies reflect that the best evidence-based

approach used in managing burnouts includes cognitive-behavioral therapy. It is an approach that

supports the training of coping skills and establishes a positive relationship between

demographics attributes of employment and burnout. In other terms, cognitive and behavioral

therapy promotes better training resources to enable nurses to attain better experience and

adaptability skills (Bagheri et al., 2019). Unfortunately, health practitioners have criticized the

approach for decades since the course is only useful for new and inexperienced emergency

nurses or younger nurses without adequate knowledge and information toward coping with the

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emergency department duties. With such critics on the cognitive and behavioral therapy model,

some studies have advised affected nurses to ensure they deduce individual plans by seeking help

since collective approaches might not assist with the burnout.

The norms of burnout have been a significant issue in the healthcare sector for quite some

time. While developed nations seek ways of solving the problem, most developing countries are

still gathering information based on the topic. Literary studies highlight that the norms of nursing

shortages and working in highly demanding environments, and emergency personnel can

experience burnouts that might affect their physical and mental health. Unfortunately, there are

inconsistencies in the burnout curve among emergency nurses, particularly since not all

emergency departments experience the same environmental intensity, among other health issues

such as excessive workload, stress, and anxiety. Without an exact percentage of emergency

nurses affected by burnout, there are different information and statistical data to assist the

population. Medical facilities have deduced a series of mitigation approaches to help emergency

nurses cope with their work environment.

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References

Ahwal, S., & Arora, S. (2015). Workplace stress for nurses in emergency department.

International Journal of Emergency & Trauma Nursing, 1(2): 17–21.

Aryankhesal, A., Mohammadibakhsh, R., Hamidi, Y., Alidoost, S., Behzadifar, M., Sohrabi, R.,

& Farhadi, Z. (2019). Interventions on reducing burnout in physicians and nurses: A

systematic review. Medical Journal of Islamic Republic of Iran., 33: 77. doi:

10.34171/mjiri.33.77.

Bagheri, T., Fatemi, M., Payandan, H., Skandari, A., & Momeni, M. (2019). The effects of

stress-coping strategies and group cognitive-behavioral therapy on nurse burnout. Ann

Burns Fire Disasters, 32(3): 184–189.

de Oliveira, S., Sousa, L., Gadelha, M., & do Nascimento, V. (2019). Prevention actions of

burnout syndrome in nurses: An integrating literature review. Clinical Practice

Epidemiology Ment Health, 15: 64–73. doi: 10.2174/1745017901915010064.

Dyrbye, L., Shanafelt, T., Johnson, P., Johnson, L., Satele, D., & West, C. (2019). A cross-

sectional study exploring the relationship between burnout, absenteeism, and job

performance among American nurses. BMC Nursing, 18:57. 1-8.

Hamdan, M., & Hamra, A. (2017). Burnout among workers in emergency eepartments in

Palestinian hospitals: Prevalence and associated factors. BMC Health Services Research,

17. https://doi.org/10.1186/s12913-017-2356-3.

Melby, V., & Harkin, M. (2014). Comparing burnout in emergency nurses and medical nurses.

Clinical Nursing Studies, 2(3):152-163. DOI: 10.5430/cns.v2n3p152.

Moukarzel, A., Michelet, P., Durand, A.-C., Sebbane, M., Bourgeois, S., Markarian, T., &

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Gentile, S. (2019). Burnout syndrome among emergency department staff: Prevalence

and associated factors. BioMed Research International, 2019.

https://doi.org/10.1155/2019/6462472.

Moustaka, Ε., & Constantinidis, T. (2010). Sources and effects of work-related stress in nursing.

Health Science Journal, 210-216.