Akash 8
Akash 8
Akash 8
REVIEW ARTICLE
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
Emergency Medicine and Australasian Society for Emergency Medicine
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8 A JOHNSTON ET AL.
Current literature suggests that ED stressors within the ED and to estab- Methods
staff are also subject to many external lish areas of deficit in existing litera-
A multi-stage process based on the
pressures around patient waiting times ture to focus future research.
model of Pluye and Hong28 was used
and the deleterious impacts of shift The questions this review aimed to
for this integrative review.29,30 Because
work.13,19,20 Despite this, emergency is answer were the following:
of the varied nature of the available
often identified as a ‘prestigious and 1. How do ED staff perceive their
evidence, the mixed methods assess-
high value’ area of clinical work, which working environment?
ment tool (MMAT)28,30 was utilised
is known to enable development of high 2. Do gender and/or clinical roles im-
by four independent reviewers after
personal levels of clinical skills and the pact staff perceptions of the ED
the application of systematic inclusion
development of positive supportive working environment?
and exclusion criteria.
team working environments.14,21,22 3. Are staff perceptions of the ED work-
The broad literature presents a con- ing environment different to those of
trasting view of EDs, as a clinical area other specialist clinical areas?
Search strategy
fraught with stressors and also as an 4. What recommendations can be The search strategy used is represented
exciting and challenging environment. drawn from the literature to guide in Figure 1. Informing the search
Synonymous with both these views, improvements in satisfaction with strategy were search terms: ED/EDs,
high levels of staff turn-over, clinician ED working environment? Emergency room/s, ER/s, or A&E
burn-out15,18 and post-traumatic stress
disorder have been noted.18,23,24 These,
almost dichotomous, views of EDs as
both inspiring and demoralising work-
ing environments, both of which have
been associated with development of
burnout in ED staff,18 coupled with
the increasing expectations of care
delivery placed on EDs, provided
impetus for a thorough and systematic
evaluation of the literature regarding
ED staff perception of their working
environment, particularly of stressors
in this space.
There has been relatively little re-
search exploring stressors specific to
the ED. Staff perceptions of their
working environment and work-
related stressors are complex areas that
can encompass a range of concepts,
including the physical environment
and the underlying personality charac-
teristics of co-workers.10,14,16,25 Our
definition of working environment
encompasses factors influencing the
professional context in which ED clin-
ical staff work. The outcomes of staff
stress include sick leave,26 resignation
and turn-over;16 the development of
physiological alterations such as corti-
sol and blood pressure in staff;27 or
the onset of mental health conditions
such as burnout (listed in ICD10).18
However, this review focuses on sub-
jective staff perception of their work-
ing conditions, rather than potential
outcomes of their working conditions.
The aim of this integrative review is
to identify, thematically group and
critically evaluate published literature
around ED staff members’ perceptions Figure 1. Schematic representation of the stepwise processes used in undertaking this
of working environment, with a parti- systematic review, including inclusion/exclusion criteria applied to the papers. The numbers
cular focus on identification of the in each box refer to the number of papers included in each step.
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
Emergency Medicine and Australasian Society for Emergency Medicine
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ED STAFF PERCEPTION OF WORKING ENVIRONMENT 9
coupled with (and) working environ- a range of clinical personnel (e.g. and reduced or managed responses to
ment, working condition/s, and staff nurses, nursing assistants and doctors). ED stressors.3,41,43,44 Experience and
perception/s. The included dates were The studies varied widely in quality (0– work profile (part-time/full time), rather
1993–Jan 2015. Activation of ‘smart 100% MMAT scores). Independent as- than role or chronological age, seem
text’ and automatic word variation sessment of MMAT scores revealed to play a large role in perception of
options during searches ensured that some variability based around the re- work-related stress.3,45–47 Where staff
word combination options including search experience of the user; for this demographic/stress relationships were
US and UK spelling variations and plural study, we reported the modal score. explored, they were often coupled with
terms were detected. Reference chaining The studies were grouped into those high rates of staff turnover.1,3,41,43,48
was undertaken. All final searches were exclusively exploring nursing staff This may lead to a self-selection process,
conducted in January 2015. (n = 12, Table 1), mixed clinical popu- with coping staff developing greater
lations (n = 11, Table 2) and medical clinical competence, role identification
staff (n = 8, Table 3). and security. Non-coping staff often
Inclusion/exclusion criteria leave the ED. Reinforcing this self-
Studies were included if they were pub- selection concept are some findings sug-
ED staff: unique population gesting that ED physicians attend more
lished in English between 1993 and
2015 and focused on staff perception Comparisons highlighted differences ongoing education and are less likely
of working environment. Literature between ED staff and those working to move into the administrative hierar-
was excluded if it covered ED staff per- in other clinical areas, with ED staff chy1 and that more senior ED medical
ception of violence against staff,17 as- consistently reporting higher levels of staff report high work satisfaction than
sessment of compassion fatigue and stress. However, the evidence also medical staff in other specialty areas.4,47
burnout,15,31 communication difficul- showed that, irrespective of the clinical Role satisfaction may also be related to
ties in ED,32–34 shift work,11,19,20,35 population examined, ED staff self- the higher remuneration and feelings of
internal cultural diversity36 and staff identify as a unique population with ‘reward’ and ‘value’ of more senior,
undergoing training processes (e.g. higher autonomy, skill base, level of experienced staff.3,45–47,49
specific ED clinical training),34 as these team work and communication,5,37,38
have already been explored in highly with such factors often ameliorating
focused reviews (see also Fig. 1). the impacts of stress.10,21,39 Perception of workplace stress in
One reviewer (AJ) screened titles and Studies focused on ED nurses ED clinical populations
abstracts for inclusion based on criteria frequently reported different demo-
Studies that included both medical and
and retrieved 112 full-text articles that graphic profiles than other nursing
nursing staff noted that medical staff
met all criteria. Review of full text arti- populations, with a greater proportion
were more likely to report adverse psy-
cles and a final moderation process (AJ, of male staff, with advanced qualifica-
chological outcomes from their work
JC, and MW) indicated that 31 met the tions and longer clinical experience.
stress,8,50 that is, stress outcomes,
inclusion and exclusion criteria. However, this was culturally specific.
whereas nursing staff were more likely
Studies conducted in Taiwan,3 China,40
to report dissatisfaction from rapid
Brazil11 and Iran2 included primarily
Quality appraisal doctor turnover46 and environmental
female staff populations with limited
factors such as parking.12 Perceptions
The MMAT30 provides a structured qualifications.
of management practices, social sup-
approach for data abstraction and syn- Studies of ED nursing staff, which re-
ports, work autonomy and the impact
thesis of themes from quantitative, ported more balanced gender popula-
of physical load differed between med-
qualitative and mixed method research tions, tended to report better social
ical and nursing staff, with nursing
in an unbiased manner.28 Three re- support, and job satisfaction/work
staff reporting poorer management
viewers (AJ, LA and MW) indepen- engagement,38,41,42 while those in less
practices, greater social supports and
dently evaluated the MMAT level of diverse populations (i.e. primarily
also greater physical load.
evidence for each article and completed women) reported fewer positive percep-
an unbiased data extraction table.29 tions of many aspects of working
environment.2,40 Thus, while there is
Staff perception of ED work
cultural variability, clinical staff in EDs
environment
Results perceive their working environment in
different ways to other groups of clinical While it was almost universally ac-
Search strategies and study quality staff. Their identified satisfaction with knowledged that EDs are stressful
The search resulted in 31 articles that their work identity may protect them places to work, staff perceptions of
comprised 24 quantitative-descriptive from some of the debilitating effects of stressors varied. Some studies sug-
studies, four mixed descriptive/com- stress in their working environment. gested that exposure to ED stressors
parative (non-randomised controlled was often unsustainable,5,7,15 while
trial) studies and three qualitative stud- others suggested that they are a criti-
ies in terms of the MMAT assessment.
ED staff experience cal and crucial part of the job.1,4 Five
Studies were conducted in a range of There is a highly consistent positive key stressors are identified in the
countries (mostly Europe) and covered relationship between ED experience succeeding text.
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
Emergency Medicine and Australasian Society for Emergency Medicine
10
TABLE 1. Research evidence around ED nurses perceptions of their working environment
1. Hawley, 1992, To identify and ED nurses n = 68 – Descriptive cross-sectional – Guided by the model – Emergency nurses experience work- – Study provides an – Limited information – Required development of 25
Urban Canada describe the from four EDs correlational design from a self- for organisational related stress originating from a interesting historical about participant strategies dealing directly
intraorganisational reported, previously validated, stress research of variety of sources including context – with limited selection, follow up with stressors and the
sources of stress modified Stress Diagnostic Survey Ivancevich and inadequate staffing and resources, too identified impact of procedures or creation of a workplace that
perceived by with 41 items each with a Likert-type Matteson many non-nursing tasks, changing workload on staff stress participation/response fosters more support and
emergency nurses scaling 1–7 – Stipulated inclusion trends in ED use, patient transfer – Informed by a strong rate recognition of nurses and
– Survey coupled with open-ended criteria: RNs, problems and also continual theoretical model – Limited reporting of promotes professional
questions >3 months ED confrontation with patients and demographic data growth may also help to
– Limited participant demographic experience families who exhibited crisis or including % women reduce the stressors
data also collected problematic behaviours
– Mixed method/§§quantitative
descriptive
2. Helps, 1997, To assess ED nurses n = 51/ – §§Mixed method study including – 89% response rate – Top 10 identified ‘hassles’ were – Use of multiple tools – ††Validity checks not – In general, A&E nurses 25
UK psychological and 57 distributed semi-structured interview, cross- ambient temperature and Lighting, enabled a broad view of cited satisfied in their work, with
physiological across three grade sectional a self-reported quantitative Too much to do, Budget cuts, these nurses states – Face and construct overall levels of occupational
experiences of levels questionnaire Doctors, Erratic workload, Other – Broad process for validity for ‘hassles’ and stress akin to or lower than
occupational – Single site – A 42 item ‘Hassles’ Questionnaire, a nurses, People in charge, Time and inclusion of staff ‘responses to stress’ general nurses
stressors General Health Questionnaire work pressures, Lack of staff and questionnaires not cited – Urgent need for debriefing
in ED staff – 28, a Responses to Stress interpersonal relationships were cited – No analysis of data, no for staff and high risk of
Questionnaire (RSQ) and The as the greatest sources of occupational identification of themes PTSD
Maslach Burnout inventory (2nd edn) stress within interviews – Strategies to promote
– Descriptive analysis (mean, SD, – Greatest satisfaction was derived provided successful coping and
range), statistical analysis reported from patients (and staff) saying thank – No follow up of prevent the development of
but tests not cited you, Providing a good service, non-respondents to the negative outcomes to
supporting/helping/calming people survey occupational stress could
– 25–30% of nurses reported then be implemented and
significant psychological compromise evaluated
– The most commonly suggested
solution to stress was to employ more
staff, followed by a ‘time out room’
and effective debriefing
3. Adeb-Saeedi, To identify sources ED nurses – 120/160 – Mixed methods/§§quantitative – Random sampling – No significant correlation between – Relatively good – ‡‡, ††Sample all – Requirement for improved 25
2002, Iran of stress for nurses selected at random descriptive including descriptive cross- of possible ED nurses stress, age, shift work or qualification/s mixture of women drawn from one support and working
working in ED – Qualifications sectional correlational design from a 75% response rate – Women reported higher levels of (66%) and men (33%) University teaching pool conditions for nurses
from school self-reported validated quantitative – Cronbach’s alpha stress staff with good – Not previously including provision of
diploma (24%) to questionnaire 0.87 – The most stressful demand on distribution across validated survey, no counselling/debriefing and
Masters trained – Survey examining demographics nurses was dealing with pain, working shifts possible comparison to stress management training
(4%) with the and experience as well as 25 suffering and grief and patient/ other study findings
majority baccala- previously identified stressor items family responses – Unclear how many
ureate trained that participants were asked to rate – Heavy workloads coupled with sites involved
(68%) using a 1–5 Likert scale staff shortages and lack of resources
– Analysed using SPSSx also rated as highly stressful
4. Ross-Adjie, Leslie To determine which ED nurses – Mixed methods/§§cross-sectional – 52% response rate – In order of significance, stressors – Quant data was – 10% respondents were – Debriefing after stress- 50
and Gillman, 2007, stress-evoking n = 156/300 quantitative descriptive study was were the following: violence against enriched by free men (twice the proportion evoking incidents in the
Australia incidents ED nurses undertaken staff, workload, skill-mix, dealing comment to employed in these EDs) workplace should be mandatory
perceive as the most – Non-parametric testing (Kruskal– with a mass casualty incident, the contextualise findings – No information about not optional, and should be
significant, and Wallis) to identify and rank 15 listed death/sexual abuse of a child, dealing survey follow up conducted by professionals
whether demographic workplace stressors and determine with high acuity patients – Non-validated, with specific debriefing and
characteristics affect whether demographic sub-groups – There was a relationship between unpiloted, author counselling skills
these perceptions ranked the identified stressors the paediatric death/sexual assault developed survey may
differently stressor and number of years ED
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
A JOHNSTON ET AL.
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TABLE 1. (Continued)
To discuss current – Three-part questionnaire experience, as well as the acuity compromise survey – Nurses perceived
debriefing practices – SPSSx was used to manage data stressor and number of years ED validity and results debriefing to be a useful
in EDs experience part of maintaining a
– 40% of respondents reported healthy WE
having personally sought debriefing – A consistent and objective
while almost 60% reported that system of staff allocation to
workplace debriefing is not routinely manage workload and
offered after a stress-evoking incident patient acuity should be
in their workplace implemented, matching
– Free text listing of stressors included resources with workloads
lack of, or outdated equipment’ and
‘shift work’
5. Kilcoyne and To identify themes ED nurses – §§Qualitative study using – Study participants – The primary themes that emerged – Enables a free flow of – Data maybe biassed by – Managers must work to 100
Dowling, 2007, from nurses – Purposive sample unstructured interviews from which were asked to confirm around WE were lack of space, lived experiences to be volunteer self-selection listen to and act on stressors
Ireland narratives n = 11 data were extracted using an interpreted findings powerlessness including not feeling recorded – enriching the – Small sample from one experienced by nurses in ED
around ED – Wide range of interpretive phenomenological together with a peer valued, feeling stressed, lack of respect published record around site limits generalisability to improve patient care and
crowding time in ED, approach validation process. and dignity and poor service delivery areas of stress of findings nurses perceptions of WE
2–20 years – Colaizzis 7 procedural steps for data Interviewer journaled – Non-probabilistic and
– Single site analysis was used their experiences to intentional sampling
ED STAFF PERCEPTION OF WORKING ENVIRONMENT
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
(Continues)
11
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12
TABLE 1. (Continued)
Maes, 2011, from those of – carried out in 15 quantitative questionnaires including previous study general hospital nursing population population enhanced health problems
Belgium general hospital EDs of Belgian the Leiden Quality of Work Gelsema, van der – ED nurses also recorded more understanding of the – Increasing skills,
nurses and to general hospitals in Questionnaire for Nurses, the Doef, Maes and opportunity for skill discretion and study findings (i.e. ED autonomy, effective working
describe to what 2007–2008 Checklist Individual Strength, the Akerboom, 2005 better social support by colleagues nurses are procedures and quality
extent these Utrecht Work Engagement Scale and – Senior nurses and – Work-time was rated as an demographically supervisors will positively
characteristics can the Brief Symptom Inventory – each managers excluded important contributor to fatigue in different to general impact on ED nurses
predict job with a 4-point Likert scale response – 0.93 >Cronbach’s ED nurses hospital nurses – with
satisfaction, – Descriptive statistics (chi squared) alpha >0.57 on all – Apart from personal characteristics, more experience, males,
turnover intention, and hierarchical regression analyses scales decision authority, skill discretion, qualifications, shift
work engagement, for each measure, via SPSSx adequate work procedures, perceived work and number of
fatigue and distress reward and social support by shifts worked per week
supervisors proved to be strong
determinants of job satisfaction, work
engagement and lower turnover
intention in emergency nurses
9. Wu, Sun and To describe factors ED nurses – §§Quantitative descriptive cross- – Validated scales – Female ED nurses report greater – Included EDs with – ‡‡, ††Only 0.4% of – Improve work conditions, 100
Wang, 2012, linked to – n = 510 sectional correlational design from a providing quantitative work stress than reported in other varying patient loads potential population health education and
China occupational stress – 16 hospital EDs self-reported validated quantitative ordinal (parametric occupational groups – Comparison with was men occupational training to
in ED nurses – In Liaoning questionnaire see ‡) data on scale of – Personal strain or ‘stress’ was equivalent data from a – EDs were all located in reduce stress in female ED
province – Chinese version of the Personal 1–5 correlated with role overload, role broader population urban regions nurses
strain questionnaire – Data tested for boundaries, role insufficiencies, lack – No follow up of non-
+ demographics + information about normality of social support, chronic disease and respondents to the
occupational roles (overload, – Response rate 78% inadequate self-care survey
insufficiency, ambiguity, boundaries,
responsibilities) + personal resources
(recreation, self-care, social support
and rational coping)
– One-way ANOVA Pearson
correlation, general linear regression
modelling
10. Chiang and To compare the ED nurses – §§Quantitative descriptive cross- – Used validated – Significant variations in reported – Good comparison of – ‡‡, ††Almost no male – ER is a relatively well 50
Chang, 2012, levels of stress, – 29/314 sectional correlational design from a scales stress levels in nurses, with ER nurses ER nurses compared nurses supported WE for north
Taiwan depression, and – Recruited from self-reported quantitative rating fairly low in the categories of with other speciality – Relatively few (~9%) Taiwanese district nurses
intention to leave regional hospitals in questionnaire, including the context- nurses who were stressed, depressed nurses and general ER nurses compared with other clinical
amongst clinical the Northern area specific adaptation of the Centre for and intending to leave nurses within the same – Limited information areas
nurses employed in Taiwan Epidemiological Studies Depression – Demographic characteristics hospital environments provided about – Requirement broadly for
different medical – Nurses >99% Scale (CES-D), the Perceived Stress (i.e. tenure, marital status, education, – Inexperienced nurses recruitment strategies policymakers and nursing
units in relation to women Scale, Intention to Leave Scale and and age) were not mainly influential and nurses who were and response rates managers to more clearly
their demographic general demographic information factors in the level of stress, married were more – Number of discrete direct policies that correctly
characteristics including hospital area of work depression, and intention to leave likely to intend to leave data collection sites is reflect effective nursing
– Descriptive statistics, and amongst nurses in various medical and more likely to show unclear human resource
Spearman’s correlations for all study unit and thus other factors need to be signs of depression – Sample sizes from management
variables to identify possible factors considered – Samples drawn from different clinical units
for multiple regression modelling, multiple sites varied; therefore, results
ANOVA to identify clinical area need to be considered
differences with caution and may
lack generalisability
– Limited follow up of
non-respondents to the
survey
75
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TABLE 1. (Continued)
11. Adriaenssens, To repeat a ED nurses – §§Comparative (non-RCT) – 83% response rate – One-fifth of nurses (~20%) had left – High repeated – ‡‡No consideration of – Staff turnover rates can be
De Gucht and previous study: to – n = 170/204 descriptive cross-sectional – Comparison against ED nursing positions over the 18- response rate ED or hospital size or very high and cause a
Maes, 2013, establish if job and nurses still working correlational and comparative design n = 254 ED nurses month study period with large – Large sample size for setting significant loss of staff capital
Belgium organisational from previous using self-reported validated from a previous study variance between sites (5–36%) comparison – High turnover may – Rapid (~18 months)
factors reported by study, 2007–2008; quantitative questionnaires including Adriaenssens et al., – Gender differences included that bias results, recording changes in nurse reported
ED nurses differ where n = 254 was the Leiden Quality of Work 2011 female nurses reported higher job exclusively from work-related factors
across time carried out in 15 Questionnaire for Nurses, the – Senior nurses and satisfaction, higher work engagement ‘survivors’ – staff who influencing stress provides
(18 months) and to EDs of Belgian Checklist Individual Strength, the managers excluded and lower emotional exhaustion remained managers many
describe to what general hospitals in Utrecht Work Engagement Scale and – 0.95 > Cronbach’s – Reported job demands remained opportunities to positively
extent these 2009 the Brief Symptom Inventory – each alpha >0.56 on all high but stable over time, while social impact on WE and staff
characteristics with a 4-point Likert scale response scales support and intention to leave varied satisfaction
continue to predict – Descriptive statistics (chi squared) widely, as did control, predicted job – Frequent assessment of WE
job satisfaction, and hierarchical regression analyses satisfaction, work engagement and in ED is important, as it can
ED STAFF PERCEPTION OF WORKING ENVIRONMENT
turnover intention, using difference scores (T1 versus T2) emotional exhaustion, reward, social change rapidly and impact
work engagement, for each measure, via SPSSx harassment and work agreements. staff retention
fatigue and distress This suggests a rapid and significant
in ED nurses. flux in nurse perception of working
12. Kogien and To determine ED nurses – §§Quantitative descriptive cross- – An estimated 50% – Low intellectual engagement, poor – Little research – ‡‡Non-probabilistic – Increase social support for 50
Cedaro, 2014, factors that may – n = 189 sectional study using a correlational proportion of staff social support and high occupational undertaken in South and intentional staff in EDs to reduce the
Brazil increase nurse- – Wide range of design from a1 self-reported validated totals drawn from a demands or a passive work America and published – Biased population negative consequences of
related work stress ages, experience quantitative surveys including the Job large ED (Rondonia) expectation were the main risk factors in English (76% women; 81% stress on staff, promote
and decrease and average stress scale, the WHOQOL-brief and – Helps to support an for concern in the physical domain of – Strong and nursing technicians) wellness, provide a
quality of life for workloads the job content questionnaire international quality of life, altering rest/sleep comprehensive – Sampling based on predisposition to good
ED nurses – Analysed using SPSSx and MS Excel conceptualisation of quality statistical analysis of participant availability health and improve
2
– Pearson’s χ test (or Fisher’s exact the work stressors in – Psychological demands of ED quantitative and – No follow up of non- indicators of quality of life
test, when necessary) for the categorical EDs environment are high – with staff qualitative data participation
variables, and Student’s t test was exposed to pain, distress, helplessness, – No information
used for the continuous variables, anxiety, fear, hopelessness, feelings of provided about response
then, multivariate analysis using abandonment and loss rate
logistic regression was performed – Working conditions can be poor
and the odds ratios (OR) were because of overcrowding, scarcity of
obtained and adjusted for socio- resources, work overload and the fast
demographic variables pace of the work required of the
professionals providing care
†Note: all survey completion was deidentified and voluntary, with appropriate accompanying ethical approval unless noted otherwise. ‡Data type (quantitative/qualitative) is identified in the study and/or on the basis of the analysis performed. §Note: all survey and interview data are
subject to potential prevarication bias and even response falsification. Additionally, the selections required in surveys are often ‘relative’ and so can be challenging ascertain consistently and reliably (‘soft’ responses). Additionally, there may be a response bias based on the psychological
well-being of participants (single point in time survey). ¶There were additional study findings not related to the focus of this review not reported here. ††Convenience (cross-sectional) sampling and thus no causal inferences can be drawn. ‡‡No provision for open-ended responses so
participants’ responses are constrained by study. §§MMAT classification system. EM, Emergency Medicine; ER, Emergency room; MMAT, mixed methods appraisal tool; NWI-R, revised nurse work index; PTSD, posttraumatic stress disorder; RA, research assistant; RN, registered
nurse; RPPE, Revised Professional Practice Environment; SAS, statistical analysis systems; SD, standard deviation; SEM, standard error of the mean; SPSSx, statistics package for the social sciences; USA, United States; WE, work environment; WHOQOL, World Health Organization
Quality of Life.
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
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14
TABLE 2. Research evidence around mixed ED clinical staff perceptions of their working environment
1. Joe, Kennedy and To demonstrate a n = 323/500 staff from – §§Quantitative descriptive – 64% response rate – Staff rated a safe environment, – Utilised widely – ††Skewed – Provides direction for further 100
Bensberg, 2002, comprehensive seven Melbourne study using a cross-sectional – Employee survey professional standards, and staff used mixed population; 75% research into ED workplace
Australia workplace health suburban public correlational design from a self- commonly used morale the most important factors for method survey women and 61% nurses health, enabling refinement of
survey that is able to hospital EDs with reported validated employee (Marketshare); workplace health. They were most tools across a – No follow up of non- indicators reflecting various
identify indicators similar attendance survey designed by Service refined and validated satisfied with the flexibility of work number of sites respondents to the aspects of workplace health,
that contribute to staff numbers, case mix and Management Australia (a regularly by research arrangements (86%) and leadership and a wide range survey and correlation of indicators
workplace welfare demography subsidiary of Marketshare) with conducted locally and (80%), and were least satisfied with of staff with sick leave, stress and
n = 59 doctors, n = 198 terminology within the survey compared with data the performance management of staff – Explored a injury
nurses, n = 30 clerical/ altered to make it relevant to from abroad (69%) and job satisfaction and range of ED – Also indicators of how
admin staff and n = 22 the ED morale (67%) aspects from various indicators affect
other staff – Included closed, rating (5-point – The largest gaps between perceived communication different staff groups and
scale) and open questions for importance and performance were in and staff morale Workplace health in EDs
quant and qual content; mixed the provision of safe well-lit parking, to staff injuries
methods study staff morale, and the use of reward
– Calculated a ‘performance gap’ and recognition systems
around key issues – the difference
between importance rating and
perceived performance rating
2. McFarlane, Duff To explore factors 28/33 of health – §§Quantitative descriptive – Response – A&E was reported to be stressful, – Little published – Abstract only available – Increased monetary 25
and Bailey, 2004, associated with personnel working in cross-sectional design using two rate = 85%, 54% with the major sources of stress information from – No evidence of ethical compensation, more staff and
Jamaica, West Indies occupational stress in the A&E self-reported, trialled, doctors, 29% reported as the external environment West Indian approval positive feedback from
ED staff and the n = 15 doctors, n = 8 quantitative and open-ended registered nurses and and the amount and quality of the hospitals managers as factors that may
coping strategies used registered nurses and (qualitative) items that included 18% enrolled workload and resulted in emotional, relieve work stress
n = 5 enrolled assistant limited demographic information assistant nurses physical and behavioural symptoms – Organised counselling and
nurses – Open-ended data were analysed – Effective use of humour, teamwork stress management
– Single site thematically and ‘extracurricular’ activities in programmes may be useful
buffered the effects of stress
3. Escriba-Aguir and To determine if SSEM members – §§Quantitative descriptive – Supported by – Psychosocial WE factors strongly – Baseline data – ‡‡, ††Sample all – Greater need for capacity of 75
Perez-Hoyos, 2007, psychosocial WE including ED doctors study using a cross-sectional Karasek and influenced clinical staff psychological comparison with drawn from one control for doctors in EDs
Spain differentially altered and nurses correlational design from a self- Theorell’s demand- well-being, but the effect varied in normative data professional society – Need for further investigation
psychological well- Reported n = 639; data reported validated quantitative control WE model nurses and doctors from American – No information including the role of
being for ED clinical collected from n = 278 questionnaire – Careful – Doctors were more likely to show health provided about the professional career choices and
staff nurses and n = 358 – Mental health and vitality consideration of low vitality, poor mental health and professionals number of EDs or the work-family roles on clinical
doctors dimension of the SF-36 Health potential confounding high levels of emotional exhaustion – Comparison size/busyness of the ED staff in ED
survey, emotional exhaustion factors including from high psychological demands across health on results – Need to establish
dimension of Maslach’s burn-out socio-professional – Low levels of job control and co- professionals – Limited follow up of improvements in psychosocial
inventor and the job content and gender-role workers social support also increased drawn from a non-respondents to the WE to reduce the risk of
questionnaire related variable the risk of poor mental health in similar clinical survey psychological distress in ED
– Descriptive statistics and – Response rate 68% doctors and the risk of high emotional pool clinical staff, especially doctors
logistic regression exhaustion in nurses
– Little impact of physical workload
on reported well-being
– Lack of supervisor support for
doctors but not nurses
4. Magid, Sullivan, To assess the degree to n = 3562 from 69 sites – §§Quantitative descriptive – The developed – Survey respondents commonly – Multiple step – ‡‡Excluded military, – Substantial improvements in 100
Cleary et al., 2009, which ED staff felt – Participation invited cross-sectional design using a self- scales generally had reported problems in four systems survey Veterans institutional design,
USA that EDs are designed, from sites affiliated with reported, extensively validated 50 good reliability critical to ED safety: physical development, Administration, and management, and support for
(Continues)
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
A JOHNSTON ET AL.
managed, and the Emergency Medicine question quantitative (Cronbach’s): environment, staffing, inpatient validation, children’s hospitals, as emergency care are necessary
supported in ways Network, postings on questionnaire that included physical environment coordination and information piloting and well as hospitals in US to maximise patient safety in
that ensure patient emergency medicine list- limited (5) demographic (0.60), staffing (0.65), coordination testing territories US EDs
safety, including the servers and through questions equipment and – Generally, factors around working establishing face – A modest honorarium
physical work presentations at – Multisite research included supplies (0.93), environment, including ‘blame’ and construct was given to survey
environment, staffing, emergency medicine collecting information about size, nursing (0.90), culture, staff supervision, cross- validity respondents to minimise
equipment, supplies, meetings complexity of each research site teamwork (0.60), discipline team work, were rated very – Piloted at 10 nonresponse bias
teamwork and – Response rate 66% random culture (0.79), triage highly. EDs and then – Four EDs with
coordination with sample of 80 eligible staff at each and monitoring administered to response rates of 45%
other services ED who worked an average of (0.91), information 65 different EDs or less and individual
one or more ED clinical shifts per coordination and across the USA questionnaires with
week consultation (0.64), answers to less than
– Eligible survey respondents and inpatient 80% of the survey items
included physicians, nurses, nurse coordination (0.88) were excluded
practitioners, physician assistants – 69/102 sites initially – Results of this study
and nursing assistants interested actually may not be generalisable
– Respondents had the option of took part (68%) to all EDs, because the
ED STAFF PERCEPTION OF WORKING ENVIRONMENT
(Continues)
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
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16
TABLE 2. (Continued)
(Continues)
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
A JOHNSTON ET AL.
9. Person, Spiva and To examine the – Included ED nurses, – §§Qualitative study using – Team member – Culture primarily described by four – Exploring a rich – Only a small portion – Management must value staff 100
Hart, 2013, USA culture of an ED physicians, clinical care focused ethnographic checks and meetings, categories; cognitive including and wide range of of the ED culture
(Continues)
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
17
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18
TABLE 2. (Continued)
11. Lambrou, To examine nurses’ n = 224 – Quantitative descriptive study – 224/277 of possible – Medical staff rated the professional – Clear data – ‡‡No description – Improvements in professional 100
Papastavrou, and physicians’ – n = 174 nurses and cross-sectional correlational participants (81% practice environment slight more collection period provided of other environment can ultimately
Merkouris and perceptions of n = 50 physicians design from a self-reported response rate) highly than nursing staff, particularly and well- possible sites (private?) improve patient safety
Middleton, 2014, professional – All five possible public validated quantitative – 174/210 eligible around ‘staff relationships’, ‘internal stipulated – RPPE Questionnaire – Identified a need to focus on
Cyprus environment and its ED sites questionnaire including the nurses – response rate motivation’ and ‘cultural sensitivity’. eligibility criteria was used in both leadership interventions on the
association with Revised Professional Practice 83%, and 50/67 While both groups rated teamwork – Reasonable medical and nursing problematic areas to create an
patient safety in Environment (RPPE) Scale and physicians – response highly, both groups also rated ‘control gender spread; staff, and some environment that is conducive
public EDs in Cyprus (b) the Safety Climate Domain of rate 75% over practice’ as the lowest domain women (54%) of questions could have to the delivery of safe and high-
the Emergency Medical Services – The internal examined -Staff are highly motivated sample amongst been perceived quality care
Safety Attitudes Questionnaire consistency of each of and in indicate that they value and both physicians differently by the
(EMS-SAQ) each with 4- to the RPPE sub-scales practice team work and nurses (56% participants; impacting
5-point Likert scale ratings was assessed using and 53%, responses provided
– Demographic and professional Cronbach’s alpha respectively) – A relatively low
experience data were also coefficient – Direct Cronbach’s alpha was
collected comparison with observed for two factors
– Descriptive statistics, Mean staff from other of the PPE as well as for
differences were assessed using hospital areas EMS-SAQ (safety
t-tests and ANOVA, Bivariate was possible domain)
association was evaluated using – Previously
Pearson’s correlation coefficients undertaken
– Logistic and stepwise multiple research also
regression modelling were enabled
undertaken to determine longitudinal
important relationship factor comparison of
predictors data from nurses
across three
previous years
†Note: all survey completion was deidentified and voluntary, with appropriate accompanying ethical approval unless noted otherwise. ‡Data type (quantitative/qualitative) is identified in the study and/or on the basis of the analysis performed. §Note: all survey and interview data are
subject to potential prevarication bias and even response falsification. Additionally, the selections required in surveys are often ‘relative’ and so can be challenging ascertain consistently and reliably (‘soft’ responses). Additionally, there may be a response bias based on the psychological
well-being of participants (single point in time survey). ¶There were additional study findings not related to the focus of this review not reported here. ††Convenience (cross-sectional) sampling and thus no causal inferences can be drawn. ‡‡No provision for open-ended responses so
participants’ responses are constrained by study. §§MMAT classification system A&E, accident and emergency; hrs, hours; MD, medical doctor; MMAT, mixed methods appraisal tool; OD, Orthopaedics department; RN, registered nurse; RPPE, Revised Professional Practice
Environment; SAS, statistical analysis systems; SD, standard deviation; SEM, standard error of the mean; SPSSx, statistics package for the social sciences; SSEM, Spanish Society of Emergency Medicine; SHOs, senior house officers; USA, United States; WE, work environment;
WHOQOL, World Health Organization Quality of Life.
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
A JOHNSTON ET AL.
1. Heyworth, Whitley, To describe n = 201 respondents – §§Quantitative descriptive – 72% overall response – Overall levels of occupational – Captured a large – ‡‡Highly skewed – Staff stress-management 75
Allison and Revicki, occupational stress, – n = 154 consultants cross-sectional correlational rate, response rate from stress and depression were low proportion of this clinical population – with a high probably reflects the
1993, UK depression, task and (71%) and n = 47 design from a self-reported consultants 71% and 77% WEs were evaluated group and thus multi-site proportion of married personality of physicians
role clarity, work senior registrars validated questionnaire, from senior registrars favourably information (86%), men (88%) – Continue to identify
group functioning and (77%) drawn from a including the work-related – Survey tools previously – Levels of occupational stress – Quantitative analysis of respondents character traits of
overall satisfaction in register of all ED stress, depressive validated in other groups were proportional to ED size, a number of key variables – Limited analysis (no successful ED practitioners
senior ED medical consultants and symptomatology and of medical staff but not on-call work, patient or cited in literature factor analysis/regression to provide a proven
staff registrars respondent evaluations of three – No ethics approval listed staffing and was similar to attempted) personality profile for
aspects of the WE: task and those reported by other groups – Limited follow up of junior doctors considering
role clarity, work group of health care providers non-respondents to the a career in ED
functioning, and overall – Respondents generally survey – Provide and encourage
satisfaction with work considered tasks and roles to be use of counselling
– General demographic clearly defined, work groups to
information including hospital/ be supportive, efficient units
ED size and average capacity, and work satisfying
years of service and shift – Senior staff with >10 years
patterns ED experience and consultants
– Descriptive statistics, and over 45 years old reported
Pearson’s correlations to relate more satisfaction with work
ED STAFF PERCEPTION OF WORKING ENVIRONMENT
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
(Continues)
19
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TABLE 3. (Continued)
20
intrinsically options, subdivided into (r = 0.33; P < 0.05), while the targets
challenging anxiety, depression, health and coping style ‘Active’ was – Requirement for
environment social functioning and Brief significantly related to lower managers and consultants
COPE has 28 items with four anxiety to generate a culture that
response options covering nine (r = 0.38; P < 0.05), somatic supports training and
scales: substance misuse, complaints (r = 0.46; development of evidence-
religion, humour, behavioural P < 0.001) and years since based coping skills
disengagement, use of support, qualification (r = 0.40;
active coping/planning, P < 0.05)
venting/self-distraction, denial/
self-blame and acceptance
– Correlational analyses using
Pearson’s r
4. Burbeck, Coomber, To assess UK practicing ED – Mixed methods including – Validated scales – High levels of psychological – Large pool of specialist – ‡‡Sample all drawn – Assessment of 100
Robinson and Todd, occupational stress consultants complete §§quantitative descriptive providing scaled data distress amongst doctors clinicians from one professional characteristics, or
2002, UK levels in ED lists provided by cross-sectional correlational (non-parametric‡) working in ED compared with – Commonly used tools society combination of
consultants British Association of design from a self-reported – Response rate = 78% other groups of doctors and thus comparison with – Limited follow up of characteristics, within ED
Emergency Medicine validated questionnaire – Completion rate 73% – Respondents were highly other doctors was possible non-respondents to the that are particularly
(BAEM) and the – Demographic and work- satisfied with ED as a specialty – Free text options enabled survey problematic
Faculty of Accident related information and – The number of hours key themes to be identified – Requirement for NHS
and Emergency included the general health reportedly worked during – Open-ended text provision of employment
Medicine (FAEM) questionnaire-12 (GHQ-12) to previous week significantly questions and stressful environments, in which
– n = 371/479 assess psychological distress, correlated with stress outcome scenario description for doctors can practice
responses 15 and the symptom checklist- measures qualitative comment effectively without
– 350/479 survey depression scale (SCL-D) to – Factors including ‘being – Also explored the effects compromising health
completion measure depression overstretched’, ‘effect of hours’, of ‘protective’ factors
– Non-parametric statistics for ‘stress on family life’, ‘lack of identified in other studies
GHQ-12 and SCL-D scores. recognition’, ‘low prestige of (minimal input)
Qualitative data, including specialty’ and ‘dealing with
aspects of the job respondents management’ were all shown
enjoyed, analysed using the to be important
constant comparative method
to develop coding frames
– Logistic regression was used
to build a predictive model of
GHQ-12- and SCL-D
– Demographic and stressor
variables were correlated
individually with both GHQ-
12 and SCL-D scores. The six
most highly correlated stressors
were entered as independent
variables in multivariate
logistic regressions with GHQ-
12 and SCL-D scores as
dependent variables
5. Taylor, Pallant, To evaluate – n = 323 – §§Quantitative descriptive – Validated scales – Significant positive – Comparison to – ‡‡Skewed FACEM – FACEMs had as good or 100
Crook and Cameron, psychological health – ACEM fellows cross-sectional correlational providing quantitative correlation between work and community population population limiting better psychological health
2004, Australasia of ED physicians and design from a self-reported ordinal (parametric‡) data life satisfaction and perception data validity of comparison than the comparison
identify factors that validated questionnaire on scale of 1–4 to 1–10 of control over hours worked – Conservative statistical with community data population with moderate
impact on their health and professional activity mix significance set at 0.01
(Continues)
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
A JOHNSTON ET AL.
– Perceived stress scale, Zung – Response rate 64% – Significant negative – Good follow up of non- – Response rate may have work stress and work
depression scale, Zung anxiety correlation between work and responders to limit introduced a selection bias satisfaction scores
scale, Revised life orientation life satisfaction and work stress possible bias by responder – Important to provide
test, Mastery scale, Physical – Maladaptive strategies characteristics some level of working
symptoms checklist, Perceived (alcohol/drugs/disengagement) autonomy/flexibility
control of internal states scale, positively associated with around hours worked and
Satisfaction with life scale + anxiety, depression and stress activity mix
demographics – Very weak relationship – Stress identification and
– Pearson’s correlations, between work stress/ management (coping)
ANOVA and t-tests satisfaction and demographic, should be included in
workplace factors or hours ACEM training and
worked aside from gender workforce subjected to
regular review
6. Wrenn, Lorenzen, To identify factors n = 18 postgraduate – Prospective cohort evaluation – The RA had no other – Only anticipated overtime – Explicit control for many – ‡‡Non-probabilistic and – It is unlikely that solving 100
Jones, Zhou and other than work year (PGY)-2 and of stress levels connection to the ED, and process failures were workload factors intentional sampling based the ED overcrowding issue
Aronsky, 2010, USA hours in the ED WE PGY-3 EM residents – Self-reported quantitative administered the survey correlated with stress – Multiple controls for on participant availability will necessarily translate
contributing to – Twelve surveys and survey consisted of a modified and was the only one who – Factors related to ED bias – Timing of administration into less stress for the
resident stress questionaires were version of the previously knew the tracking number overcrowding had no – The survey took less than of the surveys at the end of residents
collected from each validated Perceived Stress – RA was not involved in significant effect on reported 5 min to complete a shift may have led some – In fact ‘solving’
ED STAFF PERCEPTION OF WORKING ENVIRONMENT
participant, four each Questionnaire normalised to a any sort of evaluation of resident stress variables, such as overcrowding might
from the day, evening possible range of 0 to 100 and, residents – EM resident shift-specific anticipated overtime, to increase resident stress as
and night shifts because of the modifications, a – All investigators except stress was associated primarily influence the results more throughput pressure
– Single site rating of self-perceived stress the RA were blinded to the with the perception of excessive than they would have if the increases
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
(Continues)
21
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22
TABLE 3. (Continued)
8. Xiao, Wang, Chen To measure n = 205 ED – §§Quantitative descriptive – All the physicians from – Psychological distress is – Used well validated – ‡‡, ††Non-probabilistic – National healthcare 75
et al., 2014, China psychological distress physicians from three cross-sectional design using the EDs of three large prevalent in Chinese EM instruments to capture a and intentional sampling administrators need to
and job satisfaction general hospitals three self-reported surveys general hospitals across a physicians and they are at risk good sample of senior ED based on participant legislate regulations to
amongst Chinese including the Hospital Anxiety month were invited to of having their mental health doctors, providing a availability forbid attacking
emergency physicians and Depression Scale (HADS), participate undermined gradually unique view of – Participants in the healthcare staff, guarantee
Maslach Burnout Inventory- – Response rate = 82% – Job satisfaction is moderate responsibilities in Chinese present study may fairly physicians resting time and
General Survey and Minnesota – ED physicians experienced EDs represent the ED increase their income
Satisfaction Questionnaire higher levels of anxiety and physicians in city hospitals – Need for further research
– Descriptive statistics and depression as measured by the but might not be across clinical levels and
Pearson correlation was used HADS, compared with the representative of those geographical regions
to explore data relationships general population working in township
– Worsening psychological health centres or private
distress might partly be related clinics
to the worsening physician/
patient relationship and the
mistrust for doctors
†Note: all survey completion was deidentified and voluntary, with appropriate accompanying ethical approval unless noted otherwise. ‡Data type (quantitative/qualitative) is identified in the study and/or on the basis of the analysis performed. §Note: all survey and interview data are
subject to potential prevarication bias and even response falsification. Additionally, the selections required in surveys are often ‘relative’ and so can be challenging ascertain consistently and reliably (‘soft’ responses), response bias based on the psychological well-being of participants (single
point in time survey). ¶There were additional study findings not related to the focus of this review not reported here. ††Cross-sectional, study and thus no causal inferences can be drawn. ‡‡No provision for open-ended responses so participants’ responses are constrained by study
§§MMAT classification system ACEM, Australian College of Emergency Medicine; EM, Emergency Medicine; FACEMs, fellows of the Australasian college of emergency medicine; MD, medical doctor; MMAT, mixed methods appraisal tool; PGY, post graduate year; PTSD,
posttraumatic stress disorder; RA, research assistant; RN, registered nurse; RPPE, Revised Professional Practice Environment; SAS, statistical analysis systems; SD, standard deviation; SEM, standard error of the mean; SPSSx, statistics package for the social sciences; SSEM, Spanish
Society of Emergency Medicine; SHOs, senior house officers; USA, United States; WE, work environment.
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
A JOHNSTON ET AL.
Leadership and management collection of baseline data prior to appear to have been undertaken. This
attempting potentially stress-reducing may be a valuable next step in develop-
‘Dealing with management’ and less fre-
interventions. ED crowding is com- ing international ED standards, as ex-
quent participation in the management
monplace and is, perhaps, now consid- posure to health and safety hazards
(administrative) hierarchy were nega-
ered ‘the norm’, therefore contributing and physical workload are becoming
tive working factors noted in studies of
less to stress levels.52 Note that work- noted issues in literature from non-
medical staff stressors and some mixed
load is different to hours worked. developed countries.2,11
population studies.4,46,47,51 However,
Hours worked, where investigated, did
some mixed clinical groups commented
contribute to staff stress levels.4 Pro-
positively on ability of management to Improving satisfaction with
cesses around balancing patient acuity,
offer flexible working arrangements working environment
staff skill mix and resources are often
and good quality leadership.12,39 Varia-
cited as potential stress reducers, and While there are few studies examining
tion in supervisor support, with appa-
thus, management of such processes, temporal fluctuations in staff opinions
rently good support for nurses and less
including staff role expectation,40,43 of work environment, those have
effective support for medical staff,8,50
can enhance service delivery.49 showed large and rapid (i.e. within
may reflect actual support levels, the
18 months) alterations.41 While many
mixed roles of professional colleges,
studies conclude with recommenda-
variations in managerial support or Emotional drain
tions for improving ED staff percep-
different expectations of leadership and
Emotional drain was another stressor tion of their working environment,38
management support in these groups.
noted within the literature. All of the very few report actual interventions
Studies exploring nurses’ perceptions
studies that allowed for identification aimed at achieving this goal.
seemed to highlight lack of medical
or rating of work stressors cited ‘emo- A number of studies suggest deb-
support as key factor contributing to
tional drain’ as critical to developing riefing processes would help reduce
stress in the ED.2,38
an understanding of the ED working ED staff stress,9,45 some even suggest
environment.2,8,9,11,37,40,41,43,45,46,49,50 debriefing should be mandatory fol-
Communication Managing the emotional ‘fall-out’ of lowing stress-evoking incidents;43 how-
Communication was infrequently cited work was often cited in research with ever, some evidence suggests that
as a key factor in staff perception of nurses2,43 but was not always evident coping strategies around venting were
stress in the ED.5 There are a number in studies of medical officers or with related to greater staff anxiety49 and
of possible explanations for this mixed clinical staff. Three quarters distress.2,50 Thus, evidence-based inter-
including that it really was not a factor (9/12) of the studies examining nurses vention is required.
or conversely, because it is so much a explored the psychological stress
‘given’ in hospital contexts that staff associated with the emotional burden
of working in the ED, while only one
Discussion
acknowledge it as a ‘universal’ issue.
Other cited factors that included a quarter (2/8) did so with medical staff. This integrative review indicated that
component of communication, such While broad-based investigations pro- each of the 31 included studies
as inter-professional and interpersonal vide evidence suggesting that mental indicated that ED staff were aware of,
relationships were often cited as impor- strain is critical for all clinical staff, and articulate, problematic issues in
tant potential stressors in nurses38,40,41 variable study focus may bias evidence- their workplaces. Excluding work-
and mixed groups,8,10,12,46,50 and based perceptions of key staff issues. place violence17 and communication
yet these often did not appear as Like emotional drain, work–life balance issues,34 workplace perceptions des
significant components of stress in and control of total working hours cribed by ED staff centre around
studies examining exclusively medical were often an issue raised in papers common themes including perceived
populations. examining medical staff, but far less fre- excessive workload, teamwork and feel-
quently raised in mixed or nursing stud- ing a skilled and valued member of a
ies. However, the effects of shift work team, the impacts of traumatic events,
Workload/work time pressures and control of shifts were a common is- the need for support (managerial, peer
One of the major factors consistently sue, especially for more junior medical and social) and autonomy. Increasingly,
noted within the literature as a stressor and nursing staff.37,43,46,48 evidence is demonstrating that poor
was staff workload.2,11,43 It is interest- staff perception of workplaces impacts
ing that stress was not always related on staff retention and, thus, personnel
to workload per se (rather patient
Cultural variation and professional capital in an ED41
load, staffing or flow) but often related Geographical stratification of studies and creates concomitant risks to patient
to perceived time pressures.8,44,47,52 appeared to demonstrate more ex- safety.53 Such environments also
While this is a variable finding in clini- treme levels of distress in Iranian45 increase the risk of developing mental
cal staff,4,11,37,40 it suggests that objec- and Chinese ED clinicians7,40 using health conditions such as burnout.18
tive measures (actual patient load and the psychometric (translated) instru- While essential for effective organi-
working hours) must be coupled with ments applied to clinical personnel in sational management, standardised,
subjective (self-reported) measures western countries. However, no specif- repeatable and comprehensive assessment
such as perceived stress, for effective ically designed cross-cultural studies of staff perception of ED working
© 2016 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for
Emergency Medicine and Australasian Society for Emergency Medicine
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24 A JOHNSTON ET AL.
environment remains problematic. There more desirable autonomy, teamwork be used to evaluate the effects of
are a considerable number of tools and and levels of communication were ap- training and practice interventions.
processes being used to explore staff per- parent in staff questionnaire responses. The evidence base provided by this in-
ception of working environment in ED, These response patterns occurred tegrative review can be used to assist
and they change across time. This makes across nurses and doctors, across gen- retention of professional capital in the
longitudinal and comparative studies very der and apparently across levels of workspace, enhancing hospital ED
difficult. Consistent approaches need to seniority/experience. Thus, the ED practice and patient management.
be applied in a longitudinal manner, so staff population would appear to be
that there is a clear picture of key features quite specific and an interesting group
of stressors in a range of staff, data on for investigation, comparison and Acknowledgement
baseline stressors and the scope of eventual intervention. We acknowledge QEMRF for funding
‘normal’ fluctuation. Moreover, research Our literature search showed very and contributing to this review.
needs to be consistently well-designed few intervention studies. Where posi-
and conducted to enhance the validity tive perceptions of ED were docu-
of findings. mented, staff often cited teamwork, Competing interests
EDs draw highly skilled staff and collegiality, respect for multidisciplin-
support staff morale and satisfaction ary expertise and positive social and None declared.
through high levels of teamwork professional support as key to the pos-
and clinical autonomy. Unfortunately, itivity. This would suggest that a col-
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More work-related stress, but also port ED development. The data should cross-sectional study of physicians in
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Emergency Medicine and Australasian Society for Emergency Medicine
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