Analysis

Pinpointing and relieving stress in emergency departments

Working in an emergency department (ED) is a demanding and high-pressure job. Previous studies have suggested that ED staff may experience higher rates of anxiety, depression and burnout than their colleagues, but exactly what may be the triggers of the stress is less well known.

Working in an emergency department (ED) is a demanding and high-pressure job. Previous studies have suggested that ED staff may experience higher rates of anxiety, depression and burnout than their colleagues, but exactly what may be the triggers of the stress is less well known.

Researchers at the University of Sheffield recently carried out a literature review to dig deeper into what makes ED staff stressed. Factors such as high demand came up frequently in the 25 studies.

But a number of studies also found that other issues such as role ambiguity, low managerial and peer support, insufficient pay, lack of professional recognition and limited opportunities to attend educational conferences also contribute to burnout and compassion fatigue. Some of the studies included in the Emergency Medicine Journal (EMJ) review cited

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Working in an emergency department (ED) is a demanding and high-pressure job. Previous studies have suggested that ED staff may experience higher rates of anxiety, depression and burnout than their colleagues, but exactly what may be the triggers of the stress is less well known.


Pinpointing where stress begins in EDs was the focus of a recent study. Picture: Alamy

Researchers at the University of Sheffield recently carried out a literature review to dig deeper into what makes ED staff stressed. Factors such as high demand came up frequently in the 25 studies.

But a number of studies also found that other issues such as role ambiguity, low managerial and peer support, insufficient pay, lack of professional recognition and limited opportunities to attend educational conferences also contribute to burnout and compassion fatigue. Some of the studies included in the Emergency Medicine Journal (EMJ) review cited the four-hour waiting target in England as a stressor.

Age contributors

Several studies reported higher rates of anxiety and depressive symptoms in female healthcare workers, while burnout was most prevalent among younger staff and those with fewer years of experience in the specialty.

11.7 million

Working days lost to work-related stress, anxiety and depression in Great Britain in 2015-16

‘Those workers encountering stress, but remaining in work may experience physical and psychological illness, be prone to making errors and develop maladaptive lifestyle behaviours,’ the study says.

‘It follows that work stress, burnout and intention to leave the specialty may often be related.’

Work-related stress can lead to a wide range of physical and mental health problems, including anxiety, depression and hypertension. In the 2016 NHS staff survey, more than one third of staff (37%) reported feeling unwell due to work-related stress.

Employer concern

Workplace pressures should also be of concern to employers, as the Health and Safety Executive has identified work-related stress as a leading cause of sickness absence, high staff turnover and early retirement in the UK workforce.

ED clinical coordinator at the Royal Victoria Hospital in Belfast Linsey Sheerin says that camaraderie and support from teams can keep emergency nurses going. But the volume of work keeps growing and is putting nurses under more and more pressure. 

‘Crowding in EDs is regularly documented and probably one of the biggest moral battles for an emergency nurse is when care is left undone, because they are faced with having to pick the least worst situation,’ Ms Sheerin says.

‘This can often lead to frustration and moral distress, which ultimately can lead to burnout, stress and chronic stress. The ED is seen as a stress-heavy environment and there can be a high turnover of staff. Post-traumatic stress disorder in emergency care is a real phenomenon and we must think radically about how to support our staff or we will continue to ride the waves of high staff turnover and burnout.’

37%

of all work-related ill health caused by stress in Great Britain, 2015-16

Michael Paynter, Somerset Partnership NHS Foundation Trust consultant nurse in urgent care, says that a more recent cause of significant stress in the ED is the increasing level of responsibility and clinical decision-making taken on by emergency nurses.

Many band 6 and band 7 nurses are working at the same level as a senior registrar, having to make constant rapid assessments of whether patients should be admitted or not. With the push towards fewer referrals, nurses work with the fear of being accused of not admitting a patient at the right time. This has changed significantly over the past five years.

Higher thresholds

‘There are judgements made now that five years ago would have been considered unethical. The threshold for admission has become higher. The volume of patients we see in EDs or urgent care units is something like 22 million in England each year, and most of these things go right. But when they don’t we need to look after our teams.’

Emergency nurses are leaving due to this pressure, Mr Paynter says. Good occupational health services and support from managers, employers and defence organisations such as the RCN can help staff cope with the arduous nature of investigations and allegations, he says.

Loss of control can be a significant stressor for senior ED nurses trying to help a busy department run smoothly, says University of Wolverhampton senior lecturer in emergency care Jim Bethel.

‘When demand outstrips supply in any aspect, then it feels like control of the shift has been lost and may be difficult to retrieve,’ he says. ‘This loss of control – while maintaining responsibility for its consequences – is stressful.’

Identifying stress

Signs of stress include:

  • Negative or depressive feelings.
  • Increased emotional reactions – more tearful, sensitive or aggressive.
  • Loneliness and feeling withdrawn.
  • Loss of motivation, commitment and confidence.
  • Mood swings.
  • Poor concentration and memory.
  • Changes in eating habits.
  • Increased smoking, drinking or drug-taking 'to cope'.
  • Changes in sleep patterns.
  • Changes in attendance such as arriving later or taking more time off.

Source: Health and Safety Executive

 

The EMJ research suggests that EDs should try to pinpoint the causes of some stress and address them through initiatives such as supporting managers to provide additional staff support, increasing workers’ autonomy over the job or improving relationships through building morale. Staff who could benefit from stress-reduction techniques should be offered counselling, mindfulness and cognitive-behavioural therapies. More complex cases may need support from trained specialists such as occupational health professionals.

Retired RCN professional lead for mental health Ian Hulatt says staff can help protect their well-being. ‘The first thing is for individuals to be honest with themselves about whether they are feeling stressed and then to have a look, either on their own or with a good friend or significant other, at whether they are managing it.’

23.9

Average number of working days lost to stress in Great Britain during 2015-16

Source: Health and Safety Executive

Nurses need to consider how they can alter their lifestyle to help them cope, Mr Hulatt says. Exercise, including intense activities and more relaxing approaches such as yoga, and mindfulness can be helpful to reduce the impact of stress. Smartphone apps on mindfulness, which research suggests can help people cope with physical and mental health issues, can be an easy and cheap way to incorporate this practice into a person’s life.

The EMJ study suggests that approaches used by staff could include counselling, mindfulness and cognitive-behavioural therapies.

‘Be honest and open, develop some selfcare and be kind to yourself,’ says Mr Hulatt. ‘There is a lot that people can do which is not extraordinarily expensive or time consuming.’

Find out more

Mental health and staff well-being in the emergency department – RCNi articles

 

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