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Experiences of and actions towards worries among ambulance nurses in their professional life: A critical incident study
International Emergency Nursing (2008) 16, 35–42
www.elsevierhealth.com/journals/aaen
Experiences of and actions towards worries among ambulance nurses in their professional life: A critical incident study Anders Svensson RNPEN, MNSc (Lecturer) RNT, PhD (Professor) a
a,b,*
, Bengt Fridlund RNAN,
a
¨xjo ¨ University, Centre for Acute and Critical Care, School of Health Sciences and Social Work, Va ¨xjo ¨, Sweden SE-351 95 Va b ¨xjo ¨, Sweden Department of Emergency Care, Central Hospital, Va Received 20 March 2007; received in revised form 26 September 2007; accepted 14 October 2007
KEYWORDS
Abstract Nurses working in the ambulance service are frequently exposed to situations in which they have to take sole responsibility for sick or injured patients, many of which can be emotionally trying. The purpose of this study was therefore to describe critical incidents in which ambulance nurses experience worry in their professional life and the actions they take in order to prevent and cope with it. The sample consisted of 13 male and 12 female nurses working in ambulance services in three small to medium-sized counties in the south of Sweden. The data were collected by means of interviews and analysed according to Critical Incident Technique (CIT). The result showed that nurses worried about specific emergency situations as well as situations related to their working environment. Worry was alleviated by their own actions or with help from others. It was also shown that, with increasing experience, came a responsibility to be able to cope with all kinds of situations. This responsibility was experienced as worrying. However, if the nurse felt confident in their colleague, the worry could ease. It was concluded that the worry experienced by ambulance nurses in specific emergency situations requires flexibility on the part of the ambulance service. Nurses must be given the opportunity to address their worries in the way that is most appropriate for each individual. c 2008 Elsevier Ltd. All rights reserved.
Ambulance nurse; Worry; Qualitative method; Ambulance service
* Corresponding author. Address: Centre for Acute and Critical Care, School of Health Sciences and Social Work, Va ¨xjo ¨ University, SE-351 95 Va ¨xjo ¨, Sweden. Tel.: +46 470 708379. E-mail address: [email protected] (A. Svensson).
Background Ambulance personnel are frequently faced with situations in which they have to take sole
1755-599X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2007.10.002
36 responsibility for seriously sick or injured patients as well as those in shock; a reality in which the circumstances vary from one situation to another. Patients with life threatening symptoms are treated under conditions complicated by emotional, cultural and social factors (Suserud, 2002). Some situations are perceived as more overwhelming, resulting in the ambulance personnel experiencing a higher level of worry (Alexander and Klein, 2001). It has been found that a person with a tendency to worry about problems that occur in his/ her everyday life runs the risk of developing anxiety and depression (Boehnke et al., 1998). Intense worry undermines the active measures he/she normally takes in complex and possibly problematic situations. Further, such difficulties tend to escalate; the more worried and anxious the person is, the more threatening the potential problem appears to be (Boehnke et al., 1998). The pressure the ambulance personnel frequently have to endure can lead to post-traumatic stress syndrome (Jonsson et al., 2003; Jonsson and Segesten, 2004). Ambulance personnel, independent of their level of education (Suserud and Haljama ¨e, 1997), are seldom distressed by major accidents or grave personal injuries but rather by situations in which they feel compassion for the patients and their relatives. Such situations can be related to accidents involving children or suicide (Regehr et al., 2002). There is a connection between this work related worry and physical and psychological symptoms like stomachache, headache and sleeping disorders, when studying both female and male ambulance personnel. It has been shown that 25% of female and 20% of male ambulance personnel experienced two or more of the above-mentioned symptoms as a result of their professional life (Assa et al., 2005). Therefore, worry as a risk factor for ambulance personnel should not be ignored. In order to identify active measures to prevent worrying there is a need for a more detailed mapping of emergency situations that cause ambulance personnel to worry. Therefore, the purpose of this study was to describe critical incidents in which ambulance nurses experience worry in their professional life and the actions they take in order to prevent and cope with it.
Method Study design and method The study had a descriptive qualitative design and was analysed according to Flanagan’s Critical Incident Technique (CIT) (Flanagan, 1954). The
A. Svensson, B. Fridlund objective of this method is to gather observations of human behaviour by means of descriptions of real, well-defined and meaningful incidents. The incidents can be collected through observations, interviews, questionnaires or self-reports (Flanagan, 1954). It is of great importance that the subject under investigation has a well-defined purpose and that the respondents are given the opportunity to describe both positive and negative critical incidents that they perceive as important. The number of incidents can vary, depending on the complexity of the purpose, but more than 100 is usually recommended in order to achieve an adequate analysis (Andersson and Nilsson, 1964).
Ambulance nurses In line with qualitative designs the respondents were selected strategically; i.e. with regard to socio-demographic and professional characteristics such as age, education level, sex and years in the profession (Fridlund, 2006). The group of respondents were collected from three ambulance services in small to medium-sized counties in the south of Sweden and consisted of 13 male and 12 female ambulance nurses. Their work experience in the ambulance profession varied between 1 and 20 years and some had specialist education within different fields of nursing (see Table 1).
Table 1 Socio-demographic and professional characteristics of the ambulance nurses (N = 25) Sex Male Female Number of years in the profession 1–4 5–9 10–14 15–19 20– Specialist education Prehospital emergency nurse Anaesthetic nurse Prehospital emergency and Anaesthetic nurse No specialist education Number of years in ambulance service 1–4 5–9 10–14 15–19 20–
13 12 8 4 6 4 3 12 3 2 8 6 7 6 5 1
Experiences of and actions towards worries among ambulance nurses
Ethical considerations
Extract descriptions of critical incidents of importance to the activity under investigation
The study adhered to the principles outlined in the Declaration of Helsinki (World Medical Association Declaration of Helsinki, 2005). In Sweden there is no need for consent to be obtained from an ethical board if written consent has been obtained from the respondents and if the study does not involve a physical intervention affecting a person. The managers of the ambulance service involved gave approval for the study to be conducted in their department. Ambulance nurses, suggested by the managers, were sent a letter containing information about the purpose of the study, that participation was voluntary and that they were free to withdraw from the study at any time without having to provide an explanation. The respondents gave their written consent to take part in the study. They were also assured that the data would be treated confidentially. The interviews were conducted at a location chosen by the nurses. Three interviews took place over the phone, since it suited those respondents best (Swedish National Board of Health and Welfare, SPS 2003:460).
Label and classify the incidents with similar behavior into: SUB-CATEGORIES
Label and classify the sub categories after content into: CATEGORIES
Label and classify the categories after the comprehensive structure of the data into: MAIN AREAS
Data collection Data were collected by means of semi-structured interviews, which were recorded on an MP3 player and later transcribed verbatim. The interviews started with an open question about critical incidents; i.e. emergency situations in which the nurses experienced worry and the actions he/she took in order to deal with it. This question was followed by more in-depth questions such as ‘‘How do you mean? Explain how you felt!’’ in order to obtain a clear picture of how the nurses had experienced the situation. The interviews lasted between 12 and 25 min.
Data analysis The data analysis started by carefully reading through the interviews on several occasions in order to become familiar with the content. Incidents related to the aim were delimited and subjected to a structural analysis in line with the CIT-tradition (see Box 1). A total of 262 critical incidents were identified. Comparison of the incidents was then made in order to find similarities and differences and with the aim of grouping them together. These incidents were categorized by experiences and actions, in 12 and 13 sub-categories, respectively. Some of the behaviours fitted into more than one of the sub-categories, thus the sub-category that
37
Box 1 Framework summery on how the data was categorized according to the Critical Incident Technique (Flanagan, 1954).
best accorded with the behaviour described was chosen. The sub-categories were then divided in a similar way into 5 and 6 categories as well as 2 and 2 main areas, respectively. The purpose of a category is to describe the general character of the sub-categories, while that of the main area is to describe the overall theme contained in the data (Andersson and Nilsson, 1966).
Results Worry related to specific emergency situations (Table 2) Worrying about feeling inadequate The nurses worried about situations in which he/ she felt inadequate. The worry derived from not knowing how to manage the assignment when meeting a patient. ‘‘The worry comes from not being able to help the patient in a satisfactory way’’. Unusual calls could lead to insecurity:
38 Table 2
A. Svensson, B. Fridlund Summary of the main areas, categories and sub-categories of emergency situations that worry nurses
Main area
Category
Sub-category
Worry related to specific emergency situations
Worrying about feeling inadequate
The nurse feels worried in situations where he/she cannot manage the assignment (8) The nurse feels worried in situations for which he/she is unprepared (7) The nurse feels worried in situations where he/she lacks experience (6)
Worrying about emergency situations in which the nurse may be personally involved
The nurse feels worried in situations where he/she knows the patient (11) The nurse feels worried in situation she/she can associate with his/her personal life (9)
Worrying about specific calls
The nurse feels worried in situations involving children (14) The nurse feels worried in situations involving child birth (4)
Worrying about emergency situations which there is a lack of control
The nurse feels worried in situations where he/she risks his/ her own safety (20) The nurse feels worried in situations that he/she cannot control (11) The nurse feels worried in situations where the technical equipment fails (7)
Worrying related to lack of trust
The nurse feels worried in situations where he/she lacks confidence in his/ her colleague (9) The nurse feels worried in situations where he/she experiences a lack of trust from management (8)
Worry related to the working environment
Number of incidents in brackets.
‘‘. . . lack of experience makes you a beginner every time’’. It was considered important to be prepared for all possible scenarios: ‘‘. . . if you do not get a lot of information on the way out, you do not know what to expect’’.
nurses could relate to how they would have reacted themselves if they had been personally involved: ‘‘I could see myself in the parents’ situation’’. It seemed that their own family situation governed their emotions: ‘‘. . . I have children myself, so I could see myself in their situation’’.
Worrying about emergency situations in which the nurse may be personally involved The nurses worried when a situation could be associated with their personal life. They worried about going to addresses or places where relatives or friends might be: ‘‘. . . the worry you feel when you leave is that it might be one of your own’’. They sometimes experienced situations that were very similar to their own private life: ‘‘I went out on a call pertaining to sudden infant death . . . it concerned twins, and I have twins myself’’. The
Worrying about specific calls The nurses worried in situations involving children or childbirth. In many cases the worry was due to the feeling that everything they did had to be right: ‘‘Because they have their whole life ahead of them, so to speak. Older people have lived their lives, more or less’’. They also felt the pressure from the parents: ‘‘. . . what a disaster for the parents if something were to happen’’. A feeling of helplessness in situations where the children were unable to express themselves could also be identi-
Experiences of and actions towards worries among ambulance nurses fied: ‘‘. . . so it is difficult to get a correct anamnesis of what is wrong’’.
Worry related to the working environment (Table 2) Worrying about emergency situations in which there is a lack of control The nurses were worried about situations in which they lacked control: ‘‘That you cannot control the situation//you want to be in control when you are at the scene of an accident or in someone’s home’’. They were also faced with threats and violence: ‘‘. . . the feeling of discomfort when someone gets really mad and you can see it in their eyes that they may explode at any moment and you cannot escape’’. Colleagues exposed nurses to situations that they could not control: ‘‘. . . the driver of the emergency vehicle was not capable of doing his job//I do not really feel that I can trust the colleague I am travelling with’’. Some worried when the technical equipment failed: ‘‘. . . you try to transmit an ECG from a heart patient and it does not work and you can see for yourself that the patient has suffered an infarction.’’ Worrying related to lack of trust The nurses were worried in situations in which they lacked confidence in their colleague: ‘‘. . . if I lack
39
confidence in my colleague I worry about both him/her and myself, that we will not manage it’’. Lack of trust on the part of the management team was also a reason: ‘‘Our managers do not provide us with a sense of security’’.
Alleviating worry by one’s own actions (Table 3) Reflecting on worry The nurses reflected on their worry: ‘‘I think it is a healthy kind of worry in a way. A certain amount of stress and worry is good so to speak, because it makes you more alert’’. Worry was analysed on the way to a patient: ‘‘You have to prepare yourself as much as possible when you are on your way to the patient. Think about different scenarios, the kind of equipment you have, the kind of measures you might have to take’’. Sometimes the nurses tried to ignore the worry, in order not to be influenced by it: ‘‘I cannot say that I go around worrying, because if I did, I don’t think I could cope with this job’’. Experience has an influence on worry Professional experience influenced worry: ‘‘. . . the longer you have worked and the more you have experienced, the calmer you are, because you know you can manage//I think that experience is
Table 3 Summary of the main areas, categories and sub-categories describing what actions nurses take in order to alleviate and cope with their worry Main area
Category
Sub-category
Alleviating worry by one’s own actions
Reflecting on worry
The nurse ignores his/her worry (12) The nurse’s worry decreases with mental preparation (12) The nurse’s worry results in focused energy (8)
Experience has an influence on worry
The nurse’s worry decreases with increasing experience (25) The nurse’s worry changes over the years (6)
Alleviating worry by theoretical means
The nurse’s worry decreases by gleaning knowledge from literature (14) The nurse’s worry decreases with increasing education (8)
Alleviating worry by practical means
The nurse’s worry decreases by means of training exercises (11) The nurse’s worry decreases with the help of clinical practice in other departments (9)
Worry is alleviated Seeking support after by healthcare the emergency situation professionals and next-of-kin’s actions Seeking support in the emergency situation Number of incidents in brackets.
The nurse’s worry decreases when he/she talks to someone he/she considers trustworthy (17) The nurse’s worry decreases/increases by means of debriefing (7) The nurse’s worry decreases if he/she feels confidence in his/her colleague (10) The nurse’s worry decreases if back-up is called in (9)
40 the most important thing in this job’’. However, worry about some situations increased with experience: ‘‘. . . the more you have learnt through the years, the more you can do, and the more responsibility you take in the ambulance, the more reason you have to worry’’. The worry changed over the years: ‘‘. . . you get more familiar with some things, but you also realise that you are not good at everything. Perhaps you were more naive before and thought that everything would work out in one way or the other.’’ Alleviating worry by theoretical means The nurses tried to alleviate worry through theoretical studies: ‘‘. . . I have done the specialist education now//education provides knowledge and knowledge provides security’’. The nurses reflected on how to fill gaps in their knowledge by means of education: ‘‘. . . you wish that you had more training in the area of children’’. Literature studies led to in-depth knowledge: ‘‘. . . If you feel insecure you should study the guiding principles of this workplace, and if I think about something at home, then I look it up in books.’’ Alleviating worry by practical means The nurses tried to alleviate worry by improving their clinical practice: ‘‘. . . you take part in as many exercises and training sessions as possible’’. It was seen as important to do exercises together with other professions: ‘‘. . . practise together with the fire brigade and so on’’. The nurses practiced at different departments in order to fill gaps in their knowledge ‘‘. . . I try to go to the delivery ward sometimes//then you are prepared for that and you gain experience too’’.
Worry is alleviated by healthcare professionals and next-of-kin’s actions (Table 3) Seeking support after the emergency situation The nurses coped with worry by seeking support after a difficult situation: ‘‘. . . you talk about it with a colleague you have confidence in and feel secure with’’. They also spoke to persons from outside the ambulance service: ‘‘We have a lot of contact with the hospital chaplains’’ and with next-ofkin: ‘‘my partner works within medicine too, and she knows what it is like to meet patients . . . it feels good to talk to someone about it sometimes’’. This was not always a positive experience: ‘‘It can be difficult to get other people to understand. If you tell different people, they find other
A. Svensson, B. Fridlund aspects more distressing than the ones I find unpleasant’’. Seeking support in the emergency situation Worry could disappear if the colleague was considered trustworthy: ‘‘If I work together with the same people as usual, then we know each other well. Then you work more as a team. You know each other well and know what the other person can and cannot do.’’ Knowing that one had a competent colleague could relieve worry: ‘‘. . . my colleague is a good communicator, so he would have to deal with that aspect’’. In some situations, back-up was called in to relieve worry: ‘‘I have sent for a midwife in some situations in which I felt insecure’’. Contact could also be made by phone: ‘‘. . . you can dial the emergency service centre’’.
Discussion Methodological issues According to Fridlund (2006), the researcher of a qualitative study needs to reflect on the applicability, concordance, security and accuracy of the material, in order to safeguard the security of the data collection. Applicability describes how well the sample conforms to the purpose of the study. Respondents from three organisations were selected from a broad base of age group, specialist education and number of years in the profession, in order to obtain a clear picture of the concept of worry from an ambulance nurse’s perspective. Interviews were chosen as the data collection method, which allowed the respondents to describe their thoughts in more detail with the help of follow-up questions. The CIT method also makes it possible to collect data via observations, questionnaires and self-reports (Flanagan, 1954). However, these methods would probably not result in the same breadth of data, since the possibility for reflection would not be available. However, they could have been used as a complement to the interviews, thus enhancing the researchers’ understanding. Concordance describes the validity of the design in relation to the purpose. The design was seen as highly applicable in this kind of study, since the purpose was to describe situations the nurses found meaningful and decisive for their experience and behaviour. As both the researchers and the nurses were familiar with the environment in which the study was conducted, the risk of misunderstanding during the interviews was minimised.
Experiences of and actions towards worries among ambulance nurses The interviews and transcriptions were carried out by the same person in order to safeguard the security of the study. The interviews were also read through several times before categorizing them into sub-categories, in order to further improve security. The incidents were analysed according to character and content. This step was repeated several times before the end result emerged. The categorizing of incidents into sub-categories was conducted in cooperation with the second researcher, experienced both in theory and practice, which minimised the risk of subjectivity (Andersson and Nilsson, 1964). Direct quotes from the interviews strengthened the accuracy of the study.
Results issues Worry related to specific emergency situations The nurses worried about specific situations that could arise in their profession. Situations that evoked worry were related to children. Alexander and Klein (2001) and Regehr et al. (2002) also found that situations involving children were a source of worry for ambulance personnel. The nurses found it difficult to describe why such calls distressed them, but a certain amount of external influence was evident. It could arise from the demands placed on the nurses by the parents of the sick or injured child or from the father in situations involving childbirth. The nurses worried about becoming personally involved in situations where they knew the patient or could associate the case with something in their personal life. According to Alexander and Klein (2001), this can be very emotionally trying. Since most of the nurses in the study worked and lived in the same area, they ran the risk of being exposed to such situations quite frequently. The nurses found the feeling of inadequacy to be a source of worry. It could arise from the insecurity they experienced at seeing the sick or injured patient with their own eyes. According to Jonsson and Segesten (2004), ambulance personnel can divert this type of worry by engaging in an inner dialogue with themselves by which they prepare mentally for what they are about to see. The nurses felt that their worry eased, the more they were exposed to emergency situations. Worry related to the working environment The nurses worried in situations where they felt a lack of confidence in their colleague or lack of trust from their managers. Similar results were obtained in a study by Van der Ploeg and Kleber (2003). Lack of confidence in close colleagues arose from situations in which the nurse had felt little or no support
41
when working with that particular person. Not being able to trust a colleague is seen as very trying (Alexander and Klein, 2001). The nurses also worried about situations they could not control, the most characteristic being violence or threats against them. The worry in such situations came from the fear of being hurt. According to Suserud et al. (2002), threats against ambulance personnel are increasing. They point out that managers need to see the importance of providing self-defence training and equipping their personnel with alarms. Worry is alleviated by one’s own actions The nurses believed that worry could be alleviated through more training exercises as well as clinical practice in other departments at the hospital. According to Alexander and Klein (2001), it is of great importance that ambulance personnel are given the opportunity to do clinical exercises in order to prepare themselves for the emotional and exhausting calls that they may have to face. The nurses reflected on their worry in specific situations and considered it to result in focused energy and a strong ability to take action. Reflection on previous experiences is a tool for ambulance personnel to mentally prepare for future scenarios (Jonsson and Segesten, 2004). The nurses felt that their worry changed over the years. The worry evoked by certain types of situation decreased in line with increasing experience. However, the opposite could also be seen. Situations that were not worrying initially could become a source of worry with increasing experience, which was also pointed out by Alexander and Klein (2001). The ambulance nurses felt that, with increasing experience, came a responsibility to be able to cope with all kinds of situations. This responsibility led to worry in some situations. Worry is alleviated by healthcare professionals and next-of-kin’s actions The nurses sought support in emergency situations by calling in back-up, thus reducing their worry. They used trustworthy persons as sparring partners in order to ventilate their worry. This could take place during or after the situation. In order to leave trying situations behind and move on, it is important to talk about thoughts, emotions and experiences with a trusted person (Jonsson and Segesten, 2004). Most of the time, the ambulance nurses consulted a colleague. Some found debriefing a good method for reducing worry. Others, however, claimed that this only served to increase their worry.
42
A. Svensson, B. Fridlund
Conclusions and implications The study has shown that worry among ambulance nurses can both be related to specific nursing situations and to the working environment. Since worry is a subjective term, experienced in various ways by different people, it is complex and demands an ambulance service that can offer a broad range of methods of support in order to help the nurses to deal with their worry. The study has also revealed that worry is handled individually or with help from others. Nurses need to verbalise practical ways of learning to tackle their worry and to obtain support from the ambulance organisation in order to do so. There is a need for more in-depth studies of ambulance nurses’ experiences of worry. Such studies should be based on the actions the nurses find efficient for minimising their individual worry. These actions should then be included in educational interventions and follow-up training for ambulance nurses. One way to facilitate the nurses is to provide them with an opportunity to practise things that are important for reducing their worry in specific situations. Furthermore, ambulance nurses point out the importance of working with a skilled colleague. The cooperation with the colleague can both increase and decrease the worry in some situations. This phenomenon should be studied more in-depth in order to map how the interaction with colleagues influences the worry among ambulance nurses.
References Alexander, D.A., Klein, S., 2001. Ambulance personnel and critical incidents. British Journal of Psychiatry 178, 76–81. Andersson, B.-E., Nilsson, S.-G., 1964. Studies in the reliability and validity of the critical incident technique. Journal of Applied Psychology 48 (6), 398–403.
Andersson, B.-E., Nilsson, S.-G., 1966. Analysis in Work and Educational Areas by Means of the Critical Incident Technique. La ¨romedelsfo ¨rlaget, Stockholm. ¨ngquist, K.-A., Barnekow-Bergqvist, M., Assa, U., Brulin, C., A 2005. Work-related psychosocial factors, worry about work conditions and health complaints among female and male ambulance personnel. Scandinavian Journal of Caring Sciences 19, 251–258. Boehnke, K., Schwartz, S., Stromberg, C., Sagiv, L., 1998. The structure and dynamics of worry: theory, measurement, and cross-national replications. Journal of Personality 66 (5), 745–782. Flanagan, J.C., 1954. The critical incident technique. Psychological Bulletin 51, 327–358. Fridlund, B., 2006. Writing a scientific manuscript: some formal and informal proposals. European Journal of Cardiovascular Nursing 5, 185–187. Jonsson, A., Segesten, K., 2004. Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel. Accident and Emergency Nursing 12, 215–223. Jonsson, A., Segesten, K., Mattsson, B., 2003. Post-traumatic stress among Swedish ambulance personnel. Emergency Medicine Journal 20, 79–84. Regehr, C., Goldberg, G., Hughes, J., 2002. Exposure to human tragedy, empathy, and trauma in ambulance paramedics. American Journal of Orthopsychiatry 72 (4), 505–513. Suserud, B.-O., 2002. Ambulance responses at a disaster site. Emergency Nurse 9 (10), 22–27. Suserud, B.-O., Haljama ¨e, H., 1997. Role of nurses in prehospital emergency care. Accident and Emergency Nursing 5, 145–151. Suserud, B.-O., Blomqvist, M., Johansson, I., 2002. Experiences of threats and violence in the Swedish ambulance service. Accident and Emergency Nursing 10, 127–135. Swedish National Board of Health and Welfare, 2003. SFS 2003:460. The Ministry of Education and Cultural Affairs. The Act Concerning the Ethical Review of Research involving Humans. Swedish National Board of Health and Welfare, Stockholm. Van der Ploeg, E., Kleber, R.J., 2003. Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occupational Environment Medicine 60, 40– 46. World Medical Association Declaration of Helsinki, 2005. Ethical principles for medical research involving human subjects. (accessed 23.09.05).
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/aaen
Experiences of and actions towards worries among ambulance nurses in their professional life: A critical incident study Anders Svensson RNPEN, MNSc (Lecturer) RNT, PhD (Professor) a
a,b,*
, Bengt Fridlund RNAN,
a
¨xjo ¨ University, Centre for Acute and Critical Care, School of Health Sciences and Social Work, Va ¨xjo ¨, Sweden SE-351 95 Va b ¨xjo ¨, Sweden Department of Emergency Care, Central Hospital, Va Received 20 March 2007; received in revised form 26 September 2007; accepted 14 October 2007
KEYWORDS
Abstract Nurses working in the ambulance service are frequently exposed to situations in which they have to take sole responsibility for sick or injured patients, many of which can be emotionally trying. The purpose of this study was therefore to describe critical incidents in which ambulance nurses experience worry in their professional life and the actions they take in order to prevent and cope with it. The sample consisted of 13 male and 12 female nurses working in ambulance services in three small to medium-sized counties in the south of Sweden. The data were collected by means of interviews and analysed according to Critical Incident Technique (CIT). The result showed that nurses worried about specific emergency situations as well as situations related to their working environment. Worry was alleviated by their own actions or with help from others. It was also shown that, with increasing experience, came a responsibility to be able to cope with all kinds of situations. This responsibility was experienced as worrying. However, if the nurse felt confident in their colleague, the worry could ease. It was concluded that the worry experienced by ambulance nurses in specific emergency situations requires flexibility on the part of the ambulance service. Nurses must be given the opportunity to address their worries in the way that is most appropriate for each individual. c 2008 Elsevier Ltd. All rights reserved.
Ambulance nurse; Worry; Qualitative method; Ambulance service
* Corresponding author. Address: Centre for Acute and Critical Care, School of Health Sciences and Social Work, Va ¨xjo ¨ University, SE-351 95 Va ¨xjo ¨, Sweden. Tel.: +46 470 708379. E-mail address: [email protected] (A. Svensson).
Background Ambulance personnel are frequently faced with situations in which they have to take sole
1755-599X/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2007.10.002
36 responsibility for seriously sick or injured patients as well as those in shock; a reality in which the circumstances vary from one situation to another. Patients with life threatening symptoms are treated under conditions complicated by emotional, cultural and social factors (Suserud, 2002). Some situations are perceived as more overwhelming, resulting in the ambulance personnel experiencing a higher level of worry (Alexander and Klein, 2001). It has been found that a person with a tendency to worry about problems that occur in his/ her everyday life runs the risk of developing anxiety and depression (Boehnke et al., 1998). Intense worry undermines the active measures he/she normally takes in complex and possibly problematic situations. Further, such difficulties tend to escalate; the more worried and anxious the person is, the more threatening the potential problem appears to be (Boehnke et al., 1998). The pressure the ambulance personnel frequently have to endure can lead to post-traumatic stress syndrome (Jonsson et al., 2003; Jonsson and Segesten, 2004). Ambulance personnel, independent of their level of education (Suserud and Haljama ¨e, 1997), are seldom distressed by major accidents or grave personal injuries but rather by situations in which they feel compassion for the patients and their relatives. Such situations can be related to accidents involving children or suicide (Regehr et al., 2002). There is a connection between this work related worry and physical and psychological symptoms like stomachache, headache and sleeping disorders, when studying both female and male ambulance personnel. It has been shown that 25% of female and 20% of male ambulance personnel experienced two or more of the above-mentioned symptoms as a result of their professional life (Assa et al., 2005). Therefore, worry as a risk factor for ambulance personnel should not be ignored. In order to identify active measures to prevent worrying there is a need for a more detailed mapping of emergency situations that cause ambulance personnel to worry. Therefore, the purpose of this study was to describe critical incidents in which ambulance nurses experience worry in their professional life and the actions they take in order to prevent and cope with it.
Method Study design and method The study had a descriptive qualitative design and was analysed according to Flanagan’s Critical Incident Technique (CIT) (Flanagan, 1954). The
A. Svensson, B. Fridlund objective of this method is to gather observations of human behaviour by means of descriptions of real, well-defined and meaningful incidents. The incidents can be collected through observations, interviews, questionnaires or self-reports (Flanagan, 1954). It is of great importance that the subject under investigation has a well-defined purpose and that the respondents are given the opportunity to describe both positive and negative critical incidents that they perceive as important. The number of incidents can vary, depending on the complexity of the purpose, but more than 100 is usually recommended in order to achieve an adequate analysis (Andersson and Nilsson, 1964).
Ambulance nurses In line with qualitative designs the respondents were selected strategically; i.e. with regard to socio-demographic and professional characteristics such as age, education level, sex and years in the profession (Fridlund, 2006). The group of respondents were collected from three ambulance services in small to medium-sized counties in the south of Sweden and consisted of 13 male and 12 female ambulance nurses. Their work experience in the ambulance profession varied between 1 and 20 years and some had specialist education within different fields of nursing (see Table 1).
Table 1 Socio-demographic and professional characteristics of the ambulance nurses (N = 25) Sex Male Female Number of years in the profession 1–4 5–9 10–14 15–19 20– Specialist education Prehospital emergency nurse Anaesthetic nurse Prehospital emergency and Anaesthetic nurse No specialist education Number of years in ambulance service 1–4 5–9 10–14 15–19 20–
13 12 8 4 6 4 3 12 3 2 8 6 7 6 5 1
Experiences of and actions towards worries among ambulance nurses
Ethical considerations
Extract descriptions of critical incidents of importance to the activity under investigation
The study adhered to the principles outlined in the Declaration of Helsinki (World Medical Association Declaration of Helsinki, 2005). In Sweden there is no need for consent to be obtained from an ethical board if written consent has been obtained from the respondents and if the study does not involve a physical intervention affecting a person. The managers of the ambulance service involved gave approval for the study to be conducted in their department. Ambulance nurses, suggested by the managers, were sent a letter containing information about the purpose of the study, that participation was voluntary and that they were free to withdraw from the study at any time without having to provide an explanation. The respondents gave their written consent to take part in the study. They were also assured that the data would be treated confidentially. The interviews were conducted at a location chosen by the nurses. Three interviews took place over the phone, since it suited those respondents best (Swedish National Board of Health and Welfare, SPS 2003:460).
Label and classify the incidents with similar behavior into: SUB-CATEGORIES
Label and classify the sub categories after content into: CATEGORIES
Label and classify the categories after the comprehensive structure of the data into: MAIN AREAS
Data collection Data were collected by means of semi-structured interviews, which were recorded on an MP3 player and later transcribed verbatim. The interviews started with an open question about critical incidents; i.e. emergency situations in which the nurses experienced worry and the actions he/she took in order to deal with it. This question was followed by more in-depth questions such as ‘‘How do you mean? Explain how you felt!’’ in order to obtain a clear picture of how the nurses had experienced the situation. The interviews lasted between 12 and 25 min.
Data analysis The data analysis started by carefully reading through the interviews on several occasions in order to become familiar with the content. Incidents related to the aim were delimited and subjected to a structural analysis in line with the CIT-tradition (see Box 1). A total of 262 critical incidents were identified. Comparison of the incidents was then made in order to find similarities and differences and with the aim of grouping them together. These incidents were categorized by experiences and actions, in 12 and 13 sub-categories, respectively. Some of the behaviours fitted into more than one of the sub-categories, thus the sub-category that
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Box 1 Framework summery on how the data was categorized according to the Critical Incident Technique (Flanagan, 1954).
best accorded with the behaviour described was chosen. The sub-categories were then divided in a similar way into 5 and 6 categories as well as 2 and 2 main areas, respectively. The purpose of a category is to describe the general character of the sub-categories, while that of the main area is to describe the overall theme contained in the data (Andersson and Nilsson, 1966).
Results Worry related to specific emergency situations (Table 2) Worrying about feeling inadequate The nurses worried about situations in which he/ she felt inadequate. The worry derived from not knowing how to manage the assignment when meeting a patient. ‘‘The worry comes from not being able to help the patient in a satisfactory way’’. Unusual calls could lead to insecurity:
38 Table 2
A. Svensson, B. Fridlund Summary of the main areas, categories and sub-categories of emergency situations that worry nurses
Main area
Category
Sub-category
Worry related to specific emergency situations
Worrying about feeling inadequate
The nurse feels worried in situations where he/she cannot manage the assignment (8) The nurse feels worried in situations for which he/she is unprepared (7) The nurse feels worried in situations where he/she lacks experience (6)
Worrying about emergency situations in which the nurse may be personally involved
The nurse feels worried in situations where he/she knows the patient (11) The nurse feels worried in situation she/she can associate with his/her personal life (9)
Worrying about specific calls
The nurse feels worried in situations involving children (14) The nurse feels worried in situations involving child birth (4)
Worrying about emergency situations which there is a lack of control
The nurse feels worried in situations where he/she risks his/ her own safety (20) The nurse feels worried in situations that he/she cannot control (11) The nurse feels worried in situations where the technical equipment fails (7)
Worrying related to lack of trust
The nurse feels worried in situations where he/she lacks confidence in his/ her colleague (9) The nurse feels worried in situations where he/she experiences a lack of trust from management (8)
Worry related to the working environment
Number of incidents in brackets.
‘‘. . . lack of experience makes you a beginner every time’’. It was considered important to be prepared for all possible scenarios: ‘‘. . . if you do not get a lot of information on the way out, you do not know what to expect’’.
nurses could relate to how they would have reacted themselves if they had been personally involved: ‘‘I could see myself in the parents’ situation’’. It seemed that their own family situation governed their emotions: ‘‘. . . I have children myself, so I could see myself in their situation’’.
Worrying about emergency situations in which the nurse may be personally involved The nurses worried when a situation could be associated with their personal life. They worried about going to addresses or places where relatives or friends might be: ‘‘. . . the worry you feel when you leave is that it might be one of your own’’. They sometimes experienced situations that were very similar to their own private life: ‘‘I went out on a call pertaining to sudden infant death . . . it concerned twins, and I have twins myself’’. The
Worrying about specific calls The nurses worried in situations involving children or childbirth. In many cases the worry was due to the feeling that everything they did had to be right: ‘‘Because they have their whole life ahead of them, so to speak. Older people have lived their lives, more or less’’. They also felt the pressure from the parents: ‘‘. . . what a disaster for the parents if something were to happen’’. A feeling of helplessness in situations where the children were unable to express themselves could also be identi-
Experiences of and actions towards worries among ambulance nurses fied: ‘‘. . . so it is difficult to get a correct anamnesis of what is wrong’’.
Worry related to the working environment (Table 2) Worrying about emergency situations in which there is a lack of control The nurses were worried about situations in which they lacked control: ‘‘That you cannot control the situation//you want to be in control when you are at the scene of an accident or in someone’s home’’. They were also faced with threats and violence: ‘‘. . . the feeling of discomfort when someone gets really mad and you can see it in their eyes that they may explode at any moment and you cannot escape’’. Colleagues exposed nurses to situations that they could not control: ‘‘. . . the driver of the emergency vehicle was not capable of doing his job//I do not really feel that I can trust the colleague I am travelling with’’. Some worried when the technical equipment failed: ‘‘. . . you try to transmit an ECG from a heart patient and it does not work and you can see for yourself that the patient has suffered an infarction.’’ Worrying related to lack of trust The nurses were worried in situations in which they lacked confidence in their colleague: ‘‘. . . if I lack
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confidence in my colleague I worry about both him/her and myself, that we will not manage it’’. Lack of trust on the part of the management team was also a reason: ‘‘Our managers do not provide us with a sense of security’’.
Alleviating worry by one’s own actions (Table 3) Reflecting on worry The nurses reflected on their worry: ‘‘I think it is a healthy kind of worry in a way. A certain amount of stress and worry is good so to speak, because it makes you more alert’’. Worry was analysed on the way to a patient: ‘‘You have to prepare yourself as much as possible when you are on your way to the patient. Think about different scenarios, the kind of equipment you have, the kind of measures you might have to take’’. Sometimes the nurses tried to ignore the worry, in order not to be influenced by it: ‘‘I cannot say that I go around worrying, because if I did, I don’t think I could cope with this job’’. Experience has an influence on worry Professional experience influenced worry: ‘‘. . . the longer you have worked and the more you have experienced, the calmer you are, because you know you can manage//I think that experience is
Table 3 Summary of the main areas, categories and sub-categories describing what actions nurses take in order to alleviate and cope with their worry Main area
Category
Sub-category
Alleviating worry by one’s own actions
Reflecting on worry
The nurse ignores his/her worry (12) The nurse’s worry decreases with mental preparation (12) The nurse’s worry results in focused energy (8)
Experience has an influence on worry
The nurse’s worry decreases with increasing experience (25) The nurse’s worry changes over the years (6)
Alleviating worry by theoretical means
The nurse’s worry decreases by gleaning knowledge from literature (14) The nurse’s worry decreases with increasing education (8)
Alleviating worry by practical means
The nurse’s worry decreases by means of training exercises (11) The nurse’s worry decreases with the help of clinical practice in other departments (9)
Worry is alleviated Seeking support after by healthcare the emergency situation professionals and next-of-kin’s actions Seeking support in the emergency situation Number of incidents in brackets.
The nurse’s worry decreases when he/she talks to someone he/she considers trustworthy (17) The nurse’s worry decreases/increases by means of debriefing (7) The nurse’s worry decreases if he/she feels confidence in his/her colleague (10) The nurse’s worry decreases if back-up is called in (9)
40 the most important thing in this job’’. However, worry about some situations increased with experience: ‘‘. . . the more you have learnt through the years, the more you can do, and the more responsibility you take in the ambulance, the more reason you have to worry’’. The worry changed over the years: ‘‘. . . you get more familiar with some things, but you also realise that you are not good at everything. Perhaps you were more naive before and thought that everything would work out in one way or the other.’’ Alleviating worry by theoretical means The nurses tried to alleviate worry through theoretical studies: ‘‘. . . I have done the specialist education now//education provides knowledge and knowledge provides security’’. The nurses reflected on how to fill gaps in their knowledge by means of education: ‘‘. . . you wish that you had more training in the area of children’’. Literature studies led to in-depth knowledge: ‘‘. . . If you feel insecure you should study the guiding principles of this workplace, and if I think about something at home, then I look it up in books.’’ Alleviating worry by practical means The nurses tried to alleviate worry by improving their clinical practice: ‘‘. . . you take part in as many exercises and training sessions as possible’’. It was seen as important to do exercises together with other professions: ‘‘. . . practise together with the fire brigade and so on’’. The nurses practiced at different departments in order to fill gaps in their knowledge ‘‘. . . I try to go to the delivery ward sometimes//then you are prepared for that and you gain experience too’’.
Worry is alleviated by healthcare professionals and next-of-kin’s actions (Table 3) Seeking support after the emergency situation The nurses coped with worry by seeking support after a difficult situation: ‘‘. . . you talk about it with a colleague you have confidence in and feel secure with’’. They also spoke to persons from outside the ambulance service: ‘‘We have a lot of contact with the hospital chaplains’’ and with next-ofkin: ‘‘my partner works within medicine too, and she knows what it is like to meet patients . . . it feels good to talk to someone about it sometimes’’. This was not always a positive experience: ‘‘It can be difficult to get other people to understand. If you tell different people, they find other
A. Svensson, B. Fridlund aspects more distressing than the ones I find unpleasant’’. Seeking support in the emergency situation Worry could disappear if the colleague was considered trustworthy: ‘‘If I work together with the same people as usual, then we know each other well. Then you work more as a team. You know each other well and know what the other person can and cannot do.’’ Knowing that one had a competent colleague could relieve worry: ‘‘. . . my colleague is a good communicator, so he would have to deal with that aspect’’. In some situations, back-up was called in to relieve worry: ‘‘I have sent for a midwife in some situations in which I felt insecure’’. Contact could also be made by phone: ‘‘. . . you can dial the emergency service centre’’.
Discussion Methodological issues According to Fridlund (2006), the researcher of a qualitative study needs to reflect on the applicability, concordance, security and accuracy of the material, in order to safeguard the security of the data collection. Applicability describes how well the sample conforms to the purpose of the study. Respondents from three organisations were selected from a broad base of age group, specialist education and number of years in the profession, in order to obtain a clear picture of the concept of worry from an ambulance nurse’s perspective. Interviews were chosen as the data collection method, which allowed the respondents to describe their thoughts in more detail with the help of follow-up questions. The CIT method also makes it possible to collect data via observations, questionnaires and self-reports (Flanagan, 1954). However, these methods would probably not result in the same breadth of data, since the possibility for reflection would not be available. However, they could have been used as a complement to the interviews, thus enhancing the researchers’ understanding. Concordance describes the validity of the design in relation to the purpose. The design was seen as highly applicable in this kind of study, since the purpose was to describe situations the nurses found meaningful and decisive for their experience and behaviour. As both the researchers and the nurses were familiar with the environment in which the study was conducted, the risk of misunderstanding during the interviews was minimised.
Experiences of and actions towards worries among ambulance nurses The interviews and transcriptions were carried out by the same person in order to safeguard the security of the study. The interviews were also read through several times before categorizing them into sub-categories, in order to further improve security. The incidents were analysed according to character and content. This step was repeated several times before the end result emerged. The categorizing of incidents into sub-categories was conducted in cooperation with the second researcher, experienced both in theory and practice, which minimised the risk of subjectivity (Andersson and Nilsson, 1964). Direct quotes from the interviews strengthened the accuracy of the study.
Results issues Worry related to specific emergency situations The nurses worried about specific situations that could arise in their profession. Situations that evoked worry were related to children. Alexander and Klein (2001) and Regehr et al. (2002) also found that situations involving children were a source of worry for ambulance personnel. The nurses found it difficult to describe why such calls distressed them, but a certain amount of external influence was evident. It could arise from the demands placed on the nurses by the parents of the sick or injured child or from the father in situations involving childbirth. The nurses worried about becoming personally involved in situations where they knew the patient or could associate the case with something in their personal life. According to Alexander and Klein (2001), this can be very emotionally trying. Since most of the nurses in the study worked and lived in the same area, they ran the risk of being exposed to such situations quite frequently. The nurses found the feeling of inadequacy to be a source of worry. It could arise from the insecurity they experienced at seeing the sick or injured patient with their own eyes. According to Jonsson and Segesten (2004), ambulance personnel can divert this type of worry by engaging in an inner dialogue with themselves by which they prepare mentally for what they are about to see. The nurses felt that their worry eased, the more they were exposed to emergency situations. Worry related to the working environment The nurses worried in situations where they felt a lack of confidence in their colleague or lack of trust from their managers. Similar results were obtained in a study by Van der Ploeg and Kleber (2003). Lack of confidence in close colleagues arose from situations in which the nurse had felt little or no support
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when working with that particular person. Not being able to trust a colleague is seen as very trying (Alexander and Klein, 2001). The nurses also worried about situations they could not control, the most characteristic being violence or threats against them. The worry in such situations came from the fear of being hurt. According to Suserud et al. (2002), threats against ambulance personnel are increasing. They point out that managers need to see the importance of providing self-defence training and equipping their personnel with alarms. Worry is alleviated by one’s own actions The nurses believed that worry could be alleviated through more training exercises as well as clinical practice in other departments at the hospital. According to Alexander and Klein (2001), it is of great importance that ambulance personnel are given the opportunity to do clinical exercises in order to prepare themselves for the emotional and exhausting calls that they may have to face. The nurses reflected on their worry in specific situations and considered it to result in focused energy and a strong ability to take action. Reflection on previous experiences is a tool for ambulance personnel to mentally prepare for future scenarios (Jonsson and Segesten, 2004). The nurses felt that their worry changed over the years. The worry evoked by certain types of situation decreased in line with increasing experience. However, the opposite could also be seen. Situations that were not worrying initially could become a source of worry with increasing experience, which was also pointed out by Alexander and Klein (2001). The ambulance nurses felt that, with increasing experience, came a responsibility to be able to cope with all kinds of situations. This responsibility led to worry in some situations. Worry is alleviated by healthcare professionals and next-of-kin’s actions The nurses sought support in emergency situations by calling in back-up, thus reducing their worry. They used trustworthy persons as sparring partners in order to ventilate their worry. This could take place during or after the situation. In order to leave trying situations behind and move on, it is important to talk about thoughts, emotions and experiences with a trusted person (Jonsson and Segesten, 2004). Most of the time, the ambulance nurses consulted a colleague. Some found debriefing a good method for reducing worry. Others, however, claimed that this only served to increase their worry.
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A. Svensson, B. Fridlund
Conclusions and implications The study has shown that worry among ambulance nurses can both be related to specific nursing situations and to the working environment. Since worry is a subjective term, experienced in various ways by different people, it is complex and demands an ambulance service that can offer a broad range of methods of support in order to help the nurses to deal with their worry. The study has also revealed that worry is handled individually or with help from others. Nurses need to verbalise practical ways of learning to tackle their worry and to obtain support from the ambulance organisation in order to do so. There is a need for more in-depth studies of ambulance nurses’ experiences of worry. Such studies should be based on the actions the nurses find efficient for minimising their individual worry. These actions should then be included in educational interventions and follow-up training for ambulance nurses. One way to facilitate the nurses is to provide them with an opportunity to practise things that are important for reducing their worry in specific situations. Furthermore, ambulance nurses point out the importance of working with a skilled colleague. The cooperation with the colleague can both increase and decrease the worry in some situations. This phenomenon should be studied more in-depth in order to map how the interaction with colleagues influences the worry among ambulance nurses.
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