PREDICTORS OF STRESS IN THE ACCIDENT AND EMERGENCY UNITS

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CHAPTER 2 LITERATURE REVIEW

INTRODUCTION

Rebar, Gersch, Macnee and McCabe (2011:206) describe literature review as a synthesis of the literature that describes what is known or has been studied regarding the particular research question or purpose. According to Kumar (2011:32) literature review used in a study can help in making the subject of investigation to be understood better, and shape the research problem so that it can be conceptualized clearly and precisely. This makes it more pertinent to the researcher’s field of enquiry. It reveals the aspects of the subject of research that have been examined by others, what they have found out about these aspects, what gaps they have identified and what suggestions they have made for the future research. All these discoveries help to gain insight into one’s own research questions and provide with clarity, which are central to a relevant and valid study.
The topic of research in this study is about strategies to enhance the support systems of the nurses in an accident and emergency unit of a regional urban hospital at KwaZulu-Natal. This chapter therefore involves the discussion of published information from various reliable sources regarding the A&E unit issues. It gives a summary of the arguments, ideas and conclusions of previous researchers based on these issues. These arguments have provided the researcher with a foundation for the research topic, which aims at improving the health of nurses and in turn patient care in the A&E units.
There is a close relationship between the researcher’s topic of inquiry and the previous investigations based on A&E issues. Previous investigations traced mainly focus on the factors that have been noted to be the sources of high stress levels in that they are associated with critical incidents. The consideration of these previous investigations has helped the researcher to explore the information that is directly related to this study, making it important to credit those who have made such information available and worth acknowledging. This information has shaped and directed the researcher’s investigation to take place within its own context without having to duplicate other researchers’ findings about A&E units. It explores administrative-environmental factors as well as characteristic specific A&E unit work factors that are associated with critical incidents. Most of the previous literature avails this information in the form of qualitative research studies, which coincides, with the researcher’s planned qualitative approach of investigation that will ensure exploration of subjective views about the targeted A&E units.
Searching for the published information involved mainly the use of two engines, namely, the University of South Africa (UNISA) online library and the public online search, namely, the google scholarly search. The advantage of the UNISA online library is that it guides to the specific field of search such as ‘Health Studies’ and Nursing Research’ in the case of this study. From the specific field it then provides a variety of resources/sites for information such as, among other things, the books, articles, and theses and dissertations. The researcher to reach the subject database with nursing articles commonly used the site for articles. The data base sites included the academic research premier, health resource and CINALL, which led to the EBSCO host search. In order to obtain the relevant information, the researcher entered the key words that form the backbone of the research topic such as ‘emergency unit’, ‘nurse’, ‘support’ and ‘urgency’. The theoretical framework selected by the researcher for the study suggested more key words like ‘coping’ and ‘stress’. The latest articles were retrieved by adjusting the period of publication to the latest years, namely 2008 – 2016. Less frequently, the public online search engine was used although the researcher had to be specific to request scholarly articles to ensure reliability of the information. For every article retrieved, references were checked for latest articles used as an additional source of information. The researcher’s own experience in the A&E unit also guided the search.
Fifty-three (53) articles with the identified key words were retrieved for use in both Chapters 1 and Chapter 2 of the study. Countries associated with the accepted articles abound outside South Africa especially in the Middle East, Europe and United Sates of America (USA). Most of the articles discuss the overwhelming A&E conditions followed by a suggestion for support strategies for nurses as the way forward.
While many are based in the A&E units, a few are based in other hospital units such as psychiatric and paediatric units, which are also noted to have high stress levels. The researcher for comparison also used the later with the A&E units regarding the levels of stress and health outcomes. South Africa and Africa as a whole do not show many articles related to nurse support in the A&E units though much work has been done in relation to the state of emergency in the continent, triage and improving A&E units in many other ways other than supporting the nurses only.

 DEVELOPMENT OF INTERVENTION STRATEGIES

Since stress in the form of physical, psychological, and emotional reactions is quite predictable in workplaces where critical incidents form part of daily activities, intervention strategies are becoming popular for protection of those exposed to workplace trauma. Intervention strategies aim at neutralizing the traumatizing effects of critical incidents by dealing hands on with people concerned during or following the occurrence of a critical incident (Davis 2013:68).
While on one hand it is important to understand how work issues/pressures act as predictors of workplace stress, it is, on the other hand, also relevant to take note of the contribution of other related variables that predict the perception of workplace stress. It is therefore appropriate that any attempts to investigate into workplace issues involving critical events with the aim of developing intervention strategies, should also explore into the influence of cognitive styles, personality dimensions and coping strategies of people concerned (Pino & Rossini 2012:2). This would lead to better decisions for development of sustainable intervention programs, which, according to Chou, Li and Hu (2014:2) should be feasible stress reducing programs in hospitals. Milutinovic, Golubovic and Prokes (2012:177) add that the understanding and recognizing of all risk factors is important in that it can also contribute in the prevention of work-related diseases.
Development of intervention strategies can be based on the interpretation given by those concerned about the work situation. Regarding the accident and emergency (A&E) work situation, it is noted that some of the A&E staff may not even identify and interpret some of the A&E incidents as critical and stressful because of the frequency with which they take place; also that to certain staff, a certain amount of stress resulting from such incidents can act as a motivational factor, encouraging them to focus on tasks at hand (Healy & Tyrrel 2012:35). In another instance, it is noted that A&E staff do perceive workplace stress but show differences in the levels of their perception of stressfulness as indicated by the extent to which they develop physical and psychological symptoms (Milutinovic, Golubovic & Prokes 2012:177).
Studies that rank the A&E events according to their severity also show that staff concerned may differ in their opinions regarding the severity of stress, in that incidents identified by staff as ranking very high in determining the occurrence of stress in one study maybe identified as ranking low or very low in another or other studies and vice versa (Adriaaenssens, de Gucht & Maes 2012:1415; Healy & Tyrrel 2012:34; Milutinovic, Golubovic & Prokes 2012:177).
Thus, the need to carefully estimate the magnitude to which the A&E issues have had physical, psychological and emotional consequences regarding staff safety, health and performance, as well as assessing the coping abilities and the amount of support interventions that have been in place over years for the staff working in these units cannot be overemphasized. According to Healy and Tyrrell (2011:37), establishing a supportive culture for the situation, should value staff and demonstrate recognition of and concern for the effects of stress. Uren and Graham (2013: 5) believe that support is often a fundamental component in dealing with the daily stressful situations experienced by caregivers at work and that the absence of such structures allocates further responsibility to the caregiver to find on her/his own, the needed support.

 PREDICTORS OF STRESS IN THE ACCIDENT AND EMERGENCY UNITS

In predicting the occurrence and consequences of occupational stress among health workers, certain studies have analysed and highlighted the relationship between certain identified stressors and health stress related outcomes (Adriaenssens, de Gucht & Maes 2015:347; Pino & Rossini 2012:2; Sterud, Hem, Lau & Ekeberg 2011:2).
Two main categories of stressors have been studied to determine the extent to which they can influence health outcomes.
These involve the administrative-organizational, and the job characteristic/specific factors. Among administrative-organizational factors, problems cited include, among others, the environmental conditions, workload, staff shortage, inadequate material resources, and little or lack of support from managers. Job specific factors include the type of events inherent in the job, the degree and frequency of exposure of staff to the related events, especially, high job demand, and low job control. For this reason, Sterud, Hem, Lau & Ekeberg 2011:2) raise the importance of assessing well the category of stressors that is more specific in a situation in order to determine health outcomes on staff concerned. For instance, administrative – organizational stressors may not be an issue in jobs like ambulance work, but job specific related factors such as high frequency in dealing with critical incidents may be the most important source of frustration and low job satisfaction.

Administrative-organizational factors

Carrus, Corbett and Khandelwal (2010:1) indicate that the issues that confront the hospital A&E units cannot be understood to be emanating only from the malfunctioning of the A&E units. To a certain extent, extra-departmental problems involving even the environment in general, contribute. There is therefore a reason to expect administrators to also evaluate the root causes of the A&E issues, and anticipate participation from all the relevant departments in solving them while A&E staff receives necessary support. House, Nyabera, Yusi and Rusyniak (2013: 2) suggest even going outside the hospital to the extent of knowing about the local patient population, which involves their demographics, volumes and patterns of their arrival in A&E units, as well as common complaints. This information is required to tailor the programs for staff, students, and patient support in these units. In terms of these observations, concentration on identifying local sources of issues affecting staff output and patient care outcomes in the A&E units can resolve A&E issues to a certain extent. However, a wider approach of investigating beyond these units can prove more profitable and add more value towards suggesting strategies that can enhance the support systems to staff working in them.

CHAPTER 1  ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 RESEARCH PROBLEM
1.4 RESEARCH PURPOSE
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITION OF TERMS
1.7 THEORETICAL FOUNDATION OF THE STUDY
1.8 THEORETICAL FRAMEWORK
1.9 INTRODUCTION TO RESEARCH DESIGN AND METHODS
1.10 STRUCTURE OF THE THESIS
1.11 SUMMARY
CHAPTER 2  LITERATURE REVIEW
2.1 INTRODUCTION
2.2 DEVELOPMENT OF INTERVENTION STRATEGIES
2.3 PREDICTORS OF STRESS IN THE ACCIDENT AND EMERGENCY UNITS
2.4 EFFECTS OF EXPOSURE TO CRITICAL EVENTS
2.5 NURSES’ COPING STRATEGIES WITH CRITICAL INCIDENTS
2.6 SOCIAL SUPPORT
2.7 SUMMARY
CHAPTER 3  RESEARCH DESIGN AND METHODS
3.1 NTRODUCTION
3.2 RESEARCH APPROACH FOR PHASE I
3.3 RESEARCH DESIGN
3.4 RESEARCH METHOD
3.5 ETHICAL CONSIDERATIONS
3.6 TRUSTWORTHINESS
3.7 RESEARCH METHODS FOR PHASE II
3.8 SUMMARY
CHAPTER 4  ANALYSIS, PRESENTATION, AND DESCRIPTION OF THE RESEARCH FINDINGS
4.1 INTRODUCTION
4.2 DATA MANAGEMENT
4.3 DATA COLLECTION PROCESS
4.4 DATA ANALYSIS
4.5 RESEARCH RESULTS
4.6 DISCUSSION OF THE FINDINGS
4.7 SUMMARY
CHAPTER 5  PRESENTATION OF THE STRATEGIES
5.1 INTRODUCTION
5.2 THE PURPOSE OF THE STRATEGIES
5.3 THEORETICAL FRAMEWORK
5.4 METHODOLOGY FOR DEVELOPMENT OF STRATEGIES
5.5 SUPPORT STRATEGIES
5.6 VALIDATION OF THE STRATEGIES
5.7 SUMMARY
CHAPTER 6  CONCLUSIONS AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 THE PURPOSE OF THE STUDY
6.3 RESEARCH DESIGN AND METHODS
6.4 CONCLUSIONS FROM THE STUDY
6.5 RECOMMENDATIONS
6.6 CONTRIBUTIONS OF THE STUDY
6.7 LIMITATIONS OF THE STUDY
6.8 SUMMARY
LIST OF REFERENCES
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